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Bin Abdulqader S, Alzhrani G. Endoscopic Endonasal Resection of a Cavernous Malformation of the Third Ventricle: Case Report and Literature Review. J Neurol Surg A Cent Eur Neurosurg 2024; 85:221-226. [PMID: 35644135 DOI: 10.1055/s-0041-1741070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM. CASE DESCRIPTION A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively. CONCLUSION This report demonstrates safe resection of a third ventricle CM via the endonasal route.
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Affiliation(s)
- Sarah Bin Abdulqader
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Gmaan Alzhrani
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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Tian A, Cui Z, Ren J, Ren Y, Ye M, Li G, He C, Li X, Zeng G, Hu P, Ma Y, Yu J, Li J, Bian L, Yang F, Li Q, Ling F, Hong T, Sun L, Zhang H. Surgical timing and long-term outcomes in patients with severe haemorrhagic spinal cord cavernous malformations. Stroke Vasc Neurol 2023:svn-2023-002745. [PMID: 37949480 DOI: 10.1136/svn-2023-002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/07/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Surgical resection of the lesions remains the main treatment method for most symptomatic spinal cord cavernous malformations (SCCMs) to eliminate the occupation and associated subsequent lifelong haemorrhagic risk. However, the timing of surgical intervention remains controversial, especially for patients in the acute stage after severe haemorrhage. METHODS Patients diagnosed with SCCMs who were surgically treated between January 2002 and December 2021 were selected and retrospectively reviewed. The Modified McCormick Scale (MMS) was used to evaluate neurological and disability status. All medical information was reviewed, and all patients were followed up for at least 6 months. RESULTS A total of 279 patients were ultimately included. With regard to long-term outcomes, 110 (39.4%) patients improved, 159 (57.0%) remained unchanged and 10 (3.6%) worsened. For patients with an MMS score of 2-5 on admission, in univariate and multivariate analyses, a ≤6 weeks period between onset and surgery (adjusted OR 3.211, 95% CI 1.504 to 6.856, p=0.003) was a significant predictor of improved MMS. Among 69 patients who first presented with severe haemorrhage, undergoing surgery within 6 weeks of the onset of severe haemorrhage (adjusted OR 4.901, 95% CI 1.126 to 21.325, p=0.034) was significantly associated with improvement of MMS score. CONCLUSION Surgical timing can influence the long-term outcome of SCCMs. For patients with symptomatic SCCMs, especially those with severe haemorrhage, early surgical intervention within 6 weeks can provide more benefit.
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Affiliation(s)
- An Tian
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ziwei Cui
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yeqing Ren
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, United Family Healthcare, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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Benet A, Spetzler RF. Cavernous Malformations: What They Have Taught Us. Neurosurgery 2023; 69:9-21. [PMID: 36924486 DOI: 10.1227/neu.0000000000002400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Cerebral cavernous malformation: Management, outcomes, and surveillance strategies - A single centre retrospective cohort study. Clin Neurol Neurosurg 2023; 225:107576. [PMID: 36608471 DOI: 10.1016/j.clineuro.2022.107576] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may undergo a period of clinical and/or radiographical surveillance that precedes or follows definitive treatment. There are no international guidelines on the optimal surveillance strategy. This study describes the surveillance strategies at our centre and explore the related clinical outcomes. METHODS We performed a retrospective study of adult patients with CCMs referred to a neurovascular service over an 8-year period, to determine the frequency and type of surveillance, intervention, and explore the associated outcomes. We report our findings adhering to STROBE guidelines. RESULTS 133 patients (Male:Female 73:60; men age 42 years; range 12-82) were included. CCMs were identified in patients first presenting with symptomatic intracerebral haemorrhage (42.11%); headache, focal neurological deficit, or seizure without haemorrhage (41.35%); or, as an incidental finding (16.54%). The most common CCM location was supratentorial (59.40%), followed by brain stem (21.80%), cerebellum (10.53%) and basal ganglia (6.02%). Of the 133 patients, 77 patients (57.89%) were managed conservatively, 49 patients (36.84%) were managed by surgical resection alone, and seven patients (5.26%) were managed with stereotactic radiosurgery (SRS). Patients follow-up had a mean duration of 65.94 months, and varied widely (SD = 52.59; range 0-265), for a total of 730.83 person-years of follow up. During surveillance, 16 patients suffered an ICH equating to a bleeding rate of 2.19 per 100 patient years. CCMs that increased in size had a higher bleeding rate (p = 8.58 ×10-4). There were 8 (6.02%) cases where routine clinic review or MRI resulted in a change in management. CONCLUSIONS Our single centre retrospective study supports existing literature relating to presentation and sequalae of CCM, with an increase in CCM size being associated with higher rates of detected bleeding. There remains heterogeneity, even within a single centre, on the frequency and modality of surveillance. Further, there are no international guidelines or high-quality data that recommends the optimal duration and frequency of surveillance, and its effect on clinical outcomes. This is a future research direction.
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Srinivasan VM, Karahalios K, Shlobin NA, Koester SW, Nguyen CL, Rumalla K, Rahmani R, Catapano JS, Labib MA, Mitha AP, Spetzler RF, Lawton MT. Residual and Recurrent Spinal Cord Cavernous Malformations: Outcomes and Techniques to Optimize Resection and a Systematic Review of the Literature. Oper Neurosurg (Hagerstown) 2023; 24:44-54. [PMID: 36519878 DOI: 10.1227/ons.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Intramedullary spinal cord cavernous malformations (SCCMs) account for only 5% of overall cavernous malformations (CMs). The occurrence of recurrent or residual SCCMs has not been well discussed, nor have the technical nuances of resection. OBJECTIVE To assess the characteristics of residual SCCMs and surgical outcomes and describe the techniques to avoid leaving lesion remnants during primary resection. METHODS Demographic, radiologic, intraoperative findings and surgical outcomes data for a cohort of surgically managed intramedullary SCCMs were obtained from an institutional database and retrospectively analyzed. A systematic literature review was performed using PRISMA guidelines. RESULTS Of 146 SCCM resections identified, 17 were for residual lesions (12%). Patients with residuals included 13 men and 4 women, with a mean age of 43 years (range 16-70). All patients with residual SCCMs had symptomatic presentations: sensory deficits, paraparesis, spasticity, and pain. Residuals occurred between 3 and 264 months after initial resection. Approaches for 136 cases included posterior midline myelotomy (28.7%, n = 39), pial surface entry (37.5%, n = 51), dorsal root entry zone (27.9%, n = 38), and lateral entry (5.9%, n = 8). Follow-up outcomes were similar for patients with primary and residual lesions, with the majority having no change in modified Rankin Scale score (63% [59/93] vs 75% [9/12], respectively, P = .98). CONCLUSION SCCMs may cause significant symptoms. During primary resection, care should be taken to avoid leaving residual lesion remnants, which can lead to future hemorrhagic events and neurological morbidity. However, satisfactory results are achievable even with secondary or tertiary resections.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nathan A Shlobin
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Alim P Mitha
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Hori T, Chernov M, Alshebib YA, Kubota Y, Matsuo S, Shiramizu H, Okada Y. Long-term outcomes after surgery for brainstem cavernous malformations: analysis of 46 consecutive cases. J Neurosurg 2022; 138:900-909. [PMID: 36087317 DOI: 10.3171/2022.7.jns22314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the long-term outcomes after resection of brainstem cavernous malformations (BSCMs) and to assess the usefulness of the Lawton grading system in these cases. METHODS This retrospective study analyzed 46 consecutive patients with BSCMs operated on between July 1990 and December 2020. Outcomes at the last follow-up were defined as favorable (modified Rankin Scale [mRS] score 0-2) or unfavorable (mRS score > 2). RESULTS The study cohort comprised 24 men (52%) and 22 women (48%), ranging in age from 8 to 78 years old (median 37 years). In 19 patients (41%), the preoperative mRS score was > 2. All patients had hemorrhagic BSCM. There were 12 (26%) mesencephalic, 19 (41%) pontine, 7 (15%) medullary, and 8 (17%) cerebellar peduncle lesions, with a maximal diameter ranging from 5 to 40 mm (median 15 mm). In total, 24 BSCMs (52%) had bilateral extension crossing the brainstem midline. Lawton grades of 0, I, II, III, IV, V, and VI were defined in 3 (7%), 2 (4%), 10 (22%), 11 (24%), 8 (17%), 7 (15%), and 5 (11%) cases, respectively. Total resection of BSCMs was attained in 43 patients (93%). There were no perioperative deaths. Excluding the 3 most recent cases, the length of follow-up ranged from 56 to 365 months. The majority of patients demonstrated good functional recovery, but regress of the preexisting oculomotor nerve deficit was usually incomplete. No new hemorrhagic events were noted after total resection of BSCMs. In 42 patients (91%), the mRS score at the time of last follow-up was ≤ 2 (favorable outcome), and in 18 (39%), it was 0 (absence of neurological symptoms). Forty-four patients (96%) demonstrated clinical improvement and 2 (4%) had no changes compared with the preoperative period. Multivariate analysis revealed that only lower Lawton grade had a statistically significant independent association (p = 0.0280) with favorable long-term outcome. The area under the receiver operating characteristic curve for prediction of favorable outcome with 7 available Lawton grades of BSCM was 0.93. CONCLUSIONS Resection of hemorrhagic BSCMs by an experienced neurosurgeon may be performed safely and effectively, even in severely disabled patients. In the authors' experience, preexisting oculomotor nerve palsy represents the main cause of permanent postoperative neurological morbidity. The Lawton grading system effectively predicts long-term outcome after surgery.
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Affiliation(s)
- Tomokatsu Hori
- 1Department of Neurosurgery, Tokyo Women's Medical University.,3Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Mikhail Chernov
- 2Department of Neurosurgery, Tokyo Women's Medical University Adachi Medical Center; and
| | - Yasir A Alshebib
- 3Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Yuichi Kubota
- 2Department of Neurosurgery, Tokyo Women's Medical University Adachi Medical Center; and
| | - Seigo Matsuo
- 3Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Hideki Shiramizu
- 3Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Yoshikazu Okada
- 1Department of Neurosurgery, Tokyo Women's Medical University
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Xu XY, Li D, Song LR, Liu PP, Wu ZY, Wang L, Zhang LW, Zhang JT, Wu Z. Nomogram for predicting an individual prospective hemorrhage risk in untreated brainstem cavernous malformations. J Neurosurg 2022; 138:910-921. [PMID: 36152323 DOI: 10.3171/2022.8.jns221228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
In this study, the authors aimed to create a nomogram for precisely predicting the 5-year prospective hemorrhage risk in brainstem cavernous malformations (BSCMs).
METHODS
Patients with confirmed BSCMs in a single-center prospective observational series from January 2012 to December 2016 were included in the present study for nomogram building and validation. The concordance index (C-index), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy, discriminative ability, and clinical usefulness of the nomogram. Then, a nomogram-based risk stratification model for untreated BSCMs was developed.
RESULTS
In total, 600 patients were included in the study; 417 patients who had been enrolled before July 2015 were divided into the training and validation cohorts, and 183 subsequently enrolled patients were used as the external validation cohort. By applying a backward stepwise procedure in the multivariable Cox model, variables, including prior hemorrhage (HR 1.69), hemorrhage on admission (HR 3.33), lesion size > 1.5 cm (HR 1.84), lesion depth (HR 2.35), crossing the axial midpoint (HR 1.94), and developmental venous anomaly (HR 2.62), were incorporated to develop a nomogram. The Harrell C-index values for a 5-year prospective hemorrhage were 0.752 (95% CI 0.687–0.816), 0.801 (95% CI 0.665–0.936), and 0.758 (95% CI 0.674–0.842) in the training, internal validation, and external validation cohorts, respectively. The nomogram performed well in terms of consistency between prediction and actual observation according to the calibration curve. The patients could be classified into three distinct (low, medium, and high) risk groups using the final score of this nomogram.
CONCLUSIONS
Independent predictors of the 5-year hemorrhage risk in untreated BSCMs were selected to create the first nomogram for predicting individual prospective hemorrhage. The nomogram was able to stratify patients into different risk groups and assist in clinical decision-making.
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Affiliation(s)
- Xiao-Ying Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Lai-Rong Song
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Pan-Pan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Ze-Yu Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
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Orlev A, Feghali J, Kimchi G, Salomon M, Berkowitz S, Oxman L, Levitan I, Knoller N, Auriel E, Huang J, Tamargo RJ, Harnof S. Neurological event prediction for patients with symptomatic cerebral cavernous malformation: the BLED2 score. J Neurosurg 2022; 137:344-351. [PMID: 34920431 DOI: 10.3171/2021.8.jns211321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Retrospective patient cohort studies have identified risk factors associated with recurrent focal neurological events in patients with symptomatic cerebral cavernous malformations (CCMs). Using a prospectively maintained database of patients with CCMs, this study identified key risk factors for recurrent neurological events in patients with symptomatic CCM. A simple scoring system and risk stratification calculator was then created to predict future neurological events in patients with symptomatic CCMs. METHODS This was a dual-center, prospectively acquired, retrospectively analyzed cohort study. Adult patients who presented with symptomatic CCMs causing focal neurological deficits or seizures were uniformly treated and clinically followed from the time of diagnosis onward. Baseline variables included age, sex, history of intracerebral hemorrhage, lesion multiplicity, location, eloquence, size, number of past neurological events, and duration since last event. Stepwise multivariable Cox regression was used to derive independent predictors of recurrent neurological events, and predictive accuracy was assessed. A scoring system based on the relative magnitude of each risk factor was devised, and Kaplan-Meier curve analysis was used to compare event-free survival among patients with different score values. Subsequently, 1-, 2-, and 5-year neurological event rates were calculated for every score value on the basis of the final model. RESULTS In total, 126 (47%) of 270 patients met the inclusion criteria. During the mean (interquartile range) follow-up of 54.4 (12-66) months, 55 patients (44%) experienced recurrent neurological events. Multivariable analysis yielded 4 risk factors: bleeding at presentation (HR 1.92, p = 0.048), large size ≥ 12 mm (HR 2.06, p = 0.016), eloquent location (HR 3.01, p = 0.013), and duration ≤ 1 year since last event (HR 9.28, p = 0.002). The model achieved an optimism-corrected c-statistic of 0.7209. All factors were assigned 1 point, except duration from last event which was assigned 2 points. The acronym BLED2 summarizes the scoring system. The 1-, 2-, and 5-year risks of a recurrent neurological event ranged from 0.6%, 1.2%, and 2.3%, respectively, for patients with a BLED2 score of 0, to 48%, 74%, and 93%, respectively, for patients with a BLED2 score of 5. CONCLUSIONS The BLED2 risk score predicts prospective neurological events in symptomatic CCM patients.
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Affiliation(s)
- Alon Orlev
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Feghali
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gil Kimchi
- 3Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Ramat-Gan, Israel
| | - Moran Salomon
- 4St. Georges, University of London, Cranmer Terrace, London, United Kingdom; and
| | - Shani Berkowitz
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Liat Oxman
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Idan Levitan
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Nachshon Knoller
- 3Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Ramat-Gan, Israel
| | - Eitan Auriel
- 5Department of Neurology, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Judy Huang
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sagi Harnof
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
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Catapano JS, Rutledge C, Rumalla K, Raygor KP, Srinivasan VM, Koester SW, Kimata AR, Ma KL, Labib MA, Spetzler RF, Lawton MT. External validation of the Lawton brainstem cavernous malformation grading system in a cohort of 277 microsurgical patients. J Neurosurg 2022; 136:1231-1239. [PMID: 34598133 DOI: 10.3171/2021.3.jns204291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The brainstem cavernous malformation (BSCM) grading system predicts neurological outcomes associated with microsurgical resection and assists neurosurgeons in selecting patients for treatment. The predictive accuracy of the BSCM grading system should be validated in a large cohort from high-volume centers to generalize its use. METHODS An external validation cohort comprised patients with a BSCM resected by the senior author (M.T.L.) since the publication of the BSCM grading system and those resected by another neurosurgeon (R.F.S.) over a 16-year period. Size, crossing the axial midpoint, the presence of a developmental venous anomaly, patient age, and timing of last hemorrhage were used to assign BSCM grades from 0 to VII. Poor neurological outcomes were recorded as modified Rankin Scale scores > 2 at last follow-up examination. RESULTS A total of 277 patients were included in the study. The average BSCM grade was 3.9, and the majority of BSCMs (181 patients, 65%) were intermediate grade (grades III-V). Outcomes were predicted by BSCM grade, with good outcomes observed in 47 of 54 patients (87%) with low-grade BSCMs, in 135 of 181 patients (75%) with intermediate-grade BSCMs, and in 21 of 42 patients (50%) with high-grade BSCMs. Conversely, proportions of patients with neurological deterioration increased with increasing BSCM grade, with worsening observed in 2 of 54 patients (4%) with low-grade BSCMs, in 29 of 181 patients (16%) with intermediate-grade BSCMs, and in 17 of 42 patients (40%) with high-grade BSCMs. In the chi-square analysis, high-grade BSCMs were associated with increased odds of neurological worsening compared to low- and intermediate-grade BSCMs (OR 5.0, 95% CI 2.4-10.4; p < 0.001). The receiver operating characteristic analysis demonstrated acceptable discrimination for predicting unfavorable functional outcomes (modified Rankin Scale score > 2) with an area under the curve of 0.74 (95% CI 0.68-0.80; p < 0.001). CONCLUSIONS This study validates the BSCM grading system in a large cohort of patients from two high-volume surgeons. BSCM grade predicted neurological outcomes with accuracy comparable to that of other grading systems in widespread use. The BSCM grading system establishes categories of low-, intermediate-, and high-grade BSCMs and a boundary or cutoff for surgery at BSCM grade V. BSCM grading guides the analysis of a particular patient's condition, but treatment recommendations must be individualized, and neurosurgeons must calibrate BSCM grading to their own outcome results, unique abilities, and practices.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Caleb Rutledge
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kavelin Rumalla
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kunal P Raygor
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Visish M Srinivasan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Stefan W Koester
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Anna R Kimata
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kevin L Ma
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Magnetic Resonance Imaging of Multiple Cerebral and Spinal Cavernous Malformations of a Patient with Dementia and Tetraparesis. Diagnostics (Basel) 2022; 12:diagnostics12030677. [PMID: 35328230 PMCID: PMC8946930 DOI: 10.3390/diagnostics12030677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Cavernomas are rare cerebrovascular malformations that usually occur in sporadic forms with solitary lesions located most often in the hemispheric white matter, but also in the infratentorial or spinal region. Multiple lesions at different CNS levels are considered a hallmark for the familial form of the disease. The diagnostic modality of choice for cerebral cavernous malformations (CCMs) is magnetic resonance imaging (MRI). We present an intriguing case of a 65-year-old male admitted to our hospital with tetraparesis and cognitive impairment where highly sensitive MRI sequences identified many cerebral cavernous lesions at the supra-, infratentorial and cervical–thoracic spine levels, some of them with recent signs of bleeding in a patient with oral anticoagulant therapy due to atrial fibrillation. The mechanism of cognitive impairment in this patient is most probably the interruption of strategic white matter tracts, as it is known to happen in other subcortical vascular pathologies. MRI can be helpful not only in mapping the anatomical distribution of lesions, but also in weighing the risks and making decisions regarding whether or not to continue oral anticoagulant therapy.
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11
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Fontanella MM, Zanin L, Panciani P, Belotti F, Doglietto F, Cremonesi A, Migliorati K, Roca E, Maria LD, Franzin A, Vivaldi O, Griva F, Narducci A, Draghi R, Calbucci F, Borghesi I, Crobeddu E, Cossandi C, Fioravanti A, Arias JA, Scerrati A, Bonis PD, Locatelli D, Agosti E, Veiceschi P, Ceraudo M, Zona G, Gasparotti R, Terzi di Bergamo L, Rigamonti D. Preliminary validation of FoRCaSco: a new Grading System for Cerebral and Cerebellar Cavernomas. World Neurosurg 2022; 162:e597-e604. [DOI: 10.1016/j.wneu.2022.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
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12
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Ganz JC. Cavernous malformations. PROGRESS IN BRAIN RESEARCH 2022; 268:115-132. [PMID: 35074077 DOI: 10.1016/bs.pbr.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cavernous malformations are relatively common intracerebral malformations of which we only became properly aware after the introduction of MRI. They may be sporadic or familial. Familial CMs may be multiple and new lesions appear over time requiring intermittent MR control. Many sporadic CMs have no symptoms. The commonest location is in the supratentorial cerebral parenchyma presenting with epilepsy. The best treatment is microsurgery. A small proportion are in the brainstem and may rebleed and even be lethal. Treatment includes microsurgery and radiosurgery. Microsurgery cures the patient but has substantial problems with complications, deterioration and partial removal. Radiosurgery has taken time to demonstrate that it can over 2 years substantially reduce the risk of rebleeds without the risks of microsurgery. Both methods have a part to play in the treatment.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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13
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Ren J, Jiang N, Bian L, Dmytriw AA, Zeng G, He C, Sun L, Li X, Ma Y, Yu J, Li G, Ye M, Hu P, Li J, Yang F, Li Q, Ling F, Zhang H, Hong T. Natural History of Spinal Cord Cavernous Malformations: A Multicenter Cohort Study. Neurosurgery 2022; 90:390-398. [PMID: 35049523 DOI: 10.1227/neu.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The natural history of spinal cord cavernous malformations (SCCMs) remains relatively unclear. OBJECTIVE To investigate the natural history for hemorrhagic risks and neurological outcomes, as well as relevant predicting factors, of SCCMs. METHODS All patients between 2002 and 2019 with diagnosis of SCCMs were identified retrospectively. An observational study of patients with conservative management was performed to reveal the natural history of SCCMs. RESULTS We identified 305 patients in the full cohort, including 126 patients who were conservatively treated for at least 6 months (median observational period, 24.0 months). Forty-five hemorrhage events occurred during 527 person-years of follow-up, yielding an annual hemorrhage rate of 8.5% per person-year. The 1-, 2-, and 5-year cumulative risks of hemorrhage were 13.9%, 26.1%, and 35.1%, respectively. Prior hemorrhage (hazard ratio [HR] = 12.948, P = .012) and pediatric patients (HR = 2.841, P = .031) were independent predictors of hemorrhage in the long-term follow-up. Familial form (adjusted odds ratio [OR] = 30.695, P = .010) and subsequent hemorrhage events (adjusted OR = 16.333, P = .000) were independent risk factors for worsening of neurological function, and baseline neurological status (adjusted OR = 78.984, P = .000) and presence of subsequent hemorrhage (adjusted OR = 9.611, P = .001) were significantly associated with neurological outcomes. CONCLUSION The natural history of SCCMs varies. Baseline characteristics, such as pediatric patients, familial form, and baseline neurological status, as well as prior and subsequent hemorrhagic events, significantly affect the natural history of the SCCMs, which prompts a differentiated treatment strategy.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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14
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Fontanella MM, Bacigaluppi S, Doglietto F, Zanin L, Agosti E, Panciani P, Belotti F, Saraceno G, Spena G, Draghi R, Fiorindi A, Cornali C, Biroli A, Kivelev J, Chiesa M, Retta SF, Gasparotti R, Kato Y, Hernesniemi J, Rigamonti D. An international call for a new grading system for cerebral and cerebellar cavernomas. J Neurosurg Sci 2021; 65:239-246. [PMID: 34184861 DOI: 10.23736/s0390-5616.21.05433-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Surgical indications for cerebral cavernous malformations remain significantly center- and surgeon-dependent. Available grading systems are potentially limited, as they do not include epileptological and radiological data. A novel grading system is proposed for supratentorial and cerebellar cavernomas: it considers neuroradiological features (bleeding, increase in size), neurological status (focal deficits and seizures), location of the lesion and age of the patient. The score ranges from -1 to 10; furthermore, surgery should be considered when a score of 4 or higher is present. Based on neuroradiological characteristics, 0 points are assigned if the CCM is stable in size at different neuroradiological controls, 1 point if there is an increase in volume during follow-up, 2 points if intra- or extra-lesional bleeding <1 cm is present and 3 points if the CCM produced a hematoma >1 cm. Regarding focal neurological deficits, 0 points are assigned if absent and 2 points if present. For seizures, 0 points are assigned if absent, 1 point if present, but controlled by medications, and 2 points if drug resistant. We considered the site of the CCM, and in case of deep-seated lesions in a critical area (basal ganglia, thalamus) 1 point (-1) is subtracted, while for subcortical or deep cerebellar lesions 0 points are assigned, for CCMs in a cortical critical area 1 point is assigned and in case of lesions in cortical not in critical area or superficial cerebellar area, 2 points are assigned. As far as age is concerned, 0 points are assigned for patients older than 50 years and 1 point for patients younger than 50. In conclusion, a novel grading for surgical decision making in cerebral cavernomas, based on the experience of selected neurosurgeons, basic scientists, and patients, is suggested with the aim of further improving and standardizing the treatment of CCMs. The aim of this paper was also to call for both retrospective and prospective multicenter studies with the aim of testing the efficacy of the grading system in different centers.
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Affiliation(s)
- Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Francesco Doglietto
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luca Zanin
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy -
| | - Edoardo Agosti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Panciani
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giorgio Saraceno
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Riccardo Draghi
- Department of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Alessandro Fiorindi
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Claudio Cornali
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Biroli
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Juri Kivelev
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
| | | | - Saverio F Retta
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,CCM Italian Research Network, National Coordination Center at the Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberto Gasparotti
- Unit of Neuroradiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Aichi, Toyoake, Japan
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15
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Santos AN, Rauschenbach L, Darkwah Oppong M, Chen B, Herten A, Forsting M, Sure U, Dammann P. Assessment and validation of proposed classification tools for brainstem cavernous malformations. J Neurosurg 2020; 135:410-416. [PMID: 33065538 DOI: 10.3171/2020.6.jns201585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment indications for patients with brainstem cavernous malformations (BSCMs) remain difficult and controversial. Some authors have tried to establish classification tools to identify eligible candidates for surgery. Authors of this study aimed to validate the performance and replicability of two proposed BSCM grading systems, the Lawton-Garcia (LG) and the Dammann-Sure (DS) systems. METHODS For this cross-sectional study, a database was screened for patients with BSCM treated surgically between 2003 and 2019 in the authors' department. Complete clinical records, preoperative contrast-enhanced MRI, and a postoperative follow-up ≥ 6 months were mandatory for study inclusion. The modified Rankin Scale (mRS) score was determined to quantify neurological function and outcome. Three observers independently determined the LG and the DS score for each patient. RESULTS A total of 67 patients met selection criteria. Univariate and multivariate analyses identified multiple bleedings (p = 0.02, OR 5.59), lesion diameter (> 20 mm, p = 0.007, OR 5.43), and patient age (> 50 years, p = 0.019, OR 4.26) as predictors of an unfavorable postoperative functional outcome. Both the LG (AUC = 0.72, p = 0.01) and the DS (AUC = 0.78, p < 0.01) scores were robust tools to estimate patient outcome. Subgroup analyses confirmed this observation for both grading systems (LG: p = 0.005, OR 6; DS: p = 0.026, OR 4.5), but the combined use of the two scales enhanced the test performance significantly (p = 0.001, OR 22.5). CONCLUSIONS Currently available classification systems are appropriate tools to estimate the neurological outcome after BSCM surgery. Future studies are needed to design an advanced scoring system, incorporating items from the LG and the DS score systems.
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Affiliation(s)
- Alejandro N Santos
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and
| | - Laurèl Rauschenbach
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and
| | | | - Bixia Chen
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and
| | - Annika Herten
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and
| | - Michael Forsting
- 2Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and
| | - Philipp Dammann
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and
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16
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Radiation-Induced Spinal Cord Cavernous Malformations Associated with Medulloblastoma: Case Report and Review of the Literature. World Neurosurg 2020; 141:318-322. [PMID: 32592964 DOI: 10.1016/j.wneu.2020.06.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation-induced spinal cord cavernous malformations (CMs) are rare pathologies compared with radiation-induced cerebral CMs. We present a case of a radiation-induced spinal cord CM developed 31 years after radiation therapy for medulloblastoma. CASE DESCRIPTION A 37-year-old man developed a symptomatic spinal hemorrhagic lesion 31 years after radiation therapy for medulloblastoma. Magnetic resonance imaging revealed an intramedullary cystic lesion with a fluid-fluid level in the C7 area. Surgery was performed leading to an unclear diagnosis. Two years later, the patient had a relapse and underwent a second operation, allowing a definitive diagnosis of radiation-induced spinal cord CM. This is believed to be the second case of de novo intramedullary CM formation following spinal radiation therapy for medulloblastoma. CONCLUSIONS Radiation-induced spinal cord CMs should be recognized as a possible late adverse effect in patients treated with radiation therapy for medulloblastoma.
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17
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Lashkarivand A, Ringstad G, Eide PK. Surgery for Brainstem Cavernous Malformations: Association between Preoperative Grade and Postoperative Quality of Life. Oper Neurosurg (Hagerstown) 2020; 18:590-598. [PMID: 31768544 DOI: 10.1093/ons/opz337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 09/02/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Brainstem cavernous malformations (BSCMs) are associated with substantial neurologic morbidity, but the literature on quality of life (QoL) after surgical treatment is limited. There is a need for validating the clinical utility of current grading scales for cavernous malformations. OBJECTIVE To assess outcome of surgery for BSCMs and validate how outcome is associated with current grading scales for cavernous malformations. METHODS We retrospectively reviewed a single-surgeon series of patients with BSCM treated surgically during a 10-yr period. Outcome was categorized according to modified Rankin Scale (mRS), and QoL was assessed by interviewing patients using Short Form 36 (SF-36) Health Survey and comparing results with the normative population. The mRS and QoL were correlated with the Lawton BSCM grading scale and with the Zabramski classification of cavernous malformations. RESULTS The study included 22 patients (12 males and 10 females; median age 58 yr). No mortality related to the BSCM surgery occurred, and none were in vegetative state. In SF-36, 70% of patients reported a physical and mental functioning noninferior compared to the general population of comparative age and gender group. There was a significant positive correlation between the Lawton BSCM grading and the postoperative mRS score and QoL. CONCLUSION Outcome of surgery for BSCM was good, as assessed by mRS and QoL. The Lawton grading scale for BSCMs correlated significantly with the postoperative mRS score and QoL, suggesting this grading scale may become a useful clinical tool for treatment prognostication at the individual level.
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Affiliation(s)
- Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Geir Ringstad
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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18
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Moldovan K, Konakondla S, Barber SM, Nakhla J, Fridley JS, Telfeian AE, Gokaslan ZL, Oyelese AA. Intraoperative Computed Tomography Navigation-Assisted Resection of Symptomatic Intramedullary Spinal Cord Cavernoma: A Technical Note and Case Report. World Neurosurg 2019; 129:311-317. [DOI: 10.1016/j.wneu.2019.06.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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19
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Eichberg DG, Di L, Shah AH, Ivan ME, Komotar RJ, Starke RM. Use of Tubular Retractors for Minimally Invasive Resection of Deep-Seated Cavernomas. Oper Neurosurg (Hagerstown) 2019; 18:629-639. [DOI: 10.1093/ons/opz184] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/11/2019] [Indexed: 12/18/2022] Open
Abstract
Abstract
BACKGROUND
Cavernomas located in subcortical or eloquent locations are difficult lesions to access safely. Tubular retractors, which distribute retraction pressure radially, have been increasingly employed successfully. These retractors may be beneficial in subcortical cavernoma resection.
OBJECTIVE
To review a single institution's case series to determine the safety profile and efficacy of transcortical-transtubular cavernoma resections and to describe our transtubular operative technique.
METHODS
We reviewed a single institution's transcortical-transtubular cavernoma resections using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) tubular retractors performed from 2013 to 2018 (n = 20).
RESULTS
Gross total resection was achieved in all patients. When a developmental venous anomaly (DVA) was present, avoidance of DVA resection was achieved in all cases (n = 4). All patients had a supratentorial cavernoma with mean depth below cortical surface of 44.1 mm. Average postoperative clinical follow-up was 20.4 wk. Early neurologic deficit rate was 10% (n = 2); permanent neurologic deficit rate was 0%. One patient (5%) experienced early postoperative seizures (< 1 wk postop). No patients experienced late seizures (> 1 wk follow-up). Engel class 1 seizure control at final clinical follow-up was achieved in 87.5% of patients presenting with preoperative epilepsy.
CONCLUSION
Tubular retractors provide a low-profile, minimally invasive operative corridor for resection of subcortical cavernomas. There were no permanent neurologic complications in our series of 20 cases, and long-term seizure control was achieved in all patients. Thus, tubular retractors appear to be a safe and efficacious tool for resection of subcortical cavernomas.
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Affiliation(s)
- Daniel G Eichberg
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Long Di
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Ashish H Shah
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Michael E Ivan
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Robert M Starke
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, Florida
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Ren J, Hong T, He C, Sun L, Li X, Ma Y, Yu J, Ling F, Zhang H. Coexistence of Intracranial and Spinal Cord Cavernous Malformations Predict Aggressive Clinical Presentation. Front Neurol 2019; 10:618. [PMID: 31249549 PMCID: PMC6584750 DOI: 10.3389/fneur.2019.00618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/28/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Patients with spinal cord cavernous malformations (CMs) are at increased risk for multiple neuraxis CMs. Few studies focused on the natural history of patients with coexistence of intracranial and spinal cord CMs. Methods: Forty patients who underwent both intracranial and spinal MR imaging from a single center were reviewed retrospectively. American Spinal Injury Association (ASIA) impairment scale was used to evaluate neurological and disability status. Results: The median age of the 40 patients was 40.6 years old (range 9–69), and the male-to-female ratio was 2.1:1. The mean size of the intramedullary lesions was 10.1 ± 5.8 mm (range, 3.0–34.0 mm). Six patients (15%) harbored at least one intracranial lesion. Five of the 6 patients (83.3%) suffered aggressive clinical presentations with severe neurological and disability status; in patients with sporadic spinal CMs, the proportion was 26.5% (9 of 34). Coexistence of intracranial and spinal cord CMs is more likely to follow an aggressive course (P = 0.031, OR = 19.547, 95% CI = 1.322–289.123). In the postoperative long-term follow up, the unfavorable rate of patients with associated intracranial CMs was significantly higher than that of patients with sporadic spinal cord CMs (P = 0.049). Conclusions: The prevalence of associated intracranial CMs in patients with spinal cord CMs was 15%. Coexistence of intracranial and spinal cord CMs is more likely to follow an aggressive course. This study highlights the necessity of intracranial MR imaging for patients with spinal cord CMs to benefit to the predicting prognosis and selection of treatment strategies.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuan He
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
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21
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Goyal A, Rinaldo L, Alkhataybeh R, Kerezoudis P, Alvi MA, Flemming KD, Williams L, Diehn F, Bydon M. Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations. J Neurol Neurosurg Psychiatry 2019; 90:695-703. [PMID: 30760644 DOI: 10.1136/jnnp-2018-319553] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management. METHODS We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates. RESULTS A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7%) patients underwent immediate surgical resection, 64 (75.3%) were initially managed conservatively. Among this latter group, 16 (25.0%) suffered a haemorrhage during follow-up and 11 (17.2%) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5% per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5% and 0.8%, respectively. Median time to haemorrhage was 2.3 years (0.1-12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013). CONCLUSION Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.
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Affiliation(s)
- Anshit Goyal
- Neurosurgery, Mayo Clinic, Rochester, New York, USA
| | | | | | | | | | | | | | - Felix Diehn
- Radiology, Mayo Clinic, Rochester, New York, USA
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22
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Ren J, Hong T, He C, Li X, Ma Y, Yu J, Ling F, Zhang H. Surgical approaches and long-term outcomes of intramedullary spinal cord cavernous malformations: a single-center consecutive series of 219 patients. J Neurosurg Spine 2019; 31:123-132. [PMID: 30952112 DOI: 10.3171/2018.12.spine181263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Optimal surgical strategies for intramedullary spinal cord cavernous malformations (ISCCMs) are not optimized and remain problematic. In this study the authors identify rational surgical strategies for ISCCMs and predictors of outcomes after resection. METHODS A single-center study was performed with 219 consecutive surgically treated patients who presented from 2002 to 2017 and were analyzed retrospectively. The American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate neurological functions. Patient characteristics, surgical approaches, and immediate and long-term postoperative outcomes were identified. RESULTS The average ISCCM size was 10.5 mm. The spinal level affected was cervical in 24.8% of patients, thoracic in 73.4%, and lumbar in 1.8%. The locations of the lesions in the horizontal plane were 30.4% ventral, 41.6% dorsal, and 28.0% central. Of the 214 patients included in the cohort for operative evaluation, 62.6% had superficially located lesions, while 37.4% were embedded. Gross-total resection was achieved in 98.1% of patients. The immediate postoperative neurological condition worsened in 10.3% of the patients. Multivariate logistic regression identified mild preoperative function (p = 0.014, odds ratio [OR] 4.5, 95% confidence interval [CI] 1.4-14.8) and thoracolumbar-level lesions (p = 0.01, OR 15.7, 95% CI 1.9-130.2) as independent predictors of worsening. The mean follow-up duration in 187 patients was 45.9 months. Of these patients, 63.1% were stable, 33.2% improved, and 3.7% worsened. Favorable outcomes were observed in 86.1% of patients during long-term follow-up and were significantly associated with preoperative mild neurological and disability status (p = 0.000) and cervically located lesions (p = 0.009). The depths of the lesions were associated with worse long-term outcomes (p = 0.001), and performing myelotomy directly through a yellowish abnormal surface in moderate-depth lesions was an independent predictor of worsening (p = 0.023, OR 35.3, 95% CI 1.6-756.3). CONCLUSIONS Resection performed with an individualized surgical approach remains the primary therapeutic option in ISCCMs. Performing surgery in patients with mild symptoms at the thoracolumbar level and embedded located lesions requires more discretion.
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Abstract
A unique case is presented of chronic occipital neuralgia (ON) caused by cavernous malformation (CM) in the intramedullary C2 spinal cord and subsequent pain relief and remodeling of allodynic pain following dorsal root rhizotomy. A 53-year-old male presented with a 30-year history of chronic allodynic, paroxysmal lancinating pain in the greater and lesser occipital nerves. Typically, the pain was aggravated with neck extension and head movement. Magnetic resonance imaging showed a CM in the right posterolateral side of the intramedullary C2 cord. Considering potential risks associated with removal of the lesion, intradural C1-3 dorsal root rhizotomy with dentate ligament resection was performed. The paroxysmal lancinating pain of ON was significantly alleviated, and the remodeling of the extent of allodynic pain was noted after C1-3 dorsal root rhizotomy. These changes gradually occurred during the second postoperative month, and this effect was maintained for 24 months postoperatively. Significant reduction in chronic allodynic pain of secondary ON caused by cervicomedullary CM involving central sensitization in the trigeminocervical complex was observed with reduction of irritating, afferent input with C1-C3 dorsal root rhizotomy.
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Affiliation(s)
- Sang-Woo Ha
- Department of Neurosurgery, Chosun University Hospital, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Jin-Gyu Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Byung-Chul Son
- Department of Neurosurgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea.,Catholic Neuroscience Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Azad TD, Veeravagu A, Li A, Zhang M, Madhugiri V, Steinberg GK. Long-Term Effectiveness of Gross-Total Resection for Symptomatic Spinal Cord Cavernous Malformations. Neurosurgery 2018; 83:1201-1208. [DOI: 10.1093/neuros/nyx610] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/06/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Amy Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Venkatesh Madhugiri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Dammann P, Wrede K, Jabbarli R, Müller O, Mönninghoff C, Forsting M, Sure U. Of Bubbles and Layers: Which Cerebral Cavernous Malformations are Most Difficult to Dissect From Surrounding Eloquent Brain Tissue? Neurosurgery 2017; 81:498-503. [DOI: 10.1093/neuros/nyx025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 01/14/2017] [Indexed: 11/13/2022] Open
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Terterov S, McLaughlin N, Vinters H, Martin NA. Angiographically occult vascular malformation of the intracranial accessory nerve: case report. J Neurosurg 2015; 125:167-72. [PMID: 26566204 DOI: 10.3171/2015.6.jns131105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Angiographically occult cerebral vascular malformations (AOVMs) are usually found in the supratentorial brain parenchyma. Uncommonly, AOVMs can be found within the cavernous sinus or basal cisterns and can be associated with cranial nerves. AOVMs involving the intracranial segment of the spinal accessory nerve have not been described. A 46-year-old female patient presented with a history of episodic frontal headaches and episodes of nausea and dizziness, as well as gait instability progressing over 6 months prior to evaluation. Imaging revealed a well-circumscribed 3-cm extraaxial T1-weighted isointense and T2-weighted hyperintense contrast-enhancing mass centered in the region of the right lateral cerebellomedullary cistern. The patient underwent resection of the lesion. Although the intraoperative appearance was suggestive of a cavernous malformation, some histological findings were atypical, leading to the final diagnosis of vascular malformation, not otherwise specified. The patient's postoperative course was uneventful with complete resolution of symptoms. To the authors' knowledge, this is the first report of an AOVM involving the intracranial portion of the accessory nerve. For any AOVM located within the cerebellomedullary cistern or one suspected of involving a cranial nerve, the authors recommend including immunohistochemistry with primary antibody to neurofilament in the histopathology workup.
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Affiliation(s)
| | | | - Harry Vinters
- Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
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Gross BA, Du R. Cerebral cavernous malformations: natural history and clinical management. Expert Rev Neurother 2015; 15:771-7. [DOI: 10.1586/14737175.2015.1055323] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Abstract
BACKGROUND:
Once considered inoperable lesions in inviolable territory, brainstem cavernous malformations (BSCM) are now surgically curable with acceptable operative morbidity. Recommending surgery is a difficult decision that would be facilitated by a grading system designed specifically for BSCMs that predicted surgical outcomes.
OBJECTIVE:
Informed by our efforts to develop a supplementary grading system for arteriovenous malformations, we hypothesized that a similar system might predict long-term outcomes and guide clinical decision-making.
METHODS:
A consecutive, single-surgeon series of 104 patients was used to assess preoperative clinical and imaging predictors of microsurgical outcomes. Univariable logistic regression identified predictors and a multivariable logistic regression model tested the association of the combined predictors with final modified Rankin Scale scores. A grading system assigned points for lesion size, location crossing the brainstem's midpoint, presence of developmental venous anomaly, age, and time from last hemorrhage to surgery.
RESULTS:
Average maximal diameter of BSCMs was 19.5 mm; 50% crossed the axial midpoint; 54.8% had developmental venous anomalies; mean age was 42.1 years; and median time from last hemorrhage to surgery was 60 days. One patient died (0.96%), and 15 patients (14.4%) experienced worsened cranial nerve or motor dysfunction, of which 10 increased their modified Rankin Scale scores (9.6%). BSCM grades ranged from 0 to 7 points and predicted outcomes with high accuracy (receiver operating characteristic = 0.86, 95% confidence interval: 0.78-0.94).
CONCLUSION:
Rather than developing a grading system for all cerebral cavernous malformations that is weak with BSCMs, we propose a system for the patients who need it most. The BSCM grading system differentiates patients who might expect favorable surgical outcomes and offers guidance to neurosurgeons forced to select these patients.
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Affiliation(s)
| | | | - Michael T. Lawton
- Department of Neurological Surgery,
- Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, California
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Jeon JS, Kim JE, Chung YS, Oh S, Ahn JH, Cho WS, Son YJ, Bang JS, Kang HS, Sohn CH, Oh CW. A risk factor analysis of prospective symptomatic haemorrhage in adult patients with cerebral cavernous malformation. J Neurol Neurosurg Psychiatry 2014; 85:1366-70. [PMID: 24681702 DOI: 10.1136/jnnp-2013-306844] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the risk factors of prospective symptomatic haemorrhage in a large series of adult patients with cerebral cavernous malformation (CM). METHODS Three hundred twenty-six patients >18 years of age with 410 CMs were evaluated retrospectively. Symptomatic haemorrhage was defined as new clinical symptoms with radiographic features of haemorrhage. Clinical data and the characteristics of CM were analysed. MR appearance was divided into three groups according to Zabramski's classification. RESULTS The overall haemorrhage rate of CM was 4.46% per lesion-year. The overall annual haemorrhage rate according to MR appearance was as follows: type I, 9.47%; type II, 4.74%; and type III, 1.43%. A multivariate analysis revealed that prior symptomatic haemorrhage (p<0.001) and MR appearance (p<0.001) were statistically significant. After multiple comparisons, type I (p<0.001) and type II (p=0.016) showed higher haemorrhage risk than type III. However, no significant difference in haemorrhage rate was observed between type I and type II (p=0.105). Other variables including female gender, age, location, multiplicity, hypertension, size and associated venous angioma were not significant. The haemorrhage rates based on risk factors were estimated at 3 years as follows: 33.77% in patients with prior haemorrhage versus 7.54% in patients without prior haemorrhage (p<0.001); type I, 27.62% vs type II, 15.44% vs type III, 5.38% (p<0.001). CONCLUSIONS Prior symptomatic haemorrhage and MR appearance could be related to prospective symptomatic CM haemorrhage in adults. A prospective multicentre observational study is necessary to confirm our results.
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Affiliation(s)
- Jin Sue Jeon
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Seob Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sohee Oh
- Department of Biostatistics, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Je Son
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Ho Sohn
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Badhiwala JH, Farrokhyar F, Alhazzani W, Yarascavitch B, Aref M, Algird A, Murty N, Kachur E, Cenic A, Reddy K, Almenawer SA. Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data. J Neurosurg Spine 2014; 21:662-76. [DOI: 10.3171/2014.6.spine13949] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Information pertaining to the natural history of intramedullary spinal cord cavernous malformations (ISCCMs) and patient outcomes after surgery is scarce. To evaluate factors associated with favorable outcomes for patients with surgically and conservatively managed ISCCMs, the authors performed a systematic review and metaanalysis of the literature. In addition, they included their single-center series of ISCCMs.
Methods
The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and The Cochrane Library for studies published through June 2013 that reported cases of ISCCMs. Data from all eligible studies were used to examine the epidemiology, clinical features, and neurological outcomes of patients with surgically managed and conservatively treated ISCCMs. To evaluate several variables as predictors of favorable neurological outcomes, the authors conducted a meta-analysis of individual patient data and performed univariate and multivariate logistic regression analyses. Variables included patient age, patient sex, lesion spinal level, lesion size, cerebral cavernomas, family history of cavernous malformations, clinical course, presenting symptoms, treatment strategy (operative or conservative), symptom duration, surgical approach, spinal location, and extent of resection. In addition, they performed a meta-analysis to determine a pooled estimate of the annual hemorrhage rate of ISCCMs.
Results
Eligibility criteria were met by 40 studies, totaling 632 patients, including the authors' institutional series of 24 patients. Mean patient age was 39.1 years (range 2–80 years), and the male-to-female ratio was 1.1:1. Spinal levels of cavernomas were cervical (38%), cervicothoracic (2.4%), thoracic (55.2%), thoracolumbar (0.6%), lumbar (2.1%), and conus medullaris (1.7%). Average cavernoma size was 9.2 mm. Associated cerebral cavernomas occurred in 16.5% of patients, and a family history of cavernous malformation was found for 11.9% of evaluated patients. Clinical course was acute with stepwise progression for 45.4% of patients and slowly progressive for 54.6%. Symptoms were motor (60.5%), sensory (57.8%), pain (33.8%), bladder and/or bowel (23.6%), respiratory distress (0.5%), or absent (asymptomatic; 0.9%). The calculated pooled annual rate of hemorrhage was 2.1% (95% CI 1.3%–3.3%). Most (89.9%) patients underwent resection, and 10.1% underwent conservative management (observation). Outcomes were better for those who underwent resection than for those who underwent conservative management (OR 2.79, 95% CI 1.46–5.33, p = 0.002). A positive correlation with improved neurological outcomes was found for resection within 3 months of symptom onset (OR 2.11, 95% CI 1.31–3.41, p = 0.002), hemilaminectomy approach (OR 3.20, 95% CI 1.16–8.86, p = 0.03), and gross-total resection (OR 3.61, 95% CI 1.24–10.52, p = 0.02). Better outcomes were predicted by an acute clinical course (OR 1.72, 95% CI 1.10–2.68, p = 0.02) and motor symptoms (OR 1.76, 95% CI 1.08–2.86, p = 0.02); poor neurological recovery was predicted by sensory symptoms (OR 0.58, 95% CI 0.35–0.98, p = 0.04). Rates of neurological improvement after resection were no higher for patients with superficial ISCCMs than for those with deep-seated ISCCMs (OR 1.36, 95% CI 0.71–2.60, p = 0.36).
Conclusions
Intramedullary spinal cord cavernous malformations tend to be clinically progressive. The authors' findings support an operative management plan for patients with a symptomatic ISCCM. Surgical goals include gross-total resection through a more minimally invasive hemilaminectomy approach within 3 months of presentation.
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Affiliation(s)
| | - Forough Farrokhyar
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Mohammed Aref
- 1Division of Neurosurgery, Department of Surgery, and
| | | | - Naresh Murty
- 1Division of Neurosurgery, Department of Surgery, and
| | - Edward Kachur
- 1Division of Neurosurgery, Department of Surgery, and
| | - Aleksa Cenic
- 1Division of Neurosurgery, Department of Surgery, and
| | - Kesava Reddy
- 1Division of Neurosurgery, Department of Surgery, and
| | - Saleh A. Almenawer
- 1Division of Neurosurgery, Department of Surgery, and
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Jakimovski D, Schneider H, Frei K, Kennes LN, Bertalanffy H. Bleeding propensity of cavernous malformations: impact of tight junction alterations on the occurrence of overt hematoma. J Neurosurg 2014; 121:613-20. [PMID: 25014440 DOI: 10.3171/2014.6.jns132775] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECT Endothelial tight junction (TJ) expression is mostly absent in cerebral cavernous malformations (CMs), which causes increased perilesional erythrocyte and fluid oozing. However, in a subset of CM lesions, foci of preserved TJ staining are observed along endothelial cell contacts. The clinical relevance of this finding is unclear. This study investigates the relevance of the focal TJ protein expression and its association with CM bleeding propensity. METHODS Immunohistochemical staining for the TJ proteins claudin-5, occludin, and ZO-1 was performed on 32 CM specimens that were resected during 2008-2010. The patients were allocated to 2 groups according to TJ protein expression, and the clinical and radiological parameters of aggressiveness were analyzed and compared. RESULTS Complete absence of TJ expression was identified in 20 specimens, and focal TJ protein expression in 12. CMs without TJ immunoreactivity were significantly larger (p = 0.022) and had a significantly greater propensity for development of frank hematomas (p = 0.028) and perilesional edema (p = 0.013). Symptom severity, multiplicity, developmental venous anomaly (DVA) presence, and CM location did not show a significant difference depending on TJ expression. CONCLUSIONS In a univariate analysis the authors observed significantly less propensity for frank hematomas and perilesional edema as well as smaller size in CM lesions with focal TJ expression compared with CMs without TJ expression. The observed difference in TJ protein expression might be the reason for differences in bleeding propensity of the CM lesions. Although this finding cannot be used in predictive manner at this time, it is a basis for further multivariate analyses of possible CM biological predictors.
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Moultrie F, Horne MA, Josephson CB, Hall JM, Counsell CE, Bhattacharya JJ, Papanastassiou V, Sellar RJ, Warlow CP, Murray GD, Al-Shahi Salman R. Outcome after surgical or conservative management of cerebral cavernous malformations. Neurology 2014; 83:582-9. [PMID: 24994841 DOI: 10.1212/wnl.0000000000000684] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE There have been few comparative studies of microsurgical excision vs conservative management of cerebral cavernous malformations (CCM) and none of them has reliably demonstrated a statistically and clinically significant difference. METHODS We conducted a prospective, population-based study to identify and independently validate definite CCM diagnoses first made in 1999-2003 in Scottish adult residents. We used multiple sources of prospective follow-up to assess adults' dependence and to identify and independently validate outcome events. We used univariate and multivariable survival analyses to test the influence of CCM excision on outcome, adjusted for prognostic factors and baseline imbalances. RESULTS Of 134 adults, 25 underwent CCM excision; these adults were younger (34 vs 43 years at diagnosis, p = 0.004) and more likely to present with symptomatic intracranial hemorrhage or focal neurologic deficit than adults managed conservatively (48% vs 26%; odds ratio 2.7, 95% confidence interval [CI] 1.1-6.5). During 5 years of follow-up, CCM excision was associated with a deterioration to an Oxford Handicap Scale score 2-6 sustained over at least 2 successive years (adjusted hazard ratio [HR] 2.2, 95% CI 1.1-4.3) and the occurrence of symptomatic intracranial hemorrhage or new focal neurologic deficit (adjusted HR 3.6, 95% CI 1.3-10.0). CONCLUSIONS CCM excision was associated with worse outcomes over 5 years compared to conservative management. Long-term follow-up will determine whether this difference is sustained over patients' lifetimes. Meanwhile, a randomized controlled trial appears justified. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that CCM excision worsens short-term disability scores and increases the risk of symptomatic intracranial hemorrhage and new focal neurologic deficits.
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Affiliation(s)
- Fiona Moultrie
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Margaret A Horne
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Colin B Josephson
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Julie M Hall
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Carl E Counsell
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Jo J Bhattacharya
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Vakis Papanastassiou
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Robin J Sellar
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Charles P Warlow
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Gordon D Murray
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Rustam Al-Shahi Salman
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
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Gross BA, Smith ER, Goumnerova L, Proctor MR, Madsen JR, Scott RM. Resection of supratentorial lobar cavernous malformations in children: clinical article. J Neurosurg Pediatr 2013; 12:367-73. [PMID: 23971633 DOI: 10.3171/2013.7.peds13126] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors present a series of children with supratentorial lobar cavernous malformations (CMs). Current imaging and operative techniques along with long-term follow-up were incorporated to characterize the response to surgical treatment in this pediatric population. METHODS The senior author's operative experience was reviewed retrospectively along with a review of the Boston Children's Hospital database from 1997 to 2011 for children with supratentorial lobar CMs. Lobar CM was defined as having a supratentorial location but not involving the thalamus/hypothalamus or basal ganglia. Baseline patient demographics, pertinent radiographic findings, operative outcomes, and long-term results were evaluated and compared between patients managed operatively and those who were managed nonoperatively. RESULTS Of 238 CMs identified, 181 (76%) were lobar. Compared with patients managed with observation only, those selected for surgery were older (p = 0.03), more likely to have symptomatic lesions (p < 0.001), and had larger lesions (p < 0.001). Of the 83 CMs selected for surgery, 98% were completely resected. Over a total of 384.5 patient-years of follow-up after surgery (mean 4.6 years; median 2.7 years; range 0.1-22.3 years), there were no subsequent hemorrhages in any patient undergoing complete resection; 1 of the 2 incompletely resected lesions rebled during the follow-up period. Radiographically, there was 1 recurrence (1.2%) in a child with multiple CMs; there were no recurrences of completely resected single lesions. Of the 48 patients who presented with seizures (acute or chronic), 46 (96%) were seizure free at follow-up. The permanent neurological complication rate of surgery was 5%; these complications were limited to those patients whose lesions were in eloquent locations. CONCLUSIONS Pediatric patients with symptomatic supratentorial lobar CMs are ideal candidates for surgery, for which there are high complete resection rates, rewarding long-term seizure outcomes, and low operative morbidity. Observation may be warranted in smaller asymptomatic lesions located within eloquent cortex.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Cerebrovascular neurosurgery 2011. J Clin Neurosci 2012; 19:1344-7. [DOI: 10.1016/j.jocn.2012.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 05/06/2012] [Indexed: 11/17/2022]
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Kivelev J, Koskela E, Setälä K, Niemelä M, Hernesniemi J. Long-term visual outcome after microsurgical removal of occipital lobe cavernomas. J Neurosurg 2012; 117:295-301. [PMID: 22702480 DOI: 10.3171/2012.5.jns112102] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECT Cavernomas in the occipital lobe are relatively rare. Because of the proximity to the visual cortex and incoming subcortical tracts, microsurgical removal of occipital cavernomas may be associated with a risk of visual field defects. The goal of the study was to analyze long-term outcome after operative treatment of occipital cavernomas with special emphasis on visual outcome. METHODS Of the 390 consecutive patients with cavernomas who were treated at Helsinki University Central Hospital between 1980 and 2011, 19 (5%) had occipital cavernomas. Sixteen patients (4%) were surgically treated and are included in this study. The median age was 39 years (range 3-59 years). Seven patients (56%) suffered from hemorrhage preoperatively, 5 (31%) presented with visual field deficits, 11 (69%) suffered from seizures, and 4 (25%) had multiple cavernomas. Surgery was indicated for progressive neurological deterioration. The median follow-up after surgery was 5.25 years (range 0.5-14 years). RESULTS All patients underwent thorough neuroophthalmological assessment to determine visual outcome after surgery. Visual fields were classified as normal, mild homonymous visual field loss (not disturbing the patient, driving allowed), moderate homonymous visual field loss (disturbing the patient, driving prohibited), and severe visual field loss (total homonymous hemianopia or total homonymous quadrantanopia). At the last follow-up, 4 patients (25%) had normal visual fields, 6 (38%) had a mild visual field deficit, 1 (6%) complained of moderate visual field impairment, and 5 (31%) had severe homonymous visual field loss. Cavernomas seated deeper than 2 cm from the pial surface carried a 4.4-fold risk of postoperative visual field deficit relative to superficial ones (p = 0.034). Six (55%) of the 11 patients presenting with seizures were seizure-free postoperatively. Eleven (69%) of 16 patients had no disability during the long-term follow-up. CONCLUSIONS Surgical removal of occipital cavernomas may carry a significant risk of postoperative visual field deficit, and the risk is even higher for deeper lesions. Seizure outcome after removal of these cavernomas appeared to be worse than that after removal in other supratentorial locations. This should be taken into account during preoperative planning.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
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Kivelev J, Niemelä M, Hernesniemi J. Treatment strategies in cavernomas of the brain and spine. J Clin Neurosci 2012; 19:491-7. [PMID: 22325075 DOI: 10.1016/j.jocn.2011.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/25/2022]
Abstract
The management of brain and spinal cavernomas includes two main options: (i) conservative treatment or (ii) surgical removal. Clinical experience related to cavernoma patients falls into four major categories: the surgical or conservative treatment of incidental or symptomatic cavernomas. In many patients, cavernomas exist as fairly benign lesions, frequently remaining clinically silent for life. This observation argues against the active treatment of all cavernoma patients; rather for the meticulous selection of only those more likely to benefit from surgery. Thus, the most crucial task in successful management of cavernomas is appropriate patient selection. In this review, we present our institutional experience on cavernoma management supplemented with data from the literature.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, Helsinki 00260, Finland.
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