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Al-Salihi MM, Al-Jebur MS, Al-Salihi Y, Saha R, Daie MM, Rahman MM, Ayyad A. Diffusion tensor imaging with tractography in surgical resection of brainstem cavernous malformations: a systematic review and meta-analysis. Int J Neurosci 2024; 134:1075-1097. [PMID: 37194114 DOI: 10.1080/00207454.2023.2214696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/24/2023] [Accepted: 05/11/2023] [Indexed: 05/18/2023]
Abstract
Brainstem cavernous malformations are benign subset of cerebral cavernous malformations, which need a special intervention owing to being vital and complex. The diffusion tensor imaging technique, a well-recognized neuroimaging tool, can visualize the white matter tracts and their surroundings and provide promising surgical outcomes. This systematic review and meta-analysis evaluated the effect of preoperative diffusion tensor imaging in patients undergoing surgical resection of brainstem cavernous malformations. Five databases, including PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar, were searched using a comprehensive search strategy to find any article matching our inclusion criteria. We used Comprehensive Meta-Analysis (CMA) software to analyze the collected data, get the evidence, and report the results as event rate (ER), with their 95% confidence interval (CI). Twenty-eight studies involving 467 patients matched our criteria and 19 studies entered the analysis. Our analysis showed that, in patients undergoing surgical resection of brainstem cavernous malformations assisted by preoperative diffusion tensor imaging, 82.21% achieved total resection. About 12.4% of patients achieved partial resection, 65.65% improved, 8.07% worsened, 25.04% showed no change, 3.59% experienced postoperative re-bleeding, and 0.87% died. The utilization of preoperative diffusion tensor imaging significantly increased the proportion of improved patients and decreased the proportion of worsened patients. However, further controlled research is needed to draw a definite conclusion about the usefulness of its role.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
- College of Medicine, University of Baghdad, Baghdad, Iraq
| | | | | | - Ram Saha
- Department of Neurology, VA Commonwealth University, Richmond, VA, USA
| | | | - Md Moshiur Rahman
- Neurosurgery Department, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
| | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
- Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
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Erturk M, Demircubuk I, Candar E, Sengul G. Comprehensive Morphometric Analysis of the Rhomboid Fossa: Implications for Safe Entry Zones in Brainstem Surgery. World Neurosurg 2024:S1878-8750(24)01463-3. [PMID: 39181240 DOI: 10.1016/j.wneu.2024.08.096] [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: 03/26/2024] [Revised: 08/16/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND The rhomboid fossa (RF) is a crucial anatomical region in brainstem surgery as it contains essential structures such as the reticular formation and cranial nerve nuclei. This study aimed to provide a detailed understanding of the complex microsurgical anatomy of the RF, which is vital for the safe execution of neurosurgical procedures. METHODS Morphometric analysis was conducted on 45 adult human brainstems preserved in 10% formalin. Under 20× magnification, 13 linear measurements were performed using a millimeter graph to identify key anatomical landmarks. RESULTS The RF measured 34.65 mm in length and 22.61 mm in width. The facial colliculus measured 4.26 mm in length on the left and 4.45 mm on the right, with corresponding widths of 3.77 mm and 3.50 mm. The distance between the sulcus limitans incisures was 9.52 mm, and the distance from the upper border of the medullary striae to obex was 11.53 mm. The proximity of the facial colliculus to the median sulcus was measured at 0.86 mm on the right and 0.96 mm on the left. Additionally, 2 safe entry zones-the suprafacial and infrafacial triangles-were identified, offering pathways to reach dorsal pons lesions through the RF. CONCLUSIONS This comprehensive morphometric analysis of the RF enhances the understanding of its intricate anatomy. By describing safe entry zones, the suprafacial and infrafacial triangles, and providing precise measurements of key anatomical features, this study serves as a valuable resource for neurosurgeons in planning and executing brainstem surgeries.
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Affiliation(s)
- Mete Erturk
- Department of Anatomy, School of Medicine, Ege University, Izmir, Turkey
| | - Ibrahim Demircubuk
- Department of Anatomy, Institute of Health Sciences, Ege University, Izmir, Turkey
| | - Esra Candar
- Department of Neuroscience, Institute of Health Sciences, Ege University, Izmir, Turkey
| | - Gulgun Sengul
- Department of Anatomy, School of Medicine, Ege University, Izmir, Turkey; Department of Neuroscience, Institute of Health Sciences, Ege University, Izmir, Turkey.
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Kang SM, Ha BJ, Cheong JH, Ryu JI, Won YD, Han MH. Identification of predictive factors for better outcomes in LINAC-based radiation treatment for cerebral cavernous malformation. Heliyon 2024; 10:e31184. [PMID: 38799755 PMCID: PMC11126848 DOI: 10.1016/j.heliyon.2024.e31184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/09/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024] Open
Abstract
The effectiveness of radiation therapy in the treatment of cerebral cavernous malformations (CCM) remains debatable. However, numerous studies have shown a reduction in hemorrhage risk following radiotherapy for CCM. Therefore, herein, we share our experiences utilizing linear accelerator (LINAC)-based radiation for treating CCMs, with the aim of identifying the key factors influencing the therapeutic outcomes. We conducted a retrospective review of all patients with non-brainstem CCMs who underwent radiation treatment, as recorded in the NOVALIS registry at our institution. T2-weighted MR images were used for volumetric assessments using the iPlan radiotherapy planning software. To determine the independent predictors of nidus volume reduction and perilesional brain edema (PBE), we performed multivariate Cox regression analysis to calculate hazard ratios. Twenty patients with 31 non-brainstem CCMs were enrolled in this study. Analysis revealed age as an independent predictive factor for both nidus volume reduction and PBE after radiation treatment for CCM. Furthermore, a single fraction dose of 17 Gy or more was identified as an independent predictor of nidus volume decrease, while a single fraction dose of 18 Gy or more was found to be an independent risk factor for PBE in patients with CCM following LINAC-based radiation therapy. LINAC-based radiation therapy for non-brainstem CCMs with a single fraction radiation dose between 16.5 and 17.5 Gy, or a biologically equivalent dose of approximately 120 Gy, may be the most effective at reducing nidus volume and limiting side effects, particularly in patients under the age of 55 years. We further observed that the risk of PBE increased as the maximum radiation dose delivered to a 1 cc volume of the surrounding normal brain exceeded approximately 17.3 Gy. Therefore, we believe that calculating the D1cc of the normal brain may help to predict the occurrence of PBE when radiotherapy is administered to non-brainstem CCMs.
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Affiliation(s)
| | | | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
| | - Je Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
| | - Yu Deok Won
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
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Fotakopoulos G, Georgakopoulou VE, Papalexis P, Spandidos DA, Trakas N, Sklapani P, Fountas KN. Management of intracranial cavernous malformations using conservative vs. surgical and/or radiosurgical treatment: A systematic review and meta‑analysis. Exp Ther Med 2024; 27:215. [PMID: 38590573 PMCID: PMC11000448 DOI: 10.3892/etm.2024.12503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
Intracranial cavernous malformations (CMs) are vascular lesions with a high bleeding rate. At present, the debate regarding their treatment is still ongoing. The present systematic review and meta-analysis aimed to evaluate the safety of surgery or radiosurgery (SRS) for the management of CMs and to determine their potential outcomes compared with conservative treatment. The present systematic review and meta-analysis investigated the relative articles involving the management of intracranial CMs, namely their natural history (conservative treatment) vs. surgical/SRS treatment through electronic databases until June, 2023. The collected variables included the first author's name, the study period covered, the year of publication, the total number of patients examined and their age, and the number of males. In total, six articles met the eligibility criteria. The total number of patients was 399 (157 in the surgery/SRS group and 242 in the conservative treatment group). The results revealed that surgical or SRS management is a safe procedure for CMs compared with conservative treatment. Notably, the use of hemosiderin in the pre-MRI, the free of seizures parameter and the neurological deficit parameters were associated with improved outcomes in the surgical or SRS group of patients.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Petros Papalexis
- Unit of Endocrinology, First Department of Propedeutic and Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Rodríguez RG, Agyemang K, Cearns MD, Arias SAM, Nunez M, Wuo-Silva R, Ahumada-Vizcaino JC, Filho JMDC, Chaddad-Neto F. Technical Nuances of Using the Peritrigeminal and Infrafacial Entry Zones in Brainstem Cavernoma Surgery: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01011. [PMID: 38156884 DOI: 10.1227/ons.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Rony Gómez Rodríguez
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Kevin Agyemang
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- School of Medicine, University of Glasgow, Glasgow, UK
| | | | | | - Maximiliano Nunez
- Department of Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Raphael Wuo-Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - José Maria de Campos Filho
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
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Ndandja DTK, Musa G, Nosov I, Chmutin GE, Livshitz MI, Annanepesov NS, Mwela BM. A rare case of rebleeding brainstem cavernoma in a 5-month-old-girl. Surg Neurol Int 2023; 14:227. [PMID: 37404517 PMCID: PMC10316179 DOI: 10.25259/sni_308_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023] Open
Abstract
Background Brainstem cavernomas (BSCs) are relatively rare intracranial vascular lesions that, if left untreated, can be devastating to the patient. The lesions are associated with a myriad of symptoms, depending on their size and location. However, medullary lesions present acutely with cardiorespiratory dysfunction. We present the case of a 5-month-old child with a BSC. Case Description A 5-month-old child presented for the 2nd time with sudden respiratory distress and excessive salivation. On the first presentation, brain magnetic resonance imaging (MRI) showed a 13 × 12 × 14 mm cavernoma at the pontomedullary junction. She was managed conservatively but presented 3 months later with tetraparesis, bulbar palsy, and severe respiratory distress. A repeat MRI showed enlargement of the cavernoma to 27 × 28 × 26 mm with hemorrhage in different stages. After hemodynamic stabilization, complete cavernoma resection was performed through the telovelar approach with neuromonitoring. Postoperatively, the child recovered motor function, but the bulbar syndrome persisted with hypersalivation. She was discharged on day 55 with a tracheostomy. Conclusion BSCs are rare lesions that are associated with severe neurological deficits due to the compactness of important cranial nerve nuclei and other tracts in the brainstem. Early surgical excision and hematoma evacuation for superficially presenting lesions can be lifesaving. However, the risk of postoperative neurological deficits is still a major concern in these patients.
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Affiliation(s)
- Dimitri T. K. Ndandja
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Gerald Musa
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Ilya Nosov
- Department of Neurosurgery, Morozov Children’s City Clinical Hospital, Center for the Treatment of Cerebrovascular Pathology in Children and Adolescents, Moscow, Russian Federation
| | - Gennady E. Chmutin
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Matvey I. Livshitz
- Department of Neurosurgery, Morozov Children’s City Clinical Hospital, Center for the Treatment of Cerebrovascular Pathology in Children and Adolescents, Moscow, Russian Federation
| | - Nazar S. Annanepesov
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Bupe Mumba Mwela
- Department of Pediatrics and Child Health, Peoples Friendship University of Russia (RUDN University), Moscow, Russian Federation
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Agyemang K, Gómez Rodríguez R, Rocha Marussi VH, Marte Arias SA, Feliciano Vilcahuaman Paitań A, Campos Filho JM, Chaddad-Neto F. Case report: Delayed outflow obstruction of a DVA: A rare complication of brainstem cavernoma surgery. Front Neurol 2023; 14:1073366. [PMID: 36998781 PMCID: PMC10044343 DOI: 10.3389/fneur.2023.1073366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/03/2023] [Indexed: 03/16/2023] Open
Abstract
IntroductionDevelopmental venous anomalies (DVAs) are considered variants of normal transmedullary veins. Their association with cavernous malformations is reported to increase the risk of hemorrhage. Expert consensus recommends meticulous planning with MR imaging, use of anatomical “safe zones”, intraoperative monitoring of long tracts and cranial nerve nuclei, and preservation of the DVA as key to avoiding complications in brainstem cavernoma microsurgery. Symptomatic outflow restriction of DVA is rare, with the few reported cases in the literature restricted to DVAs in the supratentorial compartment.CaseWe present a case report of the resection of a pontine cavernoma complicated by delayed outflow obstruction of the associated DVA. A female patient in her 20's presented with progressive left-sided hemisensory disturbance and mild hemiparesis. MRI revealed two pontine cavernomas associated with interconnected DVA and hematoma. The symptomatic cavernoma was resected via the infrafacial corridor. Despite the preservation of the DVA, the patient developed delayed deterioration secondary to venous hemorrhagic infarction. We discuss the imaging and surgical anatomy pertinent to brainstem cavernoma surgery, as well as the literature exploring the management of symptomatic infratentorial DVA occlusion.ConclusionDelayed symptomatic pontine venous congestive edema is extremely rare following cavernoma surgery. DVA outflow restriction from a post-operative cavity, intraoperative manipulation, and intrinsic hypercoagulability from COVID-10 infection are potential pathophysiological factors. Improved knowledge of DVAs, brainstem venous anatomy, and “safe entry zones” will further elucidate the etiology of and the efficacious treatment for this complication.
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Affiliation(s)
- Kevin Agyemang
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Neurosurgery, Beneficência Portuguesa Hospital, São Paulo, Brazil
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | | | | | | | | | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Neurosurgery, Beneficência Portuguesa Hospital, São Paulo, Brazil
- *Correspondence: Feres Chaddad-Neto
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