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01-08-2012 | Clinical Article

Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions

Authors: Maria Wostrack, Ehab Shiban, Kathrin Harmening, Thomas Obermueller, Florian Ringel, Yu-Mi Ryang, Bernhard Meyer, Michael Stoffel

Published in: Acta Neurochirurgica | Issue 8/2012

Abstract

Background

Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial.

Methods

All eloquently located CMs (n = 45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n = 16; sensorimotor, n = 8; visual pathway, n = 7; cerebellum (deep nuclei and peduncles), n = 7; basal ganglia, n = 4, and language, n = 3. Follow-up data was available for 41 patients (91 %) with a median interval of 14 months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale.

Results

Immediately after surgery, 47 % (n = 21) had a new deficit. At follow-up, 80 % (n = 36) recovered to at least preoperative status or were better than before surgery, 9 % (n = 4) exhibited a slight, and 7 % (n = 3) had a moderate neurological impairment. Only two cases (4 %) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients.

Conclusions

Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.

Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF (2010) Surgical approaches to brainstem cavernous malformations. Neurosurg Focus 29(3):E8PubMedCrossRef

Aiba T, Tanaka R, Koike T, Kameyama S, Takeda N, Komata T (1995) Natural history of intracranial cavernous malformations. J Neurosurg 83(1):56–59PubMedCrossRef

Barker FG II, Amin-Hanjani S, Butler WE, Lyons S, Ojemann RG, Chapman PH, Ogilvy CS (2001) Temporal clustering of hemorrhages from untreated cavernous malformations of the central nervous system. Neurosurgery 49:15–25PubMed

Batra S, Lin D, Recinos PF, Zhang J, Rigamonti D (2009) Cavernous malformations: natural history, diagnosis and treatment. Nat Rev Neurol 5(12):659–670PubMedCrossRef

Baumann CR, Acciarri N, Bertalanffy H, Devinsky O, Elger CE, Lo Russo G, Cossu M, Sure U, Singh A, Stefan H, Hammen T, Georgiadis D, Baumgartner RW, Andermann F, Siegel AM (2007) Seizure outcome after resection of supratentorial cavernous malformations: a study of 168 patients. Epilepsia 48(3):559–563PubMedCrossRef

Beenen LF, Lindeboom J, Kasteleijn-Nolst Trenité DG, Heimans JJ, Snoek FJ, Touw DJ, Adèr HJ, van Alphen HA (1999) Comparative double-blind clinical trial of phenytoin and sodium valproate as anticonvulsant prophylaxis after craniotomy: efficacy, tolerability, and cognitive effects. J Neurol Neurosurg Psychiatry 67(4):474–480PubMedCrossRef

Bertalanffy H, Benes L, Miyazawa T, Alberti O, Siegel AM, Sure U (2002) Cerebral cavernomas in the adult. Review of the literature and analysis of 72 surgically treated patients. Neurosurg Rev 25(1–2):1–53PubMed

Bertalanffy H, Gilsbach JM, Eggert HR, Seeger W (1991) Microsurgery of deep-seated cavernous angiomas: report of 26 cases. Acta Neurochir (Wien) 108(3–4):91–99CrossRef

Brown AP, Thompson BG, Spetzler RF (1996) The two-point method: evaluating brain stem. BNI Q 12:20–24

10.

Chang EF, Gabriel RA, Potts MB, Berger MS, Lawton MT (2011) Supratentorial cavernous malformations in eloquent and deep locations: surgical approaches and outcomes. Clinical article. J Neurosurg 114(3):814–827PubMedCrossRef

11.

Chang EF, Gabriel RA, Potts MB, Garcia PA, Barbaro NM, Lawton MT (2009) Seizure characteristics and control after microsurgical resection of supratentorial cerebral cavernous malformations. Neurosurgery 65(1):31–37PubMedCrossRef

12.

Foy PM, Copeland GP, Shaw MD (1981) The incidence of postoperative seizures. Acta Neurochir (Wien) 55(3–4):253–264CrossRef

13.

Fritschi JA, Reulen HJ, Spetzler RF, Zabramski JM (1994) Cavernous malformations of the brain stem. A review of 139 cases. Acta Neurochir (Wien) 130:35–46CrossRef

14.

Garrett M, Spetzler RF (2009) Surgical treatment of brainstem cavernous malformations. Surg Neurol 72(Suppl 2):S3–S9PubMedCrossRef

15.

Giliberto G, Lanzino DJ, Diehn FE, Factor D, Flemming KD, Lanzino G (2010) Brainstem cavernous malformations: anatomical, clinical, and surgical considerations. Neurosurg Focus 29(3):E9PubMedCrossRef

16.

Huang AP, Chen JS, Yang CC, Wang KC, Yang SH, Lai DM, Tu YK (2010) Brain stem cavernous malformations. J Clin Neurosci 17(1):74–79PubMedCrossRef

17.

Iwai Y, Yamanaka K, Yoshimura M (2007) Intracerebral cavernous malformation induced by radiosurgery. Case report. Neurol Med Chir (Tokyo) 47:171–173CrossRef

18.

Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1(7905):480–484PubMedCrossRef

19.

Jung YJ, Hong SC, Seo DW, Hong SB (2006) Surgical resection of cavernous angiomas located in eloquent areas-clinical research. Acta Neurochir Suppl 99:103–108PubMedCrossRef

20.

Karlsson B, Kihlström L, Lindquist C, Ericson K, Steiner L (1998) Radiosurgery for cavernous malformations. J Neurosurg 88(2):293–297PubMedCrossRef

21.

Kim MS, Pyo SY, Jeong YG, Lee SI, Jung YT, Sim JH (2005) Gamma knife surgery for intracranial cavernous hemangioma. J Neurosurg 102(Suppl):102–106PubMedCrossRef

22.

Kondziolka D, Lunsford LD, Coffey RJ (1990) Stereotactic radiosurgery of angiographically occult vascular malformations: indications and preliminary experience. Neurosurgery 27(6):892–900PubMedCrossRef

23.

Liscák R, Vladyka V, Simonová G, Vymazal J, Novotny J Jr (2005) Gamma knife surgery of brain cavernous hemangiomas. J Neurosurg 102(Suppl):207–213PubMedCrossRef

24.

Maesawa S, Kondziolka D, Lunsford LD (1999) Stereotactic radiosurgery for management of deep brain cavernous malformations. Neurosurg Clin N Am 10(3):503–511PubMed

25.

Matthew E, Sherwin AL, Welner SA, Odusote K, Stratford JG (1980) Seizures following intracranial surgery: incidence in the first post-operative week. Can J Neurol Sci 7(4):285–290PubMed

26.

Menzler K, Chen X, Thiel P, Iwinska-Zelder J, Miller D, Reuss A, Hamer HM, Reis J, Pagenstecher A, Knake S, Bertalanffy H, Rosenow F, Sure U (2010) Epileptogenicity of cavernomas depends on (archi-) cortical localization. Neurosurgery 67(4):918–924PubMedCrossRef

27.

Monaco EA, Khan AA, Niranjan A, Kano H, Grandhi R, Kondziolka D, Flickinger JC, Lunsford LD (2010) Stereotactic radiosurgery for the treatment of symptomatic brainstem cavernousmalformations. Neurosurg Focus 29(3):E11PubMedCrossRef

28.

Moriarity JL, Clatterbuck RE, Rigamonti D (1999) The natural history of cavernous malformations. Neurosurg Clin N Am 10(3):411–417PubMed

29.

Nagy G, Razak A, Rowe JG, Hodgson TJ, Coley SC, Radatz MW, Patel UJ, Kemeny AA (2010) Stereotactic radiosurgery for deep-seated cavernous malformations: a move toward more active, early intervention. Clinical article. J Neurosurg 113(4):691–699PubMedCrossRef

30.

Neuloh G, Schramm J (2004) Motor-evoked potential monitoring for the surgery of brain tumours and vascular malformations. Adv Tech Stand Neurosurg 29:171–228PubMedCrossRef

31.

Otten P, Pizzolato GP, Rilliet B, Berney J (1989) A propos de 131 cas d'angiomes caverneux (cavernomes) du S.N.C., repérés par l'analyse rétrospective de 24,535 autopsies. Neurochirurgie 35:82–83PubMed

32.

Perrini P, Lanzino G (2006) The association of venous developmental anomalies and cavernous malformations: pathophysiological, diagnostic, and surgical considerations. Neurosurg Focus 21:1e5CrossRef

33.

Pollock BE, Garces YI, Stafford SL, Foote RL, Schomberg PJ, Link MJ (2000) Stereotactic radiosurgery for cavernous malformations. J Neurosurg 93(6):987–991PubMedCrossRef

34.

Porter RW, Detwiler PW, Spetzler RF, Lawton MT, Baskin JJ, Derksen PT, Zabramski JM (1999) Cavernous malformations of the brainstem: experience with 100 patients. J Neurosurg 90:50–58PubMedCrossRef

35.

Pozzati E, Acciarri N, Tognetti F, Marliani F, Giangaspero F (1996) Growth, subsequent bleeding, and de novo appearance of cerebral cavernous angiomas. Neurosurgery 38:662–669PubMedCrossRef

36.

Rammos SK, Maina R, Lanzino G (2009) Developmental venous anomalies: current concepts and implications for management. Neurosurgery 65:20–30PubMedCrossRef

37.

Reithmeier T, Krammer M, Gumprecht H, Gerstner W, Lumenta CB (2003) Neuronavigation combined with electrophysiological monitoring for surgery of lesions in eloquent brain areas in 42 cases: a retrospective comparison of the neurological outcome and the quality of resection with a control group with similar lesions. Minim Invasive Neurosurg 46(2):65–71PubMedCrossRef

38.

Robinson JR Jr, Awad IA, Magdinec M, Paranandi L (1993) Factors predisposing to clinical disability in patients with cavernous malformations of the brain. Neurosurgery 32:730–736PubMedCrossRef

39.

Robinson JR, Awad IA, Little JR (1991) Natural history of the cavernous angioma. J Neurosurg 75(5):709–714PubMedCrossRef

40.

Sala F, Manganotti P, Tramontano V, Bricolo A, Gerosa M (2007) Monitoring of motor pathways during brain stem surgery: what we have achieved and what we still miss? Neurophysiol Clin 37(6):399–406PubMedCrossRef

41.

Samii M, Eghbal R, Carvalho GA, Matthies C (2001) Surgical management of brainstem cavernomas. J Neurosurg 95(5):825–832PubMedCrossRef

42.

Sarwar M, McCormick WF (1978) Intracerebral venous angioma. Case report and review. Arch Neurol 35:323–325PubMedCrossRef

43.

Sasagawa Y, Akai T, Itou S, Iizuka H (2009) Gamma knife radiosurgery-induced cavernous hemangioma: case report. Neurosurgery 64:E1006–E1007PubMedCrossRef

44.

Spetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformations. J Neurosurg 65(4):476–483PubMedCrossRef

45.

van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19(5):604–607PubMedCrossRef

46.

Vaquero J, Salazar J, Martinez R, Martinez P, Bravo G (1987) Cavernomas of the central nervous system: clinical syndromes, CT scan diagnosis, and prognosis after surgical treatment in 25 cases. Acta Neurochir (Wien) 85:29–33CrossRef

47.

Viñas FC, Gordon V, Guthikonda M, Diaz FG (2002) Surgical management of cavernous malformations of the brainstem. Neurol Res 24(1):61–72PubMedCrossRef

48.

Wang CC, Liu A, Zhang JT, Sun B, Zhao YL (2003) Surgical management of brain-stem cavernous malformations: report of 137 cases. Surg Neurol 59(6):444–454PubMedCrossRef

49.

Wascher TM, Spetzler RF (1995) Cavernous malformations of the brain stem. In: Carter LP, Spetzler RF, Hamilton MG (eds) Neurovascular Surgery. McGraw-Hill, New York, pp 541–555

50.

Washington CW, McCoy KE, Zipfel GJ (2010) Update on the natural history of cavernous malformations and factors predicting aggressive clinical presentation. Neurosurg Focus 29(3):E7PubMedCrossRef

51.

Wilson JT, Hareendran A, Grant M, Baird T, Schulz UG, Muir KW, Bone I (2002) Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke 33(9):2243–2246PubMedCrossRef

52.

Yoshimoto T, Suzuki J (1986) Radical surgery on cavernous angioma of the brainstem. Surg Neurol 26:72–78PubMedCrossRef

53.

Park YS, Kim Se Hoon, Chang JH, Chang JW, Park YG (2011) Radiosurgery for radiosurgery-induced cavernous malformation. World Neurosurg 75(1):94–98PubMedCrossRef

54.

Zabramski JM, Wascher TM, Spetzler RF, Johnson B, Golfinos J, Drayer BP, Brown B, Rigamonti D, Brown G (1994) The natural history of familial cavernous malformations: results of an ongoing study. J Neurosurg 80:422–432PubMedCrossRef

55.

Zhang N, Pan L, Wang BJ, Wang EM, Dai JZ, Cai PW (2000) Gamma knife radiosurgery for cavernous hemangiomas. J Neurosurg 93:74–77PubMed

56.

Zotta D, Di Rienzo A, Scogna A, Ricci A, Ricci G, Galzio RJ (2005) Supratentorial cavernomas in eloquent brain areas: application of neuronavigation and functional MRI in operative planning. J Neurosurg Sci 49(1):13–19PubMed

Title: Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions
Authors: Maria Wostrack
Ehab Shiban
Kathrin Harmening
Thomas Obermueller
Florian Ringel
Yu-Mi Ryang
Bernhard Meyer
Michael Stoffel
Publication date: 01-08-2012
Publisher: Springer Vienna
Published in: Acta Neurochirurgica / Issue 8/2012
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-012-1411-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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