Surgical treatment of brainstem cavernous malformations with three basic skull base approaches and minimally invasive techniques:Observations in 20 patients
Wen Yin, Jianrong Ma, Yiwei Liao
Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
Surgical treatment of brainstem cavernous malformations with three basic skull base approaches and minimally invasive techniques:Observations in 20 patients
Wen Yin, Jianrong Ma, Yiwei Liao
Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
摘要 Objective: Brainstem cavernous malformation (BSCM) is extremely challenging for neurosurgeons in terms of surgical approach choices.In this article,we summarized our experience in skull base approaches of BSCM,and elucidated the advance of surgical treatments of brain stem cavernous malformation through reviewing recent relevant articles. Methods: We retrospectively reviewed 20 consecutive patients who underwent resection between May 1,2014 and April 30,2016.Only midline suboccipital,subtemporal approach and retrosigmoid approach were used in this series.The diagnoses of all patients were confirmed by radiological and histological examination. Results: All 20 patients were completely extirpated without surgical-related mortality.The mean follow-up period was 9.5 months (range,2-20 months).Of the 20 patients,80% symptomatic patients underwent surgery after first bleeding episode within 3 months,20% after two or more bleeding episodes by magnetic resonance imaging.After resection and during follow-up,75% of patients had an improvement in their modified Rankin scale (mRS) scores,whereas 10% were worse compared with their preoperative presentation;15% were unchanged. Conclusion: Appropriate basic surgical approach and minimally invasive techniques are necessary in preventing impairment of neurologic function.The three common basic skull base approaches,combined with minimally invasive techniques can handle most of BSCMs with good surgical results.
Abstract: Objective: Brainstem cavernous malformation (BSCM) is extremely challenging for neurosurgeons in terms of surgical approach choices.In this article,we summarized our experience in skull base approaches of BSCM,and elucidated the advance of surgical treatments of brain stem cavernous malformation through reviewing recent relevant articles. Methods: We retrospectively reviewed 20 consecutive patients who underwent resection between May 1,2014 and April 30,2016.Only midline suboccipital,subtemporal approach and retrosigmoid approach were used in this series.The diagnoses of all patients were confirmed by radiological and histological examination. Results: All 20 patients were completely extirpated without surgical-related mortality.The mean follow-up period was 9.5 months (range,2-20 months).Of the 20 patients,80% symptomatic patients underwent surgery after first bleeding episode within 3 months,20% after two or more bleeding episodes by magnetic resonance imaging.After resection and during follow-up,75% of patients had an improvement in their modified Rankin scale (mRS) scores,whereas 10% were worse compared with their preoperative presentation;15% were unchanged. Conclusion: Appropriate basic surgical approach and minimally invasive techniques are necessary in preventing impairment of neurologic function.The three common basic skull base approaches,combined with minimally invasive techniques can handle most of BSCMs with good surgical results.
Wen Yin, Jianrong Ma, Yiwei Liao. Surgical treatment of brainstem cavernous malformations with three basic skull base approaches and minimally invasive techniques:Observations in 20 patients[J]. 临床转化神经科学, 2017, 3(2): 74-83.
Wen Yin, Jianrong Ma, Yiwei Liao. Surgical treatment of brainstem cavernous malformations with three basic skull base approaches and minimally invasive techniques:Observations in 20 patients. Translational Neuroscience and Clinics, 2017, 3(2): 74-83.
20170712151240 Table 1 Signs and symptoms at presentation.
20170712151327 Figure 1 MRI demonstrated the typical “porpcorn” or “mulberry-like” BSCMs. (a), (b) and (c) showed one patient with pontine cavernoma. (d), (e) and (f) showed another patient with left cerebellar peduncle cavernoma. (a) and (d) axial T1-weighted, (b) and (e) axial T2-weighted, (c) axial enhanced T1-weighted, (f) SWI.
20170712151348 Figure 2 The surgical approach designed with the aid of DTI. T1-weighted (a) showed the lesion located in the right side of pontine. The three dimensional DTI (b) showed that the anterior and posterior side of the lesion was surrounded by tracts. The right approach to resect this lesion should be from the lateral side (we chose subtemporal approach).
20170712151406 Figure 3 Case 1: Central pontine cavernous malformation. Axial gradient-echo image (a), enhanced T1-weighted postoperative with 72 hours (b) and enhanced T1- weighted postoperative scans at 3 month (c). White arrow showed the entry point.
20170712151439 Figure 4 Case 2: Left anterolateral medullary cavernous malformation. Axial T2-weighted (a) and sagital T1-weighted (b) showed the location of the lesion. Axial T1-weighed (c) and enhanced sagittal T1-weighted (d) postoperative within 72 h showed that the lesion was totally resected. Enhanced axial T1-weighted (e) and enhanced sagittal T1-weighted (f) at 5-month postoperative follow-up. Red arrow showed the entry approach (retrosigmoid approach).
20170712151506 Figure 5 Case 3: Cavernous malformation in the left pons and lower midbrain. T2-weighted (a), enhanced sagittal T1-weighted (b) and enhanced coronal T1-weighted (c) demonstrated the location of the cavernous malformation. Enhanced axial T1-weighted (d) and sagittal T1-weighted (e) postoperative within 72 hours showed that the lesion was totally resected. Enhanced coronal T1-weighted (f) showed no recurrence after 3 months follow-up. Red arrow showed the entry approach (subtemporal approach).
20170712151517 Table 2 Clinical characteristics of the patients with brain stem cavernous malformation.
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2017, Vol. 3 
