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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions
Maria Wostrack1, Ehab Shiban, Kathrin Harmening
1Department of Neurosurgery, Technical University of Munich, Munich, Germany. maria.wostrack@lrz.tum.de
Insights
Surgical treatment for eloquent cerebral cavernous malformations (CMs) offers significant recovery, with 80% improving post-operation. While transient deficits occur, long-term severe impairment is rare, suggesting surgery is beneficial for symptomatic CMs.
Area of Science:
- Neurosurgery
- Neurology
- Vascular Malformations
Background:
- Eloquent cerebral cavernous malformations (CMs) pose management challenges due to hemorrhage and neurological risks.
- Surgical intervention for these lesions remains controversial.
Purpose of the Study:
- To evaluate the outcomes of surgically treated, eloquently located CMs.
- To assess the safety and efficacy of surgical resection in specific brain regions.
Main Methods:
- Retrospective analysis of 45 patients with eloquently located CMs treated surgically.
- Classification of eloquence based on Spetzler and Martin criteria.
- Follow-up using Glasgow Outcome Scale and modified Rankin Scale.
Main Results:
- 47% experienced new deficits immediately post-surgery, but 80% recovered to or exceeded their preoperative neurological status at follow-up.
- Only 4% had new permanent severe deficits, primarily after dorsal brainstem surgery.
- Outcomes for brainstem CMs were comparable to non-brainstem CMs; preoperative status significantly impacted recovery.
Conclusions:
- Surgical treatment for symptomatic eloquent CMs yields significant long-term improvement despite transient postoperative morbidity.
- Eloquent CMs, particularly those in the dorsal brainstem or in patients with poor preoperative status, require careful consideration due to higher risks.
- Surgical intervention should be considered for symptomatic eloquent CMs when compared to natural history.
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.
