Surgical treatment of hemorrhagic brainstem cavernous malformations

Microsurgery is considered to be the optimal treatment for brainstem cavernous malformations (BCMs); however, the high surgery-related morbidity requires further assessment of therapeutic protocols.

The surgical experience and the optimal surgical strategy for the management of brainstem cavernous malformations is discussed.

From September 2007 to August 2014, a total of 120 patients with BCMs underwent surgical treatment in our hospital. The clinical features and neurological outcome of these patients were retrospectively analysed, and our institutional surgical strategy was discussed.

The preoperative annual hemorrhage and rehemorrhage rates were 4.2% and 42.9%, respectively. Gross total resection was achieved in 116 patients (96.7%) and subtotal resection in 4 (3.3%). After a mean follow-up of 50.7 ± 26.5 months (range: 18-90 months), the neurological status showed improvement in 71 patients (67.0%) and remained stable in 24 (22.6%). The postoperative new-onset or worsened symptoms occurred in 53 cases. During the follow-up period, 58.5% of these symptoms improved and 32.1% remained stable. The mean modified Rankin score (mRS) score was 2.51 ± 0.90 preoperatively, 2.73 ± 0.83 postoperatively, and 1.71 ± 0.98 at the recent follow-up. The surgery-related mortality was 1.7% (n = 2), and two patients suffered from recurrence during the follow-up period. The preoperative mRS was considered to be an independent predictive factor of the neurological outcome (P = 0.003).

Safe resection and a favourable outcome can be achieved via a standardized surgical strategy based on appropriate surgical indications, optimal selection of safe trajectories, and application of advanced supplementary techniques in the surgical treatment of BCMs.