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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Brainstem Cavernous Malformations: Surgical Indications Based on Natural History and Surgical Outcomes
Ming-Guo Xie1, Da Li1, Fang-Zhou Guo1
1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Brian Tumor; Beijing, People's Republic of China.
Abstract:
Cavernous malformations (CMs) are uncommon lesions occurring in the central nervous system, with an incidence of approximately 0.5% in the general population and constituting 5%-10% of all intracranial vascular malformations. Among CMs, prevalence within the brainstem as reported in the literature has ranged from 4% to 35%. With their precarious location and potentially devastating clinical events, brainstem CMs have attracted attention from neurosurgeons, and with these surgeons' unrelenting efforts, the microsurgical techniques to treat these lesions in the brainstem have greatly improved in recent decades. Although surgical outcomes reported in the literature have been satisfying, surgical intervention has become increasingly contraindicated because of the tendency for a benign clinical course in brainstem CMs, after weighing this fact against the high risk of surgical morbidity. Thus, it is advisable to operate on patients with symptomatic lesions abutting the pial or ependymal surface of the brainstem or where lesions are accessible to safe entry zones, which have caused more than 1 significantly symptomatic hemorrhage and can be defined as aggressive. However, treatment remains controversial for deep-seated lesions away from the surface of the brainstem or lesions that are inaccessible to safe entry zones. Other treatments, such as radiosurgery and medication, are still debatable, which might be as an alternative for lesions amenable to but at high risk with surgery.
Insights
Brainstem cavernous malformations (CMs) are rare. Surgery is recommended for aggressive, accessible lesions, but treatment for deep-seated or inaccessible CMs remains controversial.
Area of Science:
- Neurology
- Neurosurgery
- Vascular Malformations
Background:
- Cavernous malformations (CMs) are uncommon central nervous system lesions, accounting for 5%-10% of intracranial vascular malformations.
- Brainstem CMs, ranging from 4%-35% prevalence, pose significant neurosurgical challenges due to their location.
- Advances in microsurgical techniques have improved treatment outcomes for brainstem CMs.
Purpose of the Study:
- To review the current understanding and treatment strategies for brainstem cavernous malformations.
- To delineate criteria for surgical intervention versus conservative management of brainstem CMs.
- To discuss controversial aspects of brainstem CM treatment, including radiosurgery and medication.
Main Methods:
- Literature review of cavernous malformations in the brainstem.
- Analysis of surgical outcomes and risks associated with brainstem CM treatment.
- Evaluation of indications for surgical intervention in aggressive or accessible lesions.
Main Results:
- Surgical outcomes for brainstem CMs have improved, but surgery is increasingly contraindicated due to potential morbidity.
- Symptomatic lesions on the brainstem surface or accessible via safe entry zones are considered for surgery.
- Treatment for deep-seated or inaccessible brainstem CMs remains controversial, with limited evidence for alternative therapies.
Conclusions:
- Surgical intervention for brainstem CMs should be carefully considered, balancing risks and benefits.
- Aggressive, accessible brainstem CMs may benefit from surgery, while conservative management is preferred for others.
- Further research is needed to establish optimal treatment strategies for all brainstem CM presentations.
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