Individualized Surgical Management of Brainstem Cavernous Malformations: A Single-Center Experience with 50 Cases and...

Brainstem cavernous malformations (BSCMs) are associated with higher morbidity and mortality than cavernous malformations in other locations, and surgical management remains technically challenging. This study aims to evaluate the clinical manifestations, surgical decision-making, operative techniques, and postoperative outcomes of BSCMs, with emphasis on defining the value of an individualized approach based on lesion location, surgical timing, and intraoperative monitoring.

A retrospective analysis was conducted on 50 consecutive patients with BSCMs who underwent surgical treatment between January 2008 and December 2020. All patients had experienced one or more hemorrhagic events. Surgical indications, approaches, timing, and microsurgical techniques were individualized based on lesion characteristics. Clinical outcomes were assessed using the modified Rankin Scale (mRS) preoperatively and at 3, 6, 12, and 24 months postoperatively. Favorable outcome was defined as mRS 0-2.

Among 50 patients (30 female, 20 males; mean age 41 years, range 14-56), the number of preoperative hemorrhages was 1 in 38 patients, 2 in 10 patients, and 3 in 2 patients. Lesion locations were midbrain (n = 12), pons (n = 25), and medulla oblongata (n = 13). Surgical approaches were selected based on lesion location and safe entry zones: suboccipital (n = 32), retrosigmoid (n = 8), subtemporal (n = 5), and far lateral (n = 5). Gross-total resection (GTR) was achieved in 48 patients (96%), and subtotal resection (STR) in 2 patients (4%). Two patients with initial GTR experienced rehemorrhage and underwent repeat surgery. No perioperative mortality occurred. At 24-month follow-up, all 50 patients achieved favorable outcomes (mRS 0-2). Median mRS scores improved from preoperative to 24-month follow-up across all locations.

Surgical treatment of BSCMs can achieve favorable long-term outcomes with appropriate patient selection, individualized surgical approach, meticulous microsurgical technique, and intraoperative neurophysiological monitoring. Gross-total resection should be the goal when safely achievable, but individualized decision-making remains paramount.