Brainstem cavernous malformation treatment [Neurosurgery Wiki]

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====== Brainstem cavernous malformation treatment ======

[[Pontine]] [[cavernous malformation]]s (CMs) are difficult to reach and pose a higher risk of symptomatic rehemorrhage compared with their supratentorial counterparts. Resection of CMs along the floor of the [[fourth ventricle]] has been associated with worse functional outcomes. Complete resection of the CM and evacuation of the [[hematoma]] can provide the patient with relief of some of the presenting symptoms and a chance for long-term cure.

Pontine cavernous malformations (CMs) located on a peripheral pontine surface or the fourth ventricular floor are resectable lesions, but those deep within the pons away from a pial surface are typically observed. 

====Approaches====

see [[Pretemporal transcavernous transtentorial approach]]

see [[Anterior transpetrosal approach for pontine cavernous malformation]].

The anterior bulge of the pons formed by the [[brachium pontis]] creates a unique entry point for access to deep pontine lesions from below, working upward through the [[pontomedullary sulcus]].

[[Transpontomedullary sulcus approach]]

In a video from Cohen-Gadol, the author attempts to describe technical nuances for resection of large posterior pontine CMs. He presents the case of a 32-year-old man who presented with 2 [[brainstem hemorrhage]]s within a 2-month interval related to his newly diagnosed pontine CM near the floor of the 4th ventricle. The lesion was resected through a midline suboccipital craniotomy and [[telovelar approach]]. The floor of the 4th ventricle was mapped using a monopolar probe and the facial nucleus was noted to be displaced more medially. A small incision within the lateral floor of the ventricle allowed exposure of the CM and drainage of the hematoma. Bipolar coagulation was kept to a minimum to protect the brainstem fiber tracts, and the CM was debulked and removed piecemeal. Arterial feeders were coagulated and cut while the associated developmental venous abnormality was protected. The CM was removed in a gross total fashion as confirmed by postoperative MRI. The patient suffered from transient worsening of his facial weakness (House-Brackmann III -> IV) immediately after surgery. However, his neurologic deficits had significantly improved by the 1-month follow-up examination
((Cohen-Gadol AA. Large Pontine Cavernous Malformations: Resection Through the
Telovelar Approach and Mapping of the 4th Ventricular Floor. Neurosurgery. 2014
Jun 12. [Epub ahead of print] PubMed PMID: 24932709.)).

Favorable surgical outcomes can be predicted in brainstem CM patients with early age at presentation, pontine location of the cavernoma, favorable preoperative mRS and those undergoing early surgery. The outcomes at long-term follow-up were associated with location of the CM in the brainstem, size of the CM and the preoperative mRS
((Chotai S, Qi S, Xu S. Prediction of outcomes for brainstem cavernous malformation. Clin Neurol Neurosurg. 2013 Oct;115(10):2117-23. doi: 10.1016/j.clineuro.2013.07.033. Epub 2013 Aug 6. PubMed PMID: 23962756.)).

===Endoscopic===
An endoscopic, endonasal, transclival approach is a novel and effective approach to cavernous malformations presenting to the ventral surface of the pons. Recently developed techniques for closure and repair of the skull base defect have minimized but have not eliminated the risk of CSF leak in these procedures
((Sanborn MR, Kramarz MJ, Storm PB, Adappa ND, Palmer JN, Lee JY. Endoscopic,
endonasal, transclival resection of a pontine cavernoma: case report.
Neurosurgery. 2012 Sep;71(1 Suppl Operative):198-203. doi:
10.1227/NEU.0b013e318259e323. PubMed PMID: 22572676.
)).


----

Surgery is almost never indicated for [[brainstem cavernous malformation]]s that have not bled. With a bleed rate of 2–6%,
Gross et. al
((Gross BA, Batjer HH, Awad IA, Bendok BR. Brainstem cavernous malformations. Neurosurgery.
2009; 64:E805–18; discussion E818))
suggest operative management for a history of > 2 prior hemorrhages and “pial/ependymal representation” on [[T1WI]] MRI.

Bleeds that do not come to the surface cannot be removed without creating [[neurologic deficit]] (worsening of neurologic outcome was 9 % vs. 29% in superficial vs. deep brainstem CM resections, respectively
((Ferroli P, Sinisi M, Franzini A, Giombini S, Solero CL, Broggi G. Brainstem cavernomas: long-term results of microsurgical resection in 52 patients. Neurosurgery. 2005; 56:1203–12; discussion 1212-4))). 
The approach is chosen to expose the site where the bleed comes closest to the surface. Spetzler says brainstem CMs are almost always associated with a [[venous angioma]] (which, again, must be preserved since it provides the venous outflow). The outcome was worse with surgery through the floor of the 4th ventricle than with a lateral approach. The significant short-term neurologic deficit is expected with brainstem CM resection
((Gross BA, Batjer HH, Awad IA, Bendok BR. Brainstem cavernous malformations. Neurosurgery.
2009; 64:E805–18; discussion E818)).

Conservative treatment of [[brainstem cavernous malformation]]s is accompanied with poor outcome. 

===== Brainstem cavernous malformation surgery =====

[[Brainstem cavernous malformation surgery]].

===== Gamma knife radiosurgery for brainstem cavernous malformation =====

see [[Gamma knife radiosurgery for brainstem cavernous malformation]].

===== References =====