Brainstem Cavernomas: Surgical Management and Clinical Outcome

Introduction: Cavernous malformations is one of the major pathologic categories of vascular malformations of the nervous system.Because no abnormal vascularity is seen on angiography, it has been included in the description of cryptic or occult vascular malformations. It affects CNS in 0.4 to 0.9% of the population, and accounts for 8 to 15% of all vascular malformations. In the brainstem (medulla, pons, and midbrain), its incidence is estimated to range from 9 to 35%, with a predilection for the pons. Brainstem cavernomas constitute a special entity. The hemorrhage rate of these cavernomas is up to 30 times greater than that of other locations. Due to their anatomy, the hemorrhage is more likely to cause severe neurological deficits.

Material and Method: During the period from 1996 till 2012 we have operated on 54 patients with brainstem,they were 28 males 26 females, the age ranged from 17 to 63 years, The most common clinical presentation was cranial nerve deficits and gait disturbances. The surgical approaches were:

• subtemporal transtentorial in 16 patients

• supracerebellar infratentorial median and lateral in 7 patients

• transsphenoidal transclival 2 patients

• transoral transclival one patient

• retromastoid in 10 patients

• telovelar approach in 18 patients

Electrophysiological monitoring, including monitoring of cranial nerves and somatosensory, motor, and brainstem evoked potentials were used.

Results: Total excision was achieved in 50 patients.

Complications were:

• Deterioration of neurological status initially in 15 patients 7 of them improved daramaticaly almost to preop. Status within weeks.

• Pulmonary embolism in one patient

• woud healin disturbance and infection in one patient

Conclusions: Brainstem cavernomas represent a formidable treatment challenge because of their location within a parenchyma that has critical neurological functions, rendering them much more difficult to remove than those in other locations. Cavernomas can be resected safely with optimal surgical approach microsurgical techniques. Factors that affect the outcome during surgery are preoperative status, size, timing of operation and complete resection. The goal of surgical intervention should be the complete resection of the lesion without any neurological impairment. minimally invasive approaches during resection of the brainstem cavernous malformations, occasionally at the expense of achieving a complete resection, to improve patient outcomes.