gms | German Medical Science

Objective: Treatment of cavernous malformations of the brain stem (BSCM) placets high demands on surgical skill due to the vulnerability of the lesion’s location. Various surgical approaches have been described to visualize the BSCM under microscopic view. Within minimally invasive strategies, neuroendoscopic techniques have already found their way into daily routine. However, the potential benefit of additional neuroendoscopy in different surgical approaches to the brainstem remains elusive.

Methods: The department’s internal database was searched for cases of surgical removal of BSCM between 2012 and 2018. Only patients with completed medical documentation were included in the final analysis. Data sets consisted of detailed medical history, perioperative clinical status, as well as follow up documentation for at least 6 months. Pre- and postoperative imaging, as well as high-quality video documentation of the surgical procedure were reviewed by objective neurosurgeons. Focus was set on feasibility and effectiveness of additional endoscopic techniques.

Results: A total of eight patients could be included in the further analysis. Mean size of BSCM was 8.15 mm3. Associated DVAs could be identified in two cases. All patients were operated with endoscopic assistance. Four patients underwent a suboccipital midline approach. Two patients underwent a retromastoidal-supracerebellar-infratentorial approach. One patient was operated fully endoscopically via binostril-transsphenoidal-transclival approach. The resection cavity could be totally viewed by endoscopy in all cases. Endoscopy revealed significant residual BSCM in two cases. Gross-total resection was achieved in all cases (100%). There were no endoscopy-related complications. Seven patients (87.5%) improved neurologically after surgery. There were no newly developed neurological deficits. Follow-up examinations confirmed the radiologic absence of BSCM residuals in all surviving cases.

Conclusion: Operative treatment of BSCMs remains a highly demanding task. Neuroendoscopy can be applied safely by way of the common surgical approaches to the brainstem. Provided that the method is frequently used and the surgeon has experience, endoscopy enables a high-quality visualization of the lesion and may thereby lead to an improved operative and clinical outcome