gms | German Medical Science

68th Annual Meeting of the German Society of Neurosurgery (DGNC)
7th Joint Meeting with the British Neurosurgical Society (SBNS)

German Society of Neurosurgery (DGNC)

14 - 17 May 2017, Magdeburg

Functional approach for brainstem cavernomas: surgical results in the era of electrophysiology and functional imaging

Meeting Abstract

  • Marcos Tatagiba - Universitätsklinikum Tübingen, Klinik für Neurochirurgie, Tübingen, Deutschland
  • Guilherme Lepski - Tübingen, Deutschland
  • Mario Moraes - Natal RN, Brazil
  • Feigl Günther - Tübingen, Deutschland
  • Marina Liebsch - Tübingen, Deutschland
  • Ulrike Ernemann - Tübingen, Deutschland

Deutsche Gesellschaft für Neurochirurgie. Society of British Neurological Surgeons. 68. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), 7. Joint Meeting mit der Society of British Neurological Surgeons (SBNS). Magdeburg, 14.-17.05.2017. Düsseldorf: German Medical Science GMS Publishing House; 2017. DocMO.13.01

doi: 10.3205/17dgnc070, urn:nbn:de:0183-17dgnc0709

Published: June 9, 2017

© 2017 Tatagiba et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Outline

Text

Objective: Although cavernous malformations of the brainstem are benign vascular malformations, they can cause severe neurological deficits when bleeding. Since the introduction of magnetic resonance imaging (MRI) and the improvement of microsurgical techniques, surgical removal of superficially located lesions has been performed with low morbidity rates. Due to higher morbidity rates, surgery of deep-seated brain stem cavernomas is still a matter of controversial debate. For proper consideration of the best treatment strategy, it is essential to consider the actual surgical risks, in light of the recent advances in functional brain imaging, intra-operative imaging and electrophysiological monitoring (IOM). In this single-center retrospective study we compare the surgical results of a series of superficial and deep-seated brain stem cavernomas.

Methods: Forty-two consecutive cases of brain stem cavernomas treated surgically within a 12-years period were retrospective reviewed. Pre-operative neuroradiological examinations included T2- and T2*-weighted MRI sequences as well as diffusion tensor imaging (DTI) to visualize brainstem fiber tracts. Neuronavigation and brainstem mapping were used to custom tailor the surgical approach and to determine a safe point of entry. IOM included systematic MEPs and SEPs of the lower and upper extremities, facial EMG & MEPs, and AEPs as well as EMG of the motor brainstem cranial nerves. The clinical outcome was assessed by the Glasgow Outcome Scale at the last follow-up (mean 3.2 years, 2 months to 6.7 years).

Results: All patients suffered at least one hemorrhage before undergoing surgical treatment. Symptoms included headaches (n=22 / 50%), hypaesthesia (n=10 / 23.8%), gait disturbance (n=16 / 38.1%), diplopia (n=25 / 59.5%), facial palsy (n=11 / 26.2%), hearing loss (n=9 / 21.4) and difficulties in swallowing (n=6 / 14.2%). Fourteen deep-seated lesions were 1 to 5 mm distant from the surface of the brainstem. Using 3D tractography, neuronavigation, brainstem mapping, and blunt microsurgical dissection under continuous intra-operative monitoring, total removal of the lesion was achieved in 24 patients (85.7%) in the superficial group and in all deep-seated lesions. New cranial nerve deficits were observed in four patients (14.28%) after surgery in the superficial group and 2 (14.28%) in the deep-seated. Out of four patients with incomplete removal of the cavernoma, all superficially seated, re-bleeding was observed in one patient during follow-up. Overall, the GOS improved from 4 to 5 after surgery.

Conclusion: Our results show that a tailored approach guided by electrophysiology, navigation and sometimes tractography yields a high chance of total resection of CMBs even in deep-seated lesions, with low morbidity rates.