Resection of Pontine Cavernoma Through the Anterior Transpetrosal Approach

Operative Neurosurgery ◽

10.1093/ons/opab103 ◽

2021 ◽

Author(s):

Paulo A S Kadri ◽

Walid I B N Essayed ◽

Ossama Al-Mefty

Keyword(s):

Brain Stem ◽

Neurological Deficits ◽

Venous Angioma ◽

Temporal Muscle ◽

Anterior Transpetrosal Approach ◽

Anatomical Basis ◽

Direct Exposure ◽

Brainstem Cavernoma ◽

Radiation Induced ◽

Available Technology

Abstract The pons is the most frequent local for brain stem cavernoma.1 Repeated hemorrhage of brainstem cavernoma is associated with significant and accumulative neurological deficits and thus requires treatment. According to the Swedish Karolinska’s group of radiosurgery, ”it could not be concluded whether GKRS affects the natural course of a CM. The incidence of radiation-induced complications was approximately seven times higher than that expected.”2 Thus, microsurgical removal has become the mainstay of treatment. In our experience, the following details assist in obtaining favorable outcomes and avoiding postoperative complications3,4: (a) the entry into the cavernoma based on thorough knowledge of the microanatomy; (b) the detailed study of the images and the presentation of the cavernoma on or near the brain stem surface; (c) the resection of the live cavernous hemangioma and not the mere removal of the multiple aged organized hematomas; (d) the preservation of the associated venous angioma; (e) the direct and shortest access to the lesion provided by a skull base approach; and (f) the use of the available technology, such as intraoperative neuromonitoring and neuroimaging. We present the case of a 54-yr-old male with recent deterioration in year 2001, past repetitive episodes of gait imbalance, and speech difficulty over a 7-yr period from known pontine cavernoma. The anterior petrosal approach provided superb and direct exposure to the entry at the lateral pons and the cavernoma was totally removed with preservation of the venous angioma. His preoperative neurological deficit rapidly recovered. Patient consented to the procedure and photography. Images at 3:15 from Kadri et al, The anatomical basis for surgical presercation of temporal muscle. J Neurosurg. 2004;100:517-522, used with permission from JNSPG. Image at 3:27 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission.

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Microsurgical resection of medullary cavernoma via the olivary zone by the retrosigmoid supracondylar approach

Neurosurgical Focus: Video ◽

10.3171/2019.10.focusvid.19293 ◽

2019 ◽

Vol 1 (2) ◽

pp. V7

Author(s):

Ken Matsushima ◽

Michihiro Kohno ◽

Helmut Bertalanffy

Keyword(s):

Cavernous Malformation ◽

Cleavage Plane ◽

Foramen Magnum ◽

Senior Author ◽

Neurological Deficits ◽

Lateral Part ◽

Sitting Position ◽

Brainstem Cavernoma ◽

Microsurgical Resection

Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.The video can be found here: https://youtu.be/7i7SccS5HmU.

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Intraoperative monitoring of brain-stem auditory evoked potentials

Journal of Neurosurgery ◽

10.3171/jns.1982.57.3.0341 ◽

1982 ◽

Vol 57 (3) ◽

pp. 341-348 ◽

Cited By ~ 103

Author(s):

Peter A. Raudzens ◽

Andrew G. Shetter

Keyword(s):

Evoked Potentials ◽

Brain Stem ◽

Auditory Evoked Potentials ◽

Neurological Deficits ◽

Additional Patient ◽

Content Type ◽

Intracranial Surgery ◽

Surgical Measures ◽

Evoked Potential Monitoring ◽

Operating Surgeon

✓ Intraoperative brain-stem auditory evoked potentials (BAEP's) were monitored in 46 patients undergoing intracranial surgery for a variety of pathological conditions to determine whether this technique was capable of providing useful information to the operating surgeon. Intraoperative BAEP's were unchanged throughout surgery in 34 patients (74%), and these individuals had no postoperative hearing deficits. Four patients (9%) developed an abrupt ipsilateral loss of all waveform components beyond Wave I and had postoperative evidence of a pronounced hearing loss in the affected ear. An additional patient demonstrated BAEP loss contralateral to the side of surgery, and this was associated with subsequent signs of severe brain-stem dysfunction. Seven patients (15%) developed intraoperative delays of BAEP waveform latency values, but maintained recognizable waveforms beyond Wave I. Postoperatively, their hearing was either normal or mildly impaired, and there were no indications of other brain-stem abnormalities. This group represents the individuals who may have been benefited by evoked potential monitoring, since corrective surgical measures were taken when latency delays were observed. Intraoperative BAEP's can be reliably and routinely recorded in an operating room environment. They provide a good predictor of postoperative auditory status, and may have prevented permanent neurological deficits in a small segment of patients by alerting the surgeon to potentially reversible abnormalities.

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Natural history and treatment options of radiation-induced brain cavernomas: a systematic review

Neurosurgical Review ◽

10.1007/s10143-021-01598-y ◽

2021 ◽

Author(s):

Gildas Patet ◽

Andrea Bartoli ◽

Torstein R. Meling

Keyword(s):

Systematic Review ◽

Natural History ◽

Radiation Treatment ◽

Neurological Deficits ◽

Cochrane Library ◽

Average Dose ◽

Cavernous Malformations ◽

Radiation Induced ◽

The Mean

AbstractRadiation-induced cavernous malformations (RICMs) are delayed complications of brain irradiation during childhood. Its natural history is largely unknown and its incidence may be underestimated as RCIMS tend to develop several years following radiation. No clear consensus exists regarding the long-term follow-up or treatment. A systematic review of Embase, Cochrane Library, PubMed, Google Scholar, and Web of Science databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was performed. Based on our inclusion/exclusion criteria, 12 articles were included, totaling 113 children with RICMs, 86 were treated conservatively, and 27 with microsurgery. We were unable to precisely define the incidence and natural history from this data. The mean age at radiation treatment was 7.3 years, with a slight male predominance (54%) and an average dose of 50.0 Gy. The mean time to detection of RICM was 9.2 years after radiation. RICM often developed at distance from the primary lesion, more specifically frontal (35%) and temporal lobe (34%). On average, 2.6 RICMs were discovered per child. Sixty-seven percent were asymptomatic. Twenty-one percent presented signs of hemorrhage. Clinical outcome was favorable in all children except in 2. Follow-up data were lacking in most of the studies. RICM is most often asymptomatic but probably an underestimated complication of cerebral irradiation in the pediatric population. Based on the radiological development of RICMs, many authors suggest a follow-up of at least 15 years. Studies suggest observation for asymptomatic lesions, while surgery is reserved for symptomatic growth, hemorrhage, or focal neurological deficits.

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Stereotactic Aspiration of a Brain Stem Hematoma

Neurosurgery ◽

10.1227/00006123-198308000-00019 ◽

1983 ◽

Vol 13 (2) ◽

pp. 204-207 ◽

Cited By ~ 37

Author(s):

Robert M. Beatty ◽

Nicholas T. Zervas

Keyword(s):

Medical Student ◽

Brain Stem ◽

Ct Scanning ◽

Vascular Lesion ◽

Venous Angioma ◽

Stereotactic Aspiration ◽

Computed Tomographic

Abstract A medical student developed a progressive mesencephalic lesion found to be cystic in nature by computed tomographic (CT) scanning. Stereotactic aspiration of a pontomesencephalic hematoma was carried out twice, and the patient recovered. Angiography and CT scanning demonstrated a vascular lesion compatible with a venous angioma.

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Successful evacuation of a pontine hematoma secondary to rupture of a pathologically diagnosed “cryptic” vascular malformation

Journal of Neurosurgery ◽

10.3171/jns.1973.39.1.0104 ◽

1973 ◽

Vol 39 (1) ◽

pp. 104-108 ◽

Cited By ~ 56

Author(s):

Ben B. Scott ◽

Joachim F. Seeger ◽

Richard C. Schneider

Keyword(s):

Arteriovenous Malformation ◽

Brain Stem ◽

Posterior Fossa ◽

Vascular Malformation ◽

Nerve Palsy ◽

Neurological Deficits ◽

Content Type ◽

Brain Stem Lesion ◽

Seventh Nerve ◽

Fine Print

✓ A posterior fossa exploration was performed on a child thought initially to have an inoperable brain stem lesion. A pontine hematoma was discovered and evacuated. The pathological specimen was designated as a “cryptic” arteriovenous malformation. All preoperative neurological deficits disappeared except for a minimal left seventh nerve palsy.

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Repeat Gamma Knife Surgery for Incompletely Obliterated Cerebral Arteriovenous Malformations

Neurosurgery ◽

10.1227/01.neu.0000370204.68711.ac ◽

2010 ◽

Vol 67 (1) ◽

pp. 55-64 ◽

Cited By ~ 24

Author(s):

Chun-Po Yen ◽

Surbhi Jain ◽

Iftikhar-ul Haq ◽

Jay Jagannathan ◽

David Schlesinger ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Surgery ◽

Neurological Deficits ◽

Resonance Imaging ◽

Cerebral Arteriovenous Malformations ◽

Radiation Induced ◽

Induced Changes

Abstract OBJECTIVE The causes of failure after an initial Gamma procedure were studied, along with imaging and clinical outcomes, in a series of 140 patients with cerebral arteriovenous malformations (AVMs) treated with repeat Gamma Knife surgery (GKS). METHODS Causes of initial treatment failure included inaccurate nidus definition in 14 patients, failure to fill part of the nidus as a result of hemodynamic factors in 16, recanalization of embolized AVM compartments in 6, and suboptimal dose (< 20 Gy) in 23. Nineteen patients had repeat GKS for subtotal obliteration of AVMs. In 62 patients, the AVM failed to obliterate despite correct target definition and adequate dose. At the time of retreatment, the nidus volume ranged from 0.1 to 6.9 cm3 (mean, 1.4 cm3), and the mean prescription dose was 20.3 Gy. RESULTS Repeat GKS yielded a total angiographic obliteration in 77 patients (55%) and subtotal obliteration in 9 (6.4%). In 38 patients (27.1%), the AVMs remained patent, and in 16 patients (11.4%), no flow voids were observed on magnetic resonance imaging. Clinically, 126 patients improved or remained stable, and 14 experienced deterioration (8 resulting from a rebleed, 2 caused by persistent arteriovenous shunting, and 4 related to radiation-induced changes). CONCLUSION By using repeat GKS, we achieved a 55% angiographic cure rate. Although radiation-induced changes as visualized on magnetic resonance imaging occurred in 48 patients (39%), only 4 patients (3.6%) developed permanent neurological deficits. These findings may be useful in deciding the management of AVMs in whom total obliteration after initial GKS was not achieved.

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Cerebral venous malformations

Journal of Neurosurgery ◽

10.3171/jns.1990.73.4.0560 ◽

1990 ◽

Vol 73 (4) ◽

pp. 560-564 ◽

Cited By ~ 111

Author(s):

Daniele Rigamonti ◽

Robert F. Spetzler ◽

Marjorie Medina ◽

Karen Rigamonti ◽

David S. Geckle ◽

...

Keyword(s):

Venous Malformation ◽

Neurological Dysfunction ◽

Neurological Deficits ◽

Venous Angioma ◽

Venous Malformations ◽

Content Type ◽

History Of ◽

The Relationship ◽

Fine Print

✓ Although cerebral venous malformations have been reported to cause epilepsy, progressive neurological deficits, and hemorrhage, their clinical significance remains controversial. In an attempt to clarify the natural history of the lesion and suggest an appropriate management strategy, the authors review their experience with 30 patients. In four patients with cerebellar venous angioma, an acute episode of ataxia was documented. The coexistence of a cavernous malformation was pathologically confirmed in the two patients who underwent surgery for bleeding presumed caused by the venous angioma. Infarction was shown in two patients and a tumor in two others. Follow-up periods ranged between 18 and 104 months, with only five patients symptomatic at the time of this report. Rebleeding had not occurred, nor had acute episodes of neurological dysfunction been documented. This clinical experience suggests that a venous malformation is frequently associated with other, more symptomatic conditions and is often erroneously identified as the source of the symptoms. Because the nature of the relationship between the venous malformation and the allied conditions remains ambiguous, it is recommended that patients harboring a “symptomatic” venous malformation undergo high-field magnetic resonance imaging to rule out underlying pathology, and that any such pathology be treated independently of the venous malformation.

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ENDOTHELIAL DYSFUNCTION UNDER INFLUENCE OF IONIZING RADIATION: PATHOGENETIC BASIS AND OPPORTUNITIES OF PHARMACOLOGICAL CORRECTION

Kuban Scientific Medical Bulletin ◽

10.25207/1608-6228-2018-25-4-124-131 ◽

2018 ◽

Vol 25 (4) ◽

pp. 124-131 ◽

Cited By ~ 1

Author(s):

K. V. SAROYAN ◽

I. N. SYTNIK ◽

V. O. SOLDATOV ◽

M. A. PERSHINA ◽

N. I. ZHERNAKOVA ◽

...

Keyword(s):

Endothelial Dysfunction ◽

Ionizing Radiation ◽

Regulatory Systems ◽

Direct Exposure ◽

Radiation Induced ◽

Radioactive Radiation ◽

Pharmacological Correction ◽

High Doses

The problem of radiation-induced lesions is becoming increasingly urgent. Studies in recent years show that one of the most vulnerable tissues is the endothelium when exposed to high doses of ionizing radiation. The study of the pathogenetic bases of this phenomenon has shown that damage to endotheliocytes occurs both at the expense of the direct exposure to radiation and due to the systemic disturbance of homeostasis which leads to the disadaptation of the executive and regulatory systems of the organism. In this review we considered the mechanisms of the development of endothelial dysfunction under the influence of radioactive radiation and possible methods of pharmacological correction of this condition.

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Reversible temporal hypodensity on CT in a patient with minor head injury: Transient global amnesia or contusion?

Journal of Concussion ◽

10.1177/20597002211040921 ◽

2021 ◽

Vol 5 ◽

pp. 205970022110409

Author(s):

Basit Shah ◽

Sabrina Poonja ◽

Mohammed Wasif Hussain

Keyword(s):

Head Injury ◽

Young Patient ◽

Temporal Lobe ◽

Transient Global Amnesia ◽

Neurological Deficits ◽

Mri Findings ◽

Anatomical Basis ◽

Ct Head ◽

Global Amnesia ◽

Middle Aged Adults

Transient global amnesia (TGA) is a condition characterized by a sudden, temporary lapse in memory without focal neurological deficits, usually in middle aged adults, sometimes precipitated by an inciting event. We describe a case of a young patient, who presented with a constellation of symptoms consistent with TGA post-concussion with a right temporal lobe hypodensity on CT head. This patient’s memory returned to baseline within 24 hours, with only a mild residual headache which resolved within the next day and no MRI findings 48 hours after, illustrating that his clinical trajectory favours TGA rather than post-concussive amnesia. While the pathophysiology of TGA is still a mystery, clinicians and researchers continue to hypothesize the anatomical basis of this condition.

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