Introduction: The management of brainstem/deep cavernomas remains uncertain. Hypothesis: A low to high risk stratified multimodal approach to treatment appears sensible when the natural history and the effects of Stereotactic Radiosurgery (SRX) are uncertain and the risks of Surgery even in experienced hands are undue.

Methods: A stepwise increase in risk of treatment with Conservative, SRX and Surgery was applied to 18 patients (8F 10M, 14-62 years) with 21 brainstem/deep cavernomas between 2003-2012. The presentations were with a neurological event and/or a hemorrhage on CT/MRI.

Results: A 1st event was Observed in 1, treated with SRX in 3 and 1 had excision. One had SRX after a 2nd event. All stabilized. A 1st bleed occurred in 12 patients, 2nd in 8 and a 3rd in 2. A 2nd bleed in 1 was from a de novo cavernoma. One Observed patient died, 3 had SRX and 2 were excised of whom 1 died a year later of an unrelated cause. After a 2nd bleed 1 was Observed and 1 who had SRX 4Y previously chose Observation, 2 had SRX and 4 were excised of whom 1 had complete excision, 2 in part who then had SRX but one of these had a subclinical 3rd bleed and the 4th had a 3rd bleed on Amphetamine who then had SRX. All improved except the de novo patient who had excision and then stabilized. This patient had SRX to a 3rd cavernoma for an event and a patient who had SRX had an event.

Conclusions: With a graduated approach to treatment, cavernomas stabilized with minimal morbidities. For Symptomatic (Symptoms+signs correlate with the cavernoma) and Inaccessible lesions (Surgery involves traversing eloquent areas)- With an "Event": Event 1-Observe or SRX?, Event 2-SRX and Event 3 or more-ie. Progressive-Surgery; With a "Hemorrhage": Hemorrhage 1-SRX, Hemorrhage 2-SRX or if Progressive Surgery and Hemorrhage 3 or more-ie. Progressive-Surgery.

Patient Care: (1) There is evidence (See ref) that there are no side effects of SRX and that it reduces the risk of a rebleed after a latent period of 2Y in brainstem/deep cavernomas, thus it is not unreasonable to offer this mode of treatment when the alternatives are to either offer conservative treatment or surgical resection with its associated undue risks unless there is no option. (2) Hence, this will prolong the "deficit free interval" and thus the quality of activities of daily living (QUALY) unless there are situations whereby cavernomas can be resected safely in toto without a deficit. (3) The aim should be to strive for a “deficit free interval” and quality of life rather than "survival with deficits" unless patients are in dire straits. Thus, observation with its natural history is offered first, then SRX with its inferred beneficial effect after a latent period of 2Y and no side effects and finally, surgical excision with its undue risks unless it is possible to resect the cavernoma from the outset with little or no morbidity.

Learning Objectives: The participants should (1) understand that there is no consensus on the management of brainstem/deep cavernomas, (2) realize that a stepwise low to high risk treatment manoeuvre with all three modalities viz. Observation, SRX and Surgery was assessed in patients with symptomatic cavernomas, (3) appreciate that though this did not always result in their eradication it stabilized the cavernomas and minimized the risks associated with interventions, (4) thus recognize that it prolonged the "deficit free interval" and with it improved the quality of life so important when the alternative is a life-long deficit with a cure (5) and refer to a summary on the management of brainstem/deep cavernomas in the conclusions.

References: Nagy G, Razak A, Rowe JG, Hodgson TJ, Coley SC, Radatz MWR, Patel UJ, Kemeny AA: Stereotactic Radiosurgery for deep-seated cavernous malformations: a move toward more active, early intervention Clinical Article. J Neurosurgery 113(4):691-9, 2010