Introduction: Brainstem cavernous malformations (BSCM) often present with acute hemorrhage which in size is discrepant to the often mild symptoms. Management issues are the necessity of surgery, timing, risk associated and possibility of recurrence.
Methods: We retrieved the records of 74 patients seen in our department between 1988 and 2013. 61 cases (82%) presented with acute neurological deficit and space occupying hemorrhage and 13 (18%) with progressive neurological symptoms from microhemorrhages. One patient had two recurrent lesion located each in adjacent but new locations. 55 including one recurrence were pontine, pontomedullary or pontomesencephalic, 11, including one recurrece were mesencephalic and 6 in the medulla oblongata.
Results: All patients with acute hemorrhage were stable after onset of neurological symptoms, and were allowed to recover with tapering steroids for 4-6 weeks after acute hemorrhage and then operated Angiography was performed only in the very early phase of the series. CISS MR sequences are deemed mandatory to determine the safest spot for surgical approach. Access routes were through the thinnest or least functional parenchymal cover and individually tailored.using supracerebellar, telovelar, presigmoid/transtentorial and lateral/far lateral CP-angle approaches. Intraoperative ultrasound was a useful for location in the prone position when no superficial discoloration was apparent.
Two patients had recurrent hemorrhagic lesions one leading to ARDS, the other to complex cranial nerve deficits and incapacitating loss of proprioception. Postoperative deficits were divided into two categories : aggravation of preexisting deficits due to dissection of the cavernous sac(s) from the surroundings or new deficits from the approach (access morbidity). The former was found to be mild transient and unavoidable, the latter can be minimized with careful planning, intraoperative monitoring and dtiMR which can be limited the presence of hemorrhage
Conclusions: Management of BSCM requires permanent optimization of technique and individual concepts for each patient to ensure success.
Patient Care: It will show that these lesions need to be treated by specialists in their field and in referral centers only
Learning Objectives: To demonstrate that treating BSCM is safe, provided careful individual consideration is given to each lesion and patient