1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
2Department of Neurological Surgery, University of California, San Francisco, California.
J Neurosurg. 2020 Nov 20;135(3):671-682. doi: 10.3171/2020.6.JNS201555. Print 2021 Sep 1.
Proximity of brainstem cavernous malformations (BSCMs) to tracts and cranial nerve nuclei make it costly to transgress normal tissue in accessing the lesion or disrupting normal tissue adjacent to the lesion in the separation plane. This interplay between tissue sensitivity and extreme eloquence makes it difficult to avoid leaving a remnant on occasion. Recurrences require operative intervention, which may increase morbidity, lengthen recovery, and add to overall costs. An approximately 20-year experience with patients with recurrent BSCM lesions following primary microsurgical resection was reviewed.
A prospectively maintained database of 802 patients who underwent microsurgical resection of cerebral cavernous malformations during 1997-2018 was queried to identify 213 patients with BSCMs. A retrospective chart review was conducted for patients with recurrent BSCM after primary resection who required a second surgery.
Fourteen of 213 patients (6.6%) underwent repeat resection for recurrent BSCM. Thirty-four hemorrhagic events were observed among these 14 patients over 576 patient-years (recurrent hemorrhage rate, 5.9% per year; median discrete hemorrhagic events, 2; median time to rehemorrhage, 897 days). BSCM occurred in the pons in 10 cases, midbrain in 2 cases, and medulla in 2 cases. A blind spot in the operative corridor was the most common cause of residual BSCM (9 patients). All recurrent BSCMs were removed completely, although 2 patients each required 2 operations to treat recurrence. Twelve patients had unchanged or improved modified Rankin Scale scores at last clinical evaluation compared with admission, and 2 patients had worse scores. Recurrence was more common among patients who were operated on in the first versus the second half of the series (8.5% vs 4.7%).
The 6.6% rate of BSCM recurrence requiring reoperation reflects the fine lines between complete resection and recurrence and between safe and harmful surgery. The detection of remnants is difficult postoperatively and remains so even at 6 months when the resection bed has healed. The 5.9% annual hemorrhage risk associated with recurrent BSCM in this experience is consistent with that reported for unoperated BSCMs. The right-angle method helps to anticipate blind spots and meticulously inspect the resection cavity for residual BSCM during surgery. A low percentage of recurrent BSCM (5%-10%) ensures ongoing effort toward an acceptable balance of safety and completeness.
脑干海绵状血管畸形（BSCMs）与束和颅神经核的接近，使得在接近病变或在分离平面中断病变附近的正常组织时，侵犯正常组织的成本很高。这种组织敏感性和极端表达能力之间的相互作用使得很难避免偶尔留下残余物。复发需要手术干预，这可能会增加发病率，延长恢复时间，并增加总体成本。对 1997 年至 2018 年间接受显微手术切除脑海绵状血管畸形的 802 例患者的前瞻性数据库进行了回顾，以确定 213 例 BSCM 患者。对初次切除后需要再次手术的复发性 BSCM 患者进行了回顾性图表审查。
对 1997 年至 2018 年间接受显微手术切除脑海绵状血管畸形的 802 例患者的前瞻性数据库进行了检索，以确定 213 例 BSCM 患者。对初次切除后需要再次手术的复发性 BSCM 患者进行了回顾性图表审查。
14 例（6.6%）患者因复发性 BSCM 行再次切除术。在这 14 例患者中，576 患者年中观察到 34 例出血事件（复发出血率为每年 5.9%；中位数离散出血事件为 2 次；中位再出血时间为 897 天）。BSCM 发生在桥脑 10 例，中脑 2 例，延髓 2 例。手术通道中的盲点是残留 BSCM 最常见的原因（9 例）。尽管 2 例患者各需 2 次手术治疗复发，但所有复发性 BSCM 均完全切除。与入院时相比，12 例患者的改良 Rankin 量表评分在最后一次临床评估时保持不变或改善，2 例患者的评分恶化。在系列的前半段与后半段手术的患者中，BSCM 复发率分别为 8.5%和 4.7%（8.5%对 4.7%）。
需要再次手术的 BSCM 复发率为 6.6%，这反映了完全切除与复发之间、安全手术与有害手术之间的细微差别。即使在切除床愈合的 6 个月时，术后也很难发现残留，即使在术后也很难发现残留。在本研究中，复发性 BSCM 每年 5.9%的出血风险与未经手术治疗的 BSCM 报告一致。直角法有助于预测盲点，并在手术过程中仔细检查切除腔是否有残留 BSCM。低复发率（5%-10%）确保了安全和完整性之间的平衡。
