Department and Clinical Ward of Neurosurgery, Medical University of Silesia, Sosnowiec, Poland.
Department of Radiodiagnostics, Maria Sklodowska-Curie Memorial Cancer Centre and National Institute of Oncology Gliwice Branch, Gliwice, Poland.
Neurol Neurochir Pol. 2022;56(4):349-356. doi: 10.5603/PJNNS.a2022.0035. Epub 2022 May 19.
The aims of this study were to assess the prognosis of patients after a single haemorrhage from the cavernoma, and also in the case of rehaemorrhage, and to determine the indications for surgical treatment of brainstem cavernomas.
The study included a group of 35 patients with brainstem cavernomas, 23 women and 12 men aged 27 to 57 years (mean age 38.4). Up to 2005, MRI perfusion-weighted imaging/diffusion-weighted imaging had been carried out in 13 surgically treated patients. From 2005 onwards, the other 22 patients also underwent MRI diffusion tensor imaging and diffusion tensor tractography (DTI/DTT). DTI/DTT assessed the course of long fibre tracts. The course of the corticospinal tract, medial lemniscus and transverse pontine tracts was entered into the neuronavigation system. The surgical approach and the safe entry zone were determined based on the DTI/DTT.
Our study showed that rehaemorrhage from a cavernoma depends on its size and volume. However, it is not related to its location. Based on the modified Rankin scale, the results of treatment of our patients after the first haemorrhage were better compared to the assessment after another haemorrhage. Complete resection was performed in 32 cases (91%) and partial resection in the remaining three (9%). Two patients underwent another surgery after several years due to partial resection. One patient presented with another haemorrhage after three years. New deficits developed postoperatively. Already existing deficits were exacerbated, but gradually resolved. Symptoms of cerebellar dysfunction and cranial nerve injury (including respiratory disorders) were the most difficult to resolve.
Patients with brainstem cavernomas should undergo surgical treatment after their first haemorrhage, especially in the case of a large cavernoma. DTI/DTT should be used to determine the trajectory to the cavernoma, particularly to the deep cavernoma, and to determine the safe entry zone. Total resection of the cavernoma should be performed even where this means that reoperation is required.
本研究旨在评估患者单次海绵状血管畸形出血后的预后，以及再次出血后的预后，并确定脑干海绵状血管畸形的手术治疗指征。
本研究纳入了 35 例脑干海绵状血管畸形患者，其中女性 23 例，男性 12 例，年龄 27-57 岁（平均年龄 38.4 岁）。截至 2005 年，13 例手术治疗的患者进行了 MRI 灌注加权成像/弥散加权成像检查。自 2005 年起，其余 22 例患者还进行了 MRI 弥散张量成像和弥散张量纤维束成像（DTI/DTT）检查。DTI/DTT 评估了长纤维束的走行。皮质脊髓束、内侧丘系和桥脑横纤维束的走行被输入到神经导航系统中。根据 DTI/DTT 确定手术入路和安全入路区。
本研究显示，海绵状血管畸形再次出血与其大小和体积有关，但与位置无关。根据改良 Rankin 量表，首次出血后患者的治疗结果优于再次出血后。32 例（91%）患者行完全切除术，其余 3 例（9%）行部分切除术。2 例患者在数年后因部分切除而行再次手术。1 例患者在 3 年后再次出血，术后出现新的神经功能缺损。已有的神经功能缺损加重，但逐渐缓解。小脑功能障碍和颅神经损伤（包括呼吸障碍）的症状最难缓解。
对于首次出血的脑干海绵状血管畸形患者，尤其是较大的海绵状血管畸形患者，应进行手术治疗。应使用 DTI/DTT 确定通向海绵状血管畸形的轨迹，尤其是通向深部海绵状血管畸形的轨迹，并确定安全入路区。即使需要再次手术，也应行海绵状血管畸形的完全切除术。
