1Department of Neurosurgery, Tokyo Women's Medical University.
3Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan.
J Neurosurg. 2022 Sep 9;138(4):900-909. doi: 10.3171/2022.7.JNS22314. Print 2023 Apr 1.
The objective of this study was to evaluate the long-term outcomes after resection of brainstem cavernous malformations (BSCMs) and to assess the usefulness of the Lawton grading system in these cases.
This retrospective study analyzed 46 consecutive patients with BSCMs operated on between July 1990 and December 2020. Outcomes at the last follow-up were defined as favorable (modified Rankin Scale [mRS] score 0-2) or unfavorable (mRS score > 2).
The study cohort comprised 24 men (52%) and 22 women (48%), ranging in age from 8 to 78 years old (median 37 years). In 19 patients (41%), the preoperative mRS score was > 2. All patients had hemorrhagic BSCM. There were 12 (26%) mesencephalic, 19 (41%) pontine, 7 (15%) medullary, and 8 (17%) cerebellar peduncle lesions, with a maximal diameter ranging from 5 to 40 mm (median 15 mm). In total, 24 BSCMs (52%) had bilateral extension crossing the brainstem midline. Lawton grades of 0, I, II, III, IV, V, and VI were defined in 3 (7%), 2 (4%), 10 (22%), 11 (24%), 8 (17%), 7 (15%), and 5 (11%) cases, respectively. Total resection of BSCMs was attained in 43 patients (93%). There were no perioperative deaths. Excluding the 3 most recent cases, the length of follow-up ranged from 56 to 365 months. The majority of patients demonstrated good functional recovery, but regress of the preexisting oculomotor nerve deficit was usually incomplete. No new hemorrhagic events were noted after total resection of BSCMs. In 42 patients (91%), the mRS score at the time of last follow-up was ≤ 2 (favorable outcome), and in 18 (39%), it was 0 (absence of neurological symptoms). Forty-four patients (96%) demonstrated clinical improvement and 2 (4%) had no changes compared with the preoperative period. Multivariate analysis revealed that only lower Lawton grade had a statistically significant independent association (p = 0.0280) with favorable long-term outcome. The area under the receiver operating characteristic curve for prediction of favorable outcome with 7 available Lawton grades of BSCM was 0.93.
Resection of hemorrhagic BSCMs by an experienced neurosurgeon may be performed safely and effectively, even in severely disabled patients. In the authors' experience, preexisting oculomotor nerve palsy represents the main cause of permanent postoperative neurological morbidity. The Lawton grading system effectively predicts long-term outcome after surgery.
本研究旨在评估脑干海绵状血管畸形（BSCM）切除术后的长期结果，并评估 Lawton 分级系统在这些病例中的应用价值。
本回顾性研究分析了 1990 年 7 月至 2020 年 12 月期间连续接受手术治疗的 46 例 BSCM 患者。末次随访时的结果定义为良好（改良 Rankin 量表 [mRS]评分 0-2）或不良（mRS 评分＞2）。
研究队列包括 24 名男性（52%）和 22 名女性（48%），年龄 8 至 78 岁，中位数为 37 岁。在 19 例患者（41%）中，术前 mRS 评分＞2。所有患者均为出血性 BSCM。12 例（26%）病变位于中脑，19 例（41%）位于脑桥，7 例（15%）位于延髓，8 例（17%）位于小脑脚，病变最大直径为 5 至 40mm，中位数为 15mm。总共 24 例（52%）BSCM 病变存在跨越脑干中线的双侧延伸。3 例（7%）为 Lawton 0 级，2 例（4%）为 Lawton 1 级，10 例（22%）为 Lawton 2 级，11 例（24%）为 Lawton 3 级，8 例（17%）为 Lawton 4 级，7 例（15%）为 Lawton 5 级，5 例（11%）为 Lawton 6 级。43 例（93%）患者实现了 BSCM 的完全切除。无围手术期死亡病例。排除最近的 3 例病例，随访时间为 56 至 365 个月。大多数患者的功能恢复良好，但已存在的动眼神经缺陷恢复通常不完全。BSCM 完全切除后未再发生新的出血事件。在 42 例患者（91%）中，末次随访时 mRS 评分≤2（预后良好），18 例（39%）为 0（无神经症状）。与术前相比，44 例患者（96%）的临床症状得到改善，2 例（4%）无变化。多变量分析显示，只有较低的 Lawton 分级与良好的长期预后有统计学显著的独立相关性（p=0.0280）。在 7 个 Lawton 分级的情况下，预测良好预后的受试者工作特征曲线下面积为 0.93。
由经验丰富的神经外科医生进行出血性 BSCM 切除术是安全有效的，即使是在病情严重的残疾患者中。根据作者的经验，术前已存在的动眼神经麻痹是术后永久性神经功能障碍的主要原因。Lawton 分级系统能有效预测术后的长期结果。
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