Gauden Andrew J, Choi Jason L, Luo Ingrid, Han Summer S, Steinberg Gary K
1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California; and.
2Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, California.
J Neurosurg. 2025 Jun 27:1-8. doi: 10.3171/2025.3.JNS242848.
Brainstem cavernous malformations (BCMs) are low-flow vascular lesions of the central nervous system that pose significant surgical challenges due to their deep location and proximity to eloquent structures. Resection is associated with significant morbidity, and published literature is sparse. This single-institutional, single-surgeon study aimed to delineate factors affecting outcomes in the resection of BCMs and to assess the efficacy of the omnidirectional CO2 laser for lesion resection.
A retrospective review of all BCMs treated between 1990 and 2022 at Stanford Hospital and Clinics and Lucile Packard Children's Hospital by the senior author was conducted. Data from medical records and direct patient contact data, including presenting symptoms, presence of acute hemorrhage status, time from hemorrhage to surgery, radiological features, surgical approach used, and preoperative and postoperative neurological status, were recorded. The primary outcome assessed included the modified Rankin Scale (mRS) score at baseline and on follow-up. Comparisons were performed between resections with and without the use of the CO2 laser. Further analysis was performed to eliminate "learning curve" bias, and the last 75 patients in both treatment groups were compared.
In total, 277 surgical procedures for BCMs were identified in 254 patients treated from March 1990 to December 2022, and of these 236 (85%) surgical procedures in 215 patients had ≥ 3 months follow-up or mortality within 3 months postsurgery. Of these, 120/236 underwent conventional surgery and 116/236 underwent CO2 laser-assisted resection. Complete resection of the cavernous malformation was achieved in 96.4% of cases. Recurrent BCM was observed in 3/254 (1.2%) of patients, and 70 of 236 cases (30%) had immediate worsening of neurological status, with an average mRS increase of 0.47 points. The CO2 laser-assisted surgery group showed statistically significant long-term mRS score improvement compared to the conventional surgery group (28 [23%] of conventional and 45 [39%] of laser-assisted cases showed improvement; average mRS change +0.125 and -0.241, respectively, p = 0.02). Assessment of the last 75 patients in both groups showed a similar positive relationship between CO2 laser-assisted resection and long-term mRS outcomes (-0.475, 95% CI -0.881 to -0.07, p = 0.02).
BCM remains among the most challenging pathologies for the cerebrovascular neurosurgeon. This series demonstrates that good surgical outcomes are achievable when resection is performed in a high-volume center by an experienced surgeon. Furthermore, this study suggests improved outcomes using the CO2 laser.
脑干海绵状血管畸形（BCMs）是中枢神经系统的低流量血管病变，因其位置深且靠近功能区结构，给手术带来了重大挑战。切除手术会导致显著的发病率，且相关的已发表文献较少。这项单机构、单术者的研究旨在明确影响BCMs切除术后结果的因素，并评估全方位二氧化碳激光用于病变切除的疗效。
对1990年至2022年期间由资深作者在斯坦福医院及诊所和露西尔·帕卡德儿童医院治疗的所有BCMs病例进行回顾性研究。记录病历数据和直接与患者接触的数据，包括出现的症状、急性出血状态、出血至手术的时间、放射学特征、使用的手术入路以及术前和术后的神经状态。评估的主要结果包括基线和随访时的改良Rankin量表（mRS）评分。对使用和未使用二氧化碳激光的切除术进行比较。为消除“学习曲线”偏差进行了进一步分析，并比较了两个治疗组中的最后75例患者。
在1990年3月至2022年12月接受治疗的254例患者中，共确定了277例BCMs手术，其中215例患者的236例（85%）手术有≥3个月的随访或术后3个月内死亡。其中，120/236例接受了传统手术，116/236例接受了二氧化碳激光辅助切除术。96.4%的病例实现了海绵状血管畸形的完全切除。254例患者中有3例（1.2%）观察到复发性BCM，236例中有70例（30%）神经状态立即恶化，mRS平均增加0.47分。与传统手术组相比，二氧化碳激光辅助手术组在长期mRS评分改善方面具有统计学意义（传统手术组28例[23%]、激光辅助手术组45例[39%]显示改善；mRS平均变化分别为+0.125和-0.241，p = 0.02）。对两组中最后75例患者的评估显示，二氧化碳激光辅助切除术与长期mRS结果之间存在类似的正相关关系（-0.475，95%CI -0.881至-0.07，p = 0.02）。
BCM仍然是脑血管神经外科医生面临的最具挑战性的病变之一。本系列研究表明，由经验丰富的外科医生在高容量中心进行切除手术时，可以取得良好的手术效果。此外，本研究表明使用二氧化碳激光可改善结果。
