Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations

J Neurosurg. 2013 Oct;119(4):996-1008. doi: 10.3171/2013.7.JNS13462. Epub 2013 Aug 16.


Object: The aim of this study was to evaluate the pre- and postoperative rehemorrhage risk, neurological function outcome, and prognostic factors of surgically treated brainstem cavernous malformations (CMs) with long-term follow-up.

Methods: The authors conducted a retrospective review of the clinical data from 242 patients with brainstem CMs that were surgically treated between 1999 and 2010. Patient charts, imaging findings, and outcomes were examined.

Results: The study included 242 patients, with a male-to-female ratio of 1.3 and mean age of 32.6 years. The mean modified Rankin Scale scores on admission, at discharge, at 3 and 6 months after surgery, and at recent evaluation were 2.2, 2.6, 2.3, 1.8, and 1.5, respectively. The preoperative calculated annual hemorrhage and rehemorrhage rates were 5.0% and 60.9%, respectively. The complete resection rate was 95%. Surgical morbidity occurred in 112 patients (46.3%). Eighty-five patients (35.1%) demonstrated worsened condition immediately after surgery; 34 (41.0%) and 51 (61.4%) of these patients recovered to their baseline level within 3 and 6 months after surgery, respectively. At a mean follow-up of 89.4 months, the patients' condition had improved in 147 cases (60.7%), was unchanged in 70 cases (28.9%), and had worsened in 25 cases (10.3%). A total of 8 hemorrhages occurred in 6 patients, and the postoperative annual hemorrhage rate was 0.4%. Permanent morbidity remained in 65 patients (26.9%). The adverse factors for preoperative rehemorrhage were age ≥ 50 years, size ≥ 2 cm, and perilesional edema. The risk factors for postoperative hemorrhage were developmental venous anomaly and incomplete resection. The independent adverse factors for long-term outcome were increased age, multiple hemorrhages, ventral-seated lesions, and poor preoperative status. Favorable, complete improvement in the postoperative deficits over time was correlated with good preoperative neurological function and continuing improvement thereafter.

Conclusions: Favorable long-term outcomes and significantly low postoperative annual hemorrhage rates were achieved via surgery. Total resection should be attempted with an aim of minimal injury to neurological function; however, postoperative deficits can improve during the postoperative course. Close follow-up with radiological examination is proposed for patients with adverse factors predictive of rehemorrhage.

MeSH terms

  • Adolescent
  • Adult
  • Brain Neoplasms / complications
  • Brain Neoplasms / pathology
  • Brain Neoplasms / surgery*
  • Brain Stem / blood supply
  • Brain Stem / pathology
  • Brain Stem / surgery*
  • Child
  • Child, Preschool
  • Female
  • Hemangioma, Cavernous, Central Nervous System / complications
  • Hemangioma, Cavernous, Central Nervous System / pathology
  • Hemangioma, Cavernous, Central Nervous System / surgery*
  • Humans
  • Intracranial Hemorrhages / etiology*
  • Intracranial Hemorrhages / surgery
  • Male
  • Middle Aged
  • Neurosurgical Procedures / adverse effects
  • Neurosurgical Procedures / methods*
  • Retrospective Studies
  • Risk
  • Treatment Outcome