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An 8-year-old boy presenting with left-angle paralysis, tremor in upper and lower extremities, and diplopia was diagnosed with hemorrhage from a mesencephalic cavernous hemangioma. He underwent hemangiomectomy through the occipital transtentorial approach 4 weeks post-hemorrhage, after which Holmes tremor (HT) markedly reduced. A year later, hemangioma has not recurred; he is now independent in his daily activities. Early intervention in the subacute stage allows for the complete removal of brainstem cavernomas (BSCs), with minimal risk of complications or sequelae. Proper timing and surgical approach for BSCs can prevent re-bleeding and improve HT after an initial hemorrhage, without any lasting negative consequences. [ABSTRACT FROM AUTHOR]

The spatial complexity of highly vulnerable structures makes surgical resection of brainstem cavernomas (BSC) a challenging procedure. Diffusion tensor imaging (DTI) allows for the visualization of white matter tracts and enables a better understanding of the anatomical location of corticospinal and sensory tracts before and after surgery.We investigated the feasibility and clinical usefulness of DTI-based fiber tractography in patients with BSC.Pre- and postoperative DTI visualization of corticospinal and sensory tracts were retrospectively analyzed in 23 individuals with BSC. Preoperative and postoperative DTI-fiber accuracy were associated to the neurological findings. Preoperatively, the corticospinal tracts were visualized in 90 % of the cases and the sensory tracts were visualized in 74 % of the cases. Postoperatively, the corticospinal tracts were visualized in 97 % of the cases and the sensory tracts could be visualized in 80 % of the cases. In all cases, the BSC had caused displacement, thinning, or interruption of the fiber tracts to various degrees. Tract visualization was associated with pre- and postoperative neurological findings. Postoperative damage of the corticospinal tracts was observed in two patients. On follow-up, the Patzold Rating (PR) improved in 19 out of 23 patients (83 %, p = 0.0002).This study confirms that DTI tractography allows accurate and detailed white matter tract visualization in the brainstem, even when an intraaxial lesion affects this structure. Furthermore, visualizing the tracts adjacent to the lesion adds to our understanding of the distorted intrinsic brainstem anatomy and it may assists in planning the surgical approach in specific cases. [ABSTRACT FROM AUTHOR]

This study reviewed surgical experience with brainstem cavernomas in an attempt to define optimal surgical approaches and risks associated with surgical management. Clinical courses were retrospectively reviewed for 36 consecutive patients (12 men, 24 women; mean age, 42 years) who underwent microsurgical resection of brainstem cavernomas between 1996 and 2006. Medical records, surgical records, and neuroimaging examinations were evaluated. All 36 patients presented with ≥1 hemorrhage from the cavernomas and preoperatively displayed some neurological symptoms. Surgical approach was midline suboccipital for 16 pontine and/or medullary cavernomas under the floor of the fourth ventricle, retrosigmoid for 10 lateral mesencephalic, pontine, and/or medullary cavernomas, occipital transtentorial for 2 thalamomesencephalic and 3 mesencephalic cavernomas, combined petrosal for 2 pontine cavernomas, and other for 3 cavernomas. Complete resection according to postoperative magnetic resonance imaging was achieved in 33 of 36 patients. No mortality was encountered in this study. New neurological deficit occurred in the early postoperative period for 18 patients, but was transient in 15 of these. Neurological state as of final follow-up was improved in 16 patients (44%), unchanged in 17 (47%), and worsened in 3 (8%) compared with preoperatively. In conclusion, symptomatic brainstem cavernomas should be considered for surgical treatment. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory. [ABSTRACT FROM AUTHOR]

The risk of leaving a remnant after surgery for a cavernous malformation in the brainstem is generally not stressed enough, even though such remnants appear to have a high risk of re-bleeding. At least 40% of known cavernoma remnants after surgery have further bleeding episodes. A retrospective analysis of 30 patients with brainstem cavernoma who underwent surgery is presented, focusing on incidence, risk factors and management of post-surgical residuals. The sites were, medulla in three patients, pons-medulla in four, pons in 16, pons-midbrain in four and midbrain in three. All 30 patients came to our clinical observation with at least one episode of acute-onset neurological deficit and all were operated in the sub-acute phase. Only one patient had a worse stable outcome than the pre-surgical state, and 29 did better or were stable. All patients had a brain MRI scan within 72 h after surgery to confirm that complete removal had been achieved. In three, although the surgical cavity and its border appeared clean at the end of surgery, with no lesion remaining, post-operative MRI detected a residuum. These three patients were re-operated, but one had a further bleed prior to excision. In our series, the surgical finding of a multi-lobular cavernoma (as opposed to the more frequent finding of a discrete lesion with a thick capsule), with a thin wall and satellite nodules separated by a thin layer of apparently intact white matter, was common (seven patients). This group included the three patients with evidence of residuum on post-operative MRI. In our experience, the surgical finding of a multi-lobular cavernoma carries a higher risk of residuum and post-surgical re-bleeding. Immediate post-operative brain MRI scans are therefore strongly recommended for their detection, especially in this group of patients, and if a residual is detected early re-intervention is less risky than the natural history. [ABSTRACT FROM AUTHOR]

The purpose of this study was to present our experience in the management of spontaneous brainstem hematomas (BSH). Records of 58 consecutive patients were reviewed, including demographic data, symptoms, Glasgow Coma Scale, treatment, intraoperative findings (in surgical cases), and outcome according to the Glasgow Outcome Scale. Fifteen patients were comatose (GCS 4 or less): 11/15 patients were treated conservatively. Four patients with accompanying acute occlusive hydrocephalus were treated by placement of an external ventricular drainage. None survived. In nine patients (60%), arteriosclerosis and/or long-standing arterial hypertension were known and arteriopathic BSH was suspected. Forty-three patients were not comatose: 37 patients showed no impairment of consciousness (GCS 15), 6 patients presented with mild disturbance of conscious state (GCS 13), progressing to coma (GCS 8) in 1. In the majority (36/43) of the non-comatose patients (83.7%) cavernoma could be revealed and removed surgically. In six patients (14%), an atypically located arteriopathic BSH was assumed and treated medically. One patient had an underlying brainstem arteriovenous malformation and was treated radiosurgically. Many arteriopathic BSH cause immediate coma indicating direct and irreversible damage of midpontine structures. Thus, we suggest not to proceed to surgery, even if the bleeding is accompanied by acute hydrocephalus. The majority of BSH not resulting in immediate coma are caused by underlying cavernomas. In these cases surgery should be considered. [ABSTRACT FROM AUTHOR]