Minimally Invasive Parafascicular Surgery for Resection of Cerebral Cavernous Malformations Utilizing Image-Guided BrainPath System

2018 ◽  
Vol 17 (4) ◽  
pp. 348-353 ◽  
Author(s):  
Oded Goren ◽  
Christoph J Griessenauer ◽  
Christian O Bohan ◽  
Christopher M Berry ◽  
Clemens M Schirmer
Keyword(s):  
Minimally Invasive ◽  
Wound Dehiscence ◽  
The United States ◽  
Cerebral Cavernous Malformations ◽  
Cavernous Malformations ◽  
Minimal Impact ◽  
Image Guided ◽  
Small Series ◽  
Surgical Wound Dehiscence

Abstract BACKGROUND The minimally invasive parafascicular approach provides a surgical corridor to reach deep lesions with minimal impact on the surrounding brain tissue. OBJECTIVE To evaluate the safety and efficacy of this approach utilizing the image-guided tubular BrainPath system (NICO Corp, Indianapolis, Indiana) for the resection of deep and subcortical supratentorial cerebral cavernous malformations (CCMs). METHODS We performed a retrospective analysis of patients who presented with subcortical CCMs treated with the BrainPath system. Patient demographics, clinical presentation, procedural complications, and clinical and imaging follow-up information were assessed. RESULTS Six patients were identified between December 2014 and November 2017 at a large volume academic institution in the United States. There were 3 males and 3 female patients with a median age of 25 yr. Locations included frontal, temporal, and parietal lobes. In selected cases, the fiber-sparing trajectory imposed a longer approach than the closest distance to the brain surface. Except for 1 patient who suffered from surgical wound dehiscence, there were no operative complications in any of the cases. All patients remained neurologically stable postoperatively with a mean follow-up of 20 moh. CONCLUSION This small series suggests that the use of a minimally invasive surgical approach to CCMs utilizing the image-guided parafascicular tubular BrainPath system is feasible, safe, and effective.

Abstract 159: Exceptional Aggressiveness of CCM3 Phenotype

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Tania J Rebeiz ◽  
Abdul Ghani Mikati ◽  
Darlene Simkhin ◽  
Cornelia Lee ◽  
Amy Akers ◽  
...  
Keyword(s):  
Spontaneous Mutation ◽  
Mutation Screening ◽  
High Sensitivity ◽  
Skin Lesions ◽  
Cerebral Cavernous Malformations ◽  
Cognitive Disability ◽  
Cavernous Malformations ◽  
Patient Advocacy Group ◽  
Sporadic Cases

Introduction: Familial forms of cerebral cavernous malformations (CCM) account for about 1/3 of cases, involving autosomal dominant inheritance at 1 of 3 gene loci. Few studies have examined any special features of the rarest cases with CCM3 (PDCD10 ) mutation at q3, constituting <15 % of probands genotyped by sequential mutation screening, and <2% of CCM cases at large. Hypothesis: We hypothesize that CCM3 cases have unique phenotypic features not recognized in the more common CCM1 and 2 families, or in sporadic cases. Methods: Twelve probands including 17 subjects with confirmed CCM3 mutations were prospectively enrolled through systematic facilitated referral by the patient advocacy group Angioma Alliance. Clinical features were catalogued, including high sensitivity susceptibility weighted imaging (SWI). Rates of overt hemorrhage were determined based on adjudicated criteria. Comparisons were made to systematic literature review of natural history data on non-CCM3 cases. Results: The first overt hemorrhage occurred most often in the 1st decade of life (mean age 5.8). Nine of 17 subjects (52%) suffered 30 overt hemorrhages, with an estimated incidence of 6.7 % /patient/year based on exposure risk since birth, and 17% /patient/year based on risk since first symptom onset. Lesion burden on SWI was exceptionally high, >100 lesions in 28%, and > 20 lesions in 72% of cases, respectively. Adjusted bleed rate was <0.5% /lesion/year. New SWI lesions formed at a rate of 2.7/patient/year in prospective follow-up, and 1.8/patient/year based on years since birth. Scoliosis was found in 47% (an association not recognized previously), skin lesions in 29.4%, and brain tumors in 29.4% of cases, respectively. Cognitive disability affected 47% of cases, mostly in association with high lesion burden. Six of 15 cases with parental screening (40%) represented a spontaneous mutation. Conclusion: CCM3 is exceptionally aggressive compared to other familial and sporadic CCM. High risks of bleeding and cognitive disability mostly reflect severe lesion burden early in life, rather than a higher risk per lesion. These results will inform the design of clinical trials, urgently needed to address this unique CCM cohort.

scholarly journals Magnetic Resonance Thermometry-Guided Stereotactic Laser Ablation of Cavernous Malformations in Drug-Resistant Epilepsy: Imaging and Clinical Results

2015 ◽  
Vol 12 (1) ◽  
pp. 39-48 ◽  
Author(s):  
D Jay McCracken ◽  
Jon T Willie ◽  
Brad A Fernald ◽  
Amit M Saindane ◽  
Daniel L Drane ◽  
...  
Keyword(s):  
Laser Ablation ◽  
Magnetic Resonance ◽  
Minimally Invasive ◽  
Real Time ◽  
Refractory Epilepsy ◽  
Acute Hemorrhage ◽  
Cavernous Malformations ◽  
Remote Imaging ◽  
Medically Refractory Epilepsy

Abstract BACKGROUND Surgery is indicated for cerebral cavernous malformations (CCMs) that cause medically refractory epilepsy. Real-time magnetic resonance thermography (MRT)-guided stereotactic laser ablation (SLA) is a minimally invasive approach to treating focal brain lesions. SLA of CCM has not previously been described. OBJECTIVE To describe MRT-guided SLA, a novel approach to treating CCM-related epilepsy, with respect to feasibility, safety, imaging, and seizure control in 5 consecutive patients. METHODS Five patients with medically refractory epilepsy undergoing standard presurgical evaluation were found to have corresponding lesions fulfilling imaging characteristics of CCM and were prospectively enrolled. Each underwent stereotactic placement of a saline-cooled cannula containing an optical fiber to deliver 980-nm diode laser energy via twist drill craniostomy. MR anatomic imaging was used to evaluate targeting before ablation. MR imaging provided evaluation of targeting and near real-time feedback regarding the extent of tissue thermocoagulation. Patients maintained seizure diaries, and remote imaging (6-21 months postablation) was obtained in all patients. RESULTS Imaging revealed no evidence of acute hemorrhage following fiber placement within presumed CCM. MRT during treatment and immediate postprocedure imaging confirmed the desired extent of ablation. We identified no adverse events or neurological deficits. Four of 5 (80%) patients achieved freedom from disabling seizures after SLA alone (Engel class 1 outcome), with follow-up ranging 12 to 28 months. Reimaging of all subjects (6-21 months) indicated lesion diminution with surrounding liquefactive necrosis, consistent with the surgical goal of extended lesionotomy. CONCLUSION Minimally invasive MRT-guided SLA of epileptogenic CCM is a potentially safe and effective alternative to open resection. Additional experience and longer follow-up are needed.

scholarly journals Supratentorial cerebral cavernous malformations: clinical, surgical, and genetic involvement

2006 ◽  
Vol 21 (1) ◽  
pp. 1-7 ◽  
Author(s):  
Vincenzo Antonio D'Angelo ◽  
Costanzo De Bonis ◽  
Rosina Amoroso ◽  
Alessandro Calì ◽  
Leonardo D'Agruma ◽  
...  
Keyword(s):  
Mutational Analysis ◽  
Family Members ◽  
Neurological Deficits ◽  
Cerebral Cavernous Malformations ◽  
Cavernous Malformations ◽  
Psychological Burden ◽  
Management Algorithm ◽  
Screening Protocol

Object Although there is general agreement on the methods of treatment for symptomatic supratentorial cerebral cavernous malformations (CMs) located in noneloquent areas, some controversy exists regarding the management of cerebral CMs that are asymptomatic and/or located in eloquent or deep areas. Moreover, recent advances in genetic findings could influence both standard clinical management and the follow-up strategy in affected individuals. Thus, the objective of this study was to develop, based on the authors' experience and a literature review, a management algorithm to deal with supratentorial cerebral CMs. Methods The authors retrospectively reviewed the clinical data related to 118 patients who underwent surgery for symptomatic supratentorial cerebral CMs at their institution. Twenty-eight of 118 patients harbored multiple lesions, and nine of these 28 patients had a clinically positive familial history. Genetic investigations were performed in 89 patients (75%). Conclusions Surgery for supratentorial cerebral CMs in noneloquent locations is safe and curative. In cerebral CMs located in deep and eloquent areas and with symptoms including progressive neurological deficits, evidence of hemorrhage, and uncontrolled seizures, surgical treatment according to an integrated plan based on frameless stereotactic guidance and functional magnetic resonance imaging is recommended and results in acceptably low morbidity. The data support the need for long-term imaging follow up in all patients, careful preoperative vascular studies to detect associated venous anomalies, and the importance of genetic mutational analysis. The DNA screening protocol will change the care of family members of patients with familial forms of cerebral CMs, because affected asymptomatic family members may benefit by early detection of lesions. At the same time, the exclusion of family members who are not carriers of the mutation as members of the population at risk reduces the economic and psychological burden of clinical and instrumental monitoring.

scholarly journals Surgical Treatment of Brainstem Cavernous Malformations with Three Basic Skull Base Approaches and Minimally Invasive Techniques: Observations in 20 Patients

2017 ◽  
Vol 3 (2) ◽  
pp. 74-83
Author(s):  
Wen Yin ◽  
Jianrong Ma ◽  
Yiwei Liao
Keyword(s):  
Minimally Invasive ◽  
Skull Base ◽  
Surgical Approach ◽  
Cavernous Malformation ◽  
Minimally Invasive Techniques ◽  
Cavernous Malformations ◽  
Bleeding Episodes ◽  
Surgical Treatments ◽  
Invasive Techniques

Objective Brainstem cavernous malformation (BSCM) is extremely challenging for neurosurgeons in terms of surgical approach choices. In this article, we summarized our experience in skull base approaches of BSCM, and elucidated the advance of surgical treatments of brain stem cavernous malformation through reviewing recent relevant articles. Methods We retrospectively reviewed 20 consecutive patients who underwent resection between May 1, 2014 and April 30, 2016. Only midline suboccipital, subtemporal approach and retrosigmoid approach were used in this series. The diagnoses of all patients were confirmed by radiological and histological examination. Results All 20 patients were completely extirpated without surgical-related mortality. The mean follow-up period was 9.5 months (range, 2-20 months). Of the 20 patients, 80% symptomatic patients underwent surgery after first bleeding episode within 3 months, 20% after two or more bleeding episodes by magnetic resonance imaging. After resection and during follow-up, 75% of patients had an improvement in their modified Rankin scale (mRS) scores, whereas 10% were worse compared with their preoperative presentation; 15% were unchanged. Conclusion Appropriate basic surgical approach and minimally invasive techniques are necessary in preventing impairment of neurologic function. The three common basic skull base approaches, combined with minimally invasive techniques can handle most of BSCMs with good surgical results.

Natural Course of Cerebral Cavernous Malformations in Children: A Five-Year Follow-Up Study

Stroke ◽  
2021 ◽  
Author(s):  
Alejandro N. Santos ◽  
Laurèl Rauschenbach ◽  
Dino Saban ◽  
Bixia Chen ◽  
Annika Herten ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Brain Stem ◽  
Odds Ratio ◽  
Pediatric Patients ◽  
Cox Regression ◽  
Cerebral Cavernous Malformations ◽  
Multivariate Logistic Regression ◽  
Cavernous Malformations ◽  
History Of

Background and Purpose: The purpose of this study was to investigate the natural course of cerebral cavernous malformations (CCM) in the pediatric population, with special emphasis on the risk of first and recurrent bleeding over a 5-year period. Methods: Our institutional database was screened for patients with CCM treated between 2003 and 2020. Patients ≤18 years of age with complete magnetic resonance imaging data set, clinical baseline characteristics, and ≥1 follow-up examination were included. Surgically treated individuals were censored after CCM removal. We assessed the impact of various parameters on first or recurrent intracerebral hemorrhage (ICH) at diagnosis using univariate and multivariate logistic regression adjusted for age and sex. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for (re)hemorrhage. Results: One hundred twenty-nine pediatric patients with CCM were analyzed. Univariate logistic regression identified brain stem CCM (odds ratio, 3.15 [95% CI, 1.15−8.63], P =0.026) and familial history of CCM (odds ratio, 2.47 [95% CI, 1.04−5.86], P= 0.041) as statistically significant predictors of ICH at diagnosis. Multivariate logistic regression confirmed this correlation (odds ratio, 3.62 [95% CI, 1.18−8.99], P= 0.022 and odds ratio, 2.53 [95% CI, 1.07−5.98], P =0.035, respectively). Cox regression analysis identified ICH as mode of presentation (hazard ratio, 14.01 [95% CI, 1.80−110.39], P= 0.012) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of (re)bleeding was 15.9% (95% CI, 10.2%−23.6%) for the entire cohort, 30.2% (20.2%−42.3%) for pediatric patients with ICH at diagnosis, and 29.5% (95% CI, 13.9%−51.1%) for children with brain stem CCM. Conclusions: Pediatric patients with brain stem CCM and familial history of CCM have a higher risk of ICH as mode of presentation. During untreated 5-year follow-up, they revealed a similar risk of (re)hemorrhage compared to adult patients. The probability of (re)bleeding increases over time, especially in cases with ICH at presentation or brain stem localization.

scholarly journals Antithrombotic medication and bleeding risk in patients with cerebral cavernous malformations: a cohort study

2019 ◽  
Vol 130 (6) ◽  
pp. 1922-1930
Author(s):  
David Bervini ◽  
Christian Jaeggi ◽  
Pasquale Mordasini ◽  
Philippe Schucht ◽  
Andreas Raabe
Keyword(s):  
Bleeding Risk ◽  
Cerebral Cavernous Malformations ◽  
Cavernous Malformations ◽  
Vascular Abnormalities ◽  
Increased Risk ◽  
Potential Risk Factors ◽  
Hemorrhagic Risk ◽  
Risk Of Hemorrhage ◽  
Antithrombotic Medication

OBJECTIVECerebral cavernous malformations (CCMs) are frequently diagnosed vascular abnormalities. The hemorrhagic risk associated with the use of long-term antithrombotic medication (ATM) in patients with CCMs is a matter of controversy. The aim of this study was to determine the hemorrhagic risk associated with ATM use in patients diagnosed with one or more CCMs.METHODSDemographic, clinical, treatment, and ATM-related information on patients diagnosed with one or more CCMs at a single institution over more than 34 years was retrospectively recorded. Univariate and multivariate descriptive and survival analyses were used to assess potential risk factors associated with CCM-related hemorrhage at presentation and during follow-up (first or subsequent hemorrhage).RESULTSA total of 408 patients were included in the analysis and 492 CCMs were followed up after diagnosis, for a total of 1616 lesion-years. Thirty-seven (7.5%) CCMs bled during follow-up, leading to an overall annual rate of CCM-related symptomatic hemorrhage of 2.3% (95% CI 1.7%–3.2%). Eighty-two patients harboring 91 CCMs (16.8%) were on ATM. When stratified for ATM, the annual rates of hemorrhage were 0.7% (95% CI < 0.01% to 4.2%) for the lesions in patients on ATM versus 2.5% (95% CI 1.8%–3.4%) for those not on ATM. ATM was not found to be associated with either an increased risk of CCM-related hemorrhage at presentation (p = 0.355) or an increased risk of CCM-related hemorrhage (first or subsequent hemorrhage) in multivariate descriptive (p = 0.912) and survival (p = 0.145) analyses.CONCLUSIONSThe use of ATM does not seem to be associated with an increased risk of hemorrhage in patients diagnosed with CCMs.

scholarly journals Brief hospitalization protocol for pressure ulcer surgical treatment: outpatient care and one-stage reconstruction

2017 ◽  
Vol 44 (6) ◽  
pp. 574-581 ◽  
Author(s):  
Dimas André Milcheski ◽  
Rogério Rafael da Silva Mendes ◽  
Fernando Ramos de Freitas ◽  
Guilherme Zaninetti ◽  
Araldo Ayres Moneiro Júnior ◽  
...  
Keyword(s):  
Outpatient Care ◽  
Wound Dehiscence ◽  
Surgical Wound ◽  
Surgical Wound Dehiscence ◽  
Complex Wound ◽  
One Stage Reconstruction ◽  
New Surgery ◽  
Selection Of Patients ◽  
Selection Of

ABSTRACT Objective: to evaluate a brief hospitalization protocol for the treatment of pressure ulcers, proposed by the Complex Wound Group of Clinical Hospital of University of Sao Paulo Medical School, particularly in regard to selection of patients, hospitalization time, cutaneous covering, complications and sore recurrence. Methods: retrospective cohort of 20 consecutive patients with 25 pressure lesions Grade IV. All patients were ambulatorily prepared and were hospitalized for surgical one time procedure for pressure lesion closing. Results: in total, 27 flaps were performed to close 25 wounds. Three patients showed minor dehiscence (11.1%). There was no recurrence during the post-surgical follow-up period. No patient suffered a new surgery and no flap showed partial or total necrosis. Median time of hospitalization was 3.6 days (2-6 days) and median follow-up was 91 months (2-28 months). All patients maintained their lesions closed, and there was no recurrence during follow-up. Conclusion: the brief hospitalization protocol was considered adequate for the resolution of pressure wounds, showing an average time of hospitalization of 3.6 days and rate of minor surgical wound dehiscence of 11.1%.

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