Neurological and functional outcomes of 32 patients with hemorrhagic brainstem cavernous malformations: a practical guide for surgical planning

OBJECTIVE Brainstem cavernous malformations (BSCMs) were once considered inoperable. Microsurgical resection now represents a valuable option for treating patients with hemorrhagic or symptomatic lesions. The aim of this study was to provide a practical guide for surgical planning by analyzing postoperative neurological and functional outcomes. METHODS The early- and long-term neurological (National Institutes of Health Stroke Scale [NIHSS] score) and functional (modified Rankin Scale [mRS] and Glasgow Outcome Scale [GOS] scores) outcomes of 32 patients who underwent surgery for hemorrhagic BSCM were reviewed. The three-step surgical planning was based on an anatomosurgical algorithm. RESULTS Nine lesions (28.1%) were located in the mesencephalon, 19 (59.4%) in the pons, and 4 (12.5%) in the medulla. A fronto-temporo-orbito-zygomatic approach was selected to reach anterior mesencephalic BSCMs (2, 6.3%). A retrosigmoid approach and its extended variant were selected for lateral mesencephalic (6, 18.8%), anterior (2, 6.3%) and lateral (13, 40.6%) pontine, and anterior (1, 3.1%) and lateral (1, 3.1%) medullary BSCMs. A supracerebellar infratentorial approach was selected for posterior mesencephalic BSCMs (1, 3.1%). A telovelar approach was selected for posterior pontine (4, 12.5%) and medullary (2, 6.3%) BSCMs. Total resection was achieved in 29 cases (90.6%), with a 12.5% rate of surgical complications. The NIHSS score progressively improved at both the early (5.16 ± 3.70 vs 4.63 ± 2.78, p = 0.446) and late (4.63 ± 2.78 vs 2.41 ± 2.39, p < 0.001) postoperative evaluations. Functional outcomes showed an initial deterioration followed by a long-term improvement (mRS score: 2.66 ± 1.07 vs 3.06 ± 1.11 vs 2.13 ± 1.29, GOS score: 3.78 ± 0.61 vs 3.59 ± 0.62 vs 4.19 ± 0.78). Time to surgery significantly correlated with early- and long-term NIHSS, mRS, and GOS scores, while the number of hemorrhages before surgery correlated with early- and long-term mRS and GOS scores. CONCLUSIONS Early surgery after the first bleed following systematic surgical planning may be considered as an effective option for managing hemorrhagic BSCMs with acceptable operative morbidity and relatively favorable early- and long-term neurological and functional outcomes.