When is brainstem cavernous hemangioma operated?

When is brainstem cavernous hemangioma operated?  Introduction to surgical indications for brainstem cavernous hemangioma. 

When does brainstem cavernous hemangioma need surgery? What are the indications for surgery? It has always been a topic of great concern to patients, and brainstem cavernous hemangioma has plagued them as a time bomb. So when does brainstem cavernous hemangioma need surgery? There are about the following indications:

When does brainstem cavernous hemangioma need surgery?

Indication 1: Symptomatic BCMs

The diagnosis of BCMs is clear. The tumor has caused progressive and severe neurological dysfunction, or the appearance of focal neurological dysfunction or increased intracranial pressure, and the possibility of rebleeding is greater. In this case, surgical treatment should be performed in time to avoid high mortality and high disability rate due to sudden recurrence of brainstem hemorrhage.

Indication 2: Hemorrhage in the tumor and cause neurological dysfunction, especially if there are two or more hemorrhages confirmed by imaging examination

BCMs bleeding usually has obvious clinical symptoms, and the consequences are more serious. BCMs with a history of hemorrhage are more prone to rebleeding and repeated bleeding in the lesion, which leads to the continuous enlargement of the lesion, compressing the nerve nuclei and conduction bundles in the brainstem, and even causing neurological damage symptoms such as cranial nerve dysfunction and limb paralysis. Once the limbs are completely paralyzed, even if the lesion is completely removed, it is difficult to recover muscle strength after surgery. Therefore, for BCMs with clinical symptoms caused by tumor hemorrhage, especially patients with two or more bleedings confirmed by imaging examination, surgical resection of the lesion should be actively advocated.

Indication 3: The tumor is superficial, very suitable for surgical treatment

The hemorrhage of the lesion or tumor is close to the surface of the pia mater or the ependymal surface of the brainstem (≤3 mm), that is, BCMs are “exogenous” tumors, which are very suitable for surgical treatment. Some experts believe that: BCMs close to the surface of the brainstem (lesions, including hematomas, with a distance of less than 2 mm from the pia mater of the brainstem) should be treated surgically. For a single hemorrhage lesion (MRI confirmed as acute or subacute hemorrhage), if the lesion or hemorrhage breaks through the surface of the ventricle, brainstem pial membrane or the distance from the surface ≤ 2 mm, Samii and others also advocate surgery.

Indication 4: Repeated bleeding of the tumor, accompanied by neurological dysfunction, should be actively surgically removed

Tumor growth is closely related to repeated rupture and bleeding of thin-walled blood vessels, repeated epithelialization of the hematoma cavity, and neovascularization and tissue scarring after the hematoma is organized. Fritschi et al. reported 139 cases of BCMs. During the observation period of conservative treatment, 12 cases of tumors were found to be enlarged. Samii and others also believe that patients with multiple bleeding and neurological impairment should actively remove the tumor. Therefore, for repeated hemorrhagic BCMs (≥ 2 times), even if the lesion does not reach the surface of the brainstem, the best opportunity for surgery should be found.

Indication 5: The tumor is large in size and should be surgically removed

The size of the lesion (including tumor and hemorrhage) is large (the largest tumor diameter is ≥2.0 cm), and those who cause significant space-occupying effect should be surgically removed to eliminate the risk of further bleeding and increase in the tumor. Surgical removal of the lesion can not only have the effect of decompression, relieve the patient’s symptoms, and improve the efficacy of nerve function; it can also prevent the tumor from bleeding again. At the same time, tumors> 2 cm and peritumoral edema all indicate a higher risk of bleeding.

Indication 6: Surgical resection for deep BCMs

For BCMs in the deep brainstem, when the tumor is bleeding repeatedly, the symptoms are progressively worsening, or there is focal neurological dysfunction, or the neurological deficit that may be caused by the surgery itself in this area has appeared, even if the tumor is deeply located, It should be treated by surgery. Mathiesen et al. believe that if deep BCMs can achieve total tumor resection with a lower surgical risk, they also advocate surgery.

Indication 7: Treatment of special cases of BCMs such as children’s BCMs and pregnant women’s BCMs

Considering the long life expectancy of children, the cumulative risk of bleeding is high. Therefore, the surgical indications for children’s BCMs should be relatively relaxed. The existing literature suggests that the bleeding rate and rebleeding rate of children are several times higher than that of adults.

Surgery for children with BCMs can get a better prognosis. It is reported in the literature that the factors that affect the failure of the neurological function of children to recover completely after BCMs include: age> 12 years, 2 or more bleedings, and preoperative adverse conditions.

During pregnancy, BCMs should assess the risk of bleeding and the possibility of severe neurological dysfunction after bleeding, as well as the feasibility of surgery, pros and cons, and risks, and make decisions that are most beneficial to the patient.

The choice of indications for surgery and the best timing of surgery are the key to determining the efficacy of surgery.

To sum up: BCMs are caused by repeated bleeding or slow bleeding in the tumor, causing the tumor to increase acutely or slowly, compressing the important nerve nuclei and the upper and lower conduction bundles in the brainstem, causing cranial nerve dysfunction, as well as movement and Loss of nerve function such as sensory. If microsurgery is not taken in time to remove the lesions, the tumor may bleed again or repeatedly, which may induce a progressive increase in neurological dysfunction.

Early reports have reported that the mortality rate of conservative treatment of BCMs can be as high as 20%; at present, the total tumor resection rate of BCMs surgical treatment can reach more than 95%, and the mortality rate has dropped to 0-1.9%. The effect of surgical treatment is significantly better than conservative treatment (a consensus has been reached). In addition, the deep brainstem is adjacent to important nerve structures and the risk of surgery is high. Therefore, how to choose the indications for surgery and the best timing of surgery is to determine the effect of surgery key.

(source:internet, reference only)

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