Surgical treatment of cerebral cavernous hemangioma

Surgical treatment of cerebral cavernous hemangioma.   Cerebral cavernous hemangioma surgery: surgery or conservative?

Cavernous malformation (CMs) has always been regarded as an important clinicopathological classification of vascular malformations in the nervous system. CMs are classified as occult vascular malformations because no abnormal blood vessels are found in the angiography.

This term is used to describe all vascular malformations that are negative for angiography. Russell and Rubinstein used the term cavemousangioma in their accounts, which is a good indication of the pathology of this lesion.

This lesion is also called cavenous hemangio (cavernous hemangio) or caverno (cavernous hemangio). Tumor), but in recent years the name cavernous vascular malformation has been more and more widely accepted, which clearly distinguishes this disease from the real vascular tumors that use the term angionma.

Before CT was used, CMs were rarely diagnosed before surgery or before biopsy. CT can provide some help for diagnosis, especially in high-field magnetic resonance scans (after MRI was used, the specific imaging characteristics of CMs were found , So that many cases can be diagnosed. This not only improves the diagnosis of this disease, but also increases the number of reported cases of CMs.

In the treatment of patients with cavernous vascular malformations, it is usually necessary to consider whether to use surgical treatment or observe conservative treatment. Radiation therapy is rarely used, but the high complication rate and very ambiguous prognosis of this treatment hinder the use of this technology. As the natural history of this disease has become clear, we have made great progress in the indications and principles of decision-making and treatment.

Treatment options for cavernous hemangioma

For CMs patients, whether surgical treatment or observational treatment is used, the consequences and risks of treatment must be carefully compared. In some cases, radiation therapy can also be used. The patient’s age and medical conditions must also be taken into consideration. Because the experience of the treatment of this disease is still gradually improving, only some guidelines can be put forward here.

When is surgery needed?

At present, the very clear indications for surgical resection of CMs are repeated bleeding, progressive neurological deterioration, and refractory epilepsy, unless the location of the lesion is in a high-risk area that we cannot accept surgery. When the risk of surgery is high, observation and radiotherapy can be considered. Because most of the lesions are located in areas with lower surgical risk, such as those located in the brain or cerebellum with obvious bleeding, those who have seizures and those who are very worried about the existence of lesions, should be considered in these cases Surgical treatment.” In children, Scot et al. believe that “the principle of surgical treatment of cavernous hemangioma is that the lesion can be safely exposed, and there are symptoms caused by space occupation or bleeding, or epilepsy symptoms, or the lesion has had previous symptoms. History of bleeding”.

A special category of patients is young women who are about to become pregnant. Robinson et al. mentioned that two of the six patients they treated had acute bleeding during the first three months of pregnancy. Therefore, they believe that if a woman intends to become pregnant, it is also an indication for surgical removal of the lesion. In addition, some authors believe that this is related to changes in hormone levels. Aiha et al. reported that women accounted for the majority of bleeding patients, and young women had a higher rate of rebleeding.

Once the CMs are removed by surgery, the lesions can generally be removed completely, and the mortality rate is very low. This process becomes easy with the help of microsurgery. The glial tissue around the lesion is cut under a microscope, microsurgery technology is applied, and the surrounding area is carefully separated using bipolar electrocoagulation, micro-aspirator, etc. Clear interface. Once the lesion is exposed, the pressure inside the lesion is decompressed and the envelope of the lesion is retracted inward, which can prevent the surrounding normal brain tissue from increasing in pressure during the resection. When the lesion has obvious calcification, the ultrasonic aspirator can be used to remove the lesion. Bleeding is generally not a big problem during surgery.

Under what circumstances can it be observed?

Some patients with CMs should be observed conservatively. Almost all asymptomatic patients can be observed, because they may remain asymptomatic indefinitely. Even if there is bleeding afterwards, it is usually very small bleeding and will not cause serious neurological dysfunction. . Some other patients who need to be observed are those whose lesions are located in deep structures or cerebral cortex, and the neurological function has not improved or re-bleeds, and the danger of surgical treatment is obvious.

Some patients with headache or epilepsy without bleeding can also be observed, but such patients, as we talked about below, are also treated with surgery. Which treatment method is appropriate depends on changes in the clinical situation and the results of consultation with the patient himself. There is no clear guideline on how long to repeat MRI examinations. We usually do it once every 6 months for the first 2 years. If the lesion is relatively stable, then we will review it once a year in the future.

In the INC World Neurosurgery Advisory Group, Professor Bart Langfeld of Germany has spent more than 20 years on the brainstem cavernous hemangioma in the “forbidden zone” of surgery, and has achieved excellent clinical results. The small brainstem can be affected according to the characteristics of tumor growth. More than a dozen surgical approaches. Professor Bart Langfei believes that the principle of surgical treatment of brainstem cavernous hemangioma is to remove the lesion as much as possible and to protect the normal brainstem tissue as much as possible. For this reason, the correct surgical approach and morphological characteristics should be selected according to the specific location and morphological characteristics of tumor growth. The choice of safe brainstem safe zone incision, proper surgical technique, and application of surgical auxiliary facilities are particularly important.

Professor Bart Langfei said: We can almost achieve 100% removal of brainstem cavernous hemangioma, and in a few cases it is impossible to achieve 100% because it faces a high-risk situation. No one wants to have such a high risk, so the surgeon must evaluate it during the operation, which is what I am doing. In most cases, 95% can achieve 100% tumor or cavernous hemangioma resection.

(source:internet, reference only)

Disclaimer of medicaltrend.org