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Surgery Indicated for Treatment of Brainstem Cavernous Malformations in Children Despite Higher Morbidity Rates: Presented at AANS

By Mary Beth Nierengarten

CHICAGO -- May 5, 2008 -- Children surgically treated for brainstem cavernous malformations (BSCMs) have higher rates of morbidity following surgery than do adults, but despite this increased morbidity, surgery is indicated for those with accessible symptomatic lesions given the good clinical outcome, according to a patient chart review.

Gregory P. Lekovic, MD, PhD, Chief Neurosurgical Resident, Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, discussed the findings in an oral presentation on April 29 here at the 76th Annual Meeting of the American Association of Neurological Surgeons (AANS).

To better understand the role of surgery in the management of children with BSCMs, Dr. Lekovic and colleagues looked at their institutional experience by conducting a retrospective review of the charts of patients who were aged up to 18 years at the time of undergoing surgery between 1984 and 2006.

Overall, 14 girls and 13 boys were identified, aged from 2 to 18 years (mean of 12.3 years). The majority of patients were Caucasian (n = 21), followed by Hispanic (n = 5), and Asian (n = 1). Imaging was obtained the day following surgery and yearly thereafter in all patients.

The chart review found that 26 of 27 patients presented with an average of 1.5 episodes of haemorrhage before surgery per patient. After surgery, the retrospective haemorrhage rate was 12%, and the rate of repeat bleeds was 29%.

"In our experience, paediatric BSCMs may be larger at presentation and have higher rates of retrospective bleed rates than adults," said lead author of the study, "but similar rebleed rates as adults."

According to the author, caution is needed in interpreting the 12% retrospective haemorrhage rate, given that it is based on the assumption that the lesions were present since birth. Lesion size at presentation in 25 of the patients was an average of 2.24 cm.

With a mean follow-up of 27 months, 6 patients showed recurrence on imaging. Of these patients, 4 had clinical haemorrhage, 1 underwent repeat surgery, and 1 died. Overall, 9 patients had worsening of existing neurological deficits or new postoperative deficits. The deficits resolved in 5 patients and persisted in 4 patients.

At last follow-up, 23 patients had a mean Glasgow Outcome Scale score of 4.3 out of 5; the score following discharge from hospital after surgery was 3.95 out of 5 in 27 patients. Overall, these are good outcomes, said the author.

Although children with BSCMs are more likely to recur than adults after surgery and have a higher rate of haemorrhage, the authors concluded that this morbidity rate is acceptable given the excellent clinical outcomes, and that "surgery is indicated in patients presenting with surgically accessible symptomatic lesions."


[Presentation title: Surgical Management of Cavernous Malformations of the Brainstem Presenting in Childhood. Abstract 701]

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