Brainstem cavernous malformations: 1390 surgical cases from the literature

Objective: Although surgical resection of brainstem cavernous malformations (CM) has been reviewed, numerous large surgical series have been recently reported. Methods: Eighteen new surgical series with 710 patients were found via a PubMed search, in addition to our previous meta-analysis. Complete excision, complications, and long-term outcome results were compiled across these series. They were then compared and subsequently combined with those of our previous report. Results: We combined results of 68 surgical series with 1390 patients, incorporating results from our previous meta-analysis. Across 61 series, 1178 of 1291 (91%) CMs were completely excised. Of 105 partially resected CMs with ample follow-up, 65 rebled (62%). Across 46 series providing information on early neurologic morbidity, the overall rate was 45%. Specifically, 12% of patients required tracheostomy and/or gastrostomy procedures. Overall long-term condition was improved in 62% of patients across 51 series. Across 60 series, overall long-term condition was improved or the same in 84% of patients, with worsening in the remaining 16%. The overall surgical and/or cavernoma related mortality rate for all 1390 patients was 1.5%. Notably, these results did not differ significantly between our initial review and the combined data from the subsequent 18 surgical series recently reported in the literature. Conclusion: Surgical resection of brainstem CM continues to present a considerable challenge with resultant morbidity akin to another CM hemorrhage. We therefore prefer to offer surgery only to patients with at least one previous hemorrhage with CM pial representation. Appropriate patient counseling about expected early morbidity and the potential for long-term worsening is crucial.