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Microsurgical treatment and outcome of pediatric supratentorial cerebral cavernous malformation.

Noh JH, Cho KR, Yeon JY, Seol HJ, Shin HJ - J Korean Neurosurg Soc (2014)

Bottom Line: In selected cases, transparent tubular retractor system (TTRS) was used to reduce retraction injury and intraoperative neuromonitoring (IONM) was held to preserve functioning cortex.In the 29 operated children, the overall long-term results were satisfactory : 25 (86%) patients had no signs or symptoms associated with CMs, 3 had controllable seizures, and 1 had mild weakness.With the assistance of neuronavigation systems, intraoperative neuromonitoring, and TTRS, CMs could be targeted more accurately and excised more safely.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT

Objective: The purpose of this study was to investigate the clinical features and outcomes of pediatric cavernous malformation (CM) in the central nervous system.

Methods: Twenty-nine pediatric patients with supratentorial CM underwent microsurgical excision. In selected cases, transparent tubular retractor system (TTRS) was used to reduce retraction injury and intraoperative neuromonitoring (IONM) was held to preserve functioning cortex. Patients' demographics and symptoms were reviewed and surgical outcomes were discussed.

Results: THE MAIN INITIAL CLINICAL MANIFESTATIONS INCLUDED THE FOLLOWING : seizures (n=13, 45%), headache (n=7, 24%), focal neurological deficits (n=3, 10%), and an incidental finding (n=6, 21%). Overt hemorrhage was detected in 7 patients (24%). There were 19 children (66%) with a single CM and 10 (34%) children with multiple CMs. In 7 cases with deep-seated CM, we used a TTRS to minimize retraction. In 9 cases which location of CM was at eloquent area, IONM was taken during surgery. There was no major morbidity or mortality after surgery. In the 29 operated children, the overall long-term results were satisfactory : 25 (86%) patients had no signs or symptoms associated with CMs, 3 had controllable seizures, and 1 had mild weakness.

Conclusion: With the assistance of neuronavigation systems, intraoperative neuromonitoring, and TTRS, CMs could be targeted more accurately and excised more safely. Based on the satisfactory seizure outcome achieved, complete microsurgical excision in children is recommended for CMs presenting with seizures but removal of hemosiderin-stained areas seems to be unnecessary.

No MeSH data available.


Related in: MedlinePlus

Preoperative MRI of 15-year-old boy showed multiple dark signal structures including right parieto-occipital area (A). Transparent tubular retraction system (TTRS) was inserted via minimal corticotomy. Without wide cortical incision and excessive parenchymal retraction, competent surgical view and flexible working space through TTRS was achieved (B). MRI performed at 3 month after surgery did not show a residual lesion, but dark signal intensity was observed in T2WI, which indicates that the hemosiderin-stained area was left behind (C).
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Figure 2: Preoperative MRI of 15-year-old boy showed multiple dark signal structures including right parieto-occipital area (A). Transparent tubular retraction system (TTRS) was inserted via minimal corticotomy. Without wide cortical incision and excessive parenchymal retraction, competent surgical view and flexible working space through TTRS was achieved (B). MRI performed at 3 month after surgery did not show a residual lesion, but dark signal intensity was observed in T2WI, which indicates that the hemosiderin-stained area was left behind (C).

Mentions: We used intraoperative ultrasonography in the earlier cases (n=4). A frameless navigation system (BrainLab, Feldkirchen, Germany) has been applied in 24 patients since 2006. The navigation system helped us to choose the shortest pathway to a deeply located lesion and to remove the lesion precisely with mini-craniotomy (Fig. 1). We used the transparent tubular retraction system (TTRS) in 7 patients who had the lesion in a deep-seated region to minimize the incidence of retraction injury to the normal parenchyma and secure an adequate working space for gross removal of the lesion (Fig. 2). We have previously reported the feasibility of TTRS in patients with deep-seated tumors13). When the lesion was located in an eloquent area, especially in the primary motor cortex or descending pyramidal tracts, intraoperative monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEPs) were performed. In all cases, immediate postoperative CT was performed to detect hemorrhagic complications. MRI was taken postoperatively to detect residual lesions as well as late complications. In seizure patients, residual hemosiderin-stained areas were assessed on MRI for confirming the role of hemosiderin in seizure patients.


Microsurgical treatment and outcome of pediatric supratentorial cerebral cavernous malformation.

Noh JH, Cho KR, Yeon JY, Seol HJ, Shin HJ - J Korean Neurosurg Soc (2014)

Preoperative MRI of 15-year-old boy showed multiple dark signal structures including right parieto-occipital area (A). Transparent tubular retraction system (TTRS) was inserted via minimal corticotomy. Without wide cortical incision and excessive parenchymal retraction, competent surgical view and flexible working space through TTRS was achieved (B). MRI performed at 3 month after surgery did not show a residual lesion, but dark signal intensity was observed in T2WI, which indicates that the hemosiderin-stained area was left behind (C).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4217061&req=5

Figure 2: Preoperative MRI of 15-year-old boy showed multiple dark signal structures including right parieto-occipital area (A). Transparent tubular retraction system (TTRS) was inserted via minimal corticotomy. Without wide cortical incision and excessive parenchymal retraction, competent surgical view and flexible working space through TTRS was achieved (B). MRI performed at 3 month after surgery did not show a residual lesion, but dark signal intensity was observed in T2WI, which indicates that the hemosiderin-stained area was left behind (C).
Mentions: We used intraoperative ultrasonography in the earlier cases (n=4). A frameless navigation system (BrainLab, Feldkirchen, Germany) has been applied in 24 patients since 2006. The navigation system helped us to choose the shortest pathway to a deeply located lesion and to remove the lesion precisely with mini-craniotomy (Fig. 1). We used the transparent tubular retraction system (TTRS) in 7 patients who had the lesion in a deep-seated region to minimize the incidence of retraction injury to the normal parenchyma and secure an adequate working space for gross removal of the lesion (Fig. 2). We have previously reported the feasibility of TTRS in patients with deep-seated tumors13). When the lesion was located in an eloquent area, especially in the primary motor cortex or descending pyramidal tracts, intraoperative monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEPs) were performed. In all cases, immediate postoperative CT was performed to detect hemorrhagic complications. MRI was taken postoperatively to detect residual lesions as well as late complications. In seizure patients, residual hemosiderin-stained areas were assessed on MRI for confirming the role of hemosiderin in seizure patients.

Bottom Line: In selected cases, transparent tubular retractor system (TTRS) was used to reduce retraction injury and intraoperative neuromonitoring (IONM) was held to preserve functioning cortex.In the 29 operated children, the overall long-term results were satisfactory : 25 (86%) patients had no signs or symptoms associated with CMs, 3 had controllable seizures, and 1 had mild weakness.With the assistance of neuronavigation systems, intraoperative neuromonitoring, and TTRS, CMs could be targeted more accurately and excised more safely.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT

Objective: The purpose of this study was to investigate the clinical features and outcomes of pediatric cavernous malformation (CM) in the central nervous system.

Methods: Twenty-nine pediatric patients with supratentorial CM underwent microsurgical excision. In selected cases, transparent tubular retractor system (TTRS) was used to reduce retraction injury and intraoperative neuromonitoring (IONM) was held to preserve functioning cortex. Patients' demographics and symptoms were reviewed and surgical outcomes were discussed.

Results: THE MAIN INITIAL CLINICAL MANIFESTATIONS INCLUDED THE FOLLOWING : seizures (n=13, 45%), headache (n=7, 24%), focal neurological deficits (n=3, 10%), and an incidental finding (n=6, 21%). Overt hemorrhage was detected in 7 patients (24%). There were 19 children (66%) with a single CM and 10 (34%) children with multiple CMs. In 7 cases with deep-seated CM, we used a TTRS to minimize retraction. In 9 cases which location of CM was at eloquent area, IONM was taken during surgery. There was no major morbidity or mortality after surgery. In the 29 operated children, the overall long-term results were satisfactory : 25 (86%) patients had no signs or symptoms associated with CMs, 3 had controllable seizures, and 1 had mild weakness.

Conclusion: With the assistance of neuronavigation systems, intraoperative neuromonitoring, and TTRS, CMs could be targeted more accurately and excised more safely. Based on the satisfactory seizure outcome achieved, complete microsurgical excision in children is recommended for CMs presenting with seizures but removal of hemosiderin-stained areas seems to be unnecessary.

No MeSH data available.


Related in: MedlinePlus