CHICAGO—In select patients, brainstem cavernous malformations may be surgically treatable in children with acceptable morbidity, investigators at the Barrow Neurological Institute reported at a plenary of the American Association of Neurological Surgeons annual meeting here in April.
“Not every child with brainstem cavernous malformations should have surgery,” said the lead author of the study Gregory Lekovic, MD, PhD, chief neurosurgical resident at the Barrow Neurological Institute, St. Joseph's Hospital and Medical Center in Phoenix, AZ. “But our results show that in selected patients, surgery can be done safely and with appropriate morbidity.”
The senior author of the study was Robert Spetzler, MD, director of the Barrow Neurological Institute and chair of neurological surgery, chair of the division of neurological surgery, and director of neurological research.
The study included 27 patients (14 girls and 13 boys) ranging in age from two to 18 years. In 25 patients, lesion size was an average of 2.24 cm. Before surgery, 26 of 27 patients had had a history of 1.5 hemorrhages.
After surgery, neurologic functioning was the same or improved in 12 patients; 14 patients had new or worsening neurologic deficits. Over time, neurologic functioning improved as demonstrated by a Glasgow Outcome Scale (GOS) score of 3.95 in the 27 patients at the time of hospital discharge to a score of 4.6 in 23 patients at mean last follow up of 40 months. The GOS measures disability, and patients with a GOS of 4 or less are increasingly disabled.
Along with these good outcomes, however, the study found a surprisingly high rate of recurrence, said Dr. Lekovic; 22 percent of patients had bleeding after surgery — a rate that is higher than found in adults.
Although Dr. Lekovic and his colleagues expected the children to fare worse than adults, he emphasized that the study actually showed that the children only did worse in terms of their GOS at hospital discharge (as well as the recurrence rate).
“The overall rate of new deficits was actually very comparable between adults and children,” he said, adding that the children selected for surgery tended to have larger lesions than adults and presented with worse a neurological condition.
Given the difficulty of these cases, Dr. Lekovic urged neurosurgeons to recognize that these lesions are often treatable and that it is appropriate to refer these children to centers with experience in the surgical management of these lesions.
R. Michael Scott, MD, neurosurgeon-in-chief at the Children's Hospital in Boston, said the study highlights just how difficult these cases can be even in experienced hands. Dr. Scott, who was not involved with the study, said that rather than showing the surgery to be safe in children, it emphasizes the risk of the procedure.
“Surgery for brainstem cavernous malformations is fraught with hazards and even in the most skilled hands the complication rate has been demonstrated to be extremely high,” he said. “I don't operate on such patients unless the natural history of the lesion is clear or the patient requires urgent surgery because of life-threatening deficits.”
• Lekovic GP, et al. Surgical management of vavernous malformations of the brainstem presenting in childhood. Annual meeting of the American Association of Neurological Surgeons. April 29, 2008. Abstract 701.