Brainstem Cavernous Malformations: Surgical Results in 104 Patients and a Proposed Grading System to Predict Neurological Outcomes
Brainstem Cavernous Malformations: Surgical Results in 104 Patients and a Proposed Grading System to Predict Neurological Outcomes
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DOI：
10.1227/neu.0000000000000602
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发表时间：
2015-03-01
期刊：
影响因子：
4.8
通讯作者：
Lawton, Michael T.
中科院分区：
文献类型：
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作者：
Garcia, Roxanna M.;Ivan, Michael E.;Lawton, Michael T.
背景：脑干海绵状血管瘤（BSCM）一度被认为是不可侵犯区域中不可手术的病变，但现在可以通过手术治愈，且手术发病率可接受。推荐手术是一个困难的决定，专门为 BSCM 设计的预测手术结果的分级系统将有助于做出这一决定。 目的：根据我们为动静脉畸形开发补充分级系统的努力，我们假设类似的系统可以预测长期结果并指导临床决策。方法：使用连续的、单外科医生系列的 104 名患者来评估显微手术的术前临床和影像学预测因素结果。单变量逻辑回归确定了预测变量，多变量逻辑回归模型测试了组合预测变量与最终修改后的Rankin量表分数的关联。分级系统根据病变大小、穿过脑干中点的位置、是否存在发育性静脉异常、年龄以及从最后一次出血到手术的时间进行评分。结果：BSCM 的平均最大直径为 19.5 毫米； 50%穿过轴向中点； 54.8%有发育性静脉异常；平均年龄为 42.1 岁；从最后一次出血到手术的中位时间为 60 天。 1 名患者死亡（0.96%），15 名患者（14.4%）出现脑神经或运动功能障碍恶化，其中 10 名患者改良 Rankin 量表评分增加（9.6%）。 BSCM 分级范围为 0 至 7 分，预测结果具有很高的准确性（接受者操作特征 = 0.86，95% 置信区间：0.78-0.94）。结论：我们没有为 BSCM 较弱的所有脑海绵状血管瘤开发一个分级系统，而是为最需要的患者提出一个系统。 BSCM 分级系统区分可能期望良好手术结果的患者，并为被迫选择这些患者的神经外科医生提供指导。
BACKGROUND: Once considered inoperable lesions in inviolable territory, brainstem cavernous malformations (BSCM) are now surgically curable with acceptable operative morbidity. Recommending surgery is a difficult decision that would be facilitated by a grading system designed specifically for BSCMs that predicted surgical outcomes.OBJECTIVE: Informed by our efforts to develop a supplementary grading system for arteriovenous malformations, we hypothesized that a similar system might predict long-term outcomes and guide clinical decision-making.METHODS: A consecutive, single-surgeon series of 104 patients was used to assess preoperative clinical and imaging predictors of microsurgical outcomes. Univariable logistic regression identified predictors and a multivariable logistic regression model tested the association of the combined predictors with final modified Rankin Scale scores. A grading system assigned points for lesion size, location crossing the brain-stem's midpoint, presence of developmental venous anomaly, age, and time from last hemorrhage to surgery.RESULTS: Average maximal diameter of BSCMs was 19.5 mm; 50% crossed the axial midpoint; 54.8% had developmental venous anomalies; mean age was 42.1 years; and median time from last hemorrhage to surgery was 60 days. One patient died (0.96%), and 15 patients (14.4%) experienced worsened cranial nerve or motor dysfunction, of which 10 increased their modified Rankin Scale scores (9.6%). BSCM grades ranged from 0 to 7 points and predicted outcomes with high accuracy (receiver operating characteristic = 0.86, 95% confidence interval: 0.78-0.94).CONCLUSION: Rather than developing a grading system for all cerebral cavernous malformations that is weak with BSCMs, we propose a system for the patients who need it most. The BSCM grading system differentiates patients who might expect favorable surgical outcomes and offers guidance to neurosurgeons forced to select these patients.