Emergency surgery for brainstem cavernoma haemorrhage with severe neurological presentation. Is it indicated and worthwhile?

Abstract

Background: Brainstem Cavernoma (BSCM) haemorrhage is a complex condition, especially when patients present rapid neurological deterioration. Traditionally, these patients were initially treated by non-interventional means. Surgery was generally reserved for cases who presented a ‘benign’ evolution in a subacute/delayed fashion. Timing of surgery remains controversial. Since rebleeding is frequent and carries a high mortality, many of these patients do not tolerate this approach. Urgent/emergent surgery may be indicated and lifesaving.

Methods: A single center experience is reported in which an aggressive approach was used with urgent/emergency surgery carried out on patients with BSCM haemorrhage and rapid neurological deterioration, ventilatory impairment and/or coma. A review of 5 consecutive cases where urgent/emergent surgery was performed is presented. The pre-operative status, pre- and post-operative examinations, surgical approach and neurological residual deficits/outcomes are reported.

Results: Four females and one male with ages ranging from 36 to 66 years with rapid neurological deterioration, ventilatory impairment and/or coma were operated between 2011 and 2018. Favourable outcomes were observed with a modified Rankin Scale varying from 1 to 4. Cranial nerve deficits as well as motor and sensitive deficits were observed but all the patients recovered cognitive integrity.

Conclusions: Our small series reveals an acceptable outcome with ultra-early surgery. This approach appears to be a valid option when there is rapid neurological deterioration, respiratory impairment and/or early onset coma. However, further studies are required to elucidate the optimal strategy.

Keywords:

• Brainstem
• haemangioma
• cavernous
• intracranial haemorrhages
• craniotomy
• neurosurgery

Acknowledgements

The authors would like to thank Professor James Van Dellen for critical review and suggestions to improve this paper.

Authors’ contributions

Cristiano M. Antunes designed and wrote the article and also participated in acquisition, analysis and interpretation of data; Renata S.F. Marques, Maria J.S. Machado and Miguel A.R. Filipe made contributions writing the article and also participated in acquisition of data and critically revised the article; Leandro T.M. Marques contributed in neurological evaluation and registry of the patients in the last follow-up. João S. Fernandes contributed in the selection of most relevant images from patients’ exams. Carlos M.G. Alegria was the responsible surgeon in all presented cases and critically revised the article. All the authors approved the final version to be published.

Patient consent

All the patients have signed the informed consent to the submission of their case report for submission to this journal.

Disclosure statement

No potential conflict of interest was reported by the author(s).