Thirty-one cases of intracerebral cavernous hemangioma were admitted to our department since 1997 and treated by microsurgery with satisfactory results, as reported below.
1 Clinical data 1.1 General data: 22 cases in men and 19 cases in women, age 14~53 years, average 33 years, duration of disease 4 hours~12 years. Symptoms and signs: mostly sudden onset of hemorrhage, headache and inactivity of one limb in 5 cases, recurrent seizures in 4 cases, cranial nerve damage in 14 cases, vertigo in 11 cases, ataxia in 8 cases, crossed mild paralysis in 4 cases, impaired consciousness in 4 cases, obstructive hydrocephalus in 2 cases, and asymptomatic in 3 cases with incidental finding by CT examination. Zhang Rongwei, Department of Neurosurgery, General Hospital of Jinan Military Region
1.2 Tumor location: 6 cases with lesions located in frontal lobe, 1 case with huge lesion from frontoparietal area cortex to subventricular canal, 4 cases with functional area of parietal lobe, 1 case with basal ganglia of insula, 1 case with posterior temporal, 3 cases with one side of cerebral peduncle, 9 cases with pontocerebrum and pontocerebral arm, 4 cases with pontocerebrum-medulla, 2 cases with medulla oblongata.
1.3 Imaging CT scan: 27 cases were found to have intra-brainstem hemorrhage in the corresponding area, and no abnormality was found in 4 cases. MRI: in the 4 patients with no abnormality found by CT, T1 low signal and T2 high signal occupying shadows were found in the pontocerebral arm and medulla oblongata, and the enhancement effect was obvious; 3 cases had hemorrhage in the pontocerebral extension, and 1 of them broke into the four ventricles, and there was enhancement around the hematoma; in the cases with intra-brainstem hematoma found by CT, MRI was found in In the cases of intracerebral hematoma detected by CT, MRI found spherical or sphere-like hemorrhagic signals at the corresponding sites, and there were isosignal focal shadows within the hemorrhagic foci or on the lateral wall, and the foci had reinforcing effects. The hemispheric lesions larger than 3 cm had the following imaging commonalities: CT showed irregular mixed density shadow in the brain with uneven density and scattered calcification shadow in the brain, MRI showed abnormal cauliflower-like signal in the brain with multiple cystic lesions with irregular enhancement and no peri-tumor edema, and no obvious abnormal vascular shadow in CTA or DSA.
1.4 Surgical approach: the hemispheric lesion was craniotomized with the nearest bone flap; the brainstem lesion was treated with four surgical approaches: the cavernous hemangioma of the superior peduncle of the pontine arm via the supratentorial cerebellar approach; the unilateral cerebral peduncle and the anterior superior pontine brain via the temporo-occipital cerebellar curtain approach; the pontine arm via the pontocerebellar angle approach; the posterior inferior pontine brain and the medulla oblongata via the posterior median occipital approach, all without occlusion of the cricocephalic vertebrae, one of which required incision of the cerebellar earth to increase exposure. One case required incision of the cerebellar earth to increase exposure. Under high magnification, we carefully observed the color change of the brainstem surface and the vascular condition, selected the part of the tumor closest to the brainstem surface to enter, kept the patient breathing on his own before taking the tumor so as to observe the effect of operation on breathing, cut 1~2cm on the tumor surface, and operated under low pressure suction and low current electrocoagulation.
2 Results There were 30 cases of total microscopic resection and 1 case of subtotal resection. There were 4 cases of hemiplegia with increased muscle strength and 1 case with no change after surgery; 3 cases of epilepsy with no seizure within 1 month after surgery and 1 case with 1 mild seizure; the symptoms of patients with vertigo were significantly reduced after surgery, and the cranial nerve damage was either reduced or kept in the same state except for 1 case with newly developed diplopia after surgery. Pathological findings: cavernous hemangioma. Three cases in this group had multiple intraoperative apnea, and none of them had postoperative respiratory disturbance and gastrointestinal bleeding complications. 3 Discussion
Cavernous angioma is a spongy abnormal vascular mass composed of many thin-walled blood vessels, which is not a true tumor and belongs to cerebral vascular malformation according to histological classification. It can grow in any part of the brain. The main clinical manifestations are symptoms of epilepsy, hemorrhage and neurological deficits, and recurrent intracranial hemorrhage is the main cause of symptoms caused by this disease [1]. Intracranial cavernous hemangiomas account for approximately 5% to 16% of all cerebrovascular malformations [2]. The typical intracerebral CA is mostly thought to be a vascular malformation originating from the level of the capillaries in the brain. It consists of a plexiform thin-walled vascular sinus-like structure with a wall composed of thin endothelial cells and fibroblasts, lacking elastic fibers and muscle layer. The intracerebral type of cavernous hemangioma is hard in texture, with a clear boundary between the lesion and brain tissue, and a nodular or mulberry-shaped purple-red mass, with thrombosis, mechanization and calcification visible in the lesion, and some of the lesions are accompanied by cystic degeneration or hemorrhage, which do not contain brain tissue [3, 4]. Previously reported CAs were mostly seen in the brain parenchyma and small spheres in the brainstem. In the present group of hemispheric CA, there were eight cases with lesions larger than 3 cm in diameter, including two cases with maximum diameters of 6 cm and 7 cm, respectively, penetrating the cortex and ventricular wall, which is rare.
The overall incidence of brainstem cavernous hemangioma is low, and before MRI was widely used, it was often treated conservatively as hemorrhagic or ischemic stroke. However, it is a common disease of the brainstem and has been reported to account for 33.2% of brainstem lesions. Kupersmith et al [5] reported that about 18%-35% of intracranial cavernous hemangiomas were located in the brainstem, especially in the cerebral bridge, and that intra-tumoral hemorrhage was more likely to occur than other sites of cavernous hemangioma, with annual hemorrhage and rebleeding rates of about 2.4% and 5.1% in this group of 37 cases. After bleeding, rebleeding is more likely to occur, and the annual bleeding rate and rebleeding rate are 5% and 30%, respectively. In China, Wang Loyalty et al[7] reported 137 cases, and the annual bleeding rate and rebleeding rate were higher than those abroad, which were 6% and 60%, respectively. In our group, two cases had rebleeding during hospitalization pending surgery. Some advocate conservative treatment and stereotactic radiation therapy, while Ferroli et al [8] are cautious about conservative treatment and believe that bleeding from brainstem cavernous hemangioma is not the only indication for surgery. It should be managed aggressively, weighing the pros and cons according to the patient’s specific situation. If the neurological symptoms and signs have significantly improved at the time of the patient’s visit, MRI shows that the hemorrhage has been absorbed, and the brainstem volume has basically returned to normal, then temporary non-operation can be considered regardless of whether the lesion is located in the deep or superficial part. For some deep and small hemorrhagic lesions. Those who do not have severe symptoms can also be closely followed up. The fundamental goal of surgery is to excise the lesion completely without disturbing the surrounding normal brain tissue as much as possible to prevent rebleeding. Cases with progressive focal neurological deficits, intratumoral hemorrhage causing clinical neurological deficits, lesions close to the surface of the brainstem, and significant occupational effects due to hemorrhage within the lesion should be treated aggressively surgically [9, 10, 11]. Wang Loyalty in China advocates that brainstem cavernous hemangioma should be operated as soon as it is detected, and the occurrence of hemorrhage during the pending surgery in two cases in our group fully supports the necessity of early surgery, not only to prevent the catastrophic consequences of brainstem hemorrhage, but also to completely remove the lesion and cure the disease.
There is also confusion about whether to operate for intrahemispheric cavernous hemangioma, especially in functional CA. Through our treatment experience, we believe that with accurate localization, cerebral sulcus access, complete resection of the lesion, postoperative improvement of dysfunction, avoidance of complications, and complete cure of the disease is entirely possible. In contrast, stereotactic radiation therapy can cause radioactive cerebral edema to aggravate the disease, and the improvement of the occupancy effect and epilepsy is not ideal, not to mention the inability to avoid rebleeding of the lesion during the biological effect. For hemispheric large lesion surgery, the glial membrane layer around the lesion and normal brain tissue should be strictly peeled off, pulled with force to the side of the lesion, and electrocautery the surface of the lesion to make it crumple to obtain surgical space; open the cystic area around the lesion layer by layer from superficial to deep to release bleeding and cystic fluid for easy operation; electrocautery cut the tiny blood vessels connected with the lesion one by one to prevent pulling off to cause retraction bleeding and increase surgical damage; electrocoagulation power The power of electrocoagulation should be small, and the arteries around the lesion and the passing arteries should be strictly protected; brainstem tumor surgery is dangerous, especially the operation near the latch of medulla oblongata, which can easily cause respiratory arrest. Surgical excision should be complete. The abnormal fibers and blood sinus envelope should be completely separated and removed. During the operation, old bleeding should be aspirated first to enlarge the surgical space, and then separated along the perimeter of the hematoma wall, electrocautery and severing the surrounding vascular connection. Intratumoral resection should be performed with gelatin sponge for compression hemostasis as much as possible to reduce the number of electrocoagulation and to control the electrocoagulation flow to a minimum to reduce surgical trauma. When separating the periphery of the lesion, the separation should be performed close to the tumor wall. Since the brain tissue surrounding the lesion with iron-containing heme deposits is functional, the extra-tumoral iron-containing heme ring should be kept intact as much as possible. If the cortical incision is smaller than the diameter of the hemangioma, the hemangioma can be removed in pieces to reduce the strain on the normal brainstem. In addition, choosing the best surgical approach, different order of tumor removal for different tumors, and careful and gentle operation under high-powered microscope are also the guarantee of good results.