Kavernöz Malformasyon Endikasyon ve Cerrahi Teknik

KAVERNÖZ MALFORMASYON

ENDİKASYON VE CERRAHİ TEKNİK

PROF. DR. NİHAT EGEMEN
ANKARA ÜNİ. TIP FAKÜLTESİ
BEYİN CERRAHİ A.B.D
nihategemen@hotmail.com


VASKÜLER MALFORMASYONLAR ( % 0.1 - 4.0 )

1- ARTERİÖ-VENÖZ MALFORMASYON
2- VENÖZ MALFORMASYON
3- KAPİLLER TELENJİEKTAZİ

4- KAVERNÖZ MALFORMASYON

EGEMEN


OTOPSİ SERİLERİNDE KM İNSİDANSI
% 0.02- BERRY VE ARK 1966
% 4.9 - SARWAR VE Mc CORMİCK 1978
% 0.53- OTTEN 1989

TÜM VASKÜLER MALFORMASYONLARIN
% 8- 15
SPİNAL VE KRANİAL KM
KM’NUN GERÇEK İNSİDANSINI ÖNGÖRMEK DİĞER
VASKÜLER MALFORMASYONLARLA
ÖRTÜŞMESİ NEDENİYLE ZORDUR.
EGEMEN


İKİ BÜYÜK OTOPSİ SERİSİNDE KM- AVM ORANI
1/ 1.5
BERRY VE ARK. 1966
SARWAR VE Mc CORMİCK 1978

CT ÖNCESİ DEVİRDEKİ İKİ BÜYÜK SERİDE
KM-AVM ORANI 1/20 ( % 5 )
POOL VE POTS 1965
GİOMBİNİ VE MORELLO 1978

EGEMEN


EPİLEPSİ% 40- 70

KANAMA % 6- 30
FOKAL KİTLE ETKİSİ % 35- 50
GENELDE TEK LEZYONLAR TARZINDA GÖRÜLÜRLER
ANCAK ÇOKLU OLANLAR AİLEVİ OLANLARDIR % 11- 19
.

EGEMEN


KM SPORADİK OLARAK GÖRÜLÜRLER,
AİLEVİ KM LARIN % 50 SİNDE
PENETRASYONU TAM OLMIYAN
OTOZOMAL DOMİNAT
GENETİK GEÇİŞ VARDIR.
HİSPANİK AİLELERDE GENETİK GEÇİŞ FAZLADIR.

AİLEVİ OLANLARDA ÇOKLU LEZYON ORANI
% 50 DOBYNS 1987
% 73 RİGAMONTİ VE ARK 1988 EGEMEN


MAKROSKOPİ

LOBULE İYİ SINIRLI,
KIRMIZI PEMBE,
KARADUT BENZERİ
LEZYONLARDIR

EGEMEN


KM MİKROSKOPİSİ,
İNCE DUVARLI
TEK ENDOTEL DÖŞELİ KAPİLLERLER
VE İNCE ADVENTİSİA'DAN OLUŞAN
İÇİNDE BEYİN DOKUSU İÇERMİYEN
YAPILARDIR.
DAHA ÖNCEKİ KANAMALARA
BAĞLI OLARAK FİBRÖZ DOKU ARTIMI,
HEMOSİDERİN YÜKLÜ MAKROFAJLAR.
İLTİHAP, KALSİFİKASYON,
OSSİFİKASYON OLUŞUR.
DAMAR YAPILARI TROMBOZE,
ÇEŞİTLİ YENİDEN YAPILANMA

EGEMEN


ÜÇ TİP KAVERNÖZ MALFORMASYON TANIMLANMIŞTIR

1- KİSTİK FORM
(KİST ETRAFINDA ÖDEM, DAHA ÇOK POSTERİOR FOSSADA,BÜYÜME
EĞİLİMİNDE)
2- DURA TABANLI MALFORMASYONLAR
( DAHA ÇOK ORTA FOSSA VE PARASELLAR YERLEŞİMLİ, AMELİYATTA ÇOK
KANAR,
GENİŞLEMİŞ DÜZ KASTAN YOKSUN KAVERNLERDEN OLUŞUR,
KLİNİK OLARAK DAHA AGRESSİVE)
3- HEMANGİOMA KALSİFİKANS
YOĞUN OLARAK KALSİFİYE , GENELDE TEMPORAL LOBDA YERLEŞİMLİDİR
VE SIKLIKLA EPİLEPSİYE NEDEN OLUR NADİREN KANAR

EGEMEN


1- KİSTİK FORM
( KİST ETRAFINDA ÖDEM, DAHA ÇOK POSTERİOR FOSSADA,BÜYÜME EĞİLİMİNDE )

EGEMEN


2- DURA TABANLI MALFORMASYONLAR

( ORTA FOSSA VE PARASELLAR YERLEŞİMLİ,
AMELİYATTA ÇOK KANAR,
GENİŞLEMİŞ DÜZ KASTAN
YOKSUN KAVERNLERDEN OLUŞUR,
KLİNİK OLARAK DAHA AGRESSİVE)

EGEMEN


3- HEMANGİOMA KALSİFİKANS
YOĞUN OLARAK KALSİFİYE , GENELDE TEMPORAL LOBDA YERLEŞİMLİDİR
VE SIKLIKLA EPİLEPSİYE NEDEN OLUR NADİREN KANAR

EGEMEN


BELİRTİLERİN ORTAYA ÇIKMA YAŞI
20- 40 GİOMBİNİ VE MORELLO
20-50 VOİGT VE YAŞARGİL

SUPRATENTORİAL LOKALİZASYON
% 64-% 90 ARSINDA DEĞİŞMEKTE

KADIN/ ERKEK : 1/1

EGEMEN


BİLGİSAYARLI TOMOGRAFİ

BELİRLEYİCİ DEĞİL
KANAMAYA BAĞLI DEĞİŞİKLİK
KALSİFİKASYON

DİJİTAL ANJİOGRAFİ
TANIDA YERİ AZ
KANAMA OLAN HASTALARDA
AYIRICI TANI İÇİN ÖNEMLİ
VENÖZ ANGİOMLARI BELİRLER EGEMEN


MAGNETİK REZONANS GÖRÜNTÜLEME

KANAMA DURUM T1-A T2-A

AKUT HÜi DO-Hb İZ HİPO
E-SA HÜi MET Hb HİP HİPO
G-SA HÜD MET Hb HIPO HİP
KRONiK HEMOSİDERİN HİPO HİP+HİPO

EGEMEN


TRACTOGRAPHY

EGEMEN


CERRAHİ TEDAVİ ENDİKASYONLARI

1- DÖKÜMANTE EDİLMİŞ YENİDEN KANAMA,
2- MEDİKAL OLARAK TEDAVİ EDİLEMİYEN EPİLEPSİ,
3-İLERLİYEN NÖROLOJİK DEFİSİT,
4-MRI GÖRÜNTÜSÜNÜN TANISAL OLMAMASI
HALİNDE TANI AMACI İLE

EGEMEN


EPİLEPSİ

KM % 50-70
AVM % 20-40
GLİOM % 10-30

EGEMEN


YENİDEN KANAMA RİSKİ % 2.76

YENİ BİR KANAMAYI ÖNLEMEK
CERRAHİ TEDAVİNİN AMACI OLMALIDIR

EGEMEN


CERRAHİ KARAR

HANGİ YAKLAŞIM EN İYİ ?

AMELİYAT ÖNCESİ LOKALİZASYON

MRI
EGEMEN


CERRAHİ TEKNİK

KM REZEKSİYONU SIRASINDAKİ KANAMA ÖNEMLİ DEĞİLDİR,

KANAMIŞ KM´A SUB AKUT DÖNEMDE CERRAHİ YAPILMALIDIR,

İYİ SINIRLI GLİOTİK PLAN KM KOLAYCA AYRILMASINI SAĞLAR,

SUPRATENTORİAL KM LARDA GLİOTİK DOKU TEMİZLENMELİDİR,

TAM OLARAK KM ÇIKARILMAMASI YENİ BİR KANAMA RİSKİDİR,

EGEMEN


CERRAHİ TEKNİK

HİSTOLOJİK TANIYI DA KARIŞTIRACAĞI İÇİN FAZLA
KOAGÜLASYONDAN KAÇINILMALIDIR,
LASERİN TEDAVİDE YERİ YOKTUR,
BİPOLAR KOAGULASYON YETERLİDİR.
KAVİTE İLAVE VASKÜLER MALFORMASYONLAR AÇISINDAN
GÖZDEN GEÇİRİLMELİDİR (VENÖZ ANGİOM)

EGEMEN


CERRAHİ LOKALİZASYON

YÜZEYEL KORTİKAL LEZYONLAR
SEREBRAL KORTEKSTE RENK DEĞİŞİMİ

KÜÇÜK SUB KORTİKAL LEZYONLAR
KORTİKAL RENK DEĞİŞİMİNE RASTLANMAZ
CT- MRI YÖNLENDİRİLMİŞ STEROTAKSİK TEKNİK
OPERATİF ULTRASONOGRAFİ

NÖRO NAVİGASYON
EGEMEN


EGEMEN


ANNE OĞUL

EGEMEN


CERRAHİ YAKLAŞIM
DERİN LEZYONLAR
STEROTAKSİK KEY HOLE KRANİOTOMİ
TRANSSULKAL

EGEMEN


CERRAHİ YAKLAŞIM
DERİN LEZYONLAR
NÖRONAVİGATİON

KEY HOLE KRANİOTOMİ
TRANSSULKAL

EGEMEN

Surgical treatment of intracranial cavernous angiomas.
Attar A, Ugur HC, Savas A, Yuceer N, Egemen N.
School of Medicine, Department of Neurosurgery, Ankara
University, Ankara, Turkey.
We present a surgical series of 35 patients (25 males and 10 females) with
histopathologically verified intracranial cavernous angiomas. The 35
malformations were located as follows: 21 were in the cerebral hemispheres;
4 in the lateral ventricles, 4 in the brain stem; and 6 in the cerebellum.
Seizures and focal neurological deficits were the main clinical features
observed in patients with intracranial cavernous angiomas. A number of
these vascular malformations were misdiagnosed by computerized
tomography. In the last 10 years, magnetic resonance imaging has been the
most sensitive method for detecting these lesions. Thirty-five cavernous
angiomas were treated surgically; in 33 patients a complete excision, and
in 2 patients subtotal excision were obtained. One of the patients died
one year after the operation. The overall outcome was good in all of the 34
remaining patients, resulting in improved seizure control or neurological
deficit. The rationale for neurologic differential diagnosis and surgical
treatment and follow up results are discussed.
EGEMEN
J Clin Neurosci 2001 May;8(3):235-9


(51 OLGU)

EPİLEPSİ % 60.0
FOKAL ARTAN NÖROLOJİK DEFİSİT % 16.0
BAŞ AĞRISI (KANAMA ? ) % 40.0

EGEMEN


(51 OLGU)

PARİETAL 18 OLGU
FRONTAL 10 OLGU
TEMPORAL 6 OLGU
OCCİPİTAL 1 OLGU
BAZAL GANG 1 OLGU
BEYİN SAPI 4 OLGU
İNTRAVENTRİKÜLER 4 OLGU
SEREBELLER 6 OLGU

EGEMEN


(51 OLGU)

CERRAHİ TEKNİK
KONVANSİYONEL 36 OLGU
CT GUİDED STEREOTAKSİK 11 OLGU
NÖRONAVİGASYON 4 OLGU

EGEMEN


(51 OLGU)

MORBİDİTE
HİDROSEFALİ 1 OLGU
3.SİNİR PAREZİSİ 1 OLGU
HEMİPAREZİ 1 OLGU
GÖRME ALANI DEFEKTİ 1 OLGU

MORTALİTE
1 OLGU - KANAMIŞ PONTİNE KAVERNOM

EGEMEN

Neurosurgery. 2003 Dec;53(6):1299-304; discussion 1304-5.
Image-guided transsylvian, transinsular approach for insular cavernous angiomas.
Tirakotai W, Sure U, Benes L, Krischek B, Bien S, Bertalanffy H.
Department of Neurosurgery, Philipps University, Marburg, Germany. sure@med.uni-marburg.de
OBJECTIVE: Surgical treatment of cavernomas arising in the insula is especially challenging because of
the proximity to the internal capsule and lenticulostriate arteries. We present our technique of image
guidance for operations on insular cavernomas and assess its clinical usefulness. METHODS: Between
1997 and 2003, with the guidance of a frameless stereotactic system ( BrainLab AG, Munich,
Germany), we operated on eight patients who harbored an insular cavernoma. Neuronavigation was used
for 1) accurate planning of the craniotomy, 2) identification of the distal sylvian fissure, and, finally, 3)
finding the exact site for insular corticotomy. Postoperative clinical and neuroradiological evaluations were
performed in each patient. RESULTS: The navigation system worked properly in all eight neurosurgical
patients. Exact planning of the approach and determination of the ideal trajectory of dissection toward the
cavernoma was possible in every patient. All cavernomas were readily identified and completely removed
by use of microsurgical techniques. No surgical complications occurred, and the postoperative course was
uneventful in all patients. CONCLUSION: Image guidance during surgery for insular cavernomas
provides high accuracy for lesion targeting and permits excellent anatomic orientation.
Accordingly, safe exposure can be obtained because of a tailored dissection of the sylvian fissure and
minimal insular corticotomy.

EGEMEN

Folia Med (Plovdiv). 2008 Apr-Jun;50(2):11-7. Links
Neuronavigated surgery of intracranial cavernomas--enthusiasm for high technologies or a gold
standard?
Enchev YP, Popov RV, Romansky KV, Marinov MB, Bussarsky VA.
Clinic of Neurosurgery, St. I. Rilsky University Hospital, Medical University, Sofia, Bulgaria. dr.y.enchev@gmail.com
AIM: The aim of this study was to investigate the effect of neuronavigation on the following parameters:
"skin incision", "craniotomy", "intraoperative anatomical orientation", "dissection guiding", "localization of
the pathological formation", "assessment of the degree of resection" and "duration of surgical procedure" in
resections of intracranial cavernomas and to specify the indications for neuronavigation in their surgical
treatment. PATIENTS AND METHODS: The present prospective study included 20 patients with intracranial
cavernomas who underwent neuronavigated surgery between March 2003 and December 2005 at the Clinic
of Neurosurgery of the "St. I. Rilsky" University Hospital, Medical University, Sofia. The female/male ratio in
the series was 9/11 (45%-55%). The patients' mean age was 27.96 +/- 11.61 years (age range 1.2 to 44
years). The patients were examined and followed up in a standard manner. RESULTS: Cavernous
malformations were totally removed in 19 patients. One patient with thalamic cavernoma underwent
navigated endoscopic biopsy. There was no morbidity or mortality associated with the method.
Neuronavigation allowed precise localization and individual design of the skin incision and craniotomy.
Neuronavigated intraoperative anatomical orientation, dissection guiding, localization of the pathological
formation, and assessment of degree of resection were evaluated as markedly useful. They resulted in
excellent surgery results and reduced operation time in comparison with the conventional surgery.
CONCLUSION: In intracranial cavernomas frameless stereotaxy provides the surgeon with useful
feedback in the preoperative anatomical orientation, the planning and simulation of surgical approach, the
intraoperative navigation, in avoiding vital neurovascular structures, in the assessment of the
degree of resection and the identification of possible residual parts. That is why cavernous
malformations are among the most common indications for cranial
neuronavigation.
EGEMEN


Neurosurgery. 2006 Apr;58(4 Suppl 2):ONS-292-303; discussion ONS-303-4.
Implementation of fiber tract navigation.
Nimsky C, Ganslandt O, Fahlbusch R.
Department of Neurosurgery, University Erlangen-Nürnberg, Erlangen, Germany. nimsky@nch.imed.uni-erlangen.de
OBJECTIVE: To implement fiber tracking in a common neuronavigation environment for routine clinical use to visualize major
white matter tracts intraoperatively. METHODS: A single-shot, spin-echo diffusion weighted echo planar imaging sequence
with six diffusion directions on a 1.5 T magnetic resonance scanner was used for diffusion tensor imaging. For three-
dimensional (3-D) tractography, we applied a knowledge-based multiple volume of interest approach. Tracking was initiated in
each voxel of the initial seed volume in retrograde and orthograde directions according to the direction of the major
eigenvector by applying a tensor deflection algorithm. Tractography results were displayed as streamlines assigned direction
encoding color. After selecting the fiber tract bundle of interest by defining inclusion and exclusion volumes, a 3-D object was
generated automatically by wrapping the whole fiber tract bundle. This 3-D object was displayed along with other contours
representing tumor outline and further functional data with the microscope heads-up display. RESULTS: In 16 patients (three
cavernomas, 13 gliomas), major white matter tracts (pyramidal tract, n = 14; optic radiation, n = 2) were visualized
intraoperatively with a standard navigation system. Three patients developed a postoperative paresis, which resolved in two in
the postoperative course. Additional planning time for tractography amounted to up to 10 minutes. Comparing the
tractography results with a fiber bundle generated on a different platform by applying a distortion-free sequence revealed a
good congruency of the defined 3-D outlines in the area of interest. CONCLUSION: Fiber tract data can be reliably
integrated into a standard neuronavigation system , allowing for intraoperative visualization
and localization of major white matter tracts such as the pyramidal tract or optic
radiation.
EGEMEN

Clin Neurol Neurosurg. 2008 Sep;110(8):834-7. Epub 2008 Jun 27.

Endoscopic resection of cavernoma of foramen of Monro in a patient with familial
multiple cavernomatosis.
Prat R, Galeano I.
Valencia, Spain. ricprat@ono.com
Department of Neurosurgery, Hospital La Fe Avda, Campanar 21, 46009
Intraventricular cavernomas are extremely infrequent and only 11 cases of cavernous hemangioma to
occur at the foramen of Monro have been reported in the literature. This 56 years old patient was
admitted with progressive and intractable headache of 10 days of evolution. He was known to suffer
familial multiple cavernomatosis. Magnetic resonance imaging (MRI), revealed obstructive hydrocephalus
due to a cavernoma located in the area of the left foramen of Monro. Under neuronavigation guidance,
complete endoscopic resection of the cavernoma was performed and normal ventricular size achieved.
The patient experienced transient recent memory loss that resolved within a month after surgery. In the
literature attempted endoscopic resection is reported to be abandoned due to bleeding and
ineffectiveness of piecemeal endoscopic resection. In this case, the multiplicity of the lesions made it
advisable to resect the lesion endoscopically, to avoid an open procedure in a patient with multiple
potentially surgical lesions. Endoscopic resection was uneventful with easy control of bleeding with
irrigation, suction, and bipolar coagulation despite dense vascular appearance of the lesion. During the
procedure, precise visualization of the vascular structures around the foramen of Monro allowed complete
resection with satisfactory control of the instruments. To the best of the authors' knowledge, this is the
first published cavernoma of foramen of Monro successfully resected using an endoscopic approach.

EGEMEN

Arq Neuropsiquiatr. 2008 Sep;66(3A):534-8
Cortical stimulation of language fields under local anesthesia: optimizing
removal of brain lesions adjacent to speech areas.
de Amorim RL, de Almeida AN, de Aguiar PH, Fonoff ET, Itshak S, Fuentes D, Teixeira MJ.
Division of Functional Neurosurgery, Department of Neurology, Clinics Hospital, University of São Paulo
School of Medicine, São Paulo, Brazil. amorim.robson@uol.com.br
OBJECTIVE: The main objective when resecting benign brain lesions is to minimize risk of postoperative
neurological deficits. We have assessed the safety and effectiveness of craniotomy under local anesthesia
and monitored conscious sedation for the resection of lesions involving eloquent language cortex.
METHODS: A retrospective review was performed on a consecutive series of 12 patients who underwent
craniotomy under local anesthesia between 2001 and 2004. All patients had lesions close to the speech
cortex. All resection was verified by post-operative imaging. Six subjects were male and 6 female, and were
aged between 14 and 52 years. RESULTS: Lesions comprised 7 tumour lesions, 3 cavernomas and 1
dermoid cyst. Radiological gross total resection was achieved in 66% of patients while remaining cases had
greater than 80% resection. Only one patient had a post-operative permanent deficit, whilst another had a
transient post-operative deficit. All patients with uncontrollable epilepsy had good outcomes after surgery.
None of our cases subsequently needed to be put under general anesthesia. CONCLUSION: Awake
craniotomy with brain mapping is a safe technique and the "gold standard" for resection of lesions
involving language areas.
EGEMEN


SONUÇ

KM TEDAVİSİ CERRAHİDİR
KANAMA VE KANAMA RİSKİ,
İLERLİYEN NÖROLOJİK DEFİSİT
VE EPİLEPSİ AMELİYAT ENDİKASYONUDUR.

MRG EN ÖNEMLİ TANI YÖNTEMİDİR

EGEMEN


SONUÇ
KANAMAMIŞ DERİN YERLEŞİMLİ
KÜÇÜK LEZYONLARIN TEDAVİSİNDE
CT-MRG YÖNLENDİRİLMİŞ STEROTAKTİK CERRAHİ
VE NAVİGASYONUN KATKISI YADSINAMAZ
FONKSİYONEL MRI, FİBER TRACTOGRAFİ
CERRAHİ GİRİŞİMİN PLANLANMASINDA
ÖNEMLİDİR

EGEMEN


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