CASE REPORT J Neurosurg 128:1289–1296, 2018 H ISTORICALLY, brainstem cavernous malformations (CMs) have been remarkably challenging to neu- rosurgeons. Because of their deep-seated location and high surgical risks, conservative therapy has been the mainstay of treatment for many decades. Recently, with advances in our understanding of surgical anatomy, in mi- crosurgical techniques, and in neurophysiological moni- toring modalities, overall success in treating what were traditionally deemed “unresectable” lesions has been more promising. As our understanding of CMs has evolved, we have come to realize that brainstem and other deep-seated CMs may have higher rates of symptomatic hemorrhage and of- ten present with higher rates of neurological compromise compared with their cerebral counterparts. In a recent meta-analysis, the overall estimated annual incidences of hemorrhage and recurrent hemorrhage were 0.3% and 6.3%, respectively, for non-brainstem CMs compared with 2.8% and 32.3% for brainstem CMs. 8,15 Moreover, the outcomes of untreated brainstem CMs can be poor, as pa- tients with recurrent neurological deficits are less likely to recover after multiple bouts of rehemorrhage. 1,2,4,5,7 As a result, there has been debate among those in the neurosur- gical field over the optimal treatment strategy. In young and healthy patients with severe and rapidly progressive deficits we have been aggressive in our man- agement of CMs, especially when surgery appears to be the last resort. Case Reports Case 1 This 23-year-old woman was transferred from an outside facility after being diagnosed with a brainstem hemorrhage on CT (Fig. 1A). She presented with a sud- den onset of headaches, left hemiparesis, hemihypoesthe- sia, dysarthria, double vision, facial paralysis, and ataxia. Upon arrival, MRI was performed that was suggestive of a hemorrhagic neoplasm or brainstem CM (Fig. 1B–D). Over the course of the next several hours after admission, her condition progressed and she became quadriplegic and unresponsive. She underwent intubation and a ventriculos- tomy was performed. Despite these measures, she stopped having spontaneous respirations, her pupils became pin- ABBREVIATIONS CM = cavernous malformation; CN = cranial nerve; EMG = electromyography; EVD = external ventricular drain; GCS = Glasgow Coma Scale; GTR = gross-total resection; KPS = Karnofsky Performance Scale; MEP = motor evoked potential; mRS = modified Rankin Scale; SSEP = somatosensory evoked potential. SUBMITTED July 6, 2016. ACCEPTED January 26, 2017. INCLUDE WHEN CITING Published online July 7, 2017; DOI: 10.3171/2017.1.JNS161693. * Drs. Tumturk and Li contributed equally to this work. Emergency resection of brainstem cavernous malformations *Abdulfettah Tumturk, MD, Yiping Li, MD, Yahya Turan, MD, Ulas Cikla, MD, Bermans J. Iskandar, MD, and Mustafa K. Baskaya, MD Department of Neurological Surgery, University of Wisconsin Medical School, Madison, Wisconsin Brainstem cavernous malformations (CMs) pose significant challenges to neurosurgeons because of their deep locations and high surgical risks. Most patients with brainstem CMs present with sudden-onset cranial nerve deficits or ataxia, but uncommonly patients can present in extremis from an acute hemorrhage, requiring surgical intervention. However, the timing of surgery for brainstem CMs has been a controversial topic. Although many authors propose delaying surgery into the subacute phase, some patients may not tolerate waiting until surgery. To the best of the authors’ knowledge, emergency surgery after a brainstem CM hemorrhage has not been described. In cases of rapidly progressive neuro- logical deterioration, emergency resection may often be the only option. In this retrospectively reviewed small series of patients, the authors report favorable outcomes after emergency surgery for resection of brainstem CMs. https://thejns.org/doi/abs/10.3171/2017.1.JNS161693 KEY WORDS brainstem hemorrhage; cavernous malformation; emergency surgery; vascular disorders ©AANS, 2018 J Neurosurg Volume 128 • May 2018 1289 Unauthenticated | Downloaded 02/04/23 08:16 AM UTC