kavernöz malformasyon endikasyon ve cerrahi teknik

KAVERNÖZ MALFORMASYON

PROF. DR. NİHAT EGEMENANKARA ÜNİ. TIP FAKÜLTESİ

BEYİN CERRAHİ A.B.Dnihategemen@hotmail.com

ENDİKASYON VE CERRAHİ TEKNİK

VASKÜLER MALFORMASYONLAR ( % 0.1 - 4.0 )

1- ARTERİÖ-VENÖZ MALFORMASYON

2- VENÖZ MALFORMASYON

3- KAPİLLER TELENJİEKTAZİ

4- KAVERNÖZ MALFORMASYON

EGEMEN

TÜM VASKÜLER MALFORMASYONLARIN

% 8- 15 SPİNAL VE KRANİAL KM

KM’NUN GERÇEK İNSİDANSINI ÖNGÖRMEK DİĞER VASKÜLER MALFORMASYONLARLA ÖRTÜŞMESİ NEDENİYLE ZORDUR.

EGEMEN

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

İKİ BÜYÜK OTOPSİ SERİSİNDE KM- AVM ORANI1/ 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 1965GİOMBİNİ VE MORELLO 1978

EGEMEN

EPİLEPSİ% 40- 70

KANAMA % 6- 30

FOKAL KİTLE ETKİSİ % 35- 50

GENELDE TEK LEZYONLAR TARZINDA GÖRÜLÜRLERANCAK ÇOKLU OLANLAR AİLEVİ OLANLARDIR% 11- 19

EGEMEN

AİLEVİ OLANLARDA ÇOKLU LEZYON ORANI

% 50 DOBYNS 1987

% 73 RİGAMONTİ VE ARK 1988

EGEMEN

KM SPORADİK OLARAK GÖRÜLÜRLER,AİLEVİ KM LARIN % 50 SİNDE PENETRASYONU TAM OLMIYAN

OTOZOMAL DOMİNAT GENETİK GEÇİŞ VARDIR.

HİSPANİK AİLELERDE GENETİK GEÇİŞ FAZLADIR.

LOBULE İYİ SINIRLI,

KIRMIZI PEMBE,

KARADUT BENZERİ

LEZYONLARDIR

EGEMEN

MAKROSKOPİ

KM MİKROSKOPİSİ, İNCE DUVARLI TEK ENDOTEL DÖŞELİ KAPİLLERLERVE İNCE ADVENTİSİA'DAN OLUŞANİÇİNDE 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 KALSİFİKANSYOĞUN 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 KALSİFİKANSYOĞUN OLARAK KALSİFİYE , GENELDE TEMPORAL LOBDA YERLEŞİMLİDİRVE SIKLIKLA EPİLEPSİYE NEDEN OLUR NADİREN KANAR

EGEMEN

BELİRTİLERİN ORTAYA ÇIKMA YAŞI20- 40 GİOMBİNİ VE MORELLO

20-50 VOİGT VE YAŞARGİL

SUPRATENTORİAL LOKALİZASYON

% 64-% 90 ARSINDA DEĞİŞMEKTE

EGEMEN

KADIN/ ERKEK : 1/1

BİLGİSAYARLI TOMOGRAFİ

BELİRLEYİCİ DEĞİLKANAMAYA BAĞLI DEĞİŞİKLİK

KALSİFİKASYON

DİJİTAL ANJİOGRAFİTANIDA YERİ AZ

KANAMA OLAN HASTALARDA

AYIRICI TANI İÇİN ÖNEMLİ

VENÖZ ANGİOMLARI BELİRLER EGEMENEGEMEN

MAGNETİK REZONANS GÖRÜNTÜLEME

EGEMEN

KANAMA DURUM T1-A T2-A AKUT HÜi DO-Hb İZ HİPOE-SA HÜi MET Hb HİP HİPO G-SA HÜD MET Hb HIPO HİPKRONiK HEMOSİDERİN HİPO HİP+HİPO

EGEMEN

TRACTOGRAPHY

EGEMEN

TRACTOGRAPHY

EGEMEN

TRACTOGRAPHY

EGEMEN

TRACTOGRAPHY

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 % 50-70AVM % 20-40GLİOM % 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

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 LEZYONLARSEREBRAL KORTEKSTE RENK DEĞİŞİMİ

KÜÇÜK SUB KORTİKAL LEZYONLARKORTİKAL RENK DEĞİŞİMİNE RASTLANMAZ

CT- MRI YÖNLENDİRİLMİŞ STEROTAKSİK TEKNİK

OPERATİF ULTRASONOGRAFİ

NÖRO NAVİGASYON

EGEMEN

ANNE OĞUL

EGEMEN

CERRAHİ YAKLAŞIM

DERİN LEZYONLARSTEROTAKSİK KEY HOLE KRANİOTOMİTRANSSULKAL

EGEMEN

CERRAHİ YAKLAŞIM

DERİN LEZYONLARNÖRONAVİGATİON

EGEMEN

KEY HOLE KRANİOTOMİTRANSSULKAL

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 diedone year after the operation. The overall outcome was good in all of the 34 remaining patients, resulting in improved seizure control or neurologicaldeficit. The rationale for neurologic differential diagnosis and surgicaltreatment and follow up results are discussed.

EGEMENJ Clin Neurosci 2001 May;8(3):235-9

EPİLEPSİ % 60.0

FOKAL ARTAN NÖROLOJİK DEFİSİT % 16.0

BAŞ AĞRISI (KANAMA ? ) % 40.0

(51 OLGU)

EGEMEN

(51 OLGU)

PARİETAL 18 OLGUFRONTAL 10 OLGUTEMPORAL 6 OLGUOCCİPİTAL 1 OLGUBAZAL GANG 1 OLGUBEYİN SAPI 4 OLGUİNTRAVENTRİKÜLER 4 OLGUSEREBELLER 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.deOBJECTIVE: 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. LinksNeuronavigated 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.comAIM: 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.

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.Department of Neurosurgery, Hospital La Fe Avda, Campanar 21, 46009 Valencia, Spain. ricprat@ono.comIntraventricular 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.

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.brOBJECTIVE: 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 CERRAHİDİRKANAMA 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 CERRAHİVE NAVİGASYONUN KATKISI YADSINAMAZ

FONKSİYONEL MRI, FİBER TRACTOGRAFİ CERRAHİ GİRİŞİMİN PLANLANMASINDA

ÖNEMLİDİR

EGEMEN

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