Stereotactic laser interstitial thermal therapy for brainstem cavernous malformations: two preliminary cases
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CASE REPORT - VASCULAR NEUROSURGERY - ARTERIOVENOUS MALFORMATION
Stereotactic laser interstitial thermal therapy for brainstem cavernous malformations: two preliminary cases Nicholas T. Gamboa 1 & Michael Karsy 1 & Rajiv R. Iyer 1,2 & Robert J. Bollo 1,2 & Richard H. Schmidt 1 Received: 4 December 2019 / Accepted: 29 March 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
Abstract Brainstem cavernous malformations (CMs) often have high hemorrhage rates and significant posthemorrhage morbidity. The authors present two cases in which magnetic resonance thermography-guided laser interstitial therapy was used for treatment of pontine CMs after recurrent hemorrhage. Both patients showed significant symptomatic improvement and were hemorrhage-free at 12- and 6-month follow-up, respectively. Each had radiographic evidence of lesion involution on serial follow-up imaging. These early results demonstrate this treatment modality may be technically safe; however, larger case numbers and longer followup are needed to demonstrate efficacy. Keywords Brainstem . Cavernous malformation . Cavernoma . Laser interstitial thermal therapy . Magnetic resonance imaging . Minimally invasive . Stereotactic laser ablation . Thermometry
Introduction Cavernous malformations (CM) or cavernomas of the central nervous system are characterized by angiogenically immature, low-flow, dilated sinusoidal vascular channels without interposed neural parenchyma [1, 2]. Most CMs are supratentorial, but the brainstem is involved in approximately 18% of cases [4, 6, 8, 10, 16]. Brainstem CMs have been shown to have symptomatic hemorrhage rates of up to 10.6% per patient-year and often follow a more aggressive clinical course than other CMs given their proximity to ascending and descending tracts and brainstem nuclei [8, 12, 15]. Brainstem CMs most commonly present with cranial neuropathy but can also present with motor deficits, sensory loss, headache, nausea or vomiting, or ataxia [1, 5]. Conventional treatment paradigms of symptomatic brainstem CMs typically involve close
observation, microsurgical resection, or stereotactic radiosurgery [1, 3]. In addition, several authors have shown satisfactory results for microsurgical resection of brainstem CMs during the subacute phase of hemorrhage in selected patients; however, even in experienced hands and when using safe entry zones to the brainstem, surgical resection can carry a high risk of postoperative morbidity [7, 12, 13]. Magnetic resonance (MR) thermography-guided laser interstitial thermal therapy (LITT) (or stereotactic laser ablation) is a minimally invasive technology that has been successfully used in the treatment of primary brain tumors, focal epilepsy, and CMs of the cerebrum [9, 14]. Although it was thought that LITT was absolutely contraindicated in the treatment of brainstem CMs, we show that LITT therapy may serve as an effective treatment modality in select patients to alter the often-malignant natural history of brainstem CMs.
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