Clinic Study Of Transcerebral Sulcus Microsurgery Of Cavernous Hemangioma In Cerebral Motional Area By Stereotactic Technique

Objective Cavernous haemangiomas in central nervous system, are also known as cavernous malformations, are uncommon a type of cerebral vascular malformations, 5%～16% of cerebrai vascular malformations is cerebral cavernous haemangiomas. Following with advance of central nervous imaging, especially clinic performance of MR imaging, identifying the incidence of cerebral cavernous haemangiomas is increased. 80% of cerebral cavernous haemangiomas is Supratentorial cerebral cavernous haemangiomas. 60% first clinic symptoms in adult patients with cerebral cavernous haemangiomas is epileptic seizures, cerebral cavernous haemangiomas occur more in cerebral motional area, most of patients without hemorrhage of lesions is not presence of neurological deficits, resection of cavernous haemangiomas located in cerebral motional area occurred frequently motion functional deficits ; Epileptogenesis of cerebral cavernous haemangiomas originate in gliotic hemosiderin-stained brain tissue adjacent to the lesions, After lesionectomy, again resection of gliotic hemosiderin-stained brain tissue adjacent to the lesions is more apt to result in neurologic deficit for control epileptic seizures. In this clinic study, utilizing normal cerebral anatomic structure-cerebral sulcus, using stereotactic technique with frame and neuronavigation technique without frame, transcerebral sulcus microsurgery of cavernous hemangiomas in cerebral motional area explore the effect on avoiding neurological deficits and lesionectomy alone for control epileptic seizures.Methods Preoperative electroencephalography and video-electroencephalography were performed in all cases, with preoperative MR imaging cerebral cavernous haemangiomas were identified in central motional areas. First utilizing stereotactic technique with frame, subsequently neuronavigation without frame, determine smaller incision of scalp and smaller craniotomy, identify the cerebral sulcus which subcortical cavernous haemangiomas were located under. Under microscope, avoiding draining vein, incising surface arachnoid to the cerebral sulcus, dissecting adequate long of cerebral sulcus, subcortical cavernous haemangiomas were found under the floor of cerebral sulcus with yellow-stained brain tissue adjacent to the lesions. Retracting gyrus with self-retaining retractor, sighting olden hemorrhage, cleaning olden blood spot without bleeding, dissecting border of lesions through yellow-stained gliotic brain tissue with part removal of lesions, finding small feeding artery in cerebral sulcus, electric coagulating and cut this feeding artery, eventually, total resection of cavernous haemangiomas were performed. Postoperative electroencephalography following up was performed in all cases.Results 6 patients with cerebral cavernous haemangiomas in motional area were mean 36.05 years old. 3 cases located in right precentral sulcus, 2cases in right central sulcus, 1 case in left central sulcus. Maximal diameter of lesions was 1～3cm. The first clinic manifestation was epilepsy in all patients. The predominant seizure type was partial seizures, without and with secondary generalization. With antiepileptic drugs 5 patients had free seizures, 1 patient remained seizures. 1 patient complicated with headache. 6 patients occurred without neurologic deficits. 3 patients was treated by cerebral hemorrhage , because the signs of CT scans was considered as the presence of cerebral hemorrhage. Cerebral cavernous haemangiomas did not altered significantly by multi-repeat CT scans, preoperative following up 2 months～5years. In six patients, CT scans showed some round or ovate patches of high intensity, enhanced mildly; 5 cases without obvious peri-lesions edema, 1 case with mild edema, 1 case with calcification. In 6 patients, the preoperative brain MR imaging protocol included obtaining T2-weighted image, or gradient-echo MR image, T1-weighted image, postcontrast T1-weighted image, T1-weighted image demonstrated single round or ovate mixed intensity signal lesion in central motional area, T2-weighted image or gradient-echo MR image showed typical representation of a perilesion ring of hypointensity, 5cases without perilesion oedema, one case with mild oedema; all cases were enhanced mildly after intravenous infusing Gd-GTPA. One patient performed general cerebral angiography and showed normal. EEG and video-EEG demonstrated perilesion spike-slow wave in 5 patients, one patient only paroxysmal slow wave. All were diagnosed as cavernous haemangiomas in central motional area.The cavernous haemangiomas of 6 patients were totally resected by means of stereotactic guidance-stereotactic technique with frame and neuronavigation without frame. Postoperative pathology confirmed haemangiomas combined with bleeds. 5 patients had no neurological deficits, only 1 patient had unilateral upper extremity paresis. All patients could be off bed for locomotion 2 days after operation. All continued to took the antiepileptic drugs, and no seizures following up from half to 3 years. Repeat EEG demonstrated no spike-low wave postoperative 3 months in all cases, 2 cases had no seizures after antiepileptic drugs withdrawal.Conclusions For cerebral haemangiomas in the motional area which the first clinic manifestation was epilepsy, if no significant bleeding, the lesions may be no alterations long term, but epileptic seizures were tendency to increase; damage of normal brain tissue may be to a great extent to decrease by trans-anatomic structure-sulcus, total resection of haemangiomas do not result in neurological deficit through perilesion gliotic layer of brain tissue, therefore this location of haemangiomas is considered as lesions of external brain tissue. Lesionectomy alone of this haemangiomas may acquire good effect for control epileptic seizure.