2025 Poster Presentations
P074: SURGICAL MANAGEMENT OF PONTINE BRAINSTEM CAVERNOUS MALFORMATIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS EMPHASIZING SAFE ENTRY ZONES AND CLINICAL OUTCOMES
Brandon M Edelbach, BS1; Ahmad K AlMekkawi, MD2; Dylan Glaser, MS3; Vani B Patel, BS3; Amulya Manchikanti, BS3; Rohit Rajput, BS3; Carlos A Bagley, MD, MBA2; Tarek Y El Ahmadieh, MD1; Jonathan D Breshears, MD2; Yifei Duan, MD2; Yifei Duan, MD2; 1Loma Linda University Department of Neurosurgery; 2Saint Luke's Marion Bloch Neuroscience Institute Department of Neurosurgery; 3Univeristy of Missouri-Kansas City School of Medicine
Objective: Safe entry zones (SEZs) have emerged as important corridors for accessing brain stem cavernous malformations (BSCM) while minimizing morbidity. This systematic review and meta-analysis aims to analyze the surgical management of pontine BSCM with a focus on SEZs.
Methods: A systematic literature search was performed in PubMed for articles published from 1986 to June 2024 reporting on the surgical management of pontine BSCM. Data were extracted on patient demographics, clinical presentation, BSCM characteristics, surgical approach, use of SEZs, and clinical outcomes. Statistical analyses were performed to identify factors associated with improved outcomes.
Results: Fifty-seven studies with a total of 490 patients were included. The cohort was 54% female with an average age of 33.42±17.7 years. The most common presenting symptoms varied based on BSCM location within the pons. The two most common BSCM locations were peritrigeminal (31.25%) and rhomboid (33.13%). The most frequently used surgical approach was the suboccipital telovelar approach (31.8%), and the most commonly utilized SEZ was the lateral pontine zone (34.1%). Gross total resection was achieved in 65.6% of cases. Good clinical outcome (follow-up mRS<2) was observed in 64.1% of patients, with an overall mortality rate of 1.0%. The use of SEZs for BSCM located in the middle peduncular region was associated with improved clinical outcomes.
Conclusion: Surgical resection of pontine BSCM can be performed with acceptable morbidity and mortality rates when utilizing SEZs. The lateral pontine, supratrigeminal, and peritrigeminal SEZs are associated with high rates of complete resection and improved neurological outcomes. BSCM location dictates the choice of SEZ and surgical approach, emphasizing the importance of understanding the regional anatomy of the brainstem.
| Descriptor | Outcome |
| Cohort | 490 |
| Age | 33.42±17.7 |
| Hemorrhagic Presentation | 299 |
| Number of Pre-operative Hemorrhages | 1.68±0.92 |
| Duration of Pre-operative Symptoms (weeks) | 68.63±154.8 |
| SEZ | Frequency (%) | Location of BSCM | GTR (%) | Change in mRS |
| LPZ | 34.1 |
Peritrigeminal Middle peduncule |
82.8 | -0.86 |
| STZ | 12.9 | Middle peduncle | 72.7 | -1.0 |
| PTZ | 11.8 | middle peduncle | 60.0 | -0.50 |
| ICZ | 9.4 | inferior peduncle | 75.0 | -1.5 |
| Variable | Odds Ratio | 95% C.I. | p-value |
| Pre-operative Hemorrhage | 0.748 | 0.520-1.076 | .118 |
| Use of SEZ | 2.409 | 1.279-4.54 | .006 |
| GTR | 1.369 | 0.959-1.953 | .083 |
| Basilar Pons | 0.075 | 0.010-0.584 | .013 |
| Middle Peduncular Pons | 6.759 | 2.322-19.673 | .0005 |
| Cross Midline | 0.466 | 0.138-1.567 | .217 |
