Open Brain/Spinal Surgery

The Alliance to Cure Cavernous Malformation Clinical Care Consensus Guidelines provide guidance on clinical decision-making around surgery. Most commonly, surgery is appropriate after a second cavernous malformation hemorrhage or for lesions that are causing epilepsy. For epilepsy, some craniotomies are being replaced by minimally invasive procedures.

In-depth discussion of cavernous malformation surgery can be found in webinars with prominent neurosurgeons that we have hosted:

Pediatric: Dr. Edward Smith, Boston Children’s Hospital

Adult: Dr. Anthony Wang, UCLA

And in a presentation from a recent patient conference: Dr. Min Park, University of Virginia

Specific Topics

Types of neurosurgeons

Open surgery to “resect” or remove a cavernous malformation is performed by a cerebrovascular neurosurgeon. There are additional subspecialties that you may want to look for depending on the location of your lesions. Neurosurgeons may specialize in skull-base lesions (brainstem), epilepsy, or spinal lesions. Cavernous malformation surgery is not performed by surgeons who specialize only in endovascular surgery. One critical question to ask your surgeon is, “How many resections of cavernous malformation lesions have you performed?” Experience is the best teacher, and you will want a surgeon who has performed many such surgeries, particularly if your lesion is in the brainstem. Please see Questions to Ask Your Doctor for additional questions you will want to have answered before your surgery.

“Approach”

One of the more important considerations for a neurosurgeon is the approach they will take to the lesion. In their use of the term, “approach” is literal and means the path that the surgeon will take from outside of the skull or spine to the lesion. Surgeons try to take a path that allows them to avoid as much brain or spinal cord tissue as possible, especially tissue or nerves that control important functions. Different surgeons may select different approaches to the same lesion. If you are seeking multiple surgical opinions, it may be helpful to discuss the approach each neurosurgeon would recommend and their reasons for selecting it.

3D Modeling

For very difficult surgeries, some institutions are able to use MRI imaging to create a 3D printed model of the brain. This model is used to practice the surgery ahead of time. A discussion of 3D Modeling by Dr. Edward Smith of our Boston Children’s Hospital Center of Excellence is found in this webinar on our YouTube channel.

“Awake” surgery

There are occasions where a cavernous malformation resection is being performed on a lesion that is in an area of critical function, like speech. These areas are called eloquent areas. In these rare situations, “awake” surgery may be performed to allow the surgeon to avoid the eloquent area and preserve function. During an awake surgery, the patient is woken for a brief period after the surgery is well underway. The patient has no sensation or pain and is asked to perform tasks related to the function being preserved.

Laminectomy

This is the term for the type of surgery used for spinal lesions. It literally means “unroofing” because the back of a vertebra, called the lamina, is lifted to allow access to the spinal cord. Spinal cord cavernous malformations are very rare and the threshold for performing surgery is typically quite high relative to brain surgeries.

Updated 4.16.22