Symptomatic Brainstem Cavernoma of Elderly Patients: Timing and Strategy of Surgical Treatment. Two Case Reports and Review of the Literature

BACKGROUND: Brainstem cavernomas (BSCs) are rare and difficult to treat. The treatment strategy for symptomatic lesions in elderly patients remains unclear. In this review, we discuss the optimal treatment strategy and consider effective surgical strategies in elderly patients. CASE DESCRIPTION: The clinical data of 8 elderly patients (age > 70 years) with symptomatic BSCs drawn from the literature and 2 of our cases are summarized in this review. The mean patient age was 73.3 +/- 3.13 years, and the most common location was the pons. Multiple rebleeding before surgery was seen in at least 4 cases, with clinical presentation and surgical approach varying depending on the location. Surgical removal was performed in 9 cases, and 1 case was treated with radiosurgery. The mean duration of clinical follow-up was 26.1 +/- 18.2 months. Neurologic improvement was found in 5 cases, and postoperative decline was seen in 1 of the surgery cases. CONCLUSIONS: Radical resection of the cavernoma with severe symptoms might be recommended in elderly patients, especially in those with multiple rebleeding events. From the viewpoint of surgery, we consider the subacute phase the optimal time to remove cavernomas in elderly hemorrhagic patients. However, multiple rebleeding events might exacerbate the neurologic deficit. Therefore, the subacute phase from the first or second rebleeding might be the best time for the surgical resection. At surgical intervention, preservation of the surrounding brain should be prioritized over complete removal of the cavernoma and hematoma.