{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T00:17:56Z","timestamp":1776212276406,"version":"3.50.1"},"reference-count":38,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,10,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n \n Brainstem cavernous malformations (BCMs) are low-flow vascular lesions of the central nervous system that pose significant surgical challenges due to their deep location and proximity to eloquent structures. Resection is associated with significant morbidity, and published literature is sparse. This single-institutional, single-surgeon study aimed to delineate factors affecting outcomes in the resection of BCMs and to assess the efficacy of the omnidirectional CO\n 2<\/jats:sub>\n laser for lesion resection.\n <\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n \n A retrospective review of all BCMs treated between 1990 and 2022 at Stanford Hospital and Clinics and Lucile Packard Children\u2019s Hospital by the senior author was conducted. Data from medical records and direct patient contact data, including presenting symptoms, presence of acute hemorrhage status, time from hemorrhage to surgery, radiological features, surgical approach used, and preoperative and postoperative neurological status, were recorded. The primary outcome assessed included the modified Rankin Scale (mRS) score at baseline and on follow-up. Comparisons were performed between resections with and without the use of the CO\n 2<\/jats:sub>\n laser. Further analysis was performed to eliminate \"learning curve\" bias, and the last 75 patients in both treatment groups were compared.\n <\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n \n In total, 277 surgical procedures for BCMs were identified in 254 patients treated from March 1990 to December 2022, and of these 236 (85%) surgical procedures in 215 patients had \u2265 3 months follow-up or mortality within 3 months postsurgery. Of these, 120\/236 underwent conventional surgery and 116\/236 underwent CO\n 2<\/jats:sub>\n laser\u2013assisted resection. Complete resection of the cavernous malformation was achieved in 96.4% of cases. Recurrent BCM was observed in 3\/254 (1.2%) of patients, and 70 of 236 cases (30%) had immediate worsening of neurological status, with an average mRS increase of 0.47 points. The CO\n 2<\/jats:sub>\n laser\u2013assisted surgery group showed statistically significant long-term mRS score improvement compared to the conventional surgery group (28 [23%] of conventional and 45 [39%] of laser-assisted cases showed improvement; average mRS change +0.125 and \u22120.241, respectively, p = 0.02). Assessment of the last 75 patients in both groups showed a similar positive relationship between CO\n 2<\/jats:sub>\n laser\u2013assisted resection and long-term mRS outcomes (\u22120.475, 95% CI \u22120.881 to \u22120.07, p = 0.02).\n <\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n \n BCM remains among the most challenging pathologies for the cerebrovascular neurosurgeon. This series demonstrates that good surgical outcomes are achievable when resection is performed in a high-volume center by an experienced surgeon. Furthermore, this study suggests improved outcomes using the CO\n 2<\/jats:sub>\n laser.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.3.jns242848","type":"journal-article","created":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T22:46:22Z","timestamp":1751064382000},"page":"952-959","source":"Crossref","is-referenced-by-count":1,"title":["Outcomes of brainstem cavernous malformation resection, without and with use of a flexible omnidirectional carbon dioxide laser: a single-surgeon series of 277 surgical procedures"],"prefix":"10.3171","volume":"143","author":[{"given":"Andrew J.","family":"Gauden","sequence":"first","affiliation":[{"name":"Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jason L.","family":"Choi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ingrid","family":"Luo","sequence":"additional","affiliation":[{"name":"Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Summer S.","family":"Han","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California; and"},{"name":"Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gary K.","family":"Steinberg","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California; and"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"2","key":"b1","series-title":"Neurosurgery","first-page":"403","article-title":"Advances in the treatment and outcome of brainstem cavernous malformation surgery: a single-center case series of 300 surgically treated patients","volume":"68","author":"Abla AA","year":"2011","unstructured":"Abla AA, Lekovic GP, Turner JD, de Oliveira JG, Porter R, Spetzler RF. Advances in the treatment and outcome of brainstem cavernous malformation surgery: a single-center case series of 300 surgically treated patients. Neurosurgery. 2011;68(2):403\u2013415."},{"issue":"4","key":"b2","series-title":"Neurosurgery","first-page":"573","article-title":"Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients","volume":"72","author":"Pandey P","year":"2013","unstructured":"Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients. Neurosurgery.2013;72(4):573-589."},{"issue":"5","key":"b3","series-title":"Neurosurgery","first-page":"665","article-title":"Synopsis of guidelines for the clinical management of cerebral cavernous malformations: consensus recommendations based on systematic literature review by the Angioma Alliance Scientific Advisory Board clinical experts panel","volume":"80","author":"Akers A","year":"2017","unstructured":"Akers A, Al-Shahi Salman R, Awad IA, Synopsis of guidelines for the clinical management of cerebral cavernous malformations: consensus recommendations based on systematic literature review by the Angioma Alliance Scientific Advisory Board clinical experts panel. Neurosurgery. 2017;80(5):665\u2013680."},{"issue":"10","key":"b4","series-title":"Stroke","first-page":"2964","article-title":"Outcomes of surgery for brainstem cavernous malformations: a systematic review","volume":"50","author":"Kearns KN","year":"2019","unstructured":"Kearns KN, Chen CJ, Tvrdik P, Park MS, Kalani MYS. Outcomes of surgery for brainstem cavernous malformations: a systematic review. Stroke. 2019;50(10):2964\u20132966."},{"issue":"suppl 1","key":"b5","series-title":"Neurosurgery","first-page":"34","article-title":"Flexible omnidirectional carbon dioxide laser as an effective tool for resection of brainstem, supratentorial, and intramedullary cavernous malformations","volume":"10","author":"Choudhri O","year":"2014","unstructured":"Choudhri O, Karamchandani J, Gooderham P, Steinberg GK. Flexible omnidirectional carbon dioxide laser as an effective tool for resection of brainstem, supratentorial, and intramedullary cavernous malformations. 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Expert Rev Neurother. 2015;15(10):1109\u20131111."},{"issue":"3","key":"b10","series-title":"World Neurosurg","first-page":"317","article-title":"Management of brainstem cavernous malformations","volume":"83","author":"Almefty KK","year":"2015","unstructured":"Almefty KK, Spetzler RF. Management of brainstem cavernous malformations. World Neurosurg. 2015;83(3):317\u2013319."},{"issue":"1","key":"b11","series-title":"Asian J Neurosurg","first-page":"131","article-title":"Management and surgical approaches of brainstem cavernous malformations: our experience and literature review","volume":"14","author":"Cannizzaro D","year":"2019","unstructured":"Cannizzaro D, Sabatino G, Mancarella C, Management and surgical approaches of brainstem cavernous malformations: our experience and literature review. 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J Neurosurg. 2019;130(1):286\u2013301."},{"issue":"1","key":"b13","series-title":"Neurosurg Rev","first-page":"252","article-title":"Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis","volume":"46","author":"Albalkhi I","year":"2023","unstructured":"Albalkhi I, Shafqat A, Bin-Alamer O, Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis. Neurosurg Rev. 2023;46(1):252."},{"issue":"1-2","key":"b14","series-title":"World Neurosurg","first-page":"89","article-title":"Brainstem cavernous malformations: 1390 surgical cases from the literature","volume":"80","author":"Gross BA","year":"2013","unstructured":"Gross BA, Batjer HH, Awad IA, Bendok BR, Du R. Brainstem cavernous malformations: 1390 surgical cases from the literature. World Neurosurg. 2013;80(1-2):89\u201393."},{"issue":"4","key":"b15","series-title":"Neurosurgery","first-page":"573","article-title":"Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients","volume":"72","author":"Pandey P","year":"2013","unstructured":"Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients. Neurosurgery. 2013;72(4):573\u2013589."},{"issue":"3","key":"b16","series-title":"Neurosurgery","first-page":"265","article-title":"Brainstem cavernous malformations: surgical results in 104 patients and a proposed grading system to predict neurological outcomes","volume":"76","author":"Garcia RM","year":"2015","unstructured":"Garcia RM, Ivan ME, Lawton MT. Brainstem cavernous malformations: surgical results in 104 patients and a proposed grading system to predict neurological outcomes. Neurosurgery. 2015;76(3):265\u2013278."},{"key":"b17","series-title":"Front Neurol","first-page":"600461","article-title":"Microsurgery vs. Gamma Knife radiosurgery for the treatment of brainstem cavernous malformations: a systematic review and meta-analysis","volume":"12","author":"Gao X","year":"2021","unstructured":"Gao X, Yue K, Sun J, Microsurgery vs. Gamma Knife radiosurgery for the treatment of brainstem cavernous malformations: a systematic review and meta-analysis. Front Neurol. 2021;12:600461."},{"key":"b18","series-title":"Front Surg","first-page":"630134","article-title":"Brainstem cavernous malformations management: microsurgery vs. radiosurgery, a meta-analysis","volume":"8","author":"Fotakopoulos G","year":"2022","unstructured":"Fotakopoulos G, Andrade-Barazarte H, Kivelev J, Tjahjadi M, Goehre F, Hernesniemi J. Brainstem cavernous malformations management: microsurgery vs. radiosurgery, a meta-analysis. 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Outcomes of surgery for brainstem cavernous malformations: a systematic review. Stroke. 2019;50(10):2964\u20132966."},{"issue":"suppl 1","key":"b5","series-title":"Neurosurgery","first-page":"34","article-title":"Flexible omnidirectional carbon dioxide laser as an effective tool for resection of brainstem, supratentorial, and intramedullary cavernous malformations","volume":"10","author":"Choudhri O","year":"2014","unstructured":"Choudhri O, Karamchandani J, Gooderham P, Steinberg GK. Flexible omnidirectional carbon dioxide laser as an effective tool for resection of brainstem, supratentorial, and intramedullary cavernous malformations. 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J Neurosurg. 2019;130(1):286\u2013301."},{"issue":"1","key":"b13","series-title":"Neurosurg Rev","first-page":"252","article-title":"Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis","volume":"46","author":"Albalkhi I","year":"2023","unstructured":"Albalkhi I, Shafqat A, Bin-Alamer O, Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis. Neurosurg Rev. 2023;46(1):252."},{"issue":"1-2","key":"b14","series-title":"World Neurosurg","first-page":"89","article-title":"Brainstem cavernous malformations: 1390 surgical cases from the literature","volume":"80","author":"Gross BA","year":"2013","unstructured":"Gross BA, Batjer HH, Awad IA, Bendok BR, Du R. Brainstem cavernous malformations: 1390 surgical cases from the literature. World Neurosurg. 2013;80(1-2):89\u201393."},{"issue":"4","key":"b15","series-title":"Neurosurgery","first-page":"573","article-title":"Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients","volume":"72","author":"Pandey P","year":"2013","unstructured":"Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients. Neurosurgery. 2013;72(4):573\u2013589."},{"issue":"3","key":"b16","series-title":"Neurosurgery","first-page":"265","article-title":"Brainstem cavernous malformations: surgical results in 104 patients and a proposed grading system to predict neurological outcomes","volume":"76","author":"Garcia RM","year":"2015","unstructured":"Garcia RM, Ivan ME, Lawton MT. Brainstem cavernous malformations: surgical results in 104 patients and a proposed grading system to predict neurological outcomes. Neurosurgery. 2015;76(3):265\u2013278."},{"key":"b17","series-title":"Front Neurol","first-page":"600461","article-title":"Microsurgery vs. Gamma Knife radiosurgery for the treatment of brainstem cavernous malformations: a systematic review and meta-analysis","volume":"12","author":"Gao X","year":"2021","unstructured":"Gao X, Yue K, Sun J, Microsurgery vs. Gamma Knife radiosurgery for the treatment of brainstem cavernous malformations: a systematic review and meta-analysis. Front Neurol. 2021;12:600461."},{"key":"b18","series-title":"Front Surg","first-page":"630134","article-title":"Brainstem cavernous malformations management: microsurgery vs. radiosurgery, a meta-analysis","volume":"8","author":"Fotakopoulos G","year":"2022","unstructured":"Fotakopoulos G, Andrade-Barazarte H, Kivelev J, Tjahjadi M, Goehre F, Hernesniemi J. Brainstem cavernous malformations management: microsurgery vs. radiosurgery, a meta-analysis. 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