Approach Selection Strategies for Repeat Resection of Brain Cavernous Malformations: Cohort Study.

Background: Neurosurgical management of cerebral cavernous malformations (CMs) often benefits from using skull base approaches. Although many CMs are cured by resection, residual or recurrent disease may require repeat resection.

Objective: To review approach selection strategies for reoperation of CMs to aid decision-making for repeat procedures.

Methods: In this retrospective cohort study, a prospectively maintained single-surgeon registry was queried for patients with CMs who underwent repeat resection from January 1, 1997, to April 30, 2021.

Results: Of 854 consecutive patients, 68 (8%) underwent 2 operations; 40 had accessible data on both. In most reoperations (33/40 [83%]), the index approach was repeated. In most reoperations using the index approach (29/33 [88%]), that approach was deemed ideal (no equivalent or superior alternative), whereas in some (4/33 [12%]), the alternative approach was deemed unsafe because of conformation of the tract. Among patients with reoperations using an alternative approach (7/40 [18%]), 2 with index transsylvian approaches underwent bifrontal transcallosal approaches, 2 with index presigmoid approaches underwent extended retrosigmoid revisions, and 3 with index supracerebellar-infratentorial approaches underwent alternative supracerebellar-infratentorial trajectory revisions. Among patients with reoperations with an alternative approach considered or selected (11/40 [28%]), 8 of 11 patients had a different surgeon for the index resection than for the repeat resection. The extended retrosigmoid-based approaches were used most often for reoperations.

Conclusion: Repeat resection of recurrent or residual CMs is a challenging neurosurgical niche at the intersection of cerebrovascular and skull base disciplines. Suboptimal index approaches may limit surgical options for repeat resection.