Abstract：
Anatomical taxonomy is a practical tool to successfully guide clinical decision-making for patients with brain arteriovenous malformations and brainstem cavernous malformations (CMs). Deep cerebral CMs are complex, difficult to access, and highly variable in size, shape, and position. The authors propose a novel taxonomic system for deep CMs in the thalamus based on clinical presentation (syndromes) and anatomical location (identified on MRI).
The taxonomic system was developed and applied to an extensive 2-surgeon experience from 2001 through 2019. Deep CMs involving the thalamus were identified. These CMs were subtyped on the basis of the predominant surface presentation identified on preoperative MRI. Six subtypes among 75 thalamic CMs were defined: anterior (7/75, 9%), medial (22/75, 29%), lateral (10/75, 13%), choroidal (9/75, 12%), pulvinar (19/75, 25%), and geniculate (8/75, 11%). Neurological outcomes were assessed using modified Rankin Scale (mRS) scores. A postoperative score ≤ 2 was defined as a favorable outcome and > 2 as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes.
Seventy-five patients underwent resection of thalamic CMs and had clinical and radiological data available. Their mean age was 40.9 (SD 15.2) years. Each thalamic CM subtype was associated with a recognizable constellation of neurological symptoms. The common symptoms were severe or worsening headaches (30/75, 40%), hemiparesis (27/75, 36%), hemianesthesia (21/75, 28%), blurred vision (14/75, 19%), and hydrocephalus (9/75, 12%). The thalamic CM subtype determined the selection of surgical approach. A single approach was associated with each subtype for most patients. The main exception to this paradigm was that in the surgeons\' early experience, pulvinar CMs were resected through a superior parietal lobule-transatrial approach (4/19, 21%), which later evolved to the paramedian supracerebellar-infratentorial approach (12/19, 63%). Relative outcomes implied by mRS scores were unchanged or improved in most patients (61/66, 92%) postoperatively.
This study confirms the authors\' hypothesis that this taxonomy for thalamic CMs can meaningfully guide the selection of surgical approach and resection strategy. The proposed taxonomy can increase diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the clarity of clinical communications and publications, and improve patient outcomes.
The taxonomic system was developed and applied to an extensive 2-surgeon experience from 2001 through 2019. Deep CMs involving the thalamus were identified. These CMs were subtyped on the basis of the predominant surface presentation identified on preoperative MRI. Six subtypes among 75 thalamic CMs were defined: anterior (7/75, 9%), medial (22/75, 29%), lateral (10/75, 13%), choroidal (9/75, 12%), pulvinar (19/75, 25%), and geniculate (8/75, 11%). Neurological outcomes were assessed using modified Rankin Scale (mRS) scores. A postoperative score ≤ 2 was defined as a favorable outcome and > 2 as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes.
Seventy-five patients underwent resection of thalamic CMs and had clinical and radiological data available. Their mean age was 40.9 (SD 15.2) years. Each thalamic CM subtype was associated with a recognizable constellation of neurological symptoms. The common symptoms were severe or worsening headaches (30/75, 40%), hemiparesis (27/75, 36%), hemianesthesia (21/75, 28%), blurred vision (14/75, 19%), and hydrocephalus (9/75, 12%). The thalamic CM subtype determined the selection of surgical approach. A single approach was associated with each subtype for most patients. The main exception to this paradigm was that in the surgeons\' early experience, pulvinar CMs were resected through a superior parietal lobule-transatrial approach (4/19, 21%), which later evolved to the paramedian supracerebellar-infratentorial approach (12/19, 63%). Relative outcomes implied by mRS scores were unchanged or improved in most patients (61/66, 92%) postoperatively.
This study confirms the authors\' hypothesis that this taxonomy for thalamic CMs can meaningfully guide the selection of surgical approach and resection strategy. The proposed taxonomy can increase diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the clarity of clinical communications and publications, and improve patient outcomes.
摘要：
目的：解剖分类学是成功指导脑动静脉畸形和脑干海绵状畸形（CMs）患者临床决策的实用工具。大脑深部CM很复杂,难以接近,大小变化很大，形状,和位置。作者根据临床表现（综合征）和解剖位置（在MRI上识别）提出了一种新的丘脑深层CM分类系统。
方法：从2001年到2019年，该分类系统被开发并应用于广泛的2-外科医生经验。确定了涉及丘脑的深层CM。这些CM是根据术前MRI确定的主要表面表现进行分型的。在75个丘脑CMs中定义了六个亚型：前(7/75，9%)，中间（22/75，29%），横向（10/75，13%），脉络膜(9/75,12%),pulvinar(19/75，25%)，和膝状(8/75，11%)。使用改良的Rankin量表（mRS）评分评估神经系统结果。术后评分≤2被定义为有利结果，>2被定义为不良结果。比较了不同亚型的临床和手术特征以及神经系统转归。
结果：75例患者接受了丘脑CMs切除术，并获得了临床和放射学数据。他们的平均年龄为40.9（SD15.2）岁。每个丘脑CM亚型都与可识别的神经系统症状有关。常见的症状是严重或恶化的头痛（30/75，40％），偏瘫（27/75，36%），半麻醉（21/75，28%），视力模糊（14/75，19%），和脑积水（9/75，12％）。丘脑CM亚型决定了手术方式的选择。对于大多数患者，单一方法与每种亚型相关。这种模式的主要例外是，在外科医生的早期经验中，通过顶叶上小叶-经心房入路切除pulvinarCMs（4/19，21％），后来演变为辅助大脑上小脑-幕下入路（12/19，63%）。大多数患者（61/66，92%）术后mRS评分所暗示的相对结果不变或改善。
结论：这项研究证实了作者的假设，即丘脑CMs的分类法可以有意义地指导手术入路和切除策略的选择。拟议的分类法可以提高患者床边的诊断敏锐度，帮助确定最佳的手术方法，提高临床通信和出版物的清晰度，改善患者预后。
方法：从2001年到2019年，该分类系统被开发并应用于广泛的2-外科医生经验。确定了涉及丘脑的深层CM。这些CM是根据术前MRI确定的主要表面表现进行分型的。在75个丘脑CMs中定义了六个亚型：前(7/75，9%)，中间（22/75，29%），横向（10/75，13%），脉络膜(9/75,12%),pulvinar(19/75，25%)，和膝状(8/75，11%)。使用改良的Rankin量表（mRS）评分评估神经系统结果。术后评分≤2被定义为有利结果，>2被定义为不良结果。比较了不同亚型的临床和手术特征以及神经系统转归。
结果：75例患者接受了丘脑CMs切除术，并获得了临床和放射学数据。他们的平均年龄为40.9（SD15.2）岁。每个丘脑CM亚型都与可识别的神经系统症状有关。常见的症状是严重或恶化的头痛（30/75，40％），偏瘫（27/75，36%），半麻醉（21/75，28%），视力模糊（14/75，19%），和脑积水（9/75，12％）。丘脑CM亚型决定了手术方式的选择。对于大多数患者，单一方法与每种亚型相关。这种模式的主要例外是，在外科医生的早期经验中，通过顶叶上小叶-经心房入路切除pulvinarCMs（4/19，21％），后来演变为辅助大脑上小脑-幕下入路（12/19，63%）。大多数患者（61/66，92%）术后mRS评分所暗示的相对结果不变或改善。
结论：这项研究证实了作者的假设，即丘脑CMs的分类法可以有意义地指导手术入路和切除策略的选择。拟议的分类法可以提高患者床边的诊断敏锐度，帮助确定最佳的手术方法，提高临床通信和出版物的清晰度，改善患者预后。
