Surgical treatment of brainstem cavernous malformations in pregnancy: a retrospective single-center series and systematic review of the literature

OBJECTIVE: Brainstem cavernous malformations (BSCMs) are rare neurovascular lesions, and they are especially rare during pregnancy. Pregnancy was not considered in the international consensus on patient-related factors that influence surgical treatment decisions for BSCMs. Therefore, the authors sought to analyze the association between pregnancy and surgical outcomes of BSCMs. METHODS: The authors retrospectively identified women who were pregnant and underwent microsurgical treatment for a BSCM during a period of 37 years. Pregnant women who underwent surgery antepartum were compared with those who underwent surgery postpartum. Demographics, clinical presentation, BSCM characteristics, gestational age, mode of delivery, neurological outcomes, and obstetric and fetal complications were assessed. Primary maternal outcomes were classified as favorable (modified Rankin Scale [mRS] score ≤ 2) or unfavorable (mRS score > 2) and stable, improved, or worse relative to baseline. A systematic review of the literature was also performed to identify all pregnant women with BSCMs who underwent surgical treatment. RESULTS: The study identified 11 pregnant women with BSCMs. BSCMs were low grade (Lawton grade 0-II) in 7 of 9 (78%) pregnant women and intermediate grade (III-V) in 2 of 9 (22%). Seven of 11 (64%) pregnant women had ≥ 2 bleeds, and 4 of 11 (36%) had 1 bleed. Seven (64%) patients underwent surgery antepartum and 4 (36%) postpartum; all had favorable final and stable or improved outcomes (p > 0.05). Twelve additional pregnant women with BSCMs who underwent surgical treatment were identified in the literature. CONCLUSIONS: Based on these findings, the authors argue that pregnancy poses no additional risk for poor neurological outcome after surgical treatment of BSCM. Surgical treatment decisions for women with BSCMs should include Lawton BSCM grade, number of symptomatic hemorrhages, and presence of severe or progressive neurological deficits rather than pregnancy status.