Affected health domains in patients with brainstem cavernous malformations

BACKGROUND

Brainstem cavernous malformations (CM) carry high risks of hemorrhage and neurologic morbidity. While much is published on physical effects of brainstem CM, very little is known about these patients' quality of life. This study aimed to assess the quality of life PROMIS-29 health domains of brainstem CM patients and identify quality of life predictors.

METHODS

This was a cross-sectional study of adult patients with at least one brainstem CM identified by advertising on the Angioma Alliance website and from our institutional CM registry. A web-based questionnaire was administered and included self-reported information about the patient, cavernous malformation, residual clinical symptoms, and treatment. In addition, patients filled out the PROMIS-29 (version 1.0). The PROMIS-29 has 7 health domains and is standardized against the general population. We defined impaired quality of life as at least one out of 7 abnormal domains and used a 1 standard deviation cutoff for abnormal. We verified clinical and radiographic data to self-reported data in 28.8% of patients.

RESULTS

A total of 104 patients (mean age of 46.5 ± 11.5 years; 77.9% females) were recruited. Most (82.7%) reported at least one symptomatic hemorrhagic event and 36.5% reported at least 1 surgical procedure. At least one abnormal PROMIS domain was present in 64.4% of patients with fatigue (34.6%), anxiety (35.6%), social (28.2%), and physical (27.9%) domains being the most common. Among patients with a Rankin Score of 0-2, 55% had at least one abnormal domain. Gait difficulty, but not age, sex, or surgery predicted impaired quality of life.

CONCLUSION

More than half of patients with brainstem CM have impaired quality of life. Fatigue, anxiety, and social function, in addition to physical dysfunction, are common; practitioners should be aware of these concerns. PROMIS-29 provides additional information than modified Rankin Score and should be considered in clinical trials and when assessing treatment outcomes until a disease-specific outcome tool is available.

Transcriptome clarifies mechanisms of lesion genesis versus progression in models of Ccm3 cerebral cavernous malformations

Cerebral cavernous malformations (CCMs) are dilated capillaries causing epilepsy and stroke. Inheritance of a heterozygous mutation in CCM3/PDCD10 is responsible for the most aggressive familial form of the disease. Here we studied the differences and commonalities between the transcriptomes of microdissected lesional neurovascular units (NVUs) from acute and chronic in vivo Ccm3/Pdcd10ECKO mice, and cultured brain microvascular endothelial cells (BMECs) Ccm3/Pdcd10ECKO.We identified 2409 differentially expressed genes (DEGs) in acute and 2962 in chronic in vivo NVUs compared to microdissected brain capillaries, as well as 121 in in vitro BMECs with and without Ccm3/Pdcd10 loss (fold change ≥ |2.0|; p < 0.05, false discovery rate corrected). A functional clustered dendrogram generated using the Euclidean distance showed that the DEGs identified only in acute in vivo NVUs were clustered in cellular proliferation gene ontology functions. The DEGs only identified in chronic in vivo NVUs were clustered in inflammation and immune response, permeability, and adhesion functions. In addition, 1225 DEGs were only identified in the in vivo NVUs but not in vitro BMECs, and these clustered within neuronal and glial functions. One miRNA mmu-miR-3472a was differentially expressed (FC = - 5.98; p = 0.07, FDR corrected) in the serum of Ccm3/Pdcd10+/- when compared to wild type mice, and this was functionally related as a putative target to Cand2 (cullin associated and neddylation dissociated 2), a DEG in acute and chronic lesional NVUs and in vitro BMECs. Our results suggest that the acute model is characterized by cell proliferation, while the chronic model showed inflammatory, adhesion and permeability processes. In addition, we highlight the importance of extra-endothelial structures in CCM disease, and potential role of circulating miRNAs as biomarkers of disease, interacting with DEGs. The extensive DEGs library of each model will serve as a validation tool for potential mechanistic, biomarker, and therapeutic targets.

Surgical resection of cavernous angioma located within eloquent brain areas: International survey of the practical management among 19 specialized centers

PURPOSE

The practical management of cavernous angioma located within eloquent brain area before, during and after surgical resection is poorly documented. We assessed the practical pre-operative, intra-operative, and post-operative management of cavernous angioma located within eloquent brain area.

METHOD

An online survey composed of 61 items was sent to 26 centers to establish a multicenter international retrospective cohort of adult patients who underwent a surgical resection as the first-line treatment of a supratentorial cavernous angioma located within or close to eloquent brain area.

RESULTS

272 patients from 19 centers (mean 13.6 ± 16.7 per center) from eight countries were included. The pre-operative management varied significantly between centers and countries regarding the pre-operative functional assessment, the pre-operative epileptological assessment, the first given antiepileptic drug, and the time to surgery. The intra-operative environment varied significantly between centers and countries regarding the use of imaging systems, the use of functional mapping with direct electrostimulations, the extent of resection of the hemosiderin rim, the realization of a post-operative functional assessment, and the time to post-operative functional assessment. The present survey found a post-operative improvement, as compared to pre-operative evaluations, of the functional status, the ability to work, and the seizure control.

CONCLUSIONS

We observed a variety of practice between centers and countries regarding the management of cavernous angioma located within eloquent regions. Multicentric prospective studies are required to solve relevant questions regarding the management of cavernous angioma-related seizures, the timing of surgery, and the optimal extent of hemosiderin rim resection.

Klippel-Trenaunay-Weber Syndrome with Atypical Presentation of Cerebral Cavernous Angioma: A Case Report and Literature Review

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare syndrome characterized by the triad of cutaneous hemangiomas, venous varicosities, and osseous-soft tissue hypertrophy of the affected limb. Clinical manifestations, genetic testing, and radiologic imaging are the key steps in diagnosing this syndrome.

CASE DESCRIPTION

An 18-month-old boy was brought for follow-up brain magnetic resonance imaging (MRI) with a history of right lower limb hypertrophy, cutaneous varicosities, and hemangiomas diagnosed at birth. A baseline MRI at 12 months revealed multiple hemorrhagic lesions within the cerebrum, the largest in the right temporal lobe, which was treated surgically at the age of 18 months because of its rapid growth. This is the youngest patient with KTWS treated surgically for intracranial hemangiomas.

CONCLUSION

KTWS is a rare disease with a wide range of manifestations. Multisystemic evaluation of this group of patients should be performed to identify cavernous hemangiomas at the early stage of life and adequately treat them in the future. Treatment of KTWS patients with cavernous hemangiomas should not be different from the treatment of patients with any other hemangiomas, and surgical intervention should be considered on a case-to-case bases.

Tumors of the Orbit: Case Report and Review of Surgical Corridors and Current Options

Tumors that involve the orbit can be classified into two major groups: primary tumors of the orbit and tumors that extend into the orbit from other sites. The most frequent primary orbital lesions in adults include cavernous hemangiomas, lymphoid tumors, and meningiomas. The most common tumors that extend into the orbit are meningiomas, followed by sinonasal carcinomas. In this article, we report a case of intraconal orbital lesion operated at our center and a review of the surgical approaches to the orbit.

Acute Transient Oculomotor Nerve Palsy from Presumed Cavernous Angioma in an Infant

Cavernous angiomas of the cranial nerves are extremely rare, and those of the oculomotor (third) cranial nerve are rarer still, with no previous cases having been reported in the literature. We report herein the first case of a presumed cavernous angioma involving the subarachnoid portion of the left third nerve presenting as an acute left third nerve palsy in an infant. The child was followed without intervention and the palsy completely resolved. Given the poor functional results with attempted surgical excision and the potential for spontaneous improvement in oculomotor nerve function, it is reasonable to follow patients with these lesions without intervention.

Supratentorial dural-based collision of cavernoma and meningioma: a case report

Background

Collision tumor is a very rare case of cerebral lesion. Approximately 50 reports of intracranial collision tumors were described in the literature. We present a case of supratentorial dural-based convexity collision tumor radiologically mimicking cavernous malformation and composed of cavernous malformation and meningioma.

Case presentation

The case presents a 63-year-old female having MR findings such as hemorraged supratentorial dural-based mass with “popcorn” signs and hemosiderin deposits. The patient underwent craniotomy and evacuation of the subdural hematoma with resection of the tumor mass. Histologically the lesion had signs of a cavernoma and meningioma. MRI in a year after surgery did not reveale residual tumor mass or recurrence.

Conclusions

Collision tumor is a very rare case. Preoperative diagnosis of a dural lesion is difficult and challenging. A neuroradiological differential diagnosis of similar cases needs focused attention.

Usefulness of Ultrasound-Guided Microsurgery in Cavernous Angioma Removal

BACKGROUND

Primary elements of surgical treatment of cavernous angiomas (CAs) are precise lesion identification and optimal trajectory determination. Navigation techniques allow for better results compared to microsurgery alone. In this study, we examined the benefits of intraoperative ultrasound (IOUS) use as an adjunct to standard localization systems.

METHODS

We retrospectively analyzed 59 CAs, comparing outcomes in 2 groups of patients: 34 who underwent frame-based or frameless navigation-assisted microsurgery (no-IOUS group) and 25 who underwent IOUS-guided microsurgery associated with these techniques (IOUS group).

RESULTS

The use of IOUS did not significantly increase the surgery time (mean, 172 ± 1.7 minutes in the IOUS group and 192.6 ± 11.5 in no-IOUS group; P = 0.08). In all 25 patients in the IOUS group, IOUS allowed for ready identification of CA as a hyperechoic mass. At the last follow-up (mean, 41.7 ± 3.5 months postsurgery), 95.2% of the IOUS group and 80.8% of the no-IOUS group had a modified Rankin Scale score of 0-1 and an Extended Glasgow Outcome Scale score of 7-8 (P = 0.2), with 100% and 64%, respectively, included in Engel outcome scale class IA (P = 0.006). Complete removal, as confirmed on postoperative magnetic resonance imaging, was achieved in all patients in the IOUS group and in almost all (97.1%; P = 0.4) patients in the no-IOUS group.

CONCLUSIONS

IOUS is a valid tool for the intraoperative identification of CAs. Implementation of standard localization methods with IOUS guidance was associated with complete resection in all cases, without increasing surgical time. Compared with microsurgery without IOUS guidance, long-term functional outcomes showed better trends, and the epilepsy-free rate was significantly higher.

Pediatric cerebellar giant cavernous malformation: case report and review of literature

BACKGROUND AND IMPORTANCE

Giant cavernous malformations (GCM) are low flow, angiographically occult vascular lesions, with a diameter >4 cm. Cerebellar GCMs are extremely rare, with only seven cases reported based on English literature. These lesions are most commonly seen in the pediatric age group, which is known to have an increased risk of hemorrhage, being surgery clearly recommended.

CLINICAL PRESENTATION

An 18-month-old girl presented with a 6-month history of cervical torticollis and upper extremities clumsiness. An MRI revealed a 57 × 46 × 42 mm multi-cystic, left cerebellar hemisphere mass, showing areas of hemorrhages and cysts with various stages of thrombus. There was no enhancement with contrast. Cerebral angiography ruled out an arteriovenous malformation. She underwent a left paramedian occipital craniotomy, and macroscopic gross total resection was accomplished. Histopathologic examination was consistent with a cavernous malformation. After surgery, the patient had no new neurological deficit and an uneventful postoperative recovery. Follow-up MRI confirmed total removal of the lesion.

CONCLUSION

Cerebellar GCMs in children are symptomatic lesions, which prompt immediate surgical treatment. These are rare lesions, which can radiologically and clinically mimic a tumor with bleed, having to be considered in the differential diagnosis of neoplastic lesions. Cerebellar GCMs might be suspected in the presence of large hemorrhagic intra-axial mass with "bubbles of blood," multi-cystic appearance, surrounded by hemosiderin ring, fluid-fluid levels, and accompanying edema-mass effect. Careful radiological study provides a preoperative diagnosis, but its confirmation requires histopathological examination. Complete surgical removal should be attempted when possible.

Clinical Management of Cavernous Malformations

PURPOSE OF REVIEW

This study aims to review the current epidemiology and clinical management of patients with cavernous malformations (CM).

RECENT FINDINGS

Hemorrhage is the most feared complication and leads to morbidity in patients with CM. Multiple studies including three meta-analyses have provided useful estimates of hemorrhage risk, but have failed to identify a modifiable risk factor for prevention of cavernous malformation related hemorrhage. In treating the CM itself, surgical risk is weighed against the natural history. However, accumulating knowledge regarding the roles of CCM 1, 2, and 3 genes has led to the discovery of potential therapeutic targets. The risk of future hemorrhage in patients with CM is highest in those who have had previously clinical hemorrhages. Estimated risks are helpful in counseling patients and comparing to the risk of surgery. Future clinical trials of candidate medications are likely to target those patients with prior clinical hemorrhage in whom the surgical risk is deemed high.

Pilocytic astrocytoma mimicking cavernous angioma: Imaging features and histological characteristics

Pilocytic astrocytoma (PA) commonly occurs during the first two decades of life. Typical locations include cerebellum, optic nerve, optic chiasm/hypothalamus and brainstem. PA should be considered in the differential diagnosis of patients with brain tumors manifesting with hemorrhagic onset. We report a case of a hemorrhagic onset of cerebellar PA in a young adult with imaging findings mimicking cavernous angioma. We also discuss imaging features and histological characteristics with a focus on the etiology of the hemorrhagic onset.

Development of cystic malacia after high-dose cranial irradiation of pediatric CNS tumors in long-term follow-up

PURPOSE

The purpose of this study is to investigate the incidence of cystic malacia in long-term survivors of pediatric brain tumors treated with high-dose cranial irradiation.

MATERIALS AND METHODS

Between 1997 and 2015, we treated 41 pediatric patients (26 males, 15 females; age ranging from 3.3 to 15.7 years, median 9-year-old) of pediatric brain tumors [17 medulloblastomas, 7 primitive neuroectodermal tumors (PNET), 3 pineoblastomas, 6 non-germinomatous germ cell tumors (NGGCT), 8 gliomas (including 4 ependymomas, 1 anaplastic astrocytoma, 1 oligodendroglioma, 1 pilocytic astrocytoma, 1 astroblastoma)] with high-dose craniospinal irradiation. Follow-up ranged from 14.0 to 189.2 months (median 86.0 months, mean 81.5 months), the irradiation dose to the whole neural axis ranged from 18 to 41.4 Gy, and the total local dose from 43.2 to 60.4 Gy. All patients underwent follow-up magnetic resonance imaging (MRI) studies at least once a year. Diagnosis of cystic malacia was based solely on MRI findings. Of the 41 patients, 31 were censored during their follow-up due to recurrence of the primary disease (n = 5), detection of secondary leukemia after development of cystic malacia (n = 1), or the absence of cystic malacia on the last follow-up MRI study (n = 25). We also evaluated the development of post-irradiation cavernous angioma and white matter changes.

RESULTS

Following irradiation treatment, 11 patients developed 19 cystic malacia during a median course of 30.8 months (range 14.9 to 59.3 months). The site of predilection for cystic malacia was white matter around trigone of lateral ventricles with an incidence of 47.4% (9 of 19 lesions, 7 in 11 patients). Patients with supratentorial tumors developed cystic malacia statistically earlier than the patients with infratentorial tumors (P = 0.0178, log-rank test). Among the same patient group, incidence of post-irradiation cavernous angioma increased progressively, while the incidence of post-irradiation cystic malacia did not increase after 5 years. White matter degeneration developed earlier than cystic malacia or cavernous angioma, and these three clinical entities developed mutually exclusive of each other.

CONCLUSION

We attribute the higher incidence of post-irradiation cystic malacia, in our long-term follow-up study, to the cranial irradiation for pediatric brain tumors, particularly supratentorial brain tumors, and recommend a regular, long-term follow-up of brain tumor patients treated with cranial irradiation.

Completely Thrombosed Distal Middle Cerebral Artery Aneurysm Mimicking a Cavernous Angioma: Case Report and Review of the Literature

BACKGROUND

Distal middle cerebral artery (MCA) aneurysms originate from branches of MCA distal to its main bifurcation or the peripheral branches. Distal MCA aneurysms are uncommon compared with saccular aneurysms, which develop along the proximal trunks of MCA. However, thrombotic aneurysms, characterized by organized intraluminal thrombus and solid mass, are frequently in the large and giant size range, whereas complete thrombosis of non-giant MCA aneurysms is very rare.

CASE PRESENTATION

We present the clinical case of a 53 years-old woman with a completely thrombosed medium distal MCA aneurysm mimicking a cavernous angioma. She came to our emergency department after the onset of tinnitus and persistent headache. Magnetic resonance imaging performed subsequently showed a nodular mass surrounded by edema located in the temporal lobe with a homogeneous peripheral contrast enhancement. Furthermore, angiography showed regular flow in the MCA and confirmed the diagnosis of cavernous angioma. The patient underwent surgery, and the lesion was found to be a thrombosed aneurysm originating from the distal temporal branch of the left MCA (M2 segment).

CONCLUSIONS

To our knowledge, this is the first report of a thrombosed distal medium MCA aneurysm that mimicked a cavernous angioma. The completely thrombosed aneurysm can be confused with intracranial lesions or cavernous malformations, which can have similar radiographic features without angiographic anomalies, so it is mandatory to consider the possibility of a thrombosed aneurysm for a correct differential diagnosis.

Management of Cerebral Radiation Necrosis: A Retrospective Study of 12 Patients

BACKGROUND

Cerebral radiation necrosis (RN) is a severe complication of radiotherapy for cerebral pathologies. This study discusses the radiographic and pathological features of 12 patients with RN and investigates the management strategy.

METHODS

Eleven patients with brain tumors, and one with cerebral cavernous angioma, treated by surgical resection or Gamma Knife alone before radiotherapy developed RN during follow-up. Surgical resection for the cerebral RN was performed in nine patients, and the other three patients received medical treatment. The clinical features, magnetic resonance imaging (MRI), surgical findings, and pathological sections are reviewed.

RESULTS

The diagnosis of RN was confirmed by histological study in all the patients; those with surgical and medical treatment recovered.

CONCLUSION

As a major complication of radiotherapy, from the clinical and neuroradiological points of view, RN may simulate tumor recurrence. Due to the increasing number of patients with RN who will need to be treated in future years, the definite diagnosis and appropriate treatment of RN remain critical.

Cavernous Angioma of the Cerebral Aqueduct

BACKGROUND

Among the rare intraventricular cavernomas, purely intra-aqueductal cavernomas are exceptionally rare.

CASE DESCRIPTION

A 62-year-old patient presented with progressive headache, memory loss, gait instability, and urinary incontinence. Magnetic resonance imaging showed the presence of a mass lesion located in the lumen of the cerebral aqueduct, associated with triventricular hydrocephalus.

CONCLUSIONS

We discuss the rationale that led us to treat hydrocephalus with neuroendoscopy, which offered the possibility to directly inspect the intra-aqueductal lesion, make the diagnosis of cavernoma, and treat symptoms resulting from hydrocephalus without increasing the risk of bleeding.

Endoscope-assisted resection of cavernous angioma at the foramen of Monro: a case report

INTRODUCTION

Intraventricular cavernous angiomas are rare pathological entities, and those located at the foramen of Monro are even rarer. We herein present a case of cavernous angioma at the foramen of Monro that was successfully treated by neuroendoscope-assisted surgical removal, and review the relevant literature.

CASE PRESENTATION

A 65-year-old woman had experienced headache and vomiting for 10 days before admission to another hospital. Magnetic resonance imaging (MRI) showed a mass at the foramen of Monro, and obstructive hydrocephalus of both lateral ventricles. The patient was then referred to our hospital. Neurological examination on admission to our hospital showed memory disturbance (Mini-Mental State Examination 20/30) and wide-based gait. A cavernous angioma at the foramen of Monro was diagnosed based on the typical popcorn-like appearance of the lesion on MRI. The lesion was completely removed by neuroendoscope-assisted transcortical surgery with the Viewsite Brain Access System (Vycor Medical Inc., Boca Raton, FL), leading to a reduction in the size of the ventricles. The resected mass was histologically confirmed to be cavernous angioma. The patient's symptoms resolved immediately and there were no postoperative complications.

CONCLUSION

Minimally invasive neuroendoscope-assisted surgery was used to successfully treat a cavernous angioma at the foramen of Monro.

Cavernous haemangioma of the cauda region: case report and review of literature

Cavernomas arising from nerve roots in the cauda quina are extremely rare with less than 30 reported cases in world literature. We report a case of a 21-year old lady with a L3-4 cavernoma successfully managed by surgery thereby adding to the general fund of knowledge on this rare entity.

Cavernous hemangioma of the internal auditory canal encasing the VII and VIII cranial nerve complex: case report and review of the literature

Cavernous angiomas originating in the internal auditory canal are very rare. In the available literature, only 65 cases of cavernomas in this location have been previously reported. We describe the case of a 22-year-old woman surgically treated for a cavernous hemangioma in the left internal auditory canal, mimicking on preoperative magnetic resonance imaging MRI an acoustic neuroma. Neurological symptoms were hypoacusia and dizziness. The cavernous angioma encased the seventh and, partially, the eighth cranial nerve complex. A "nearly total" removal was performed, leaving a thin residual of malformation adherent to the facial nerve. Postoperative period was uneventful; hearing was unchanged, but the patient had a moderate inferior left facial palsy (House-Brackmann grade II) slightly improved during the following weeks. On the basis of the observation of this uncommon case, we propose a revision of the literature and discuss clinical features, differential diagnosis, and treatment.

Cavernous angioma after chemotherapy for desmoplastic/nodular medulloblastoma associated with anhidrotic ectodermal dysplasia

PURPOSE

While cavernous angioma (CVA) after cranial irradiation has been documented, its development after high-dose chemotherapy with autologous peripheral blood stem cell transplantation (PBSCT) has not. We present a patient with desmoplastic/nodular medulloblastoma (DNMB) associated with anhidrotic ectodermal dysplasia (AED) who developed CVA 2 years after high-dose chemotherapy and PBSCT.

METHODS

A 1-year-old boy with ingravescent vomiting was admitted to our institute. He presented with a large head, a depressed nasal bridge, low-set ears, thick lips with peg-shaped teeth, hypohidrosis, sparse hair, thin atrophic skin, scaly dermatitis with frontal bossing, and a bulging anterior fontanel. Neuroradiological examination revealed multiple cerebellar masses with heterogeneous enhancement and speckled calcifications and severe obstructive hydrocephalus. The histological diagnosis of surgical specimens was DNMB, and he underwent postoperative multiple-drug chemotherapy with autologous PBSCT. The outcome was favorable and he did not undergo radiotherapy.

RESULTS

After 2 years, intracranial hemorrhage was detected at his regular radiological check-up and he again underwent surgery. The histological diagnosis was CVA.

CONCLUSIONS

To our knowledge, this is the first report of AED-associated DNMB and CVA.

Long Follow-Up of Radiosurgery for Brainstem Cavernoma

BACKGROUND

There is a relative paucity of long-term follow-up of treatment of brainstem cavernous angiomas. This has led to uncertainty and a lack of consensus regarding optimum therapy, especially radiosurgery.

METHODS

Report of a single case with a 24-year follow-up.

RESULTS

This patient was minimally symptomatic before her radiosurgery procedure. She developed an acute complication, from which she incompletely recovered. Two decades later she has become more symptomatic, with new deficits, and magnetic resonance imagings disclose progressive brainstem atrophy.

CONCLUSIONS

Long-term follow-up of patients treated with radiosurgery is important.

Intraventricular foramen of Monro cavernous malformation

We present a 64-year-old woman who was evaluated after being found unresponsive. Imaging revealed a foramen of Monro cavernoma resulting in hydrocephalus. Supratentorial cavernomas are most frequently found in the cerebral cortex, and although ventricular cavernomas do occur, they are rarely located in the foramen of Monro. Foramen of Monro cavernomas are extremely dangerous, requiring aggressive management when identified.

The value of susceptibility weighted magnetic resonance imaging in evaluation of patients with familial cerebral cavernous angioma

OBJECTIVES

We investigated the imaging features of Cavernous angioma (CA) lesions and the value of Susceptibility-weighted imaging (SWI) by comparing with T2*-weighted gradient echo (GRE) sequences in patients with familial CA disease.

MATERIAL AND METHODS

We retrospectively evaluated 19 familial CA patients (8 men, 11 women; mean age, 36 years). T1-weighted, T2-weighted, T2*-weighted GRE, and SWI sequences were performed to all patients. The numbers of CA lesions seen on T2*-weighted GRE and SWI sequences were analyzed. The correlations between the numbers of lesions on both sequences with age were evaluated. CA lesions were classified according to the classification of Zabramski et al.

RESULTS

The number of CA lesions was higher on SWI than T2*-weighted GRE significantly (P<.001). There was a significant strong correlation between the age of the patients and number of lesions in the cohort on T2*-weighted GRE (r = 0.81, P<0.001) and SWI (r = 0.85, P<0.001) sequences. Approximately 44% of the CA lesions which were detected only by SWI could not be categorized according to the classification of Zabramski et al.

CONCLUSION

SWI can provide helpful additional information by determining the CA lesions more accurately than T2*-weighted GRE. Thus, routine clinical neuroimaging protocols should contain SWI to assess the true prevalence of lesions for optimal diagnosis and treatment. Moreover, this study show that the Zabramski classification is insufficient to identify all CA lesions, and a new type (type V) should be added to represent lesions that are seen on SWI but not on T2*-weighted GRE.

Olfactory auras caused by a very focal isolated epileptic network in the amygdala

Epileptic olfactory auras manifesting as simple partial seizures are rare. We report a patient who presented with olfactory auras after hemorrhage from a cavernous angioma in the left mesial temporal region. His olfactory auras persisted 12 years after two surgeries for a cavernous angioma. Intracranial depth electrodes revealed a very focal isolated epileptogenic zone in the amygdala. Olfactory auras were successfully treated by focus resection.

Beyond the lesion: the epileptogenic networks around cavernous angiomas

The relationship between epileptogenic lesions and the extension of epileptogenicity is a major challenge in presurgical evaluation of drug resistant epilepsies. In this study, we aimed at quantifying the epileptogenic properties of brain structures explored by depth electrodes in patients investigated by stereoelectroencephalography (SEEG) and suffering from focal drug-resistant epilepsy associated with cavernous angioma (CA). Epileptogenicity of the perilesional region and distant brain areas was calculated according to the "epileptogenicity index" (EI), a technique that allows mathematical quantification of rapid discharges at seizure onset taking into account the time at which the discharge occurs. Thirteen seizures from 6 patients were studied. Localization of the cavernoma was the frontal lobe (two cases), the temporal lobe (three cases) or the anterior insula (one case). Visual inspection of the ictal discharge showed that in the majority of cases (5/6) the perilesional region was either not involved or involved with other distant sites. Using EI quantification, complex patterns of epileptogenicity were observed in five patients. A large number of brain regions out of the lesional region disclosed higher values than the lesion site. Mean values in the perilesional region and in the extralesional sites were not significantly different (p=0.34). Complex organization of the epileptogenic zone may be found in drug-resistant CA associated epilepsy. Thus, this result should be borne in mind when patients with CA and drug resistant epilepsy are investigated. If there is a suspicion of a larger epileptogenic zone than the lesion, intra-cerebral exploration by SEEG may be required before surgery that may be guided by the definition of the EZ.

Two cystic cavernous angiomas after radiotherapy for atypical meningioma in adult woman : case report and literature review

A correlation between radiation therapy and cavernoma has been suspected since 1994. Since then, only a few cases of radio-induced cavernomas have been reported in the literature (85 patients). Most of them were children, and the most frequent original tumour had been medulloblastoma. The authors report a case of two cystic cavernous angiomas after radiation therapy for atypical meningioma in adult woman. This is the first case of cavernous angioma after radiotherapy for low grade meningioma. A 39-year-old, Latin american woman was operated on for a frontal atypical meningioma with intradiploic component and adjuvant radiotherapy was delivered (6000 cGy local brain irradiation, fractionated over 6 weeks). Follow-up MR imaging showed no recurrences of the tumour and no other lesions. Ten years later, at the age of 49, she consulted for progressive drug-resistant headache. MR imaging revealed two new well defined areas of different signal intensity at the surface of each frontal pole. Both lesions were surgically removed; the histopathological diagnosis was cavernous angioma. This is the first case of cavernous angioma after radiation therapy for atypical meningioma : it confirms the development of these lesions after standard radiation therapy also in patients previously affected by non-malignant tumours.