Successful treatment of hemorrhagic brainstem cavernous malformation with hematoma evacuation and postoperative propranolol

In this case, we describe an evident hemorrhagic brainstem cavernous malformation successfully treated with a planned sequence of surgical evacuation of the hematoma followed by postoperative propranolol therapy. In contrast to common practice, the cavernoma itself was not resected. A nearly 3-year-old male presented with altered mental status, gait disturbance, and facial palsy. CT and MRI demonstrated a large acute pontine hematoma. A large nearby vein suggested cavernous malformation. He was initially treated conservatively but a repeat CT scan demonstrated further expansion of hematoma and he was taken emergently to the OR. Due to the sensitive location of the hematoma in the pons, we planned to evacuate the hematoma without resecting any of the presumed cavernoma. Instead, we planned to treat the cavernoma with propranolol. Postoperatively, the patient's condition improved and was still improving at hospital discharge 2 weeks later. Six-month follow-up MRI showed no cavernoma with only hemosiderin at the site of the evacuated hematoma. This is the first reported case of a hemorrhagic brainstem cavernous malformation treated with a planned sequence of hematoma evacuation followed by propranolol without an attempt to resect the cavernoma.

Intracranial meningioma and concomitant cavernous malformation: A series description and review of the literature

OBJECTIVES

Intracranial meningioma with concomitant cavernous malformation has been rarely described in the literature. This study aimed to investigate the correct neurosurgical conduct.

PATIENTS AND METHODS

We retrieved clinical and radiological data for 39 outpatients or patients that underwent surgery (mean age: 60 years; n = 25 females) for a single or multiple meningiomas and concomitant single or multiple cavernous malformations. Cavernous malformations were classified according to Zabramski's type scale. Our results were compared to results published in the literature.

RESULTS

All patients had at least one meningioma and at least one concomitant cavernous malformation. Most meningiomas and cavernous malformations were located in the supratentorial region. Nine patients (23 %) had multiple meningiomas and nine had concomitant multiple cavernous malformations. Cavernous malformations were classified as type I (n = 0), type II (n = 9), type III (n = 11), or type IV (n = 19). The surgical priority was meningioma removal. A single patient underwent simultaneous removal of a meningioma and a contiguous cavernous malformation. In the postoperative period and long term follow-up, no complications occurred related to cavernous malformations, intra- or extra-lesional bleeding, or morphology/size changes. Years after surgical treatment, a new type IV cavernous malformation occurred in two patients.

CONCLUSION

Our findings corroborate that meningioma removal should take priority in patients with intracranial meningioma and concomitant cavernous malformation. Concomitant cavernous malformations showed no change in morphology or size; therefore, they should merely be observed during follow-up. In patients that harbor a single meningioma, a type IV cavernous malformation should preferably be considered a concomitant cerebral microbleed.

Stereotactic laser interstitial thermal therapy for brainstem cavernous malformations: two preliminary cases

Brainstem cavernous malformations (CMs) often have high hemorrhage rates and significant posthemorrhage morbidity. The authors present two cases in which magnetic resonance thermography-guided laser interstitial therapy was used for treatment of pontine CMs after recurrent hemorrhage. Both patients showed significant symptomatic improvement and were hemorrhage-free at 12- and 6-month follow-up, respectively. Each had radiographic evidence of lesion involution on serial follow-up imaging. These early results demonstrate this treatment modality may be technically safe; however, larger case numbers and longer follow-up are needed to demonstrate efficacy.

Role of aspirin and statin therapy in patients with cerebral cavernous malformations

Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.

Cavernous Malformation Hemorrhagic Presentation at Diagnosis Associated with Low 25-Hydroxy-Vitamin D Level

BACKGROUND

Cavernous malformations (CM) are angiographically occult vascular malformations that may be incidental or present with intracerebral or spinal hemorrhage, seizures, or nonhemorrhagic focal neurologic deficit (FND). Recently in vitro data have suggested vitamin D may play a role in stabilizing CCM2 endothelial cells. Little is known about the effect of vitamin D in human CM disease.

METHODS

Beginning in 2015, consecutive patients at our institution with radiologically confirmed CM were recruited to participate in a prospective clinical registry as well as 25-hydroxy-vitamin D study. A structured interview, survey, and examination were performed at baseline. Medical records and magnetic resonance imaging studies were reviewed and data collected included comorbid conditions, medication use, and location of CM. Standard definition of clinical hemorrhage, FND, and seizures was used. Univariate and multivariate logistic regression models were used, and OR, 95% CIs, and likelihood-ratio p values were calculated to determine the influence of the 25-hydroxy-vitamin D level on clinical presentation with hemorrhage.

RESULTS

Of 213 patients enrolled in the clinical registry between January 2015 and October 2018, 70 participated in the vitamin D study (median age: 38.3 years; 51.4% female). Of the 70 participants, 30 (42.9%) presented with hemorrhage. 25-Hydroxy-vitamin D levels were performed within 1 year of symptoms in 64.1% of patients. Patients presenting with hemorrhage had a lower 25-hydroxy-vitamin D level compared to those presenting with seizure without hemorrhage, FND, or as an incidental finding (median 25.5 ng/mL; range 11-59 hemorrhage vs. median 31.0; range 14-60, no hemorrhage; p = 0.04). After adjusting for age, month of blood draw, and body mass index, 25-hydroxy-vitamin D remained a significant predictor of hemorrhagic presentation. Brainstem location also predicted hemorrhage at presentation.

CONCLUSION

Low 25-hydroxy-vitamin D level was more common in patients with CM presenting with hemorrhage. This study supports the potential role of modifiable factor in the initial clinical presentation of CM. Further study is needed to determine the role of vitamin D on prospective hemorrhage risk and whether supplementation may be beneficial.

Translamina Terminalis Approach to Laser-Assisted Resection of Thalamomesencephalic Cavernous Malformation

Cavernous malformations of the midbrain require careful consideration of the risks and benefits of intervention as well as the optimal surgical approach for these challenging lesions. Excellent results can be achieved with careful surgical planning and technique. We demonstrate a contralateral left pterional craniotomy for a translamina terminalis approach to carbon dioxide laser-assisted microsurgical resection of a thalamomesencephalic cavernoma in a 59-year-old woman with progressive debilitating diplopia secondary to partial third nerve palsy (Video 1). We performed a contralateral left modified pterional craniotomy in which we limited dissection of the temporalis muscle to approximately one third rather than extending the muscle split down to the zygoma. The cavernous malformation was resected with no complications, and the patient was discharged from the hospital on postoperative day 3. She noted immediate improvement and nearly complete resolution of symptoms over ensuing weeks. This approach offers a direct route to the lesion with minimal brain transgression, while avoiding the critical structures within the interpeduncular cistern, including the basilar artery and thalamomesencephalic perforating arteries, as well as bordering neural structures, including cerebral peduncles, oculomotor nerves, and mamillary bodies. Use of the carbon dioxide laser with its 0.55-mm tip offers a low surgical profile and allows for precise cutting, thus minimizing thermal damage to surrounding tissues. The translamina terminalis approach through a pterional craniotomy offers a safe and potentially less morbid alternative to select thalamomesencephalic lesions compared with exposure through the mesencephalic surface, which in our experience often necessitates an orbitozygomatic craniotomy.

De novo thalamic arteriovenous malformation in a boy with a brainstem cavernous malformation

Brain arteriovenous malformations (bAVMs) have long been considered to be congenital, developing between the third and eighth weeks of embryogenesis. However, cases reporting their de novo formation suggest that these lesions can develop after birth and have challenged this concept. We present a case of a 6-year-old boy with a history of a brainstem cavernous malformation diagnosed after birth who later developed a de novo bAVM. The de novo occurrence of this bAVM distant to the site of the cavernous malformation and a prior negative catheter angiography contributes to the uncertainty of the dynamics and pathophysiology of bAVMs.

Primary Brainstem Angiosarcoma Mimicking Cavernous Malformation

BACKGROUND

Cerebral angiosarcoma is an extremely rare malignant tumor that originates from vascular endothelial cells of the brain or meninges. Especially, primary brainstem angiosarcoma has not been reported.

CASE DESCRIPTION

A 64-year-old man presented with left subjective weakness, hypesthesia, and dizziness. Brain imaging showed a multistage hemorrhagic mass in the right dorsal pons, which was initially misdiagnosed as a cavernous malformation. The patient's neurologic status suddenly deteriorated over a few months, and the mass grew rapidly. Surgical resection was performed, and the final pathology showed brainstem angiosarcoma.

CONCLUSIONS

To our knowledge, this is the first case of brainstem angiosarcoma confirmed by pathology after surgical resection. This report highlights that clinicians need to consider angiosarcoma as part of the differential diagnosis for rare hemorrhagic lesions in the brainstem when both imaging findings and neurologic deterioration indicate rapid progression.

Cavernous malformation hemorrhage due to trans-mural pressure alterations after cerebrospinal fluid diversion: a case report

BACKGROUND

Cavernous malformations are rare cerebral pseudo-vascular lesions with annualized bleeding rates of 0.5-3% in most studies. Of the various explored risk factors for bleeding to date, only prior hemorrhage has shown significant correlation.

CASE PRESENTATION

In this case, we describe a 65-year old man with a peri-ventricular atrial cavernous malformation that hemorrhaged after CSF diversion via ventriculoperitoneal shunting. Serial imaging showed that bleeding continued until the shunt was revised with a programmable valve set at maximum resistance with the addition of a gravitational unit, thereby lowering the trans-mural pressure differential across the cavernous malformation.

CONCLUSIONS

Given that other vascular lesions are subject to hemorrhage from alterations in trans-mural pressure dynamics, we hypothesize that cavernous malformations are similarly affected by trans-mural pressure gradients as they are composed of primitive vascular elements. This hypothesis is corroborated by the temporal correlation of interventions, imaging, and exam findings in the present case, and suggests a potentially important risk factor for hemorrhage in CM patients that affects prognostication and management.

Hemorrhage owing to cerebral cavernous malformation: imaging, clinical, and histopathological considerations

Cavernous malformation (CM) is the second most common cerebral vascular malformation and is often found incidentally. Their natural history is usually benign, however, patients with CM who present with symptomatic hemorrhage may later follow a serious clinical course if left untreated. The risk of hemorrhage is associated with previous hemorrhage, lesion location (infratentorial and deep), and the presence of associated developmental venous anomaly (DVA). Histopathological specimens also indicate that coexistence of DVA and other vascular malformations may be associated with hemorrhage owing to CMs. Diagnosing CMs is difficult, even in patients who initially present with symptomatic hemorrhage. Computed tomography scans typically reveal a hemorrhagic CM as a nonspecific heterogenous mass of high density, which may not be misdiagnosed as a solitary hematoma, especially when located in the infratentorial region. Magnetic resonance imaging demonstrates internal loculation with mixed-signal intensities typical for CMs, although this may be partially or completely masked by acute hemorrhage. Susceptibility-weighted imaging (SWI) reveals a significant "blooming" effect of hemosiderin deposition. Three-dimensional postcontrast T1-weighted imaging is essential to identify associated DVAs, and this is important for both diagnosis and planning of surgical treatment. Contrast-enhanced MRI should be performed to diagnose hemorrhagic CMs and differentiate them from spontaneous solitary hematoma or hemorrhagic tumors.

Cervical Laminoplasty for Resection of Hemorrhagic Cavernous Malformation Using a Biportal Technique

This Video 1 presents the surgical management of a 36-year-old woman who presented with progressive weakness in her right arm associated with a pins-and-needles sensation. Magnetic resonance imaging of the cervical spine revealed a likely hemorrhagic cavernous malformation of the spinal cord at the C3-4 level. The lesion was wholly intramedullary with no presentation to the surface of the spinal cord. It was located in the spinal cord centrally with some right-side predominance. Treatment options were presented to the patient, who agreed to surgery. A resection was performed after a hemilaminotomy at C3 and C4 levels. A biportal technique was used, demonstrating resection of the malformation through 2 small myelotomies made between the entering rootlets at the dorsal root entry zone. This was intended to preserve all roots at the entry zone while enabling visualization of the entire cavernous malformation and its cavity from 2 different portals of entry, essentially providing the same field of access while preserving all roots. After successful resection, the cavity was carefully inspected and closure of the dura was performed, followed by fixation of the osteotomy sites of the laminae at C3 and C4. The patient awoke with no new neurologic deficits and has had no evidence of lesion recurrence or symptoms in 3-year follow-up. The patient provided consent for publication.

The Influence of Physical Activity on Cavernous Malformation Hemorrhage

BACKGROUND AND AIM

Cavernous malformations are low-flow vascular malformations of the central nervous system. Brainstem location and prior hemorrhage increase future hemorrhage risk. We sought to determine the influence of physical activity on hemorrhage risk.

METHODS

Consecutive patients with radiologically confirmed cavernous malformations participated in a prospective registry with structured, baseline interviews, surveys, and examinations. Patients were asked about unusual events prior to initial clinical presentation. Medical records and MRIs were reviewed. Patients were surveyed about their physical activity after receiving their diagnosis. Annual follow-up surveys to patients ascertained new hemorrhages. Follow-up terminated at last follow-up, hemorrhage, surgery, or death. Univariate analysis assessed the risk of physical activities on prospective hemorrhage.

RESULTS

Of 195 patients, 117 (60%) were female. Median diagnosis age was 41 years. After diagnosis, 103 (52.8%) patients returned the physical activity survey (cerebral n = 100; spine n = 3). Over 539.4 patient years, 23 had a prospective hemorrhage. Five patients were removed from analysis because they had less than 6 weeks of physical-activity exposure before censor. The remaining 98 had no difference in prospective hemorrhage risk than those patients participating greater than or equal to 3 times monthly in walking, running, greater than 20-pound or less than 20-pound weight lifting, or noncontact sports. Few (n = 5) reported contact-sport participation, scuba diving (n = 2), or high-altitude climbing (n = 1) greater than 3 times monthly.

CONCLUSIONS

Aerobic activity and noncontact sports do not increase hemorrhage risk in cerebral cavernous malformation; patients should not be restricted. Less is known about contact sports, high-altitude climbing, scuba diving, and those with spinal-cord cavernous malformation.

Epilepsy caused by an unrecognized pencil lead misdiagnosed as intracerebral cavernous malformation

Transorbital penetrating injury is relatively uncommon following head trauma, and delayed onset of neurological complications due to retained intracerebral foreign bodies has rarely been reported. We describe the first child case of late-onset epilepsy caused by an accidental transorbital penetrating injury, resulting in a retained pencil lead fragment that was mistaken for cavernous malformation. A 14-year-old girl presented with abrupt onset of nocturnal bilateral tonic seizures. The patient was previously healthy and denied any head trauma. The seizures were not well controlled by antiepileptic drugs. Right frontal lobe epilepsy due to a cavernous malformation was suspected on the basis of brain magnetic resonance imaging and electroencephalography findings. A planned operation unexpectedly revealed the intracerebral pencil lead. This foreign body had gone undetected for 11 years following a minor transorbital penetrating injury. The patient remained seizure-free during the 1-year post-operative follow-up period. Head trauma by a pencil can cause transorbital penetrating injury in children. It is difficult to detect retained small foreign body fragments and the clinical presentation can be delayed. It may be mistakenly diagnosed as other pathologies, especially when patients deny any history of head trauma.

Giant intraventricular and paraventricular cavernous malformations with multifocal subependymal cavernous malformations in pediatric patients: Two case reports

BACKGROUND

Giant cavernous malformation (GCM) is rarely found in intraventricular or paraventricular locations.

CASE SUMMARY

We present two cases of 6-mo and 21-mo boys with intraventricular and paraventricular GCMs including a literature review focused on location and imaging findings. Characteristic magnetic resonance imaging findings such as multicystic lesions and a hemosiderin ring or bubbles-of-blood appearance can assist in the differential diagnosis of a hemorrhagic intraventricular and/or paraventricular mass.

CONCLUSION

Multifocal intraventricular and/or paraventricular GCM in small children is rare. The characteristic magnetic resonance imaging findings can help to differentiate GCMs from other intraventricular tumors.

Outcomes of basal ganglia and thalamic cavernous malformation surgery: A meta-analysis

Surgical resection of basal ganglia (BG) and thalamic cavernous malformations (CMs) has not yet become standardized in the field of neurosurgery due to the eloquent location of these lesions and the relative paucity of literature on the subject. This review presents a consolidation of the available literature on outcomes and complication rates after surgical resection of these lesions. A systematic literature review was performed via PubMed database for articles published between 1985 and 2019. Studies comprising ≥2 patients receiving surgery for BG or thalamic CMs with available follow-up data were included. Pooled data included patient demographics, CM preoperative characteristics, and surgical outcomes Twenty studies comprising 227 patients were included for analysis. Complete resection was achieved in 94.7% (fixed-effects pooled estimate [FE]: 94.9%[91.0%-97.8%]; random-effects pooled estimate [RE]: 90.0%[79.8%-96.9%]), and hemorrhage of incompletely resected CMs occurred in 50% (FE: 55.9%[25.9%-83.6%]; RE: 55.9%[25.9%-83.6%]) of patients. Early morbidity was observed in 24.0% (FE: 24.9%[17.8%-32.6%]; RE: 24.9%[17.8%-32.6%]). At final follow-up, 67.3% (FE: 67.7%[58.8%-76.0%]; RE: 67.8%[52.2%-81.6%]) and 20.6% (FE: 20.6%[13.6%-28.6%]; RE: 20.9%[9.8%-34.9%]) had improvement and stability of preoperative symptoms, respectively. Mortality rate was 1.3% (FE: 2.3%[0.6%-5.1%]; RE: 2.3%[0.6%-5.1%]). Therefore, high cure rates with low rates of postoperative morbidity can be achieved in BG or thalamic CM surgery. Most patients had improved neurological function at final follow-up. Complete resection should be attempted to reduce rates of repeat hemorrhage.

Presentation, Surgical Management, and Postoperative Outcome of a Fourth Ventricular Cavernous Malformation: Case Report and Review of Literature

BACKGROUND

Brainstem cavernous malformations (CMs) represent dangerous clinical entities associated with high rates of rebleeding and morbidity compared with those in other locations. Particularly rare are those located within the fourth ventricle. Although fourth ventricular CMs are favorable from a surgical standpoint, there are no defined guidelines on definitive indications and optimal timing of surgery. In addition, the surgical approaches, anatomic considerations, and general observations regarding these lesions are not well reported in the literature.

CASE PRESENTATION

A 27-year-old man with a known history of a CM on the floor of the fourth ventricle presented with new cranial nerve deficits and signs of increased intracranial pressure. Imaging revealed acute bleeding from a fourth ventricular CM. The patient was urgently taken to surgery for resection. Despite a noneventful surgery which resulted in gross total resection, the patient developed a unique constellation of cranial nerve deficits postoperatively, most notably of which was eight-and-a-half syndrome.

CONCLUSIONS

CMs of the fourth ventricle are rare clinical entities that can be treated successfully with surgery. The indications for surgery may not always be clear-cut; therefore, the neurosurgeon's decision to proceed with surgery must reside on a case-by-case basis using a multifactorial approach. The location of these lesions presents unique challenges given their proximity to vital structures and the technical difficulty required. For these reasons, the resection of these lesions often results in new or persistent neurologic deficits. However, despite the associated risks, the potential benefits of surgery oftentimes outweigh the risks of the alternative.

Transient Aphasia Following Resection of a Thalamic Cavernous Malformation

BACKGROUND

The thalamus has a demonstrated role in language, particularly through its connectivity to frontal language cortices.

CASE DESCRIPTION

A 59-year-old man with transient mixed aphasia following resection of a left-sided thalamic cavernous malformation is reported. No operative complications were encountered, and there was no surgical contact with cortical language areas. The patient recovered full language function within a week postoperatively.

CONCLUSIONS

The role of thalamic nuclei in language processes and other reports of transient thalamic aphasia are reviewed.

Distinguishing mimics from true hemorrhagic cavernous malformations

Cavernous malformations (CM) are angiographically occult vascular malformations. CM appear as discrete, small lesions with mixed-signal characteristics on T2 reflecting the underlying pathology. However, the appearance is not pathognomonic. Distinguishing true CM from hemorrhagic tumors can be difficult. We report 5 cases of tumors mimicking CMs. We compared clinical, initial radiologic features, and MRI evolution between 5 tumor mimics and 51 true hemorrhagic, sporadic, brain CM. Compared to true CM, mimic patients were older (47.0 vs. 38.3 years; p = 0.076) and more likely to have a history of primary neoplasm (60% vs 12%; p = 0.0267). Radiologically, the CM mimics demonstrated a higher likelihood of lesion enhancement on the initial diagnostic MRI (60% vs. 16.7%%; p = 0.0609). On follow-up MRI (<1 year after baseline), CM mimics typically had persistent edema (100.0% vs. 6.25%, p = 0.0003) and demonstrated mixed density on ADC (100% vs. 32.1%; p = 0.0199) as well as increased likelihood of enhancement (100% vs 25.8, p = 0.0852). CM mimics were less likely to evolve to Type 2 or 3 lesions (25.0% vs. 84.4%, p = 0.0278). Clinical and radiologic factors may distinguish tumor metastases from true hemorrhagic CM. CM mimics should be suspected in older patients with a history of neoplasm and contrast enhancement on initial MRI. A repeat MRI within 90 days post-initial hemorrhage should be considered to confirm CM diagnosis. Persistent edema without rebleed, lesion enhancement, mixed signal on apparent diffusion co-efficient, and persistence of a Type 1 lesion should raise suspicion of a metastatic tumor.

Transblepharo-Preseptal Modified Orbitozygomatic Approach for Resection of Giant Frontal Cavernous Malformation: 3-Dimensional Operative Video

A previously healthy 44-year-old woman presented with a first-time seizure. Magnetic resonance imaging (MRI) revealed a right frontal intraaxial mass extending from the orbitofrontal gyri and gyrus rectus to the head of the caudate (Video 1). The mass demonstrated heterogeneous signal intensity on precontrast T1-weighted MRI, minimal contrast enhancement, and mixed intensity on gradient echo MRI sequence consistent with a likely cavernous malformation. Given the location above the orbital roof with cranial-caudal extension to the level of the caudate, a transblepharo-preseptal modified orbitozygomatic craniotomy was recommended. With the assistance of plastic surgery, the lesion was approached through an eyelid incision that extended laterally to expose the keyhole. A McCarty burr hole was made, followed by a tailored orbitozygomatic craniotomy with osteotomies extending through the superolateral orbit and greater sphenoid wing to expose the proximal sylvian fissure. Dura was opened in a C-shaped fashion over the periorbital fat to allow for mild downward retraction of the globe, exposing the subfrontal trajectory. The opticocarotid cistern was opened to allow for cerebrospinal fluid egress and relaxation, and the lesion was readily identified through the use of stereotactic neuronavigation and presence of a faint hemosiderin blush within the underlying parenchyma. The standard microsurgical technique was used to perform a gross total resection of the pathologically confirmed cavernous malformation. The orbitozygomatic bone flap was replaced and plated, and the wound was closed in multiple layers. The patient was seen at a 3-month follow-up without further seizures.

Incidence, Prevalence, and Clinical Presentation of Cerebral Cavernous Malformations

The incidence, prevalence, and mode of presentation of cavernous malformations is important to better understand the disease, educate patients and practitioners, aid in treatment decisions, and to design clinical trials. Prior to the advent of MRI, cavernous malformations were often diagnosed only when a catastrophic event occurred and/or the lesion was removed. With the more frequent diagnostic use of MRI, it has become clear that cavernous malformations are more prevalent than previously thought and many are identified incidentally. The remainder may present to clinical attention with intracerebral hemorrhage, seizure without hemorrhage, or focal neurologic deficit without overt hemorrhage. The precise reason why some cavernous malformations become symptomatic and others remain asymptomatic is not clear. However, evolving data suggests that brainstem location, estrogen use in women, and low vitamin D may play a role in hemorrhagic presentation.

Left Retrosigmoid Craniotomy for Resection of Cavernous Malformation: 2-Dimensional Operative Video

Pontine cavernous malformations are highly morbid lesions that require thorough preoperative planning of the surgical approach and meticulous surgical technique to successfully remove. The patient in this case has a large pontine cavernous malformation coming to the parenchymal surface along the pontine-middle cerebellar peduncle interface. The depth of the surgical field and narrow trajectory of approach require use of lighted suction, lighted bipolar forceps, and stereotactic neuronavigation to successfully locate and remove the entire lesion. The cavernous malformation is removed in a piecemeal manner with close inspection of the resection cavity for any remnants. Postoperative imaging demonstrates gross total resection of the lesion. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Spinal Cavernoma in an Infant: A Rare Pathological Entity with an Atypical Presentation

INTRODUCTION

Cavernous malformation (CM) of the pediatric spine is uncommon, and its presentation especially in infancy is extremely rare. We report an unusual case of thoracolumbar intramedullary CM with hemorrhage in a 5-month-old male child.

CASE PRESENTATION

The child presented with the predominant symptom of urinary retention, and the underlying neurological cause was initially overlooked. However, magnetic resonance imaging obtained after the onset of progressive limb weakness revealed a D11-L1 intramedullary lesion with features of intralesional bleed. Intraoperatively, the lesion showed evidence of hemorrhage and was completely excised. The final histopathology confirmed a cavernoma.

CONCLUSION

Although rare, spinal CM can present with bleed in very young children. It is imperative to identify the subtle clinico-radiological findings and suspect such lesions, as an early treatment portends a good outcome.

Symptomatic Hemorrhage From Cerebral Cavernous Malformations: Evidence from a Cohort Study

OBJECTIVE

Patients with a cerebral cavernous malformation (CCM) can have intracranial hemorrhages ranging from insignificant and chronic microbleeds to life-threatening hemorrhage. Management decisions and patient counseling are based on a heterogeneous body of evidence. We sought to improve the literature by providing our results based on the standardized definitions and aimed to delineate differences in the symptomatic burden for CCMs, based on their anatomic location and presence of developmental venous anomalies. This evidence will aid in clinical decision making and patient counseling.

METHODS

A retrospective cohort analysis between 1990 and 2018 was performed, including patients with a diagnosis of a CCM. The primary outcome was acute symptomatic hemorrhages.

RESULTS

We identified 438 patients harboring 632 CCMs. Mean age at diagnosis was 50 years (standard deviation ±17 years). Median follow-up was 26 months (interquartile range, 7-72 hours). Multiple lesions were encountered in 64 patients (15%). An initial symptomatic presentation was observed in 64% of the patients. There were 438 supratentorial lesions (69%) and 194 infratentorial lesions (31%). A symptomatic hemorrhage was observed in 25% of the supratentorial lesions and 29% of the infratentorial lesions (P < 0.001). A linear mixed-effects regression model showed a significant difference in developing a symptomatic hemorrhage at diagnosis or follow-up between CCMs with an infratentorial location and those with a supratentorial location (odds ratio, 1.81; 95% confidence interval, 1.17-2.81; P = 0.008).

CONCLUSIONS

Infratentorial cavernous malformations are more likely to present with symptomatic hemorrhages at diagnosis or during follow-up when accounting for size differences between lesions.

Simultaneous hemorrhage of multiple cerebral cavernous malformations of the insular lobe and Meckel's cave: a case report and literature review

We describe a case of sporadic cavernous malformation (CM) in a patient suffering from multiple hemorrhagic intracranial lesions, including one originating from the trigeminal nerve (TN). The patient presented with left side facial pain and disturbed right limb movement. The patient was pre-operatively diagnosed with multiple cerebral CMs. This diagnosis was confirmed by postoperative pathology.

Anterior Interhemispheric Transcallosal Approach for Thalamic Cavernous Malformation: 2-Dimensional Operative Video

This patient had a large left ventral thalamic cavernous malformation abutting the third ventricle with evidence of recent hemorrhage. The patient was placed supine with the head in the horizontal position with the dependent hemisphere down to permit use of the anterior interhemispheric transcallosal approach. The lateral ventricle is entered, and the septum pellucidum is opened to prevent it from obstructing the surgical field. The deep cavernous malformation is located with stereotactic neuronavigation and removed piecemeal with the aid of lighted suckers and bipolars. Surgical visualization and postoperative imaging demonstrate a complete resection of the lesion, and the patient remained neurologically stable postoperatively. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.