Cavernous hemangiomas of the dura mater at the convexity. Report of a case and therapeutical considerations

Extra-Axial Cavernous Angioma: A Case Report and Review of the Literature

Cavernous angiomas (CAs) are benign vascular malformations predominantly seen in the brain parenchyma and therefore referred to as intra-axial. Extra-axial dural-based cavernous angiomas, on the other hand, are rare vascular lesions found outside of the brain parenchyma. They occur in the middle fossa and may be easily misdiagnosed as meningiomas due to their extra-axial location. In addition, CAs that are located outside the middle fossa, such as in the convexity, have a better prognosis since they are more surgically accessible. Surgical resection is the main treatment of choice in CAs. However, other options, such as embolization and radiotherapy, may also be considered therapeutic choices or additive treatment options. The pathogenesis of CA and the involvement of other factors (genetics or environmental factors) are still unknown and require further investigation. We are presenting a young man who presented for evaluation of seizure-like events without any family history of neurologic conditions. The physical examination was unremarkable except for a slightly antalgic gait. Imaging studies showed an extra-axial left tentorial mass suggestive of a meningioma, hemangiopericytoma, or other extra-axial lesions. The lesion was resected where its vascular nature was mentioned initially, and the histology proved the diagnosis of cavernous angioma. Here we give an overview of the known pathogenesis, causes, clinical features, and diagnostic and therapeutic options in CA. Better knowledge about CA, its causes, clinical features, and treatment options would help clinicians in early diagnosis and patient management.

The dural angioleiomyoma harbors frequent GJA4 mutation and a distinct DNA methylation profile

The International Society for the Study of Vascular Anomalies (ISSVA) has defined four vascular lesions in the central nervous system (CNS): arteriovenous malformations, cavernous angiomas (also known as cerebral cavernous malformations), venous malformations, and telangiectasias. From a retrospective central radiological and histopathological review of 202 CNS vascular lesions, we identified three cases of unclassified vascular lesions. Interestingly, they shared the same radiological and histopathological features evoking the cavernous subtype of angioleiomyomas described in the soft tissue. We grouped them together with four additional similar cases from our clinicopathological network and performed combined molecular analyses. In addition, cases were compared with a cohort of 5 soft tissue angioleiomyomas. Three out 6 CNS lesions presented the same p.Gly41Cys GJA4 mutation recently reported in hepatic hemangiomas and cutaneous venous malformations and found in 4/5 soft tissue angioleiomyomas of our cohort with available data. Most DNA methylation profiles were not classifiable using the CNS brain tumor (version 12.5), and sarcoma (version 12.2) classifiers. However, using unsupervised t-SNE analysis and hierarchical clustering analysis, 5 of the 6 lesions grouped together and formed a distinct epigenetic group, separated from the clusters of soft tissue angioleiomyomas, other vascular tumors, inflammatory myofibroblastic tumors and meningiomas. Our extensive literature review identified several cases similar to these lesions, with a wide variety of denominations. Based on radiological and histomolecular findings, we suggest the new terminology of "dural angioleiomyomas" (DALM) to designate these lesions characterized by a distinct DNA methylation pattern and frequent GJA4 mutations.

Atypical Presentation of Parietal Convexity Dural-Based Cavernous Hemangioma: A Case Report and Review of Literature

BACKGROUND

Dural presentation of a cavernous hemangioma is a rare occurrence. Classically an intraparenchymal lesion with varying symptomatology including mostly headaches, seizures, and neurologic deficits depending on its location, a few cases have been reported along the convexity of the brain, even less eroding the calvaria, with none occasioning abnormal movements as the initial presentation.

CASE DESCRIPTION

This is a case of a 67-year-old male who presented to the clinic for atypical progressive choreiform movements of the right side of his body and a soft subgaleal mass. Radiographic imaging showed a parietal tumor with intradural and extradural invasion mimicking a meningioma, which does not provide, given its location, a clear explanation of the symptoms. A craniotomy was performed on 29 January, 2018, during which the tumor was resected along with the invaded dura mater and calvaria.

CONCLUSIONS

A pathology report was positive for cavernous hemangioma, an unexpected diagnosis based on the tumor's characteristics. After surgery, the patient recovered completely without residual symptoms, suggesting a compressive mass effect causing the atypical movement disorders.

Dural-Based Cavernous Malformation at the Cerebral Convexity: Report of Two Pediatric Patients

BACKGROUND

Intracranial cavernous malformations (CMs) are usually located at the cerebral parenchyma; dural-based CMs outside the middle fossa are rarely reported. To our knowledge, dural-based CMs located at the cerebral convexity are even rarer in that only 2 pediatric cases have ever been reported. In this report, we present 2 extremely rare cases of dural-based CMs at the cerebral convexity in pediatric patients. The clinical course, radiologic and pathologic features, treatment, and follow-up are described.

CASE DESCRIPTION

The first case is a 6-year-old boy who presented with headache and vomiting and was found to have an acute subdural hematoma and space-occupying lesion. Intraoperative findings and histologic examination were consistent with a CM. He experienced an uneventful postoperative recovery. The second case is a 43-day-old female neonate who presented with a progressively enlarging neoplasm at the right occipital region since birth. Computed tomography of the head performed at admission showed a slight hyperdense occupying lesion communicating between the intra- and extracranial cavity through a skull defect. The lesion was resected en bloc and histologic examination was in accord with a CM.

CONCLUSIONS

The clinical manifestations and radiologic characteristics of dural-based CMs are nonspecific. Unlike that of their cerebral parenchymal counterparts, the radiologic appearance of dural-based CMs is confusing and misleading. Surgical resection is the primary treatment selection for dural-based CMs. In cases with no close relationship to dural sinuses, complete surgical resection with minimal blood loss and few neurologic deficits could be easily achieved.

Cavernous hemangioma of the dura mater mimicking meningioma

Background:

Cavernomas are benign lesions that most commonly occur intra-parenchymally, but occasionally they have been described as arising from the dura mater. Extra-axial cavernous angiomas (or hemangiomas) account for 0.4–2% of all intracranial vascular malformations, and they usually occur in the middle cranial fossa, associated with the cavernous sinus. Other possible localizations (e.g. tentorium, convexity, anterior cranial fossa, cerebellopontine angle, Meckel's cave, sella turcica and internal auditory meatus) are rare, and they account only for 0.2–0.5%.

Case Description:

We report a case of a 30-year-old female presenting with a 2 years history of headache unresponsive to drug therapy. The magnetic resonance imaging showed a dural-based lesion in the left frontal region; the lesion size was: 1.5 cm × 3.5 cm. The appearance suggested a convexity meningioma. A left frontal craniotomy was performed, and the histopathological diagnosis deposed for a cavernous hemangioma of the dura mater. The follow-up at 1-year was good without any neurologic deficit.

Conclusions:

Dural-based cavernous hemangiomas of the convexity are uncommon lesions. Up to now, only 13 cases have been described in the literature. The authors have discussed clinical aspects, radiological features, surgical treatment, and operative findings.

Successful removal of a huge hypervascular tentorial cavernous angioma after preoperative endovascular embolization

The authors report a rare case of a huge hypervascular tentorial cavernous angioma treated with preoperative endovascular embolization, followed by successful gross-total removal. A 15-year-old girl presented with scintillation, diplopia, and papilledema. Computed tomography and MRI studies revealed a huge irregularly shaped tumor located in the right occipital and suboccipital regions. The tumor, which had both intra- and extradural components, showed marked enhancement and invasion of the overlying occipital bone. Angiography revealed marked tumor stain, with blood supply mainly from a large branch of the left posterior meningeal artery. Therefore, this lesion was diagnosed as a tentorium-based extraaxial tumor. For differential diagnosis, meningioma, hemangiopericytoma, and malignant skull tumor were considered. Tumor feeders were endovascularly embolized with particles of polyvinyl alcohol. On the following day, the tumor was safely gross totally removed with minimum blood loss. Histopathological examination confirmed the diagnosis of cavernous angioma. To date, there have been no reports of tentorium-based cavernous angiomas endovascularly embolized preoperatively. A tentorial cavernous angioma is most likely to show massive intraoperative bleeding. Therefore, preoperative embolization appears to be quite useful for safe maximum resection. Hence, the authors assert that the differential diagnosis of tentorium-based tumors should include tentorial cavernous angioma, for which preoperative endovascular embolization should be considered.

Unusual locations for cavernous hemangiomas: report of two cases and review of the literature

Cavernous hemangiomas are most commonly found within the subcortical neural parenchyma near the fissura Rolandi, in the basal ganglia, or in the brain stem. Because of advancing neuro-imaging technology and thus resulting in a higher incidence of cavernous hemangiomas they have rising impact in neurosurgery. We present two unusual cases of extra-axial cavernous hemangiomas: one located at the frontal falx, the other within the bone of the right frontal bone. We discuss these and other cases in the literature with respect to the more common differential diagnoses and the appropriate therapy regimen for cavernous hemangiomas in these locations.

Dural cavernous angioma: a preoperative diagnostic challenge

BACKGROUND

Dural cavernous angiomas are uncommon benign vascular malformations which may present intraoperative difficulties in hemostasis when the diagnosis is not suspected preoperatively. Preoperative diagnosis can be difficult when angiomas show atypical features and share imaging characteristics with other entities.

METHODS

A patient presented with a radiographically aggressive lesion, subsequently identified as a dural cavernous angioma. The lesion is reviewed and its clinical, radiographic, and pathological features are compared with other vascular malformations.

CASE REPORT

A 40-year-old man presented with new onset seizures and an enhancing lesion infiltrating the floor of the right middle cranial fossa. Due to its aggressive radiographic appearance, initial considerations included chondrosarcoma, meningioma or metastasis. Pathological examination, however, revealed the lesion to be a cavernous angioma of dura.

CONCLUSION

This uncommon lesion may present a diagnostic challenge with significant intraoperative implications. T2 sequence hyperintensity in a relevant lesion should raise suspicion of an hemangioma. It is important to be aware of this entity and its potential to mimic other entities on radiographic grounds.