Cystic cavernous angiomas

Cystic Cerebral Cavernous Malformations: Report of Five Cases and a Review of Literature

Introduction  Cerebral cavernous malformations (CCMs) account for about 5 to 13% of intracranial vascular malformations. Cystic cerebral cavernous malformations (cCCMs) are a rare morphological variant and can cause diagnostic and therapeutic dilemmas. We describe our five such cases and review the existing literature on this entity. Methods  A search of the PubMed database for cCCMs was done, and all articles in English emphasizing the reporting of cCCMs were selected. A total of 42 publications describing 52 cases of cCCMs were selected for analysis. Epidemiological data, clinical presentation, imaging features, the extent of resection, and outcome were analyzed. Radiation-induced cCCMs were excluded. We have also described five of our cases of cCCMs and reported our experience. Results  The median age at presentation was 29.5 years. Twenty-nine patients had supratentorial lesions, 21 had infratentorial lesions, and 2 had lesions in both compartments. Among our four patients, three had infratentorial lesions, whereas one had a supratentorial lesion. Multiple lesions were seen in four patients. A majority (39) had symptoms of mass effect (75%), and 34 (65.38%) had raised intracranial pressure (ICP), whereas only 11 (21.15%) had seizures. Among our four operated patients, all of them had symptoms of mass effect, and two of them also had features of raised ICP. The extent of resection was gross total in 36 (69.23%), subtotal in 2 (3.85%), and not reported in 14 (26.93%). All four of our operated patients underwent gross total resection, but two of them underwent a second surgery. Of the 48 patients in whom the surgical outcome was reported, 38 improved (73.08%). One showed a transient worsening followed by improvement, one developed a worsening of the pre-existing focal neurological deficit (FND), two developed a new FND, and 5 had no improvement in their FNDs. Death occurred in one patient. All four of our operated patients improved after surgery, although three of them showed a transient worsening of FNDs. One patient is under observation. Conclusion  cCCMs are rare morphological variants and can cause considerable diagnostic and therapeutic dilemmas. They should be considered in the differential diagnosis of any atypical cystic intracranial mass lesion. Complete excision is curative, and the outcome is generally favorable; although transient deficits may be seen.

Pathological Changes in Surgically Resected Cystic Cerebral Cavernous Malformation 13 Years After Radiosurgery: Case Report and Review of the Literature

BACKGROUND

Stereotactic radiosurgery (SRS) as a treatment for cerebral cavernous malformation (CCM) has been controversial, but there are few pathological reports showing its long-term therapeutic effect, and literature reporting the CCM cyst formation after SRS is also rare.

CASE DESCRIPTION

We present a 30-year-old woman with a ruptured right parietal CCM treated with SRS 13 years ago. The post-SRS imaging follow-up revealed CCM rehemorrhage and cyst formation. Surgical resection was performed, and a subsequent pathological examination revealed that the CCM still had some incomplete occluded vessels and a large number of newly formed capillaries, and hemorrhagic band and hemosiderin were seen around the nodule.

CONCLUSIONS

Recurrent hemorrhage after SRS for CCM could be related to incomplete occluded vessels and newly formed capillaries. Repeated hemorrhage from CCM newly formed capillaries into the small cavity increased the osmotic pressure, resulting in fluid entering the cavity and cyst enlargement.

Multiple Large-Size Cystic Cerebral Cavernomas

BACKGROUND

Cerebral cavernomas are vascular malformations characterized by networks of abnormally dilated capillaries. They typically present as nodules with mixed signal intensity and a surrounding hemosiderin rim on magnetic resonance imaging. They may occur as multiple lesions in the autosomal-dominant familial form. In rare cases, cavernomas may form cystic masses, mimicking other pathologies.

CASE DESCRIPTION

A 35-year-old man presented with recurrent seizures, aphasia, and gait disturbance with onset at age 14 years. He had previously undergone surgical drainage of multiple cysts across the brain with suspected parasitic infection. On magnetic resonance imaging, 22 cystic lesions were seen across the brain. A large cyst was located in the midline cerebellum, compressing the fourth ventricle. Occipital craniotomy and transvermian dissection allowed total resection of the cyst along with its wall. The postoperative course was uneventful and symptoms progressively improved. Histological analysis revealed cavernoma. Three more surgeries were performed for removal of large supratentorial cavernomas.

CONCLUSIONS

In patients with cystic lesions of the brain, the neurosurgeon should consider the possibility of cavernoma. Total excision along with the cyst wall is crucial for timely diagnosis and therapy.

Cystic Cavernoma of Fourth Ventricle in Pediatric Patient

BACKGROUND

Cystic cerebral cavernomas belong to a rare subset of cavernous malformations in the brain. At present, there is limited information with regard to the demographics and etiology of this condition.

CASE DESCRIPTION

The authors present a case of a previously well 13-year-old male who presented with symptoms secondary to a cystic lesion of the fourth ventricle compressing on his brainstem. He underwent stereotactic aspiration of the cystic lesion and insertion of an Ommaya reservoir in the same setting. Postoperatively, his symptoms improved. The cyst fluid did not yield any positive cytology or culture results. A repeat MRI brain did not demonstrate evidence of any underlying lesion. However, the patient was readmitted for hemorrhage into the region of his previous fourth ventricular lesion. Surgical evacuation of the haematoma was performed and intraoperative tissue was sent for pathological interrogation. The final histology reported a cavernoma.

CONCLUSIONS

This is an unusual presentation of an intracranial vascular anomaly in a pediatric patient. Key features of the case include the diagnostic dilemma and management challenges faced from a neurosurgical perspective.

Surgical Treatment of Cerebellar Cavernous Malformations: A Single-Center Experience with 58 Cases

OBJECTIVE

The goal of this study was to discuss the surgical indications, surgical approaches, and prognostic factors of cerebellar cavernous malformation (CM).

METHODS

We retrospectively reviewed the presentation, surgery, and outcome of 58 consecutive patients who underwent resection of cerebellar CMs between 2009 and 2013 in our center.

RESULTS

The study population consisted of 31 males and 27 females, mean age 39.9 years. Fifty-eight patients experienced 67 symptomatic hemorrhages. The median diameter of all lesions was 2.2 ± 0.9 cm (range, 0.8-4.8 cm). The locations were classified into 3 groups: group 1, cerebellar hemisphere (17 cases, 29.3%); group 2, vermis (18 cases, 31.0%); and group 3, cerebellar peduncle (23 cases, 39.7%). Complete resection was achieved in all patients without surgical mortality. Postoperatively, 11 patients developed new surgical complications, including facial paralysis in 6 patients, ataxia in 2 patients, dizziness in 2 patients, and decrease in facial sensation in 1 patient. The mean modified Rankin Scale (mRS) at final follow-up was significantly improved compared with the preoperative score (0.5 ± 0.5 vs. 1.4 ± 0.7, P = 0.035). The symptoms and neurologic deficits improved in most patients. The lesion location was the only factor that predicted a worse outcome, and the mRS was significantly lower in group 3 than groups 1 and group 2 (P = 0.019).

CONCLUSIONS

Patients with cerebellar CMs usually achieve favorable outcomes via surgery. Cerebellar peduncle CMs cause significantly more neurologic deficits than other locations. A reasonable surgical approach and meticulous manipulation are necessary to prevent impairment of neurologic function.

Pathological characteristics of cyst formation following gamma knife surgery for arteriovenous malformation

BACKGROUND

The pathological characteristics of cyst development after gamma knife surgery (GKS) for arteriovenous malformation (AVM) were analysed.

METHOD

Sixteen male and 12 female patients aged 17-67 years (mean 31.3 years) were retrospectively identified among 868 patients who underwent GKS for AVM at our hospital. The pathological characteristics of the reddish nodular lesion and chronic encapsulated expanding haematoma associated with cyst following GKS for AVM were examined.

RESULTS

Cyst was associated with chronic encapsulated expanding haematoma in 13, and with nodular lesion in 12 patients. The nidus volume at GKS was 0.1-36 ml (median 6.0 ml), and the prescription dose at the nidus margin was 18-25 Gy (median 20 Gy). Cyst formation was detected from 1.1 to 16 years (mean 7.3 years) after GKS. Seven of the 12 patients with nodular lesion underwent surgery. Ten of the 13 patients with expanding haematoma underwent surgical removal of expanding haematoma. Histological examination was possible in 17 cases. Dilated capillary vessels with wall damage such as hyalinisation and fibrinoid necrosis, marked protein exudation and haemorrhage were the most common findings. Brain parenchyma was observed among the dilated vessels in some cases. Structureless necrotic tissue was not evident.

CONCLUSIONS

The present study suggests that enhanced nodular lesion on magnetic resonance imaging and chronic encapsulated expanding haematoma associated with cyst may have common aetiopathology caused by late radiation effects, mainly consisting of dilated capillary vessels with wall damage. Massive protein exudation from such damaged capillary vessels is important in cyst development.

Unusual Presentation of Cerebral Cavernous Malformation

Cerebral cavernous malformations (CMs) are vascular malformations of the central nervous system, which can be detected in the absence of any clinical symptoms. Nodules and cysts with mixed signal intensity and a peripheral hemosiderin rim are considered brain magnetic resonance imaging (MRI) findings typical of CMs. A 48-year-old man was admitted to our hospital because of abnormal MRI findings without significant neurological symptoms. A cyst with an internal fluid-fluid level was found in the left basal ganglia on the initial brain MRI. We decided to observe the natural course of the asymptomatic lesion with serial MRI follow-up. On MRI at the 5-month follow-up, the cystic mass was enlarged and showed findings consistent with those of cystic CM. Surgical resection was performed and the pathological diagnosis was CM. Our experience suggests that the initial presentation of a CM can be a pure cyst and neurosurgeons should consider the likelihood of CMs in cases of cystic cerebral lesions with intracystic hemorrhage.

Giant cystic cerebral cavernous malformation with multiple calcification - case report

Cerebral cavernous malformation with giant cysts is rare and literature descriptions of its clinical features are few. In this case study, the authors describe the clinical symptoms, radiological findings, and pathological diagnosis of cerebral cavernous malformations with giant cysts, reviewing the relevant literature to clearly differentiate this from other disease entities. The authors present a case of a 19-year-old male with a giant cystic cavernous malformation, who was referred to the division of neurosurgery due to right sided motor weakness (grade II/II). Imaging revealed a large homogenous cystic mass, 7.2×4.6×6 cm in size, in the left fronto-parietal lobe and basal ganglia. The mass had an intra-cystic lesion, abutting the basal portion of the mass. The initial diagnosis considered this mass a glioma or infection. A left frontal craniotomy was performed, followed by a transcortical approach to resect the mass. Total removal was accomplished without post-operative complications. An open biopsy and a histopathological exam diagnosed the mass as a giant cystic cavernous malformation. Imaging appearances of giant cavernous malformations may vary. The clinical features, radiological features, and management of giant cavernous malformations are described based on pertinent literature review.

A rare case of an extra-axial cavernous angioma in the cerebellopontine angle

Intracranial extra-axial cavernous angiomas are rare lesions. We report a rare case of extra-axial cavernous angioma in the cerebellopontine angle (CPA) in a 50-year-old male, who presented with lower cranial nerve palsy and gait ataxia. Computed tomography (CT) scan of the brain showed a hyperdense lesion in the left cerebellopontine angle. The lesion was totally excised by the retrosigmoid approach and a pathological examination confirmed the lesion to be a cavernous angioma. Following surgery, the lower cranial nerve palsy recovered significantly.

Cystic cavernous malformation of the cerebellopontine angle: case report and literature review

BACKGROUND

Cavernous malformations (CMs) in the cerebellopontine angle (CPA) are rare, and most of such CMs reported to date are solid and extend from the internal auditory canal into the CPA. In contrast, cystic CMs that arise in the CPA and do not involve the internal auditory canal and dura of the skull base are extremely rare.

CASE PRESENTATION

A 50-year-old man presented with vertigo and progressive hearing loss in the right ear. MRI examination revealed a lesion in the CPA with solid and cystic components. Surgery was performed. Well-circumscribed adhesion to cranial nerves, the cerebellum, or the brain stem was noted during surgery. The lesion was totally resected. Pathological examination suggested the lesion to be a CM. At 1-year follow-up, the symptoms at presentation had resolved and no complications had occurred.

CONCLUSION

Although cystic CMs of the CPA have no established imaging features, a diagnosis of CMs may be suspected when a cystic lesion is present in the CPA and does not involve internal acoustic meatus or dura mater of the skull base. Skillful microsurgical techniques and monitoring of cranial nerves will secure good outcomes for patients with cystic CMs in the CPA.