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

Vertigo due to cerebellar cavernous malformation: A case report

Central vertigo is a result of vestibular structure dysfunction in the central nervous system. Currently, misdiagnoses between peripheral and central lesions are frequent, and diagnostic testing costs are high. Identifying the characteristics of these 2 conditions is challenging. We can provide better treatment if we can establish a diagnosis earlier. Cerebral cavernous malformation (CCM) at the cerebellum is a cerebellar lesion that causes symptoms of central vertigo. We report a patient, 20th years old, female, with vertigo for 1 month before being admitted. Vertigo was getting worse, and when the patient arrived at our hospital, vertigo was accompanied by headache, right and left abducens nerve palsy, horizontal nystagmus bidirectional, vertical nystagmus, and weakness on the right side of the body. A brain magnetic resonance imaging (MRI) was performed before surgery and shows a lesion suggestive of CCM at the cerebellum with a hemorrhagic component inside and non-communicating hydrocephalus. There is no vascular malformation based on digital subtraction angiography result. MRI is the most sensitive and specific modality for detecting CCM, whereas cerebral angiography rarely detects this malformation. The patient got surgical treatment, with suboccipital decompression procedures and CCM excision. The histopathological results after surgical treatment revealed a cerebral cavernous malformation. Vertigo, headache, double vision, and weakness on the right side of the body were resolved after surgery.

Tailored Treatment Options for Cerebral Cavernous Malformations

The diagnosis and treatment of cerebral cavernous malformations (CCMs), or cavernomas, continues to evolve as more data and treatment modalities become available. Intervention is necessary when a lesion causes symptomatic neurologic deficits, seizures, or has high risk of continued hemorrhage. Future medical treatment directions may specifically target the pathogenesis of these lesions. This review highlights the importance of individualized treatment plans based on specific CCM characteristics.

Endoscope-assisted resection of brainstem cavernous malformations

Targeted surgical precision and minimally invasive techniques are of utmost importance for resectioning cavernous malformations involving the brainstem region. Minimisation of the surgical corridor is desirable but should not compromise the extent of resection. This study provides detailed information on the role of endoscopy in this challenging surgical task. A retrospective analysis of medical documentation, radiologic studies and detailed intraoperative video documentation was performed for all consecutive patients who underwent surgical resection of brainstem cavernous malformations between 2010 and 2020 at the authors’ institution. A case-based volumetry of the corticotomy was performed and compared to cavernoma dimensions. A total of 20 procedures have been performed in 19 patients. Neuroendoscopy was implemented in all cases. The mean size of the lesion was 5.4 (± 5) mm3. The average size of the brainstem corticotomy was 4.5 × 3.7 (± 1.0 × 1.1) mm, with a median relation to the cavernoma’s dimension of 9.99% (1.2–31.39%). Endoscopic 360° inspection of the resection cavity was feasible in all cases. There were no endoscopy-related complications. Mean follow-up was 27.8 (12–89) months. Gross-total resection was achieved in all but one case (95%). Sixteen procedures (80%) resulted in an improved or stable medical condition. Eleven patients (61.1%) showed further improvement 12 months after the initial surgery. With the experience provided, endoscopic techniques can be safely implemented in surgery for BSCM. A combination of neuroendoscopic visualisation and neuronavigation might enable a targeted size of brainstem corticotomy. Endoscopy can currently be considered a valuable additive tool to facilitate the preparation and resection of BSCM.

Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature

PURPOSE

Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs.

MATERIAL AND METHODS

We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome.

RESULTS

A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14 years (3-18 years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6 cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162 months (mean 47.2 months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series.

CONCLUSION

Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.

Brainstem and cerebellar cavernous malformations

Cavernous malformations are vascular lesions that occur throughout the central nervous system, most commonly in the supratentorial location, with brainstem and cerebellar cavernous malformations occurring more rarely. Cavernous malformations are associated with developmental venous anomalies that occur sporadically or in familial form. Patients with a cavernous malformation can present with headaches, seizures, sensorimotor disturbances, or focal neurologic deficits based on the anatomic location of the lesion. Patients with infratentorial lesions present more commonly with a focal neurologic deficit. Cavernous malformations are increasingly discovered incidentally due to the increasing use of magnetic resonance imaging. Understanding the natural history of these lesions is essential to their management. Observation and surgical resection are both reasonable options in the treatment of patients with these lesions. The clinical presentation of the patient, the location of the lesion, and the surgical risk assessment all play critical roles in management decision-making.