Cavernomas of the central nervous system: clinical and neuroimaging manifestations in 47 patients

The Dawn and Advancement of the Knowledge of the Genetics of Migraine

Background: Migraine is a prevalent episodic brain disorder known for recurrent attacks of unilateral headaches, accompanied by complaints of photophobia, phonophobia, nausea, and vomiting. Two main categories of migraine are migraine with aura (MA) and migraine without aura (MO). Main body: Early twin and population studies have shown a genetic basis for these disorders, and efforts have been invested since to discern the genes involved. Many techniques, including candidate-gene association studies, loci linkage studies, genome-wide association, and transcription studies, have been used for this goal. As a result, several genes were pinned with concurrent and conflicting data among studies. It is important to understand the evolution of techniques and their findings. Conclusions: This review provides a chronological understanding of the different techniques used from the dawn of migraine genetic investigations and the genes linked with the migraine subtypes.

Radiation-induced cavernous malformations in the spine: patient series

BACKGROUND

Radiation-induced spinal cord cavernous malformations (RISCCMs) are a rare subset of central nervous system lesions and are more clinically aggressive than congenital cavernous malformations (CMs). The authors assessed the characteristics and outcomes of patients with RISCCM at a single institution and systematically reviewed the pertinent literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

OBSERVATIONS

Among the 146 spinal CMs at the authors' institution, 3 RISCCMs were found. Symptom duration ranged from 0.1 to 8.5 months (mean [standard deviation], 3.2 [4.6] months), and latency ranged from 16 to 29 years (22.4 [9.6] years). All 3 RISCCMs were surgically treated with complete resection; 2 patients had stable outcomes, and 1 improved postoperatively. A review of 1240 articles revealed 20 patients with RISCCMs. Six of these patients were treated with resection, 13 were treated conservatively, and in 1 case, the treatment type was not stated. Five of the 6 patients treated surgically reported improvement postoperatively or at follow-up; 1 was stable, and none reported worsened outcomes.

LESSONS

RISCCMs are rare sequelae following radiation that inadvertently affect the spinal cord. Altogether, the frequency of stable and improved outcomes on follow-up suggests that resection could prevent further patient decline caused by symptoms of RISCCM. Therefore, surgical management should be considered primary therapy in patients presenting with RISCCMs.

Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas

In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.

Application of functional imaging, neuronavigation, and intraoperative MR imaging in the surgical treatment of brain cavernomas

Objective: The aim of this study was to investigate whether preoperative functional imaging and intraoperative magnetic resonance imaging (iMRI) facilitate surgery and improve outcomes in the surgical treatment of cavernous malformations of the brain (CM).Materials and Methods: Retrospective data analysis was performed for consecutive patients diagnosed with a CM who underwent surgical treatment at a single academic institution during a 12 year period. A total of 91 patients was eligible for analysis with a mean age of 38.8 ± 15 years (range 2-72 years). Altogether, 89.0% of CM had supratentorial and 11% infratentorial location.Results: Neuronavigation and iMRI was used in 69 (75.8%) patients with 28 (30.8%) of them together with functional MRI (fMRI) all in the supratentorial location. In 4.3% (3 cases) an intraoperative second-look surgery was performed. Altogether, a complete resection was achieved in 93% of the patients. In supratentorial surgeries, surgical times were significantly shorter in the fMRI group (p = 0.036), but altogether, infratentorial CM surgery took significantly longer (p = 0.014). Moreover, in the fMRI group, reduction of seizure medication was achieved significantly more often (p = 0.026). At an FU of 6.1± 3.1 years, 96% of the patients were assessed modified Rankin Scale 0 or 1.Conclusion: Neuronavigation together with intraoperative and functional MRI had a significant impact on resection amount, surgical time, and neurological and seizure outcome of supratentorial CM. In addition, iMRI was beneficial in few-selected cases.

Seizure Outcome in Adult Patients with Supratentorial Cavernomas

Background  Cavernomas are usually found in the supratentorial area, and epileptic seizures are one of the presenting symptoms.

Objective  This study aims to provide the seizure outcome in adult patients who underwent surgical excision of single supratentorial cavernomas.

Materials and Methods  A total of 23 patients with single supratentorial cavernomas were operated between May 2011 and January 2019. Pre- and postoperative seizure semiology, clinical, and radiological findings were collected from medical records. At the last follow-up, each patient was seen during regular visits and clinical variables were noted.

Results  The mean age was 37.08 ± 10.5 years, and 11 (57.8%) and 12 (52.2%) were females and males, respectively. Headache (43.5%) and seizure (43.5%) were the most common presenting symptoms. Cavernomas were located on the right side in 13 and on the left side in 10 patients. The most common locations were the frontal (43.5%) and temporal (43.5%) lobes. The mean follow-up in this series was 41.4 ± 30.8 months. Our results showed that surgery was effective in seizure outcome, as almost 70% of patients who had seizure before surgery was seizure free after surgery, and the difference between those who had seizure pre- and postoperative periods was statistically significant ( p = 0.0001).

Conclusion  Surgery is safe and effective for supratentorial cavernomas. The excision of cavernoma together with the surrounding hemosiderin should be performed to obtain a satisfactory seizure outcome.

Predictors of Outcome in Patients with Medullary Hemorrhage

BACKGROUND

Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intraparenchymal hemorrhage. The relationship between MH and neurological outcome is not well known. This study aims to assess predictive parameters for the outcome of medullary hemorrhage.

METHODS

We conducted an extensive search of the literature for cases with spontaneous, isolated MH. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA). Forty-three cases diagnosed by CT or MRI have been reported in the literature, to which we add three confirmed by MRI. The ventrodorsal size of hemorrhage was taken into account as a parameter of outcome. Early neurologic deterioration (END) was defined as an incremental increase in the National Institutes of Health Stroke Scale score by ≥1 point in motor power, or ≥2 points in the total score within the first week after admission. Modified Rankin Score (mRS) 0-2 was presumed as favorable outcome (FO) and mRS 3-6 score as unfavorable outcome (UO) at discharge and at 3 months after stroke.

RESULTS

We enrolled 46 patients, and 17 (37%) patients were diagnosed with END. The cause of medullary hemorrhage was mostly vascular malformations, including cavernous malformation (33%) and arteriovenous malformation (11%). In univariate analyses, neither arteriovenous malformations (OR, 1.04; 95%CI, 0.10-10.53; P = 0.68) nor cavernomas (OR, 1.04; 95%CI, 0.22-4.89; P = 0.62) were associated with UO. Acute respiratory distress syndrome was higher in patients with UO group (44%) compared to those with FO group (16%), but this difference did not reach to a significant level (OR, 4.13; 95%CI, 0.85-20.04; P = 0.09). The diameter of hemorrhage was significantly larger (≥1 cm) in patients with UO compared to those with FO (OR, 16.67; 95%CI, 1.87-148.89; P = 0.003). Three months after stroke, 37 patients (80%) had FO and 9 (19.5%) had UO, and 5 (11%) died. Multiple logistic regression analysis using predetermined variables found to be significant in univariate analyses (END, consciousness disturbance at admission, hemorrhage size, and hypertension) showed that END at stroke onset was significantly associated with UO (OR, 4.97; CI95%, 1.13-21.94; P = 0.03).

CONCLUSIONS

These results suggest that the END is a predictor for UO in patients with medullary hemorrhage. The extent of the medullary hemorrhage along the conduction tract may contribute to deterioration.

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.

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.

Familial Cerebral Cavernous Malformations Are Associated with Adrenal Calcifications on CT Scans: An Imaging Biomarker for a Hereditary Cerebrovascular Condition

Purpose To determine if adrenal calcifications seen at computed tomography (CT) are associated with familial cerebral cavernous malformations (fCCMs) in carriers of the CCM1 Common Hispanic Mutation. Materials and Methods This study was approved by the institutional review board. The authors retrospectively reviewed abdominal CT scans in 38 patients with fCCM, 38 unaffected age- and sex-matched control subjects, and 13 patients with sporadic, nonfamilial cerebral cavernous malformation (CCM). The size, number, and laterality of calcifications and the morphologic characteristics of the adrenal gland were recorded. Brain lesion count was recorded from brain magnetic resonance (MR) imaging in patients with fCCM. The prevalence of adrenal calcifications in patients with fCCM was compared with that in unaffected control subjects and those with sporadic CCM by using the Fisher exact test. Additional analyses were performed to determine whether age and brain lesion count were associated with adrenal findings in patients with fCCM. Results Small focal calcifications (SFCs) (≤5 mm) were seen in one or both adrenal glands in 19 of the 38 patients with fCCM (50%), compared with 0 of the 38 unaffected control subjects (P < .001) and 0 of the 13 subjects with sporadic CCM (P = .001). Adrenal calcifications in patients with fCCM were more frequently left sided, with 17 of 19 patients having more SFCs in the left adrenal gland than the right adrenal gland and 50 of the 61 observed SFCs (82%) found in the left adrenal gland. No subjects had SFCs on the right side only. In patients with fCCM, the presence of SFCs showed a positive correlation with age (P < .001) and number of brain lesions (P < .001). Conclusion Adrenal calcifications identified on CT scans are common in patients with fCCM and may be a clinically silent manifestation of disease. ^© RSNA, 2017.

Epidemiology of cavernous malformations

Cavernous malformations, accounting for approximately 5-15% of all vascular abnormalities in the central nervous system, are angiographically occult lesions which most often present with seizures, rather than acute hemorrhage. Widely variable across populations, the incidence of cavernous malformations has been reported to be 0.15-0.56 per 100 000 persons per year, with an annual hemorrhage rate of 0.6-11% per patient-year. Seen in 0.17-0.9% of the population, up to one-half are familial, and at least three gene loci have been associated with a familial form, more common among Hispanic Americans. Most cavernous malformations are supratentorial, with 10-23% in the posterior fossa, and approximately 5% found in the spine.

Giant Cavernous Malformations in Childhood: A Case Report and Review of the Literature

Cavernous malformations (CMs) of the central nervous system are benign, angiographically occult vascular lesions and are diagnosed by magnetic resonance imaging techniques. Giant CMs do not differ from smaller-sized CMs in their clinical, surgical or histopathological presentation but may be radiologically different. In this paper, we report a 10-year-old male with a giant CM of 8 × 7.5 × 7 cm in diameter that was completely removed by microsurgical treatment. This case addresses important points for practicing neurosurgeons to consider when making a differential diagnosis of large intracranial mass lesions in pediatric patients. In this report, the radiological features of this vascular malformation are described based on a pertinent literature review.

Association between trauma and acute hemorrhage of cavernous malformations in children: report of 3 cases

OBJECTIVE Cavernous hemangiomas are benign congenital vascular abnormalities. Intracerebral cavernous hemangiomas have an appreciable risk of spontaneous hemorrhage. Little is known as to whether head trauma increases the risk of bleeding for these lesions. In this study, the authors present a case series of 3 patients with posttraumatic nonspontaneous hemorrhage of intracerebral cavernous malformations (CMs). For the first time, to the authors' knowledge, they propose that trauma might constitute a risk factor for acute hemorrhage in intracerebral cavernomas. METHODS The authors reviewed the charts of all patients with a new diagnosis of intracerebral cavernoma at their pediatric hospital between 2010 and 2014. Patients with a history of head trauma prior to presentation were subsequently studied to identify features common to these posttraumatic, hemorrhage-prone lesions. RESULTS A history of head trauma was identified in 3 of 19 cases. These 3 patients presented with seizures and/or headaches and were found to have acute hemorrhage within a cavernous hemangioma. None of these patients had any history of abnormal neurological symptoms. All 3 abnormal vascular lesions had associated developmental venous anomalies (DVAs). The 3 patients underwent resection of their respective vascular abnormalities, and the diagnosis of cavernous hemangioma was confirmed with postsurgical tissue pathology. All 3 patients had complete resolution of symptoms following complete excision of their lesions. CONCLUSIONS Trauma may represent a risk factor for acute hemorrhage in patients with CMs. The presence of associated DVAs may represent a risk factor for posttraumatic hemorrhage of cavernomas. Excision should be considered in such cases, if feasible.

Angiomi cavernosi multipli cerebrali ed epatici

Gli angiomi cavernosi cerebrali (ACC) sono una delle malformazioni vascolari del SNC meno frequenti. É nota peraltro la possibilità di ricorrenza familiare con modalità di trasmissione autosomica dominante. Presentiamo una famiglia italiana, seguita lungamente nel tempo, in cui 10 soggetti in 4 generazioni presentano ACC.

Il reperto cerebrale era associato ad angioma cavernoso epatico (ACE) in 2 soggetti e ad angioma cavernoso retinico (ACR) in uno.

La TC, eseguita in 9 soggetti, ha dimostrato una maggior capacità rispetto alla RM di rilevare le calcificazioni spesso presenti in queste malformazioni; la RM ha evidenziato d'altra parte un numero maggiore di cavernomi, soprattutto in sede sottotentoriale. 7 pazienti sono stati sottoposti ad esame angiografico con tecnica digitale sottrattiva. In nessun caso è stata dimostrata malformazione angiomatosa di tipo artero-venoso ed in 1 solo caso è stata rilevata una lieve persistenza di contrasto nelle fasi capillare-venose.

Riteniamo meritevole di segnalazione questa famiglia per:

l'associazione di ACC con ACE segnalata in 1 solo caso in letteratura (Filling - Katz) e la contemporanea associazione, pur in un solo paziente, di ACR; la costante molteplicità delle lesioni cerebrali, quasi sempre presenti sia in sede sopra che sottotentoriale; il contrasto tra la povertà dei sintomi e l'imponenza del quadro radiologico e la sua variabilità espressiva nelle diverse generazioni; l'elevato numero di soggetti affetti rispetto ad altre famiglie riportate in letteratura.

I rilievi clinico-radiologici nella presente casistica ed i dati riportati dalla letteratura suggeriscono la necessità di uno studio neuroradiologico complementare TC ed RM nei soggetti affetti da ACC e nei familiari.

Va peraltro tenuta presente la possibilità attuale di selezionare i pazienti da sottoporre ad angiografia tradizionale sulla base dei reperti ottenibili con angio-RM. Va sottolineata infine l'opportunità di una attenta e ponderata valutazione della terapia chirurgica proposta da molti autori, data la relativa benignità del decorso clinico riscontrata nei soggetti della nostra serie casistica.

Dural Cavernous Hemangioma: An Under-recognized Lesion Mimicking Meningioma

We report a 77-year-old woman who presented with partial seizures and was found to have an enhancing dural-based parietal convexity mass. The lesion enlarged on serial examination by computed tomography (CT) over a one year period. The clinical features and radiologic appearance were compatible with a pre-operative diagnosis of meningioma; however, pathologic findings were typical of a dural cavernous hemangioma. Accumulating evidence suggests that these lesions are an uncommon but distinct type of vascular malformation most often arising from the cavernous sinus, tentorium, or cerebello-pontine angle. With CT, magnetic resonance imaging and angiography, these lesions can closely resemble meningioma in terms of signal characteristics, enhancement pattern, and location. This is of importance both in the practical management of meningiomas where the diagnosis is often based on radiologic studies alone, and in clinical trials where incorrect entry diagnosis should be avoided.

Surgical Resection Can Be Successful in a Large Fraction of Patients With Drug-Resistant Epilepsy Associated With Multiple Cerebral Cavernous Malformations

BACKGROUND:

Multiple cerebral cavernous malformations (mCCMs) are known as potentially epileptogenic lesions. Treatment might be multimodal. Management of patients with mCCMs and epilepsy is challenging.

OBJECTIVE:

To evaluate (1) algorhythmic therapeutic sequences in patients with epilepsy associated to mCCMs, (2) whether there are predictive parameters to anticipate the development of drug-resistant epilepsy, and (3) seizure after epilepsy surgery compared to conservatively-treated drug-resistant patients.

METHODS:

All inpatients and outpatients with epilepsy associated to mCCMs from 1990 to 2010 and follow-up &gt;12 months available were retrospectively analyzed.

RESULTS:

Twenty-three patients matched inclusion criteria. Epilepsy became drug-resistant in 18/23 (78%) patients. No predictors were found for development of drug-resistant epilepsy. Median follow-up for both groups was 7.8 years. Nine patients did not qualify for surgical therapy and were treated conservatively. One patient of this cohort (11%) was seizure-free (International League Against Epilepsy [ILAE] class 1). Surgical treatment was performed in 9 patients; 7/9 (78%) of these patients were seizure-free (ILAE class 1) after epilepsy surgery for at least 12 months compared with 1/9 patients in the non-operated group. In 7/9 cases (78%) the largest CCM was resected. In 8/9 (89%) not all CCMs were resected.

CONCLUSION:

After initial diagnosis of epilepsy associated to mCCMs, a primary conservative approach is reasonable. Surgical treatment can be successful in a large fraction of cases with drug-resistant epilepsy where an epileptogenic lesion is identified. Cases where surgery is not undertaken are likely to remain intractable.

Long-term seizure outcomes following resection of supratentorial cavernous malformations

OBJECTIVE

Symptomatic supratentorial cavernous malformations may present with seizure, headache, neurological deficit, or a combination thereof. Factors that contribute to treatment algorithms commonly include patient age, lesion size and location, lesion multiplicity, hemorrhage history, and the ability to control seizure activity with medication. A better appreciation of the impact of patient and lesion characteristics on post-operative seizure control may provide insight into management strategies. To determine long-term seizure outcomes following surgical resection of supratentorial cavernous malformations, the predictive value of characteristics including seizure duration and number, presence of generalized seizures, and lesion multiplicity and size on seizure control rate was evaluated.

METHODS

We performed a single institution retrospective review of consecutive patients with supratentorial cavernous malformations presenting with at least one seizure between 1995 and 2008. Univariate and multivariate analyses were used to determine the influence of patient and lesion characteristics on postoperative seizure control.

RESULTS

Fifty-six patients met inclusion criteria. Mean follow-up duration was 87.9 months. At last follow-up there were 46 patients (82.1%) that were free from impairing seizures (Engel Class 1). Ten patients (17.9%) were classified as Engel Class 2-4. Univariate analysis demonstrated that only the presence of multiple cavernomas was associated with worse post-operative seizure outcome (p=0.006). Multivariate analysis demonstrated that multiple cavernomas remained a significant predictor for development of worse seizure outcome controlling for number and duration of seizures prior to operation, presence of generalized tonic-clonic seizures, and size (odds ratio, 0.17; 95% confidence interval, 0.03, 0.99).

CONCLUSION

Resection of supratentorial cavernomas is associated with a high rate of postoperative seizure freedom. The presence of multiple cavernomas is predictive of seizure persistence following surgery.

Intracranial cavernous malformation in children: a single-centered experience with 30 consecutive cases

Objectives: To determine the clinical presentation and treatment outcome of pediatric intracranial cavernous malformation (CM) in a single-centered institution. Methods: Clinical data review of 30 patients under 18 years-old who had undergone surgery for cavernous malformation from January 1993 to December 2011. Results: The Study Group included 18 males and 12 females (mean age: 8.7 years-old). Symptoms at presentation were seizures (16/30, 53.3%), headache (15/30, 50.0%), and focal neurological deficits (11/30, 36.6%). Multiple cavernous malformations were found in 5/30 (16.6%). According to location, patients were classified in groups: (G1) brain-steam in 5/30 (16.6%), (G2) cerebellum in 2/30 (6.6%), (G3) supratentorial associated with seizures in 16/30 (53.3%), and (G4) supratentorial without seizures in 7/30 (23.3%). Surgical resection was performed in 26 out of 30 (86.6%) patients. The mean follow-up period was 4.1 years. Of 15 children followed-up with preoperative seizures, all were rendered seizure-free after surgery. Conclusions: For symptomatic solitary cavernous malformation, the treatment of choice is complete microsurgical excision preceded by careful anatomical and functional evaluation. For multiple cavernous malformation or asymptomatic patients, the treatment modalities must be cautiously considered.

Multiple intracranial cavernomas with focal amyloid deposition - diagnostic pitfalls

We report a case of a patient with multiple, intracranial superficial calcified tumorous lesions with focal amyloid deposition. On the basis of the first neuronavigated needle biopsy, the tumors were originally assessed as amyloidomas. Additional data was obtained from a second biopsy and supplementary neuroimaging information and the tumors were diagnosed as of vascular origin, probably cavernomas. The report exemplifies how only one diagnostic tool may sometimes be misleading in establishing a final diagnosis. The additional imaging may thoroughly enhance, supplement and improve the diagnostic process.

Extra-axial cavernous hemangioma: two case reports

Two patients with extra-axial cavernous hemangioma who presented with headache and oculovisual disturbances were investigated with computed tomography and magnetic resonance imaging. The lesions masqueraded as basal meningioma, but this diagnosis was not supported by magnetic resonance spectroscopy in one patient. Cerebral angiography with embolization was indicated in one patient, but embolization was not justified in the other. Both patients underwent a pterional craniotomy. The lesions were extradural and highly vascular, necessitating excessive transfusion in one patient in whom gross total resection was achieved, and precluding satisfactory removal in the other. There was no mortality. Transient ophthalmoplegia, the only complication in one patient, was due to surgical manipulation of the cavernous sinus; it resolved progressively over 3 months. Extra-axial skull base cavernous hemangiomas are distinct entities with clinical and radiological characteristics that differ from those of intraparenchymal cavernous malformations. They can mimic meningiomas or pituitary tumors. In some cases, magnetic resonance spectroscopy may narrow the differential diagnoses. Surgical resection remains the treatment of choice, facilitated by preoperative embolization to reduce intraoperative bleeding and by the application of the principles of skull base surgery. Fractionated radiotherapy is an alternative in partial or difficult resections and in high-risk and elderly patients.

A diagnostic dilemma of intracranial pathology: coincidence or the result of cranial trauma?

A 21-year-old man presented to the accident and emergency department at St Peter's Hospital, London, in September 2008. Following consumption of alcohol, the patient had been assaulted and had experienced facial trauma. Later, the patient had a witnessed generalised tonic-clonic seizure and the next day noted weakness of the right leg. A CT scan of the brain revealed a solitary lesion in the left presylvian region close to the vertex, involving the leg area of the primary motor cortex. A subsequent MRI scan showed the lesion to be a cavernous haemangioma. The patient had no history of epilepsy. This raised the question as to whether the assault caused the lesion to haemorrhage, resulting in the seizure and spastic monoparesis, or did the formerly asymptomatic cavernoma bleed spontaneously with the assault being coincidental?

Epileptogenicity of Cavernomas Depends on (Archi-) Cortical Localization

BACKGROUND:

Patients with cerebral cavernomas have an estimated risk of the development of epilepsy of 1.5% to 2.4% per patient-year.

OBJECTIVE:

To clarify the predictive value of different risk factors for epilepsy in patients with supratentorial cavernomas.

METHODS:

We retrospectively analyzed data of 109 patients with supratentorial cavernomas. The correlation of epilepsy with the variables of single or multiple cavernomas, sex, age, side, cortical involvement, mesiotemporal archicortical vs neocortical involvement, lobar location of neocortical cavernomas, the presence of a hemosiderin rim and of edema, and the maximal diameters of cavernoma, hemosiderin rim, and edema, if present, were calculated using univariate and multivariate penalized likelihood logistic regression models.

RESULTS:

Cortical involvement was the most relevant risk factor for epilepsy (P &lt; .0001). No patient with a subcortical cavernoma presented with epilepsy. Epilepsy was more common in patients with mesiotemporal archicortical cavernomas than in patients with neocortical cavernomas (P = .02), whereas the lobar location of neocortical cavernomas was not significantly associated with the risk of the development of epilepsy. In the multivariate analysis, a greater diameter of the cavernoma, the absence of edema, and localization in the left hemisphere were also associated with the occurrence of epilepsy (P &lt; .05).

CONCLUSION:

The epileptogenicity of supratentorial cavernomas depends on cortical, especially mesiotemporal archicortical, involvement. Exclusively subcortical cavernomas are highly unlikely to cause epilepsy. This information is helpful in counseling patients with cavernomas regarding their risk of epileptic seizures and in patients with multiple cavernomas and epilepsy to generate a valid hypothesis of which cavernoma may cause epilepsy.

Brainstem cavernous malformations: a review with two case reports

Central nervous system (CNS) cavernous malformations (CMs) are developmental malformations of the vascular bed with a highly variable clinical course due to their dynamic nature. We present one case of 'de novo' brainstem cavernous malformation after radiation therapy adding to the increasing number of reported cases in the medical literature, and the case of a pregnant patient with symptomatic intracranial hemorrhage related to brainstem CMs to illustrate the complex nature in management of these patients, followed by a review of clinical and radiographic characteristics. CMs account for 8-15% of all intracranial and intraspinal vascular malformations. Although traditionally thought to be congenital in origin, CMs may present as acquired lesions particularly after intracranial radiation therapy. Clinical manifestations are protean and surgical treatment should be considered for patients with progressive neurologic deficits.

Cavernous angiomas of the brain stem and spinal cord

This article reviews the pathology, clinical course and management of cavernous angiomas in the brain stem and spinal cord. Both lesions have been diagnosed with increasing frequency as a result of magnetic resonance image scanning. Brain stem lesions tend to present dramatically; their treatment remains microsurgical excision despite some studies that have looked at the use of radiosurgery. Spinal lesions are either extra-, or more commonly, intramedullary. Intramedullary cavernomas present with a wide spectrum of symptoms ranging from acute haematomyelia to presentations that mimic demylelinating conditions; extramedullary cavernous angiomas tend to produce radicular symptoms or subarachnoid haemorrhage. Both are treated by microsurgical excision.

Right Third Nerve Palsy Caused by Extra-Axial Cavernoma in a Patient with Multiple Intracranial Cavernomas

We report an unusual case of a 54-year-old man with third nerve palsy caused by an extra-axial cavernoma in relation to the cisternal portion of the oculomotor nerve. In addition to this lesion, the patient had multiple intracranial cavernomas. Interestingly, an initial MRI without T2* gradient sequence missed the multiple cavernomas. A subsequent MRI done after one month showed an increase in size with fluid level within the extra-axial cavernoma.

Giant cavernous hemangiomas: report of three cases

Giant cavernous hemangiomas occur very rarely, and little has been reported about their behavior. In this case report three cavernous hemangiomas with a diametric measure between 6 cm and 7 cm and distinct features will be described. A 36-year-old female patient presented with headache and nausea. A CT scan disclosed a large circumscribed tumor with strong contrast enhancement in the temporo-parieto-occipital region of the right cerebral hemisphere and extension into the right cerebellar hemisphere. A 35-year-old woman was admitted to our emergency ward with a generalized seizure and a dilated pupil. The CT scan showed an extensive left frontal lesion containing a substantial hyperintense part, suspicious for hemorrhage. A 3-year-old girl was admitted with generalized seizure and progressively declining consciousness. A large left frontotemporal paraventricular multi-cystic lesion was encountered on the CT scan. All three patients were operated on. Two recovered very well. In the case of the 3-year-old girl stable disease was reached. Giant cavernomas do not differ from average-sized cavernomas in clinical, surgical or histopathological presentation but may differ radiologically. However, the possible diagnosis of cavernoma can be overlooked, due to their size and possible differential diagnosis.

Supratentorial cerebral cavernous malformations: clinical, surgical, and genetic involvement

Object

Although there is general agreement on the methods of treatment for symptomatic supratentorial cerebral cavernous malformations (CMs) located in noneloquent areas, some controversy exists regarding the management of cerebral CMs that are asymptomatic and/or located in eloquent or deep areas. Moreover, recent advances in genetic findings could influence both standard clinical management and the follow-up strategy in affected individuals. Thus, the objective of this study was to develop, based on the authors' experience and a literature review, a management algorithm to deal with supratentorial cerebral CMs.

Methods

The authors retrospectively reviewed the clinical data related to 118 patients who underwent surgery for symptomatic supratentorial cerebral CMs at their institution. Twenty-eight of 118 patients harbored multiple lesions, and nine of these 28 patients had a clinically positive familial history. Genetic investigations were performed in 89 patients (75%).

Conclusions

Surgery for supratentorial cerebral CMs in noneloquent locations is safe and curative. In cerebral CMs located in deep and eloquent areas and with symptoms including progressive neurological deficits, evidence of hemorrhage, and uncontrolled seizures, surgical treatment according to an integrated plan based on frameless stereotactic guidance and functional magnetic resonance imaging is recommended and results in acceptably low morbidity. The data support the need for long-term imaging follow up in all patients, careful preoperative vascular studies to detect associated venous anomalies, and the importance of genetic mutational analysis. The DNA screening protocol will change the care of family members of patients with familial forms of cerebral CMs, because affected asymptomatic family members may benefit by early detection of lesions. At the same time, the exclusion of family members who are not carriers of the mutation as members of the population at risk reduces the economic and psychological burden of clinical and instrumental monitoring.

Cerebral cavernous malformations and epilepsy

✓Seizures and epilepsy are frequent clinical manifestations of cerebral cavernous malformations (CCMs) and represent the most common symptomatic presentation of supratentorial lesions. Clinicians often diagnose CCMs in patients after a first seizure, or in some cases after obtaining neuroimaging studies in patients suffering from chronic epilepsy previously thought to be idiopathic. In some cases, the lesion is clinically significant solely because of its epileptogenicity, but in others there may be concern about potential hemorrhage or focal neurological deficits from a similar lesion.

The authors present current pathophysiological concepts related to epilepsy associated with CCMs. They discuss the spectrum of seizure disorders associated with these lesions and review the natural history, prognosis, and options for therapeutic intervention.

Variations in structural protein expression and endothelial cell proliferation in relation to clinical manifestations of cerebral cavernous malformations

OBJECTIVE

Cerebral cavernous malformations (CCMs) are associated with hemorrhagic proliferation of endothelial-lined vascular caverns, resulting in hemorrhagic stroke, epilepsy, and other neurological manifestations. We hypothesize that structural protein expression and endothelial cell proliferation markers within CCM lesions are different in the setting of various clinical manifestations.

METHODS

The percentage of immunohistochemically stained caverns positive for collagen IV, fibronectin, laminin, alpha-smooth muscle actin, myosin, and smoothelin and the percentage of dividing endothelial cells within caverns were determined in 36 excised CCM surgical specimens. These were compared in CCMs with different multiplicity, location, and size in patients of different age, sex, seizure status, and hemorrhage status.

RESULTS

Comparisons of seven lesion features and clinical manifestations with the fraction of caverns containing the structural proteins studied and endothelial cell proliferation demonstrated no significant differences. A possible exception was the difference (P < 0.05) in the fraction (mean +/- standard deviation) of positively stained caverns for collagen IV between adult (0.63 +/- 0.39) and pediatric patients (0.87 +/- 0.21) as well as fewer caverns with laminin expression in older patients. These trends did not sustain significance with Bonferroni's correction for multiple comparisons.

CONCLUSION

The fraction of caverns containing the particular structural proteins studied and endothelial cell proliferation within caverns are not correlated with particular lesion features and clinical manifestations that were investigated in CCMs. The possible fewer fractions of caverns containing collagen IV and laminin in adult lesions compared with pediatric lesions may have implications for lesion regression and quiescence with age.

Surgical resection of cavernous angiomas located in eloquent areas--clinical research

BACKGROUND

In patients with lesions at the eloquent areas, the aim of surgical interventions should be a more radical removal of the lesions with preservation of brain function. In this retrospective study, our techniques for localizing lesion and the postoperative results of 26 patients with cavernous angiomas (CA) located at the eloquent areas are summarized.

METHOD

The MR based 3D-rendering images were reconstructed from the 2D MR images by using a computerized program. These images were obtained in all patients for the localization of their lesion. Following craniotomy, to verify the actual location of lesions, we compared the 3D-image to the exposed cortical surface. Simultaneously, intraoperative ultrasonogram (IOUS) was used for the accurate localization of the lesion. In order to minimize the damage to the eloquent area, the minimal corticotomy was planned at the margin of the sulcus nearest to the lesion.

FINDINGS

An accurate localization of the lesion was possible in all 26 patients and the eloquent areas near the lesions were identified on the operation field. Complete removal of the CAs was done in all cases. One patient developed temporary monoparesis postoperatively, but the patient fully recovered in a month. Fourteen patients presented with preoperative seizures, and all patients had excellent seizure outcome after their surgery. The mean duration of the follow-up period was 27 months.

CONCLUSIONS

We could localize the lesion accurately using MRI 3D-rendering images and IOUS during the operation for CA. We planned minimal corticotomy to the lesion and we completely removed the lesion without causing any additional neurological deficit. Although CA can be located in eloquent areas, surgical removal of these lesions is a safe and effective treatment option for lowering the risk of developing symptoms and controlling the seizure.

Intracranial cavernous angioma: a practical review of clinical and biological aspects

BACKGROUND

Cavernomas are an uncommon lesion seen in neurosurgical practice that can occasionally rupture. Recent developments in neurosurgical technique and microbiology have brought greater insight into the treatment and molecular pathogenesis of cavernoma. In this review, a historical overview of cavernous angioma, a current paradigm for treatment, promising new molecular biological developments, and suggestions for future directions in neurosurgical research are presented, with emphasis on practical clinical applications.

METHODS

A survey of the literature on cavernous angioma and consultation with the Department of Neurosurgery at Northwestern Memorial Hospital was conducted by the authors to gain greater insight regarding this lesion. Papers and consultation revealed the importance of careful evaluation of this lesion, new techniques such as functional magnetic resonance imaging and frameless stereotaxy that simplify clinical management of cavernomas, and potential mechanisms by which to tackle this lesion in the future. New basic knowledge on disease biology is summarized with practical applications in the clinical arena.

RESULTS

There appear to be a number of controversies regarding management of this lesion. These include risk factors faced by the patient, controversy over the importance of resection, and modality through which the treatment should occur. An algorithm is presented to aid the neurosurgeon in management of these lesions.

CONCLUSIONS

Exciting developments in neurosurgery and molecular biology will continue to have a major impact on clinical treatment of this disease. Unresolved issues regarding the importance of certain risk factors, the role for radiotherapy in treatments, and the underlying molecular abnormalities must be tackled to gain greater clarity in treatment of this lesion.

[Cavernous haemangiomas: hearing and vestibular inaugural symptoms]

INTRODUCTION

Cavernous haemangiomas (cavernomas)(CH) are relatively rare (2% of cranial tumoral pathology) vascular malformations mostly observed in the central nervous system. Their most common topographical site in brain stem is midline in the pons, for which clinical course may mimic symptoms of peripheral origin (sudden deafness, fluctuating hearing loss, Meniere-like vertigo).

AIM

To establish the correlation between the clinical manifestations of hearing and balance disturbance and the anatomical site within the pons of cavernous haemangiomas, and to describe their clinical features, and the findings on auditory brainstem response (ABR) and magnetic resonance imaging (MRI). To propose a literature review about CH and its implications.

MATERIAL AND METHOD

We made a retrospective review of the histories of three patients aged 24, 44 and 45 years, diagnosed as having cavernomas of the brainstem in which audiometric evaluation, videonystagmography (VNG), ABR and imaging techniques lead to the diagnosis of intracranial cavernoma.

RESULTS

The clinical and radiological files were reviewed and a direct relationship between symptoms and localization was found in all 3 patients, especially in relation to our understanding of the auditory and vestibular pathways within the brainstem.

CONCLUSION

The literature regarding cavernomas of the pons is reviewed and the clinical, neuroimage, pathological, natural course and management aspects of the disease are discussed. We recommend the use of cerebral MRI for initial diagnosis which shows a typical rosette-like appearance with a heterogeneous signal on T2-weighted images, along with follow-up and investigation into similar profiles among family members. At present there is no consensus about the treatment to follow when cavernomas are located in the brain stem. There is no specific medical treatment for this condition, and surgery is indicated only exceptionally. Anticoagulant therapy, platelet-dispersing medication and violent sports activities are contraindicated.

Multiple Spinal Cavernous Malformations with Atypical Phenotype after Prior Irradiation: Case Report

OBJECTIVE AND IMPORTANCE:

This is the first reported case of histologically proven multiple spinal cavernous malformations (CMs) associated with previous irradiation. There are only two cases reported in the literature of solitary spinal CM after irradiation. In addition, the lesions in our patient had an atypical magnetic resonance imaging appearance mimicking intraspinal drop metastasis.

CLINICAL PRESENTATION:

A 33-year-old man had an incidental finding of multiple enhancing intraspinal lesions as revealed by magnetic resonance imaging during staging tests for hepatocellular carcinoma. He had a history of Wilms' tumor at a young age with irradiation to the abdomen and pelvis. His family history included a paternal cousin with multiple cerebral CMs. The diagnosis of spinal drop metastasis was made, and further intervention was undertaken for confirmation.

INTERVENTION:

The patient underwent a lumbar laminectomy with durotomy and excision of two of the lesions. Macroscopic analysis revealed mulberry-like appearance with nerve root involvement, and pathological analysis confirmed the diagnosis of CM. Genetic testing of the patient and his affected cousin was negative for the CCM1 gene.

CONCLUSION:

The occurrence of multiple spinal lesions in the context of known neoplasia indicates a diagnosis of metastasis. Spinal CMs were not suspected preoperatively because of the atypical appearance revealed by magnetic resonance imaging scans, with uniform contrast enhancement and absence of hemosiderin rim. This case report is discussed relative to previous literature regarding radiation-induced CMs and other known causes of the disease.

Putaminal cavernous angioma presenting with hemichorea

We report on a 63-year-old man presenting with hemichorea on his right side. Magnetic resonance imaging revealed a left putaminal cavernoma. To our knowledge this is the first report of such a case caused by contralateral putaminal cavernous angioma.

Cavernous angioma presenting as epilepsy 13 years after initial diagnosis

A 22-year-old man presented with tonic-clonic seizure and was admitted to our hospital. He had suffered from frequent headaches, and had been diagnosed with a brain tumour on MRI 13 years ago. However, neither further examination nor follow-up neuroimaging study have been performed. Computed tomography and magnetic resonance imaging demonstrated an intraaxial tumor with granular calcification in the right frontal lobe, attached to the adjacent dura mater, which was enlarged compared with the lesion on CT 13 years before. The lesion was surgically excised through right frontal craniotomy. Histopathological analysis indicated cavernous angioma. In cavernous angioma in younger children, more aggressive surgical indications than in adults may be favorable both to prevent haemorrhagic complications and to confirm pathologic diagnosis.

MRI and intraoperative findings in cavernous haemangiomas of the spinal cord

More sensitive imaging techniques, such as MRI, have led to an increase in the number of reported cases of spinal cord cavernous haemangioma (SCCH). Complete surgical resection has been performed with good outcomes. However, operative findings do not always confirm preoperative MRI as to the size and site (superficial or deep) of the lesion. We evaluated whether MRI can be used to predict whether or not SCCH reach the surface of the spinal cord, since this has an impact on surgical strategy. We reviewed the preoperative MRI, case-notes and video recordings of 12 patients who underwent surgery, at which five superficial and seven deep-seated lesions were identified. T1-weighted images correctly indicated the site of the lesion in ten, T2-weighted images in only eight. One deep lesion was thought to be superficial on both T1- and T2-weighted images. Intravenous contrast medium was not helpful in diagnosis or localisation. In no case was a surgically proven superficial lesion interpreted as deep in the spinal cord.

Intramedullary spinal cavernous malformation following spinal irradiation. Case report and review of the literature

There is a growing body of evidence in the literature suggesting that cavernous malformations of the central nervous system may develop after neuraxis irradiation. The authors discuss the case of a 17-year-old man who presented with progressive back pain and myelopathy 13 years after undergoing craniospinal irradiation for a posterior fossa medulloblastoma. Spinal magnetic resonance (MR) imaging, performed at the time of his initial presentation with a medulloblastoma, demonstrated no evidence of a malformation. Imaging studies and evaluation of cerebrospinal fluid revealed no evidence of recurrence or dissemination. Spinal MR imaging demonstrated an extensive lesion in the thoracic spine with an associated syrinx suggestive of a cavernous malformation. A thoracic laminectomy was performed and the malformation was successfully resected. Pathological examination confirmed the diagnosis. The patient did well after surgery and was ambulating without assistance 6 weeks later. To the best of the authors' knowledge, this is the second reported case in the literature and the first in the young adult age group suggesting the de novo development of cavernous malformations in the spinal cord after radiotherapy. An increased awareness of these lesions and close follow-up examination are recommended in this setting.

Cerebral cavernous malformation: novel mutation in a Chinese family and evidence for heterogeneity

Familial cerebral cavernous malformation (CCM) is an autosomal dominant disorder producing vascular anomalies throughout the central nervous system associated with seizures and hemorrhagic stroke. Linkage analysis has shown evidence for at least three genetic loci underlying this disorder with a founder mutation in the Mexican/Hispanic community. We report the first family of Chinese ethnic origin with CCM having a novel mutation in the CCM1 gene. The mutation in exon 19 causes a premature stop codon (Q698X) predicted to produce a truncated Krev1 interaction-trapped 1 (KRIT1) protein. Members of the family with this mutation have a wide range in age of onset with seizures, ataxia, spinal cord vascular malformation, headaches and skin lesions. An additional unrelated sporadic subject with brain lesions compatible with CCM as well as vascular skin findings suggesting the blue rubber bleb nevus (BRBN) syndrome has no mutation detected in the CCM1 gene. These findings expand the phenotype of and demonstrate further evidence for the heterogeneity in the CCM syndrome.

Congenital cerebral and cerebrovascular anomalies: magnetic resonance imaging

Magnetic resonance is the imaging modality of choice for the evaluation of infants and children with known or suspected cerebral and cerebrovascular abnormalities. Entities described include cephaloceles, holoprosencephaly, dysgenesis of corpus callosum, and anomalies of neuronal migration. Congenital vascular lesions described include aneurysm, arteriovenous malformation, cavernous malformation, and Galenic malformations.

Distonia segmentar como manifestação de angioma cavernoso: relato de caso

A distonia é uma síndrome neurológica cuja etiologia costuma não ser bem definida. Relatamos caso de uma paciente que apresentou aos 16 anos de idade dificuldade para tocar piano, havendo um comprometimento progressivo da mão, antebraço e braço esquerdo que posteriormente evoluiu com crises de "ausência" e cefaléia. Realizou exames de imagem que evidenciaram angioma cavernoso na região temporal profunda direita (ínsula). É rara a associação entre essas duas enfermidades, não havendo na literatura relato de distonia segmentar associada a crises de pseudoausência e cefaléia com características migranosas secundária ao angioma cavernoso. Vinte e cinco por cento das distonias são secundárias, o que nos faz sugerir uma investigação mínima em neuroimagem.

Cavernous haemangiomas (angiomas) of the brain

This paper highlights the importance of cavernous haemangiomas as clinically significant lesions and the role of imaging, particularly MRI, in suggesting the diagnosis. An understanding of the pathology of these lesions helps to explain the features demonstrated by imaging techniques.

Dynamic nature of cavernous malformations: a prospective magnetic resonance imaging study with volumetric analysis

OBJECT

Although cavernous malformations (CMs) are not detected in angiographic studies, they have a characteristic appearance on magnetic resonance (MR) images. A number of reports published in the last decade have focused on the behavior of these lesions within the clinical environment. However, little has been published about the evolution of CMs over time, as observed in imaging studies. To understand imaging-documented changes in CMs over time, we analyzed MR images of 114 cavernous malformations in 68 patients who were followed prospectively.

METHODS

For each CM the location, volume, and MR imaging signal characteristics were recorded. Volume data were available for 107 lesions from initial images. The mean volume of these 107 CMs was 2779 mm3. The lesions ranged in size from 0.5 to 46,533 mm3 (46.5 cm3). Volume data from a second set of images were available for 76 CMs (mean interval from first imaging session 26 months), and from a third set of images for 24 lesions (mean interval from second imaging session 18 months). Over the first follow-up interval, the mean volume change was -991 mm3 (a decrease of approximately 1 cm3) and over the second interval the mean volume change was -642 mm3. Although these mean volume changes appear modest, volume changes in single lesions during follow-up intervals were more dramatic, with decreases as large as 45,629 mm3 (45.6 cm3) and increases as large as 6,074 mm3 (6 cm3). Serial examinations of the MR imaging signal characteristics of these CMs demonstrate a trend for maturation of blood products from a subacute, to a mixed, and finally to a chronic appearance. Three lesions appeared de novo during the follow-up period.

CONCLUSIONS

On the basis of their analysis, the authors conclude that CMs exhibit a range of dynamic behaviors including enlargement, regression, and de novo formation, as well as progression through a series of characteristic MR imaging appearances.