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Demir MK, Kılıc D, Zorlu E, Kılıc T. Giant Intracranial Cavernous Malformations: A Review on Magnetic Resonance Imaging Characteristics. Indian J Radiol Imaging 2024; 34:511-521. [PMID: 38912256 PMCID: PMC11188748 DOI: 10.1055/s-0044-1779587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Background Intracranial cavernous malformations (CMs), commonly known as cavernomas or cavernous angiomas, are low-flow, well-circumscribed vascular lesions composed of sinusoidal spaces lined by a single layer of endothelium and separated by a collagenous matrix without elastin, smooth muscle, or other vascular wall elements. A diameter greater than 3 cm for a CM is unlikely. These lesions may have atypical appearances on magnetic resonance imaging (MRI). MRI with advanced techniques such as a susceptibility-weighted image or T2-gradient echo, a diffusion-weighted image and corresponding apparent diffusion coefficient map, and diffusion tensor tractography have revolutionized the diagnostic approach to these lesions. Materials and Method The present study reviews the etiopathogenesis, clinical manifestations, MRI strategy, and MRI appearances of the CMs, with a few examples of the giant CMs from our archive. Results Intracranial giant CMs may have unexpected locations, sizes, numbers, and varied imaging appearances due to repeated hemorrhages, unusual enhancement patterns, intense perifocal edema, and unusual associations, making the differential diagnosis difficult. Conclusion Familiarity with the MRI appearances of the giant intracranial CMs and the differential diagnosis improves diagnostic accuracy and patient management.
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Affiliation(s)
- Mustafa Kemal Demir
- Clinic of Radiology, Bahcesehir University Goztepe Medical Park Hospital, Istanbul, Turkey
| | - Deniz Kılıc
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
| | - Emre Zorlu
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
| | - Turker Kılıc
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
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Dulamea AO, Lupescu IC. Cerebral cavernous malformations - An overview on genetics, clinical aspects and therapeutic strategies. J Neurol Sci 2024; 461:123044. [PMID: 38749279 DOI: 10.1016/j.jns.2024.123044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
Cerebral cavernous malformations (CCMs) are abnormally packed blood vessels lined with endothelial cells, that do not exhibit intervening tight junctions, lack muscular and elastic layers and are usually surrounded by hemosiderin and gliosis. CCMs may be sporadic or familial autosomal dominant (FCCMs) caused by loss of function mutations in CCM1 (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10) genes. In the FCCMs, patients have multiple CCMs, different family members are affected, and developmental venous anomalies are absent. CCMs may be asymptomatic or may manifest with focal neurological deficits with or without associated hemorrhage andseizures. Recent studies identify a digenic "triple-hit" mechanism involving the aquisition of three distinct genetic mutations that culminate in phosphatidylinositol-3-kinase (PIK3CA) gain of function, as the basis for rapidly growing and clinically symptomatic CCMs. The pathophysiology of CCMs involves signaling aberrations in the neurovascular unit, including proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammation and immune mediated processes, anticoagulant vascular domain, and gut microbiome-driven mechanisms. Clinical trials are investigating potential therapies, magnetic resonance imaging and plasma biomarkers for hemorrhage and CCMs-related epilepsy, as well as different techniques of neuronavigation and neurosonology to guide surgery in order to minimize post-operatory morbidity and mortality. This review addresses the recent data about the natural history, genetics, neuroimaging and therapeutic approaches for CCMs.
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Affiliation(s)
- Adriana Octaviana Dulamea
- Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; Fundeni Clinical Institute, Department of Neurology, 258 Fundeni Street, 022328 Bucharest, Romania.
| | - Ioan Cristian Lupescu
- Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; Fundeni Clinical Institute, Department of Neurology, 258 Fundeni Street, 022328 Bucharest, Romania
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Nico E, Adereti CO, Hackett AM, Bianconi A, Naik A, Eberle AT, Cifre Serra PJ, Koester SW, Malnik SL, Fox BM, Hartke JN, Winkler EA, Catapano JS, Lawton MT. Assessing the Relationship between Surgical Timing and Postoperative Seizure Outcomes in Cavernoma-Related Epilepsy: A Single-Institution Retrospective Analysis of 63 Patients with a Review of the Literature. Brain Sci 2024; 14:494. [PMID: 38790473 PMCID: PMC11120247 DOI: 10.3390/brainsci14050494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Patients with supratentorial cavernous malformations (SCMs) commonly present with seizures. First-line treatments for cavernoma-related epilepsy (CRE) include conservative management (antiepileptic drugs (AEDs)) and surgery. We compared seizure outcomes of CRE patients after early (≤6 months) vs. delayed (>6 months) surgery. Methods: We compared outcomes of CRE patients with SCMs surgically treated at our large-volume cerebrovascular center (1 January 2010-31 July 2020). Patients with 1 sporadic SCM and ≥1-year follow-up were included. Primary outcomes were International League Against Epilepsy (ILAE) class 1 seizure freedom and AED independence. Results: Of 63 CRE patients (26 women, 37 men; mean ± SD age, 36.1 ± 14.6 years), 48 (76%) vs. 15 (24%) underwent early (mean ± SD, 2.1 ± 1.7 months) vs. delayed (mean ± SD, 6.2 ± 7.1 years) surgery. Most (32 (67%)) with early surgery presented after 1 seizure; all with delayed surgery had ≥2 seizures. Seven (47%) with delayed surgery had drug-resistant epilepsy. At follow-up (mean ± SD, 5.4 ± 3.3 years), CRE patients with early surgery were more likely to have ILAE class 1 seizure freedom and AED independence than those with delayed surgery (92% (44/48) vs. 53% (8/15), p = 0.002; and 65% (31/48) vs. 33% (5/15), p = 0.03, respectively). Conclusions: Early CRE surgery demonstrated better seizure outcomes than delayed surgery. Multicenter prospective studies are needed to validate these findings.
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Affiliation(s)
- Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Christopher O. Adereti
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Ashia M. Hackett
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Andrea Bianconi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Adam T. Eberle
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Pere J. Cifre Serra
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Stefan W. Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Samuel L. Malnik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Brandon M. Fox
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joelle N. Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
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Narita M, Miyairi Y, Motobayashi M, Chiba A, Inaba Y. Incidence of Cerebral Cavernous Malformation-Related Epilepsy in Children: A Single Center Survey. Cureus 2023; 15:e38178. [PMID: 37252508 PMCID: PMC10220326 DOI: 10.7759/cureus.38178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION Cerebral cavernous malformations (CCMs) are rare developmental cerebrovascular malformations. The risk of epilepsy is high in patients with CCMs, but the incidence of epilepsy has not been reported in a pure pediatric population. We herein present 14 pediatric cases of CCMs, including five with CCM-related epilepsy, and examine the incidence of CCM-related epilepsy in this pediatric population. Methods: Pediatric patients with CCMs who visited our Hospital between November 1, 2001, to September 31, 2020, were retrospectively screened for inclusion, and 14 were enrolled. Results: Fourteen enrolled patients were divided into two groups based on the presence or absence of CCM-related epilepsy. The "CCM-related epilepsy group" (n = 5) consisted of five males with a median age of 4.2 (range: 0.3-8.5) years at the first visit. The "non-epilepsy group" (n = 9) consisted of seven males and two females with a median age of 3.5 (range: 1.3-11.5) years at the first visit. The prevalence of CCM-related epilepsy at the time of the present analysis was 35.7%. Follow-up periods in CCM-related epilepsy and non-epilepsy groups were 19.3 and 24.9 patient-years, respectively: the incidence was 11.3% per patient-years. The frequency of seizures due to intra-CCM hemorrhage as the primary symptom was significantly higher in the CCM-related epilepsy group than in the non-CCM-related epilepsy group (p = 0.01). Other clinical characteristics, i.e., primary symptoms including vomiting/nausea and spastic paralysis, magnetic resonance imaging findings, including the number or maximum diameter of CCMs, cortical involvement, intra-CCM hemorrhage, and infratentorial lesions, surgical resection, and non-epileptic sequelae, such as motor disability and intellectual disability, did not significantly differ between the groups. Discussion: The incidence of CCM-related epilepsy in the present study was 11.3% per patient year, higher than in adults. This discrepancy may be attributed to these studies including both adult and pediatric patients, whereas the present study examined a pure pediatric population. The presence of seizures due to intra-CCM hemorrhage as the initial symptom was a risk factor for CCM-related epilepsy in the present study. To elucidate the pathophysiology of CCM-related epilepsy or the reason for its higher incidence in children than in adults, further analyses of a large number of children with CCM-related epilepsy are warranted.
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Affiliation(s)
- Masahiro Narita
- Pediatric Neurology, Nagano Children's Hospital, Azumino, JPN
| | | | | | - Akihiro Chiba
- Neurosurgery, Nagano Children's Hospital, Azumino, JPN
| | - Yuji Inaba
- Pediatric Neurology, Nagano Children's Hospital, Azumino, JPN
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5
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Zhang P, Zhang H, Shi C, Zhou J, Dong J, Liang M, Li R, Cheng J, Chen Y, Yuan J, Chen Y. Clinical characteristics and risk factors of cerebral cavernous malformation-related epilepsy. Epilepsy Behav 2023; 139:109064. [PMID: 36640483 DOI: 10.1016/j.yebeh.2022.109064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE This study aimed to summarize the clinical characteristics and explore the risk factors for cerebral cavernous malformation (CCM)-related epilepsy (CRE). METHODS We retrospectively analyzed the clinical data of patients with CCM in our cerebral vascular malformations database. Descriptive statistics were used to present the clinical characteristics of CRE patients. Patients were divided into a CRE and a non-CRE group according to clinical presentation. Binary logistic regression analysis was used to analyze the risk factors of CRE. RESULTS A total of 199 patients with CCM confirmed by postoperative pathological examination were enrolled, 93 of whom were diagnosed with CRE, and 34 patients had drug-resistant epilepsy. The most common seizure type of CRE patients was focal to bilateral tonic-clonic seizure (FBTCS), followed by focal impaired awareness motor seizure. All CCM lesions were supratentorial, 97.8% of which involved the cerebral cortex, 86.0% of lesions had hemosiderin rim, and 50.5% of lesions were located in the temporal lobe. Binary logistic regression analysis indicated that CCM diagnosis age ≤ 44 years (odds ratio [OR] 2.79, p = 0.010), temporal lobe lesion location (OR = 9.07, p = 0.042), medial temporal lobe lesion (OR = 14.09, p = 0.002), cortical involvement of the lesion (OR = 32.77, p = 0.010), and hemosiderin rim around the lesion (OR = 16.48, p = 0.001) significantly increased the risk of CRE. CONCLUSIONS The most common seizure type of CRE was FBTCS. Those whose CCM diagnosis age was ≤ 44 years, having a temporal lobe lesion location, especially the medial temporal lobe lesion, cortical involvement, and hemosiderin rim around the lesion had a higher risk of developing CRE.
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Affiliation(s)
- Peng Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing 400010, China.
| | - Hui Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing 400016, China.
| | - Chenjun Shi
- Department of General Practice, Xinqiao Hospital, Army Medical University, 83 Xinqiao Central Street, Shapingba District, Chongqing 400037, China.
| | - Jinyu Zhou
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Jun Dong
- Department of Neurology, Daping Hospital, Army Medical University, 10 Daping Changjiang Branch Road, Yuzhong District, Chongqing 400042, China
| | - Minxue Liang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Rong Li
- Department of Neurology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, 157 Jinbi Road, Xishan District, Kunming 650034, China
| | - Jing Cheng
- Department of Neurology, The Third Affiliated Hospital of Chongqing Medical University, 1 Shuanghu Branch Road, Yubei District, Chongqing 401120, China
| | - Yalan Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Jinxian Yuan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing 400010, China.
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Berber T, Celik SE, Aksaray F, Yoney A, Harmanci K, Tambas M, Yılmaz BD, Numanoglu C, Yolcu A, Açan Hİ, Dinçer ST, Yıldırım BA. Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas. JOURNAL OF RADIATION RESEARCH 2023; 64:133-141. [PMID: 36208871 PMCID: PMC9855324 DOI: 10.1093/jrr/rrac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Tanju Berber
- Corresponding author. Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Kaptan Pasa, SSK Okmeydani Hst. No: 25, 34384 Sisli/Istanbul, Turkey. Tel: +905324111202;
| | - Suat Erol Celik
- Department of Neurosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ferdi Aksaray
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Adnan Yoney
- Department of Internal Medicine, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Kemal Harmanci
- Department of Radiology, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Makbule Tambas
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Binnur Dönmez Yılmaz
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Cakir Numanoglu
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ahmet Yolcu
- Department of Radiation Oncology, Namık Kemal University Medical Faculty of Medicine, Tekirdag, Turkey
| | - Hilal İrem Açan
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Selvi Tabak Dinçer
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Berna Akkuş Yıldırım
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
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Rajeswarie RT, Aravinda HR, Arivazhagan A, Bevinahalli NN, Rao MB, Mahadevan A. Evaluating the Role of Perilesional Tissue in Pathobiology of Epileptogenesis of Vascular Malformations of the Central Nervous System. J Epilepsy Res 2022; 12:53-61. [PMID: 36685742 PMCID: PMC9830028 DOI: 10.14581/jer.22010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose Seizures are common presentation of cerebral vascular malformation (CVM). Topography and haemodynamic alterations are proposed as mechanisms for epileptogenesis, but the role of glial/neuronal alterations in perilesional tissue has not received much attention. Identification of the exact pathophysiologic basis could have therapeutic implications. To evaluate whether angioarchitectural factors of CVM or alterations in neuroglial/stroma of the adjacent cortex contribute to seizures. Method The clinical, imaging and histological characteristics of arteriovenous malformation (AVM) and cerebral cavernous malformation (CCM) with and without seizures was evaluated using neuroimaging imaging and digital subtraction angiography parameters and histopathology by morphology and immunohistochemistry. Results Fifty-six cases of CVM were diagnosed over a 2-year study period. Of these, 32 had adequate perilesional tissue for evaluation (AVM, 24; CCM, 8). Seizures at presentation was seen in 12/24 (50%) of AVM and 5/8 (62.5%) CCM. In AVM, hemosiderin deposition and gliosis in parenchyma (p=0.01) had significant association with seizure. Siderotic vessels in the adjacent cortex was exclusively seen only in CCM with seizures (p=0.018). Angioarchitectural features of CVM on imaging and neuronal alterations in adjacent cortex on histology failed to show any statistically significant difference between the two groups (p>0.05). Conclusions We propose that changes in adjacent cortex appear to be epileptogenic rather than the malformation per se. Reactive gliosis and hemosiderin deposits in perilesional tissue in AVM and siderotic vessels in CCM were associated with seizure. This explains the better outcomes following extended lesionectomy that includes epileptogenic perilesional tissues.
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Affiliation(s)
- RT Rajeswarie
- Department of Neuropathology, National Institute of Mental Health & Neurosciences, Bangalore,
India
| | - HR Aravinda
- Department of Neuroimaging & Interventional Radiology, National Institute of Mental Health & Neurosciences, Bangalore,
India
| | - A Arivazhagan
- Department of Neurosurgery, National Institute of Mental Health & Neurosciences, Bangalore,
India
| | - N Nandeesh Bevinahalli
- Department of Neuropathology, National Institute of Mental Health & Neurosciences, Bangalore,
India
| | - Malla Bhaskara Rao
- Department of Neurosurgery, National Institute of Mental Health & Neurosciences, Bangalore,
India
| | - Anita Mahadevan
- Department of Neuropathology, National Institute of Mental Health & Neurosciences, Bangalore,
India
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Rauschenbach L, Bartsch P, Santos AN, Lenkeit A, Darkwah Oppong M, Wrede KH, Jabbarli R, Chmielewski WX, Schmidt B, Quesada CM, Forsting M, Sure U, Dammann P. Quality of life and mood assessment in conservatively treated cavernous malformation-related epilepsy. Brain Behav 2022; 12:e2595. [PMID: 35470577 PMCID: PMC9226805 DOI: 10.1002/brb3.2595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/03/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To estimate the quality of life, anxiety, depression, and illness perception in patients with medically treated cerebral cavernous malformation (CCM) and associated epilepsy. METHODS Nonsurgically treated patients with CCM-related epilepsy (CRE) were included. Demographic, radiographic, and clinical features were assessed. All participants received established questionnaires (short-form 36 health survey, SF-36; hospital anxiety and depression score, HADS-A/D; visual analogue scale score, VAS) assessing the functional and psychosocial burden of disease. To some extent, calculated values were compared with reference values from population-based studies. Test results were related to seizure control. RESULTS A total of 37 patients were included. Mean age was 45.8 ± 14.4 years, and 54.1% were female. Diagnosis of CRE was significantly associated with attenuated quality of life and increased level of anxiety, affecting physical and psychosocial dimensions. The assessment of illness perception identified considerable burden. HADS was significantly associated with VAS and SF-36 component scores. Efficacy of antiepileptic medication had no restoring impact on quality of life, anxiety, depression, or illness perception. CONCLUSIONS CRE negatively influences quality of life and mood, independent of seizure control due to antiepileptic medication. Screening for functional and psychosocial deficits in clinical practice might be useful for assessing individual burden and allocating surgical or drug treatment.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Pauline Bartsch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Annika Lenkeit
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Witold X Chmielewski
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Carlos M Quesada
- Department of Neurology, Division of Epilepsy, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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9
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Shih YC, Chou CC, Peng SJ, Yu HY, Hsu SPC, Lin CF, Lee CC, Yang HC, Chen YC, Kwan SY, Chen C, Wang SJ, Lin CJ, Lirng JF, Shih YH, Yen DJ, Liu YT. Clinical characteristics and long-term outcome of cerebral cavernous malformations-related epilepsy. Epilepsia 2022; 63:2056-2067. [PMID: 35593439 DOI: 10.1111/epi.17309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 05/06/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCMs) present variably and epileptic seizures are the most common symptom. The factors contributing to cavernoma-related epilepsy (CRE) and drug resistance remain inconclusive. The outcomes of CRE after different treatment modalities have not yet been fully addressed. This study aimed to characterize the clinical features of patients with CRE and the long-term seizure outcomes of medical and surgical treatment strategies. METHODS This was a retrospective cohort of 135 patients with CCM who were diagnosed in 2007~2011 and followed up for 93.6 months on average. The patients were divided into drug-resistant epilepsy (DRE) (n = 29), non-DRE (NDRE) (n = 45), and no epilepsy (NE) (n = 61). RESULTS Temporal CCM was the factor most strongly associated with the development of both CRE and DRE. The majority of patients with single temporal CCMs had CRE (86.8%, n = 33) and 50% had DRE, whereas only 14.7% (n = 5) with a non-temporal supratentorial CCM had DRE (P < 0.05). The most common lesion site in the DRE group was the mesiotemporal lobe (50%). Multiple CCMs were more frequently observed in the CRE (29.2%) than the NE (11.5%) group (P < 0.05). In patients with CRE, multiple lesions were associated with a higher rebleeding rate (odds ratio: 11.1), particularly in those with DRE (odds ratio: 15.4). The majority of patients who underwent resective surgery for DRE (76.5%, n = 13) achieved ILAE class I and II seizure outcomes even after a long disease course. SIGNIFICANCE Temporal CCM not only predisposes to CRE but is also a major risk factor for drug resistance. The mesiotemporal lobe is the most epileptogenic zone. Multiple CCMs are another risk factor for CRE and increase the rebleeding risk in these patients. Surgical resection could provide beneficial long-term seizure outcomes in patients with DRE.
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Affiliation(s)
- Yen-Cheng Shih
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Chien-Chen Chou
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiang-Yu Yu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Sanford P C Hsu
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Chieh Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Yeong Kwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Chien Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiing-Feng Lirng
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yang-Hsin Shih
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Der-Jen Yen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Yo-Tsen Liu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
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10
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Dziedzic TA, Koczyk K, Nowak A, Maj E, Marchel A. Long-Term Management of Seizures after Surgical Treatment of Supratentorial Cavernous Malformations : A Retrospective Single Centre Study. J Korean Neurosurg Soc 2022; 65:415-421. [PMID: 35508959 PMCID: PMC9082132 DOI: 10.3340/jkns.2020.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Seizure recurrence after the first-ever seizure in patients with a supratentorial cerebral cavernous malformation (CCM) is almost certain, so the diagnosis and treatment of epilepsy is justified. The optimal method of management of these patients is still a matter of debate. The aim of our study was to identify factors associated with postoperative seizure control and assess the surgical morbidity rate.
Methods We retrospectively analysed 45 consecutive patients with a supratentorial CCM and symptomatic epilepsy in a single centre. Pre- and postoperative epidemiological data, seizure-related patient histories, neuroimaging results, surgery details and outcomes were obtained from hospital medical records. Seizure outcomes were assessed at least 12 months after surgery.
Results Thirty-five patients (77.8%) were seizure free at the long-term follow-up (Engel class I); six (13,3%) had rare, nocturnal seizures (Engel class II); and four (8.9%) showed meaningful improvement (Engel class III). In 15 patients (33%) in the Engel I group; it was possible to discontinue antiepileptic medication. Although there was not statistical significance, our results suggest that patients can benefit from early surgery. No deaths occurred in our study, and mild postoperative neurologic deficits were observed in two patients (4%) at the long-term follow-up.
Conclusion Surgical resection of CCMs should be considered in all patients with a supratentorial malformation and epilepsy due to the favourable surgical results in terms of the epileptic seizure control rate and low postoperative morbidity risk, despite the use of different predictors for the seizure outcome.
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11
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He K, Alriashy MHS, Fan Z, Qiao N, Liao Y, An Q, Xu B, Song J, Zhang X, Zhu W, Chen L, Mao Y. Cavernoma -Associated Epilepsy Within the Mesial Temporal Lobe: Surgical Management and Seizure Outcome. World Neurosurg 2022; 160:e464-e470. [PMID: 35051640 DOI: 10.1016/j.wneu.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Kangmin He
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - M H S Alriashy
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Zhen Fan
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Nidan Qiao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Yujun Liao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Qinzhu An
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Bin Xu
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Jianping Song
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Xin Zhang
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Wei Zhu
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Liang Chen
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China.
| | - Ying Mao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
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12
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Frazzini V, Cousyn L, Navarro V. Semiology, EEG, and neuroimaging findings in temporal lobe epilepsies. HANDBOOK OF CLINICAL NEUROLOGY 2022; 187:489-518. [PMID: 35964989 DOI: 10.1016/b978-0-12-823493-8.00021-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Temporal lobe epilepsy (TLE) is the most common type of focal epilepsy. First descriptions of TLE date back in time and detailed portraits of epileptic seizures of temporal origin can be found in early medical reports as well as in the works of various artists and dramatists. Depending on the seizure onset zone, several subtypes of TLE have been identified, each one associated with peculiar ictal semiology. TLE can result from multiple etiological causes, ranging from genetic to lesional ones. While the diagnosis of TLE relies on detailed analysis of clinical as well as electroencephalographic (EEG) features, the lesions responsible for seizure generation can be highlighted by multiple brain imaging modalities or, in selected cases, by genetic investigations. TLE is the most common cause of refractory epilepsy and despite the great advances in diagnostic tools, no lesion is found in around one-third of patients. Surgical treatment is a safe and effective option, requiring presurgical investigations to accurately identify the seizure onset zone (SOZ). In selected cases, presurgical investigations need intracerebral investigations (such as stereoelectroencephalography) or dedicated metabolic imaging techniques (interictal PET and ictal SPECT) to correctly identify the brain structures to be removed.
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Affiliation(s)
- Valerio Frazzini
- AP-HP, Department of Neurology and Department of Clinical Neurophysiology, Epilepsy and EEG Unit, Reference Center for Rare Epilepsies, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris Brain Institute, Team "Dynamics of Neuronal Networks and Neuronal Excitability", Paris, France
| | - Louis Cousyn
- AP-HP, Department of Neurology and Department of Clinical Neurophysiology, Epilepsy and EEG Unit, Reference Center for Rare Epilepsies, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris Brain Institute, Team "Dynamics of Neuronal Networks and Neuronal Excitability", Paris, France
| | - Vincent Navarro
- AP-HP, Department of Neurology and Department of Clinical Neurophysiology, Epilepsy and EEG Unit, Reference Center for Rare Epilepsies, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris Brain Institute, Team "Dynamics of Neuronal Networks and Neuronal Excitability", Paris, France.
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13
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Chou CJ, Lee CC, Chen CJ, Yang HC, Peng SJ. Displacement of Gray Matter and Incidence of Seizures in Patients with Cerebral Cavernous Malformations. Biomedicines 2021; 9:biomedicines9121872. [PMID: 34944688 PMCID: PMC8698264 DOI: 10.3390/biomedicines9121872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
Seizures are the most common presentation in patients with cerebral cavernous malformations (CCMs). Based on the hypothesis that the volume or proportion of gray matter (GM) displaced by CCMs is associated with the risk of seizure, we developed an algorithm by which to quantify the volume and proportion of displaced GM and the risk of seizure. Image analysis was conducted on 111 patients with solitary CCMs (divided into seizure and nonseizure groups) from our gamma knife radiosurgery (GKRS) database from February 2005 and March 2020. The CCM algorithm proved effective in quantifying the GM and CCM using T1WI MRI images. In the seizure group, 11 of the 12 patients exhibited seizures at the initial presentation, and all CCMs in the seizure group were supratentorial. The location of the limbic lobe within the CCM was significantly associated with the risk of seizure (OR = 19.6, p = 0.02). The risk of seizure increased when the proportion of GM displaced by the CCM exceeded 31%. It was also strongly correlated with the volume of displaced GM. The volume and proportion of displaced GM were both positively correlated with the risk of seizure presentation/development and thus could be used to guide seizure prophylaxis in CCM patients.
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Affiliation(s)
- Chi-Jen Chou
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan;
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (C.-C.L.); (H.-C.Y.)
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei 11221, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA;
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (C.-C.L.); (H.-C.Y.)
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei 11221, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei 10675, Taiwan
- Correspondence: ; Tel.: +886-2-66382736; Fax: +886-2-27321956
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14
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Fox CK, Nelson J, McCulloch CE, Weinsheimer S, Pawlikowska L, Hart B, Mabray MC, Zafar A, Morrison L, Zabramski JM, Akers A, Kim H. Seizure Incidence Rates in Children and Adults With Familial Cerebral Cavernous Malformations. Neurology 2021; 97:e1210-e1216. [PMID: 34389651 PMCID: PMC8480481 DOI: 10.1212/wnl.0000000000012569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Seizure incidence rates related to familial cerebral cavernous malformation (FCCM) are not well described, especially for children. To measure the seizure incidence rate, examine seizure predictors, and characterize epilepsy severity, we studied a cohort of children and adults with FCCM enrolled in the Brain Vascular Malformation Consortium (BVMC). METHODS Seizure data were collected from participants with FCCM in the BVMC at enrollment and during follow-up. We estimated seizure probability by age and tested whether cerebral cavernous malformation (CCM) counts or genotype were associated with earlier seizure onset. RESULTS The study cohort included 479 FCCM cases. Median age at enrollment was 42.5 years (interquartile range 22.5-55.0) and 19% were children (<18 years old). Median large CCM count was 3 (interquartile range 1-5). Among 393 with genotyping, mutations were as follows: CCM1 (Common Hispanic Mutation) (88%), another CCM1 mutation (5%), CCM2 mutations (5%), and CCM3 mutations (2%). Prior to or during the study, 202 (42%) had a seizure. The cumulative incidence of a childhood seizure was 20.3% (95% confidence interval [CI] 17.0-23.4) and by age 80 years was 60.4% (95% CI 54.2-65.7). More total CCMs (hazard ratio [HR] 1.24 per SD unit increase, 95% CI 1.1-1.4) or more large CCMs (HR 1.5 per SD unit increase, 95% CI 1.2-1.9) than expected for age and sex increased seizure risk. A CCM3 mutation also increased risk compared to other mutations (HR 3.11, 95% CI 1.15-8.45). Individuals with a seizure prior to enrollment had increased hospitalization rates during follow-up (incidence rate ratio 10.9, 95% CI 2.41-49.32) compared to patients without a seizure history. DISCUSSION Individuals with FCCM have a high seizure incidence and those with more CCMs or CCM3 genotype are at greater risk. Seizures increase health care utilization in FCCM.
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Affiliation(s)
- Christine K Fox
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC.
| | - Jeffrey Nelson
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Charles E McCulloch
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Shantel Weinsheimer
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Ludmila Pawlikowska
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Blaine Hart
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Marc C Mabray
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Atif Zafar
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Leslie Morrison
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Joseph M Zabramski
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Amy Akers
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
| | - Helen Kim
- From the Departments of Neurology and Pediatrics (C.K.F.), Center for Cerebrovascular Research (C.K.F., J.N., C.E.M., S.W., L.P., H.K.), Department of Epidemiology and Biostatistics (C.E.M., H.K.), and Institute for Human Genetics (S.W., L.P.), University of California San Francisco; Departments of Radiology (B.H., M.C.M.) and Neurology (L.M.), University of New Mexico, Albuquerque; Department of Medicine (A.Z.), Division of Neurology, University of Toronto, Canada; Department of Neurosurgery (J.M.Z.), Barrow Neurological Institute, Phoenix, AZ; and Angioma Alliance (A.A., H.K.), Durham, NC
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15
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Reactive astrocytes contribute to epileptogenesis in patients with cavernous angioma. Epilepsy Res 2021; 176:106732. [PMID: 34332257 DOI: 10.1016/j.eplepsyres.2021.106732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Patients with cavernous angioma (CA) often suffer from severe epilepsy, and surgical resection is often performed to attenuate these epileptic seizures. Several studies have suggested that surgical removal of the surrounding hemosiderin-pigmented tissues adjacent to CA achieves better seizure control than restricted lesionectomy. Pathological examination of the resected foci reveals not only hemosiderin pigmentation but also various degrees of inflammatory change, such as hemosiderin-laden macrophages, gliosis and fibrosis. However, there is some controversy regarding the epileptogenic potential of these regions due to the uncertain nature of the mechanisms contributing to these histopathological changes. METHODS To investigate the correlations between neuron hyperexcitability and evident pathological changes, we performed ex vivo flavoprotein fluorescence imaging using surgically resected epileptogenic foci surrounding CA. The mirror surfaces of the tissues used for the physiological experiment were also subjected to morphological examination. RESULTS Hemosiderin-laden macrophages and many gemistocytic astrocytes were observed in the area adjacent to CA, where horizontal spreading excitations were detected significantly more frequently. Outside these areas, we found fine granular iron deposits and only a few fibrillary astrocytes, and weakly propagating excitations were detected. Furthermore, areas of enhanced activation were more clearly correlated with the glial proliferation index than with iron deposition. CONCLUSION These results suggest that the epileptogenesis in patients with CA may be based on a biological process, such as alteration of glial function, rather than direct chemical reactions involving iron deposition.
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16
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Fontanella MM, Bacigaluppi S, Doglietto F, Zanin L, Agosti E, Panciani P, Belotti F, Saraceno G, Spena G, Draghi R, Fiorindi A, Cornali C, Biroli A, Kivelev J, Chiesa M, Retta SF, Gasparotti R, Kato Y, Hernesniemi J, Rigamonti D. An international call for a new grading system for cerebral and cerebellar cavernomas. J Neurosurg Sci 2021; 65:239-246. [PMID: 34184861 DOI: 10.23736/s0390-5616.21.05433-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Surgical indications for cerebral cavernous malformations remain significantly center- and surgeon-dependent. Available grading systems are potentially limited, as they do not include epileptological and radiological data. A novel grading system is proposed for supratentorial and cerebellar cavernomas: it considers neuroradiological features (bleeding, increase in size), neurological status (focal deficits and seizures), location of the lesion and age of the patient. The score ranges from -1 to 10; furthermore, surgery should be considered when a score of 4 or higher is present. Based on neuroradiological characteristics, 0 points are assigned if the CCM is stable in size at different neuroradiological controls, 1 point if there is an increase in volume during follow-up, 2 points if intra- or extra-lesional bleeding <1 cm is present and 3 points if the CCM produced a hematoma >1 cm. Regarding focal neurological deficits, 0 points are assigned if absent and 2 points if present. For seizures, 0 points are assigned if absent, 1 point if present, but controlled by medications, and 2 points if drug resistant. We considered the site of the CCM, and in case of deep-seated lesions in a critical area (basal ganglia, thalamus) 1 point (-1) is subtracted, while for subcortical or deep cerebellar lesions 0 points are assigned, for CCMs in a cortical critical area 1 point is assigned and in case of lesions in cortical not in critical area or superficial cerebellar area, 2 points are assigned. As far as age is concerned, 0 points are assigned for patients older than 50 years and 1 point for patients younger than 50. In conclusion, a novel grading for surgical decision making in cerebral cavernomas, based on the experience of selected neurosurgeons, basic scientists, and patients, is suggested with the aim of further improving and standardizing the treatment of CCMs. The aim of this paper was also to call for both retrospective and prospective multicenter studies with the aim of testing the efficacy of the grading system in different centers.
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Affiliation(s)
- Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Francesco Doglietto
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luca Zanin
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy -
| | - Edoardo Agosti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Panciani
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giorgio Saraceno
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Riccardo Draghi
- Department of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Alessandro Fiorindi
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Claudio Cornali
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Biroli
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Juri Kivelev
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
| | | | - Saverio F Retta
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,CCM Italian Research Network, National Coordination Center at the Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberto Gasparotti
- Unit of Neuroradiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Aichi, Toyoake, Japan
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Jagathesan T, OBrien M. Aeromedical Implications of Cerebral Cavernomas. Aerosp Med Hum Perform 2021; 92:120-123. [PMID: 33468293 DOI: 10.3357/amhp.5747.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND: Cavernomas, cavernous angiomas, or cerebral cavernous malformations are clusters of endothelium-lined blood vessels usually found in the brain. With the increasing use of radiological imaging, these are being detected incidentally in asymptomatic aircrew. The UK Civil Aviation Authority (CAA) experience of cavernomas is described and the aeromedical concerns, that is, the risk of epilepsy, hemorrhage, and the development of a neurological deficit, are considered.METHODS: A search of the CAA database between 1990 and 2020 was performed for the term cavernoma. The gender, age at diagnosis, class of certification held, clinical presentation, location, and size of the lesion were noted. A PubMed literature review for papers with complications of cavernoma was performed.RESULTS: Six cases of cavernoma have been declared to the CAA: five professional pilots and one private pilot. Five were men and one was a woman. The age range was between 38 and 60 yr, with a mean of 48 yr. Two cases presented with clinical symptoms and four were asymptomatic. Complication rates for seizure and hemorrhage were extracted from the published literature together with the significance of other factors such as cavernoma size, family history, multiplicity, and the development of new lesions.DISCUSSION: A policy for the medical certification of aircrew with cavernomas that have presented with clinical symptoms and those that are detected incidentally is proposed.Jagathesan T, OBrien M. Aeromedical implications of cerebral cavernomas. Aerosp Med Hum Perform. 2021; 92(2):120123.
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Lazor JW, Stein JM, Schmitt JE, Davis KA, Nabavizadeh SA. Epilepsy Lesion Localization is not Predicted by Developmental Venous Anomaly Location or its FDG-PET Metabolic Activity. J Neuroimaging 2020; 30:544-550. [PMID: 32384221 DOI: 10.1111/jon.12722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/05/2020] [Accepted: 04/19/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE This study's purpose is to correlate location and metabolic activity of developmental venous anomalies (DVAs) in epilepsy patients to the seizure focus as determined by ictal/interictal encephaloelectrogram (EEG). METHODS A retrospective search was performed for epilepsy patients with DVAs who underwent brain 18 F-fluorodeoxyglucose positron emission tomography (18 F-FDG-PET) and magnetic resonance imaging (MRI). MRI exams were analyzed to characterize DVA location and associated structural findings. MRI and PET images were co-registered and assessment of 18 F-FDG uptake in the DVA territory was performed. The electronic medical record was reviewed for each subject to determine seizure semiology and site of seizure focus by ictal/interictal EEG. RESULTS Twenty-eight DVAs in 25 patients were included. Twelve DVAs demonstrated regional metabolic abnormality on 18 F-FDG-PET. There was no significant correlation between DVA site and seizure focus on EEG. DVA location was concordant with EEG seizure focus in three subjects, and all three demonstrated hypometabolism on 18 F-FDG-PET. This significance remains indeterminate, as one of these DVAs was associated with cavernoma, which could serve as the true seizure focus, and one of the patients underwent resection of the DVA without decrease in seizure frequency. Furthermore, there was no statistically significant relationship between DVA metabolic activity and DVA-EEG lobar or laterality concordance. CONCLUSIONS In this sample, there is no significant correlation between location of DVA and seizure focus, and hypometabolism within the DVA territory is not predictive of EEG/DVA co-localization. As use of 18 F-FDG-PET for evaluation of epilepsy increases, knowledge of this poor correlation is important to avoid diagnostic confusion and potentially unnecessary surgery in epilepsy patients.
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Affiliation(s)
- Jillian W Lazor
- Department of Neuroradiology, The Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joel M Stein
- Department of Neuroradiology, The Hospital of the University of Pennsylvania, Philadelphia, PA
| | - James Eric Schmitt
- Department of Neuroradiology, The Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Kathryn A Davis
- Department of Neurology, The Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Seyed Ali Nabavizadeh
- Department of Neuroradiology, The Hospital of the University of Pennsylvania, Philadelphia, PA
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Lee CC, Wang WH, Yang HC, Lin CJ, Wu HM, Lin YY, Hu YS, Chen CJ, Chen YW, Chou CC, Liu YT, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Hsu SPC. Gamma Knife radiosurgery for cerebral cavernous malformation. Sci Rep 2019; 9:19743. [PMID: 31874979 PMCID: PMC6930272 DOI: 10.1038/s41598-019-56119-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022] Open
Abstract
This is a retrospective study examining the efficacy and safety of Gamma Knife radiosurgery (GKS) in treating patients with cerebral cavernous malformations (CCMs). Between 1993 and 2018, 261 patients with 331 symptomatic CCMs were treated by GKS. The median age was 39.9 years and females were predominant (54%). The median volume of CCMs was 3.1 mL. The median margin dose was 11.9 Gy treat to a median isodose level of 59%. Median clinical and imaging follow-up times were 69 and 61 months, respectively. After the initial hemorrhage that led to CCM diagnosis, 136 hemorrhages occurred in the period prior to GKS (annual incidence = 23.6%). After GKS, 15 symptomatic hemorrhages occurred within the first 2 years of follow-up (annual incidence = 3.22%), and 37 symptomatic hemorrhages occurred after the first 2 years of follow-up (annual incidence = 3.16%). Symptomatic radiation-induced complication was encountered in 8 patients (3.1%). Mortality related to GKS occurred in 1 patient (0.4%). In conclusion, GKS decreased the risk of hemorrhage in CCM patients presenting with symptomatic hemorrhage. GKS is a viable alternative treatment option for patients with surgically-inaccessible CCMs or significant medical comorbidities.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsin Wang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Yu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Chen Chou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yo-Tsen Liu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sanford P C Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Agosti E, Flemming KD, Lanzino G. Symptomatic Cavernous Malformation Presenting with Seizure without Hemorrhage: Analysis of Factors Influencing Clinical Presentation. World Neurosurg 2019; 129:e387-e392. [DOI: 10.1016/j.wneu.2019.05.157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
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Khallaf M, Abdelrahman M. Supratentorial cavernoma and epilepsy: Experience with 23 cases and literature review. Surg Neurol Int 2019; 10:117. [PMID: 31528453 PMCID: PMC6744744 DOI: 10.25259/sni-178-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/30/2019] [Indexed: 11/04/2022] Open
Abstract
Background The current study aimed to assess the role of microsurgical treatment of patients with supratentorial cavernoma with epilepsy based on analysis of our patients. Methods This retrospective study included 23 patients with supratentorial cavernoma on computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain admitted to the Department of Neurosurgery, Assiut University Hospitals (single tertiary hospital) between January 2014 and January 2018 (minimum 12-month follow-up). Deep-seated hemispheric and multiple cavernomas were excluded. Radiographs and hospital data of the patients were gathered and analyzed. All patients underwent the surgical procedure by one experienced neurosurgeon and the diagnosis was confirmed by pathologic evaluation. Results A total of 23 patients underwent surgical intervention consist of 15 (65%) men and 8 (35%) women. Their age varies from 11 to 59 year with an average of 36.6 years. All patients presented with seizure. The supratentorial cavernomas were located commonly in temporal lobes; 9 patients (39.1%). 19 (83%) of cavernoma located in the left side. 18 (78%) of cavernoma had a size <2 cavernoma. Complete excision was confirmed in postoperative investigations (CT and MRI brain images). All 10 patients with only one seizure preoperatively were seizure free at follow-up. Of nine patients who had experienced between two and five seizures preoperatively, 7 (78%) were seizure free, and of four patients with numerous seizures preoperatively, 3 (75%) were seizure free. Conclusion Our retrospective population study demonstrates an insight into the supratentorial cavernoma and suggests that microsurgical removal of the symptomatic cavernoma is generally accepted as the most effective and safe method.
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Affiliation(s)
| | - Mohamed Abdelrahman
- Department of Neurology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Kashida Y, Usui N, Matsuda K, Terada K, Baba K, Kondo A, Hirozawa D, Tottori T, Mihara T, Hanaya R, Arita K, Inoue Y. Is additional mesial temporal resection necessary for intractable epilepsy with cavernous malformations in the temporal neocortex? Epilepsy Behav 2019; 92:145-153. [PMID: 30660057 DOI: 10.1016/j.yebeh.2018.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/24/2018] [Accepted: 12/24/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE Cavernous malformation (CM) in the temporal neocortex causes intractable epilepsy. Whether to resect additional mesial temporal structures in addition to the lesionectomy is a still controversial issue. To clarify the need for the procedure, we retrospectively analyzed pre- and postoperative clinical data of patients with surgically removed CM. SUBJECTS AND METHODS We included data from 18 patients with CM in the temporal neocortex who presented with intractable epilepsy. Eleven patients of our early series were treated with extended resection, i.e., lesionectomy and the resection of additional mesial temporal structures. Seven patients underwent lesionectomy, i.e., removal of the CM and of hemosiderin-stained surrounding brain tissue. Pathological assessments of the resected hippocampus were performed. Chronic intracranial electroencephalography (EEG) recordings were obtained in 6 patients. We performed perioperative neuropsychological assessments in all patients. RESULTS The seizure outcome was recorded as Engel class I in 17 patients (94.4%); Ia = 12 (66.7%) Ib = 2 (11.1%), Ic = 1 (5.6%), Id = 2 (11.1%), and class IIb in one patient (5.6%). Adding resection of the mesial temporal structures to lesionectomy did not alter the seizure outcome. Pathology of hippocampus revealed limited neuronal loss in CA4. Ictal onsets in the ipsilateral lateral cortex were detected in all 6 patients who underwent intracranial EEG. In 4 patients each, we also detected ictal onsets from the ipsilateral mesial temporal structures and from the contralateral temporal lobe. Postoperatively, in the patients where their CM was located in the language-dominant hemisphere (n = 10), the full-scale intelligence quotient (IQ) and the performance IQ increased (p < 0.05), whereas the verbal memory (WMS-R) deteriorated in two of 5 patients. CONCLUSION Excellent seizure outcomes were obtained even the lesionectomy alone. To confirm appropriate surgical strategy for lateral temporal CM with intractable epilepsy, further studies in large sample size are needed.
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Affiliation(s)
- Yumi Kashida
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Naotaka Usui
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan.
| | - Kazumi Matsuda
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Kiyohito Terada
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Koichi Baba
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Akihiko Kondo
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Daisuke Hirozawa
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Takayasu Tottori
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Tadahiro Mihara
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yushi Inoue
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
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Grigoryan YA, Sitnikov AR, Grigoryan GY, Timoshenkov AV, Mishnyakova LP. [Surgical treatment of epilepsy in patients with mediobasal temporal cavernous malformations]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:45-56. [PMID: 30137038 DOI: 10.17116/neiro201882445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Epilepsy is a frequent clinical manifestation of cavernous malformations (CMs) of the mediobasal temporal region (MBTR). Surgical removal of CMs is an excellent technique for treating associated epilepsy and may range from pure lesionectomy to tailored resection of the temporal lobe. PURPOSE The study purpose was to determine the optimal surgical management for epilepsy in patients with CMs of the MBTR. MATERIAL AND METHODS We retrospectively analyzed the clinical data, neuroimaging findings, surgical techniques, and surgical outcomes in 11 patients with epilepsy and CMs of the MBTR. All patients underwent video-electroencephalography, magnetic resonance imaging, and computed tomography in the pre- and postoperative periods. Nine patients underwent preoperative implantation of foramen ovale electrodes. In all cases, surgery was accompanied by electrocorticography (ECoG). RESULTS CMs were located in the anterior MBTR in 7 cases, anterior and middle thirds of the MBTR in 1 case, middle third in 2 cases, and middle and posterior thirds in 1 case. In 8 patients, preoperative monitoring revealed a seizure onset area in the MBTR. These patients underwent cavernomectomy with ECoG-guided resection of the hemosiderin ring and adjacent tissue using the pterional (4 cases) or supracerebellar transtentorial approach (4). In 3 cases, anterior temporal lobectomy with cavernomectomy was additionally used due to spreading of pathological activity to the lateral temporal neocortex. Seizure control after surgery was excellent in 7 patients (class 1 ILAE) and good in 4 (class 2 ILAE). CONCLUSION Surgery in patients with epilepsy caused by CMs of the MBTR should be performed based on non-invasive and invasive presurgical evaluation. If the seizure onset area is located in the MBTR, lesionectomy with ECoG-guided resection of the adjacent temporal cortical areas can be performed using the pterional or supracerebellar transtentorial approach. Lateral spread of epileptic activity requires cavernomectomy and anterior temporal lobectomy.
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Affiliation(s)
| | - A R Sitnikov
- Treatment and rehabilitation center, Moscow, Russia
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Jones JM, Gouveia JP, Rodrigues NM. Pneumocephalus and seizures following combined spinal-epidural for labor. J Clin Anesth 2018; 44:123-124. [DOI: 10.1016/j.jclinane.2017.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
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Yang PF, Pei JS, Jia YZ, Lin Q, Xiao H, Zhang TT, Zhong ZH. Surgical Management and Long-Term Seizure Outcome After Surgery for Temporal Lobe Epilepsy Associated with Cerebral Cavernous Malformations. World Neurosurg 2017; 110:e659-e670. [PMID: 29175574 DOI: 10.1016/j.wneu.2017.11.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Operative strategies for cerebral cavernous malformation (CCM)-associated temporal lobe epilepsy and timing of surgical intervention continue to be debated. This study aimed to establish an algorithm to evaluate the efficacy of surgical intervention strategies, to maximize positive surgical outcomes and minimize postsurgical neurologic deficits. METHODS 47 patients having undergone operation for CCM-associated temporal lobe epilepsy were retrospectively reviewed. They had received a diagnostic series for seizure localization, including long-term video electroencephalography (vEEG), high-resolution magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT). In patients with mesial temporal lobe CCMs, the involved structures (amygdala, hippocampus, or parahippocampal gyrus) were resected in addition to the lesions. Patients with neocortical epileptogenic CCM underwent extended lesionectomy guided by intraoperative electrocorticography; further performance of amygdalohippocampectomy depended on the extent of hippocampal epileptogenicity. RESULTS The study cohort contained 28 patients with drug-resistant epilepsy (DRE), 12 with chronic epilepsy (CE), and 7 with sporadic seizure (SS). Normal temporal lobe metabolism was seen in 7/7 patients of the SS group. Hypometabolism was found in all patients with chronic disease except for those with posterior inferior and middle temporal gyrus cavernous malformations (CMs). Of the 31 patients with superficial neocortical CCM, 7 had normal PET without hippocampal sclerosis, 14 had ipsilateral temporal lobe hypometabolism without hippocampal sclerosis, and 10 had obvious hippocampal sclerosis and hypometabolism. Seizure freedom in DRE, CE, and SS was 82.1%, 75%, and 100%, respectively. A significant difference was found between lesion laterality and postoperative seizure control; the rate was lower in left-sided cases because of less aggressive resection. CONCLUSIONS Our study demonstrates that the data from the presurgical evaluation, particularly regarding CM location, responsiveness to antiepileptic drugs, and temporal lobe metabolism, are crucial parameters for choosing surgical approaches to CCM-associated temporal lobe epilepsy. By this operative strategy, patients may receive maximized seizure control and minimized postsurgical neurologic sequelae.
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Affiliation(s)
- Peng-Fan Yang
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China.
| | - Jia-Sheng Pei
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Yan-Zeng Jia
- Department of Epileptology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Qiao Lin
- Department of Epileptology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Hui Xiao
- Department of Medical Imaging, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Ting-Ting Zhang
- Department of Pathology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Zhong-Hui Zhong
- Department of Epileptology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
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Dammann P, Wrede K, Jabbarli R, Neuschulte S, Menzler K, Zhu Y, Özkan N, Müller O, Forsting M, Rosenow F, Sure U. Outcome after conservative management or surgical treatment for new-onset epilepsy in cerebral cavernous malformation. J Neurosurg 2017; 126:1303-1311. [DOI: 10.3171/2016.4.jns1661] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The aim of this study was to determine seizure outcome, functional outcome, and the withdrawal of antiepileptic drugs (AEDs) after conservative or surgical treatment of patients with new-onset cavernoma-related epilepsy (CRE).
METHODS
The authors conducted a retrospective comparative observational study of 79 consecutive patients, each with a single sporadic cerebral cavernous malformation (CCM) and new-onset CRE.
RESULTS
Forty-one patients underwent initial surgery (IS), and 38 patients underwent initial conservative (IC) treatment. Of those in the latter group, 19 underwent delayed surgical (DS) treatment. At the last follow-up, 88%, 32%, and 79% of patients in the respective groups had been seizure free for at least 2 years (International League Against Epilepsy [ILAE] Class 1; IS vs IC, p < 0.0001) and 78%, 8%, and 58%, respectively, had been off AEDs (IS vs IC, p < 0.0001). The cumulative probability of staying seizure free (ILAE Class 1) during a 5-year period was 73% (mean seizure-free follow-up 49.8 ± 2.7 months, 95% CI 44.4–55.1 months) for the IS group, 22% (mean 31.8 ± 3.6 months, 95% CI 24.8–38.8 months) for the IC group, and 68% (mean 48.6 ± 4.3 months, 95% CI 40.1–57.1 months) for the DS group (IS vs IC p < 0.001). Long-term operative morbidity was 3%, and long-term morbidity in the conservatively treated group was also 3%.
CONCLUSIONS
Patients with CCM and new-onset CRE who underwent IS treatment showed better results in seizure control and the discontinuation of AEDs than the conservatively treated patients. Operative morbidity was comparable to the morbidity from symptomatic CCM hemorrhage in the conservative group. Half of the patients who started with conservative treatment underwent subsequent surgical treatment; however, a longer duration of epilepsy prior to surgery did not worsen postoperative seizure outcome.
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Affiliation(s)
- Philipp Dammann
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Karsten Wrede
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Ramazan Jabbarli
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Salome Neuschulte
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Katja Menzler
- 2Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main
- 3Epilepsy Center Hessen-Marburg, Department of Neurology, Philipps-University, Marburg
| | - Yuan Zhu
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Neriman Özkan
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Oliver Müller
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Michael Forsting
- 4Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Felix Rosenow
- 2Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main
- 3Epilepsy Center Hessen-Marburg, Department of Neurology, Philipps-University, Marburg
| | - Ulrich Sure
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
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Abstract
Cavernous malformations (CMs) are low-pressure angiographically occult lesions, composed of blood-filled sinusoidal locules known as "caverns." Although these lesions were once believed to be congenital in nature, there is compelling evidence to support de novo formation of CMs as well. They can occur as sporadic lesions or be inherited in an autosomal-dominant phenotype in familial forms of the disease. The pathophysiology of CMs is commonly believed to be due to abnormal vascular pathology. Three genes, CCM1, CCM2, and CCM3, have been extensively studied for their role in vascular pathology, resulting in abnormal angiogenesis and compromising the structural integrity of vessel endothelial cell. The expression of growth factors has been researched to gain insight into the dynamic behavior of CM lesions. Gross and microscopic images are utilized in this chapter to illustrate the pathologic findings of these lesions. Ultrastructural analysis demonstrates the aberrations in CM endothelial cells and structural integrity that may provide better understanding into how and why these lesions have a propensity to hemorrhage.
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Affiliation(s)
- Efrem M Cox
- Department of Neurosurgery, University Hospitals, Case Western Reserve University, Cleveland, OH, USA.
| | - Nicholas C Bambakidis
- Department of Neurosurgery, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Mark L Cohen
- Department of Pathology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
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Vale FL, Vivas AC, Manwaring J, Schoenberg MR, Benbadis SR. Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes. Acta Neurochir (Wien) 2015; 157:1887-95; discussion 1895. [PMID: 26416611 DOI: 10.1007/s00701-015-2592-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/15/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCM) of the temporal lobe often present with seizures. Surgical resection of these lesions can offer durable seizure control. There is, however, no universally accepted methodology for assessing and surgically treating these patients. We propose an algorithm to maximize positive surgical outcomes (seizure control) while minimizing post-surgical neurological deficit. METHODS A retrospective review of 34 patients who underwent epilepsy surgery for radiographically proven temporal lobe CCM was conducted. Patients underwent a relatively standard work-up for seizure localization. In patients with mesial temporal lobe epilepsy (MTLE), a complete resection of the epileptogenic zone was performed including amygdalo-hippocampectomy in addition to a lesionectomy if not contraindicated by pre-operative work-up. Patients with neocortical epilepsy underwent intraoperative electrocorticography (ECoG)-guided lesionectomy. RESULTS Seizure-free rate for mesial and neocortical (anterior, lateral, and basal) location was 90 vs. 83 %, respectively. Complete resection of the lesion, irrespective of location, was statistically significant for seizure control (p = 0.018). There was no difference in seizure control based on disease duration or location (p > 0.05). Patients with mesial temporal CCM who presented with MTLE were presumed to also have mesial temporal sclerosis (MTS), or dual pathology. These patients underwent routine resection of the mesial structures. Interestingly, patients who had MTLE and basal (neocortical) lesions who underwent a mesial resection for suspected MTS were found not to have dual pathology. CONCLUSIONS Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.
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Affiliation(s)
- Fernando L Vale
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Andrew C Vivas
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jotham Manwaring
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mike R Schoenberg
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Selim R Benbadis
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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29
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Shan YZ, Fan XT, Meng L, An Y, Xu JK, Zhao GG. Treatment and outcome of epileptogenic temporal cavernous malformations. Chin Med J (Engl) 2015; 128:909-13. [PMID: 25836611 PMCID: PMC4834007 DOI: 10.4103/0366-6999.154289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The aim of this study is to explore the treatment and outcome of epileptogenic temporal lobe cavernous malformations (CMs). Methods: We analyzed retrospectively the profiles of 52 patients diagnosed as temporal lobe CMs associated with epilepsy. Among the 52 cases, 11 underwent a direct resection of CM along with the adjacent zone of hemosiderin rim without electrocorticogram (ECoG) monitoring while the other 41 cases had operations under the guidance of ECoG. Forty-six patients were treated by lesionectomy + hemosiderin rim while the other six were treated by lesionectomy + hemosiderin rim along with extended epileptogenic zone resection. The locations of lesions, the duration of illness, the manifestation, the excision ranges and the outcomes of postoperative follow-up were analyzed, respectively. Results: All of the 52 patients were treated by microsurgery. There was no neurological deficit through the long-term follow-up. Outcomes of seizure control are as follows: 42 patients (80.8%) belong to Engel Class I, 5 patients (9.6%) belong to Engel Class II, 3 patients (5.8%) belong to Engel Class III and 2 patients (3.8%) belong to Engel Class IV. Conclusion: Patients with epilepsy caused by temporal CMs should be treated as early as possible. Resection of the lesion and the surrounding hemosiderin zone is necessary. Moreover, an extended excision of epileptogenic cortex or cerebral lobes is needed to achieve a better prognosis if the ECoG indicates the existence of an extra epilepsy onset origin outside the lesion itself.
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Affiliation(s)
| | | | | | | | - Jian-Kun Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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30
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Barçin E, Aktekin B. State of the Art Approach to the Classification of Epileptic Seizures and Epilepsies. Noro Psikiyatr Ars 2014; 51:189-194. [PMID: 28360625 DOI: 10.4274/npa.y7062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 02/22/2013] [Indexed: 12/01/2022] Open
Abstract
In the light of the latest knowledge acquired from clinical and laboratory research dealing with genetic, molecular biology and neuroimaging, existing classifications were successively revised by the International League Against Epilepsy (ILAE) in 2001, 2006, and 2010. In the latest classification established in 2010, proposals articulated radical changes in terms of concepts and definitions of the previously published classifications and put forward new classifications for epileptic seizures, epilepsies and electroclinical syndromes. This review refers to the changes of the new classification with their reasons and criticisms.
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Affiliation(s)
- Ebru Barçin
- Akdeniz University Faculty of Medicine, Department of Neurology, Antalya, Turkey
| | - Berrin Aktekin
- Yeditepe University Faculty of Medicine, Department of Neurology, İstanbul, Turkey
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31
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Jehi LE, Palmini A, Aryal U, Coras R, Paglioli E. Cerebral cavernous malformations in the setting of focal epilepsies: pathological findings, clinical characteristics, and surgical treatment principles. Acta Neuropathol 2014; 128:55-65. [PMID: 24831066 DOI: 10.1007/s00401-014-1294-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 11/29/2022]
Abstract
Cavernous cerebral malformations (CCMs) are a well-defined epilepsy-associated pathology. They represent lesions/conglomerates of abnormally configured vessels leading to seizures either as a result of physiological changes affecting the cerebral cortex immediately surrounding the CCM (an epileptogenic mechanism that is relevant for both temporal and extratemporal lesions), or as a result of promoting epileptogenicity in remote but anatomo-functionally connected brain regions (a mechanism that is particularly relevant for temporal lobe lesions). This review details the pathological findings in CCMs and discusses the mechanisms of epileptogenicity in this context. The bulk of the review will focus on therapeutic strategies. Medical therapy using antiepileptic drugs is recommended as a first-line therapy, but surgical removal of the CCM with the surrounding cortex should be pursued if seizures prove to be drug resistant. Early timing of the resection and complete removal of any associated epileptic pathology are critical for best outcomes. In addition to reviewing the available data from prior series, we present original research from two specialized epilepsy centers targeted at answering particularly pressing clinical questions mainly related to the ideal timing and extent of surgery. Further research is needed to define the best surgical strategies in patients with temporal lobe CCMs and structurally normal hippocampi.
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Affiliation(s)
- Lara E Jehi
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, 44195, USA,
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32
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Brelie CVD, von Lehe M, Raabe A, Niehusmann P, Urbach H, Mayer C, Elger CE, Malter MP. Surgical Resection Can Be Successful in a Large Fraction of Patients With Drug-Resistant Epilepsy Associated With Multiple Cerebral Cavernous Malformations. Neurosurgery 2013; 74:147-53; discussion 153. [DOI: 10.1227/neu.0000000000000210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
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 >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.
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Affiliation(s)
- Christian von der Brelie
- Department of Neurosurgery, University of Bonn Medical Centre, Bonn, German
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Marec von Lehe
- Department of Neurosurgery, University of Bonn Medical Centre, Bonn, German
| | - Anna Raabe
- Department of Epileptology, University of Bonn Medical Centre, Bonn, German
| | - Pitt Niehusmann
- Department of Pathology/Neuropathology, University of Bonn Medical Centre, Bonn, German
| | - Horst Urbach
- Department of Radiology, University of Bonn Medical Centre, Bonn, Germany
- Department of Neuroradiology, University of Freiburg Medical Center, Freiburg, Germany
| | - Christian Mayer
- Department of Radiology, University of Bonn Medical Centre, Bonn, Germany
| | | | - Michael P. Malter
- Department of Epileptology, University of Bonn Medical Centre, Bonn, German
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33
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Rosenow F, Alonso-Vanegas MA, Baumgartner C, Blümcke I, Carreño M, Gizewski ER, Hamer HM, Knake S, Kahane P, Lüders HO, Mathern GW, Menzler K, Miller J, Otsuki T, Özkara C, Pitkänen A, Roper SN, Sakamoto AC, Sure U, Walker MC, Steinhoff BJ. Cavernoma-related epilepsy: Review and recommendations for management-Report of the Surgical Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2013; 54:2025-35. [DOI: 10.1111/epi.12402] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Felix Rosenow
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Mario A. Alonso-Vanegas
- ABC Neurological Center & National Institute of Neurology and Neurosurgery; México City Mexico
| | - Christoph Baumgartner
- Second Neurological Department; Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology; General Hospital Hietzing with Neurological Center Rosenhügel; Vienna Austria
| | - Ingmar Blümcke
- Department of Neuropathology; University Hospitals Erlangen; Friedrich-Alexander University Erlangen-Nuremberg; Erlangen Germany
| | - Maria Carreño
- Neurology Service; Epilepsy Unit; Hospital Clinic of Barcelona; Barcelona Spain
| | - Elke R. Gizewski
- Department of Radiology; University Clinic for Neuroradiology; Medical University Innsbruck; Innsbruck Austria
| | - Hajo M. Hamer
- Department of Neurology; Epilepsy Center Erlangen; University Hospitals Erlangen; Friedrich-Alexander University Erlangen-Nuremberg; Erlangen Germany
| | - Susanne Knake
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Philippe Kahane
- Department of Neurology and GIN INSERM U836-UJF-CEA; University Hospital of Grenoble; Grenoble France
| | - Hans O. Lüders
- Department of Neurosurgery; Epilepsy Center; University Hospitals Case Medical Center/Case Western Reserve University; Cleveland Ohio U.S.A
| | - Gary W. Mathern
- Departments of Neurosurgery and Psychiatry & BioBehavioral Medicine; David Geffen School of Medicine; Mattel Children's Hospital; University of California; Los Angeles California U.S.A
| | - Katja Menzler
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Jonathan Miller
- Department of Neurosurgery; University Hospitals Case Medical Center/Case Western Reserve University; Cleveland Ohio U.S.A
| | - Taisuke Otsuki
- Epilepsy Center; National Center of Neurology and Psychiatry; Tokyo Japan
| | - Cigdem Özkara
- Cerrahpasa Medical Faculty; Istanbul University; Istanbul Turkey
| | - Asla Pitkänen
- A. I. Virtanen Institute for Molecular Sciences; University of Eastern Finland (UEF); Kuopio Finland
- Department of Neurology; Kuopio University Hospital; Kuopio Finland
| | - Steven N. Roper
- Department of Neurosurgery; University of Florida; Gainesville Florida U.S.A
| | - Americo C. Sakamoto
- Department of Neurosciences and Behavioral Science; Ribeirão Preto School of Medicine; University of São Paulo; São Paulo Brazil
| | - Ulrich Sure
- Department of Neurosurgery; University Hospital Essen; University of Duisburg-Essen; Essen Germany
| | - Matthew C. Walker
- Department of Clinical and Experimental Epilepsy; UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery; London United Kingdom
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34
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von der Brelie C, Malter MP, Niehusmann P, Elger CE, von Lehe M, Schramm J. Surgical management and long-term seizure outcome after epilepsy surgery for different types of epilepsy associated with cerebral cavernous malformations. Epilepsia 2013; 54:1699-706. [DOI: 10.1111/epi.12327] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Michael P. Malter
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - Pitt Niehusmann
- Department of Neuropathology; University of Bonn Medical Centre; Bonn Germany
| | - Christian E. Elger
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - Marec von Lehe
- Department of Neurosurgery; University of Bonn Medical Centre; Bonn Germany
| | - Johannes Schramm
- Department of Neurosurgery; University of Bonn Medical Centre; Bonn Germany
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35
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Al-Shahi Salman R. The outlook for adults with epileptic seizure(s) associated with cerebral cavernous malformations or arteriovenous malformations. Epilepsia 2012; 53 Suppl 4:34-42. [PMID: 22946719 DOI: 10.1111/j.1528-1167.2012.03611.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cerebral cavernous malformations (CCMs) and arteriovenous malformations (AVMs) are common: their asymptomatic prevalence on brain magnetic resonance imaging (MRI) is 1 in 625 and 1 in 2,000, respectively. The risk of epileptic seizure(s) for people with AVMs and CCMs affects their domestic, social, and professional lives, and may influence their decisions about treatment. This article summarizes the seizure risks for people with AVMs and CCMs, gleaned from published original articles indexed in OVID Medline and Embase before 1 January 2012. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, a population-based study in Scotland, United Kingdom, found that the 5-year risks of first seizure were 8% for AVM and 4% for CCM; presentation with intracranial hemorrhage or focal neurologic deficit raised this risk for AVM (23%) but not for CCM (6%). Features associated with the occurrence of epileptic seizures for CCM are lesion multiplicity and cortical CCM location, whereas for AVM the most consistently reported associations are younger age, temporal location, cortical involvement, and nidus diameter >3 cm. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, the 5-year risk of developing epilepsy following a first seizure is 58% for AVM and 94% for CCM, though there is no difference in the chance of achieving 2-year seizure freedom in this time frame (45% AVM vs. 47% CCM). Observational case series describe encouraging differences in seizure frequency before and after AVM and CCM treatment, but the shortage of studies demonstrating dramatic effects in comparison to concurrent control groups justifies the need for more controlled studies, ideally with randomized treatment allocation when the benefits of AVM or CCM treatment are uncertain.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom.
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36
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Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions. Acta Neurochir (Wien) 2012; 154:1419-30. [PMID: 22739772 DOI: 10.1007/s00701-012-1411-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 05/29/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial. METHODS All eloquently located CMs (n = 45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n = 16; sensorimotor, n = 8; visual pathway, n = 7; cerebellum (deep nuclei and peduncles), n = 7; basal ganglia, n = 4, and language, n = 3. Follow-up data was available for 41 patients (91 %) with a median interval of 14 months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale. RESULTS Immediately after surgery, 47 % (n = 21) had a new deficit. At follow-up, 80 % (n = 36) recovered to at least preoperative status or were better than before surgery, 9 % (n = 4) exhibited a slight, and 7 % (n = 3) had a moderate neurological impairment. Only two cases (4 %) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients. CONCLUSIONS Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.
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Alonso-Vanegas MA, Cisneros-Franco JM, Otsuki T. Surgical management of cavernous malformations presenting with drug-resistant epilepsy. Front Neurol 2012; 2:86. [PMID: 22319505 PMCID: PMC3249612 DOI: 10.3389/fneur.2011.00086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 12/07/2011] [Indexed: 11/30/2022] Open
Abstract
Cerebral cavernous malformations (CMs) are dynamic lesions characterized by continuous size changes and repeated bleeding. When involving cortical tissue, CMs pose a significant risk for the development of drug-resistant epilepsy, which is thought to be result of an altered neuronal network caused by the lesion itself and its blood degradation products. Preoperative evaluation should comprise a complete seizure history, neurological examination, epilepsy-oriented MRI, EEG, video-EEG, completed with SPECT, PET, functional MRI, and/or invasive monitoring as needed. Radiosurgery shows variable rates of seizure freedom and a high incidence of complications, thus microsurgical resection remains the optimal treatment for CMs presenting with drug-resistant epilepsy. Two thirds of patients reach Engel I class at 3-year follow-up, regardless of lobar location. Those with secondarily generalized seizures, a higher seizure frequency, and generalized abnormalities on preoperative or postoperative EEG, show poorer outcomes, while factors such as gender, duration of epilepsy, lesion size, age, bleeding at the time of surgery, do not correlate consistently with seizure outcome. Electrocorticography and a meticulous removal of all cortical hemosiderin - beyond pure lesionectomy - reduce the risk of symptomatic recurrences.
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Dionisio S, Koenig A, Murray J, Somerville E. A gut feeling about insular seizures. BMJ Case Rep 2011; 2011:bcr.12.2010.3647. [PMID: 22692493 DOI: 10.1136/bcr.12.2010.3647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 43-year-old man presented to the Prince of Wales Hospital, Sydney, New South Wales, Australia, after experiencing his first tonic-clonic seizure. For the previous 2 years he had undergone gastroenterological investigation of episodes of gagging associated with hypersalivation and lachrymation, occurring three or four times per week. EEG showed epileptiform discharges in the right anterior temporal region; brain MRI revealed a lesion in the right insular cortex. Video-EEG telemetry demonstrated that the episodes of gagging were focal seizures. Antiepileptic drug therapy resulted in no further episodes occurring over the next 10 months.
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Affiliation(s)
- S Dionisio
- Comprehensive Epilepsy Service, Prince of Wales Hospital, Randwick, Sydney, New South Wales, Australia.
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Hiraishi T, Oishi M, Kitaura H, Ryufuku M, Fu YJ, Fukuda M, Takahashi H, Fujii Y, Kakita A. Epidermoid cyst involving the medial temporal lobe: surgical pathologic features of the epileptogenic lesion. Neuropathology 2011; 32:196-201. [PMID: 21801236 DOI: 10.1111/j.1440-1789.2011.01243.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Epidermoid cysts in the middle fossa are rare and may involve the temporal lobe and lateral ventricle. Affected patients often suffer from seizures, but the pathomechanisms underlying the epileptogenic lesions have remained unclear. Here we report the surgical pathological features of the hippocampus in a 31-year-old woman with mesial temporal lobe epilepsy (mTLE), in whom an epidermoid cyst involving the right basal cistern and inferior horn of the lateral ventricle was evident. The ictal electrocorticogram indicated seizure onset at the parahippocampal gyrus. An anterior temporal lobectomy and amygdalohippocampectomy were performed. Histologically, the hippocampus showed marked atrophy with severe loss of pyramidal neurons in the cornu Ammonis subfields and granule cell loss in the dentate gyrus. At the ventricular surface of the hippocampus, there were small granulomatous lesions with spicularly anchored keratin substance. These features indicated multiple and chronic stab wounds by the cyst contents and consequent local inflammatory responses within the parenchyma. The predisposition to adhesion between the tumor and hippocampus may have caused neurons to develop abnormal irritability to certain chemical mediators present in the cyst. Epileptogenicity involving the atrophic hippocampus and medial temporal lobes nearby may have developed in association with these processes. This case appears to provide information that is useful for surgical planning in patients with mTLE and epidermoid cysts involving the medial temporal lobe.
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Affiliation(s)
- Tetsuya Hiraishi
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan
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40
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Menzler K, Thiel P, Hermsen A, Chen X, Benes L, Miller D, Sure U, Knake S, Rosenow F. The role of underlying structural cause for epilepsy classification: Clinical features and prognosis in mesial temporal lobe epilepsy caused by hippocampal sclerosis versus cavernoma. Epilepsia 2011; 52:707-11. [DOI: 10.1111/j.1528-1167.2011.02984.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cerebral cavernous malformations and intractable epilepsy: the limited usefulness of current literature. Acta Neurochir (Wien) 2011; 153:249-59. [PMID: 21190120 DOI: 10.1007/s00701-010-0915-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) are known to be highly epileptogenic lesions. A number of studies on CCM surgery deal with CCM-associated seizures and/or epilepsy. In order to counsel patients with CCM-associated epilepsy, clear results from such studies would be highly useful. This study reviews the current literature with the aim to assess its usefulness for presurgical decision-making with emphasis on differentiating outcomes in different epilepsy types. METHODS A systematic Medline search identified 27 studies between 1991 and 2009 through the keywords "cavernomas, cavernous, hemangioma, AND epilepsy, AND surgery". They were analysed with regard to clarity of definition of epilepsy subtypes, precision of definition of drug-resistant epilepsy, information on surgical procedure and presurgical workup, seizure outcome and length of follow-up. RESULTS Twenty studies included only surgically treated patients. Three types of epilepsy were defined: drug-resistant epilepsy, epilepsy or single/sporadic seizures. In 12 of 27 studies, at least one of these categories remained unclear. The classic definition of drug-resistant epilepsy was not used in the vast majority of studies, with many groups using their own definition. In 30%, the surgical procedure was not described precisely, although 52% of studies used a differentiated preoperative evaluation. Seizure outcome was described using a widely accepted classification in only 48% of series, and in over half of the studies outcome results contained cases with insufficient length of follow-up. CONCLUSIONS A large proportion of recent studies on surgery for CCM-associated epilepsy are not using criteria and definitions for the classification of epilepsy and outcome that are commonly used by epileptologists or epilepsy surgeons. This results in the limited usefulness of a large part of the literature for the purpose of preoperative counselling a patient with CCM-associated epilepsy.
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