Intraventricular cerebral cavernomas: a series of 12 patients and review of the literature

Microsurgical removal of supratentorial and cerebellar cavernous malformations: what has changed? A single institution experience

BACKGROUND

Features associated with a safe surgical resection of cerebral cavernous malformations (CMs) are still not clear and what is needed to achieve this target has not been defined yet.

METHODS

Clinical presentation, radiological features and anatomical locations were assessed for patients operated on from January 2008 to January 2018 for supratentorial and cerebellar cavernomas. Supratentorial CMs were divided into 3 subgroups (non-critical vs. superficial critical vs. deep critical). The clinical outcome was assessed through modified Rankin Scale (mRS) and was divided into favorable (mRS 0-1) and unfavorable (mRS ≥ 2). Post-operative epilepsy was classified according to the Maraire Scale.

RESULTS

A total of 144 were considered eligible for the current study. At 6 months follow-up the clinical outcome was excellent for patients with cerebellar or lobar CMs in non-critical areas (mRS ≤ 1: 91.1 %) and for patients with superficial CMs in critical areas (mRS ≤ 1: 92.3 %). Patients with deep-seated suprantentorial CMs showed a favorable outcome in 76.9 %. As for epilepsy 58.5 % of patients presenting with a history of epilepsy were free from seizures and without therapy (Maraire grade I) at last follow-up (mean 3.9 years) and an additional 41.5 % had complete control of seizures with therapy (Maraire grade II).

CONCLUSIONS

Surgery is safe in the management of CMs in non-critical but also in critical supratentorial locations, with a caveat for deep structures such as the insula, the basal ganglia and the thalamus/hypothalamus.

Endoscopic Endonasal Resection of a Cavernous Malformation of the Third Ventricle: Case Report and Literature Review

BACKGROUND

 Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM.

CASE DESCRIPTION

 A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively.

CONCLUSION

 This report demonstrates safe resection of a third ventricle CM via the endonasal route.

Case report: Surgical treatment and long-term successful outcome of a spinal intramedullary vascular malformation in a dog

A 3.5-year-old male intact Staffordshire terrier crossbreed dog was presented with a one-week history of progressive paraparesis with fecal and urinary incontinence. Neurological examination was consistent with a T3-L3 myelopathy. A magnetic resonance imaging study revealed the presence of a well-circumscribed hemorrhagic space-occupying lesion at the level of T12, suspected to be a vascular malformation, such as cavernoma or arteriovenous fistula, primary hematoma or hamartoma; less likely considerations included hemorrhagic inflammation or hemorrhagic primary or secondary neoplasia. A dorsal laminectomy, durotomy, and midline dorsal myelotomy were performed with a surgical microscope, and the vascular lesion was identified and removed. Histological examination of surgical samples yielded fibrin, hemorrhage, hematoidin pigment, and some neural tissue. Although a lining wall was visualized during surgery consistent with a vascular malformation, there was no histological confirmation of such a structure, hampering definitive classification of the lesion. There was no gross or histopathological evidence that would support a diagnosis of a hamartoma or benign neoplasia. The dog was paraplegic with intact nociception the day following surgery. Ambulation was recovered within 2 weeks. Progressive and complete recovery of neurological function was seen over the next 12 weeks. No recurrence of neurological dysfunction was seen over a 12-month follow-up period. Surgical treatment should be considered in dogs with spinal intramedullary vascular lesions which can have a successful long-term outcome.

Cerebral cavernous malformations: Typical and atypical imaging characteristics

Cavernous malformations (CMs) are benign vascular malformations that maybe seen anywhere in the central nervous system. They are dynamic lesions, growing or shrinking over time and only rarely remaining stable. Size varies from a few millimeters to a few centimeters. CMs can be sporadic or familial, and while most of them are congenital, de novo and acquired lesions may also be seen. Etiology is still unknown. A genetic molecular mechanism has been proposed since a cerebral cavernous malformation gene loss of function was found in both familial and sporadic lesions. Additionally, recent studies suggest that formation of CMs in humans may be associated with a distinctive bacterial gut composition (microbioma). Imaging is fairly typical but may vary according to age, location, and etiology. Follow-up is not well established because CMs patients have a highly unpredictable clinical course. Angiogenic and inflammatory mechanisms have been implicated in disease activity, as well as lesional hyperpermeability and iron deposition. Imaging and serum biomarkers of these mechanisms are under current investigation. Treatment options, including surgery or radiosurgery, are not well defined and are dependent upon multiple factors, including clinical presentation, lesion location, number of hemorrhagic events, and medical comorbidities. Our purpose is to review the imaging features of CMs based on their size, location, and etiology, as well as their differential diagnosis and best imaging approach. New insights in etiology will be briefly considered. Follow-up strategies, including serum and imaging biomarkers, and treatment options will also be discussed.

Surgical resection of intracranial cavernous hemangioma located at uncommon location: Clinical presentation and management

Background

Intracranial cavernous hemangiomas (CHs) usually originate from the cerebral and cerebellar hemispheres, while the clinical features and optimum treatment of CHs that originate from atypical locations remain unclear.

Methods

We conducted a retrospective analysis of CHs that originated from the sellar, suprasellar, or parasellar region, the ventricular system, the cerebral falx, or the meninges in patients who underwent surgery from 2009 to 2019 in our department.

Results

In our study, fourteen patients with pathologically confirmed CHs in uncommon locations (UCHs) were enrolled; 5 were located at the sellar or parasellar region, 3 at the suprasellar region, 3 at the ventricular system, 2 at the cerebral falx, and 1 originated from parietal meninges. The most common symptoms were headache and dizziness (10/14); however, none presented with seizures. All UCHs located in the ventricular systems and 2 of the 3 UCHs located in the suprasellar region manifested as hemorrhagic lesions and shared similar radiological features compared with axial CHs; other locations of UCHs did not have a "popcorn" appearance on T2-weighted image. Nine patients achieved GTR, 2 achieved STR, and 3 achieved PR. Four out of five patients who received incomplete resection underwent adjuvant gamma-knife radiosurgery. During the average follow-up of 71.1 ± 43.3 months, no patient died and one patient encountered recurrence and de novo formation of midbrain CH. Most patients had an excellent KPS score of 90-100 (9 of 14) or a good KPS score of 80 (1 of 14).

Conclusion

We suggest that surgery is the optimum therapeutic method for UCHs located at the ventricular system, dura mater, and cerebral falx. Stereotactic radiosurgery plays an important role in the treatment of UCHs located at the sellar or parasellar region and remnant UCHs. Favorable outcomes and lesion control could be achieved by surgery.

Intraventricular Choroid Plexus Cavernoma Resection Using Tubular Retractor System and Exoscope Visualization: A Technical Case Report

BACKGROUND AND IMPORTANCE

Cavernous malformations (CMs) account for approximately 5% to 10% of all CNS vascular malformations, and intraventricular CMs (IVCMs) are a rare subtype, accounting for 2.5% to 10.8% of all intracranial CMs. IVCMs can expand rapidly, leading to compression of adjacent structures, intraventricular hemorrhage, and obstructive hydrocephalus. Diagnosis is challenging because it can mimic a variety of other lesions.

CLINICAL PRESENTATION

A 71-year-old man presented after a fall because of imbalance. MRI of the head showed a homogenously enhancing 2-cm mass in the posterior aspect of the right lateral ventricle, with blood layering in the right occipital horn and adjacent parietal edema and leptomeningeal enhancement, as well as a pituitary lesion.

DISCUSSION

The patient underwent a right parietal craniotomy for resection of the mass. The ventricle was accessed through a transsulcal approach through the intraparietal sulcus using a tubular retractor system. The mass was arising from the choroid plexus and dissected free in a piecemeal fashion. Postoperative imaging confirmed gross total resection, and the patient had an uneventful recovery.

CONCLUSION

Here, we present the first case of a choroid plexus IVCM removed using a tubular retractor system. We demonstrate that this is a safe and effective approach for this rare lesion given the minimal traction on brain parenchyma and enhanced visualization of a deep-seated cavernoma in the lateral ventricle.

Virtual endoscopy assisted pure ventriculoscopic resection of cavernomas occluding foramen of Monroe: Technical note and literature review

OBJECTIVE

Cavernomas at Foramen of Monroe (FoM) are rare cases among the intracranial cavernomas. Pure ventriculoscopic removal of cavernoma at FoM through a single burr hole is challenging and rarely reported.

METHODS

We herein introduced the virtual endoscopy (VE) assisted ventriculoscopic resection to treat the cavernomas at FoM. Two cases diagnosed with cavernomas at FoM, a 31-year-old male patient (case 1) and a 26-year-old male patient (case 2), were included. Both of them suffered from headache, nausea and vomiting. The pre-operative MRI revealed masses at the FoM. We reconstructed the VE on a free and open-source platform (3D Slicer) for the pre-surgical evaluation. And then ventriculoscopic operation through a single burr hole was made to remove the cavernomas at FoM.

RESULTS

The VE displayed a 14×19×16 mm lesion in case 1 and an 18×20×29 mm lesion in case 2 and both cases revealed some attachment between the lesions and the periventricular tissue. The ventriculoscopic operations indicated by VE were performed to achieve total resection of the cavernomas without neurological deficit.

CONCLUSIONS

Although the neuroendoscopic treatment to cavernoma at FoM through a single burr hole was rarely reported among the previous literatures, it was a quite effective and useful method in our cases. And the application of VE before ventriculoscopic operation could help to provide a three-dimensional and panorama view of the intraventricular lesions.

An international call for a new grading system for cerebral and cerebellar cavernomas

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.

Sudden bilateral vision loss due to third ventricular cavernous angioma with intratumoral hemorrhage - case report

Background

We report a rare case of sudden bilateral vision loss due to third ventricular cavernous angioma with intratumoral hemorrhage.

Case presentation

A 45-year-old woman presented decreased visual acuity in both eyes. Her best corrected visual acuity was 0.1 in the right eye and 0.15 in the left eye. Goldmann perimetry showed bilateral central scotomas and bitemporal visual field defects. MRI demonstrated a lesion with mixed hypo- and hyperintensity at the optic chiasm, which was thought to be an intratumoral hemorrhage. The patient underwent bifrontal craniotomy. The tumor was exposed via an anterior interhemispheric approach, and histological evaluation of the mass led to a diagnosis of cavernous angioma. Six months after the surgery, her best corrected visual acuity was 0.9 in the right eye and 0.9 in the left, with slight bitemporal visual field defects.

Conclusion

Third ventricular cavernous angioma is considered in the differential diagnosis of chiasmal syndrome. Contrast-enhanced MRI and FDG-PET might be useful for differential diagnosis of cavernous angioma from other chiasmal tumors including glioblastoma.

Cavernoma of the Right Lateral Ventricle: A Rare Case Report

Intraventricular cavernoma (IVC) is a rare pathological entity constituting 2.5%–10.8% of cerebral cavernomas. The lateral ventricles are the most frequent site, followed by the third and fourth ventricles. IVCs usually attain a large size compared to parenchymal cavernomas and cause signs and symptoms mainly due to mass effect. IVCs lack specific clinical manifestations and radiological features. Microsurgical excision of IVCs is a safe and effective treatment option. We present a 71-year-old male patient with right lateral ventricle cavernous angioma. The patient underwent microsurgical resection of the vascular lesion with good neurological outcome.

Endoscopic resection of an intraventricular cavernoma: a case report

Cerebral cavernous malformations occur in 0.5% of the population. They consist of thin-walled vessels and can be found as congenital or sporadic lesions. Most of them are asymptomatic, however, due to their anatomical features blood leakage into the surrounding tissue can cause severe neurological symptoms. Although risk of bleeding is low, symptomatic lesions should be treated, with microsurgical resection being the therapy of choice for surgically accessible cavernomas. Intraventricular cavernous malformations are a rare subtype, and due to their anatomical localization, they are eligible for endoscopic surgery. However, there are only a few reports on endoscopic resection of intraventricular cavernomas to be found in the literature. We report the case of a 48-year-old woman who suffers from multiple cerebral cavernous malformations. Since the first diagnosis, several of these cavernomas had been removed in open microsurgical interventions. Most recently, a new lesion arose intraventricularly, adjacent to the ependymal wall of the right lateral ventricle. In follow-up, cranial MR imaging microbleeding and an increasing size were detected. Eventually, the lesion was endoscopically removed. Presurgery the patient suffered from right-sided sensibility loss and gait disturbances as a consequence of prior surgeries. Postsurgery, no new neurological symptoms could be found. We here present MR images and intraoperative pictures as well as a short video of the resection itself. In our opinion, endoscopic resection of intraventricular cavernomas should be considered in selected cases.

Purely Endoscopic Resection of Cavernoma of the Septum Pellucidum

The intraventricular location of a cavernoma is a rare entity and accounts for approximately 2.5% of all cavernomas of the central nervous system. They are commonly found in the lateral ventricle followed by the third and fourth ventricles. The location in the septum pellucidum is rare, and only four cases have been reported in the international literature. An open craniotomy was performed in all these cases. To the best of our knowledge, this is the first case of a cavernoma of the septum pellucidum successfully resected using a purely endoscopic transventricular approach.

Chronic encapsulated intraventricular hematoma in a pediatric patient: case report

Chronic encapsulated intraventricular hematoma (CEIVH) is a rare, intraventricular, nonneoplastic mass lesion that can become symptomatic from mass effect or obstructive hydrocephalus. Only 5 cases have been reported in the literature, and only one of these occurred in a pediatric patient and dates back to the pre-modern neuroimaging and pre-microsurgical era of neurosurgery. Imaging features can mimic those of many more common intraventricular lesions, such as choroid plexus tumors or cavernous malformations. In all reported symptomatic cases, resection was safely performed and led to a cure and symptom resolution. Here, the authors present a case of CEIVH in a pediatric patient, describe the operative techniques of resection, review the available literature, and discuss current understanding of the pathophysiology, making this the most comprehensive report on this disease entity to date. The case is a 14-year-old boy who presented with headaches and emesis. Computed tomography showed a hyperdense mass in the trigone of the right lateral ventricle. Magnetic resonance imaging showed a contrast-enhancing well-circumscribed mass. Right temporal craniotomy utilizing a posterior middle temporal gyrus transcortical approach was performed, and gross-total resection was achieved. Pathology revealed a CEIVH. The boy's postoperative course was uncomplicated, and he was discharged 2 days after surgery.

Microsurgical Treatment of Intraventricular Cavernoma with Prior Planning Neuroendoscopy

Microsurgery remains the gold standard treatment for intraventricular lesions, but it is not without limitations. The cerebral ventricles approach is considered a challenge for neurosurgeons because of their deep location and their intimate association with critical areas of the brain. It has been shown that direct endoscopic view is superior to magnetic resonance imaging (MRI) in identifying intraventricular structures and lesions. Also, during neuroendoscopy, there is no cerebrospinal fluid leak causing brain collapse as seen in microsurgery. Different surgical strategies should be shared and may improve and facilitate intraventricular lesions resection. Herein, a case of a successful microsurgical cavernoma resection with prior ventriculoscopy is described. A 28-year-old woman was admitted with intense holocranial headache. A mild stiff neck was observed. MRI showed a 3-cm lesion with heterogeneous signal intensity and no contrast enhancement suggestive of cavernoma. Initially, a ventriculoscopy was done to inspect the lesion and the surrounding ventricular structures. After that, a conversion technique from endoscopy to microsurgery was performed. The initial corticectomy was extended and the endoscope pathway was followed into the ventricular cavity. Then, the cavernoma was completely removed by microsurgical technique. No complications were observed. Control MRI showed total tumour removal. The patient remained asymptomatic with no recurrence after 1 year. This case illustrates a successful prior endoscopic approach followed by microsurgery as an alternative to a direct microsurgical approach for intraventricular cavernoma. A previous direct endoscopic view of the lesion and its relation with intraventricular structures may ensure a safe and complete resection by microsurgery.

Clinical features and neurosurgical treatment of trigonal cavernous malformations

The goals of this study were to analyze the incidence, clinical manifestations, neuroimaging findings, surgical treatments, and neurological outcomes of trigonal cavernous malformations (TCMs). Among 1395 cases of intracranial and intraspinal cavernous malformations (CMs) surgically treated between 2003 and 2016 at Beijing Tiantan Hospital, a series of 12 patients with TCM was chosen for analysis and their records were reviewed. We also performed an exhaustive literature search using PubMed to identify all previously reported cases in the literatures. TCMs accounted for 0.86% of the entire series of the central nervous system (CNS) CMs. The case series consisted of five male and seven female patients (ratio 1:1.4), with an average age at presentation of 32.9 years (7-53 years). In all the cases, headache was the most common initial symptom (66.7%). Complete resection without surgical mortality was achieved in all the cases. Postoperative complications included fever, lower limb weakness, sensory aphasia, and calculational capacity declination. Follow-up period after diagnosis was 15 to 74 months (mean 48.3 months); no patient was lost to follow-up. All the patients were considered to be in excellent clinical condition. TCMs are rare lesions; they can reach large size, and their symptoms and signs commonly resulted from mass effect. Surgical intervention is the treatment of choice for TCMs; patients can obtain favorable neurological outcomes after complete resection.

Electromagnetic navigation-guided neuroendoscopic removal of radiation-induced intraforniceal cavernoma as a late complication of medulloblastoma treatment

INTRODUCTION

Medulloblastoma is the most frequent malignant brain tumour in children. Radiation-induced cavernous haemangiomas (RICHs) are a known late complication of radiation exposure, especially in young children.

CASE REPORT

We present a patient who underwent subtotal resection of posterior fossa medulloblastoma with subsequent chemotherapy and radiotherapy at the age of 10 years. A new lesion in the region of the left foramen of Monro appeared 16 years later. Based on the imaging results, metastasis or radiation-induced cavernoma was considered. The lesion had the same appearance on imaging as a rarely published intraventricular cavernoma of the foramen of Monro. Unlike the cavernoma of the foramen of Monro, this lesion was subependymal and intraforniceal. Using electromagnetic navigation and neuroendoscopy, the lesion was completely removed. Histopathological examination revealed a cavernous haemangioma.

CONCLUSION

This is a unique case of intraforniceal paraforaminal cavernoma that was successfully removed endoscopically using electromagnetic neuronavigation and without neurological sequelae.

Endoscopic management of a cavernous malformation on the floor of third ventricle and aqueduct of Sylvius: Technical case report and review of the literature

Background:

Intraventricular cavernous malformations are unusual intracranial vascular malformations; their deep anatomical location complicates their surgical management. Microsurgical approaches are the gold standard approaches for the resection of ventricular lesions, however, they imply considerable neurovascular risks.

Case Description:

A 51-year-old patient presented with acute headache, diplopia, vertigo, blurred vision, and a depressed level of consciousness. A ventricular hemorrhage was treated with a ventriculostomy and the patient was discharged without hydrocephalus. After 11 days, he developed ataxia, diplopia, and a depressed level of consciousness. The patient was diagnosed with hydrocephalus secondary to the previous third ventricle hemorrhage. An endoscopic exploration using a 30° rigid ventricular endoscope was performed; after the third ventriculostomy, an intraventricular cavernous malformation located on the floor of the third ventricle and the aqueduct of Sylvius was resected.

Conclusions:

Three days after the surgery, magnetic resonance imaging demonstrated a gross total resection and adequate third ventriculostomy flow. One year after the surgery, the patient was asymptomatic. Neuroendoscopy has evolved towards minimally invasiveness, and in selected cases is an equally effective surgical approach to ventricular lesions. It provides minimal cerebral cortex disruption and vascular manipulation.

The open access video collection project "Hernesniemi's 1001 and more microsurgical videos of Neurosurgery": A legacy for educational purposes

BACKGROUND

Neurosurgical educational programs and courses are helpful to improve the quality of training. Moreover, nowadays, online activities may represent a very useful tool to globally enhance neurosurgical education. The "Hernesniemi's 1001 and more microneurosurgical videos" project aims to show the microsurgical style developed by the senior author and his TEAMs in more than 40 years of experience.

METHODS

More than 1100 high-definition videos of microneurosurgical operations performed by the senior author were carefully edited. These videos illustrate the philosophy of "simple, clean, fast and preserving the normal anatomy" while offering a step by step guide of different neurosurgical procedures.

RESULTS

All the aforementioned material is well organized in an electronic videobook, freely available in Surgical Neurology International. The book also includes comments of great current neurosurgeons and writings of the authors and editors.

CONCLUSION

We are sure that our project will be able to instill in and spread across the neurosurgical community the microneurosurgical style of the senior author, thus representing an efficient educational tool for surgeons all around the world.

A case of a cerebral cavernous malformation of the third ventricle that caused the syndrome of inappropriate secretion of antidiuretic hormone

Background:

Cerebral cavernous malformations (CCMs, also known as cavernous hemanigiomas) of the third ventricle are uncommon. Here, we present a rare case of a CCM that caused the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

Case Description:

A 68-year-old man presented with acute-onset cognitive and memory disturbance. Endocrinological examinations revealed hyponatremia due to SIADH. Computed tomography indicated a high-density mass in the third ventricle that caused left unilateral hydrocephalus due to obstruction of the foramen Monroe. On magnetic resonance imaging, the mass showed high intensity in both T1 and T2-weighted images and low intensity in susceptibility-weighted images, suggesting subacute intralesional hemorrhage. We completely excised the mass via a basal interhemispheric translamina terminalis approach. Intraoperatively, the mass adhered tightly to the left hypothalamus, which was supposed to the origin and was well circumscribed from the surroundings. The histopathological diagnosis was CCM, and his SIADH improved after the operation.

Conclusion:

We presented a rare case of a CCM in the third ventricle that caused SIADH, which improved after complete excision of the mass via a basal interhemispheric translamina terminalis approach.

Radiology and imaging for cavernous malformations

Cavernous malformations are low-flow vascular malformations that are histologically characterized by the lack of mural elements of mature vascular structures and intervening parenchymal neural tissue. They are often clinically quiescent, and may grow, bleed, and regress, but can also manifest clinically as neurologic deficits or seizures in the setting of an acute hemorrhage. The low-flow nature of cavernous malformations renders them inherently occult on cerebral angiography. Magnetic resonance imaging has become the mainstay imaging modality in evaluating cavernous malformations, producing characteristic imaging features that usually provide a straightforward diagnosis. Features on magnetic resonance imaging include a reticulated pattern of mixed hyper- and hypointensity on T1- and T2-weighted imaging, with a characteristic hypointense rim best appreciated on T2-weighted imaging or gradient-echo sequences. Contrast enhancement is useful for revealing coexisting developmental venous anomalies that are frequently associated with sporadic cavernous malformations, and may further support the diagnosis. Susceptibility-weighted imaging is highly sensitive for cavernous malformations and accompanying developmental venous anomalies, and is superior to gradient-echo sequences in screening for multifocal, familial cavernous malformations.

Isolated intraventricular haemorrhage in adults

While intraventricular haemorrhage is frequently found in association with intraparenchymal or subarachnoid haemorrhage, isolated intraventricular haemorrhage (iIVH) is rare in adults and seldom described. Awareness of possible causes is important in order to guide patient management. After elimination of a traumatic cause, numerous aetiologies remain possible. The most frequently found underlying lesions are arteriovenous malformations and aneurysms, but other vascular causes should also be sought, including cavernous malformations and moyamoya disease. Arterial hypertension, anticoagulant use, coagulopathies and certain toxic substances are also associated with iIVH. Finally, iIVH may be caused by intraventricular tumours. In a high number of cases, the cause remains unknown. Vascular and non-vascular causes should be searched through an imaging work-up (with CT angiography, MRI and catheter angiography when necessary) and correlation with clinical information to yield a diagnosis. The aim of this pictorial essay was to review the aetiologies of iIVH in adults.

Cavernous Angioma of the Cerebral Aqueduct

BACKGROUND

Among the rare intraventricular cavernomas, purely intra-aqueductal cavernomas are exceptionally rare.

CASE DESCRIPTION

A 62-year-old patient presented with progressive headache, memory loss, gait instability, and urinary incontinence. Magnetic resonance imaging showed the presence of a mass lesion located in the lumen of the cerebral aqueduct, associated with triventricular hydrocephalus.

CONCLUSIONS

We discuss the rationale that led us to treat hydrocephalus with neuroendoscopy, which offered the possibility to directly inspect the intra-aqueductal lesion, make the diagnosis of cavernoma, and treat symptoms resulting from hydrocephalus without increasing the risk of bleeding.

Endoscope-assisted resection of cavernous angioma at the foramen of Monro: a case report

INTRODUCTION

Intraventricular cavernous angiomas are rare pathological entities, and those located at the foramen of Monro are even rarer. We herein present a case of cavernous angioma at the foramen of Monro that was successfully treated by neuroendoscope-assisted surgical removal, and review the relevant literature.

CASE PRESENTATION

A 65-year-old woman had experienced headache and vomiting for 10 days before admission to another hospital. Magnetic resonance imaging (MRI) showed a mass at the foramen of Monro, and obstructive hydrocephalus of both lateral ventricles. The patient was then referred to our hospital. Neurological examination on admission to our hospital showed memory disturbance (Mini-Mental State Examination 20/30) and wide-based gait. A cavernous angioma at the foramen of Monro was diagnosed based on the typical popcorn-like appearance of the lesion on MRI. The lesion was completely removed by neuroendoscope-assisted transcortical surgery with the Viewsite Brain Access System (Vycor Medical Inc., Boca Raton, FL), leading to a reduction in the size of the ventricles. The resected mass was histologically confirmed to be cavernous angioma. The patient's symptoms resolved immediately and there were no postoperative complications.

CONCLUSION

Minimally invasive neuroendoscope-assisted surgery was used to successfully treat a cavernous angioma at the foramen of Monro.

Rare and challenging extra-axial brain lesions: CT and MRI findings with clinico-radiological differential diagnosis and pathological correlation

There are many kinds of extra-axial brain tumors and tumor-like lesions, and definitive diagnosis is complicated in some cases. In this pictorial essay, we present rare and challenging extra-axial brain lesions including neuroenteric cyst, primary leptomeningeal melanomatosis, isolated dural neurosarcoidosis, intradiploic epidermoid cyst, ruptured dermoid cyst, intraventricular cavernoma, and cavernous hemangioma of the skull with imaging findings and clinico-radiological differential diagnosis, including the pathologic correlation. Familiarity with these entities may improve diagnostic accuracy and patient management.

Intraventricular foramen of Monro cavernous malformation

We present a 64-year-old woman who was evaluated after being found unresponsive. Imaging revealed a foramen of Monro cavernoma resulting in hydrocephalus. Supratentorial cavernomas are most frequently found in the cerebral cortex, and although ventricular cavernomas do occur, they are rarely located in the foramen of Monro. Foramen of Monro cavernomas are extremely dangerous, requiring aggressive management when identified.

[Cavernoma of the fourth ventricle: report of a case and review of the literature]

Le siège intraventriculaire est une localisation rare des cavernomes de l'encéphale. Le quatrième ventricule est le moins concerné de toutes les localisations. Nous rapportons le cas d'une patiente âgée de 52 ans qui présente depuis 12 mois un syndrome d'hypertension intracrânienne et trouble de l’équilibre. Elle s'est présentée aux urgences avec un GCS à 14, nuque subraide, un syndrome cérébelleux statokinétique avec une acuité visuelle basse et un oedeme papillaire bilatéral. Une TDM cérébrale réalisée aux urgences a objectivé un hématome du 4ème ventricule avec hydrocéphalie active triventriculaire. Une dérivation ventriculaire interne a été réalisée en urgence avec une bonne évolution clinique post opératoire. Le bilan a été complété par une IRM cérébrale objectivant un processus du quatrième ventricule évoquant un cavernome. Un abord direct a été réalisé permettant une exérèse totale du cavernome siégeant au sein du quatrième ventricule. L'anatomo-pathologie a confirmée le diagnostic. A notre connaissance, il s'agit du 13^ème cas rapporté dans la littérature. Les cavernomes intraventriculaires représentent 2,5-10% de tous les cavernomes dont 9% est au niveau 4ème ventricule. Les patients sont souvent admis aux urgences suite au saignement de cette malformation angiomateuse. Le diagnostic est rendu accessible par les différentes séquences de l'IRM. Le traitement est souvent chirurgical vu le risque de resaignement. Le pronostic dépend de l’état initial du patient et de l'infiltration du plancher du quatrième ventricule.

Cavernous malformations of the central nervous system (CNS) in children: clinico-radiological features and management outcomes of 36 cases

BACKGROUND

Cavernous malformations (CMs) of the central nervous system (CNS) are angiographically occult vascular lesions that affect approximately 0.5 % of the general population, and one quarter of all CMs occurs in children.

METHODS

We retrospectively analyzed demographic, clinical, radiological, management, and follow-up data of 36 pediatric patients with CMs from a single institution.

RESULTS

The mean age of the children at first presentation and at operation was 8.7 and 9.6 years, respectively. However, a bimodal age distribution was found with peak under 4 years and above 12 years. Seizure was the most common single presenting symptom (38.9 %), and 61.1 % of patients had at least one seizure before the admission. Focal neurological deficits (410.7 %), intracranial hypertension (27.8 %), and headache (2.8 %) were the other manifestations. Acute/subacute hemorrhage was evident at presentation in 63.9 %. The patients under 6 years of age were found to have significantly more giant cavernomas (69 vs 20 %; p = 0.011), and more overt hemorrhages (81 vs 47 %; p = 0.065) at diagnosis than those patients above 12 years. Surgery was performed in 31 patients (32 CMs), with 26 total and 6 incomplete resections. Mean follow-up duration was 6.9 ± 4.1 years. Of all patients, 63.8 % had excellent and 30.5 % had good clinical outcomes, and also 90.9 % of the epileptic patients were seizure-free (Engel Class I) at the last follow-up.

CONCLUSIONS

Younger children tend to harbor larger CMs and present with hemorrhage more frequently than older ones. Microsurgical resection should be the treatment of choice in symptomatic and accessible CMs.

Third ventricular cavernous malformation: an unusual lesion

Cavernomas constitute 5-10% of all the vascular malformations of the CNS. They commonly present during the 2nd and 5th decades of life. Intraventricular cavernomas constitute rare pathological entity, constituting 2.5-10.8% of cerebral cavernomas. (1) The natural history of intraventricular cavernomas remains undefined to some extent. Those in third ventricle are different in biological nature and need more aggressive therapy. These cavernomas appear to have the ability to grow very rapidly, resulting in significant morbidity. It is not known whether waiting after acute hemorrhage from an intraventricular cavernoma improves our ability to remove the lesion safely or if waiting unnecessarily increases the risk of hydrocephalus, additional bleeding, or further lesion growth.

Intraventricular cavernous hemangiomas located at the foramen of monro

Intraventricular cavernous hemangiomas are uncommon. Among them, those occurred at the foramen of Monro in the third ventricle may be of particular interest because of its rarity, development of hydrocephalus, being differentiated from other brain lesions. We present a rare case of intraventricular cavernous hemangioma at foramen of Monro which was resected through microsurgery and also review the relevant literatures.

Cerebral cavernous malformations: spectrum of neuroradiological findings

Cavernous malformations (cavernomas) are hamartomatous lesions formed by sinusoidal vascular spaces, with no cerebral parenchyma between them. Seizures are the most usual clinical presentation. They are dynamic lesions, producing changes throughout their evolution. The majority are located in the supratentorial region, but up to 20% of cases they are found in the posterior fossa. In computed tomography (CT) and in magnetic resonance (MR) their typical presentation is as a well defined round or oval lesion, with or without a minimal mass effect or oedema, with little or no contrast enhancement. Their appearance in MRI will depend on the stage of the haemorrhage, a T2 echo gradient being the most sensitive sequence. Angiography do not usually detect cavernomas. However, it may demonstrate a venous developmental anomaly. Cavernomas may present with atypical characteristics, as regards their size, appearance, location and number.

[Rare tumors of the lateral ventricle. Review of the literature]

Metastases of lateral ventricle (LV) are attached to choroidal plexus. Primary source is cancer of kidney. Two thirds of patients are male. Oligodendrogliomas occur in young females. Signs of increased intracranial pressure are a constant feature. These tumors are found in anterior portion of the LV with severe enhancement and clumped calcifications. Treatment is surgical. Cavernomas have a preponderance of rapid growth with a bleeding revelation. Seizures are rare. Rebleeding is frequent and justifies a surgical treatment. Schwannomas are a rare entity in which the majority of patients are very young. MRI shows calcifications, cystic components and a strong enhancement. They are limited to sporadic cases, never associated with neurofibromatosis. Arachnoid cysts are located in the atrium and/or in the occipital horn. Patients are young (mean age < 40 years). MRI demonstrates an intracystic lesion with signal intensity similar to the CSF. Best treatment is an endoscopic fenestration. Epidermoid cysts occur in third decade. These pearly tumors appear isointense or a little hyperintense on T1-weighted imaging, very characteristic. They are enhanced after gadolinium injection and appear strongly hyperintense on T2-weighted imaging. An incomplete removal with a thorough long-term follow-up is necessary. Cavernomas of LV are hyperintense on T1- and T2-weighted imaging. They have a bleeding risk of 25 to 45%. Therefore, they must be operated.

A Proposed Grading System of Brain and Spinal Cavernomas

BACKGROUND:

Most cavernomas in the central nervous system are characterized by a benign natural course. Progressive symptoms warrant surgical removal. In the literature, the factors affecting long-term postoperative outcome are not statistically well confirmed.

OBJECTIVE:

To perform a multifactorial analysis of risk factors on a large patient series and to use the results to propose a simple grading scale to predict outcome.

METHODS:

We studied 303 consecutive patients with cavernomas treated surgically at our department from 1980 to 2009. Follow-up assessment was performed on average 5.7 years postoperatively (range, 0.2-36 years). The main outcome measure was the patients' condition at the last follow-up on Glasgow Outcome Scale. For statistical analysis, the outcome measure was dichotomized to favorable (Glasgow Outcome Scale 5) and unfavorable (Glasgow Outcome Scale 1–4). Binary logistic regression analysis was used to estimate the effect of age, sex, seizures, preexisting neurological deficits, hemorrhage, and size and location of cavernoma on long-term outcome.

RESULTS:

Infratentorial, basal ganglia, or spinal location and preexisting neurological deficit were the only independent risk factors for unfavorable outcome, with relative risks of 2.7 (P = .008) and 3.2 (P = .002), respectively. We formulated a grading system based on a score of 1 to 3. When applied to our series, the proposed grading system strongly correlated with outcome (P &lt; .001, Pearson χ2 test). The risk for long-term unfavorable outcome was 13%, 22%, and 55% for grades 1 through 3, respectively.

CONCLUSION:

The proposed grading system showed a convincing correlation with postoperative outcome in surgically treated cavernoma patients.

A "pseudo-cavernoma" - an encapsulated hematoma of the choroid plexus

We present the first report of an intraventricular encapsulated hematoma, mimicking cavernous malformation on imaging and gross lesion appearance. A 47-year-old female on anticoagulation therapy for atrial fibrillation presented with left upper extremity apraxia, neglect, and mild gait imbalance. Her brain CT scan and MRI revealed multilobulated lesions involving the choroid plexus in the atria of both lateral ventricles. The intraoperative appearance was that of encapsulated mass, with blood clots at different stages of liquefaction and organization, all consistent with the gross appearance of a cavernous malformation. However, histopathologic examination demonstrated hematoma with components at different ages, and normal vessel infiltration without any hint of cavernous malformation histology, or underlying neoplasia. Encapsulated hematoma should be considered in the differential diagnosis of hemorrhagic intraventricular masses.

Microsurgical treatment of temporal lobe cavernomas

BACKGROUND

Cavernomas of the temporal lobe occur in 10-20% of patients with cerebral cavernomas. They frequently cause epileptic seizures, some of which tend to become refractory to medical therapy. Surgical removal of safely achievable symptomatic lesions has been frequently consistent with good long-term outcome. In the present study, a postoperative outcome is assessed.

METHODS

Of our 360 consecutive patients with cerebral cavernomas, 53 (15%) had a single cavernoma in the temporal lobe. Forty-nine patients were treated surgically and were included in the study. All data were analyzed retrospectively. The cavernomas were allocated into three groups based on the temporal lobe site: medial, anterolateral, and posterolateral. To collect follow-up data, all available patients were interviewed by phone. Seizure outcome was assessed using the Engel classification and general outcome using the Glasgow Outcome Scale (GOS).

RESULTS

Patients' median age at presentation was 37 (range, 7-64) years, with a female/male ratio of 2.5:1. Epileptic seizures occurred in 40 patients (82%). Median duration of seizures preoperatively was 3 (range, 0.1-23) years. In addition, four patients (10%) had memory disorder. Three patients without history of seizures (6%) complained of headache and two (4%) had memory problems. Three patients (6%) had an incidental cavernoma. Hemorrhage occurred in nine patients (18%) preoperatively. Median postoperative follow-up time was 6 (range, 0.2-26) years. Favorable seizure outcome (Engel class I and II) was registered in 35 patients (90%). Ten patients (25%) who had only a single seizure before surgery were seizure free during postoperative follow-up. Good general outcome (GOS, 4.5) was detected in 46 patients (96%). Two patients (4%) developed a new mild memory deficit after surgery, and in two patients existing memory deficits worsened.

CONCLUSIONS

Microsurgical removal of temporal lobe cavernomas is a safe and effective method to improve seizure outcome in patients with medically intractable epilepsy and to prevent deterioration caused by hemorrhage.

Accuracy of susceptibility-weighted imaging for the detection of arteriovenous shunting in vascular malformations of the brain

BACKGROUND AND PURPOSE

to determine the accuracy of susceptibility-weighted MRI (SWI) for the detection of arteriovenous shunting (AVS) in vascular malformations of the brain (BVM).

METHODS

we retrospectively identified 60 patients who had been evaluated for known or suspected BVM by both SWI and digital subtraction angiography, without intervening treatment, during a 3-year period. SWI images were retrospectively assessed by 2 independent reviewers for the presence of AVS as determined by the presence of signal hyperintensity within a venous structure in the vicinity of the BVM. Discrepancies were resolved by consensus among a panel of 3 neuroradiologists. Accuracy parameters of SWI for the detection of AVS were calculated using digital subtraction angiography as the reference standard.

RESULTS

a total of 80 BVM were identified in the 60 patients included in our study. Of the 29 BVM with AVS on digital subtraction angiography, 14 were untreated arteriovenous malformations, 10 were previously treated arteriovenous malformations, and 5 were untreated dural arteriovenous fistulas. Overall, SWI was 93% sensitive and 98% specific for the detection of AVS in BVM, with excellent interobserver agreement (κ=0.94). In the 14 previously treated arteriovenous malformations, SWI was 100% sensitive and specific for the detection of AVS. In the 28 BVM associated with intracerebral hemorrhage, SWI was 100% sensitive and 96% specific for the detection of AVS.

CONCLUSIONS

SWI is accurate for the detection of arteriovenous shunting in vascular malformations of the brain and, for some patients, SWI may offer a noninvasive alternative to angiography in screening for or follow-up of treated BVM.