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Shroff K, Deopujari C, Karmarkar V, Mohanty C. Paediatric giant cavernomas: report of three cases with a review of the literature. Childs Nerv Syst 2021; 37:3835-3845. [PMID: 34247276 DOI: 10.1007/s00381-021-05286-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cavernous angiomas of the brain (CCM) are being increasingly diagnosed, especially in the paediatric age group. Though classic presentations with haemorrhage or seizures are well recognised, presentation as a large lesion with mass effect is rare and creates difficulty in diagnosis as well as management. METHODS Our cases of paediatric giant CCMs that presented as a 'mass lesion' are reported here, and the PubMed database for giant CCMs in the paediatric population is reviewed. All articles where the size of the lesion was reported to be > 4 cm were selected for analysis to study the varying modes of presentation, treatment, and outcome; to gain a proper perspective on this distinct entity of 'giant CCMs'. RESULTS Analysis of a total of 53 cases (inclusive of our 3 cases) reported so far showed slight male preponderance (58.49%). The largest reported lesion was 14 cm in largest diameter. Most of the lesions (83.02%) occurred in the supratentorial region. In the infratentorial region, paediatric giant CCMs were more commonly seen in the cerebellum than in the brainstem. Seizures were observed in 47.17% at presentation. Features of mass effect were the mode of presentation in all our cases, and literature analysis has shown raised intracranial pressure in 37.74% (20 patients) and focal neurological deficit in 33.96% (18 patients) at presentation. Macrocephaly was seen in younger children up to the age of 7 years (16.98% or 9 patients). Gross total resection was carried out (with a good outcome) in all our cases and in 36 of the other 49 analysed patients who were operated on. DISCUSSION About one-fourth of CCMs occur in paediatric patients. Giant CCMs are rare but can present in children even in the immediate post-natal period. Features of a mass lesion such as raised intracranial pressure, macrocephaly, and focal neurological deficit are much more common than their smaller counterparts. Their appearance on imaging also often causes diagnostic dilemmas with other intracranial mass lesions. Timely surgery with standard microsurgical principles leads to a favourable outcome in the majority. CONCLUSION Giant CCMs, though rare, often present as a diagnostic challenge. Presentation with mass effect is common, and complete microsurgical excision remains the mainstay of treatment. Though transient neurological deficits may be encountered with this strategy, the long-term outcome remains favourable.
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Affiliation(s)
- Krishna Shroff
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020
| | - Chandrashekhar Deopujari
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020.
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020
| | - Chandan Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India, 400020
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Montoya F, Vidal A, Sepulveda F, Marileo R, Caro J, Castillo M. Cavernous Sinus Hemangioma: Imaging Diagnosis and Surgical Considerations. World Neurosurg 2020; 146:e30-e37. [PMID: 33031964 DOI: 10.1016/j.wneu.2020.09.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cavernous sinus hemangiomas (CSHs) are extraaxial vascular malformations that tend to bleed during surgery. METHODS We reviewed 12 magnetic resonance imaging scans with CSH, 5 of them biopsy proven. RESULTS In our review, CSH commonly presented as a lobulated mass with high, uniform signal intensity on T2-weighted images, a dumbbell shape, and a sellar extension. Two thirds presented a "filling-in" pattern of enhancement on dynamic imaging. These features should lead to a correct preoperative diagnosis, which is essential for surgical planning and avoiding hemorrhagic complications. CONCLUSIONS A combination of low signal on T1, high signal on T2 and fluid-attenuated inversion recovery, no diffusion restriction and homogenous enhancement should place CSH at the top of the list of differential diagnoses. This is especially true when there is a "filling-in" pattern on dynamic or delayed imaging. Doing so may alert surgeons to the possibility of copious intraoperative bleeding and therefore avoid complications of hemorrhage.
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Affiliation(s)
- Francisca Montoya
- Neuroradiology Division, Instituto de Neurocirugía Dr. Asenjo, Santiago, Chile.
| | - Aaron Vidal
- Neuroradiology Division, Instituto de Neurocirugía Dr. Asenjo, Santiago, Chile
| | - Francisco Sepulveda
- Neuroradiology Division, Instituto de Neurocirugía Dr. Asenjo, Santiago, Chile
| | - Roberto Marileo
- Neuroradiology Division, Instituto de Neurocirugía Dr. Asenjo, Santiago, Chile
| | - Joseline Caro
- Neuroradiology Division, Instituto de Neurocirugía Dr. Asenjo, Santiago, Chile
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Apra C, Dumot C, Bourdillon P, Pelissou-Guyotat I. Could propranolol be beneficial in adult cerebral cavernous malformations? Neurosurg Rev 2019; 42:403-8. [PMID: 30610500 DOI: 10.1007/s10143-018-01074-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
Surgery is the only therapeutic option for cerebral cavernous malformations (CCM) and is proposed, whenever possible, after haemorrhagic events, neurological symptoms, or epilepsy, radiosurgery being a controversial alternative in some cases. However, there is no treatment for non-accessible lesions, such as brainstem CCM, multiple CCM, or those located in functional areas. Propranolol, a non-selective beta-blocker used as first-line treatment for infantile haemangiomas, has proved spectacularly effective in a few cases of adult patients with CCM. We herein review the histological, in vitro data and clinical findings that support the idea of propranolol as a potential treatment for CCM. Since one retrospective study has not been conclusive, we support the idea that prospective trials are necessary.
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Kang K, Ju Y, Wang D, Li H, Sun L, Ma K, Zhao X, Lu J. Cerebral Venous Malformations in a Chinese Population: Clinical Manifestations, Radiological Characteristics, and Long-Term Prognosis. World Neurosurg 2018; 120:e472-e479. [PMID: 30149153 DOI: 10.1016/j.wneu.2018.08.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We elucidated the clinical and radiological characteristics and analyzed the risk factors for hemorrhage and poor outcomes of cerebral venous malformations (CVMs) in a northern Chinese population. METHODS We included 60 consecutive patients with CVM patients in Beijing Tiantan Hospital from January 2011 to February 2018. The clinical manifestations, radiological characteristics, management, and outcomes were elucidated and analyzed. The patients were followed up for 5-64 months (median, 26). Poor outcomes included repeat bleeding, secondary infarction, severe disability (modified Rankin scale score ≥3), and death. RESULTS Infratentorial CVMs were more prone to intracranial hemorrhage (75% vs. 28.6%; P < 0.001), dizziness (37.5% vs. 10.7%; P = 0.017), and focal neurological deficits (65.6% vs. 25%; P = 0.002) than were supratentorial CVMs. Supratentorial CVMs were more prone to seizure (32.1% vs. 0%; P = 0.001) than were infratentorial CVMs. Multivariate logistic regression revealed that the major risk factors for intracranial hemorrhage in CVMs were infratentorial lesions (P = 0.003) and complicated cavernous angiomas (P = 0.016). Compared with conservative treatment, resection of hematoma or cavernous angiomas with CVM preservation did not increase the risk of poor outcomes (P = 0.646). However, CVM resection significantly increased that risk (odds ratio, 44.0; P = 0.003). CONCLUSIONS Our results have shown that conservative treatment of CVMs results in a relatively good prognosis. For those complicated by hemorrhage or cavernous angiomas requiring surgical interventions, the integrity of the CVM should be preserved, irrespective of the treatment. In exceptional cases, before CVM resection, the CVM drainage should be comprehensively evaluated.
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Affiliation(s)
- Kaijiang Kang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Huan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liqian Sun
- Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Kaiqiang Ma
- Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
| | - Jingjing Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Oda K, Morimoto D, Kim K, Yui K, Kitamura T, Morita A. Spinal Cavernous Angioma Associated with Klippel-Trenaunay-Weber Syndrome: Case Report and Literature Review. World Neurosurg 2017; 109:333-337. [PMID: 29054771 DOI: 10.1016/j.wneu.2017.10.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Klippel-Trenaunay-Weber syndrome (KTWS) is a rare congenital vascular disorder characterized by the classic triad of cutaneous nevi, venous varicosities, and osseous and soft tissue hypertrophy of the affected limb. Various vascular anomalies of the central nervous system have also been described in patients with KTWS. The English language literature to date contains 6 reports of associations between KTWS and spinal cord cavernous angioma (CA), but management of these patients has not been well described. CASE DESCRIPTION A 23-year-old woman was admitted to our institution with acute onset of leg weakness accompanied by upper back pain. Thoracic magnetic resonance imaging of the spinal cord showed a heterogeneous mass with a slit component at the T1-2 level. The patient underwent left hemilaminectomy followed by removal of the tumor, and her neurologic symptoms improved postoperatively. Pathologic examination showed the spinal lesion was characterized by hemosiderin deposition and thin-walled vascular channels surrounded by fibrous tissue. CONCLUSIONS This is the first report to provide a detailed pathologic description of the features of spinal CA in a patient with KTWS. Assessment of the clinical features and management of CA associated with KTWS are discussed. This syndrome is rare, and further experience in the treatment of these patients is needed. However, considering that the pathologic findings of spinal CA in patients with KTWS include the typical features of CA, the management of CA in patients with KTWS may be identical to management of isolated CA.
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Affiliation(s)
- Kazunori Oda
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan.
| | - Daijiro Morimoto
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Kyongsong Kim
- Department of Neurosurgery, Chiba Hokusou Hospital, Nippon Medical School, Chiba, Japan
| | - Kanako Yui
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Takao Kitamura
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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Rerat K, Parker F, Nasser G, Vidaud D, Riant F, Tournier-Lasserve E, Denier C. Occurrence of multiple Cerebral Cavernous Malformations in a patient with Neurofibromatosis type 1. J Neurol Sci 2015; 350:98-100. [PMID: 25702150 DOI: 10.1016/j.jns.2015.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/08/2015] [Accepted: 02/10/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neurofibromatosis 1 (NF1) belongs to the autosomal dominant neurocutaneous disorders' group, which mainly includes NF1 and NF2, tuberous sclerosis, von Hippel-Lindau disease and Cerebral Cavernous Malformations (CCMs). NF1 has a major impact on the nervous system, eye, skin, bone or cardiovascular system. Cerebrovascular lesions have been reported in NF1 including aneurysm, pseudoaneurysm, arteriovenous malformations, vascular stenosis or occlusion and Moya moya syndrome. OBJECTIVE To report a case of an NF1 patient with multiple CCMs. OBSERVATION A 47-year-old man with café-au-lait skin lesions, countless cutaneous neurofibromas, short stature and scoliosis was admitted for progressive spinal cord compression due to histologically proven neurofibroma. Systematic cerebral MRI screening including gradient echo sequences showed multiple asymptomatic CCMs. Screening of CCM1, CCM2 and CCM3 genes was negative while a deleterious frameshift mutation was identified in NF1 gene. CONCLUSION While single CCM can occur in NF1 patients following radiation exposure, they are only rarely reported in non-irradiated NF1 brain. Even if it could be a fortuitous association, plausible links and explanations exist. If cerebral MRI can be systematic in NF1 to detect asymptomatic gliomas, used protocols in neuroradiology do not usually include gradient echo sequences, the most sensitive test for CCM detection, leading possibly to failure to detect these vascular lesions. More reports having this combination and further investigations of NF1 families will certainly provide a better understanding of links between these 2 phakomatoses, as recently reported with "multiple meningiomas" phenotype associated with multiple CCMs in patients with CCM3 gene mutations or café-au-lait skin lesions in CCM1 mutation carriers.
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Affiliation(s)
- K Rerat
- Department of Neurology, Université Paris Sud, Faculté de Médecine Paris Sud, Hôpital de Bicêtre, Assistance Publique, Hôpitaux de Paris (AP-HP), France; Department of Neurosurgery, Université Paris Sud, Faculté de Médecine Paris Sud, Hôpital de Bicêtre, Assistance Publique, Hôpitaux de Paris (AP-HP), France
| | - F Parker
- Department of Neurosurgery, Université Paris Sud, Faculté de Médecine Paris Sud, Hôpital de Bicêtre, Assistance Publique, Hôpitaux de Paris (AP-HP), France
| | - G Nasser
- Department of NeuroRadiology, Université Paris Sud, Faculté de Médecine Paris Sud, Hôpital de Bicêtre, Assistance Publique, Hôpitaux de Paris (AP-HP), France
| | - D Vidaud
- INSERM UMR745, Paris Descartes University, France
| | - F Riant
- AP-HP, Service de Génétique, Hôpital Lariboisière, France; INSERM UMR 1161, Paris Diderot University, France
| | - E Tournier-Lasserve
- AP-HP, Service de Génétique, Hôpital Lariboisière, France; INSERM UMR 1161, Paris Diderot University, France
| | - C Denier
- Department of Neurology, Université Paris Sud, Faculté de Médecine Paris Sud, Hôpital de Bicêtre, Assistance Publique, Hôpitaux de Paris (AP-HP), France.
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