Cerebral venous angiomas: Surgery as a mode of treatment for selected cases

Summary Eleven patients with venous angiomas, 6 males and 5 females ranging in age from 4 to 58, are presented. Four patients presented with intracerebral haematoma and 3 patients had associated cavernous angioma, respectively. Patients with intracerebral haematoma had signs and symptoms due to the localication of the haematoma. The other patients presented with headache, seizures, vertigo, ataxia and mental disturbances. Pre-operative diagnosis was based on computerized tomography, magnetic resonance imaging and cerebral angiography. In 9 surgical cases it was confirmed by histopathological examination of operative specimens.After establishing the type, size and location of the lesion decision for operative treatment was made in nine cases, in four of them because of the presence of an intracerebral haematoma and in 5 of them due to severe disability. Eight of these 9 patients recovered completely and one improved. No severe cerebral oedema was encountered after converging medullary veins were excised and main draining veins partially coagulated.In this small series we encountered an unexpectedly large percentage of venous angiomas causing intracerebral haemorrhage which are commonly considered more benign than other vascular malformations. After reviewing previously reported cases of venous angiomas causing intracerebral haemorrhage and severe neurological deficit we think that the term benign is worth reconsidering. We propose a thorough examination of each case of venous angioma and the operative treatment when appropriate taking into account patients state and location of angioma.     

Vascular pressures and cortical blood flow in cavernous angioma of the brain

This study was designed to investigate the hemodynamic characteristics of cavernous angiomas of the brain. Five adult patients with a cavernous angioma underwent local cortical blood flow studies and vascular pressure measurements during surgery for the excision of the cavernous angioma. Clinical presentation included headache in four patients, seizures in four patients, and recurring diplopia in one patient. Magnetic resonance imaging demonstrated the cavernous angiomas in all patients and revealed an associated small hematoma in two. Four patients with a cerebral cavernous angioma were operated on in the supine position and the remaining patient, whose lesion involved the brain stem, was operated on in the sitting position. Mean local cortical blood flow (+/- standard error of the mean) in the cerebral cortex adjacent to the lesion was 60.5 +/- 8.3 ml/100 gm/min at a mean PaCO2 of 35.0 +/- 0.6 torr. Mean CO2 reactivity was 1.1 +/- 0.2 ml/100 gm/min/torr. The local cortical blood flow results were similar to established normal control findings. Mean pressure within the lesion in the patients undergoing surgery while supine was 38.2 +/- 0.5 mm Hg; a slight decline in cavernous angioma pressure occurred with a drop in mean systemic arterial blood pressure and PaCO2. Mean pressure in the cavernous angioma in the patient operated on in the sitting position was 7 mm Hg. Jugular compression resulted in a 9-mm Hg rise in cavernous angioma pressure in one supine patient but no change in the patient in the sitting position. Direct microscopic observation revealed slow circulation within the lesions. The hemodynamic features demonstrated in this study indicate that cavernous angiomas are relatively passive vascular anomalies that are unlikely to produce ischemia in adjacent brain. Frank hemorrhage would be expected to be self-limiting because of relatively low driving pressures.     

Venous angiomas: an underestimated cause of intracranial hemorrhage

Cerebral venous angiomas are considered by many investigators as infrequent and incidental. Our experience, however, has been different. Since 1975, we have compiled a group of 21 patients with 23 venous angiomas. Nine patients (43%) presented with intracranial hemorrhage, and two in this group had recurrent hemorrhage. Surgical extirpation of the venous angioma was performed in all nine cases. An additional resection of a frontal venous angioma was performed in a woman with intractable seizures and headache. We experienced limited morbidity and no mortality. Although venous angiomas may be uncommon clinically, they have a significant potential for hemorrhage, and particularly, rehemorrhage if left untreated.     

脊髓海绵状血管瘤的诊断和治疗

目的　探讨脊髓海绵状血管瘤的诊断和治疗方法以指导临床。　方法　回顾分析 2 3例脊髓髓内海绵状血管瘤患者的临床特征、诊断和治疗方法 ,并采用Aminoff&Logue评分标准评价患者术前术后的脊髓功能。　结果　 2例患者拒绝手术而保守治疗 ,2 1例手术治疗 ,术后病理证实为海绵状血管瘤。血管瘤全切除 18例 ,次全切除 3例。术后患者症状好转 15例 ,无变化 4例 ,加重 2例 ,无手术死亡。　结论　MRI对脊髓海绵状血管瘤诊断的特异性高 ,手术治疗效果好 ,有症状者应积极手术。     

Intracerebral venous angioma with arterial blood supply: A mixed angioma

An 18-year-old man was operated upon with a diagnosis of intracerebral hematoma. Although the angiogram of the right carotid artery demonstrated the characteristic umbrella appearance of the venous angioma in the parietal lobe, fine arterial branches supplying the vascular malformation were noted in the preoperative angiogram. At the operation, no nidus was found, and delicate angiomatous networks with red veins were observed around the hematoma cavity. Histologic examination of the angiomatous network proved it to be an arteriovenous malformation. It was a mixed angioma, which combined venous angioma and arteriovenous malformations. Clinical, angiographic, and pathological features of intracerebral venous angiomas with arterial components were reviewed from the literature.     

Intraventricular haemorrhage caused by aneurysms and angiomas

Summary More than 200 intraventricular haematomas (IVH) have been treated in the Homburg Neurosurgical University Clinic since computed tomography was available and facilitated the diagnosis.Among 200 consecutive cases, which are analysed and presented in this publication, there were 71 patients with subarachnoid haemorrhage (SAH)-58 of whom with angiographically and/or pathologically verified aneurysms-, and 21 cases with intraventricular angiomas. IVH without concomitant intracerebral haematoma (ICH) and without evidence of SAH is highly suggestive of intraventricular angioma.In our experience panangiography [if available digital subtraction angiography (DAS)] should be done as soon as possible in all cases of IVH. It is a precondition for early diagnosis and operative elimination of the source of bleeding, because the retrospective analysis of our material shows that rebleeding is by far the highest single risk factor in cases with IVH caused by aneurysms or angiomas.We therefore recommend early microsurgical occlusion of the aneurysms and exstirpation or intravascular embolisation of the angioma.The best survival rate (76%) was achieved in IVH cases caused by angiomas. In aneurysms with IVH the survival rate was 35%, in IVH caused by other diseases 37%. The worst prognosis occurs in SAH with IVH without proven aneurysm or angioma. The survival rate of this group was only 8%.     

Third ventricle cavernous angioma: Report of two cases

Cavernous angioma arising in the third ventricle is an extremely rare disease. We have reviewed five cases previously reported, as well as our own two cases, and discuss the clinical characteristics of and surgical approach to cavernous angioma at this site. The bifrontal craniotomy and interhemispheric translamina terminalis approach minimize the damage to the brain and allow for an approach to the third ventricle in a wide operative field with minimal compression of the brain itself. We have found this approach to be suitable for surgery on angiomas of the anterior half of the third ventricle.     

Association of venous angioma and atypical meningioma--case report

A 67-year-old male presented with an atypical meningioma arising from the right tentorium associated with a venous angioma in the left cerebellar hemisphere. The venous angioma was detected incidentally during examinations for the brain tumor. The brain tumor was removed completely and the venous angioma followed conservatively. Venous angiomas associated with brain tumors should be followed conservatively, as the clinical significance and surgical indications are unclear.     

Natural course of the arteriovenous malformations of the brain

Arteriovenous cerebral malformations represent congenital malformations. Considering the anatomical characteristics of the cerebral angiomas and their localization, in a great number of cases they demand a combined therapeutic approach--surgery, embolization and radiotherapy. Besides the constant progress of technology, 5% of all cerebral angiomas can not be completely excluded from the circulation. Therefore, the need to understand their natural course became a necessity. Our results point to the fact that they are vascular malformations of a considerably more benign clinical course than the aneurysms. Our clinical model points to an annual risk of hemorrhage which is 3.3% with total mortality of 5.3%, especially if the size of the angioma is 2.5-5 cm, localized in the motor zone of the brain, with combined type of vein drainage and arterial supply from the vertebrobasilary confluence. Epilepsy caused by the cerebral angioma is in 26.7% refractory to medicamentous therapy and in 25% (every 4th patient) will have hemorrhage with an annual risk of 0.14%.     

Lymphatic angioma of mesentery of the small intestine: a case report

The authors presented a rare case of lymphatic angioma of mesentery of the small intestine. The patient underwent successful surgery. The study presents clinical symptoms, diagnostic and therapeutic problems in patients with lymphatic angiomas.     

The echo-guided removal of cerebral cavernous angiomas

Summary Twenty cavernous angiomas were surgically removed after being localised by intra-operative echography. 10 patients were males and 10 females, with an average age of 34 years. Four patients had had intracerebral haemorrhage; all the remaining patients presented with headaches or seizures. The size of the lesion ranged from a minimum of 2.5 to a maximum of 4.0 cm. Its localisation was subcortical in 14 cases, paraventricular in 4 and in another 2 originated from the floor of the IV ventricle.Echography showed a blackberry-like cavernous angioma, hyperechogenous with respect to the surrounding parenchyma; the lesion was well-defined in all cases due to the absence of perilesional oedema with a clear demarcation from healthy tissue.After operation, pre-operative cranial nerve deficits (brought on by haemorrhage) only persisted in the two cases where the cavernoma involved the floor of the IV ventricle. In all cases post-operative radiological investigation recorded the complete removal of the cavernous angioma, the diagnosis of which was invariably confirmed by histological analysis.The authors draw the conclusion that intra-operative echography is capable of localising cavernous angiomas, providing the surgeon with real-time guidance during microsurgical removal. It is also useful for establishing as to whether complete removal has been accomplished.     

Anterior transpetrosal approach for pontine cavernous angioma--case report

A 58-year-old male patient presented with headache and unsteady gait. Magnetic resonance imaging revealed hemorrhage from a pontine cavernous angioma. The patient experienced stepwise aggravation of symptoms due to repeated hemorrhages. We decided to surgically remove the pontine cavernous angioma through an anterior transpetrosal approach, since the angioma and hematoma were located near the ventrolateral surface of the pons. The brain stem was incised at a site caudal to the trigeminal nerve and the hematoma and angioma were totally removed. No additional neurological deficits were observed following surgery. Brain stem cavernous angiomas are usually removed via a trans-fourth ventricle or lateral suboccipital approach. However, these approaches may not be appropriate if the angioma is located ventrally to the pons. We propose that the anterior transpetrosal approach is the method of choice for ventrally located pontine cavernous angioma.     

Coexistence of intracranial and spinal cavernous angiomas: case report]

A case of a 43-year-old man with coexistence of intracranial and spinal cavernous angiomas is presented. The patient had a 2-year history of severe back pain incurred by neck flexion, and he became aware of weakness of the right lower extremity and paresthesia of the left lower extremity. Neurological examinations at the time of the first admission demonstrated incomplete Brown-Séquard syndrome. Myelograph, myelo-CT and contrast enhanced CT showed an intramedullary mass at the Th3-Th5 level. The patient received laminectomy with total removal of the lesion. Pathological diagnosis was cavernous angioma. Six years later, the patient complained of subacute weakness and numbness of the left upper extremity. Head CT demonstrated a high density lesion of about 2cm in diameter in the right frontal lobe. MRI showed a mixed signal intensity lesion with a marked low-intensity rim in the same area. Total extirpation of the lesion was performed. Pathological diagnosis of the intracerebral lesion was also cavernous angioma. Intramedullary cavernous angioma is very rare. Furthermore, bifocal cavernous angiomas involving both the spinal cord and the brain are extremely rare, and, only 5 cases have been reported in the literature. To our knowledge, this is the first case diagnosed by surgical specimens of coexisting intramedullary and intracerebral lesions.     

A case of familial cerebral cavernous angioma and review of Japanese cases

We present one pedigree of familial cerebral cavernous angioma (FCCA). Case 1 was a 52-year-old male with right hemiplegia. When he was 37 years old, a left occipital lesion was excised and histologically diagnosed as cavernous angioma. MR image showed many cavernous angiomas in the right temporal lobe, the right paraventriclar white matter, the right frontal lobe, the left basal ganglia, and the left parietal lobe. Stereotactic radiosurgery was undertaken for all the lesions. Although the size of each lesion was unchanged, neither hemorrhage nor neurological deterioration were recognized after radiosurgery. Case 2 was a 24-year-old male, a son of the patient in case 1. He has manifested tonic-clonic type epilepsy since the age of 2. MR image showed cavernous angiomas in the pons, the right frontal, and the left intra-Sylvian regions, and many paraventricular cysts with rims indication of previous hemorrhages. Two de novo lesions were observed on subsequent annual MR screening. Surgical excision for the left intra-Sylvian lesion and stereotactic radiosurgery for all lesions were undertaken. Histological diagnosis was cavernous angioma. In the literature, there were 17 pedigrees and 37 cases of FCCA in Japan. The incidence of both multiple lesions and hemorrhage were less than in found in Spanish or French cases. Stereotactic radiosurgery is considered an useful treatment for FCCA, because lesions are multiple and de novo lesions occur.     

Intramuskuläre Angiome der Hand

Intramuscular angiomas are rare vascular tumors with locally aggressive growth between the fibers of muscle. A malignant aspect poses a danger for the function of the hand.We report the case of a 32-year-old woman with a painless tumor in the thenar. Physical examination showed a 2 x 3 x 5 cm fixed and engorged swelling. Perfusion and sensibility were intact. The flexion and opposition of the thumb were reduced. CAT showed a tumor of the thenar with a solid structure with signal enhancement after administration of contrast medium. Histologic examination after local resection showed an intramuscular angioma.Intramuscular angiomas have a malignant aspect because of the rapid and infiltrative growth followed by functional impairment, pain, and deformity. A high rate of recurrence is described. Thus, radical excision is indicated.     

Intradural extramedullary cavernous angioma: case report.

Cavernous angiomas represent 5 to 12% of spinal vascular malformations and usually are located at the vertebral body level with possible extension into the extradural space. The intradural intramedullary cavernoma occurs in about 3% of cases, whereas extramedullary localization is extremely rare. A new case of an intradural extramedullary cavernous angioma is reported, and the clinical, diagnostic, and therapeutic aspects of this rare malformation are analyzed.     

Radical surgery on cavernous angioma of the brainstem

Four cases of cavernous angioma of the brainstem are reported. Three patients had angiomas of the pons; one had a lesion extending from the third ventricle to the hypothalamus. In the three patients directly operated upon the entire lesion was excised. The lesions were delimited by reactive scar tissue, so that by means of a careful technique severe associated disorders were avoided postoperatively. The importance of computed tomography for postoperative observation and the effectiveness of nuclear magnetic resonance-computed tomography have been demonstrated. It is thought that henceforth surgical treatment of brainstem lesions will be found appropriate in a far greater number of cases.     

Intramedullary cavernous angiomas of the spinal cord: clinical characteristics of 13 lesions

Magnetic resonance imaging has increased the incidence of the diagnosis of intramedullary cavernous angioma. Surgical therapy tends not to be recommended for asymptomatic lesions, but symptomatic lesions that bleed recurrently should be treated. The natural course of intramedullary cavernous angioma remains unknown and arguments have been raised against the surgical treatment of symptomatic lesions. We reviewed the clinical features of 13 intramedullary cavernous angiomas in 12 patients surgically treated between 1988 and 2009. The 7 men and 5 women were aged from 14 to 60 years, the preoperative interval ranged from 0 to 161 months, and the mean number of hemorrhages in the 13 lesions was 2.5. Sixteen operations were performed to treat the 13 lesions. The surgical approach depended on the lesion location. The outcome of patients with mild to moderate preoperative symptoms (McCormick grades I-III) was significantly better than that of patients with severe symptoms (McCormick grade IV) (p < 0.05). Symptomatic intramedullary cavernous angioma tends to bleed repeatedly. The lesion should be surgically removed to avoid further deterioration due to recurrent hemorrhages. The shortest path approach should be selected based on preoperative images and complete removal should be attempted. Residual lesion may be masked by surrounding gliosis, so careful postoperative follow up is necessary.     

Venous angiomas of the posterior fossa should be considered as anomalous venous drainage

Venous angioma of the posterior fossa has been described, and the existing literature has been reviewed. The patient presented had a venous angioma located in the pons, and both cerebellar hemispheres and was drained by an enlarged and anatomically anomalous vein within the fourth ventricle. The patient had a "cough headache" and later had signs of cerebellar involvement. A surgical attempt at collapsing the anomalous vein resulted in death in the immediate postoperative period due to venous infarction of the brain stem and cerebellum. Emphasis has been given to the following: 1. "Cough Headache" can be a presenting feature for venous angiomas of the posterior fossa. 2. Venous angiomas of the posterior fossa are developmental anatomic anomalies with enlargement of certain venous structures as a result of inadequate alternative venous drainage. 3. The enlarged vein, which is the pathognomonic feature of venous angiomas, serves a vital function in drainage of blood from structures in the posterior fossa as the usual drainage pathways are inadequate or absent. 4. Operative intervention aimed at resection or collapse of such large veins, which has been successful in treatment of venous angiomas of the frontal lobe, can be disastrous in the treatment of those lesions occurring in the posterior fossa.     

Anesthésie par voie péridurale et angiomes cutanés : y-a-t-il un intérêt à la réalisation d’une IRM ?

Epidural analgesia during labour is a well-accepted technique. Anaesthetists have to measure the risks of this technique during the first consultation with parturient. Complications, such as temporary or permanent neurological injuries due to this anaesthetic technique, are uncommon. We wonder whether the use of magnetic resonance imaging (MRI) may be relevant for the detection of spinal angiomas in case of cutaneous angiomas. The likelihood of finding a spinal angioma with MRI is low and the modus operandi is infrequently modified. We report here a case of parturient with a cutaneous median angioma in the lumbar region, which was detected by MRI. An epidural analgesia was used for pain management during her labour.