Giant cavernous hemangiomas: report of three cases

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

Diagnosis and surgical treatment of cavernous sinus hemangiomas: an experience of 20 cases

OBJECTIVE: To elucidate the advances of diagnosis and surgical treatment of the cavernous sinus hemangiomas (CSHs). METHODS: The data from 20 patients with the CSHs surgically treated by authors from 1996 through 2000 was analyzed retrospectively, and a review of relevant literature was conducted. RESULTS: These 20 cases accounted for 16.3% of all intracranial cavernous hemangiomas surgically treated in the same period at Huashan Hospital. The patients were aged from 32 approximately 69 years with an average age of 47 years. There were 17 females and 3 males. The common clinical manifestations were visual loss, diplopia, headache, facial numbness and extraocular muscle palsy. Computed tomography (CT) and magnetic resonance imaging (MRI) were major preoperative diagnostic modalities, but demonstrated nonspecific features. The preoperative misdiagnostic rate was 38.9%. Of the 20 patients undergoing craniotomy via modified pterional approach with or without orbitozygomatic osteotomy, tumors were removed through epidural approach (EDA) in 13 cases, intradural approach (IDA) in 7 cases. Hypotension was induced during the operation in 2 cases. Total tumor removal was achieved in 12 cases (92.3%) in the EDA group and nil in the IDA group. Incomplete tumor removal was 1 case (7.7%) in the EDA group and 7 cases (100%) in the IDA group. One patient in the IDA group died of intracranial hemorrhage postoperatively. Compared with preoperative manifestations, cranial neuropathies at discharge were worsened in 76.9% of patients in the EDA group and 83.3% of patients in the IDA group, improved in 15.4% of patients in the EDA group and 16.7% of patients in the IDA group, unchanged in 7.7% of patients in the EDA group. Follow-up study (range, 1 approximately 6 years; mean, 3 years) was available in 17 patients (89%). All patients in the EDA group improved without tumor recurrence. Nonimprovement (2 cases) and continued worsening (3 cases) occurred in the IDA group. In patients with tumor incompletely removed, the tumor enlarged in 2 cases, and unchanged or decreased in size in 3 cases, in which 2 cases underwent postoperative radiosurgery or radiotherapy. According to pathologic and MRI characteristics, the CSHs can be divided into two types, sponge-like type and mulberry-like type. CONCLUSION: Cavernous hemangioma should be included in differential diagnosis for middle aged females with cavernous sinus tumors. Two types of the CSHs, sponge-like type and mulberry-like type, can be identified. The best microsurgical approach for the removal of the CSHs is epidural approach via the skull-base craniotomy. Radiosurgery should be considered for patients with incomplete tumor removal.     

Giant cavernous liver hemangiomas: effect of operative approach on outcome

HYPOTHESIS: The choice of operative technique for resection of giant cavernous hepatic hemangiomas has an effect on outcome. DESIGN: Case series. SETTING: Tertiary hepatobiliary surgery-liver transplantation service.Patients and INTERVENTIONS: Fifty-two adult patients who underwent resection of symptomatic hepatic hemangiomas (38 [73%] in the right lobe; average diameter, 10.9 cm) by means of lobectomy or enucleation, with or without Pringle inflow occlusion. MAIN OUTCOME MEASURES: Blood transfusion, morbidity, mortality, and length of hospitalization. RESULTS: Patient age and sex and the size of hemangiomas were similar for patients who underwent lobectomy and enucleation. Right-lobe lesions were more often treated by enucleation, and inflow occlusion was used more frequently; transfusion requirements and length of hospitalization were similar for both techniques. Complications were more frequent after lobectomy. There were no deaths. In the latter years of the series, enucleation was used in 22 (63%) and inflow occlusion in 24 (69%) of 35 patients. CONCLUSIONS: Outcome is related to the operative approach used for resection of giant cavernous liver hemangiomas. Although lobectomy and enucleation are curative, enucleation offers greater preservation of normal hepatic parenchyma and fewer complications and is the preferred technique for suitable lesions.     

Giant cavernous hemangiomas of the caudal lobe. Clinical and therapeutically considerations

The authors present two cases of giant hepatic cavernous hemangiomas with rare topography--caudate lobe. The article debates at length the natural evolution of disease, the diagnosis and the treatment. It give emphasis to the fact that, at present, we are witnessing the limitation of surgical indications far these benign vascular tumors. On the other hand, when operation is indicated, the authors prefer tumorectomy by enucleating or enucleoresection (which are limited) instead of major hepatic resections.     

Orbital cavernous hemangiomas

Cavernous hemangiomas are the most frequently found primary tumors in the orbital region. They normally appear in adults. Diagnostic features in the majority of cases include protrusio bulbi and orbital enlargement. B-Scan and computed tomography/MRI are the prime diagnostic aids. We recommend surgical removal of these tumors, at least in cases with marked orbital protrusion or significant optic nerve compression. The prognosis is usually good.     

Radiosurgery of cavernous hemangiomas in the cavernous sinus

BACKGROUND: Cavernous hemangiomas in the cavernous sinus are rare and demonstrate unique clinical courses. Although they rarely cause spontaneous bleeding, serious bleeding is not uncommon during operations. Total eradication of such tumors is very difficult because of the location and intraoperative bleeding. Consequently, alternatives to operative resection have been examined. METHODS: Three cases of cavernous hemangiomas in the cavernous sinus, presenting chiefly with ocular signs and facial pain, were treated by radiosurgery using a gamma knife. Two of the patients had been operated on before radiosurgery, while the third patient was diagnosed on the basis of neurological signs as well as radiological findings. RESULTS: MRI scans at the time of radiosurgery showed tumors in the cavernous sinus with low or iso-intensity on T1-weighted images and high signal intensity on T2-weighted images. All of the tumors intensely enhanced with gadolinium-DTPA. The tumors had diameters of 14 to 28 mm and were treated with a marginal dose of 14 to 17 Gy (mean 15.7 Gy). In the mean follow-up period of 27 months after radiosurgery, all of the tumors decreased in size (PR). Neurologically, none of the patients showed any deterioration, and one demonstrated an obvious improvement in ocular movement. CONCLUSIONS: Radiosurgery for cavernous hemangioma in the cavernous sinus is apparently safe and effective with consistent tumor shrinkage. Therefore, radiosurgery is an excellent alternative to operative intervention and may even replace operative procedures if the tumors are small in diameter or when they recur.     

单纯椎管内海绵状血管瘤的诊断与外科治疗

目的:探讨单纯椎管内海绵状血管瘤(cavernous hemangioma,CH)的诊断与外科治疗效果。方法:回顾性分析2002年1月~2010年11月18例行手术治疗并经病理检查证实的单纯椎管内CH患者的临床资料,并依据Aminoff-Logue评分标准对手术前后患者脊髓功能进行评价。结果:18例患者术前均有相应神经系统损害表现。术前均行脊柱MRI检查,其中6例术前MRI检查有典型的CH表现,其MRI诊断与术后病理检查结果相符,17例为单发,1例L2~L3和S1节段各1个肿瘤,10例肿瘤累及2~3个节段。手术均经后正中入路,3例急性发病患者在出血急性期急诊行手术治疗,其余患者均在发现肿瘤早期(1周内)行肿瘤切除术,17例单发病例均行肿瘤全切除,另1例患者仅切除引起症状的L2~L3节段肿瘤,无症状的较小的S1节段肿瘤未行手术切除;手术时间170±20min,术中出血量280±40ml,术中均未出现相关并发症。术后均经病理检查证实为CH。术前Aminoff-Logue评分3~11分,平均6.0±2.8分;术后0~11分,平均4.2±3.8分,术后评分与术前比较有显著性差异(P<0.05)。术后脊髓功能Aminoff-Logue分级12例较术前改善,4例无明显变化,2例恶化,无死亡病例。随访2个月~5年,平均30个月,8例门诊随访患者影像学检查均未见肿瘤复发;其余患者电话随访,症状较术前改善7例,无明显变化3例。结论:MRI检查有典型的CH表现时对椎管内CH有诊断价值;对于有相应神经系统症状的椎管内CH患者,应积极、早期行肿瘤切除术,可获得良好效果。     

Giant hepatic hemangiomas: diagnostic and therapeutic dilemmas

This report describes four cases of surgically treated giant hepatic hemangiomas which illustrate some diagnostic and therapeutic difficulties encountered in the management of this condition. An important diagnostic triad has emerged, which should alert the physician to the possibility of a complicated hepatic hemangioma: the clinical signs of an acute inflammatory liver process contrasted with a normal white blood cell count and liver function tests. Hemangiomas of the left lobe were either missed or poorly demonstrated on selective hepatic angiographic examination, and in two patients the diagnosis was made only at the time of laparotomy. Hepatic resection was successfully performed in all patients; there was minimal morbidity and none of the patients died. In two patients with multiple hemangiomas, only symptomatic or easily resectable lesions were removed. All patients are alive and well; three have been followed up for more than 5 years. We conclude that resection in asymptomatic cases should be carried out only in those cases that require a diagnostic laparotomy and in those where the lesion is easily resectable. The majority of patients with symptomatic and complicated tumors should undergo resection, but even in these patients continued conservative treatment is appropriate when the risk of major resection outweighs the small risk of live-threatening bleeding.     

Multiple cavernous hemangiomas of the orbits

Intraocular tumors were detected in both orbits simultaneously by computed tomography scanning in a 45-year-old woman complaining of proptosis of the right eye, decreased visual acuity, and diplopia. The tumor in the right orbit was resected by the subfrontal extradural approach, and that in the left orbit by the Kr?nlein-Berke method. The right tumor was found on the side of the external ear of the muscle cone and the left tumor was located inferiorly on the side of the external ear of the muscle cone. Both tumors were cavernous hemangiomas with identical macroscopic and histologic features.     

Surgical removal of pontomesencephalic cavernous hemangiomas

Cavernous hemangiomas of the brain stem are usually discovered accidentally during evacuation of a hematoma, and successful surgical treatment of these lesions is seldom achieved. With the increasing use of magnetic resonance imaging, the presence of a cavernous hemangioma can be detected before surgery, allowing an elective surgical approach. We successfully removed pontomesencephalic cavernous hemangiomas from 2 patients and pontomedullary hemangiomas from 2 others. Elective surgery was performed with perioperative bimodal monitoring of somatosensory and auditory evoked potentials. Performing surgery soon after the hemorrhage minimizes the risk of additional postoperative neurological deficit, since surgical excision is facilitated when the hematoma is not completely organized. Pontine hemangiomas are approached via the 4th ventricle. Mesencephalic hemangiomas are removed by a midline supracerebellar approach when they are lateralized by using a subtemporal approach. The lesion can be removed through a small incision in the brain stem at the site of the lesion. The favorable results, which include marked improvement of preoperative neurological deficits and documentation of complete removal of the lesion by magnetic resonance imaging, support a more aggressive approach to the treatment of symptomatic cavernous hemangiomas of the brain stem. Further investigation of the natural history of these lesions is mandatory.     

肝海绵状血管瘤77例的诊断与外科治疗

目的：总结肝海绵状血管瘤的诊断与治疗经验。方法：回顾性分析1986年-2008年经手术证实的肝海绵状血管瘤77例临床资料。结果：肿瘤直径5～9cm42例,〉10cm24例,≤15cm11例。手术前确诊73例肝海绵状血管瘤,术前确诊率94．8％;4例误诊,误诊率5．2％,分别误诊原发性肝癌2例,巨大肝囊肿癌变1例,肝脏局灶结节性增生1例。3例腹腔出血、休克,急诊剖腹探查均死于术中;4例肿瘤巨大,经剖腹探查未能切除。70例均皆手术切除,手术切除率90．9％,肝叶切除术38例（4914％）,剥除术21例（27．3％）,局部切除术11例（14．3％）。70例无手术死亡,无严重并发症。结论：手术是治疗肝海绵状血管瘤最有效的手段;手术剥除术操作简单、创伤小、出血量少,便于推广应用。