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.     

Radiographic features of tumefactive giant cavernous angiomas

Summary Background. Giant cavernous angiomas (GCAs) are very rare, and imaging features of GCAs can be very different from those of typical cavernous angiomas (CAs), making them a diagnostic challenge. The purpose of the study was to evaluate the radiographic features of GCAs, with an emphasis on the differentiating features from neoplastic lesions. Methods. The neuroradiological findings of 18 patients who harbored a histologically verified GCA (CA of 4 cm or larger) were reviewed retrospectively. The magnetic resonance imaging (MRI) appearance, enhancement pattern, presence of edema or mass effect, size, and location of each lesion were recorded. When available, pertinent clinical information, including age, sex, and mode of presentation, was obtained. Findings. Seizures, neurologic deficits, hemorrhage, and hydrocephalus were the most common presenting symptoms. The lesions were hyperdense and nonenhancing on computed tomography with frequent calcifications. On MRI, the lesions most commonly had a multicystic appearance, representing blood of various ages, and multiple complete hemosiderin rings. GCAs can present in any location with associating edema and mass effect, giving them a tumefactive appearance. No developmental venous anomaly was observed with any lesion. Conclusions. Most GCAs in our series presented as multicystic lesions with complete hemosiderin rings on MRI, giving a “bubbles of blood” appearance. Although this characteristic feature is helpful in the diagnosis of many cases of GCAs, the correct diagnosis in the remaining cases may not be apparent until histopathological evaluation of the specimen is made. Correspondence: William T. Couldwell, M.D., Ph.D., Department of Neurosurgery, University of Utah School of Medicine, 175 N. Medical Drive East, Salt Lake City, UT 84132, Utah     

Management of patients with cavernous angiomas presenting epileptic seizures

BACKGROUND: The aim of this study was to establish a treatment strategy for patients with cavernous angiomas and have seizures. METHODS: We analyzed retrospectively 31 patients with cavernous angiomas presenting with seizures. Of the 31 patients, 15 (11 men, 4 women) had been treated medically (the medical group) and 16 (11 men, 5 women) had been treated surgically (the surgical group). The percentage of patients who became seizure-free and the number of anticonvulsants used were compared between these 2 groups. The mean follow-up period was 5.3 years (range, 7 months-10 years). There was no statistically significant difference between the 2 groups with regard to the number of patients, sex, age, and follow-up period. RESULTS: The percentage of patients who became seizure-free was higher in the surgical group than in the medical group (80% vs 19%, P < .01). The number of anticonvulsants required was reduced in the surgical group after surgery (from 1.5 +/- 0.7 to 1.1 +/- 0.8, P < .01) and was not reduced after in the medical group. CONCLUSIONS: Surgical intervention may have greater benefits than medical intervention for patients with cavernous angiomas presenting with epileptic seizures.     

Frame-based and frameless stereotaxy in the localization of cavernous angiomas

Cavernous angiomas are mostly small intracranial vascular lesions which can be intraoperatively localized by sonography or stereotactic methods. This paper compares the results of cavernous angioma surgery localized by frame-based vs frameless techniques. Thirty-nine patients with cortical or subcortical lobar cavernoma were operated on by a microsurgical trans-sulcal approach. The localization of the lesion was performed in 19 (49%) patients by frame-based technique and in 20 (51%) patients by frameless navigation. In 22 (56%) of the patients, the cavernomas were located in an eloquent cortical area. Ten of 22 of these lesions were localized by frame-based stereotaxy and 12/22 by frameless navigation. The patients demonstrated the following preoperative symptoms: seizures 20 (51%), hemorrhage 18 (46%), focal neurologic deficit 11 (28%), and headache three (7%), and three (7%) were asymptomatic. Thirteen of 19 patients localized with frame-based stereotaxy were postoperatively asymptomatic or their preoperative neurological symptoms improved. Four of 19 had a transitory neurologic deficit and 2/19 a permanent worsening. Seventeen of 20 patients localized by frameless navigation were asymptomatic or neurologically improved. Three out of 20 suffered from a transient neurologic deficit. Regarding the seizures, 14 (70%) patients were postoperatively free of seizures, three (15%) were improved, and three (15%) were unchanged. The frameless navigation was superior regarding the flexibility for approaches along the skull base and midline, and the frame-based method was superior regarding the accuracy for very small lesions (less than 7 mm). In other cases, both methods were equal. Frame-based and frameless stereotactic methods are useful in the localization of small cavernous angiomas. They make it possible to remove cavernous angiomas in eloquent cortical regions with low risk of a permanent neurologic deficit. Electronic Publication     

Multiple cystic cavernous angiomas associated with hemorrhage

Summary. A 29-year-old man presented with impaired mental concentration and inability to remember. Magnetic resonance and computed tomography studies revealed multiple calcified cysts. Craniotomy was performed and one of the lesions was resected. The histological diagnosis was cavernous angioma. The first report of multiple cystic cavernous angiomas is reported.     

功能磁共振联合神经导航辅助切除功能区海绵状血管瘤

目的探讨功能磁共振联合神经导航辅助的显微手术在治疗功能区海绵状血管瘤中的应用价值。方法用功能磁共振联合神经导航技术,对功能区的5例海绵状血管瘤行显微外科手术切除。结果病灶全切除率为100％,无重要神经功能受损表现,无手术并发症及死亡。结论功能磁共振联合神经导航辅助的显微手术治疗功能区内海绵状血管瘤,定位精确,微侵袭,可提高海绵状血管瘤切除率,降低手术并发症。对手术切除脑功能区海绵状血管瘤并保留运动功能有重要的指导作用。     

Microsurgery of deep-seated cavernous angiomas: Report of 26 cases

Summary The authors review 26 patients with deep-seated cavernous angiomas which were removed by microsurgery. Ten of the angiomas were located in the insula and basal ganglia, 2 in the thalamus, 5 in the midbrain, 8 in the pons, and 1 in the brachium pontis. The patients were among 73 consecutive cases operated on between August 1983 and December 1989 for symptomatic cavernous angiomas in various locations.In 11 cases total excision of the cavernoma was achieved without producing additional neurological deficits. Postoperative neurological recovery was delayed in 7 patients. In the remaining 8, the complicated postoperative course was caused by bleeding from residual parts of the malformation or damage to long-tract pathways in two cases, respectively, vascular injury during dissection in three cases, and paradoxical air embolism in one case. In order to achieve a satisfactory surgical result, it is stressed that particular attention has to be paid to the operative approach, to careful dissection and complete removal of the malformation, to perforating arteries, and to anomalous venous drainage.     

Extradural spinal cavernous angiomas: report of seven cases

The authors describe seven cases of extradural spinal cavernous angioma. Although cavernoma itself is not rare, the extradural spinal localization is uncommon and makes preoperative differential diagnosis difficult. Routine MRI investigation has aided neurosurgeons in evaluating the true incidence of these vascular malformations, which was understimated in the past. The data published so far have not entirely clarified the treatment of choice for these lesions. Considering their rarity in this site, their presenting symptoms and the difficulties involved in neuroradiological diagnosis, the authors discuss the role of surgery as the principal form of treatment and review the relevant literature. Seven patients (4 male, 3 female) were admitted to our Institute of Neurosurgery between 1992 and 2004, with a 5–6 month history (range=2–365 days) of low back pain or radicular pain, sometimes associated with paresthesia. All patients had a CT scan, as well as MRI with gadolinium when possible, which detected an extradural roundish lesion: differential diagnosis was very difficult, especially between neurinoma and cavernoma. Treatment was always surgical and resection of the lesion radical. Postoperatively, all patients presented complete regression of clinical symptoms. In all cases histological diagnosis was cavernous angioma. Postoperative MRI with gadolinium or CT scan with IV contrast, performed before discharge, confirmed radical removal of the vascular malformation in all cases. Our experience confirms that surgery should be the treatment of choice for these lesions, in view of both their tendency to bleed and their straightforward surgical removal.     

Large cavernous hemangioma of the kidney presenting as a solid renal mass

We report a case of large renal hemangioma that completely filled the collecting system in a 43-year-old man. Most of the renal hemangiomas are small in size and this situation is extremely rare. The diagnosis and treatment of the case is discussed.     

Cerebral cavernomas, epilepsy and seizures. Natural history and therapeutic strategy

PURPOSE: To review, from a retrospective series of 48 patients presenting with seizures associated with one or more supratentorial cavernoma(s), the natural history of the seizures and outcome according to medical and surgical treatment. METHODS: Patients were divided into two groups: group A included patients presenting with a single seizure or rare seizures (n=21), and group B patients having intractable epilepsy (n=27). All received antiepileptic drugs and 35 were operated on (12 in the group A and 23 in the group B). Stereo-EEG was performed in 8 patients in group B. Surgery included lesionectomy alone (n=16), resection of the cavernoma and perilesional tissue (n=7) or tailored corticectomy including the cavernoma (n=12). RESULTS: The natural history of seizures was different in the two groups: mean age at seizure onset was 25 years in group B and 33 years in group A (p<0.05), seizures were partial in all patients in group B and 8 patients in group A (p<0.05). Seizure frequency and periodicity also varied. Prolonged seizure-free periods were observed. The cavernoma was temporal in 17 patients in group B and 4 patients in group A (p<0.01). In group A, seizure outcome was favorable following surgery or with antiepileptic medication only (7 patients out of 12 operated were seizure-free, as were 5 out of 7 non-operated). In group B, seizure outcome was better after surgery than with medication only (17 patients out of 23 operated were in Engel's Class I, while 3 patients of 4 non-operated patients had persisting seizures despite antiepileptic polytherapy). CONCLUSION: Variations in seizure severity in patients harboring cavernomas suggest different therapeutic approaches. In case of unique or rare seizures, surgical resection of the cavernoma is appropriate, but benefits of surgery over antiepileptic medication in terms of seizure control remains unclear. Intractable epilepsy associated with cavernomas is better controlled after surgery rather than with medication only. In these patients, a detailed preoperative work-up is necessary and should be followed by wide resection associated or not with corticectomy, especially in the temporal lobe. Evaluation of outcome after surgery should consider the surgical strategy, antiepileptic medications and the patient's seizure history.     

Seizure control following surgery in supratentorial cavernous malformations: a retrospective study in 77 patients

Summary Of 168 patients operated on consecutively for a supratentorial cavernous malformation, 77 had seizures as the initial symptom. The effectiveness of surgery in controlling seizures and the risk of surgery were evaluated by retrospective review of the patients' charts. The follow-up period was 1 to 9 years (mean 39 months) and the review period totalled 284 lesion-years. Only two patients showed postoperative deterioration in neurological status (morbidity risk: 2.6%), no patient died (mortality: 0%). Sixty-eight (88.3%) patients were seizure-free after operation and five (6.5%) showed a marked reduction in the frequency of their seizures. This corresponds to an overall positive effect of surgery in 94.8% of the patients. There was no substantial evidence that excision of the haemosiderin-stained tissue around the cavernoma along with the lesion itself provided better results than resection of only the cavernoma. Better results with regard to seizure control, however, were associated with shorter duration of symptoms before surgery.     

Pure lesionectomy versus tailored epilepsy surgery in treatment of cavernous malformations presenting with epilepsy

Cerebral cavernous malformations (CM) are well-circumscribed vascular malformations that often present with epileptic seizures. Although patients may initially benefit from antiepileptic drugs, surgical treatment may become necessary due to medically intractable seizures. However, it is unclear whether lesionectomy alone or tailored epilepsy surgery with previous invasive monitoring is the optimal strategy in such cases. We report two patients with epileptic seizures due to CM. One patient with few seizures prior to surgery became seizure-free following resection of the CM and the surrounding tissue. In the second patient with long-lasting epilepsy, lesionectomy was performed because of the proximity to a functioning left hippocampus. This limited resection failed and the patient still had seizures. Subsequently, invasive monitoring with intracranial depth and strip electrodes was performed in order to localize the epileptogenic area and determine whether the left hippocampus could be spared. The invasive study showed the seizure origin in the tissue around the former CM but no epileptic discharges in the hippocampus. In a second operation, an anterior temporal resection was performed with removal of the epileptogenic surrounding tissue and the patient became seizure-free without cognitive deficits. The optimal surgical strategy for CM presenting with epileptic seizures must take into account various factors such as underlying mechanisms and duration of epilepsy, and location of the lesion.     

大肠海绵状血管瘤的腹腔镜治疗

目的 探讨大肠海绵状血管瘤的临床特点、诊治原则,及腹腔镜下结肠、乙状结肠、直肠部分切除术在治疗大肠海绵状血管瘤中的运用方法及优越性.方法对8例大肠海绵状血管瘤患者的临床资料进行回顾性分析.结果 8例患者的病变累及直肠4例,直肠和乙状结肠3例,直肠、降结肠及乙状结肠1例,诊断明确后行腹腔镜下病变部位结、直肠、乙状结肠部分切除,术后恢复顺利,无死亡,无复发.结论 大肠海绵状血管瘤较为罕见,易误诊,常见病变部位为乙状结肠、直肠.腹腔镜下结肠、乙状结肠、直肠部分切除术治疗大肠海绵状血管瘤安全、有效.     

神经导航下切除海绵状血管瘤

目的 介绍ＳｔｅａｌｔｈＳｔａｔｉｏｎ神经导航系统在颅内海绵状管瘤手术中应用。方法 在６例以癫痫起病的海绵状血管瘤手术中,ＳｔｅａｌｔｈＳｔａｔｉｏｎ神经导航系统提供手术野和ＣＴ影像的实时吻合,术中导航,其中４例锁眼外科手术,２例皮瓣开颅手术,结果 ６例手术均导航定位全切病灶及其周边含铁血黄一 着带,胶质增生和钙化,无手术并发症,术后癫痫消失,平均注册误差１．６５－４．５３ｍｍ,每１０ｃｍ预期准确     

An unusual case of giant cavernous hemangioma presenting as a lytic lesion in manubrium sterni

Primary tumors of the chest wall are uncommon. Cavernous hemangioma is rare. A presternal giant cavernous hemangioma is presented.     

Indications for surgery and prognosis in patients with cerebral cavernous angiomas.

Seventy-three cerebral cavernous angiomas were removed microsurgically from a series of 71 patients between August, 1983 and December, 1989. This retrospective investigation assessed the current indications for surgery and determined the prognosis for patients with cerebral cavernous angioma. There were 38 males and 33 females with a mean age of 37 years. Analysis included clinical presentation and history, neuroradiological findings, indications for surgery, and postoperative course. After an average follow-up period of 15 months, 35 patients were symptom-free, 16 had improved preoperative complaints, six were unchanged, and eight had deteriorated. Microsurgical extirpation of the malformation is indicated in all symptomatic patients where neuroimaging demonstrates the presence of a readily accessible cerebral cavernoma. Surgery is recommended in cases with deep-seated lesions causing massive hemorrhage, repetitive minor bleeding, or significant long-standing and progressive neurological disabilities. Clinically silent cavernomas located in eloquent regions of the brain contraindicate surgery, but should be closely monitored. Patients presenting with convulsions or neurological deficits caused by easily accessible cavernomas of the hemispheres have the best prognosis and a negligible risk for surgical complications. Those with deep-seated lesions of eloquent regions of the brain that have bled or caused sustained neurological disorders face the highest risk for morbidity owing to the surgical intervention, requiring careful preoperative evaluation.     

以栓塞硬化为主综合治疗眼睑海绵状血管瘤

目的 探讨治疗眼睑海绵状血管瘤的有效方法。方法 用栓塞硬化注射术，或结合手术切除部分硬化瘤体，或结合铜针留置术。治疗眼睑海绵状血管瘤。结果 治疗患者17例，其中11例只进行栓塞硬化治疗，2例栓塞硬化后手术切除治疗，4例铜针留置后栓塞硬化治疗。所有患者治疗后眼睑瘤体缩小，未出现并发症。随访6个月至4年。治疗部位无复发，局部功能形态良好。结论以栓塞硬化为主综合治疗眼睑海绵状血管瘤，简便有效，创伤小，不易复发。     

Symptomatic spinal cavernous malformations: indication for microsurgical treatment and outcome

Purpose  

We demonstrate clinical features, therapy and outcome of 14 patients with symptomatic spinal cavernous malformations (CM).