Venous malformation in the posterior fossa: guidelines for treatment

Gamma Knife Stereotactic Radiosurgery for Trigeminal Neuralgia Caused by a Developmental Venous Anomaly

Background: Trigeminal neuralgia (TN) is mostly caused by vascular compression of the nerve's root entry zone due to an ectatic artery. Rarer causes include compression from tumors, vascular malformations or multiple sclerosis plaques. Developmental venous anomalies (DVAs) are benign, aberrantly appearing venous structures that drain normal cerebral tissue. DVAs are a rare etiology of TN. The management of TN caused by a DVA is controversial as disruption of the DVA can be catastrophic. Methods: We report a case of a young man with severe medically refractory TN related to a brachium pontis DVA who was successfully treated by gamma knife stereotactic radiosurgery (GKSR) to the trigeminal nerve. Results: Within 2 weeks of GKSR, the patient reported experiencing 60% pain relief; 5 years postoperatively, he remains completely pain free with some mild sensory loss in the V2 and V3 areas. Conclusions: GKSR has an established role in the management of TN. This is the first reported case of using GKSR to treat TN caused by a DVA. In the setting of a DVA, GKSR should be an initial consideration for TN therapy after medical failure because of the high surgical risk related to disrupting the DVA. © 2015 S. Karger AG, Basel.

Cerebellar cavernous malformations with and without associated developmental venous anomalies

BACKGROUND

The clinical profiles of cerebellar cavernous malformations (CCMs) with and without associated developmental venous anomalies (DVAs) are not well known. The aims of this study were to analyze the clinical and radiological characteristics of CCMs and to assess the various therapeutic strategies.

METHODS

A consecutive series of 41 patients with identified CCMs were retrospectively reviewed. Of these, 11 patients (26.8%) were found to have associated DVAs. We compared the clinical profile of the two groups of patients (CCMs with and without DVAs). The CCMs with DVAs cases underwent radical resection of the CCMs, and the distal radicles of the DVAs that directly drain from the CCMs were coagulated and dissected at the length of the CCMs.

RESULTS

There were no statistically significant differences between the two groups with regard to age, sex, location and size of lesions, multiplicity, and surgical prognosis. The patients with CCMs with DVAs did not experience any brain swelling or hemorrhagic tendency intraoperatively. The postoperative course was uneventful for all of the 36 surgical patients with the exception of two of the patients with CCMs with associated DVAs, who suffered from serious cerebellar edema, and one of these two patients underwent an emergency suboccipital decompression craniotomy. With the exception of three patients who were lost to follow-up (mean, 22.3 months), all of the CCMs patients exhibited good long-term prognosis (modified Rankin scale values of 0-2) and no reoccurrence.

CONCLUSIONS

It is not rare that associated DVAs occur in CCMs. The total removal of the CCM combined with the coagulation and dissection of the distal radicles of DVA at the length of the associated CCM may result in good long-term prognosis in patients.

Developmental venous anomaly of petrous veins: intraoperative findings and indocyanine green video angiographic study

OBJECTIVE

We describe the intraoperative findings and results of an indocyanine green (ICG) video angiographic study in a patient with a developmental venous anomaly of the petrous veins.

CLINICAL PRESENTATION

A 56-year-old man sought treatment after experiencing lacerating facial pain on the right side for almost 2 years. His neurological examination results were normal. A magnetic resonance imaging scan revealed the presence of a venous angioma in close relationship with the trigeminal nerve and the intrapontine tract of its fibers. The patient underwent a retrosigmoid craniotomy to explore the cerebellopontine angle. Near-infrared ICG video angiography was used to study the venous pattern of circulation. The venous angioma did not appear to be the source of any compression and was left untouched. At the entry zone of the nerve root, the trigeminal nerve was found to be compressed by a loop of the superior cerebellar artery, which was moved and repositioned away from the nerve.

RESULTS

Near-infrared ICG video angiography disclosed an unexpected difference in filling time between developmental venous anomaly drainage veins and normal veins. The patient's pain resolved after microvascular decompression.

CONCLUSION

Near-infrared ICG video angiography was particularly accurate and useful in the study of the venous dynamic of circulation. Further studies are required to confirm the supposed capability of ICG video angiography to differentiate developmental venous anomaly drainage veins and normal veins. Although magnetic resonance imaging supported the involvement of the venous angioma in the etiopathogenesis of this patient's trigeminal pain, surgical exploration disclosed a different cause.