Intraventricular cavernoma in pediatric age

Surgical management of pediatric intracranial cerebral cavernous malformations: a 10-year single-center experience

BACKGROUND

Cerebral cavernous malformations (CCMs) are low-flow vascular malformations made up of dilated vascular spaces without intervening parenchyma that can occur throughout the central nervous system. CCMs can occur sporadically or in familial forms. Presentation is diverse, ranging from incidental discovery of asymptomatic CCMs to drug-resistant epilepsy and hemorrhages.

METHODS

We describe the surgical management of CCMs in pediatric patients at Bambino Gesù Children's Hospital in Rome over the last 10 years. The cases have been stratified based on the clinical presentation and the relevant literature is discussed accordingly.

RESULTS

We discuss the rationale and technique used in these cases based on their presentation, as well as the generally positive outcomes we achieved with early surgical management, use of intraoperative ultrasound (ioUS) and intraoperative neuromonitoring.

CONCLUSIONS

Surgical management of pediatric CCMs is a safe and effective strategy, low rates of postoperative morbidity and partial resection were observed.

Giant Frontotemporal Cavernous Malformation in a 2-Month-Old Infant: A Case Report and Review of the Literature

INTRODUCTION

Cavernous malformations in the pediatric population are exceedingly rare, especially in infants. Giant cavernous malformations (GCM) are even more rare and have a diameter >4 cm. The onset of symptoms predominantly occurs in adulthood, but the rate of hemorrhage is significantly higher in the pediatric population. Similar to non-GCM, GCM can be misidentified as tumors on imaging due to their tumefactive pattern with edema. Here, we present a rare case of a right frontotemporal GCM in a 2-month-old girl, the youngest recorded case in the existing literature.

CASE PRESENTATION

A previously healthy 2-month-old girl presented to the emergency department following an increasing frequency of seizure-like activity that began 3 days prior to presentation. Magnetic resonance imaging of the brain with and without contrast characterized a large (5.8 × 4.3 × 4.2 cm) heterogeneous lesion of the right temporal lobe with diffuse scattered blood products of various ages seen throughout the lesion. She underwent a right-sided craniotomy where a gross total excision was achieved. Pathology confirmed the diagnoses of a GCM. The patient's seizures subsequently resolved, and she continues to do well postoperatively.

DISCUSSION/CONCLUSION

GCM can be mistaken for tumors due to their large size, cystic nature, and surrounding edema, but a vascular lesion should always remain in the differential diagnosis before operating, even in infants. Surgery is generally recommended in patients that present with a symptomatic hemorrhage, recurrent hemorrhages, persistent seizures despite medical management, or progressively worsening neurological deficits if the GCM is in a safe location. It has been shown that 70-99% of patients undergoing surgery with successful removal of the GCM can achieve seizure freedom 2 years postoperatively. Complete surgical excision of this infant's GCM was successful in treating her neurologic symptoms; therefore, pathological confirmation of this lesion is critical and should prompt a complete surgical excision.

Giant intraventricular and paraventricular cavernous malformations with multifocal subependymal cavernous malformations in pediatric patients: Two case reports

BACKGROUND

Giant cavernous malformation (GCM) is rarely found in intraventricular or paraventricular locations.

CASE SUMMARY

We present two cases of 6-mo and 21-mo boys with intraventricular and paraventricular GCMs including a literature review focused on location and imaging findings. Characteristic magnetic resonance imaging findings such as multicystic lesions and a hemosiderin ring or bubbles-of-blood appearance can assist in the differential diagnosis of a hemorrhagic intraventricular and/or paraventricular mass.

CONCLUSION

Multifocal intraventricular and/or paraventricular GCM in small children is rare. The characteristic magnetic resonance imaging findings can help to differentiate GCMs from other intraventricular tumors.

Multiple Intracranial Cavernous Angiomas With a Trigonal Cavernous Angioma Mimicking Glioma

Intracranial cavernous angiomas (CAs) are hamartomatous vascular malformations consisting of thin-walled vascular channels located within the brain, but typically lacking intervening neural parenchyma, large feeding arteries, or draining veins. The CAs occurring in the ventricular system are rare, with an incidence of 2.5% to 10.3% of the intracranial CAs, and those arising from the trigone of the lateral ventricle are even rarer. Till now, there are <20 patients with trigonal CAs have been reported in the English literature. In this study, the authors describe an extremely rare case of multiple intracranial CAs with a trigonal CA mimicking glioma. Furthermore, they also discuss the characteristic aspects of symptoms, radiologic findings, diagnosis, and treatment of this benign lesion.

Clinical features and neurosurgical treatment of trigonal cavernous malformations

The goals of this study were to analyze the incidence, clinical manifestations, neuroimaging findings, surgical treatments, and neurological outcomes of trigonal cavernous malformations (TCMs). Among 1395 cases of intracranial and intraspinal cavernous malformations (CMs) surgically treated between 2003 and 2016 at Beijing Tiantan Hospital, a series of 12 patients with TCM was chosen for analysis and their records were reviewed. We also performed an exhaustive literature search using PubMed to identify all previously reported cases in the literatures. TCMs accounted for 0.86% of the entire series of the central nervous system (CNS) CMs. The case series consisted of five male and seven female patients (ratio 1:1.4), with an average age at presentation of 32.9 years (7-53 years). In all the cases, headache was the most common initial symptom (66.7%). Complete resection without surgical mortality was achieved in all the cases. Postoperative complications included fever, lower limb weakness, sensory aphasia, and calculational capacity declination. Follow-up period after diagnosis was 15 to 74 months (mean 48.3 months); no patient was lost to follow-up. All the patients were considered to be in excellent clinical condition. TCMs are rare lesions; they can reach large size, and their symptoms and signs commonly resulted from mass effect. Surgical intervention is the treatment of choice for TCMs; patients can obtain favorable neurological outcomes after complete resection.

Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature

PURPOSE

Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs.

MATERIAL AND METHODS

We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome.

RESULTS

A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14 years (3-18 years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6 cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162 months (mean 47.2 months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series.

CONCLUSION

Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.

Radiology and imaging for cavernous malformations

Cavernous malformations are low-flow vascular malformations that are histologically characterized by the lack of mural elements of mature vascular structures and intervening parenchymal neural tissue. They are often clinically quiescent, and may grow, bleed, and regress, but can also manifest clinically as neurologic deficits or seizures in the setting of an acute hemorrhage. The low-flow nature of cavernous malformations renders them inherently occult on cerebral angiography. Magnetic resonance imaging has become the mainstay imaging modality in evaluating cavernous malformations, producing characteristic imaging features that usually provide a straightforward diagnosis. Features on magnetic resonance imaging include a reticulated pattern of mixed hyper- and hypointensity on T1- and T2-weighted imaging, with a characteristic hypointense rim best appreciated on T2-weighted imaging or gradient-echo sequences. Contrast enhancement is useful for revealing coexisting developmental venous anomalies that are frequently associated with sporadic cavernous malformations, and may further support the diagnosis. Susceptibility-weighted imaging is highly sensitive for cavernous malformations and accompanying developmental venous anomalies, and is superior to gradient-echo sequences in screening for multifocal, familial cavernous malformations.

Cavernous Angioma of the Cerebral Aqueduct

BACKGROUND

Among the rare intraventricular cavernomas, purely intra-aqueductal cavernomas are exceptionally rare.

CASE DESCRIPTION

A 62-year-old patient presented with progressive headache, memory loss, gait instability, and urinary incontinence. Magnetic resonance imaging showed the presence of a mass lesion located in the lumen of the cerebral aqueduct, associated with triventricular hydrocephalus.

CONCLUSIONS

We discuss the rationale that led us to treat hydrocephalus with neuroendoscopy, which offered the possibility to directly inspect the intra-aqueductal lesion, make the diagnosis of cavernoma, and treat symptoms resulting from hydrocephalus without increasing the risk of bleeding.

Trigonal cavernous malformation with intraventricular hemorrhage: a case report and literature review

We reported a case of trigonal cavernous malformation (CM) with intraventricular hemorrhage. This 67-year-old woman experienced sudden onset of loss of consciousness and her Glasgow Coma Scale (GCS) was 5 points (E1V1M3) on admission. CT scan demonstrated intraventricular hemorrhage and acute hydrocephalus. Angiography did not demonstrate any vascular abnormality. Ventricular drainage was performed for acute hydrocephalus and the postoperative course was good. CT showed a hyperdense lesion in the left trigone, which was contrast-enhanced on T1-weighted MR. Removal of CM was performed via the left middle temporal sulcus. We conducted a Pub Med search for trigonal CM and found 17 cases. Herein we discuss the symptoms, CT and MR findings and treatment.

Intraventricular cerebral cavernomas: a series of 12 patients and review of the literature

Object

Intraventricular cavernomas (IVCs) occur in only 2–10% of patients with cerebral cavernomas. Reports concerning IVC are scarce and are limited mostly to sporadic case reports. In this paper, the authors present a series of 12 patients with IVCs that were treated at a single neurosurgical department. In addition, the authors reviewed the literature.

Methods

All clinical data were analyzed retrospectively. Follow-up questionnaires were sent to all patients. Outcome was assessed using the Glasgow Outcome Scale. The authors also conducted a PubMed search and found 77 cases of IVC.

Results

The patients' median age was 47 years, and the male/female ratio was 2:1. A cavernoma occurred in the lateral ventricle in 6 patients, in another 5 it was in the fourth ventricle, and 1 had a lesion in the third ventricle. Almost all patients presented with acute headache on admission and in more than half, the symptoms were related to cavernoma bleeding. In total, 8 rebleedings occurred in 5 patients during a median of 0.4 years. Three patients with a cavernoma of the fourth ventricle presented with a cranial nerve deficit. In 8 cases, a cavernoma was surgically treated an average of 1.3 years after the diagnosis. Only 1 patient underwent surgery in the acute phase after a major intraventricular/intracerebral hemorrhage. The median follow-up time was 2 years. No patient was lost to follow-up, and no patient died. In total, on follow-up 9 patients improved and 3 had a persistent neurological deficit, of which 2 existed before surgery.

Conclusions

In the present series, the IVCs had a high tendency for rehemorrhage. Surgery is advocated when hemorrhages are frequent, and the mass effect causes progressive neurological deficits. Microsurgical removal of the IVC is safe, but in the fourth ventricle it can carry increased risk for cranial nerve deficits.

Trigonal cavernous angioma: a short illustrated review

PURPOSE

Intraventricular cavernomas are rare. Even more rare are those presenting in the trigone of the lateral ventricles.

METHODS

We performed a search of the literature of the last 30 years and identified all cases of intraventricular cavernous angiomas. Trigonal cavernomas were separately identified and analysed. Our search yielded a total of 13 trigonal cavernomas.

RESULTS

Of a total of 61 intraventricular cases, 13 were located in the trigone of the lateral ventricles. The most prominent presenting symptom was intracranial hypertension (68.9%), followed by seizures (18.2%) and hemorrhage (13.1%).The literature review revealed a trend of intraventricular cavernomas to present with intracranial hypertension rather than seizures or focal neurologic deficit, unlike their intraparenchymal counterparts. We feel that this difference has received little attention in the international literature. We discuss a possible pathogenetic mechanism for the presence of intracranial hypertension and address different aspects of diagnosis and treatment of this benign lesion.

CONCLUSIONS

Trigonal cavernomas are benign lesions that have an excellent outcome after radical excision. Symptoms and signs of intracranial hypertension and hydrocephalus may be the prominent initial presentation of this rare ailment.

[Intraventricular cavernoma in the foramen of Monro: particularities due to its atypical location]

Although cavernomas are relatively common vascular malformations in the central nervous system, they are rarely located in the ventricles and are even more rarely located in the region of the foramen of Monro. This atypical location results in a series of differential clinical and radiological characteristics that can make the diagnosis of these lesions extremely difficult and lead to inefficacious procedures like radiotherapy or a neuroendoscopic surgical approach or even to procedures that endanger the patient like stereotactic biopsy. We present a case of intraventricular cavernoma in the region of the foramen of Monro with the aim of illustrating the difficulties involved in the diagnosis of this rare lesion.

Cavernous angiomas of the lateral ventricles

BACKGROUND

Cavernous angiomas are vascular malformations which rarely involve the cavities of the lateral ventricles. Knowledge of the specific clinical and neuroradiological features displayed by these lesions is limited by the scarcity of patients included in the reported series.

OBJECTIVE AND METHODS

The aim of this study was to compile and analyse the epidemiological, clinical, neuroradiological and surgical characteristics of these lesions as provided by the well-described examples reported in the scientific literature. A total of 49 were gathered, including three patients operated on recently in our Department.

FINDINGS AND CONCLUSIONS

Cavernomas developing within the ventricular cavities attain a larger size than parenchymal counterpart lesions, causing symptoms and signs derived mainly from the mass effect. The characteristic parenchymal hypointense rim is less frequently identified on T2-weighted echo-gradient MRI sequences. Total surgical excision is the treatment of choice for these lesions, yet the surgical routes employed may still be associated with a high rate of neurological complications.

Intraventricular cavernous malformation radiologically mimicking meningioma

We report a case of trigonal cavernous malformation (CM) radiologically mimicking meningioma. The computed tomographic (CT) head angiography and magnetic resonance imaging (MRI) showed a partially calcified lesion with slight contrast enhancement located in the area of the left atrium of lateral ventricle. The lesion was completely removed using microsurgery with a parieto-occipital transcortical approach. The resected mass was histologically confirmed as CM. CM should be considered as differential diagnosis in case of the atrial mass lesion due to lack of hemosiderin ring characteristically seen other seated CM.

Intraventricular vascular malformations mimicking tumors: case reports and review of the literature

Vascular malformations of the ventricular system are rare, and their clinical and radiologic characteristics vary depending on the location of the lesions. Many types are described, but a comprehensive summary is lacking. Herein, we add two cases to the literature and review known types of ventricular vascular malformations. One case involved a 37-year-old woman who presented with headache due to hydrocephalus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion of the foramen of Monro. The other case involved a 7-year-old boy who had dizziness and headache due to hydrocephalus. CT and MRI demonstrated a lesion of the third ventricle. In both cases, the images mimicked those of tumors with or without bleeding. As a result, the malformations were misdiagnosed, though surgical treatment was successful. In both cases, the lesions were proven to be arteriovenous malformations on pathologic evaluation. Correct diagnosis of ventricular vascular malformations is sometimes difficult but essential for good treatment planning. Their incidence is low. However, their bleeding and rebleeding rate is high, and they commonly cause hydrocephalus. Treatment should be timely and based on the type of lesion and its presentation.

Cavernomes du système nerveux central chez l'enfant

Cavernomas represent 1.7 to 18% of all vascular malformations in children and 25% are observed in children under 18 years of age. Cases observed in neonates and infants have been published, but the mean age varies from 9.1 to 10.2 years. There is no predominance between boys and girls.

CLINICAL PRESENTATION

In children, hemorrhage is a common manifestation with an incidence varying from 27.3 to 78% versus 8 to 37% in adult patients. Isolated headaches occur in 2.8% of patients and elevated ICP is observed in 20.1%. Epilepsy is reported in 16 to 60% of children, depending on the series. Neurological deficits are observed in 22.7% of patients and are more severe for deep-seated and brainstem cavernoma. About 14.2% of the cases are discovered fortuitously in asymptomatic patients. Spinal cord deficits are observed in 5% of the cases.

LOCATION

Using data in the literature plus our personal series of 57 cases, 79.4% of lesions are in the supratentorial compartment and 20.6% in the posterior fossa, the majority located in the brainstem, most of them in the pons. Spinal cord cavernomas represent 5% and multiples cavernomas (12.6%) of the reviewed cases.

MANAGEMENT

Appropriate management of cavernomas has long been a subject of much debate. Today, a consensus has been reached to favor medical management of asymptomatic and non hemorrhagic lesions and surgical management of symptomatic and/or hemorrhagic cavernomas whatever the localization. Progress in neuroimaging, surgical mapping, intraoperative monitoring and microsurgical techniques has greatly contributed to improved approach to those lesions.

RESULTS

Results obtained in 217 cases were reviewed. Near 70% of the children are neurologically intact, 19.3% are improved or stable, 2.7% worsened and 1.13% died. Results for epilepsy are very encouraging, surgery is efficient in almost all the children except for temporal lobe cavernomas where invasive presurgical evaluation is recommended. Deep-seated and brainstem cavernomas can safely be removed in most of the cases. Only two children died from recurrent hemorrhage due to residual lesions.

Trigonal cavernous angiomas: report of three cases and review of literature

BACKGROUND

Intraventricular cavernous angiomas are very rare. Only few cases of trigonal angiomas have been reported.

CASE DESCRIPTION

We report three cases of trigonal cavernous angiomas who presented with raised intracranial pressure or seizures and who underwent total excision with a good recovery. We also review the literature and discuss surgical approaches.

CONCLUSION

On magnetic resonance imaging, intraventricular cavernous angiomas lack the hemosiderin ring characteristically seen around parenchymal cavernous angiomas. This explains why trigonal cavernous angiomas can mimic malignant neoplasm on imaging, and they should be considered in the differential diagnosis of intraventricular masses. Total excision should be the goal of surgery.

Third ventricular cavernous haemangioma

We report a case of a third ventricular cavernous haemangioma (cavernoma). Cavernomas rarely occur within the ventricular system. Only 47 well-documented cases have been reported in the literature, 21 of which were located in the third ventricle. Cavernomas should be considered in the differential diagnosis of third ventricular lesions. Ventriculoscopy is very useful in establishing the diagnosis.