Cavernous angiomas of the lateral ventricles

Surgical resection of intracranial cavernous hemangioma located at uncommon location: Clinical presentation and management

Background

Intracranial cavernous hemangiomas (CHs) usually originate from the cerebral and cerebellar hemispheres, while the clinical features and optimum treatment of CHs that originate from atypical locations remain unclear.

Methods

We conducted a retrospective analysis of CHs that originated from the sellar, suprasellar, or parasellar region, the ventricular system, the cerebral falx, or the meninges in patients who underwent surgery from 2009 to 2019 in our department.

Results

In our study, fourteen patients with pathologically confirmed CHs in uncommon locations (UCHs) were enrolled; 5 were located at the sellar or parasellar region, 3 at the suprasellar region, 3 at the ventricular system, 2 at the cerebral falx, and 1 originated from parietal meninges. The most common symptoms were headache and dizziness (10/14); however, none presented with seizures. All UCHs located in the ventricular systems and 2 of the 3 UCHs located in the suprasellar region manifested as hemorrhagic lesions and shared similar radiological features compared with axial CHs; other locations of UCHs did not have a "popcorn" appearance on T2-weighted image. Nine patients achieved GTR, 2 achieved STR, and 3 achieved PR. Four out of five patients who received incomplete resection underwent adjuvant gamma-knife radiosurgery. During the average follow-up of 71.1 ± 43.3 months, no patient died and one patient encountered recurrence and de novo formation of midbrain CH. Most patients had an excellent KPS score of 90-100 (9 of 14) or a good KPS score of 80 (1 of 14).

Conclusion

We suggest that surgery is the optimum therapeutic method for UCHs located at the ventricular system, dura mater, and cerebral falx. Stereotactic radiosurgery plays an important role in the treatment of UCHs located at the sellar or parasellar region and remnant UCHs. Favorable outcomes and lesion control could be achieved by surgery.

Usefulness of Ultrasound-Guided Microsurgery in Cavernous Angioma Removal

BACKGROUND

Primary elements of surgical treatment of cavernous angiomas (CAs) are precise lesion identification and optimal trajectory determination. Navigation techniques allow for better results compared to microsurgery alone. In this study, we examined the benefits of intraoperative ultrasound (IOUS) use as an adjunct to standard localization systems.

METHODS

We retrospectively analyzed 59 CAs, comparing outcomes in 2 groups of patients: 34 who underwent frame-based or frameless navigation-assisted microsurgery (no-IOUS group) and 25 who underwent IOUS-guided microsurgery associated with these techniques (IOUS group).

RESULTS

The use of IOUS did not significantly increase the surgery time (mean, 172 ± 1.7 minutes in the IOUS group and 192.6 ± 11.5 in no-IOUS group; P = 0.08). In all 25 patients in the IOUS group, IOUS allowed for ready identification of CA as a hyperechoic mass. At the last follow-up (mean, 41.7 ± 3.5 months postsurgery), 95.2% of the IOUS group and 80.8% of the no-IOUS group had a modified Rankin Scale score of 0-1 and an Extended Glasgow Outcome Scale score of 7-8 (P = 0.2), with 100% and 64%, respectively, included in Engel outcome scale class IA (P = 0.006). Complete removal, as confirmed on postoperative magnetic resonance imaging, was achieved in all patients in the IOUS group and in almost all (97.1%; P = 0.4) patients in the no-IOUS group.

CONCLUSIONS

IOUS is a valid tool for the intraoperative identification of CAs. Implementation of standard localization methods with IOUS guidance was associated with complete resection in all cases, without increasing surgical time. Compared with microsurgery without IOUS guidance, long-term functional outcomes showed better trends, and the epilepsy-free rate was significantly higher.

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.

Microsurgical Treatment of Intraventricular Cavernoma with Prior Planning Neuroendoscopy

Microsurgery remains the gold standard treatment for intraventricular lesions, but it is not without limitations. The cerebral ventricles approach is considered a challenge for neurosurgeons because of their deep location and their intimate association with critical areas of the brain. It has been shown that direct endoscopic view is superior to magnetic resonance imaging (MRI) in identifying intraventricular structures and lesions. Also, during neuroendoscopy, there is no cerebrospinal fluid leak causing brain collapse as seen in microsurgery. Different surgical strategies should be shared and may improve and facilitate intraventricular lesions resection. Herein, a case of a successful microsurgical cavernoma resection with prior ventriculoscopy is described. A 28-year-old woman was admitted with intense holocranial headache. A mild stiff neck was observed. MRI showed a 3-cm lesion with heterogeneous signal intensity and no contrast enhancement suggestive of cavernoma. Initially, a ventriculoscopy was done to inspect the lesion and the surrounding ventricular structures. After that, a conversion technique from endoscopy to microsurgery was performed. The initial corticectomy was extended and the endoscope pathway was followed into the ventricular cavity. Then, the cavernoma was completely removed by microsurgical technique. No complications were observed. Control MRI showed total tumour removal. The patient remained asymptomatic with no recurrence after 1 year. This case illustrates a successful prior endoscopic approach followed by microsurgery as an alternative to a direct microsurgical approach for intraventricular cavernoma. A previous direct endoscopic view of the lesion and its relation with intraventricular structures may ensure a safe and complete resection by microsurgery.

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.

Awad I, Dahlem K, Flemming K, Hart B, Kim H, Jusue-Torres I, Kondziolka D, Lee C, Morrison L, Rigamonti D, Rebeiz T, Tournier-Lasserve E, Waggoner D, Whitehead K. Synopsis of Guidelines for the Clinical Management of Cerebral Cavernous Malformations: Consensus Recommendations Based on Systematic Literature Review by the Angioma Alliance Scientific Advisory Board Clinical Experts Panel

BACKGROUND

Despite many publications about cerebral cavernous malformations (CCMs), controversy remains regarding diagnostic and management strategies.

OBJECTIVE

To develop guidelines for CCM management.

METHODS

The Angioma Alliance ( www.angioma.org ), the patient support group in the United States advocating on behalf of patients and research in CCM, convened a multidisciplinary writing group comprising expert CCM clinicians to help summarize the existing literature related to the clinical care of CCM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and radiology standards, (4) neurosurgical considerations, and (5) neurological considerations. The group reviewed literature, rated evidence, developed recommendations, and established consensus, controversies, and knowledge gaps according to a prespecified protocol.

RESULTS

Of 1270 publications published between January 1, 1983 and September 31, 2014, we selected 98 based on methodological criteria, and identified 38 additional recent or relevant publications. Topic authors used these publications to summarize current knowledge and arrive at 23 consensus management recommendations, which we rated by class (size of effect) and level (estimate of certainty) according to the American Heart Association/American Stroke Association criteria. No recommendation was level A (because of the absence of randomized controlled trials), 11 (48%) were level B, and 12 (52%) were level C. Recommendations were class I in 8 (35%), class II in 10 (43%), and class III in 5 (22%).

CONCLUSION

Current evidence supports recommendations for the management of CCM, but their generally low levels and classes mandate further research to better inform clinical practice and update these recommendations. The complete recommendations document, including the criteria for selecting reference citations, a more detailed justification of the respective recommendations, and a summary of controversies and knowledge gaps, was similarly peer reviewed and is available on line www.angioma.org/CCMGuidelines .

Rare association of secondary superficial siderosis caused by a fourth ventricle hemorrhagic ependymoma mimicking a cavernoma: Case report and literature review

Background:

The association of a hemorrhagic tumor with secondary superficial siderosis (SS) is a relatively rare although well described phenomenon.

Case Description:

We present the case report of a 35-year-old male with a history of drowsiness, hypoacusia, drop attacks, and multidirectional nystagmus during the last 2 months, who presented with acute obstructive hydrocephalus caused by a fourth ventricle mass displaying radiological signs of repeated intra and extratumoral hemorrhage with SS. He underwent gross surgical removal of the solid component of the tumor. Microscopic examination revealed an ependymoma with atypical features, including prominent angiomatous formations and internal chronic hemorrhages with hemosiderin deposits, resembling a cavernoma. The scarce tumoral component, which extended around these cavernous vessels, lacked the gross typical features of fibrillary stroma or perivascular pseudorosettes.

Conclusion:

To our knowledge, including the present case, there are 45 published reports of tumors associating secondary SS. Besides ependymoma, no other hemorrhagic lesion, tumoral or vascular, has been previously published associating a fourth ventricle location with secondary SS. The present case represents the fifth with this finding, and we strongly suggest ependymoma as a presumptive diagnosis when this rare association is encountered. In addition, this appears to be the first case reported in the scientific literature of a hemorrhagic fourth ventricle ependymoma mimicking both, radiologically and histologically, a cavernous malformation.

[Rare tumors of the lateral ventricle. Review of the literature]

Metastases of lateral ventricle (LV) are attached to choroidal plexus. Primary source is cancer of kidney. Two thirds of patients are male. Oligodendrogliomas occur in young females. Signs of increased intracranial pressure are a constant feature. These tumors are found in anterior portion of the LV with severe enhancement and clumped calcifications. Treatment is surgical. Cavernomas have a preponderance of rapid growth with a bleeding revelation. Seizures are rare. Rebleeding is frequent and justifies a surgical treatment. Schwannomas are a rare entity in which the majority of patients are very young. MRI shows calcifications, cystic components and a strong enhancement. They are limited to sporadic cases, never associated with neurofibromatosis. Arachnoid cysts are located in the atrium and/or in the occipital horn. Patients are young (mean age < 40 years). MRI demonstrates an intracystic lesion with signal intensity similar to the CSF. Best treatment is an endoscopic fenestration. Epidermoid cysts occur in third decade. These pearly tumors appear isointense or a little hyperintense on T1-weighted imaging, very characteristic. They are enhanced after gadolinium injection and appear strongly hyperintense on T2-weighted imaging. An incomplete removal with a thorough long-term follow-up is necessary. Cavernomas of LV are hyperintense on T1- and T2-weighted imaging. They have a bleeding risk of 25 to 45%. Therefore, they must be operated.

A "pseudo-cavernoma" - an encapsulated hematoma of the choroid plexus

We present the first report of an intraventricular encapsulated hematoma, mimicking cavernous malformation on imaging and gross lesion appearance. A 47-year-old female on anticoagulation therapy for atrial fibrillation presented with left upper extremity apraxia, neglect, and mild gait imbalance. Her brain CT scan and MRI revealed multilobulated lesions involving the choroid plexus in the atria of both lateral ventricles. The intraoperative appearance was that of encapsulated mass, with blood clots at different stages of liquefaction and organization, all consistent with the gross appearance of a cavernous malformation. However, histopathologic examination demonstrated hematoma with components at different ages, and normal vessel infiltration without any hint of cavernous malformation histology, or underlying neoplasia. Encapsulated hematoma should be considered in the differential diagnosis of hemorrhagic intraventricular masses.

Aneurysm of the distal anterior cerebral artery radiologically mimicking a ventricular mass

The ventricular system is a rare localization for intracranial aneurysms. Most ventricular aneurysms arise from a distal branch of the choroidal arteries and a major branch point of the circle of Willis. A 41-year-old-man suffering from dizziness of 2 weeks' duration was admitted to the clinic. On radiological examination, he had a well-circumscribed mass involving the frontal horn of the right lateral ventricle without radiological evidence of a prior or recent hemorrhage. Localization and radiological appearance were not typical of a ventricular mass and did not allow diagnosis. After cerebral angiography, an aneurysm arising from the distal anterior cerebral artery was incidentally found in an intraventricular location. This unruptured aneurysm was successfully treated via the endovascular route. The authors describe the unusual case of a distal anterior cerebral artery aneurysm with a dome extending into the right lateral ventricle, which appears to be the first such case in the literature. Angiography may be helpful to neurosurgeons in avoiding the disastrous complications of a biopsy procedure in such unusual cases.