461 - Microsurgery for Cerebral Cavernous Malformations

Abstract

Cerebral cavernous malformations (or cavernomas) are angiographically occult, thin-walled vascular lesions found in 0.17% to 0.9% of the population. They can result in seizures, hemorrhage, headaches, and focal neurological deficits. Magnetic resonance imaging is required for work-up of suspected cavernomas, which classically appear as popcorn lesions with a heterogeneous center and a low-intensity hemosiderin rim. Susceptibility-weighted or postcontrast sequences should also be obtained to assess for associated developmental venous anomalies. Formal angiography is not indicated unless the diagnosis is uncertain. The need for surgical resection is determined for each patient on the basis of clinical presentation and cavernoma location. Symptomatic and surgically accessible lesions are typically recommended for microsurgical resection (after clot liquefaction in hemorrhagic cases), with a goal of complete cavernoma removal and preservation of any associated developmental venous anomalies. Eloquent, deep-seated supratentorial and brainstem lesions should be considered for surgical resection after multiple hemorrhages with progressive neurological decline. Surgical approaches are dictated by functional imaging, the two-point method, and described safe entry zones. Intraoperative navigation and neurological monitoring are also typically used. With meticulous preparation and strict adherence to proper microsurgical technique, safe resection of even deep-seated or brainstem cavernomas can be achieved.