Cavernous malformations presenting with seizures: Therapeutic options and outcome

Abstract

Controversies exist regarding the appropriate initial management of patients with cavernous malformations associated with a seizure disorder. We retrospectively reviewed our experience with simple lesionectomy in the treatment of 82 patients with supratentorial cortical cavernous malformations who presented with seizures. Fifty-five patients had adequate follow up (at least 1 year; mean, 52 months) to assess outcome related to seizure control. Forty (73%) patients had single and 15 (27%) had multiple cavernous malformations. Eighteen (33%) patients underwent surgery within the first 2 months of their initial seizure. Thirty-seven (67%) patients had seizures for more than 6 months before their lesionectomy. All patients were treated with lesionectomy alone as their initial management. Outcomes were evaluated based on Engel's criteria. Seizure outcome was based on the number of seizures pre- and postoperatively, lesion location, and number of lesions. Of the 55 patients with adequate follow up, 69% were seizure free (grade 1) and 13% were almost seizure free (grade II). All 18 patients who were operated on within 2 months of their initial seizure have remained seizure free. Of the patients with chronic epilepsy before surgery, 57% are seizure free, and 17% are almost seizure free. Patients with multiple cavernous malformations and well-localized seizure activity on preoperative testing responded well to lesionectomy. Lesion location was not significant in predicting seizure outcome after surgery. Lesionectomy is a valuable treatment for patients with cavernous malformations associated with epilepsy and represents the best initial treatment option. Patients with chronic epilepsy who fail to become seizure free after lesionectomy may require further epilepsy monitoring and resection. Initial lesionectomy, however, will avoid unnecessary epilepsy surgery in most of these patients.