Cavernous Hemangioma Research Articles

Use of the Median Sulcus Entry Zone for Microsurgical Resection of a Ruptured Cavernous Malformation of the Pons: A 2-Dimensional Operative Video

Use of the Median Sulcus Entry Zone for Microsurgical Resection of a Ruptured Cavernous Malformation of the Pons: A 2-Dimensional Operative Video

Multifocal osteolytic lesions of the skull: a primary cavernous hemangioma mimicking a neoplastic invasive lesion

Multifocal osteolytic lesions of the skull: a primary cavernous hemangioma mimicking a neoplastic invasive lesion

SURGICAL APPROACH TO THALAMIC CAVERNOUS MALFORMATIONS

Introduction Thalamus is a high eloquent brain region, because it contains important relay nucleus and is surrounded by vital neural and vascular structures. Cavernous malformations involving deep structures such as the basal ganglia and thalamus account for 5–10% of all cerebral cavernomas and can cause devastating neurological deficits. Surgical approach to thalamic cavernomas is associated with risks of new or worsening neurologic deficits. The benefit of surgery must be carefully weighed on an individualized basis. There are several surgical routes that can be used to approach thalamic lesions, mainly transcortical and interhemispheric approaches. A particular approach should be selected based on the location of the cavernoma in the thalamus to minimize lesion of the unaffected brain. Methods We present the case of a 43-year-old right-handed lady with right bleeding posterolateral thalamic cavernoma, admitted to the neurosurgery department of Sibiu MedLife Polisano Hospital in February 2024. The patient underwent surgery, through a transcortical trans-sulcal para-fascicular, navigation guided approach. Preoperative tractography imaging, tubular cerebral corridor retractor system and intraoperative monitoring of the cortico-spinal tract, through motor evoked potentials (transcortical, cortical and subcortical mapping) and of the spinotahamic tract through somatosensory evoked potentials were used. The postoperative course was uneventful and the patient was discharged on the 7th postoperative day. Conclusions Thalamus is a complex structure located in a deep brain area and surgery for these region carries high risks, so the surgeon must carefully tailor these patients. The transcortical transsulcal para-fascicular approach is feasible and safe using the cerebral tubular corridor, neuronavigation and neuromonitoring. Advanced surgical technology offers the advantages of minimizing the risks of new neurological deficits.

NIMG-38. DIAGNOSIS AND TREATMENT OF BRAIN TUMORS USING METHIONINE PET

Abstract INTRODUCTION The usefulness of methionine PET examination in diagnosing brain tumors is widely recognized, and it is a frequently used examination method for distinguishing primary tumors from non-neoplastic lesions and recurrent lesions from radiation necrosis. In addition, during surgery, it has the property of being taken up by actively dividing tumor cells, which is useful for identifying the extent of resection. Method: Methionine PET examination was performed in 228 consecutive cases in our department from January 2021 to April 2023, and medical records and genetic analysis data were retrospectively analyzed. RESULTS Of the 228 cases, 146 cases provided useful data for clinical practice, such as the diagnosis of tumors and the differentiation of recurrent tumors from necrosis. On the other hand, there were 9 cases in which the pathological diagnosis of the resected specimen was “tumor” despite the lack of significant methionine accumulation. The details were astrocytoma, cavernous hemangioma, spinal ependymoma, etc. On the other hand, 26 cases were finally diagnosed as “non-neoplastic disease”. Of these, 13 cases had methionine accumulation. The details of the cases that were finally diagnosed as “non-neoplastic disease” were multiple sclerosis, cerebral infarction, dural arteriovenous fistula, inflammatory disease, etc. There were 12 cases in which a diagnosis of “neoplastic disease” was not revealed after methionine PET examination, and the patient was continuously observed. None of these 12 cases had an acute or malignant course. CONCLUSION Although methionine PET is considered useful for diagnosing neoplastic disease, there are cases in which there is no uptake, especially in astrocytoma, and a certain number of cases in which uptake was observed even in non-neoplastic diseases, so caution is required. In addition, in terms of treatment, it is possible to aim to improve surgical accuracy by integrating methionine PET images with intraoperative MRI and intraoperative molecular analysis techniques, and we report an example of this.

RADT-33. GAMMA KNIFE RADIOSURGERY FOR ORBITAL CAVERNOUS HEMANGIOMA: A SYSTEMATIC REVIEW AND SINGLE-ARM META-ANALYSIS

Abstract Gamma knife radiosurgery (GKRS) for orbital cavernous hemangioma (OCH) has emerged as a promising method due to its significant clinical improvement and low incidence of complications. This study aimed to evaluate the safety and efficacy of GKRS for the treatment of OCH. Following the PRISMA framework, we searched PubMed, Cochrane Central, and Embase for studies reporting outcomes of GKRS for OCH, including complications, visual improvement, proptosis, tumor reduction rate, and tumor progression rate. From 1856 search results, six studies with 100 patients were included. Only five minor complications related to GKRS were reported, including three with orbital pain and two with periorbital chemosis, resulting in a complication rate of 13% (95% CI: 7% - 25%). Visual acuity and visual field improvement rates after GKRS were 80% (95% CI: 63% - 96%) and 71% (95% CI: 47% - 95%), respectively. Proptosis improved in 94% of cases (95% CI: 83% - 100%). The tumor reduction rate was 77% after GKRS (95% CI: 69% - 85%). In conclusion, GKRS for OCH appears to be a safe technique, as evidenced by the rate of clinical improvement and radiological improvement. However, studies are limited by the absence of a control group, and additional studies are needed to evaluate the relative efficacy of GKRS compared with alternative surgical modalities for OCH.

An Algorithm for the Microsurgical Resection of Cerebellar Cavernomas.

Cavernous malformations (CMs) account for 8% to 15% of all cerebrovascular anomalies and pose clinical significance due to their potential to cause symptomatic hemorrhage, seizures, and focal neurological deficits. While the majority of CMs are located supratentorial, the less common posterior fossa, particularly cerebellar CMs (cCMs), pose a unique treatment challenge. This study aims to contribute to the understanding and management of cerebellar CMs, thereby assisting in the decision-making process for clinical interventions in this patient population. We conducted a retrospective analysis of all patients who were treated for CMs from 2010 to 2023 at our tertiary healthcare facility. Patients with cCMs were further analyzed concerning their treatment strategy and functional outcome based on the modified Rankin Scale. Nine hundred fourteen patients with CMs were treated between 2013 and 2023 at our center. Among these subjects, 6.5% (n = 59) presented with cerebellar lesions. The median age was 54 [37-64] years, and 15 (25.4%) patients showed associated developmental venous anomalies. Nearly half of these patients (49.0%) were surgically treated. Surgical approaches were tailored and individualized to the specific CM location based on a treatment algorithm and encompassed supracerebellar-infratentorial, telovelar, suboccipital transcortical, retrosigmoid transcortical, and retrosigmoidal transhorizontal fissure approaches. Univariate analysis revealed no risk factors concerning postoperative morbidity. The surgically treated patients showed a significant improvement between preoperative and follow-up functional outcomes. cCMs are rare but frequently necessitate surgical intervention. This study enhances the current understanding of cCMs, underscoring the intricate challenges associated with their management. Differentiated algorithms with tailored approaches ensure the optimization of outcomes in the treatment of these challenging lesions.

Retinal arteriovenous malformation and cerebral cavernous malformation in a 6-year-old child

Retinal arteriovenous malformation and cerebral cavernous malformation in a 6-year-old child

Role of the endonasal endoscopic approach in intraorbital tumor surgery: insights from a single-center experience.

This study aimed to evaluate the effectiveness of the endoscopic endonasal approach (EEA) in the surgical management of intraorbital tumors and analyze the adjunctive role of the transorbital approach (TOA) and extended modified medial maxillectomy (EMMM) in addressing anatomically complex tumors. This study retrospectively reviewed 13 cases of primary intraorbital tumors managed with EEA, integrating TOA and EMMM, based on specific tumor location and extent. A detailed analysis was conducted on the surgical techniques used, tumor size and location in relation to critical structures such as the optic nerve, and overall surgical outcomes, with a focus on the extent of resection and postoperative visual function. Of the 13 cases analyzed (4 cavernous hemangiomas, 3 schwannomas, mucosa-associated lymphoid tissue lymphoma, diffuse large B-cell lymphoma, liposarcoma, inflammatory myofibroblastic tumor, osteoma, and myxoid spindle tumor), the EEA served as the primary surgical method, especially for the 8 intraconal tumors situated medially to the optic nerve, with 1 tumor situated inferiorly to the optic nerve. Extraconal tumors, present in 5 cases, necessitated additional approaches: TOA was utilized for tumors with anterior extension, and EMMM was applied to those extending toward the inferior orbital wall. Gross-total resection was accomplished in 80% of the operative cases, with an overall improvement in visual function observed in 69.2% of the patients postsurgery. Complications were infrequent, with enophthalmos requiring subsequent reconstruction and a permanent slight visual field defect in the upper outer quadrant, occurring in 1 case each, underscoring the safety and efficacy of integrated surgical approaches. The combination of EEA with TOA and EMMM provides a comprehensive and adaptable surgical strategy for intraorbital tumors, accommodating various lesion locations and complexities. This combined approach not only facilitates extensive tumor resection but also maximizes the preservation of ocular function and cosmetic outcomes. The favorable results of this study support the use of a multidisciplinary surgical approach and highlight the potential for improved patient outcomes with the continued development of endoscopic techniques. Further research with a larger cohort is essential to validate these findings and establish guidelines for the combined use of these surgical methods.

Cavernous Hemangioma of the Palatine Tonsil: A Case Report and Review of the Literature

Cavernous Hemangioma of the Palatine Tonsil: A Case Report and Review of the Literature

Lesions of the Palm – Mimickers of Dupuytren’s Disease

Background and Aims: Dupuytren’s contracture is a prevalent, hereditary fibroproliferative disorder affecting the palmar aponeurosis, which can resemble various neoplastic and non-neoplastic disorders of the hand. This resemblance poses a diagnostic challenge for healthcare professionals. This observational study aims to evaluate the range of conditions that can be mistaken for Dupuytren’s contracture over a 12-year period (2008–2020) at a specialised orthopaedic oncology centre. Materials and Methods: A retrospective analysis of palmar lesions referred to our tertiary orthopaedic oncology hospital was conducted. Data were gathered from oncology, radiology and histopathology databases. We specifically examined lesions located solely on the palmar aponeurosis, excluding the thenar and hypothenar regions. Patient demographics, clinical features, imaging results and clinical management outcomes were documented for descriptive analysis. Results: A total of 21 palmar lesions meeting the inclusion criteria were identified. The average age of the participants was 48 years (ranging from 3 to 69 years). There was no significant difference in gender distribution, with 11 females and 10 males represented in the cohort. The majority of the identified lesions were benign tumours (16), with one case of malignant rhabdomyosarcoma. Among the benign tumours, lipomas were the most common ( n = 5). Other benign tumours included three neurofibromas, a schwannoma, a granuloma, a ganglion cyst, a giant cell tumour (GCT), an angiomyxoma, a myofibroma, a cavernous haemangioma, a non-specific fibrovascular lesion and four additional non-neoplastic lesions. Conclusion: A variety of benign, malignant or neoplastic conditions of the hand can closely resemble Dupuytren’s contracture, particularly in the initial stages of their development. A thorough clinical examination, combined with a high level of suspicion, along with supplementary investigations and histopathological analysis, is essential for accurate diagnosis and effective management of patients.

Stereotactic radiosurgery (SRS) for patients with brainstem cerebral cavernous malformations (CCMs): an international, multicentric study

Brainstem cerebral cavernous malformations (CCM) are clinically more aggressive compared to superficial CCMs. Due to their location, resection can be challenging, making stereotactic radiosurgery (SRS) an attractive alternative for symptomatic patient. Brainstem CCM patients (n = 170) were treated with Gamma Knife SRS at 11 radiosurgical centers. Hemorrhagic risk reduction, risk factors of post-SRS hemorrhage, and clinical outcomes were retrospectively analyzed. Most patients had a single (165/170 patients) brainstem CCMs treated; the majority of CCMs (165/181) presented with bleeding. Single-session SRS decreased the risk of repeat hemorrhage in patients with hemorrhagic brainstem CCM (HR: 0.17, p < 0.001) using recurrent multivariate analysis. The annual hemorrhage rate decreased from 14.8 per 100 CCM-years before SRS to 2.3 after treatment. Using univariate Cox-analysis, the probability of a new hemorrhages after SRS was reduced for patient older than 35 years (HR = 0.21, p = 0.002) and increased with a margin dose > 13 Gy (HR = 2.57, p = 0.044). Adverse radiation effect (ARE) occurred in 9 patients (5.3%) and was symptomatic in four (2.4%). At a median follow-up of 3.4 years (Inter-quartile range: 5.4), 13 patients (8.0%) had a worsened clinical status, with the treated CCM being the cause in 5.6% (10) of the patients. Single-session SRS decreased the risk of repeat hemorrhage in patients with hemorrhagic brainstem CCM and conveyed this benefit with a low risk of advrse radiation effects (ARE) and worsening clinical status.

In toto resection of a rare intradural extramedullary cavernous malformation on the S1 nerve root: illustrative case.

Cavernous malformations (CMs) are vascular malformations that usually occur in the brain and occasionally in the spine. Most CMs are sporadic, but they can also be caused by heterozygous cerebral cavernous malformation (CCM) gene mutations. This case describes an intradural extramedullary CM in a unique location, within a fascicle of the S1 nerve root. This tumor was found to have a CCM2 mutation. An operative video demonstrates the surgical procedure used to remove this S1 intradural extramedullary CM. A 61-year-old male with an intradural extramedullary CM, located within a fascicle of the S1 nerve root, presented with pain and neurological symptoms. Additional imaging revealed two CCMs. The S1 CM was removed in toto. Subsequently, genetic screening revealed a CCM2 mutation. Given the rarity of a radicular CM, diagnosis can be challenging. CMs should be considered in patients with radicular pain and corresponding nerve root thickening. When a CM is suspected, imaging of the complete neuraxis should be performed. If multiple CMs are found, genetic screening is indicated. Complete resection of the CM yields good clinical results. The operative video in this case might help surgeons encountering this rare pathology to prepare for surgery. https://thejns.org/doi/10.3171/CASE24270.

Multimodality imaging of right ventricular apical atypical cavernous hemangioma.

Multimodality imaging of right ventricular apical atypical cavernous hemangioma.

Radiosurgery versus observation for brainstem cavernous malformations: a 5-year multicentre cohort study.

The role of radiosurgery in preventing haemorrhage in brainstem cavernous malformations remains a subject of debate. This study aims to evaluate whether radiosurgery provides a protective benefit against haemorrhage in these patients. This multicentre, prospective observational study was conducted in 17 centres and enrolled eligible patients with brainstem cavernous malformations consecutively. Data collected included clinical baseline information, radiosurgery planning details, periodic follow-up evaluations, and any adverse radiation effects. The primary outcome of the study was the incidence of first prospective haemorrhage, while the secondary outcome was the development of new or worsening neurological dysfunctions. The impact of radiosurgery was assessed using multivariate Cox regression analysis. From March 2016 to August 2018, the study enrolled 377 patients: 280 in the observation group receiving standard care alone and 97 in the radiosurgery group receiving both radiosurgery and standard care. The overall cohort consisted of 173 females (45.9%) with a mean age of 40.5 years (range, 18-68 years), and there were no significant differences in baseline characteristics between the two groups. After a median follow-up period of 70 months, haemorrhage occurred in 25.0% (n = 70) of patients in the observation group and 10.3% (n = 10) of patients in the radiosurgery group. Multivariate Cox regression analysis identified radiosurgery as an independent protective factor against haemorrhage (hazard ratio 0.379, 95% confidence interval 0.195-0.738, P = 0.004). Following 1:2 propensity score matching, the incidence of prospective haemorrhage were 24.9% (45/181) in the observation group compared to 10.3% (10/97) in the radiosurgery group (hazard ratio 0.379, 95% confidence interval 0.190-0.755, P = 0.006). Adverse radiation effects were observed in 12 patients (12.4%), with none were permanent. Additionally, new or worsening neurological dysfunctions were significantly more common in the observation group (28.9%) compared to the radiosurgery group (16.5%) (P = 0.016). These results suggest that radiosurgery is associated with a low rate of haemorrhage in patients with brainstem cavernous malformations and could provide a benefit in selected patients. However, further research is required to confirm these findings.

Pure Spinal Epidural Cavernous Hemangioma: A Rare Cause of Thoracic Myelopathy

Cavernous hemangiomas mostly occur in intracranial structures but they also may occur in the spine very rarely. Even if found, spinal hemangiomas are commonly vertebral origin and solely epidural hemangiomas not originating from the vertebral bone are very rare. Our case is a 65-year-old man presented to us with progressive paraparesis from six months with motor power 3/5 in both lower extremities. The pathology was total epidural spinal hemangioma at D9-10 vertebral level with typical myelopathy like presentation. Bang. J Neurosurgery 2024; 13(2): 149-151

On Vascular Lesions of the Thyroid Gland with Emphasis on Intrathyroidal Hemangioma: Clinicopathologic Characterization of Two Cases and Review of the Literature

Mesenchymal neoplasms of the thyroid gland are exceptionally rare accounting for less than 0.5% of all intrathyroidal tumors with hemangiomas comprising merely 6% of them. The clinicopathologic characteristics of two additional examples of thyroid hemangioma together with a thorough review of the pertinent literature are presented. A 62-year-old man and an 18-year-old woman presented with asymptomatic, soft-to-palpation, mobile nodules of the right thyroid lobe classified as TI-RADS 5 and TI-RADS 4, respectively, on ultrasound imaging. Microscopically, lesions featured a circumscribed, unencapsulated, lobular proliferation of variably-sized, congested, vascular channels lined by a single layer of flattened, cytologically bland endothelial cells, together with interspersed residual follicles. Vascular endothelial cells were strongly positive for CD31, CD34 and ERG, and negative for pancytokeratin AE1/AE3, TTF1, and PAX8. A diagnosis of cavernous hemangioma was rendered in the clinical setting of Hashimoto thyroiditis and follicular adenoma, respectively. Following inclusion of the current cases, a total of 53 intrathyroidal hemangiomas were identified in the literature with a patient mean age of 48.9 years (range = 0.17-84) and a slight female predilection (F:M = 1.4:1). A proclivity for the right thyroid lobe (59.6%) was noted with the striking majority of cases exhibiting features of cavernous hemangioma (95.2%). Prognosis is favorable and surgical resection is considered curative. The occasionally alarming clinical presentation in conjunction with absence of pathognomonic imaging features and limited diagnostic accuracy of FNA cytopathology for such lesions renders surgical intervention necessary for definitive diagnosis of intrathyroidal hemangiomas and exclusion of other epithelial and non-epithelial pathologic entities.

Intraoperative changes in electrophysiological monitoring can be used to predict clinical outcomes in patients with spinal cavernous malformation.

The study aimed to evaluate the sensitivity and specificity of these monitoring parameters in predicting postoperative neurological dysfunction. In this study, a total of 85 patients with spinal cavernous malformations (SCMs) treated at Xuanwu Hospital, Capital Medical University, from November 2012 to August 2017 were included. During the surgical procedures, all patients underwent monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SEP). The criteria for warning included a reduction of ≥80% in MEP amplitude and ≥50% in SEP amplitude. Among 85 patients, 40 (47.1%) had SCMs located in the thoracic segment, 35 (41.2%) in the cervical segment, 6 (7.1%) in the cervical thoracic segment, and 4 (4.7%) in the lumbar segment. MEP recordings were obtained from 81 patients, and the preoperative McCormick score was 1.53 ± 0.69. The sensitivity of multimodal monitoring combined with the criteria of 80% reduction in MEP amplitude and SEP was 83.9%, with a specificity of 69%, a positive predictive value of 69%, and a negative predictive value of 90.4%. This study emphasizes the crucial role of electrophysiological monitoring, particularly MEP and SEP, during the surgical resection of SCMs. The findings demonstrate that this approach is effective in predicting and preventing postoperative neurological dysfunction, thereby improving patient outcomes.

Efficacy of endoscopic submucosal tunnel dissection in the management of a large esophageal cavernous hemangioma.

Efficacy of endoscopic submucosal tunnel dissection in the management of a large esophageal cavernous hemangioma.

Rare Co-occurrence of Spinal Cord Hemorrhage from Radiation-induced Cavernous Hemangioma and Classical Hodgkin Lymphoma Post-transplant Lymphoproliferative Disorder.

Post-transplant lymphoproliferative disorders (PTLDs) are lymphoproliferative diseases that occur after solid organ transplantation or hematopoietic stem cell transplantation (HSCT). The development of PTLD is often associated with reactivation of Epstein-Barr virus (EBV). A 26-year-old woman with a history of HSCT and total-body irradiation developed spinal cord hemorrhage from a radiation-induced cavernous hemangioma (RICH) shortly after the development of classical Hodgkin lymphoma PTLD with EBV reactivation. Although little is known about the factors leading to hemorrhagic events from spinal cord RICH, we suspect that EBV reactivation may have been a factor contributing to the hemorrhage in the present case.

A Rare Case Report of Cervical Hemangiomatous Polyp.

The uterine cervix is a rare site for cavernous hemangiomas. Cervical hemangiomas are slow-growing tumors with characteristic histological findings, including dilated vessels with increased endothelial cells. Although their pathophysiology remains unclear, hormones are believed to play an important role in the development of these vascular tumors. They may be asymptomatic due to their small size, but they can cause gynecological and obstetrical complications, including abnormal uterine bleeding and impaired fertility. Due to their small size, conservative treatment is the first line of management. Hysterectomy is considered for refractory cases or for patients who are not of childbearing age. We present a case report of a 62-year-old postmenopausal female with postmenopausal bleeding and a polypoid mass hanging over the anterior cervical wall through its stalk. The surgical biopsy revealed no signs of neoplastic changes, with the only notable finding being a polypoidal lesion representing a cavernous hemangiomatous cervical polyp.