Intracranial Cavernous Malformations Research Articles

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations

Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR). This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD. One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N= 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics. Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

Management of intracranial cavernous malformations using conservative vs. surgical and/or radiosurgical treatment: A systematic review and meta‑analysis.

Intracranial cavernous malformations (CMs) are vascular lesions with a high bleeding rate. At present, the debate regarding their treatment is still ongoing. The present systematic review and meta-analysis aimed to evaluate the safety of surgery or radiosurgery (SRS) for the management of CMs and to determine their potential outcomes compared with conservative treatment. The present systematic review and meta-analysis investigated the relative articles involving the management of intracranial CMs, namely their natural history (conservative treatment) vs. surgical/SRS treatment through electronic databases until June, 2023. The collected variables included the first author's name, the study period covered, the year of publication, the total number of patients examined and their age, and the number of males. In total, six articles met the eligibility criteria. The total number of patients was 399 (157 in the surgery/SRS group and 242 in the conservative treatment group). The results revealed that surgical or SRS management is a safe procedure for CMs compared with conservative treatment. Notably, the use of hemosiderin in the pre-MRI, the free of seizures parameter and the neurological deficit parameters were associated with improved outcomes in the surgical or SRS group of patients.

Giant Intracranial Cavernous Malformations: A Review on Magnetic Resonance Imaging Characteristics.

Background Intracranial cavernous malformations (CMs), commonly known as cavernomas or cavernous angiomas, are low-flow, well-circumscribed vascular lesions composed of sinusoidal spaces lined by a single layer of endothelium and separated by a collagenous matrix without elastin, smooth muscle, or other vascular wall elements. A diameter greater than 3 cm for a CM is unlikely. These lesions may have atypical appearances on magnetic resonance imaging (MRI). MRI with advanced techniques such as a susceptibility-weighted image or T2-gradient echo, a diffusion-weighted image and corresponding apparent diffusion coefficient map, and diffusion tensor tractography have revolutionized the diagnostic approach to these lesions. Materials and Method The present study reviews the etiopathogenesis, clinical manifestations, MRI strategy, and MRI appearances of the CMs, with a few examples of the giant CMs from our archive. Results Intracranial giant CMs may have unexpected locations, sizes, numbers, and varied imaging appearances due to repeated hemorrhages, unusual enhancement patterns, intense perifocal edema, and unusual associations, making the differential diagnosis difficult. Conclusion Familiarity with the MRI appearances of the giant intracranial CMs and the differential diagnosis improves diagnostic accuracy and patient management.

Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis.

Brainstem cavernous malformations (CMs) encompass up to 20% of all intracranial CMs and are considered more aggressive than cerebral CMs because of their high annual bleeding rates. Microsurgical resection remains the primary treatment modality for CMs, but long-term functional outcomes and complications are heterogenous in the literature. The authors performed a systematic review on brainstem CMs in 4 databases: PubMed, EMBASE, Cochrane library, and Google Scholar. We included studies that reported on the long-term functional outcomes and complications of brainstem CMs microsurgical resection. A meta-analysis was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search yielded 4781 results, of which 19 studies met our inclusion criteria. Microsurgery was performed on 940 patients (mean age 35years, 46.9% females). Most of the brainstem CMs were located in the pons (n = 475). The pooled proportions of improved, stable, and worsened functional outcomes after microsurgical resection of brainstem CMs were 56.7% (95% CI 48.4-64.6), 28.6% (95% CI 22.4-35.7), and 12.6% (95% CI 9.6-16.2), respectively. CMs located in the medulla were significantly (p = 0.003) associated with a higher proportion of improved outcome compared with those in the pons and midbrain. Complete resection was achieved in 93.3% (95% CI 89.8-95.7). The immediate postoperative complication rate was 37.2% (95% CI 29.3-45.9), with new-onset cranial nerve deficit being the most common complication. The permanent morbidity rate was 17.3% (95% CI 10.5-27.1), with a low mortality rate of 1% from the compiled study population during a mean follow-up of 58months. Our analysis indicates that microsurgical resection of brainstem CMs can result in favorable long-term functional outcomes with transient complications in the majority of patients. Complete microsurgical resection of the CM is associated with a lower incidence of CM hemorrhage and the morbidity related to it.

Prognostic Factors Analysis for Intracranial Cavernous Malformations Treated with Linear Accelerator Stereotactic Radiosurgery.

Stereotactic radiosurgery (SRS) is generally considered a substitute for cranial cavernous malformations (CCMs). However, prognostic factors for post-radiosurgery CCM rebleeding and adverse radiation effects have not been well evaluated, and the effect of timing and optimal treatment remains controversial. Therefore, this study evaluated prognostic factors for post-radiosurgical rebleeding and focal edematous changes in 30 patients who developed symptomatic intracranial hemorrhage due to solitary non-brainstem CCM and received linear accelerator (LINAC) SRS in a single medical center from October 2002 to June 2018. An overall post-radiosurgical annual hemorrhage rate with 4.5% was determined in this study. In addition, a higher marginal dose of >1600 centigray and earlier LINAC SRS intervention were correlated with a significantly lower post-radiosurgical annual hemorrhage rate. A lesion size larger than 3 cm3 and a coexisting developmental venous anomaly were significant risk factors for post-radiosurgical focal brain edema but mostly resulted in no symptoms and were temporary. This study demonstrated the efficacy of LINAC SRS in preventing CCM rebleeding and suggests that earlier radiosurgery treatment with a higher dose for non-brainstem symptomatic CCMs be considered.

How can we optimize the long-term outcome in children with intracranial cavernous malformations? A single-center experience of 61 cases

The objective is to provide a treatment algorithm for pediatric patients with intracranial cavernous malformations (CMs) based on our experience. Patients < 18 years of age who were treated either surgically or conservatively at the authors’ institution between 1982 and 2019 were retrospectively evaluated. A total of 61 pediatric patients were treated at the authors’ institution: 39 with lobar CMs; 18 with deep CMs, including 12 in the brainstem and 6 in the basal ganglia; and 4 with CMs in the cerebellar hemispheres. Forty-two patients underwent surgery, and 19 were treated conservatively. The median follow-up time was 65 months (1–356 months). In surgically treated patients, lesions were larger (2.4 cm vs 0.9 cm, p < 0.001). In patients with lobar CMs, seizures were more common (72% vs 21%, p = 0.003) in the surgery group than in conservatively managed patients. In deep CMs, modified Rankin scale (mRS) was higher (4 vs 1, p = 0.003) in the surgery group than in conservatively treated patients. At the time of last follow-up, no differences in Wieser outcome class I were seen (86% vs 67%) in lobar CMs, and mRS scores had aligned between the treatment groups in deep CMs (1 vs 0). We encountered no new permanent neurological deficit at time of last follow-up. We propose a treatment algorithm according to lesion location and size, burden of symptoms, epilepsy workup, and further clinical course during observation. A conservative management is safe in pediatric patients with asymptomatic CMs. Gross total resection should be the aim in patients with symptomatic lobar CMs. A less aggressive approach with subtotal resection, when required to prevent neurological compromise, sustainably improves neurological outcome in patients with deep CMs.

Laser Interstitial Thermal Therapy for Cavernous Malformations: A Systematic Review.

BackgroundMicrosurgical resection of intracranial cavernous malformations (CM) is regarded as the standard treatment, but in recent years, there has been a trend toward minimally invasive procedures like ablation of such lesions by using laser interstitial thermal therapy (LITT).MethodsA systematic search using keywords ‘laser interstitial thermal therapy’ OR ‘LITT’ AND ‘cavernoma’ OR ‘cavernous angiomas’ OR ‘cavernous malformations’ was conducted in MEDLINE (PubMed), Scopus, Embase, and Cochrane electronic bibliographic databases and studies reporting the outcome of LITT procedure on intracranial CM were included. The demographic data, symptoms of patients, location and size of the lesion, and surgical outcome were extracted from the articles.ResultSix studies, reporting the outcome of 33 patients were included in this review. In 26 patients, CM was identified as the epileptogenic foci and in others, CM was the source of headache or focal neurological deficits. LITT led to a satisfactory outcome in all patients except for three who achieved improvement in symptoms after the open resection of the lesion. Most of the post-operative complications were transient and resolved at the time of the last follow up. Cyst formation at the previous ablated CM site was reported as the long-term complication of LITT in one case.ConclusionLITT can provide a comparable outcome to the open resection of CMs, by having less invasiveness, even in deep and eloquent area lesions, and complications that are often temporary and disappear gradually. However, technical issues, such as thermal monitoring during the procedure, are considered a challenge for this procedure in CMs. Further studies with a larger population are needed to report this method's long-term outcome and complications on CMs.

Intraventricular Choroid Plexus Cavernoma Resection Using Tubular Retractor System and Exoscope Visualization: A Technical Case Report

Cavernous malformations (CMs) account for approximately 5% to 10% of all CNS vascular malformations, and intraventricular CMs (IVCMs) are a rare subtype, accounting for 2.5% to 10.8% of all intracranial CMs. IVCMs can expand rapidly, leading to compression of adjacent structures, intraventricular hemorrhage, and obstructive hydrocephalus. Diagnosis is challenging because it can mimic a variety of other lesions. A 71-year-old man presented after a fall because of imbalance. MRI of the head showed a homogenously enhancing 2-cm mass in the posterior aspect of the right lateral ventricle, with blood layering in the right occipital horn and adjacent parietal edema and leptomeningeal enhancement, as well as a pituitary lesion. The patient underwent a right parietal craniotomy for resection of the mass. The ventricle was accessed through a transsulcal approach through the intraparietal sulcus using a tubular retractor system. The mass was arising from the choroid plexus and dissected free in a piecemeal fashion. Postoperative imaging confirmed gross total resection, and the patient had an uneventful recovery. Here, we present the first case of a choroid plexus IVCM removed using a tubular retractor system. We demonstrate that this is a safe and effective approach for this rare lesion given the minimal traction on brain parenchyma and enhanced visualization of a deep-seated cavernoma in the lateral ventricle.

How can we optimize the long-term outcome in children with intracranial cavernous malformations? A single-center experience of 61 cases

How can we optimize the long-term outcome in children with intracranial cavernous malformations? A single-center experience of 61 cases

Spontaneous regression of multiple intracranial capillary hemangiomas in a newborn—long-term follow-up and literature review

Intracranial capillary hemangiomas (ICHs) have a natural history and behavior that is very different from intracranial cavernous malformations. The literature is not consistent as to the best management strategy for ICHs. Our patient is a 40-day-old male infant who presented with progressive increase in head circumference and multiple cutaneous capillary and ICHs. Obstructive hydrocephalus necessitated urgent cerebrospinal fluid (CSF) diversion, but no other surgical intervention was pursued due to the high risk-to-benefit ratio. All intracranial lesions spontaneously regressed by 11 years of age, albeit at a slower speed than the cutaneous lesions, with no functional or cognitive sequelae. We conducted a comprehensive literature review and provided a summary of all reported ICH cases. Asymptomatic patients with ICHs are best approached with close follow-up and serial imaging studies as the potential for spontaneous regression is relatively high. Patients with isolated lesions or unclear diagnoses may benefit from a stereotactic biopsy, and surgical resection should be reserved for symptomatic lesions only.

Utility of a Quantitative Approach Using Diffusion Tensor Imaging for Prognostication Regarding Motor and Functional Outcomes in Patients With Surgically Resected Deep Intracranial Cavernous Malformations.

Resection of deep intracranial cavernous malformations (CMs) is associated with a higher risk of neurological deterioration and uncertainty regarding clinical outcomes. To examine diffusion tractography imaging (DTI) data evaluating the corticospinal tract (CST) in relation to motor and functional outcomes in patients with surgically resected deep CMs. Perilesional CST was characterized as disrupted, displaced, or normal. Mean fractional anisotropy (FA) values were obtained for whole ipsilateral CST and in 3 regions: subcortical (proximal), perilesional, and distally. Mean FA values in anatomically equivalent regions in the contralateral CST were obtained. Clinical and radiological data were collected independently. Multivariable regression analysis was used for statistical analysis. A total of 18 patients [brainstem (15) and thalamus/basal ganglia (3); median follow-up: 270 d] were identified over 2 yr. The CST was identified preoperatively as disrupted (6), displaced (8), and normal (4). Five of 6 patients with disruption had weakness. Higher preoperative mean FA values for distal ipsilateral CST segment were associated with better preoperative lower (P<.001), upper limb (P=.004), postoperative lower (P=.005), and upper limb (P<.001) motor examination. Preoperative mean FA values for distal ipsilateral CST segment (P=.001) and contralateral perilesional CST segment (P<.001) were negatively associated with postoperative modified Rankin scale scores. Lower preoperative mean FA values for overall and defined CST segments corresponded to worse patient pre- and postoperative motor examination and/or functional status. FA value for the distal ipsilateral CST segment has prognostic potential with respect to clinical outcomes.

P03.06 Cavernous malformations of the brainstem: radiosurgical management with gamma knife

Abstract BACKGROUND About 20% of intracranial cavernous malformations (CM) occur in the brainstem. The greatest risk of brainstem CM is hemorrhage which can be devastating and even fatal in this location. The optimal management for these lesions would naturally be microsurgical resection. However, surgery in this location is associated with significant morbidity and mortality. Gamma knife radiosurgery provides a safer alternative. The purpose of this study is to investigate the efficacy of gamma knife radiosurgery for brainstem CM in preventing bleeding, as well as, assess safety with regards to radiation-induced complications. Additionally, we aimed to evaluate the feasibility and safety of volume-staged gamma knife radiosurgery for larger CM in the brainstem. MATERIAL AND METHODS Between September 2007 and August 2017, 48 patients with brainstem CM were treated by gamma knife. Thirty-two patients were available for follow up of at least one year. A total of 33 lesions were treated (one patient had two brainstem CM). Twenty-eight patients had at least one hemorrhagic event before radiosurgery. The patients underwent 40 gamma knife sessions. These included 28 single sessions (including two sessions for same patient for 2 different lesions in pons). Five patients had volume-staged gamma knife treatments due to the large size of the CM. The median total CM volume/lesion was 0.8 cc (0.1–30.4 cc), while the median target volume/session was 1 cc (0.1–11.5 cc). The median prescription dose was 12 Gy (10–14 Gy). RESULTS The mean follow up after treatment was 40 months (12–95 months). The annual hemorrhage rate (AHR) before gamma knife radiosurgery was 25.5%. After treatment there were a total of 5 hemorrhagic events with an overall AHR of 4.5%. Three hemorrhagic events occurred in the first 2 years after treatment with an AHR of 2.7% and 2 events more than 2 years after treatment with an AHR of 2.2%. No hemorrhagic events occurred among the patients treated by volume-staged radiosurgery. Clinical improvement was observed in 15 (46.9%) patients. Temporary adverse radiation events developed in 6 patients (19%). CONCLUSION Gamma knife radiosurgery provides an effective and safe treatment alternative to surgery for brainstem CM. Volume-staged gamma knife radiosurgery for brainstem CM appears to be a viable option for larger CM.

Coexistence of Intracranial and Spinal Cord Cavernous Malformations Predict Aggressive Clinical Presentation.

Background: Patients with spinal cord cavernous malformations (CMs) are at increased risk for multiple neuraxis CMs. Few studies focused on the natural history of patients with coexistence of intracranial and spinal cord CMs.Methods: Forty patients who underwent both intracranial and spinal MR imaging from a single center were reviewed retrospectively. American Spinal Injury Association (ASIA) impairment scale was used to evaluate neurological and disability status.Results: The median age of the 40 patients was 40.6 years old (range 9–69), and the male-to-female ratio was 2.1:1. The mean size of the intramedullary lesions was 10.1 ± 5.8 mm (range, 3.0–34.0 mm). Six patients (15%) harbored at least one intracranial lesion. Five of the 6 patients (83.3%) suffered aggressive clinical presentations with severe neurological and disability status; in patients with sporadic spinal CMs, the proportion was 26.5% (9 of 34). Coexistence of intracranial and spinal cord CMs is more likely to follow an aggressive course (P = 0.031, OR = 19.547, 95% CI = 1.322–289.123). In the postoperative long-term follow up, the unfavorable rate of patients with associated intracranial CMs was significantly higher than that of patients with sporadic spinal cord CMs (P = 0.049).Conclusions: The prevalence of associated intracranial CMs in patients with spinal cord CMs was 15%. Coexistence of intracranial and spinal cord CMs is more likely to follow an aggressive course. This study highlights the necessity of intracranial MR imaging for patients with spinal cord CMs to benefit to the predicting prognosis and selection of treatment strategies.

Evaluation of sporadic intracranial cavernous malformations for detecting associated developmental venous anomalies: added diagnostic value of C-arm contrast-enhanced cone-beam CT to routine contrast-enhanced MRI.

Our purpose was to investigate the added diagnostic value of C-arm contrast-enhanced cone-beam CT (CE-CBCT) to routine contrast-enhanced MRI (CE-MRI) in detecting associated developmental venous anomalies (DVAs) in patients with sporadic intracranial cavernous malformations (ICMs). Fifty-six patients (53 with single and three with double ICMs) met the inclusion criteria. All patients had routine CE-MRI scans performed at 1.5 Tesla. The imaging studies (CE-MRI and CE-CBCT) were retrospectively and independently reviewed by two observers, with consensus by a third. Group difference, intra- and interobserver agreement, and diagnostic performance of the modalities in detecting associated DVAs were calculated. Reference standard was CE-MRI. On CE-MRI and CE-CBCT, 37 (66%; of 56) and 47 patients (84%; of 56) had associated DVAs, respectively. In 10 patients (52.6%; of CE-MRI negatives [n=19]), CE-CBCT improved the diagnosis. Nine patients (16%; of 56) had no DVA on both imaging techniques. Difference in proportions of associated DVAs on CE-MRI and CE-CBCT was statistically significant, p < 0.05. Sensitivity, specificity, positive likelihood ratio, and area under the curve of CE-CBCT were 100% (95% confidence interval [CI]: 90.5-100%), 47.3% (95% CI: 24.4-71.1%), 1.9 (95%CI: 1.240-2.911), 0.737 (95%CI: 0.602-0.845), respectively. Intraobserver agreement was excellent for CE-MRI, kappa (κ) coefficient = 0.960, and CE-CBCT, κ=0.931. Interobserver agreement was substantial for CE-MRI, κ=0.803, and excellent for CE-CBCT, κ=0.810. CE-CBCT is a useful imaging technique especially in patients with negative routine CE-MRI in terms of detecting associated DVAs. In nearly half of these particular patients, it reveals an associated DVA as a new diagnosis. • Although it is known to be the gold standard, some of the DVAs associated with ICMs are underdiagnosed with CE-MRI. • In nearly half of the patients with negative routine CE-MRI, CE-CBCT reveals an associated DVA as a new diagnosis. • Intra- and interobserver agreement on CE-CBCT is excellent in terms of detecting associated DVAs.

Risk Factors for Unfavorable Outcomes in Surgically Treated Brainstem Cavernous Malformations.

Brainstem cavernous malformations (BSCMs) account for up to 18% of all intracranial cavernous malformations. Due to their complex anatomic location, they represent a significant challenge for neurosurgeons. As such, the identification of risk factors associated with negative outcomes is of significant importance. We analyze a series of 50 cases of BSCMs treated surgically in order to identify risk factors for unfavorable outcomes. Patients who underwent surgical resection of BSCM at our institution between 2000 and 2015 were retrospectively reviewed. Univariate and multivariable logistic regression models were used to identify predictors of unfavorable outcomes, defined as those with a modified Rankin score (mRs) of >2. Fifty Latin American patients, with a mean age of 35.85 ± 13.06 years, consisting of 29 females (58%) and 21 males (42%), underwent surgical resection. Mean modified Rankin Scale (mRs) score at admission was 2.6 ± 1.05, and the mean BCSM size was 18.00 ± 7.19 mm. The rate of gross total resection was 92%. Overall, 80% of patients showed improved or unchanged clinical status at the last follow-up period; however, only 58% of patients had a favorable outcome with a mean mRs of 2.33 ± 1.136. Multivariable logistic binary regression identified hemorrhagic recurrence (P= 0.040), lower cranial nerve deficit (P= 0.019), and BSCMs >15 mm in diameter (P= 0.006) as predictive factors for unfavorable surgical outcomes. BSCM size, compromise of lower cranial nerves, and hemorrhagic recurrence before surgery were identified as risk factors associated with unfavorable outcomes of surgically treated BSCMs in this cohort.

術中画像支援・モニタリングを用いた頭蓋内海綿状血管腫に対する摘出術

術中画像支援・モニタリングを用いた頭蓋内海綿状血管腫に対する摘出術

Clinical Features and Treatment of Intracranial Cavernous Malformations

Clinical Features and Treatment of Intracranial Cavernous Malformations

Evaluation of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) for cerebral cavernous malformations: a 15-year single-center experience

BACKGROUND AND OBJECTIVESSurgery is the principal treatment for safely accessible hemorrhagic and symptomatic cavernous malformations. Nevertheless, the role of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) in the management of high-risk, symptomatic cavernoma lesions warrants further refinement. In this study, we evaluate the use of LINAC-based SRS for cerebral cavernous malformations (CMs) and report our 15-year single-center experience.DESIGN AND SETTINGSA retrospective study from the Department of Radiation Oncology and the Department of Neurosurgery at Gulhane Military Medical Academy and Medical Faculty, Ankara from April 1998 to June 2013.PATIENTS AND METHODSFifty-two patients (22 females and 30 males) with cerebral CM referred to our department underwent high-precision single-dose SRS using a LINAC with 6-MV photons. All patients had at least 1 bleeding episode prior to radiosurgery along with related symptoms. Median dose prescribed to the 85% to 95% isodose line encompassing the target volume was 15 Gy (range, 10–20).RESULTSOut of the total 52 patients, follow-up data were available for 47 patients (90.4%). Median age was 35 years (range, 19–63). Median follow-up time was 5.17 years (range, 0.08–9.5) after SRS. Three hemorrhages were identified in the post-SRS period. Statistically significant decrease was observed in the annual hemorrhage rate after radiosurgical treatment (pre-SRS 39% vs post-SRS 1.21, P<.0001). Overall, there were no radiosurgery-related complications resulting in mortality.CONCLUSIONLINAC-based SRS may be considered as a treatment option for high-risk, symptomatic cerebral CM of selected patients with prior bleeding from lesions located at surgically inaccessible or eloquent brain areas.

Left retrosigmoid craniotomy for cavernous malformation of the middle cerebellar peduncle

We present a 25-year-old female with a history of multiple intracranial cavernous malformations complaining of vertigo. Imaging is significant for increasing size of a lesion in her left cerebellar peduncle. Given the proximity to the lateral border of the cerebellar peduncle, a retrosigmoid approach was chosen. After performing a craniotomy that exposed the transverse-sigmoid sinus junction, the dura was open and reflected. The arachnoid was sharply opened and cerebrospinal fluid was aspirated to allow the cerebellum to fall away from the petrous bone. The cerebellopontine fissure was then opened to visualize the lateral wall of the cerebellar peduncle. The cavernous malformation was entered and resected. The video can be found here: http://youtu.be/P7mpVbaCiJE .

Clinical features and treatment of intracranial cavernous malformations

Objective To summarize the clinical features,imaging features and treatment principles of intracranial cavernous malformations ( CMs),and provide evidence for effective treatment of intracranial CMs.Methods Clinical data of 127 patients with intracranial CMs treated by microsurgical resection from September 2005 to September 2011 were retrospectively analyzed.Results There were 63 males and 64 females included in 127 patients aged 8 to 62 years.A total of 139 lesions were found with 133 intra - axial ( 103 supratentorial lesions and 30 infratentorial lesions) and 6 extra - axial lesions ( all located in left cavernous sinus ).Epilepsy was the most common clinical symptom; other symptoms included headache and impairment of cranial nerves.mulberry - like appearance was the typical features of intra - axial lesions in MRI,while extra - axial lesions had different features.All patients received microsurgical treatment.All but five giant lesions were totally removed.One patient suffered post - operative mild hemiparesis.Four patients with pre - operative epilepsy still need anti - epileptic treatment,but no post - operative seizures were found.Conclusions Intra - axial CMs,mainly supratentorial,are the most common type of intracranial CM.Surgical treatment,the first treatment choice,can get good results.Extra -axial CMs are a rare type of intracranial CM that mainly locates in cavernous sinus.Both surgical resection and radiosurgery can get satisfactory results. Key words: Cavernous malformations; Cavernous sinus; Surgical procedures,operative