Cavernoma, is it necessary to operate?
A common reason for consultation for the neurosurgeon is cavernous angioma or cavernoma, also known as cavernous hemangioma, a type of vascular malformation that can appear in different areas of the brain and is very rare in the spinal cord.
The cavernomas are constituted by a vascular ball in the shape of blackberry, formed by irregular vessels. It does not have brain tissue in its interior, neither arterial contributions nor large drainage veins, being the blood flow inside it low. This characteristic implies a low risk of bleeding. Some of these angiomas can reach a size of up to 5 cm.
In general, this type of pathology manifests as single lesions, but in approximately half of the patients there may be multiple, in which case it is more common to have associated a hereditary character.
The main symptomatology of clinical presentation is epileptic seizures, which vary in intensity and frequency, being in some patients very disabling and greatly affecting their quality of life. Most cavernomas are incidental findings that are detected when performing imaging tests for other reasons.
Up to 20% of the cavernomas are detected because they have suffered bleeding in the form of cerebral hemorrhage of various kinds. Mostly are self-limited microbleedings. An important fact is that the risk of bleeding is not conditioned by the size of the cavernoma.
For the diagnosis of cavernous angiomas we resort to imaging studies (magnetic resonance imaging), in which these lesions show a very characteristic «popcorn» appearance with a halo around low signal.
Cerebral arteriography, contrast study in brain vessels for the diagnosis of vascular lesions such as aneurysms, etc., not objective lesions in the area where the angioma is located, because the cavernomas are part of the group of vascular angiographically hidden malformations .
The treatment options are basically conservative management and surgical treatment.
We reserve the conservative option for those patients with incidental cavernomas, with periodic follow-up in external consultations of neurosurgery.
The neurosurgical treatment is indicated in patients with accessible cavernomas who have presented epileptic seizures, symptomatic bleeding or neurological deficit.
The evolution of these patients after surgery is usually very favorable, with evident improvement of their previous symptoms.
The cavernomas are sometimes located in very delicate areas of the nervous system such as the brainstem. This structure that joins the brain with the spinal cord supports vital functions of the organism. Therefore, this type of cavernoma represents one of the most complex pathologies in our specialty since they can cause very serious neurological sequelae.
Figure 1 shows a brain stem cavernoma (protuberance) that was treated by our team. This is a young man who goes to the emergency room due to loss of strength in hemibody (hemiparesis) and double vision (diplopia). In magnetic resonance, the cavernomatous lesion is complicated by significant bleeding. Fig. 2 shows the control resonance after the neurosurgical intervention in which the cavernoma was removed. The evolution of the patient was favorable, with progressive improvement of the loss of strength and diplopia. At the present time the patient is able to wander.