Makindo Medical Notes

Related Subjects: |Subarachnoid Haemorrhage |Haemorrhagic stroke

Introduction

• Cerebral cavernous malformations are the most common vascular malformations.
• They consist of a collection of abnormal blood vessels that may bleed, sometimes extending beyond their fragile walls.
• Cavernomas are found in 0.1-0.5% of the population and may have a genetic basis.
• They are more prevalent in Hispanic communities, especially among Mexican-Americans.

Pathophysiology

• Cavernomas lack large feeding arteries or draining veins.
• They can occur anywhere in the cerebrum, brainstem, or spinal cord.
• Deeper lesions are more likely to bleed than superficial ones.
• Genetic variants CCM1, CCM2, and CCM3, located on chromosomes 7q, 7p, and 3p, respectively, are linked to familial cases.

Clinical Presentation

• May be asymptomatic or present with intracerebral hemorrhage.
• Common symptoms include focal seizures, focal neurological deficits, raised intracranial pressure, headaches, or hydrocephalus.

Cavernomas in the Midbrain

Investigations

• CT or MRI: Often shows a "raspberry or popcorn-like" appearance with or without associated hemorrhage.
• MRI SWI or GRE: Preferred modality for detecting blood products; highly sensitive.
• Cerebral angiography: Cavernomas are "angiographically occult" and typically do not appear on angiograms.

Management

• Options: Microsurgical resection, stereotactic radiosurgery, or conservative management based on symptoms and location.
• Indications for Surgery: Post-hemorrhage, intractable seizures, or neurological deficits, particularly in non-eloquent brain areas.
• Brainstem cavernomas require careful consideration due to location; surgical management remains controversial. Some evidence suggests resection in brainstem cavernomas is beneficial due to frequent hemorrhage-related morbidity.
• Conservative management with annual MRI follow-up is an option for asymptomatic or low-risk cases.

References

• Management of Cerebral Cavernous Malformations: From Diagnosis to Treatment by Nikolaos Mouchtouris et al.