Cavernous Malformations

Cavernous malformations are angiographically occult; therefore, endovascu-lar techniques have no role in the treatment of these lesions. Although the natural history of these lesions is incompletely understood and variable, it is significantly more benign than the natural course of AVMs. Nonoperative therapy is probably the best course for most incidentally discovered cavernous malformations. Symptomatic lesions are best treated with standard microsurgical

Fig. 3. Transvenous embolization of dural arteriovenous fistula. (A) AP and (B) lateral venograms through a microcatheter placed at the precise site of the fistula. Arrows point to endovascular coils deposited at the site of the fistula to obliterate the lesion.

techniques. A useful addition to the surgical armamentarium is the availability of intraoperative stereotactic localization. A number of frameless stereotactic systems are now available with acceptable accuracy that are extremely useful for planning small craniotomies, locating deep-seated lesions, minimizing brain retraction, and limiting the corticectomy. (Fig. 4)

Radiosurgery has been attempted for the treatment of deep-seated cavernous malformations (14). There is a higher incidence of complications compared with similar series of patients with AVMs. This is probably owing to the deleterious

Fig. 4. Frameless stereotactic localization of cavernous malformation. Axial MRI shows small cavernous malformation below the surface of the brain that was readily located and removed utilizing frameless stereotactic guidance.

effects of radiation injury. It is also well known that cavernous malformations undergo spontaneous reduction in size after a hemorrhage. Although it has been suggested that radiosurgery may reduce the subsequent risk of hemorrhage, this remains to be proved, and evidence of disappearance of cavernous malformations following radiosurgery is lacking. Because of these factors, radiosurgery is not recommended as a treatment option for these lesions except experimentally, utilizing carefully selected criteria. An exception to this is extracerebral cavernous malformations of the middle fossae. Surgical extirpation of these lesions can be formidable because of their propensity to cause life-threatening intraoperative hemorrhages. Initial biopsy followed by radio-surgery and surgical resection provides the best results (44).

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