26 Microsurgery of Cavernous Malformations

Oludotun Ogunsola, Justin L. Sim, James Amoss, Robert A. Solomon, and E. Sander Connolly Jr

Abstract

Cavernous malformations are increasingly being identified due to the proliferation of magnetic resonance imaging (MRI) scanning. They can affect any part of the neuraxis and tend to be intra-axial. Standard surgical approaches, as might be used for other intra-axial surgery, usually suffice when removal is desired. Indications for surgery are somewhat controversial, but most agree that recurrent seizures, recurrent bleeding, or any bleeding into an eloquent area where surgery can be performed with reasonable risk justify strong consideration. Surgical risk can often be mitigated by allowing the recent bleed to liquefy, if the patient is stable. Other useful adjuncts include MRI tractography and MRI guidance, which can be merged intraoperatively. Lesions that present to or actually rupture through a pial surface lend themselves to resection as do those that present to a ventricular margin. Operative approaches should generally be designed to access the lesion perpendicularly though the least amount of eloquent brain tissue. Once one engages the margin of the lesion, care should be taken to preserve any associated venous malformation and to employ as little cautery as possible, which is often facilitated by gently retracting the lesion margin with micro-forceps and using sharp dissection. In rare cases, where surgery is not a good option and conservative management fails, radiosurgery or laser thermal ablation can be employed. That said, microsurgery remains the uncontested gold standard for the vast majority of lesions.

Key words

cavernous malformation - surgery - microsurgery - hemorrhage - vascular malformation - venous angiomas

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