Cavernous Angiomas (Cavernomas)

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Learning objectives

  • Understand the aetiology and risk factors for cavernomas
  • Understand the risks of bleeding
  • Be able to recognise the clinical presentation
  • Discuss diagnostics and treatment strategies
  • Understand the careful balance between bleeding and intervention risks

Introduction

A cavernoma is a collection of abnormal blood vessels which can bleed and this may extend beyond its fragile walls. It is red/blue in appearance and has been likened to a raspberry-like appearance. They contain blood products at various stages of evolution and are usually less than 3 centimetres in size. Cavernomas may be seen in 0.1-0.5% of the population and some have a genetic basis. They are commoner in Hispanic communities (especially Mexican-American). The pathology is different to AVM in that there is no large feeding artery or large draining vein. Can be found in either hemisphere but also in pons and cervicothoracic cord. The deep situated lesions tend to bleed more than superficial. Note that for every 100 MRIs you will find an unruptured aneurysm, for every 500 MRIs you will find an asymptomatic cavernomas, for every 2000 MRIs you will find an asymptomatic AVM.

Clinical

Clinical presentation includes silence or presentation with intracerebral haemorrhage, seizures, focal neurology or raised ICP, Headaches or Hydrocephalus.

Investigations

  • CT/MRI may show the Cavernomas. They are not well seen on a cerebral angiogram as there is no feeding vessel unlike an AVM. "Black blood" sequences on MRI will show up haemorrhagic lesions.

Management

Management may be surgical - if after a bleed, intractable seizures or neurological dysfunction, Depends on location e.g. great care in highly eloquent areas such as brainstem where a conservative approach is taken. Surgical management of particular brainstem cavernomas is controversial. There is some evidence that resection of brainstem cavernomas is the treatment of choice in the majority of these cases because of the high incidence of morbidity related to one or often several brainstem haemorrhages. [Madjid S et al 2001]

References and Further reading