Marco Giulioni

Cavernous angiomas of the spinal district: surgical treatment of 11 patients.

Cavernous angiomas, also called cavernous malformations or cavernomas, are vascular hamartomas accounting for 3–16% of all angiomatous lesions of the spinal district. Although histologically identical, these vascular anomalies may exhibit different clinical behavior and radiological features, depending on their location, hinting at different managements and therapeutic approaches. The authors report 11 cases of symptomatic spinal cavernous angiomas diagnosed and surgically treated over the past 18 years. Age of patients ranged from 15–75 years; males outnumbered females. Three patients had vertebral cavernous malformations, secondarily invading the epidural space; two had pure epidural lesions; two patients had intradural extramedullary lesions, and four intramedullary lesions. Surgical removal was completely achieved in four patients with intramedullary lesions, in two with subdural extramedullary lesions, and in one with a pure epidural lesion. Subtotal excision of another one epidural and three vertebral cavernous angiomas was followed by radiotherapy. There was no morbidity related to surgery; the mean follow-up was 2 years. The outcome was excellent in two cases, good in six, and unchanged in the other three. The authors discuss the different modalities of treatment of these vascular lesions variously placed along the spine.

Intracranial and orbital cavernous angiomas: a review of 74 surgical cases.

We present a surgical series of 74 patients (30 males and 44 females) with pathologically verified cavernous angiomas of the intracranial and orbital compartments. Patients were admitted between 1975 and 1991; six had a family history of cerebral cavernomas, and two had multiple (two) lesions. The 76 malformations were located as follows: 57 were in the cerebral hemispheres, four in the supratentorial ventricles, one was in the middle cranial fossa, two were in the brain stem, five in the cerebellum and seven in the orbits. Seizures and focal neurological deficits, and decrease of visual acuity with exophthalmus, were the main clinical signs observed in patients with intracranial and orbital cavernomas, respectively. Sixteen patients (21.6%) had a clinically significant haemorrhage attributable to the cavernous angioma. A number of these vascular malformations were misdiagnosed by computed tomography. In the last 10 years magnetic resonance imaging has been the most sensitive method for detecting these lesions. Seventy-four of the 76 diagnosed cavernomas were treated surgically: a complete excision was obtained in 68 patients; in two patients with multiple lesions only those causing symptoms were removed. Surgery for the 10 deep lesions was aided considerably by stereotactic localization. Two patients died in the immediate postoperative course. The overall outcome was good in 66 of the 72 remaining patients, resulting in improved seizure control or lessened neurological deficit.

Results of surgery in children with cerebral cavernous angiomas causing epilepsy

Epilepsy is the most frequent presenting symptom of cerebral cavernous angiomas or cavernomas, and surgical removal of these vascular malformations is considered the treatment of choice in patients with intractable or long-standing seizures, or in those with poor compliance to medical therapy. In this paper the results of surgical treatment in 11 children with seizures from cerebral cavernomas are reported. Surgery for deep-seated cavernomas was aided in 3 cases by a stereotactic localization technique, that allowed a limited approach with minimal brain damage. Major morbidity and mortality were absent; follow-up ranged between 1 to 16 years. Improved seizure control was seen in all the patients: eight (72%) became seizure-free with the same preoperative therapy; one became seizure-free with a lower drug dosage, and two (18%) were seizure-free without medical therapy. The removal of cavernomas prevented the risk of haemorrhages or further deficits from growth and, above all, avoided spreading and autonomization of the epileptogenic area induced by the cavernoma.

Surgical management of cavernous angiomas in children

Cavernous angiomas are vascular malformations affecting any part of the central nervous system (CNS). The management of asymptomatic cavernous angiomas is still debated due to their poorly understood natural history, although more data are now available regarding results of surgical treatment in symptomatic cases. The authors report their surgical experience with 18 pediatric patients operated on for symptomatic CNS cavernous angiomas. The children ranged in age from 10 months to 17 years, without a relevant sex difference. Cavernous angiomas were intracranial in 17 cases: 15 being in the supratentorial compartments and two in the cerebellum. Clinical manifestations were as follows: seizures in 11 cases, focal neurologic deficits in five, and headache in one. The 18th case was observed in a girl showing paraparesis in the spinal subdural-extramedullary space at T8-T9 level. Excision of four deep cerebral lesions was performed after stereotactic localization through non-eloquent cortex. Pathologic confirmation of cavernous angiomas was obtained in all patients. Mortality from surgical procedures was absent in this series. The follow-up period ranged from 1 to 16 years. All 11 epileptic patients obtained seizure control; improvement or stabilization of neurologic symptoms was observed in the remaining seven patients.

Intracranial squamous cell carcinoma arising in an epidermoid cyst.

Intracranial epidermoid cysts are uncommon benign tumors of developmental origin; malignant transformation is extremely rare. We report a case of squamous cell carcinoma arising in a chiasmatic-parasellar epidermoid cyst. Malignant change had not been suspected until histological examination revealed it.

Cerebral astrocytoma and cavernous angioma: A case report

The authors report a case of cerebral astrocytoma associated with a cavernous angioma. The patient presented with seizures and progressive hemiparesis. Diagnostic studies suggested the presence of a cavernous malformation with signs of previous haemorrhage. Surgery disclosed a complex tumour, which on histological examination revealed to be an anaplastic astrocytoma associated with a cavernous angioma.

Is autopsy tissue a valid control for epilepsy surgery tissue in microRNA studies

MicroRNAs (miRNAs) are differentially expressed in the brain under pathologic conditions and may therefore represent both therapeutic targets and diagnostic or prognostic biomarkers for neurologic diseases, including epilepsy. In fact, miRNA expression profiles have been investigated in the hippocampi of patients with epilepsy in comparison with control, nonepileptic cases. Unfortunately, the interpretation of these data is difficult because surgically resected epileptic tissue is generally compared with control tissue obtained from autopsies. To challenge the validity of this approach, we performed an miRNA microarray on the laser microdissected granule cell layer of the human hippocampus obtained from surgical samples of patients with epilepsy, autoptic nonepileptic controls, and patients with autoptic epilepsy, using the latter as internal control. Unfortunately, it is extremely difficult to collect autopsy material from documented epilepsy individuals who died of non–epilepsy‐related causes—we found only two such cases. However, hierarchical clustering of all samples showed that those obtained from autopsies of patients with epilepsy segregated with the other autoptic samples (controls) and not with the bioptic tissues from the surgery patients, suggesting that the origin of the tissue (surgery or autopsy) may be prevalent over the underlying pathology (epilepsy or not epilepsy). Even taking into account the limitations due to the small number of cases, this observation arises concerns on the use of autopsy tissue as control for this kind of studies.