Cavernomas hemorrhage

Spinal cavernomas are a specific problem. The vast majority ( 80%) of patients who initially present with neuropathic pain due to spinal cavernoma hemorrhage may suffer a chronic pain syndrome after resection of the lesion. The experience of Cohen-Gadol et al. (2006) is that neuropathic pain due to cavernoma hemorrhage is refractory to surgical treatment. Therefore, the pain associated with spinal cavernoma hemorrhage may not provide adequate justification for surgical therapy. Prophylactic surgery in spinal cavernoma is not recommended. 

In the presence of an intraspinal hemorrhage spinal vascular malformation, cavernoma, coagulopathy and tumor have to be differentiated. 

Pontine hemorrhages are fatal in around 50% of patients (Wijdicks and St. Louis 1997). Those caused by cavernomas or arteriovenous malformations have a better outcome (Rabinstein et at 2004). The management of patients with hypertensive pontine hemorrhage is usually conservative, but some case reports have documented successful stereotactic aspiration. However, there is likely publication bias and the natural history of the condition is difficult to predict since patients with small hemorrhages do well with conservative management. 

A major problem of most studies reporting hemorrhages due to a DVA is how they ruled out an associated cavernoma. It is clearly not enough just to obtain T2-weighted images in patients with DVAs. All... 

Cavernomas maybe calcified and have a typically pop-corn like appearance on MRI Surgical resection is recommended for cavernomas presenting with symptomatic hemorrhage in accessible and non-eloquent locations... 

The central clinical and therapeutic problem in patients with cavernomas is the question of hemorrhage. On a first view, this should be a simple question with a simple answer. However, both assumptions are wrong. The problem starts with the definition of a hemorrhage and ends with individual answers for each patient. 

The CT appearance of a cavernoma depends on the amount of internal thrombosis, hemorrhage, and calcification. Examples are shown in Figures 2.2, 2.4a, 2.7a, 2.8a, 2.10a, 2.12a, and 2.13a,b. The lesions appear hyperdense compared to adjacent brain parenchyma, but can have variable attenuation values. Because the density of blood on CT depends on clot formation, the attenuation of a thrombosed cavernoma changes with time. Calcifications do not change that much however, cavernomas tend to calcify only partially (see Figs. 2.12 and 2.13). In patients with a recent hemorrhage, the cavernoma may be suspected on CT mainly by taking into account... 

Fig. 2.4a-c. CT (a) and sagittal Tl-weighted magnetic resonance (MR) (b) scan of another brain-stem cavernoma. Due to its calcification, it is easy to see even on the CT scan. The MR nicely reveals the typical cavernoma pattern with the dark rim of hemosiderin. Note that the acute hemorrhage occurred at the dorsal aspect of the cavernoma and now facilitates easy surgical removal. A view through the microscope while removing the cavernoma (c). Note the typical mulberry aspect of the malformation... 

Fig. 2.6a,b. T2-weighted images of a patient who presented with recurrent attacks of severe headache. The referring clinician thought the patient had suffered from a subarachnoid hemorrhage. Magnetic resonance imaging revealed two mirror-like cavernomas, both located at the surface of the brain. The headache attacks were probably caused by repetitive microbleeds into the subarachnoid space and stopped after removal of the malformations... 

Hereditary hemorrhagic telangiectasia (Rendu-Osler disease) is not associated with cerebral capillary telangiectasia, but with other forms of cerebral vascular malformations (Maher et al. 2001), mainly true pial arteriovenous malformations, dural arteriovenous malformations, and, rarely, cavernomas. 

A dark lesion on GRE images, which is not visible on conventional T2, is usually not a cavernoma but a capillary malformation. Edema, gliosis, or signs of previous hemorrhage are usually absent. Follow-up images have never revealed any change in capillary malformations. 

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