Cavernous Malformation Resection

Cavernous malformations are also called cavernous angiomas, cavernous hemangiomas, capillary hemangiomas or cavernomas. These are all the same thing. There are several different types of blood vessel abnormalities that can occur in the brain and cavernomas are among the least life threatening of these.

While other blood vessel abnormalities may arise from arteries and/or veins, cavernomas are made up entirely of capillaries. Capillaries are the tiniest blood vessels in the body. Because they are so small, they do not have enough pressure to truly rupture. When a cavernoma bleeds, it tends to “ooze.”

Cavernomas are like a birthmark in the brain where the tiny capillaries form into a ball of little vessels. Most cavernomas are random, some can run in families. When this happens, patients usually have multiple cavernomas. They can occur in any part of the brain, and the size and location of the cavernoma will determine the symptoms. Many patients have no symptoms. Cavernomas occurring in the brainstem usually cause the most symptoms because there is so much vital brain tissue surrounding them. Cavernomas in the frontal lobe can get quite large without causing any symptoms. In some patients, a seizure is the first symptom.

There are two primary treatment options for cavernomas. The first is observation. If the patient has no symptoms, this is very reasonable. Over time, there is risk that the cavernoma will ooze and enlarge. This may or may not cause symptoms. The exact likelihood of a cavernoma oozing is not known, but it is estimated to be around 2% a year.

The second option is surgery to remove the cavernoma. This can usually be done safely depending on the size and location of the cavernoma. If a cavernoma is removed completely, it is considered cured, although a new cavernoma could developed in a different location.

A third option is radiation, but the data is not as clear as to the true benefit because it does not make the cavernoma go away.  It is also uncertain whether radiation treatment will truly reduce the risk of future oozing.

Surgery for cavernomas is done using anesthesia with the patient completely asleep. The hair is not shaved, but it is parted to make an incision. A window of bone is removed and the same bone is replaced at the end of surgery. Cavernomas usually occur within the brain tissue and not right on the surface. For this reason, a GPS-like system is used to navigate directly to the spot of the cavernoma. This makes the surgery safer. The surgery is done using a microscope to help remove the cavernoma by coagulating or “hardening” the small capillaries around it and ultimately removing the entire cavernoma. Once removed, all of the surgery area will be closed. The operation may take several hours, depending on the size and location of the cavernoma.

Anesthesia, infection and bleeding are risks of any operation. The risks specific to removing a cavernoma relate to its size and location. Cavernomas on the right side of the brain can affect movement on the left side of the body, and cavernomas on the left side of the brain can affect movement on the right side of the body. Cavernomas in the brainstem carry higher risks because there is so much vital tissue involved. If the patient loses some function from the surgery, it is usually temporary. However, any time brain surgery is performed, we have to include the risk of catastrophic things such as stroke, coma and death. The chance of any of these risks occurring with this operation is very low, but it is not zero. Your surgeon will discuss risks with you. 

There is no specific preparation needed for this operation, although all patients are encouraged to stop smoking. You should not eat or drink anything after midnight on the day before your surgery. You will be given instructions on when and where to show up for your surgery.

Specific discharge instructions will be provided in writing to each patient. In general, patients are encouraged to take several short walks throughout the day. Patients should not spend the day lying in bed. Medicine can be taken if there are headaches. Patients are permitted to shower and wash their hair two days after surgery. You will be given a follow-up appointment to have staples removed usually within two weeks of surgery. The patient will have a follow-up appointment with their surgeon approximately one month after surgery. At that time, there will be discussions about the patient’s potential to resume driving and returning to work.

Headaches are common after brain surgery, but they generally improve over a few days or weeks. Most patients do not have their full energy level back for several weeks. Some patients benefit from participating in therapy (physical, occupational and/or speech) after surgery, depending on the problems they may be having.