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Definition of Cavernous Hemangioma
Cavernous hemangioma is a variant of hemangioma characterized by grossly large dilated blood vessels and large vascular channels, less well circumscribed, and more involved with deep structures, with a single layer of endothelium and an absence of neuronal tissue within the lesions. These thinly walled vessels resemble sinusoidal cavities filled with stagnant blood. Blood vessels in patients with CCM can range from a few millimeters to several centimeters in diameter. Most lesions occur in the brain, but any organ may be involved.
Symptoms of Cavernous Hemangioma
Clinical symptoms of CNS origin include recurrent headaches, focal neurological deficits, hemorrhagic stroke, and seizures, but CCM can also be asymptomatic. The nature and severity of the symptoms depend on the lesion's location.
Causes of Cavernous Hemangioma
Consult with your doctor.
Diagnosis of Cavernous Hemangioma
Diagnosis is generally made by magnetic resonance imaging (MRI), particularly using a specific imaging technique known as a gradient-echo sequence MRI, which can unmask small or punctate lesions that may otherwise remain undetected. These lesions are also more conspicuous on FLAIR imaging compared to standard T2 weighing. FLAIR imaging is different from Gradient sequences, rather, it is similar to T2 weighing but suppresses free-flowing fluid signal. Sometimes quiescent CCMs can be revealed as incidental findings during MRI exams ordered for other reasons. Many cavernous hemangiomas are detected "accidentally" during MRIs searching for other pathologies. These "incedentalomas" are generally asymptomatic. In the case of hemorrhage, however, a CT scan is more efficient at showing new blood than an MRI, and when brain hemorrhage is suspected, a CT scan may be ordered first, followed by an MRI to confirm the type of lesion that has bled.
Treatment of Cavernous Hemangioma
When found incidentally, with no prior history of problems related to the discovery of one of these lesions, most physicians will follow them with serial MRI scans over the following years. Small lesions in difficult places are often left alone, even if they are responsible for seizures. The same is true when the risk/benefit ratio for surgical removal may not allow the surgeon to go ahead.
Surgical Removal: Ironically, the best time to remove these lesions is soon after they have hemorrhaged. The reason for this is that the hemorrhage does some of the surgeon’s work for him, separating the lesion from the surrounding brain. This makes the removal easier, and also limits some of the potential downside of surgery. Patients who have lesions that have bled previously, but not recently, are occasionally told to wait for their next hemorrhage before considering surgery, usually due to the difficult location of their cavernoma. When easily accessible, large, responsible for serious hemorrhage or for uncontrollable seizures, surgical removal is the way to go. Once removed, these lesions are cured.
Radiation Therapy: There is no evidence that radiation therapy does anything for Cavernous Hemangiaomas. Focus beam radiation (e.g. Gamma Knife) is currently being recommended by some physicians; however no long term results (including radiation damage, malignant tumor induction etc.) are in as yet.
Prognosis of Cavernous Hemangioma
In up to 30% there is a coincidence of CCM with a venous angioma, also known as a developmental venous anomaly (DVA). These lesions appear either as enhancing linear blood vessels or caput medusae, a radial orientation of small vessels that resemble the hair of Medusa from Greek mythology. These lesions are thought to represent developmental anomalies of normal venous drainage. These lesions should not be removed, as venous infarcts have been reported. When found in association with a CCM that needs resection, great care should be taken not to disrupt the angioma.
Prevention of Cavernous Hemangioma
Consult with your doctor.
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