Management of Intracranial Cavernous Malformation: A Retrospective Analysis of 76 Consecutive Cases

OBJECTIVE: To establish a treatment guideline for intracranial cavernous malformation, the authors analyzed the clinical features, treatment modality, complications, and late outcomes in 76 consecutive cases (45 microsurgical resections, 30 stereotactic radiosurgeries, one microsurgery followed by radiosurgery) managed at the Yonsei University Medical Center from 1985 to 1998. RESULTS: Among 104 lesions in 76 patients, 64(61.5%) lesions were supratentorial and 40(38.5%) infratentorial. Hemorrhage was the most common presentation(31 patients, 40.8%), followed by generalized seizure(15 patients, 19.7%). Fifteen(19.7%) patients had mixed presentation with generalized seizure and hemorrhage, while 9(11.9%) patients presented focal deficits. The remaining 6(7.9%) patients had headache or incidental lesion. Almost all infratentorial lesions(92.5%) were managed with radiosurgery, and 65.6% of supratentorial lesions with microsurgery. The average follow-up period was 14.6 months for the microsurgery group and 32 months for the radiosurgery group. The overall outcome was good in 68(89.5%), fair in 6(7.9%), poor in 1(1.3%), and dead in 1(1.3%). Total microsurgical resection and symptomatic cure rate was 95.6%. Two lesion were incompletely resected. One lesion was followed by radiosurgery and the other was followed by reoperation. Only 38.5% of lesions with radiosurgery were shrunken. CONCLUSION: Microsurgical removal is effective for lesions in the non-eloquent area, or with recurrent hemorrhages and seizures. Although radiosurgery could be considered for lesions with multiplicity in the eloquent or deep-seated area, further study for the radiosurgical effect on cavernous malformations is required.

Germ Cell Tumors Involving the Basal Ganglia and Thalamus

The clinicopathological findings in 9 patients with germ cell tumors originating in the basal ganglia and thalamus are presented. The incidence of germ cell tumors of the basal ganglia and thalamus was 16.4% of all 55 cases of primary intracranial germ cell tumors. These included 6 cases of germinomas and 3 cases of malignant mixed germ cell tumors(MGCT). The average age at diagnosis was 16.9 years(range 9.5-39 years). The sex incidence showed male dominance(8:1). The clinical course of germinoma in the basal ganglia and thalamus was slowly progressive and the average duration of symptoms before diagnosis was 29 months. The most common symptom and sign was hemiparesis and which was not normalized in all cases in spite of complete response to irradiation or chemotherapy. In case of germinomas, symptoms of increased intracranial pressure were found in only 1 case. Germinomas in the basal ganglia and thalamus had characteristic radiological findings different from that of pineal or suprasellar germinomas : irregular mixed density or signals. Therapy consisted of stereotactic biopsy and irradiation in 6 cases, subtotal removal followed by irradiation and chemotherapy in 1 case, irradiation alone in 1 case and chemotherapy alone in 1 case. Of the 6 patients with germinoma, 5 are alive and disease free for 5 to 111 months after diagnosis(mean 57 months, median 62 months), but one patient died of recurrence on the primary site, temporal lobe, and cerebellum 87 months after cranial irradiation. Only 1 of 3 patients with malignant MGCT is still living 6 months after diagnosis, he showed complete response to chemotherapy and is now under maintenance of chemotherapy. There was no recovery of hemiparesis in patient with advanced germinoma in this region, early detection and treatment on the basis of biopsy, radiological findings and tumor marker study are essential in the management of germ cell tumors originating in the basal ganglia and thalamus.