SUCCESSFUL SURGICAL MANAGEMENT OF A COMPLEX FRONTAL LOBE AND HIPPOCAMPAL CAVERNOUS ANGIOMA: A CASE REPORT

Abstract

Cerebral cavernous angiomas (also referred to as cavernomas or cavernous malformations) 
are vascular abnormalities composed of clusters of dilated capillary vessels with thin walls and no 
intervening brain parenchyma. Although histologically benign, these lesions may have serious 
clinical consequences, particularly when located in functionally critical areas of the brain. Their 
unpredictable natural history and potential for neurological symptoms make them a subject of 
increasing interest in neurology and neurosurgery. Cavernous angiomas are relatively rare, occurring 
in approximately 0.4% to 0.9% of the general population. They may present sporadically or as part of 
a familial syndrome, often associated with mutations in specific CCM (Cerebral Cavernous 
Malformation) genes. While many lesions remain asymptomatic, a significant number become 
clinically relevant due to hemorrhagic events or seizure activity. The lesions typically consist of 
sinusoidally dilated vascular channels lined by a single layer of endothelium, often surrounded by 
hemosiderin deposits indicating prior microbleeds. The clinical manifestations of cavernous 
angiomas are highly variable and largely dependent on lesion location. Seizures are among the most 
common symptoms, particularly when the lesion is situated in the cerebral cortex or limbic structures 
such as the hippocampus. In many cases, seizures can be the initial or only presentation. Lesions may 
also cause progressive focal neurological deficits or acute symptoms due to hemorrhage. Patients 
with epilepsy related to cavernous angiomas often become resistant to pharmacologic treatment, 
necessitating further evaluation for surgical intervention. Magnetic resonance imaging (MRI) is the 
gold standard for detecting cavernous angiomas. Advanced imaging techniques, particularly 
susceptibility-weighted imaging (SWI) and T2*-weighted sequences, are crucial for identifying small 
lesions and detecting surrounding hemosiderin rings from prior bleeding. Functional imaging, 
including functional MRI and PET, can help assess the impact of the lesion on eloquent brain areas, 
while video EEG monitoring is essential in evaluating seizure focus in surgical candidates. Surgical 
resection is a well-established treatment option for symptomatic cavernous angiomas, especially in 
cases of drug-resistant epilepsy or recurrent hemorrhage. The goal of surgery is not only to remove 
the lesion but also to excise the surrounding gliotic and hemosiderin-stained tissue that may 
contribute to epileptogenesis. Advances in intraoperative neuronavigation, cortical mapping, and 
electrocorticography have significantly improved the safety and efficacy of surgical procedures, even 
in eloquent brain regions.