What You Should Know About Surgery for Cavernous Malformation
Cavernous malformations are a cluster of enlarged and deformed blood vessels that can occur anywhere in the body but are more concerning when found in the brain or spinal cord. When symptoms are present or the risk of hemorrhage and future neurological impairment is high, treatment may be needed.
Fortunately, surgery can completely remove a cavernous malformation and provide a cure for this condition. It will be important to weigh the risks and benefits of surgery before pursuing this treatment option.
If you decide to proceed with surgery, the months and days leading up to the date of the operation can be terrifying. Knowing what exactly the surgery will entail can help to alleviate some of the concerns and anxiety. In this article, we discuss the risks and benefits of surgery, along with the general steps of the surgical procedure.
What Is a Cavernous Malformation?
A cavernous malformation is a group of abnormally formed blood vessels composed of irregular thick and thin walls. They can range widely in size but are typically 1 to 5 cm (about 0.5 to 2 inches) in diameter. Cavernous malformations go by many other names: cavernous hemangioma, cavernoma, cavernous angioma, angioma, and hemangioma are all terms that are used to refer to a cavernous malformation.
Cavernous malformations located in the brain can also be called cerebral cavernous malformation. To keep things simple, we will use “cavernous malformation” throughout the article and focus on only cavernous malformations that occur in the brain.
Treatment for Cavernous Malformations
Cavernous malformation treatment guidelines were proposed by the Angioma Alliance scientific advisory board clinical experts panel in 2017. The treatment guidelines consider the presence of symptoms, the risk of future bleeding, the location of the cavernous malformation, and patient preference when deciding whether surgery is beneficial.
In general, if the cavernous malformation causes problematic symptoms such as seizures and resides in an easily surgically accessible location, surgery may be a good option. In contrast, if the cavernous malformation produces no symptoms or is in a deep or surgically inaccessible location, surgery will be less beneficial and more risky. Observation may be more appropriate.
Each patient will have a unique situation. A thorough discussion of the risks and benefits of surgery with your neurosurgeon will be important to determine if surgery or another treatment option will be right for you.
Cavernous Malformation Surgery Success Rate and Risks
Following surgery, more than 80% of patients experience improvement in symptoms and are satisfied with the procedure. Many patients may no longer have seizures, although this may be less likely for patients who experienced seizures over longer periods. Up to 60% of patients with cavernous malformations located near a critical area of the brain such as the brainstem will also have symptom improvement after surgery.
When surgery is performed by a skilled and experienced neurosurgeon, death resulting from surgery is extremely unlikely. Even in cases of cavernous malformations located in the brainstem, mortality is reported in less than 1% to 2% of cases. Immediately after the operation, approximately 5% of patients may experience new worsening of symptoms, but most patients will recover over time.
The success of surgery highly depends on the expertise of the neurosurgeon. Deciding on a neurosurgeon for your care will be a critical aspect in the treatment process. Learn more about how to find the top expert for your surgery, and when and how to seek a second opinion in our other articles.
What Does Cavernous Malformation Surgery Entail?
Cavernous malformation surgery can last 4 to 6 hours or longer depending on the complexity of your case. Here we describe the general steps taken to remove a brain cavernous malformation.
Step 1: Patient Positioning
The patient is placed on the operating table and is given general anesthesia. Once asleep, a breathing tube is placed in the windpipe (trachea) and connected to a ventilator to pump oxygen to the lungs during the operation. A 3-pin clamp is connected to the operating table and attached to the patient’s head for immobilization. Hair is shaved near the incision site.
Step 2: Skin Incision
The skin is scrubbed with antiseptic before an incision is made through the scalp to the outer surface of the bone. Clips are applied to the edges to minimize bleeding.
Step 3: Craniotomy
If any muscles are present, they are flapped back and secured. A small opening in the skull is made using a surgical drill (burr hole). A blunt tool is inserted into the burr hole and used to gently separate the bone from the outer covering of the brain (dura). A saw-like instrument called a craniotome is then used to cut the bone and create a removable bone flap.
Step 4: Brain Exposure and Cavernous Malformation Removal
The dura is carefully cut with small scissors and flapped back, allowing the brain to be exposed. Surgical instruments are used to find and reach the cavernous malformation. Once identified, the cavernous malformation is disconnected from the surrounding brain tissue. Following removal, the cavity is inspected for any bleeding or remnants.
Cavernous Malformation Surgery Recovery
After cavernous malformation surgery, the recovery journey begins. The timeline for cavernous malformation recovery varies for each patient. Complete recovery may take 4 to 6 weeks or longer depending on the complexity of the case and any underlying medical conditions.
Immediately after surgery, you may need to stay in the intensive care unit overnight for monitoring and management of any swelling, bleeding, or neurological problems before being transferred to a regular hospital room. If there are no complications, most patients can go home within 3 to 5 days.
When performed by a skilled and experienced neurosurgeon, cavernous malformation surgery is safe and can provide symptom relief. However, the likelihood of benefit and the risk of surgery varies for each patient. It will be important to have a thorough discussion of the potential risks and benefits of surgery with your neurosurgeon.