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Neuroradiology 16,256-260 (1978)
© by Springer-Verlag1978
CT, Angiography, and RN Scans in Intracranial Cavernous H e m a n g i o m a s M. Savoiardo and A. Passerini NeuroradiologyDepartment, Istituto Neurologico,Milano,Italy
Summary. Nine cases of surgically verified intracranial cavernous hemangiomas are reported. A comparison is made between radionuclide brain scans, angiography, and CT studies: RN scans are sometimes superior to angiography in indicating the presence of the lesion; CT is the most informative investigation, although it does not present a specific pattern. A preoperative specific diagnosis can only be suggested on the basis of the whole complex of the information available, including the clinical history.
An increasing number of reports of single cases or of small series of cavernous hemangiomas have appeared in recent years in the neuroradiologic and neurosurgical literature. Attention has been drawn to the presence of capillary blush or early draining veins with venous pooling for angiographic diagnosis [2, 4-6] and to the hyperdense pattern with mild enhancement for their recognition on CT scans [ 1]. The need for specific preoperative diagnosis is stimulated by the potential curability of these vascular malformations: radical removal is generally easy and the outcome is good [3, 7]. In our institute, 27 cases of intracranial cavernous hemangiomas have been operated upon since 1954. The first 14 cases have been recently reviewed from the surgical standpoint, including the late results of operation [3]. A review of the neuroradiologic studies performed in the whole series is in preparation. The purpose of this paper is to review only the last nine cases that were also studied with CT either in our institute or in other centers, and to compare the results of angiography, CT, and radionuclide (RN) studies.
normal right carotid angiography, both performed shortly after onset of symptoms. The patient developed personality changes, dysarthria, and memory deficit. RN scan showed strongly increased uptake in right anterior temporal region. Skull films were normal. Right carotid angiography and PEG were again normal. A C T scan showed a right temporopolar lesion, isodense in its anterior part, hypodense in its posterior component, without any mass effect. The lesion became almost entirely hyperdense after contrast enhancement. At operation, a well-delimited nodule with old hemorrhages, accompanied by a cyst with brownish liquid content, was completely removed. Case 2
This was a 30-year-old woman with an 18-month history of left focal motor seizures. Increased deep tendon reflexes on t h e left side were the only neurologic abnormality. Skull films were normal. A faint increased uptake in the right retrocoronal area was present~ Right carotid angiography showed an early draining vein in the right supraventricular posterior frontal region. No mass effect was present. PEG was normal. CT scan showed a
Case Reports Case 1
A 23-year-old woman with a 6-year history of temporal lobe seizures (running epilepsy) had normal PEG and
Fig. 1. Case 2. Pre- and postcontrast scan 0028-3940/78/0016/0256/$01.00
M. Savoiardo and A. PassexSrti:CT, Angiography, and RN in Cavernous Hemangi0mas
257
Fig. 2. Case 3. A. and B. Left carotid angiography. B. Sequential subtraction. Mass effect and very faint pathologic circulation (arrows). C. Sections taken 13 mm apart, byperdense mass lesion, with minimal peripheral edema. D. 99mTc brain scan, left lateral and posterior views. Intense uptake of slightly smaller size hypodense area with a thin irregular hyperdense ring, which enhanced after contrast injection, while the central area remained unchanged (Fig. 1). At operation, a brownish nodule, well circumscribed, 3 cm in diameter, containing a central cyst, was removed.
dense area interpreted as edema (Fig. 2). At operation, a 5 x 5 x 3.5-cm nodule in the basal left posterior temporal region was completely removed. The nodule conrained scattered hemorrhages. Case 4
Case 3 A 10-year-old girl with a 3-year history of focal epilepsy had, one year after onset of symptoms, an RN scan which showed increased uptake in the left basal posterior temporal region. Carotid angiography revealed mild displacement of vessels in posterior temporal region, without definite pathologic circulation. Surgery was refused by parents, One month prior to operation, the patient developed severe headaches. Papilledema and right homonymous hemianopia were found. RN scan was unchanged. Left carotid and vertebral angiography showed a posterior temporal lesion with considerable mass effect. The lesion was essentially avascular, but a minimal peripheral pathologic circulation was recognized on stereoscopic view and sequential subtraction. A C T scan disclosed a hyperdense mass lesion with a peripheral hypo-
A 39-year-old man was on follow-up at our institute for a long history of recurrent parietal parasagittal meningioma. Visual field deficit had never been a complaint. Skull f'flms showed flakes of small calcifications in the left occipital region, not present 2 years before. A C T scan showed a densely calcified small lesion of the left occipital pole. There was slight enhancement on postcont r a s t scan. No definite recurrence of the parietal meningioma was recognizable. RN scan also showed only a small left occipital uptake. Bilateral internal and external carotid and vertebral angiography showed a small recurrence of the parietal meningioma extending to both sides of the sagittal sinus, but no abnormalities were detected in the left occipital region. At operation, both the parietal meningioma and the left occipital nodule, which turned out to be a cavernous hemangioma, were removed.
258
M. Savoiardo and A. Passerini: CT, Angiography, and RN in Cavernous Hemangiomas present (Fig. 3). Left carotid angiography showed an avascular area in late arterial and capillary phases without pathologic circulation and with questionable mass effect. At operation, a plurilobulated, well-encapsulated nodule, 4 x 4 x 3 cm, with peripheral small hematoma, was completely removed. Case 6
Fig. 3. Case 5. Pre- and postcontrast scan
A 46-year-old woman had a single major motor seizure 1 month prior to operation. The patient was admitted to another hospital. RN scan was normal. CT showed a hypodense frontal supraventricular area without changes on postcontrast scan. Carotid angiography showed an avascular mass with mild displacement of vessels in the right frontal region. The patient was referred to our institute. Neurologic examination was within normal limits. At operation, an astrocytoma was removed; on the inferior part of the frontal convexity a subcortical nodule was appreciated and removed: histologic examination of this nodule demonstrated an 8-10-mm cavernous hemangioma. Review of angiography and of CT scan failed to show any abnormality in the area where the cavernous hemangioma had been found. Case 7
Fig. 4. Case 8. High definition (320 x 320 matrix). Postcontrast scan. On precontrast scan only bone erosion was visible
A 27-year-old man with a 3.year history of major motor seizures always had normal neurologlc examinations. CT scan showed a homogeneously hyperdense area, approximately 5 x 3 x 3 cm, without sharp margins, located lateral to the left frontal horn, which was minimally compressed. The lesion enhanced after contrast medium injection. The patient was referred to our institute. RN scan showed an area of considerably increased uptake in the left frontal region, but of smaller size than on CT scan. Carotid angiography demonstrated an avascular area in capillary phase. There was a dubious increase in vascularity in arterial phase due to barely visible vessels at the periphery of this area. At operation, a 5 x 3 x 3-cm black nodule, well circumscribed, was removed. The patient developed expressive aphasia, which had almost completely cleared at 2-month follow-up.
Case 8 Fig. 5. Case 9. Postcontrast scan
Case 5 This was a 15-year-old youngster with a 10-month history of right focal epilepsy. Neurologic examination revealed mild right leg weakness with increased deep tendon reflexes on right arm and leg. CT scan showed a large left parietal area inhomogeneously hyperdense, with two central hypodense areas. After contrast medium injection, the hyperdense area moderately enhanced. There was no mass effect, although mild peripheral edema was
A 58-year-old man had a 6-year history of decreased visual acuity in the right eye (4/10) and a 1-year history of exophthalmos (2 mm). Plain skull f'flms showed a partial erosion of the right lesser wing of the sphenoid with enlargement of the superior orbital fissure and destruction of the margins of the optic canal. CT scan confirmed these' findings; the isodense, not recognizable mass lesion, became evident on postcontrast scan: from the area of bony erosion it bulged into the anteromedial part of the middle fossa (Fig 4). Carotid angi0graphy was normal; no pathologic circulation was observed even from external carotid artery. Frontal phlebography showed normal
M. Savoiardoand A. Passerini: CT, Angiography,and RN in CavernousHemangiomas falling of orbital veins. However, the right superior ophthalmic vein did not visualize the anterior part of the cavernous sinus. The posterior part of the right cavernous sinus was visualized through the circular sinus from the opposite side. At operation, a 1.5 x 1.5 x 1-cm nodule arising from the lesser wing and bulging both into the orbit and into the middle fossa, but remaining extradural, was removed. Case 9
A 28-year-old man, with focal motor seizures for the last 7 years, had his first neuroradiologic work-up (RN scan, PEG, carotid angiography) at the onset of his symptoms in another hospital. The examinations were normal. By age 25, minimal right leg weakness developed and the patient was admitted to our institute. RN scan showed mild parasagittal retrocoronal uptake. Left carotid angiography demonstrated an avascular mass with mild displacement of vessels in the same region. PEG showed minimal impingement on the ventricular roof. Considering the position of the lesion, which marginally involved the motor area, and the improvement of the patient, surgery was delayed. The patient was readmitted in status epilepticus in 1978. CT scan showed a parasagittal retrocoronal hyperdense area. A small peripheral hypodense zone was recognizable. No mass effect was present. Increase in density on postcontrast scan occurred (Fig. 5). Left carotid angiography again showed an avascular area with a minimal mass effect, diminished in respect to the previous carotid angiogram. At operation, a nodule 3.5 cm in diameter, well circumscribed but with peripheral gliosis, was completely removed. Marked right-sided weakness ensued, which cleared up almost completely within a few days.
Discussion
The only time that RN, CT, and angiography did not demonstrate the cavernous hemangioma was in Case 6 (an incidental operative finding). However, the negative pertinent findings can be explained by the small size of the hemangioma; this case, therefore, will be excluded from the following discussion. The first neuroradiologic examination performed after skull X-rays (which showed calcifications in only one case) was usually RN brain scan. This was performed in six out of eight cases and was always positive. However, comparing the size of the uptake with the size of the lesion as demonstrated by CT, a good correspondence was found in only two cases (1 and 4). In the other four cases, the size on RN scan was slightly smaller than on CT studies. Angiography was always performed. In three cases (1, 4, and 8) angiography was normal. A definite avascular area in the site of the lesion, with mild mass effect, was observed in two cases (5 and 9). A very faint pathologic
259
circulation was seen in Case 3 and was questionable in Case 7. An early draining vein without capillary blush was demonstrated in Case 2. On the whole, angiography was insufficient in too many cases for a good definition of the lesion. Its failure is well explained by the very fine size of the feeding vessels, by the slow circulation, and by the frequent presence of thrombi within the vascular spaces of this type of angioma. It is possible that magnification angiography will improve the possibility of visualization of the pathologic circulation. CT scans always clearly depicted the size of the lesion. In most of our cases, the pattern of the cavernous hemangiomas was in agreement with what has been described in the recent literature [1]: a fairly well circumscribed hyperdense area with moderate enhancement and no significant mass effect. However, in three cases (1, 2, and 5) definite hypodense areas were observed within the lesion. In the first two cases, the hypodensity was more marked: at operation, a cystic component with liquid content was found. Another unusual pattern was presented by Case 3, in which considerable mass effect and mild, but clearly evident, peripheral edema were present. Both mass effect and edema were probably caused by recent hemorrhages within the angioma. In none of the cases of this series, however, was massive intracerebral hematoma the presenting feature. Calcifications, indicated as a frequent finding in older pre-CT literature, were present only in Case 4, in which their density almost completely obscured the contrast enhancement. Enhancement was present in all cases. In spite of the high vascularity of these lesions, it was usually mild ( 1 0 15 H units); in two cases it was more than 30 H units. In conclusion, CT scan was the most accurate diagnostic tool in depicting the extension of the cavernous hemangiomas. However, its lack of characteristic patterns does not allow a specific identification of the lesion. In the last few cases, a preoperative diagnosis of cavernous hemangioma was suggested, but only on the basis of the whole complex of information available, including the clinical history. With regard to the clinical history, we have observed a changing pattern in the clinical presentation:in the first cases observed at our institute, intracranial bleeding was a fairly common presentation, accounting for approximately half of the cases, while the other half of the patients only had epileptic seizures. In the last nine cases, excluding the incidental operative finding (Case 6), seven out of eight cases had epilepsy and none had hemorrhage. The reason for this changing pattern may be found in an earlier and more frequent diagnosis rendered possible by CT scan. In fact, in the older cases, intracranial bleeding was sometimes the event prompting operation in patients with a long history of epilepsy: in these cases, traditional neuroradiologic studies had been insufficient for a surgical indication. A good example of the importance of CT scan in the definition of the extent of these angiomas is given by our Case 9: this patient had three neuroradiologic investigations; only after the last one, which included CT
260
M. Savoiardo and A. Passerini: CT, Angiography, and RN in Cavernous Hemangiomas
References
3. Giombini, S., MoreUo, G.: Cavernous angiomas of the brain. Account of fourteen personal cases and review of the literature. Acta Neurochir. 40, 61-82 (1978) 4. Jonutis, A. J., Sondheimer, F. K., Klein, H. Z., Wise, B. L.: Intracerebral eavernous hemangioma with angiographically demonstrated pathologic vasculature. Neuroradiology 3, 57 to 63 (1971) 5. Numaguehi, Y., Fukui, M., Miyake, E., Kishikawa, T., Ikeda, J., Matsuura, K., Tomonaga, M., Kitamura, K.: Angiographie manifestations of intracerebral cavernous hemangioma. Neuroradiology 14, 113-116 (1977) 6. Segall, H. D., Segal, H. L., Teal, J. S., Rumbaugh, C. L., Bergeron, R. T.: Calcifying eerebral cavernous hemangioma with brain scan and angiographic findings. Neuroradiology 7, 133-138 (1974) 7. Voigt, K., Ya~argil, M. G.: Cerebral caverngus haemangiomas or cavernomas. Neurochirurgia 19, 59-68 (1976)
1. Bartlett, J. E., Kishore, P. R. S.: Intraeranial cavernous angioma. Am. J. Roentgenol. 128, 653-656 (1977) 2. Bogren, H., Svalander, C., Wiekbom, I.: Angiography in intracranial cavernous hemangiomas. Acta Radiol. 10, 81-89 (1970)
M. Savoiardo, MD Istituto Neurologieo Via Celoria, 11 1-20133 Milano, Italy
scan, did the neurosurgeon feel that the i n f o r m a t i o n available was sufficient to operate o n a f u n c t i o n a l l y i m p o r t a n t cortical area o f a patient with m i n i m a l neurologic deficits.
Acknowledgments. We wish to thank Dr. U. Salvolini, Ancona (Cases 1 and 2), and Dr. G. Scotti, Milan (Case 3), who always kindly performed CT studies on our patients when CT was not available in our institute. We again thank Dr. Salvolini (Case 6) and Prof. A. Ceechini, Pavia (Case 7), who performed the studies in patients later referred to our institute for surgery.
Neuroradiology 16,256-260 (1978)
© by Springer-Verlag1978
CT, Angiography, and RN Scans in Intracranial Cavernous H e m a n g i o m a s M. Savoiardo and A. Passerini NeuroradiologyDepartment, Istituto Neurologico,Milano,Italy
Summary. Nine cases of surgically verified intracranial cavernous hemangiomas are reported. A comparison is made between radionuclide brain scans, angiography, and CT studies: RN scans are sometimes superior to angiography in indicating the presence of the lesion; CT is the most informative investigation, although it does not present a specific pattern. A preoperative specific diagnosis can only be suggested on the basis of the whole complex of the information available, including the clinical history.
An increasing number of reports of single cases or of small series of cavernous hemangiomas have appeared in recent years in the neuroradiologic and neurosurgical literature. Attention has been drawn to the presence of capillary blush or early draining veins with venous pooling for angiographic diagnosis [2, 4-6] and to the hyperdense pattern with mild enhancement for their recognition on CT scans [ 1]. The need for specific preoperative diagnosis is stimulated by the potential curability of these vascular malformations: radical removal is generally easy and the outcome is good [3, 7]. In our institute, 27 cases of intracranial cavernous hemangiomas have been operated upon since 1954. The first 14 cases have been recently reviewed from the surgical standpoint, including the late results of operation [3]. A review of the neuroradiologic studies performed in the whole series is in preparation. The purpose of this paper is to review only the last nine cases that were also studied with CT either in our institute or in other centers, and to compare the results of angiography, CT, and radionuclide (RN) studies.
normal right carotid angiography, both performed shortly after onset of symptoms. The patient developed personality changes, dysarthria, and memory deficit. RN scan showed strongly increased uptake in right anterior temporal region. Skull films were normal. Right carotid angiography and PEG were again normal. A C T scan showed a right temporopolar lesion, isodense in its anterior part, hypodense in its posterior component, without any mass effect. The lesion became almost entirely hyperdense after contrast enhancement. At operation, a well-delimited nodule with old hemorrhages, accompanied by a cyst with brownish liquid content, was completely removed. Case 2
This was a 30-year-old woman with an 18-month history of left focal motor seizures. Increased deep tendon reflexes on t h e left side were the only neurologic abnormality. Skull films were normal. A faint increased uptake in the right retrocoronal area was present~ Right carotid angiography showed an early draining vein in the right supraventricular posterior frontal region. No mass effect was present. PEG was normal. CT scan showed a
Case Reports Case 1
A 23-year-old woman with a 6-year history of temporal lobe seizures (running epilepsy) had normal PEG and
Fig. 1. Case 2. Pre- and postcontrast scan 0028-3940/78/0016/0256/$01.00
M. Savoiardo and A. PassexSrti:CT, Angiography, and RN in Cavernous Hemangi0mas
257
Fig. 2. Case 3. A. and B. Left carotid angiography. B. Sequential subtraction. Mass effect and very faint pathologic circulation (arrows). C. Sections taken 13 mm apart, byperdense mass lesion, with minimal peripheral edema. D. 99mTc brain scan, left lateral and posterior views. Intense uptake of slightly smaller size hypodense area with a thin irregular hyperdense ring, which enhanced after contrast injection, while the central area remained unchanged (Fig. 1). At operation, a brownish nodule, well circumscribed, 3 cm in diameter, containing a central cyst, was removed.
dense area interpreted as edema (Fig. 2). At operation, a 5 x 5 x 3.5-cm nodule in the basal left posterior temporal region was completely removed. The nodule conrained scattered hemorrhages. Case 4
Case 3 A 10-year-old girl with a 3-year history of focal epilepsy had, one year after onset of symptoms, an RN scan which showed increased uptake in the left basal posterior temporal region. Carotid angiography revealed mild displacement of vessels in posterior temporal region, without definite pathologic circulation. Surgery was refused by parents, One month prior to operation, the patient developed severe headaches. Papilledema and right homonymous hemianopia were found. RN scan was unchanged. Left carotid and vertebral angiography showed a posterior temporal lesion with considerable mass effect. The lesion was essentially avascular, but a minimal peripheral pathologic circulation was recognized on stereoscopic view and sequential subtraction. A C T scan disclosed a hyperdense mass lesion with a peripheral hypo-
A 39-year-old man was on follow-up at our institute for a long history of recurrent parietal parasagittal meningioma. Visual field deficit had never been a complaint. Skull f'flms showed flakes of small calcifications in the left occipital region, not present 2 years before. A C T scan showed a densely calcified small lesion of the left occipital pole. There was slight enhancement on postcont r a s t scan. No definite recurrence of the parietal meningioma was recognizable. RN scan also showed only a small left occipital uptake. Bilateral internal and external carotid and vertebral angiography showed a small recurrence of the parietal meningioma extending to both sides of the sagittal sinus, but no abnormalities were detected in the left occipital region. At operation, both the parietal meningioma and the left occipital nodule, which turned out to be a cavernous hemangioma, were removed.
258
M. Savoiardo and A. Passerini: CT, Angiography, and RN in Cavernous Hemangiomas present (Fig. 3). Left carotid angiography showed an avascular area in late arterial and capillary phases without pathologic circulation and with questionable mass effect. At operation, a plurilobulated, well-encapsulated nodule, 4 x 4 x 3 cm, with peripheral small hematoma, was completely removed. Case 6
Fig. 3. Case 5. Pre- and postcontrast scan
A 46-year-old woman had a single major motor seizure 1 month prior to operation. The patient was admitted to another hospital. RN scan was normal. CT showed a hypodense frontal supraventricular area without changes on postcontrast scan. Carotid angiography showed an avascular mass with mild displacement of vessels in the right frontal region. The patient was referred to our institute. Neurologic examination was within normal limits. At operation, an astrocytoma was removed; on the inferior part of the frontal convexity a subcortical nodule was appreciated and removed: histologic examination of this nodule demonstrated an 8-10-mm cavernous hemangioma. Review of angiography and of CT scan failed to show any abnormality in the area where the cavernous hemangioma had been found. Case 7
Fig. 4. Case 8. High definition (320 x 320 matrix). Postcontrast scan. On precontrast scan only bone erosion was visible
A 27-year-old man with a 3.year history of major motor seizures always had normal neurologlc examinations. CT scan showed a homogeneously hyperdense area, approximately 5 x 3 x 3 cm, without sharp margins, located lateral to the left frontal horn, which was minimally compressed. The lesion enhanced after contrast medium injection. The patient was referred to our institute. RN scan showed an area of considerably increased uptake in the left frontal region, but of smaller size than on CT scan. Carotid angiography demonstrated an avascular area in capillary phase. There was a dubious increase in vascularity in arterial phase due to barely visible vessels at the periphery of this area. At operation, a 5 x 3 x 3-cm black nodule, well circumscribed, was removed. The patient developed expressive aphasia, which had almost completely cleared at 2-month follow-up.
Case 8 Fig. 5. Case 9. Postcontrast scan
Case 5 This was a 15-year-old youngster with a 10-month history of right focal epilepsy. Neurologic examination revealed mild right leg weakness with increased deep tendon reflexes on right arm and leg. CT scan showed a large left parietal area inhomogeneously hyperdense, with two central hypodense areas. After contrast medium injection, the hyperdense area moderately enhanced. There was no mass effect, although mild peripheral edema was
A 58-year-old man had a 6-year history of decreased visual acuity in the right eye (4/10) and a 1-year history of exophthalmos (2 mm). Plain skull f'flms showed a partial erosion of the right lesser wing of the sphenoid with enlargement of the superior orbital fissure and destruction of the margins of the optic canal. CT scan confirmed these' findings; the isodense, not recognizable mass lesion, became evident on postcontrast scan: from the area of bony erosion it bulged into the anteromedial part of the middle fossa (Fig 4). Carotid angi0graphy was normal; no pathologic circulation was observed even from external carotid artery. Frontal phlebography showed normal
M. Savoiardoand A. Passerini: CT, Angiography,and RN in CavernousHemangiomas falling of orbital veins. However, the right superior ophthalmic vein did not visualize the anterior part of the cavernous sinus. The posterior part of the right cavernous sinus was visualized through the circular sinus from the opposite side. At operation, a 1.5 x 1.5 x 1-cm nodule arising from the lesser wing and bulging both into the orbit and into the middle fossa, but remaining extradural, was removed. Case 9
A 28-year-old man, with focal motor seizures for the last 7 years, had his first neuroradiologic work-up (RN scan, PEG, carotid angiography) at the onset of his symptoms in another hospital. The examinations were normal. By age 25, minimal right leg weakness developed and the patient was admitted to our institute. RN scan showed mild parasagittal retrocoronal uptake. Left carotid angiography demonstrated an avascular mass with mild displacement of vessels in the same region. PEG showed minimal impingement on the ventricular roof. Considering the position of the lesion, which marginally involved the motor area, and the improvement of the patient, surgery was delayed. The patient was readmitted in status epilepticus in 1978. CT scan showed a parasagittal retrocoronal hyperdense area. A small peripheral hypodense zone was recognizable. No mass effect was present. Increase in density on postcontrast scan occurred (Fig. 5). Left carotid angiography again showed an avascular area with a minimal mass effect, diminished in respect to the previous carotid angiogram. At operation, a nodule 3.5 cm in diameter, well circumscribed but with peripheral gliosis, was completely removed. Marked right-sided weakness ensued, which cleared up almost completely within a few days.
Discussion
The only time that RN, CT, and angiography did not demonstrate the cavernous hemangioma was in Case 6 (an incidental operative finding). However, the negative pertinent findings can be explained by the small size of the hemangioma; this case, therefore, will be excluded from the following discussion. The first neuroradiologic examination performed after skull X-rays (which showed calcifications in only one case) was usually RN brain scan. This was performed in six out of eight cases and was always positive. However, comparing the size of the uptake with the size of the lesion as demonstrated by CT, a good correspondence was found in only two cases (1 and 4). In the other four cases, the size on RN scan was slightly smaller than on CT studies. Angiography was always performed. In three cases (1, 4, and 8) angiography was normal. A definite avascular area in the site of the lesion, with mild mass effect, was observed in two cases (5 and 9). A very faint pathologic
259
circulation was seen in Case 3 and was questionable in Case 7. An early draining vein without capillary blush was demonstrated in Case 2. On the whole, angiography was insufficient in too many cases for a good definition of the lesion. Its failure is well explained by the very fine size of the feeding vessels, by the slow circulation, and by the frequent presence of thrombi within the vascular spaces of this type of angioma. It is possible that magnification angiography will improve the possibility of visualization of the pathologic circulation. CT scans always clearly depicted the size of the lesion. In most of our cases, the pattern of the cavernous hemangiomas was in agreement with what has been described in the recent literature [1]: a fairly well circumscribed hyperdense area with moderate enhancement and no significant mass effect. However, in three cases (1, 2, and 5) definite hypodense areas were observed within the lesion. In the first two cases, the hypodensity was more marked: at operation, a cystic component with liquid content was found. Another unusual pattern was presented by Case 3, in which considerable mass effect and mild, but clearly evident, peripheral edema were present. Both mass effect and edema were probably caused by recent hemorrhages within the angioma. In none of the cases of this series, however, was massive intracerebral hematoma the presenting feature. Calcifications, indicated as a frequent finding in older pre-CT literature, were present only in Case 4, in which their density almost completely obscured the contrast enhancement. Enhancement was present in all cases. In spite of the high vascularity of these lesions, it was usually mild ( 1 0 15 H units); in two cases it was more than 30 H units. In conclusion, CT scan was the most accurate diagnostic tool in depicting the extension of the cavernous hemangiomas. However, its lack of characteristic patterns does not allow a specific identification of the lesion. In the last few cases, a preoperative diagnosis of cavernous hemangioma was suggested, but only on the basis of the whole complex of information available, including the clinical history. With regard to the clinical history, we have observed a changing pattern in the clinical presentation:in the first cases observed at our institute, intracranial bleeding was a fairly common presentation, accounting for approximately half of the cases, while the other half of the patients only had epileptic seizures. In the last nine cases, excluding the incidental operative finding (Case 6), seven out of eight cases had epilepsy and none had hemorrhage. The reason for this changing pattern may be found in an earlier and more frequent diagnosis rendered possible by CT scan. In fact, in the older cases, intracranial bleeding was sometimes the event prompting operation in patients with a long history of epilepsy: in these cases, traditional neuroradiologic studies had been insufficient for a surgical indication. A good example of the importance of CT scan in the definition of the extent of these angiomas is given by our Case 9: this patient had three neuroradiologic investigations; only after the last one, which included CT
260
M. Savoiardo and A. Passerini: CT, Angiography, and RN in Cavernous Hemangiomas
References
3. Giombini, S., MoreUo, G.: Cavernous angiomas of the brain. Account of fourteen personal cases and review of the literature. Acta Neurochir. 40, 61-82 (1978) 4. Jonutis, A. J., Sondheimer, F. K., Klein, H. Z., Wise, B. L.: Intracerebral eavernous hemangioma with angiographically demonstrated pathologic vasculature. Neuroradiology 3, 57 to 63 (1971) 5. Numaguehi, Y., Fukui, M., Miyake, E., Kishikawa, T., Ikeda, J., Matsuura, K., Tomonaga, M., Kitamura, K.: Angiographie manifestations of intracerebral cavernous hemangioma. Neuroradiology 14, 113-116 (1977) 6. Segall, H. D., Segal, H. L., Teal, J. S., Rumbaugh, C. L., Bergeron, R. T.: Calcifying eerebral cavernous hemangioma with brain scan and angiographic findings. Neuroradiology 7, 133-138 (1974) 7. Voigt, K., Ya~argil, M. G.: Cerebral caverngus haemangiomas or cavernomas. Neurochirurgia 19, 59-68 (1976)
1. Bartlett, J. E., Kishore, P. R. S.: Intraeranial cavernous angioma. Am. J. Roentgenol. 128, 653-656 (1977) 2. Bogren, H., Svalander, C., Wiekbom, I.: Angiography in intracranial cavernous hemangiomas. Acta Radiol. 10, 81-89 (1970)
M. Savoiardo, MD Istituto Neurologieo Via Celoria, 11 1-20133 Milano, Italy
scan, did the neurosurgeon feel that the i n f o r m a t i o n available was sufficient to operate o n a f u n c t i o n a l l y i m p o r t a n t cortical area o f a patient with m i n i m a l neurologic deficits.
Acknowledgments. We wish to thank Dr. U. Salvolini, Ancona (Cases 1 and 2), and Dr. G. Scotti, Milan (Case 3), who always kindly performed CT studies on our patients when CT was not available in our institute. We again thank Dr. Salvolini (Case 6) and Prof. A. Ceechini, Pavia (Case 7), who performed the studies in patients later referred to our institute for surgery.
