Supratentorial cavernous angiomas and epilepsy: Which treatment?

Cavernous angiomas (CAs) are cerebrovascular malformations most commonly found in investigations of new onset epilepsy. While previously felt to be rare, widespread use of magnetic resonance imaging (MRI) studies reveals a surprisingly high incidence of these lesions, suggesting that CAs may be a frequent cause of epilepsy in the past considered to be of cryptogenic origin. The natural history of CAs is presently poorly understood. The pathogenic potential of these anomalies is still controversial as well as optimal therapeutic strategies for their management. Twelve cases (7 males and 5 females, aged 26-65 years) entered the study upon MRI documentation of supratentorial CAs, neurological examination and EECI. Four have undergone ablative surgery consisting of lesion removal ("lesionectomy") or a larger corticectomy. Of H patients under pharmacological treatment alone, 4 have been seizure-free (for a period ranging from 6 months to 3 years). In contrast, of the 4 surgical patients 2 have been seizure-free, and 2 have undergone a reduction in the frequency and/or severity of epileptic episodes. Therefore, in line with other reports indicating a low incidence of spontaneous bleeding of CAs, the present study suggests that surgery is not always recommended unless there has been a significant clinical hemorrhage and epilepsy can often be successfully managed with anti-epileptic pharmacological treatment. Moreover, the likelihood of relapse of epilepsy in patients who undergo surgical ablation seems to depend mostly upon the frequency, duration of preoperative seizure history and severity of seizures prior to surgery. Thus, surgery for CAs should probably be used only after intensive early evaluation for drug responsiveness in patients who appear unlikely to be adequately managed medically.