Cerebral cavernous malformation (CCM), also known as cavernous angioma, cavernous haemangioma, and cavernoma, is a vascular disorder of the central nervous system that may appear either sporadically or exhibit autosomal dominant inheritance. The incidence in the general population is between 0.1-0.5%, and clinical symptoms typically appear between 30 to 50 years of age. Once thought to be strictly congenital, these vascular lesions have been found to occur de novo.

This disease is characterized by grossly dilated blood vessels with a single layer of endothelium and an absence of neuronal tissue within the lesions. These thinly-walled vessels resemble sinusoidal cavities filled with stagnant blood. Blood vessels in patients with CCM can range from a few millimeters to several centimeters in diameter. CCM lesions commonly resemble raspberries in external structure.

Many patients live their whole life without knowing they have a cerebral cavernous malformation. Other patients can have severe symptoms like seizures, headaches, paralysis, bleeding in the brain (cerebral hemorrhage), and even death. The nature and severity severity of the symptoms depend on the lesion's location in the brain. Approximately 70% of these lesions occur in the supratentorial region of the brain; the remaining 30% occur in the infratentorial region.

Symptoms and Diagnosis

Clinical symptoms of this disease include recurrent headaches, focal neurological deficits, hemorrahagic stroke, and seizures, but CCM can also be asymptomatic. Diagnosis is most commonly made by magnetic resonance imaging MRI, but not all MRI exams are created equal. It's paramount that the patient request a gradient-echo MRI (aka T2-Flair) in order to unmask small or punctate lesions which may otherwise remain undetected. Sometimes quiescent CCMs can be revealed as incidental findings during MRI exams ordered for other reasons.

Sometimes the lesion appearance imaged by MRI remains inconclusive. Consequently neurosurgeons will order a cerebral angiogram or magnetic resonance angiogram (MRA). Since CCMs are low flow lesions (they are hooked into the venous side of the circulatory system), they will be angiographically occult (invisible). If a lesion is discernable via angiogram in the same location as in the MRI, then an arteriovenous malformation (AVM) becomes the primary concern.

CCMs & Venous Malformations

Many times a CCM is accompanied by a venous malformation (VM) which are also known as a developmental venous anomaly (DVA). These lesions appear either as enhancing linear blood vessels or caput medusae--a radial orientation of small vessels that resemble the hair of Medusa from Greek Mythology. These are normally benign lesions that provide normal brain drainage into the venous system. Conventional wisdom recommends leaving these lesions alone, even if surgical removal of the CCM is advocated.

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