Microsurgical or radiosurgical management of intracranial cavernomas

Cranial cavernous malformations (CCMs) constitute a heterogeneous group of lesions that tend to change dynamically over time with related periods of repeated exacerbation and alternating periods of remission. The decision on their management is based on estimating the inherent risk of further morbidity and the risk/benefit related to the particular treatment mode. Incidentally detected CCMs or lesions in asymptomatic patients presenting without major hemorrhage are best followed up. Complete resection of a CCM is the only healing option and is indicated for symptomatic or hemorrhagic lesions. In the large published series 83-92 % of the patients improved or remained unchanged after surgery, with only 8-11 % showing significant deterioration. For most patients, quality of life is improved. Analysis of the risk/benefit ratio for radiosurgery shows that it should not be regarded as an alternative option: It confers limited protection against bleeding and is related to a certain morbidity risk. In the subgroup of patients with symptomatic or hemorrhagic CCMs in locations that preclude surgical resection with acceptable risks, we recommend follow-up. The senior author is following a group of more than 80 such patients, and the vast majority remain free of hemorrhage and symptoms.