Recurrent intraparenchymal hemorrhages from angiographically occult vascular malformations

Thirteen patients with recurrent hemorrhages from angiographically occult vascular malformations are presented. Recurrent hemorrhages were indicated by the exacerbation of neurological deficits, the appearance of a new neurological deficit, or the onset of acute severe headache confirmed by evidence of recent hemorrhage on either computerized tomography or magnetic resonance imaging. Persistent neurological deficits correlated with an increased number of recurrent hemorrhages and their location. The median time from initial hemorrhage to the first recurrent hemorrhage was 12 months and the second rebleed generally occurred much earlier, with a median time of 2 months after the first. Eight patients underwent surgery with total excision and favorable results. One patient with a large pontine lesion underwent partial excision and has had a progressing neurological deficit from recurrent hemorrhages. Histopathological review confirmed the excised lesions to be cavernous angiomas. The authors conclude that angiographically occult vascular malformations are not the benign entity they were previously thought to be, and that they are prone to cause recurrent hemorrhages and persistent neurological deficits. Surgery can be effective and relatively safe in removing these lesions even in eloquent areas of the brain, but the necessity of occasional incomplete removal must be recognized in order to avoid creating an unacceptable neurological outcome.