Surgical treatment of cavernoma-related epilepsy

Cerebral cavernous malformations (CCMs) are frequently associated with a seizure disorder, and the risk of developing drug-resistant epilepsy (DRE) is substantial, especially for temporal lobe lesions. This article includes a review of the literature on the surgical treatment of epilepsy associated to CCMs in the magnetic resonance imaging (MRI) era, as well as an analysis of the Authors' experience in this field. It is concluded that microsurgery is a valuable treatment option, which may provide excellent results on seizures, with 76% of patients on average being seizure-free after surgery. Nevertheless, the optimal surgical strategy to achieve seizure control has not been clearly identified, and several attitudes have been reported in the literature. The choice of lesionectomy, associated or not to removal of surrounding hemosiderin, versus resections extended to epileptogenic cortex depends on the accurate scrutiny of several factors, which should be investigated through an adequate epileptological presurgical workup. This should include an epilepsy-oriented brain MRI study, integrated by an appropriate neurophysiological and clinical assessment, and if needed by other functional evaluations. Besides representing the optimal option in CCM-related DRE cases, microsurgery should be considered also at seizure presentation or in cases with recent-onset sporadic seizures, to protect the patient from both the possible development of drug resistance and the risk of haemorrhage.