Anatomo-functional evaluation for management and surgical treatment of insular cavernous malformation: a case series

Insular cavernous malformations (iCMs) are very rare vascular lesions. Their surgical management is challenging, due to their complex functional and vascular relationship. The continuous improvement of intra-operative tools and neuroimaging techniques has progressively enhanced the safety of iCM surgery. Nevertheless, the best surgical approach remains controversial.

To analyze the potential role of an anatomo-functional classification to guide the iCMs' management.

The study included patients affected by iCMs and referred to the Senior Author (FA). All cases were divided in 2 groups, according to a mainly pial growth pattern (exophytic group) or a subcortical one (endophytic group). Endophytic iCM was further subdivided in 3 subgroups, based on the insular gyri involved. According to this classification, each patient underwent a specific additional neuroimaging investigation and surgical evaluation.

A total of 24 patients were included. In the surgical group, trans-sylvian (TS) approach was used in 6 patients with exophytic or Zone I endophytic iCMs. The transcortical (TC) approach with awake monitoring was used in 6 cases of Zone II endophytic vascular lesions. Both TS and trans-intraparietal sulcal (TIS) approach were used for 3 cases of Zone III endophytic iCM. At follow-up, 3 patients were fully recovered from a transient speech impairment while a permanent morbidity was observed in one case.

ICMs represent a single entity with peculiar clinical and surgical aspects. The proposed iCM classification focuses on anatomical and functional concerns, aiming to suggest the best pre-operative work-up and the surgical evaluation.