Microsurgical Resection of Giant Radio-Induced Cavernous Malformation: 2- Dimensional Video

Radioinduced cavernous malformations (RICMs) are low-flow, angiographically occult vascular lesions. Giant radioinduced cavernous malformations (GRICMs) are a subtype of RICMs that are characterized by their large size. GRICMs are defined as RICMs that are larger than 3 cm in diameter.¹ They are uncommon conditions accounting for 0.1% to 0.5% among patients who have received radiation therapy for head and neck cancer or brain tumors.^2,3 The risk of developing GRICMs increases with the dose of radiation received and the length of time since radiation exposure.⁴ Other factors that may increase the risk of developing GRICMs include age, genetic predisposition, and underlying medical conditions.⁵ Due to the relatively low incidence of GRICMs and the limited number of studies on this condition, there are limited data about the management of this condition. This case report describes a 12-year-old female who was previously treated for a pilocytic astrocytoma in 2012. After undergoing stereotactic biopsy and whole-brain radiotherapy (50 gray in 28 sections), she was diagnosed with a radioinduced cavernous malformation in 2016 during follow-up imaging. The RICM was managed conservatively with imaging follow-up, which showed no increase in size between 2016 and 2019. However, in 2020, the patient experienced a seizure episode associated with left-sided hemiplegia. Further investigation with cranial magnetic resonance imaging and digital subtraction angiography showed a mixed-intensity image and surrounded by a low signal intensity rim on T2-weighted images, representing hemosiderin in the right central lobe, with intense perilesional edema, with no enhancement. Given the size and location of the mass, the patient underwent microsurgical resection of the RICM (Video 1). The surgery was successful, and the lesion was successfully resected. This case highlights the importance of careful monitoring for RICMs in patients who have received radiation therapy, as well as the potential for these lesions to cause significant symptoms and disability. The case also demonstrates that surgical intervention may be necessary in some cases to manage RICMs and that microsurgical resection can be an effective treatment option. The patient gave informed consent for surgery and video recording.