Acta Neurochirurgica

, Volume 160, Issue 10, pp 1963–1974 | Cite as

Treatment of cavernous malformations in supratentorial eloquent areas: experience after 10 years of patient-tailored surgical protocol

  • Jose L. SanmillanEmail author
  • Pablo Lopez-Ojeda
  • Isabel Fernández-Conejero
  • Alejandro Fernández-Coello
  • Gerard Plans
  • Yara Ali-Ciurana
  • Andreu Gabarrós
Original Article - Neurosurgery general
Part of the following topical collections:
  1. Neurosurgery general



Eloquent area surgery has become safer with the development of intraoperative neurophysiological monitoring and brain mapping techniques. However, the usefulness of intraoperative electric brain stimulation techniques applied to the management and surgical treatment of cavernous malformations in supratentorial eloquent areas is still not proven. With this study, we aim to describe our experience with the use of a tailored functional approach to treat cavernous malformations in supratentorial eloquent areas.


Twenty patients harboring cavernous malformations located in supratentorial eloquent areas were surgically treated. Individualized functional approach, using intraoperative brain mapping and/or neurophysiological monitoring, was utilized in each case. Eleven patients underwent surgery under awake conditions; meanwhile, nine patients underwent asleep surgery.


Total resection was achieved in 19 cases (95%). In one patient, the resection was not possible due to high motor functional parenchyma surrounding the lesion tested by direct cortical stimulation. Ten (50%) patients presented transient neurological worsening. All of them achieved total neurological recovery within the first year of follow-up. Among the patients who presented seizures, 85% achieved seizure-free status during follow-up. No major complications occurred.


Intraoperative electric brain stimulation techniques applied by a trained multidisciplinary team provide a valuable aid for the treatment of certain cavernous malformations. Our results suggest that tailored functional approach could help surgeons in adapting surgical strategies to prevent patients’ permanent neurological damage.


Brain mapping Neurophysiological monitoring Cavernous malformations Cerebrovascular Eloquent area surgery 



Electric brain stimulation


Cavernous malformation


Diffusion tensor imaging


Functional magnetic resonance imaging


Intraoperative neurophysiological monitoring


Magnetic resonance imaging


Compliance with ethical standards

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study, formal consent is not required.


  1. 1.
    Aiba T, Tanaka R, Koike T, Kameyama S, Takeda N, Komata T (1995) Natural history of intracranial cavernous malformations. J Neurosurg 83(1):56–59CrossRefPubMedGoogle Scholar
  2. 2.
    Akers A, Al-Shahi Salman R, Awad AI et al (2017) Synopsis of guidelines for the clinical management of cerebral cavernous malformations: consensus recommendations based on systematic literature review by the angioma alliance scientific advisory board clinical experts panel. Neurosurgery 80(5):665–680CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Batay F, Bademci G, Deda H (2007) Critically located cavernous malformations. Minim Invasive Neurosurg 50(2):71–76CrossRefPubMedGoogle Scholar
  4. 4.
    Berger MS (1995) Functional mapping-guided resection of low-grade gliomas. Clin Neurosurg 42:437–452PubMedGoogle Scholar
  5. 5.
    Boetto J, Bertram L, Moulinié G, Herbet G, Moritz-Gasser S, Duffau H (2015) Low rate of intraoperative seizures during awake craniotomy in a prospective cohort with 374 supratentorial brain lesions: electrocorticography is not mandatory. World Neurosurg 84(6):1838–1844CrossRefPubMedGoogle Scholar
  6. 6.
    Chang EF, Gabriel RA, Potts MB, Berger MS, Lawton MT (2011) Supratentorial cavernous malformations in eloquent and deep locations: surgical approaches and outcomes. Clinical article. J Neurosurg 114(3):814–827CrossRefPubMedGoogle Scholar
  7. 7.
    D'Angelo VA, De Bonis C, Amoroso R et al (2006) Supratentorial cerebral cavernous malformations: clinical, surgical, and genetic involvement. Neurosurg Focus 21(1):e9CrossRefPubMedGoogle Scholar
  8. 8.
    Daglioglu E, Ergungor F, Polat E, Nacar O (2010) Microsurgical resection of supratentorial cerebral cavernomas. Turk Neurosurg 20(3):348–352PubMedGoogle Scholar
  9. 9.
    Davies JM, Kim H, Lawton MT (2015) Surgical treatment of cerebral cavernous malformations. J Neurosurg Sci 59(3):255–270PubMedGoogle Scholar
  10. 10.
    De Witt Hamer PC, Robles SG, Zwinderman AH, Duffau H, Berger MS (2012) Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 30(20):2559–2565CrossRefPubMedGoogle Scholar
  11. 11.
    Duffau H (2000) Intraoperative direct subcortical stimulation for identification of the internal capsule, combined with an image-guided stereotactic system during surgery for basal ganglia lesions. Surg Neurol 53(3):250–254CrossRefPubMedGoogle Scholar
  12. 12.
    Duffau H, Fontaine D (2004) Successful resection of a left insular cavernous angioma using neuronavigation and intraoperative language mapping. Acta Neurochir 147(2):205–208CrossRefPubMedGoogle Scholar
  13. 13.
    Duffau H, Capelle L, Sichez J et al (1999) Intra-operative direct electrical stimulations of the central nervous system: the Salpêtrière experience with 60 patients. Acta Neurochir 141(11):1157–1167CrossRefPubMedGoogle Scholar
  14. 14.
    Duffau H, Capelle L, Denvil D et al (2003) Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg 98(4):764–778CrossRefPubMedGoogle Scholar
  15. 15.
    Englot DJ, Han SJ, Lawton MT, Chang EF (2011) Predictors of seizure freedom in the surgical treatment of supratentorial cavernous malformations. J Neurosurg 115(6):1169–1174CrossRefPubMedGoogle Scholar
  16. 16.
    Esposito V, Paolini S, Morace R (2006) Resection of a left insular cavernoma aided by a simple navigational tool. Technical note. Neurosurg Focus 21(1):e16CrossRefPubMedGoogle Scholar
  17. 17.
    Flemming KD, Link MJ, Christianson TJH, Brown RD (2012) Prospective hemorrhage risk of intracerebral cavernous malformations. Neurology 78(9):632–636CrossRefPubMedGoogle Scholar
  18. 18.
    Gabarros A, Young WL, McDermott MW, Lawton MT (2011) Language and motor mapping during resection of brain arteriovenous malformations: indications, feasibility, and utility. Neurosurgery 68(3):744–752CrossRefPubMedGoogle Scholar
  19. 19.
    Giussani C, Roux F-E, Ojemann J, Sganzerla EP, Pirillo D, Papagno C (2010) Is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? Review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. Neurosurgery 66(1):113–120CrossRefPubMedGoogle Scholar
  20. 20.
    Gralla J, Ganslandt O, Kober H, Buchfelder M, Fahlbusch R, Nimsky C (2003) Image-guided removal of supratentorial cavernomas in critical brain areas: application of neuronavigation and intraoperative magnetic resonance imaging. Minim Invasive Neurosurg 46(2):72–77CrossRefPubMedGoogle Scholar
  21. 21.
    Grant GA, Farrell D, Silbergeld DL (2002) Continuous somatosensory evoked potential monitoring during brain tumor resection. Report of four cases and review of the literature. J Neurosurg 97(3):709–713CrossRefPubMedGoogle Scholar
  22. 22.
    Leal PRL, Houtteville JP, Etard O, Emery E (2010) Surgical strategy for insular cavernomas. Acta Neurochir 152(10):1653–1659CrossRefPubMedGoogle Scholar
  23. 23.
    Matsuda R, Coello AF, De Benedictis A, Martinoni M, Duffau H (2012) Awake mapping for resection of cavernous angioma and surrounding gliosis in the left dominant hemisphere: surgical technique and functional results: clinical article. J Neurosurg 117(6):1076–1081CrossRefPubMedGoogle Scholar
  24. 24.
    Nabavi A, Black PM, Gering DT et al (2001) Serial intraoperative magnetic resonance imaging of brain shift. Neurosurgery 48(4):787–797 discussion 797–8 PubMedGoogle Scholar
  25. 25.
    Paolini S, Morace R, Di Gennaro G, Picardi A, Grammaldo LG, Meldolesi GN, Quarato PP, Raco A, Esposito V (2006) Drug-resistant temporal lobe epilepsy due to cavernous malformations. Neurosurg Focus 21(1):e8CrossRefPubMedGoogle Scholar
  26. 26.
    Poorthuis MHF, Klijn CJM, Algra A, Rinkel GJE, Al-Shahi Salman R (2014) Treatment of cerebral cavernous malformations: a systematic review and meta-regression analysis. J Neurol Neurosurg Psychiatry 85(12):1319–1323CrossRefPubMedGoogle Scholar
  27. 27.
    Reinges MHT, Nguyen H-H, Krings T, Hütter B-O, Rohde V, Gilsbach JM (2004) Course of brain shift during microsurgical resection of supratentorial cerebral lesions: limits of conventional neuronavigation. Acta Neurochir 146(4):369–377 discussion 377 CrossRefPubMedGoogle Scholar
  28. 28.
    Sakurada K, Sato S, Sonoda Y, Kokubo Y, Saito S, Kayama T (2006) Surgical resection of tumors located in subcortex of language area. Acta Neurochir 149(2):123–130CrossRefPubMedGoogle Scholar
  29. 29.
    Sanmillan JL, Fernández-Coello A, Fernández-Conejero I, Plans G, Gabarros A (2016) Functional approach using intraoperative brain mapping and neurophysiological monitoring for the surgical treatment of brain metastases in the central region. J Neurosurg 126(3):698–707CrossRefPubMedGoogle Scholar
  30. 30.
    Sills AK (2005) Current treatment approaches to surgery for brain metastases. Neurosurgery 57(5 Suppl):S24–S32 discusssion S1–4 PubMedGoogle Scholar
  31. 31.
    Ulkatan S, Jaramillo AM, Téllez MJ, Kim J, Deletis V, Seidel K (2016) Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures. J Neurosurg 126(4):1296–1302CrossRefPubMedGoogle Scholar
  32. 32.
    Wostrack M, Shiban E, Harmening K, Obermueller T, Ringel F, Ryang Y-M, Meyer B, Stoffel M (2012) Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions. Acta Neurochir 154(8):1419–1430CrossRefPubMedGoogle Scholar
  33. 33.
    Zhou H, Miller D, Schulte DM, Benes L, Rosenow F, Bertalanffy H, Sure U (2009) Transsulcal approach supported by navigation-guided neurophysiological monitoring for resection of paracentral cavernomas. Clin Neurol Neurosurg 111(1):69–78CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Jose L. Sanmillan
    • 1
    Email author return OK on get
  • Pablo Lopez-Ojeda
    • 1
  • Isabel Fernández-Conejero
    • 2
  • Alejandro Fernández-Coello
    • 1
  • Gerard Plans
    • 1
  • Yara Ali-Ciurana
    • 3
  • Andreu Gabarrós
    • 1
  1. 1.Neurosurgery DepartmentHospital Universitari de BellvitgeBarcelonaSpain
  2. 2.Neurophysiology DepartmentHospital Universitari de BellvitgeBarcelonaSpain
  3. 3.Universitat de BarcelonaBarcelonaSpain

Personalised recommendations