58 A Case of Unusual Giant and Complex Bifrontal Cavernoma

58

A Case of Unusual Giant and Complex Bifrontal Cavernoma

JACQUES BROTCHI, DANIELE MORELLI, AND ISAAC HOUINSOU-HANS

Diagnosis Bifrontal cavernoma

Problems and Tactics A giant bifrontal tumor was discovered on neuroradiological check-up performed because of a generalized seizure. Magnetic resonance imaging (MRI) showed a butterfly tumor that had bled. Location, calcifications, and shape were in favor of a fronto-calloso-frontal anaplastic glioma, but MRI proton-weighted sequences suggested an unusual giant cavernoma embedding both anterior cerebral arteries and branches. That is the reason why we decided on a direct approach rather than a stereotactic biopsy in spite of a bifrontal lesion.

Keywords Cavernoma, butterfly frontal lesion

Clinical Presentation

This 34-year-old woman had a generalized seizure when she was pregnant, 7 months before being admitted. Computed tomography (CT) showed a butterfly tumor looking like an oligodendroglioma. Magnetic resonance imaging (MRI) without contrast demonstrated a huge bifrontal lesion that had bled. The neurological exam was normal. After delivery, angiography was performed showing a very mild blush although MRI with gadolinium demonstrated a high contrast enhancement. Everything was in favor of a suspected anaplastic glioma that should benefit from a stereotactic biopsy, but careful MRI study with proton-weighted images nicely showed a bilateral frontal lesion, with cavernoma characteristics, embedding in both anterior cerebral and pericallosal arteries (Fig. 58–1).

Surgical Technique

The patient was lying in the supine position. After a bicoronal incision of the skin, a bifrontal bone flap was cut just in case a bilateral approach might be needed. Due to the greatest development of the tumor on the left side, the dura was opened on that side with a triangular shape and reflected over the sagittal longitudinal sinus. An interhemispheric approach was carefully made under magnification with the microscope. One frontal bridging vein had to be coagulated and divided. The tumor was immediately discovered with a typical aspect of a cavernoma. The lesion was gently coagulated with the bipolar forceps and progressively dissected from the normal brain. It progressed far deep inside, close to the ventricle. Thanks to coagulation, the lesion shrank moderate brain retraction giving enough room effectively for surgery. We also did a piecemeal removal without bleeding, but the greatest difficulties were at the level of both anterior cerebral arteries and branches, which were embedded and stretched, but not infiltrated (Fig. 58–2A

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