Pure lesionectomy versus tailored epilepsy surgery in treatment of cavernous malformations presenting with epilepsy

Cerebral cavernous malformations (CM) are well-circumscribed vascular malfo rmations that often present with epileptic seizures. Although patients may initially benefit from antiepileptic drugs, surgical treatment may become n ecessary due to medically intractable seizures. However, it is unclear whet her lesionectomy alone or tailored epilepsy surgery with previous invasive monitoring is the optimal strategy in such cases. We report two patients wi th epileptic seizures due to CM. One patient with few seizures prior to sur gery became seizure-free following resection of the CM and the surrounding tissue. In the second patient with long-lasting epilepsy, lesionectomy was performed because of the proximity to a functioning left hippocampus. This limited resection failed and the patient still had seizures. Subsequently, invasive monitoring with intracranial depth and strip electrodes was perfor med in order to localize the epileptogenic area and determine whether the l eft hippocampus could be spared. The invasive study showed the seizure orig in in the tissue around the former CM but no epileptic discharges in the hi ppocampus. In a second operation, an anterior temporal resection was perfor med with removal of the epileptogenic surrounding tissue and the patient be came seizure-free without cognitive deficits. The optimal surgical strategy for CM presenting with epileptic seizures must take into account various f actors such as underlying mechanisms and duration of epilepsy, and location of the lesion.