Cerebral cavernous malformations (CCMs) are congenital occult lesions and vascular malformations[1]. They are classified into intracranial and extracranial types[2], associated with solitary lesions with a high bleeding risk in most cases. Early clinical symptoms of cavernous malformations are not evident, with a certain misdiagnosis rate. Therefore, it is necessary to distinguish them from intracranial lesions, including meningiomas, schwannomas, and metastatic tumors[3]. This article retrospectively analyzed a CMMs patient treated at the First People's Hospital of Lianyungang in September 2020. The clinical and imaging characteristics of CMMs were analyzed after combination with relevant literature, as reported below.
1. Patient information
1.1 History of present illness: A 61-year-old male patient was admitted due to sudden onset cognitive impairment. He could not use a mobile phone, turn on the TV, or recognize words. These symptoms persisted without relief. The patient possessed no history of head trauma, nausea, vomiting, fever, or seizures. He had good mental status, with normal appetite and sleep conditions. No abnormalities were detected in limb activity, urination, or defecation. The patient visited the Geriatric Department, where a head CT scan revealed a possible mass within the left brain hemisphere and the left frontal and temporal bone destruction.
1.2 Past medical history: The patient had undergone left orbital tumor resection 10 years ago due to left eye watering and protrusion from another hospital. The pathology report indicated a plasma cell tumor without any abnormal intracranial lesions. Thus, local radiotherapy was administered after surgery. In 2015, the patient visited our hospital and was found to present multiple bone destructions on the thoracic and lumbar MRI. Then, he was transferred to Jiangsu People's Hospital, where a "multiple myeloma" diagnosis was confirmed, and the patient underwent several inpatient chemotherapy treatments. In 2019, the patient felt sudden chest tightness on the right side. The patient had a myocardial infarction and received coronary stent implantation. He has been regularly taking the medication since discharge.
1.3 Physical examination: The temperature of the patient was 36.3℃, the heart rate was 60 beats per minute, the respiratory rate was 17 breaths per minute, and the blood pressure was 142/71 mmHg. Cardiac, pulmonary, and abdominal examinations were negative. The patient possessed a clear consciousness but depicted decreased memory. The bilateral pupils were equally large and round, with a 3 mm diameter in both eyes. The right eye had light reflexes, while the left had no light perception. The forehead wrinkles were symmetrical, and hearing was normal in the ears. The left and right limbs had Grade 5 muscle strength with normal muscle tone. Finger-to-nose and heel-to-shin tests were normal bilaterally. The patient showed negative Babinski and Oppenheim signs. Blood tests revealed a white blood cell count of 6.79×109/L, with 80.7% neutrophils, a hemoglobin level of 122g/L, a platelet count of 170×109/L, a mean platelet volume of 8.9fL, and a red blood cell count of 3.78×1012/L.
1.4 Auxiliary examinations: The contrast-enhanced head CT demonstrated multiple cystic lesions with uneven wall thickness and irregular enhancement within the left frontal and temporal lobes. Some areas had solid lesions surrounded by edema with mild to moderate heterogeneous enhancement. Localized bone destruction was also observed within the left temporal and sphenoid bones (Figure 1A-1B).The left lateral ventricle was compressed, and midline structures had shifted to the right. The CT diagnosis indicated a left cerebral hemisphere space-occupying lesion and left frontal and temporal bone destruction, possibly because of multiple myeloma metastasis. The head MRI scan with contrast demonstrated irregular cystic and solid lesions within the left frontal and temporal lobes, showing enhanced cyst walls and significant heterogeneous enhancement across solid areas (Figure 2A-2C). These lesions invaded the left temporal and sphenoid bones and led to bone destruction. Large areas of edema were observed around the lesions. Moreover, the left lateral ventricle was compressed and shifted, and the midline shifted to the right. The MRI results indicated a solid-cystic lesion in the left frontal and temporal lobes, describing the possible myeloma in the left temporal and sphenoid bones involved in the left side of the brain. Based on medical history, high-grade glioma in the brain could not be ruled out.
1.5 Surgical procedures: Intraoperatively, a lesion was observed in the brain, and a soy sauce-like liquid was seen after puncturing the cystic lesion within the left temporal lobe. After the brain tissue collapsed, the left temporal lobe lesion was excised first. The lesion was purple-red and lacked a complete capsule. The tumor was approximately 2 cm × 2 cm × 2.5 cm in size and was removed along the boundary of the brain tissue. The left frontal lobe lesion of approximately 2 cm × 1.5 cm × 1 cm in size was excised along the normal brain tissue boundary surrounding the tumor. A connection was observed with the left lateral ventricle after lesion removal. The tumor tissue was sent for rapid pathological examination during the operation, indicating glial cell proliferation. A routine pathological test was performed on the excised tumor after the procedure.
1.6 Results: After treatment, the patient gradually regained consciousness, having equally large and round pupils and showing sensitive responses to light. Limb movements were normal. CT re-examination revealed that most of the intracranial mass had been removed without significant bleeding in the surgical area. When the condition of the patient improved after a week of hospitalization, he was discharged with medication. Regular outpatient follow-up was conducted after discharge, and the pathological diagnosis was CMMs(Figure 3).