Object: The authors present a series of children with supratentorial lobar cavernous malformations (CMs). Current imaging and operative techniques along with long-term follow-up were incorporated to characterize the response to surgical treatment in this pediatric population.
Methods: The senior author's operative experience was reviewed retrospectively along with a review of the Boston Children's Hospital database from 1997 to 2011 for children with supratentorial lobar CMs. Lobar CM was defined as having a supratentorial location but not involving the thalamus/hypothalamus or basal ganglia. Baseline patient demographics, pertinent radiographic findings, operative outcomes, and long-term results were evaluated and compared between patients managed operatively and those who were managed nonoperatively.
Results: Of 238 CMs identified, 181 (76%) were lobar. Compared with patients managed with observation only, those selected for surgery were older (p = 0.03), more likely to have symptomatic lesions (p < 0.001), and had larger lesions (p < 0.001). Of the 83 CMs selected for surgery, 98% were completely resected. Over a total of 384.5 patient-years of follow-up after surgery (mean 4.6 years; median 2.7 years; range 0.1-22.3 years), there were no subsequent hemorrhages in any patient undergoing complete resection; 1 of the 2 incompletely resected lesions rebled during the follow-up period. Radiographically, there was 1 recurrence (1.2%) in a child with multiple CMs; there were no recurrences of completely resected single lesions. Of the 48 patients who presented with seizures (acute or chronic), 46 (96%) were seizure free at follow-up. The permanent neurological complication rate of surgery was 5%; these complications were limited to those patients whose lesions were in eloquent locations.
Conclusions: Pediatric patients with symptomatic supratentorial lobar CMs are ideal candidates for surgery, for which there are high complete resection rates, rewarding long-term seizure outcomes, and low operative morbidity. Observation may be warranted in smaller asymptomatic lesions located within eloquent cortex.