Overview
Mayo Clinic’s Eugene L. Scharf, M.D., E. Paul Lindell, M.D., Kelly D. Flemming, M.D., and Giuseppe Lanzino, M.D., discuss referring patients with cavernous malformations and how Mayo Clinic’s team uses advanced imaging systems to evaluate the right path of care for the patient.
“The 7-tesla MRI has given us more tools to make the diagnosis in patients where it’s less clear,” says Kelly D. Flemming, M.D.
Although rare, Mayo Clinic sees 75 to 100 patients with cavernous malformations per year.
EUGENE SCHARF: Most cerebral cavernomas are what we call sporadic. There are certain disease states that predispose to the development of multiple cerebral cavernomas, and those are genetic disorders, generally speaking. And then oftentimes, if a person has a history of brain irradiation from a prior malignancy, then we can see that radiation itself can induce multiple cavernomas as well.
EUGENE SCHARF: We see a characteristic pattern of signal that helps us understand that this is a cavernous malformation as opposed to other lesions.
KELLY FLEMMING: Sometimes, the very tiny ones are hard to diagnose as well. So in those cases, we either use time and re-image, or sometimes we'll use the higher magnet MRIs. So the 7-Tesla MRI gives us a better view of the abnormality. Sometimes, we will see a single lesion on standard imaging, but on 7-Tesla, we'll see multiple cavernous malformations. So the 7-Tesla MRI has given us more tools to make the diagnosis in patients where it's less clear. I often encourage patients to get second and third opinions on cavernous malformations, because there is some controversy as to the timing of surgery, and whether a cavernous malformation can be removed.
GIUSEPPE LANZINO: Every lesion can be operated on. It's just a matter of being able to understand, what are the risks versus the benefits of removing a certain lesion?
EUGENE SCHARF: But a million question, quite literally, is will this cerebral cavernoma be the one that bleeds and causes dysfunction and ultimately impacts quality of life? If one is diagnosed with a cerebral cavernoma, due to the rarity with respect to it's encountered in the general population, I would advise that they seek care at a cavernoma center of excellence. The reason being, is that there are more advanced diagnostic modalities and clinical studies that may overall inform the optimal management with respect to the cavernoma diagnosis itself.
KELLY FLEMMING: One of the important things that we have is volume of patients. We see more than 75 to 100 patients per year with cavernous malformations.
GIUSEPPE LANZINO: We see a large number of patients, often with the bias toward those more complex lesions, that many other physicians might not see.
KELLY FLEMMING: We have neurosurgeons that have expertise in cavernous malformation resection, even in places where patients were told it was inoperable.
GIUSEPPE LANZINO: We have all the intraoperative imaging tools that are required to be able to localize the lesion, to check during the surgery, to have real-time time feedback in terms of the location, of how much of the lesion you have been able to resect.
KELLY FLEMMING: The really fascinating research over the last several years has involved looking at medications that might prevent bleeding, or might prevent the familial form from developing more lesions. That gives us a lot of hope that there may be other opportunities besides surgery.