Cerebellar cavernous hemangiomas (also called cavernomas or cavernous malformations) are low-flow vascular lesions in the brain that can cause symptoms due to bleeding or compression.

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What is a cerebellar cavernous hemangioma?

– A cavernous hemangioma is a cluster of dilated capillaries with no intervening brain tissue.
– In the cerebellum, these lesions can cause coordination issues, dizziness, and headaches—especially if they bleed.
– They are angiographically occult (not seen on angiogram) but very clear on MRI.

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Patient Presentation:

Depends on location, size, and presence of hemorrhage.

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Common Symptoms:

– Headache
– Dizziness or vertigo
– Ataxia (gait imbalance)
– Nausea, vomiting
– Signs of increased intracranial pressure (if large or bleeding)

In some cases, they’re found incidentally on imaging.

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Imaging Findings:

MRI—Gold standard
– “Popcorn” or “mulberry” appearance with a mixed-signal core (due to blood at different stages).
– Surrounded by a hypointense hemosiderin rim (from previous microbleeds).

Best seen on:
  – T2-weighted images
  – Gradient Echo (GRE) or SWI for blooming artifact from hemosiderin.

T2 axial images show cavernoma

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Angiography:

The results are typically negative, as these are low-flow lesions .

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Surgical Indications

Surgery is considered if:
– Recurrent bleeding
– Symptomatic lesion (e.g., ataxia, pressure symptoms)
– Accessible cerebellar location

Asymptomatic lesions are usually observed, unless they are high-risk (e.g., close to the fourth ventricle or brainstem).

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Surgical Approach

Suboccipital Craniotomy
Most common approach for midline or paramedian cerebellar cavernomas.

Steps:

1. The patient is placed in a prone or park bench position.
2. Midline posterior fossa incision with suboccipital bone removal.
3. Dura is opened, and the cerebellar cortex is gently retracted .
4. Lesion is carefully dissected and removed; it may have surrounding gliosis or hemosiderin.
5. Hemostasis and closure.

Key Point: Avoid incomplete resection, as residual tissue can bleed again.

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Postoperative Considerations

– Monitor for hydrocephalus (especially if lesion near 4th ventricle).
– Neurological exam for cerebellar signs
– Repeat MRI to confirm gross total resection
– Seizure prophylaxis (rarely needed unless supratentorial)

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Brainstem Cavernous Malformation Surgery:

• https://www.youtube.com/watch?v=Bl2em95FXZQ

Posterior Petrosectomy for Resection of Pontine Cavernous Malformation:

• https://www.youtube.com/watch?v=szB6YpzkuCo

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Every case is a classroom. Each incision serves as a lesson. Observing from the sidelines today, I witnessed not just a procedure but a performance of precision, patience, and purpose.

Here’s to many more steps into the OR, and many more pages in my journey as a student of the brain.

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