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The indications for treatment of cavernous malformations of the brain stem have evolved greatly in the past decade. As more experience has been gained with these lesions, it has become evident that surgical excision is possible with acceptable rates of surgical morbidity and mortality. Criteria for surgical indications include a symptomatic lesion that reaches a pial or ependymal surface and that can be reached without the need to traverse eloquent brain stem parenchyma. Advances in frameless stereotactic systems have improved localization and made resection safer, even for ''intrinsic'' symptomatic lesions that are reached through a small incision in ''safe entry-zones'' on the surface of the brain stem. Although with caution, surgical excision should also be considered for selected young asymptomatic patients with relatively large lesions that reach a pial or ependymal surface. This article summarizes the clinical characteristics, indications for surgery, technical surgical pitfalls, and outcomes of surgical resection of brain stem cavernous malformations.

Supratentorial cavernomas account for 75% of all cavernous malformations. These lesions become symptomatic as a result of hemorrhage, seizures, or mass effect. Patients with symptomatic supratentorial cavernomas are candidates for surgical resection. In recent years, resecting cavernous malformations has become safer. The procedure is straightforward utilizing neuronavigation and, when necessary, skull base techniques. This article reviews the basic surgical management of supratentorial cavernous malformations, reflecting the treatment strategies used at our institution.

Cavernous malformations of the brain are a subgroup of vascular malformations that can be asymptomatic or that can manifest with hemorrhage, seizures, or focal neurological deficits. Since the advent of magnetic resonance imaging, they are readily detectable and are diagnosed with increasing frequency. Understanding the natural history of cavernous malformations represents the first critical step in choosing the most appropriate treatment for patients. This article reviews the current literature on the natural history of cavernous malformations of the brain, including the rates of hemorrhage and seizures associated with these lesions. Potential risk factors for hemorrhage are also discussed.

Controversies exist regarding the appropriate initial management of patients with cavernous malformations associated with a seizure disorder. We retrospectively reviewed our experience with simple lesionectomy in the treatment of 82 patients with supratentorial cortical cavernous malformations who presented with seizures. Fifty-five patients had adequate follow up (at least 1 year; mean, 52 months) to assess outcome related to seizure control. Forty (73%) patients had single and 15 (27%) had multiple cavernous malformations. Eighteen (33%) patients underwent surgery within the first 2 months of their initial seizure. Thirty-seven (67%) patients had seizures for more than 6 months before their lesionectomy. All patients were treated with lesionectomy alone as their initial management. Outcomes were evaluated based on Engel's criteria. Seizure outcome was based on the number of seizures pre- and postoperatively, lesion location, and number of lesions. Of the 55 patients with adequate follow up, 69% were seizure free (grade 1) and 13% were almost seizure free (grade II). All 18 patients who were operated on within 2 months of their initial seizure have remained seizure free. Of the patients with chronic epilepsy before surgery, 57% are seizure free, and 17% are almost seizure free. Patients with multiple cavernous malformations and well-localized seizure activity on preoperative testing responded well to lesionectomy. Lesion location was not significant in predicting seizure outcome after surgery. Lesionectomy is a valuable treatment for patients with cavernous malformations associated with epilepsy and represents the best initial treatment option. Patients with chronic epilepsy who fail to become seizure free after lesionectomy may require further epilepsy monitoring and resection. Initial lesionectomy, however, will avoid unnecessary epilepsy surgery in most of these patients.

As many as 25% of all cavernous malformations occur in children, and they are distributed in a bimodal fashion with peaks at 3 and 11 years of age. Cavernous malformations in children pose a unique set of challenges. This article therefore reviews the epidemiology, pathology, clinical characteristics, and management of cavernous malformations of the pediatric central nervous system.

Carotid thromboendarterectomy can be performed safely and successfully in carefully selected patients with acute symptomatic occlusion of the internal carotid artery. This article focuses on the technical aspects of performing the procedure.