What is a cavernoma and how is it treated?

Mr Patrick Grover is a leading London-based consultant neurosurgeon with over 10 years of experience. In his latest article, Mr Grover offers his expert insight into cavernomas, explaining their symptoms and treatment options among other points.

Is a cavernoma a brain tumour?

No, cavernomas are not brain tumours. A cavernoma is in the spectrum of what we call vascular malformation. So, it's an abnormal formation of blood vessels in the brain or a sort of a blood lesion but it's certainly not a tumour. It's not something that tends to grow or require tumour-based treatments or tumour therapies. It is something that can bleed at some point in people's lifetime, and that's the reason why we consider treatments for them.

How serious is a cavernoma? Does it always need to be removed?

Well, a cavernoma can be anything in a spectrum from a completely incidental finding, which never requires any treatment or removal, or even surveillance, to one that can bleed in quite an important part of the brain that does need to be removed or needs to be treated, potentially with focal radiation treatments like radiosurgery.

What are the symptoms of a cavernoma?

So, there is a very broad spectrum of cavernoma and the symptoms depend on many factors:

• the location of the cavernoma
• a particular cavernoma's behaviour
• the extent to which it can cause seizures or epilepsy disorders
• Cavernoma can also cause what we call focal neurology, and that essentially means symptoms related to that particular position in the brain. So, if you happen to have a cavernoma in the speech area of the brain you might have a speech problem, if it's in a motor part of the brain you might have a weakness, but if it's in a path of the brain that does very little you could have a bleed from a cavernoma that causes no symptoms at all.

What are the treatment options for a cavernoma?

There are three primary treatment options:

The first option is to monitor the cavernoma, to monitor the patient's symptoms and potentially if it's a cavernoma that's changing or is symptomatic to perform serial scans. So, we might do a scan once a year or every few years.

The second option is surgery. Surgical excision is a very effective treatment for cavernoma if it can be done safely. So, if you remove a cavernoma then there's no further risk of bleeding or problems in the future if it is successful, but there are only certain cavernomas that are amenable to surgical removal. If your cavernoma is in a very difficult, deep location and you might cause more harm than good when trying to remove it then it's not feasible. However, if it's very superficial then it could be removed. 

The third option is focused radiation treatment. This could include Gamma Knife, radiosurgery or Cyberknife treatment. These treatments aim to deliver a very focused beam of radiation to the cavernoma to prevent future bleeds. It doesn't remove the cavernoma, but if you give it a very highly focused beam of radiation, which is done as a day case, potentially you can reduce the risk of behaviour in the future such as bleeding or growth.

Can I still exercise if I have a cavernoma?

Absolutely! Exercise is good for you and a cavernoma is actually not part of your normal circulation, so things like changes in your blood pressure or excessive activity shouldn't affect the risk of bleeding or activity from a cavernoma. If you have a scan and you're diagnosed with a cavernoma, I wouldn't suggest that you suddenly stop exercising or doing daily activities which are good for you because you're not going to alter the cavernoma’s behaviour.  If you have a cavernoma which is causing problems, for example, epilepsy or neurological symptoms then I think you can alter your behaviour according to the symptoms, but I wouldn't suggest doing that because of the cavernoma.

Are there any advancements in the treatment of cavernomas?

Well, one of the key questions that we are attempting to address at the moment is really that question of whether patients benefit from treatment with either open surgery, focused radiation treatment, such as gamma knife radiosurgery or conservative management. I’m a principal investigator for the CARE trial, which is the Cavernoma Randomized Effectiveness trial. This is a national and multinational study looking at comparing patients who have either surveillance, radiosurgery or open surgery.

The CARE trial aims to address that question and is funded by the National Institute of Health Research and we're recruiting at the moment. A patient who takes part in the trial will receive all the information about the risks and benefits, they will have guidance on which treatments might be suitable for them and then depending on which treatment they have, or if they have surveillance, they'll then be followed up within the trial in a structured fashion.

The CARE trial was conceptualized in association with the Cavernoma Alliance. The Cavernoma Alliance reviewed the top research questions in the management of cavernomas, such as whether conservative management, surgery or radiosurgery was the best treatment option. So that's the reason why the CARE trial exists and we're very much recruiting at the moment for patients who would like to be involved.