Giant Cystic Cerebral Cavernous Malformation with Multiple Calcification - Case Report
A right-handed, 19-year-old male was referred to the division of neurosurgery due to right sided motor weakness (grade II/II) that persisted for 3 months. Since the age of 5, the patient had been clinically diagnosed with 1st grade mental retardation and epilepsy with daily prescription medication as follows: levetiracetam 500 mg 1T twice a day (bid), valproate 600 mg 1T bid, topiramate 100 mg 1T bid, clonazepam 0.5 mg 1T per day. Also, the patient had familial history of an 18-year-old sister with an astrocytoma on her left pons, diagnosed when she was 10 years old. After a surgical resection, she fully recovered. No other family members had significant clinical history.\nThe patient's computed tomography (CT) scan revealed a well-defined cystic mass with a size of 7.2×4.6×6 cm filled with 2 cm intra-cystic nodule on left fronto-parietal lobe. There were also multiple parenchymal calcifications in both parietal lobes (). The mass was lobulated, ovoid, and bulging, and had surrounding edema with mass effect. The patient's magnetic resonance imaging (MRI) showed the mass as low signal intensity (SI) in T1-weighted images (WI), but high SI in T2WI (). The 2 cm intra-cystic nodule was heterogeneous high SI in T1WI, low SI in T2WI and slightly enhanced, heterogeneous high SI in T1-weighted contrast-enhanced coronal image (). Based on the CT and MRI findings, the lesion was diagnosed as a low-grade glioma or congenital infection such toxoplasmosis or cytomegalovirus, or even a neurocysticercosis. Surgical resection was decided upon as the course of treatment. A left frontal craniotomy was performed, followed by a transcortical approach to remove the mass. From the MRI, the T1 low SI, T2 high SI lesion in the surgical field was identified as a cyst with yellow fluid, and was removed with aspiration. The intra-cystic nodule, which was 2×2 cm in size, freely movable, relatively hard, with a yellow surface, and low vascularity, was resected en bloc. There were no significant complications or bleeding. After the operation, the patient made a rapid recovery. Motor weakness was improved to grade III/III. However, the histological exams of the mass revealed it to be a CM (). The follow-up CT scan showed no residual lesion ().