Surgical Strategy for Insular Cavernomas

  • Mehmet Turgut
  • Paulo Roberto Lacerda Leal
  • Evelyne Emery


Surgical treatment of cavernomas (CAs) of the insula are challenging because of their proximity to the corticospinal pathways in the internal capsule and to the functional role of the left insula in speech. As a result of advances in image guidance systems and intraoperative stimulation mapping to locate the subcortical language pathways, the surgical indications for CAs of the insula have increased in recent years. The bulk of the review will focus on various surgical strategies for these lesions using the image guidance system for determination of the ideal trajectory for dissection of insular cortex and planning of the surgical approach. In patients with insular CA presenting with epilepsy, complete resectioning of the lesion and the surrounding hemosiderin zone is necessary to achieve a better prognosis with the use of electrocorticography.


Cavernoma Electrocorticography Image guidance system Insula Neuronavigation Surgery Vascular malformation 


  1. 1.
    Aiba T, Tanaka R, Koike T, Kameyama S, Takeda N, Komata T. Natural history of intracranial cavernous malformations. J Neurosurg. 1995;83:56–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Duffau H, Capelle L, Lopes M, Faillot T, Sichez JP, Fohanno D. The insular lobe: physiopathological and surgical considerations. Neurosurgery. 2000;47:801–11.CrossRefPubMedGoogle Scholar
  3. 3.
    Duffau H, Capelle L, Sichez N, Denvil D, Lopes M, Sichez JP, Bitar A, Fohanno D. Intraoperative mapping of the subcortical language pathways using direct stimulations. An anatomo-functional study. Brain. 2002;125:199–214.CrossRefPubMedGoogle Scholar
  4. 4.
    Duffau H, Fontaine D. Successful resection of a left insular cavernous angioma using neuronavigation and intraoperative language mapping. Case report. Acta Neurochir. 2005;147:205–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Batra S, Lin D, Recinos PF, Zhang J, Rigamonti D. Cavernous malformations: natural history, diagnosis and treatment. Nat Rev Neurol. 2009;5:659–570.CrossRefPubMedGoogle Scholar
  6. 6.
    Shan YZ, Fan XT, Meng L, An Y, Xu JK, Zhao GG. Treatment and outcome of epileptogenic temporal cavernous malformations. Chin Med J. 2015;128:909–13.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Leal PRL, Houtteville JP, Etard O, Emery E. Surgical strategy for insular cavernomas. Acta Neurochir. 2010;152:1653–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Bertalanffy H, Gilsbach JM, Eggert HR, Seeger W. Microsurgery of deep-seated cavernomas: report of 26 cases. Acta Neurochir. 1991;108:91–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Casazza M, Broggi G, Franzini A, Avanzini G, Spreafico R, Bracchi M, Valentini MC. Supratentorial cavernomas and epileptic seizures: preoperative course and postoperative outcome. Neurosurgery. 1996;39:26–32.CrossRefPubMedGoogle Scholar
  10. 10.
    Chaskis C, Brotchi J. The surgical management of cerebral cavernous angioma. Neurol Res. 1998;20:597–606.CrossRefPubMedGoogle Scholar
  11. 11.
    Cukiert A, Forster C, Andrioli MS, Frayman L. Insular epilepsy. Similarities to temporal lobe epilepsy. Case report. Arq Neuropsiquiatr. 1998;56:126–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Woydt M, Horowski A, Krone A, Soerensen N, Roosen K. Localization and characterization of intracerebral cavernomas by intraoperative high-resolution colour-duplex-sonography. Acta Neurochir. 1999;141:143–52.CrossRefPubMedGoogle Scholar
  13. 13.
    Schmitt JJ, Ebner A. The anatomic substrate of the epigastric aura-a case report. Nervenarzt. 2000;71:485–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Tirakotai W, Sure U, Benes L, Krischek B, Siegfried B, Bertalanffy H. Image-guided transsylvian, transinsular approach for insular cavernomas. Neurosurgery. 2003;53:1299–305.CrossRefPubMedGoogle Scholar
  15. 15.
    Esposito V, Paolini S, Morace R. Resection of a left insular cavernoma aided by a simple navigational tool. Neurosurg Focus. 2006;21:1–4.CrossRefGoogle Scholar
  16. 16.
    von Lehe M, Wellmer J, Urbach H, Schramm J, Elger CE, Clusmann H. Insular lesionectomy for refractory epilepsy: management and outcome. Brain. 2009;132:1048–56.CrossRefGoogle Scholar
  17. 17.
    Chevrier MC, Bard C, Guilbert F, Nguyen DK. Structural abnormalities in patients with insular/peri-insular epilepsy: spectrum, frequency, and pharmacoresistance. AJNR Am J Neuroradiol. 2013;34:2152–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Cossu M, Raneri F, Casaceli G, Gozzo F, Pelliccia V, Lo Russo G. Surgical treatment of cavernoma-related epilepsy. J Neurosurg Sci. 2015;59:237–53.PubMedGoogle Scholar
  19. 19.
    Gross BA, Lin N, Du R, Day AL. The natural history of intracranial cavernous malformations. Neurosurg Focus. 2011;30:E24.CrossRefPubMedGoogle Scholar
  20. 20.
    Sawarkar DP, Janmatti S, Kumar R, Singh PK, Gurjar HK, Kale SS, Sharma BS, Mahapatra AK. Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature. Childs Nerv Syst. 2017;33(9):1525–38. Scholar
  21. 21.
    Raabe A, Schmitz AK, Pernhorst K, Grote A, von der Brelie C, Urbach H, Friedman A, Becker AJ, Elger CE, Niehusmann P. Cliniconeuropathologic correlations show astroglial albumin storage as a common factor in epileptogenic vascular lesions. Epilepsia. 2012;53:539–48.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Goodglass H, Kaplan E. The assessment of aphasia and related disorders. Philadelphia: Lea & Febiger; 1972. p. 1–80.Google Scholar
  23. 23.
    Ota Y, Araki O, Oki S, Inagawa T, Emoto K, Shibukawa M, Yamasaki H, Kano Y, Tani I. A case report of stereotactic craniotomy for the cerebral cavernous angioma (in Japanese). No Shinkei Geka. 2016;44:149–54.PubMedGoogle Scholar
  24. 24.
    Sommer B, Kasper BS, Coras R, Blumcke I, Hamer HM, Buchfelder M, Roessler K. Surgical management of epilepsy due to cerebral cavernomas using neuronavigation and intraoperative MR imaging. Neurol Res. 2013;35:1076–83.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Bauman CR, Schuknecht B, Russo GL, Cossu M, Citterio A, Andermann F, Siegel AM. Seizure outcome after resection of cavernous malformations is better when surrounding hemosiderin-stained brain also is removed. Epilepsia. 2006;47:563–6.CrossRefGoogle Scholar
  26. 26.
    Bello L, Gambini A, Castellano A, Carrabba G, Acerbi F, Fava E, Giussani C, Cadioli M, Blasi V, Casarotti A, Papagno C, Gupta AK, Gaini S, Scotti G, Falini A. Motor and language DTI fiber tracking with intraoperative subcortical mapping for surgical removal gliomas. NeuroImage. 2008;39:369–82.CrossRefPubMedGoogle Scholar
  27. 27.
    Ojemann G, Ojemann JG, Lettich E, Berger M. Cortical language localization in left, dominant hemisphere. An electrical stimulation mapping investigation in 117 patients. J Neurosurg. 1989;71:316–26.CrossRefPubMedGoogle Scholar
  28. 28.
    Sugano H, Shimizu H, Sunaga S. Efficacy of intraoperative electrocorticography for assessing seizure outcomes in intractable epilepsy patients with temporal-lobe-mass lesions. Seizure. 2007;16:120–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Van Gompel JJ, Rubio J, Cascino GD, Worrell GA, Meyer FB. Electrocorticography-guided resection of temporal cavernoma: is electrocorticography warranted and does it alter the surgical approach? J Neurosurg. 2009;110:1179–85.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Yeon JY, Kim JS, Choi SJ, Seo DW, Hong SB, Hong SC. Supratentorial cavernous angiomas presenting with seizures: surgical outcomes in 60 consecutive patients. Seizure. 2009;18:14–20.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Mehmet Turgut
    • 1
  • Paulo Roberto Lacerda Leal
    • 2
  • Evelyne Emery
    • 3
  1. 1.Department of NeurosurgeryAdnan Menderes University School of MedicineAydınTurkey
  2. 2.Department of NeurosurgeryFaculty of Medicine of Sobral, Federal University of CearáSobralBrazil
  3. 3.Department of NeurosurgeryUniversity of CaenCaenFrance

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