J Neurosurg Pediatrics 13:699–705, 2014

©AANS, 2014

Surgical management and long-term outcome of pediatric

patients with different subtypes of epilepsy associated with
cerebral cavernous malformations
Clinical article

Christian von der Brelie, M.D.,1,2 Stefan Kuczaty, M.D., 3 and Marec von Lehe, M.D.1,4
Departments of 1Neurosurgery and 3Epileptology, University of Bonn Medical Center, Bonn; 2Department of
Neurosurgery, Unfallkrankenhaus Berlin; and 4Department of Neurosurgery, University of Bochum, Germany

Object. Sufficient data on surgical treatment and seizure outcome of pediatric patients with different types of
epilepsy, especially drug-resistant epilepsy and associated cerebral cavernous malformations, are scarce. The aim of
this study was to carefully evaluate seizure outcome using the International League Against Epilepsy (ILAE) clas-
sification with regard to the presurgical symptom duration.
Methods. Fifty-one pediatric patients younger than 19 years with cerebral cavernous malformations of all CNS
localizations have been surgically treated at the authors’ institution. Twenty-two patients with seizures or epilepsy
who harbored cortically located supratentorial cerebral cavernous malformations underwent surgical treatment and
were retrospectively analyzed.
Results. More extensive resections were used in 82% of all patients with epilepsy symptoms for longer than 2
years. Eighty-two percent of patients with symptom duration shorter than 2 years underwent circumscribed lesionec-
tomy including the surrounding hemosiderotic rim. The overall rate of mild permanent, unanticipated postoperative
deficits was 4.5%; the rate of anticipated neurological deficits was 9%. The mean follow-up was longer than 117
months in all groups. Seizure outcome was excellent in the group with symptom duration shorter than 2 years (100%
ILAE Class 1). Seizure outcome was significantly worse in the group with longer symptom duration (p = 0.02). Seven
patients were seizure free after surgery. Seizure outcome was stable over the years.
Conclusions. Since seizure outcome is worse with longer seizure duration, early surgery and, if needed, inter-
disciplinary intervention, is recommended. Even in cases of multiple cerebral cavernous malformations and epilepsy,
surgery should be considered.
(http://thejns.org/doi/abs/10.3171/2014.2.PEDS13361)

Key Words      •      cerebral cavernous malformation      •      pediatric      •      epilepsy      •     

surgery      •      outcome

V
ascular malformations are often accompanied by
epileptic seizures and represent a common neuro-
logical and neurosurgical problem. Since the ad-
vent of MRI, cerebral cavernous malformations (CCMs)
have been increasingly recognized as being responsible
for structural epileptic seizures and epilepsy. Their over-
all incidence is 0.1%–0.5%.7,23 Around 25% of CCMs are
diagnosed in pediatric patients.22,24 These lesions make up
about 2%–18% of all vascular malformations in the pedi-
atric brain.18 Cerebral cavernous malformations typically
present either with hemorrhage or epileptic seizures.17,20,24
Regarding the CCM-associated type of epilepsy, symp-
toms may present as sporadic seizures and longer-stand-
Abbreviations used in this paper: AED = antiepileptic drug; CCM
= cerebral cavernous malformation; EEG = electroencephalography;
ILAE = International League Against Epilepsy.
ing forms of epilepsy or even drug-resistant epilepsy.
Four percent of drug-resistant epilepsy patients of all ages
are diagnosed with a CCM.2,6,16
The rate of pediatric patients with CCM-associated
drug-resistant epilepsy is estimated to be around 30%.1,13
Furthermore, children with longer symptom duration were
considered to have a worse outcome regarding seizure
freedom.13 Without epileptic seizures, the indication for
the surgical therapy of CCM is the prevention of bleeding
and its consequences. With ongoing seizure activity, the
indication changes and seizure control is the focus. There-
fore, it is advisable to adapt the surgical strategy and the
extent of the resection.
Data on CCM-associated epilepsy in the pediatric
population are scarce. Table 1 gives an overview of the
available literature. It becomes clear that most of the stud-
ies display results of rather small patient populations. In
particular, patients with drug-resistant epilepsy are under-

J Neurosurg: Pediatrics / Volume 13 / June 2014 699

 C. von der Brelie, S. Kuczaty, and M. von Lehe
TABLE 1: Overview of the available literature about surgical therapy of CCM-associated epilepsy in pediatric patients*

No. of Pts (pts w/

Authors & Year Yrs of Study Localization of CCM epilepsy/pts w/ DRE) Follow-Up Duration Seizure Outcome
Buckingham et al., 1989 1980–1988 supratentorial only 7 (6/not clear) min 2.2 yrs 100% seizure free
Fortuna et al., 1989 1952–1987 supratentorial only 6 (5/2) 6 mos–17 yrs 100% seizure free
Mazza et al., 1991 1974–1987 all intracranial 17 (4/not clear) not given not presented
Scott et al., 1992 1981–1990 intracranial & spinal 19 (3/not clear) 0.5–9 yrs not presented
Giulioni et al., 1994 1975–1992 supratentorial only 11 (11/not clear) 1–16 yrs 100% seizure free, new
  seizures in 4 after AED
 withdrawal
Di Rocco et al., 1997 1981–1995 all intracranial 22 (14/not clear) mean 4.6 yrs (6 mos–14 yrs) 100% seizure free
Mottolese et al., 2001 1985–1999 intracranial & spinal 36 (16/1) not given 5 pts w/ residual epilepsy
  controlled w/ medical
 treatment
Lee et al., 2008 1994–2006 all intracranial 33 (19/not clear) mean 5.8 yrs (2–17 yrs) 100% seizure free
Acciarri et al., 2009 1975–2006 intracranial & spinal 42 (29/9) 12–192 mos 82% seizure free
Xia et al., 2009 1998–2007 all intracranial 66 (24/not clear) 37.2 mos (5–105 mos) 87.5% seizure free
Hugelshofer et al., 2011 not given all intracranial 79 (41/12) 36.1 mos (1 mo–16 yrs) 72% seizure free

*  DRE = drug-resistant epilepsy; pts = patients.

represented. Comparisons between the different studies
are difficult since useful seizure outcome scales, such as
Engel’s classification or the International League Against
Epilepsy (ILAE) classification, are usually not reported.
Overall, there is a shortage of detailed and useful data
regarding pediatric patients with different types of epi-
lepsy and long-term epileptological follow-up after sur-
gery.1 The purpose of this paper is to generate data for a
thorough counseling of patients and caregivers.
Methods
Inclusion and Exclusion Criteria
The neurosurgical index database and the epilepsy
surgery database were screened for procedures per-
formed between 1988 and 2010. A total of 168 patients
with CCM-associated epilepsy were identified. Among
these, 22 patients were younger than 19 years (13%).
Fifty-one pediatric patients with CCMs of all CNS lo-
calizations underwent surgery at our institution in this
period. Twenty-nine patients harboring CCMs in non-
epileptogenic areas, for example, basal ganglia, thalamus,
cerebellum, brainstem, or spinal CCMs, were excluded,
except for patients with multiple CCMs. Six patients with
multiple CCMs and epilepsy in whom all epileptogenic
CCMs were located cortically or subcortically were in-
cluded. We included only cases with histopathological
confirmation of CCM. All biopsy specimens underwent
neuropathological analysis, and only cases with concor-
dant neuropathological, neuroradiological, and intraoper-
ative findings, particularly unequivocal exclusion of arte-
riovenous malformations, were considered for this study.
Analyzed data included patient age, sex, age at seizure
onset and type of seizures, duration of symptoms, surgi-
cal approach, extent of resection, and surgical morbidity
and mortality, as well as seizure outcome according to
ILAE classification. Only patients with follow-up longer
than 12 months were included in the study.
Categorization of Localization
Localization of the CCMs was analyzed on the basis
of radiological images, radiological reports, and surgical
records. Localization of symptomatic CCMs was divided
into different categories. Temporal localization was sub-
divided into temporolateral neocortical and temporome-
sial archicortical localization. Furthermore, symptomatic
CCMs were considered to be in an eloquent location if the
symptomatic CCM was located in the precentral or post-
central gyrus or in Wernicke’s (angularis region) or Bro-
ca’s area of the presumed dominant hemisphere, as well as
in the primary visual cortex. All other CCMs were con-
sidered as being localized in noneloquent brain regions.
Categorization of Duration of Epilepsy
Patients were assigned to the shorter symptom dura-
tion group (Group A) if they had symptoms for less than 2
years. If seizure duration was longer than 2 years, patients
were categorized in Group B.
Presurgical Epileptological Workup
Patients with drug-resistant epilepsy underwent de-
tailed epileptogical evaluation assessing medical his-
tory with special focus on seizure semiology. Thorough
epileptological workup also included high-quality MRI.25
Long-term video-electroencephalography (EEG) moni-
toring and in some cases invasive monitoring with strip or
grid electrodes was performed. Standards and techniques
of presurgical evaluation have been published.5
Surgical Technique and Extent of Resection
Extent of resection was evaluated by analysis of surgi-
cal records and, if available, postoperative MRI findings.

700 J Neurosurg: Pediatrics / Volume 13 / June 2014

Pediatric patients with epilepsy associated with cavernomas

Resection types were classified into lesionectomy (the TABLE 2: Demographic data of 22 patients with CCM-associated
hemosiderotic rim was completely or partially removed) epilepsy*
and extended lesionectomy. Extended lesionectomy was
usually performed as tailored resection (lesionectomy Parameter Total Group B Group A p Value
including rim and adjacent neocortex). In selected cases, no. of pts 22 11 11
lesionectomy including temporomesial resection (cases
M/F 14/8 7/4 7/4
in which the lesion and the hemosiderotic rim as well
as amygdala and hippocampus/parahippocampal gyrus mean age at seizure 11.3 10.6 12 NS
were removed) was performed.   onset (yrs)
mean age at op (yrs) 13.9 15.3 12.5 NS
Follow-Up and Seizure Outcome mean duration of 30.4 57.8 3.6 0.0005
Follow-up data were obtained by regular outpatient   symptoms (mos)
visits, routinely performed at 3, 6, and 12 months post- no. w/ multiple CCMs 6/22 (27.3) 3/6 (50) 3/6 (50)
operatively. Also, all patients and/or caregivers and/or
their general practitioners/neurologists were contacted *  Values are number of patients (%) unless stated otherwise. NS = not
by phone with standardized interviews and were asked to significant.
provide information on further seizure history and anti-
epileptic medication, subsequent neurosurgical or neuro- less than 2 years (Group A). The remaining 11 patients
logical hospital admissions, or any other subsequent neu- had symptoms for more than 2 years (Group B). Among
rosurgical procedure. Seizure outcome was determined the 11 patients in Group B, 8 patients were diagnosed as
using ILAE classification.26 having drug-resistant epilepsy.
The mean age at seizure onset in Group A was 12
Statistical Analysis years, and the mean age at surgery was 12.5 years. The
To analyze descriptive population statistics and po- mean duration of seizures in Group B was 57.8 months.
tential associations of factors with postoperative seizure The mean age at seizure onset was 10.6 years, and the
outcome we used SPSS (version 20, IBM). Statistical sig- mean age at surgery was 15.3 years in Group B (see also
nificance was reached at p < 0.05. Table 2 for other details of the groups).
Preoperative Workup
Results
Detailed epileptological evaluation was done in 9
Patient and Demographic Data (41%) of 22 patients. Detailed workup was done in 8 pa-
We identified 22 patients younger than 19 years; 14 tients in Group B (72.7%) and in 1 patient in Group A
(9%). In 7 (87.5%) of the 8 patients in Group B, electro-
(64%) of these patients were male. The mean age at onset
physiological diagnostics showed concordance between
of seizure activity was 11.3 ± 4.6 years ([± SD] range 2–18
localization of the CCM and ictal focus; the remaining
years), and the mean age at surgery was 13.9 ± 4.3 years
patient underwent invasive diagnostic testing (see below).
(range 3–18 years). The mean duration of seizures was Detailed epileptological workup was done in 4 (67%)
30.4 ± 39.2 months (range 0.03–144 months). In 4 patients of 6 patients with multiple CCMs to identify the symp-
seizures occurred as a symptom of recent significant in- tomatic CCM. Electrophysiological data were conclusive
tracerebral hemorrhage from CCM (see Tables 2 and 3 in 3 of those patients (75%); the remaining patient under-
for details). went invasive monitoring.
Localization of Symptomatic CCMs Invasive Monitoring
Sixteen patients had single supratentorial CCMs. Overall, invasive EEG recording was performed in
Nine (56.2%) of these 16 CCMs were located in the left 2 patients. Findings from noninvasive epileptological
hemisphere. In 19% the symptomatic CCM was located workup were inconclusive in these patients, and therefore
in eloquent brain regions; 6 CCMs (38%) were temporal they underwent subdural grid electrode and depth elec-
(Fig. 1). Temporal localization was statistically not pre- trode implantation. One patient in Group B (Case 4, Table
disposing for longstanding symptom duration (p > 0.05). 3) had drug-resistant epilepsy potentially due to a tem-
Six patients with multiple CCMs harbored 27 CCMs poromesial CCM located in the parahippocampal gyrus.
overall (mean 4.5, range 3–6) (Fig. 1). In these 6 patients, Noninvasive surface EEG was not sufficient to determine
a total of 8 symptomatic CCMs were removed. Regarding if the epileptogenic area included the temporomesial
the localization of the removed lesions, 37.5% of these structures. This patient underwent stereotactic implanta-
were located in the temporal lobe and 37.5% in eloquent tion of bilateral hippocampal depth electrodes and 2 left-
brain regions. sided subtemporal 4-contact strip electrodes.
The other patient (Case 13, Table 3), who was in
Clinical Data and Duration of Symptoms
Group A, harbored 3 superficial multiple CCMs in the
The patients were divided into 2 groups according to left parasagittal frontal cortex, in the left occipitobasal
their preoperative duration of seizures, which they expe- cortex, and in the left frontolateral region. Surface EEG
rienced presurgically. Eleven patients had symptoms for recorded 2 seizures for which no focus could be delineat-

J Neurosurg: Pediatrics / Volume 13 / June 2014 701

 C. von der Brelie, S. Kuczaty, and M. von Lehe
TABLE 3: Patient characteristics*

No. of Location of Seizure

Case Age at Drug AEDs Surgically Treated Permanent Outcome
No. Op (yrs) Resistance Used Invasive EEG CCMs Type of Op Postop Deficit (ILAE class)
Group B
 1 18 yes 4 no rt frontal ext lesionectomy none 1
 2 18 yes 5 no lt temporolat ext lesionectomy (incl quadrantanopia 1
 MSTs)
 3 6 yes 2 no lt parieotoccipital lesionectomy none 2
 4 18 yes 2 depth & strip electrodes lt temporomesial ext lesionectomy none 1
 5 16 yes 3 no rt frontal ext lesionectomy none 4
 6 17 yes 2 no rt frontal ext lesionectomy none 1
 7 14 yes 2 no lt frontal ext lesionectomy (incl none 2
 ECoG)
 8 13 yes 3 no lt insular, lt ext lesionectomy none 3
 temporomesial
 9 14 no 1 no lt temporolat ext lesionectomy none 1
 10 18 no 1 no lt temporomesial ext lesionectomy none 1
 (+AHE)
 11 17 no 1 no lt parietal lesionectomy sensory deficit 1
Group A
 12 11 no 1 no lt frontal lesionectomy incl rim none 1
 13 13 no 2 strip electrodes lt frontal ext lesionectomy none 1
 14 15 no 1 no rt parietal lesionectomy incl rim none 1
 15 14 no 0 no lt frontal lesionectomy incl rim none 1
 16 11 no 1 no rt parietal lesionectomy incl rim none 1
 17 8 no 1 no lt frontal lesionectomy none 1
 18 9 no 0 no lt frontal lesionectomy dysphasia 1
 19 18 no 1 no rt temporolat ext lesionectomy none 1
 20 18 no 1 no rt temporolat lesionectomy incl rim none 1
 21 17 no 1 no rt parietal lesionectomy incl rim none 1
 22 3 no 0 no lt frontal lesionectomy none 1

*  AHE = amygdalohippocampectomy; ECoG = electrocorticography; ext = extended; incl = including; MST = multiple subpial transection.

ed. Ictal SPECT evaluation was also not conclusive. This
patient was implanted with a total of 8 strip electrodes
covering all CCMs.
Neither of these patients developed a postoperative
complication due to the implantation procedure, and both
were seizure free at last available outcome.
Surgical Management
In Group B, 9 (81.8%) of 11 patients underwent ex-
tended lesionectomy. In these cases the lesion itself and
the hemosiderotic rim as well as the adjacent cortex were
removed. Two patients in Group B (18.2%) underwent le-
sionectomy. In 1 patient (12.5%), multiple subpial tran-
sections were added to the extended resection. In this
patient (Case 2), the epileptological workup revealed an
overlapping of the epileptogenic zone and the Wernicke
area (Table 3). In Group A the surgical strategy was dif-
ferent. Nine patients (81.8%) underwent lesionectomy in-
cluding complete or partial removal of the hemosiderotic
rim (Fig. 2). In summary, the longer the clinical symp-
toms of epilepsy, the more extensive the resection (p =
0.008; Fig. 2).
Surgical Morbidity and Mortality
In 8 of 11 patients in Group B, the postoperative
course was uneventful. One patient developed quadran-
tanopia, as anticipated (a calculated deficit that was dis-
cussed and accepted prior to surgery). One patient devel-
oped transient mild anomia and mild amnesic aphasia.
The patient recovered well with speech therapy and was
not impaired at the last available follow-up. Another pa-
tient developed a permanent sensory deficit (calculated
deficit) due to removal of a symptomatic postcentral
CCM. In Group A, 1 patient developed a permanent un-
anticipated mild motor aphasia due to pure lesionectomy
of a symptomatic CCM in the proximity of Broca’s area.
The overall rate of mild permanent, unanticipated postop-
erative deficits was 4.5%. The rate of anticipated deficits
was 9%. There were no systemic or local complications in
the entire study group.

702 J Neurosurg: Pediatrics / Volume 13 / June 2014

Pediatric patients with epilepsy associated with cavernomas

Fig. 1.  Localization of CCMs in patients with a single CCM (16 patients) and multiple CCMs (6 patients with 27 CCMs). Frontal
localization was found most often in patients with single supratentorial CCMs and multiple CCMs.

Seizure Outcome a CCM that is easy to reach surgically and is symptomatic

The mean follow-up in Group A was 125.3 months with a single seizure be treated with AEDs? Is it harmful
(median 103 months, range 20–202 months), and the to wait for refractory epilepsy to start thinking of surgery?
mean follow-up in Group B was 132.5 months (median Counseling patients and caregivers of sick children
163 months, range 23–260 months). Seizure outcome was can be a very challenging, and extensive data are needed.
excellent in Group A since ILAE Class 1 was achieved in This is of particular importance in planning elective pro-
all patients. Seizure outcome was significantly worse in cedures, such as the resection of a CCM.
Group B (chi-square test, p = 0.02). Seven patients were A detailed and interdisciplinary approach is known
seizure free after surgery (63.6%), and 4 patients did not to maximize potential postoperative seizure outcome.4
Patients with longstanding epilepsy in particular may
become seizure free. At the stage of last available follow-
benefit from detailed epileptological evaluation, since in
up, ILAE Class 2 was achieved in 2 patients in Group B,
those cases it is known that remote epileptogenic foci can
ILAE Class 3 in 1 patient, and ILAE Class 4 in 1 patient
develop.15,28 It has been shown in adult patients that virtu-
(Table 4). ally all patients who experience a first seizure associated
Outcome was stable over the years. Ten patients in
Group A were available for analysis of seizure freedom
5 years after surgery. All of these patients were seizure
free. Seven patients in Group B had a follow-up period of
longer than 5 years, 5 of whom were seizure free (71.4%).
Overall, seizure outcome is not significantly corre-
lated with the number of CCMs (single vs multiple). Re-
garding the entire study population, presurgical duration
of seizure symptoms is correlated with worse seizure out-
come (Mann-Whitney U-test, p = 0.01). Regarding anti-
epileptic drug (AED) weaning, 5 (26.3%) of 19 patients
with ILAE Class 1 and 2 outcomes are still on AED treat-
ment; 59.1% of all patients with CCM-associated epilepsy
are no longer being treated with AEDs.

Discussion
The present study analyzed one of the largest single-
center cohorts of pediatric patients with CCM-associated
seizures and epilepsy.1,13,17 One of the most common symp-
toms of CCMs are seizures, and there is still uncertainty
regarding if and when to treat patients surgically. Should
Fig. 2. Lesionectomy (Lx) was performed more often in patients
with a shorter seizure history. Extended lesionectomy (extended Lx)
was done more frequently in patients with more longstanding seizure
symptoms.

J Neurosurg: Pediatrics / Volume 13 / June 2014 703


TABLE 4: Seizure outcome at last available follow-up according
to the ILAE classification*
No. of Patients
ILAE Class Group A (n = 11) Group B (n = 11)
1 11 7
2 0 2 4.5%. There was a relevant rate of permanent anticipated
3 0 1 deficits (9%), as discussed and balanced with the benefit
4 0 1 of treatment with the patients and caregivers prior to sur-
5 0 0 gery. Furthermore, the impairing effect of antiepileptic
6 0 0 drug treatment on children’s cognition is frequently stat-
*  Patients in Group A had a median follow-up of 103 months, and pa-
tients in Group B a median follow-up of 163 months.
with a CCM will develop epilepsy in a 5-year follow-up
period.14
Multimodal workup diagnostic testing enables the
surgeon to individually tailor the extent of resection. Un-
til now, it has not been shown that a thorough epilepto-
logical workup influences the seizure outcome in pedi-
atric patients with CCM-associated epilepsy. In the pres-
ent series, detailed epileptological workup was done in
9 (41%) of the 22 patients, all of whom presented with
either a longstanding form of epilepsy or multiple CCMs.
The presurgical workup resulted in an extended lesionec-
tomy in 82% of patients. Of these cases, ILAE Class 1
was achieved in 75%. Since there were only 2 patients
with longstanding forms of epilepsy who did not undergo
epileptological workup, performing a comparison be-
tween those patients who were evaluated and those who
were not did not make sense. Nonetheless, the present-
ed seizure outcomes, especially in patients with longer
symptom duration and in patients with epilepsy associ-
ated with multiple CCMs, are in line with the published
data and support a combined interdisciplinary approach
to maximize seizure outcome.
In patients with short-term epilepsy prior to surgery,
seizure outcome was excellent in our study group (100%
seizure free), even though the resection was restrictive in
73% of the patients. With more longstanding epilepsy, the
rate of seizure freedom after surgery decreased to 64%.
From this it follows that the duration of epilepsy is the
strongest predictor for seizure outcome. Our data show
that this holds true even for the long-term follow-up with-
out any running-down phenomenon, irrespective of the
duration of epilepsy prior to surgery.
Hugelshofer et al. reported on 41 patients with epi-
lepsy; sufficient follow-up was available in 36 patients.13
Engel Class I was achieved in 72% of the cases using le-
sionectomy including the rim as the operative technique.
The study by Hugelshofer et al. reported on a relatively
large patient cohort and, for the first time, provided data
for 12 pediatric patients suffering from medically refrac-
tory epilepsy. The authors did not provide separate sei-
zure outcome rates for this particular group. Nonetheless,
they stated that there is a significant correlation between
the duration of preoperative seizures and the postopera-
tive Engel score, which was not shown in detail. This as-
pect could also be verified in the present study.
704
C. von der Brelie, S. Kuczaty, and M. von Lehe
Both our study and that of Hugelshofer et al.13 argue
for an early intervention in pediatric patients with CCM-
associated epilepsy and the performance of rather early
surgery. With longer symptom duration, outcomes become
worse, even with a more extensive surgical approach.
Surgery for CCMs in the pediatric population is safe.
In our series the rate of a mild postoperative deficit was
ed.19 Seizure reduction as well as discontinuation of AED
therapy were both shown to have significant effects on
improving cognition and other neuropsychological abili-
ties.9,11 In the presented series, 59.1% of all patients were
successfully weaned from AEDs. Overall, interdisciplin-
ary counseling of pediatric patients with CCM-associated
epilepsy should lead to early epilepsy surgery.
Conclusions
Cerebral cavernous malformations are benign and
usually not life-threatening lesions but are often compli-
cated due to seizures and epilepsy. Counseling parents
and caregivers of sick children can be a very challenging
task. This is of particular importance in planning elec-
tive procedures such as the resection of a CCM. In the
absence of prospective or even randomized studies, a dif-
ferentiated workup in a retrospective manner is the best
information currently available. We are well aware that
our data are based on a small patient group.
Seizure outcome is favorable after surgical treatment
of a CCM. An interdisciplinary approach led to a favor-
able seizure situation. Our data support the hypothesis
that seizure outcome is worse with longer seizure dura-
tion prior to surgery, and thus early intervention is recom-
mended. Even in cases of multiple CCMs and epilepsy,
surgery should be considered.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript prepara-
tion include the following. Conception and design: von der Brelie,
von Lehe. Acquisition of data: von der Brelie, Kuczaty. Analysis
and interpretation of data: all authors. Drafting the article: von der
Brelie. Critically revising the article: all authors. Reviewed submit-
ted version of manuscript: all authors. Approved the final version of
the manuscript on behalf of all authors: von der Brelie. Statistical
analysis: von der Brelie, von Lehe. Administrative/technical/mate-
rial support: von der Brelie, von Lehe. Study supervision: von der
Brelie, von Lehe.
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Manuscript submitted July 11, 2013.
Accepted February 27, 2014.
Please include this information when citing this paper: pub-
lished online April 4, 2014; DOI: 10.3171/2014.2.PEDS13361.
Address correspondence to: Christian von der Brelie, M.D.,
Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener
Strasse 7, 12683 Berlin, Germany. email: CvdB@gmx.net.
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