Cerebral cavernous malformation with prolonged postoperative paralysis due to perilesional inflammation: illustrative case

Abstract

BACKGROUND: Postoperative symptom exacerbation after resection of cerebral cavernous malformations (CCMs) is usually due to surgical damage to the eloquent areas or venous outflow obstruction from injury to a developmental venous anomaly (DVA). OBSERVATIONS: A 21-year-old right-handed female presented with headache, right limb weakness, and aphasia. Magnetic resonance imaging (MRI) revealed a 3.5-cm CCM with significant perilesional edema in the middle frontal gyrus. Despite medical treatment, her weakness worsened, necessitating emergency resection. Imaging revealed no DVA or venous obstructions. Histopathological examination revealed marked neutrophil infiltration, indicating noninfectious inflammation. One week postoperatively, MRI revealed increased edema around the resection site. Although the aphasia improved, paralysis (manual muscle testing grade 3) persisted, prompting betamethasone administration. The symptoms rapidly improved over 10 days, and the patient was discharged symptom free on day 20 with no recurrence thereafter. LESSONS: Patients with prolonged postoperative deficits after CCM resection can experience noninfectious inflammation. Anti-inflammatory treatments such as corticosteroids may be necessary in similar cases with poor recovery from edema and symptoms.