Coexistent cerebral cavernous malformation and developmental venous anomaly: Does an aggressive natural history always call for surgical intervention?

Coexistence of cerebral cavernous malformations (CMs) and developmental venous anomaly (DVA) represents the most common form of mixed intracranial vascular malformations. Existing literature supports not only a possible causative role of DVA for de novo CMs but also a potentially detrimental effect on an associated CM, increasing the chances of hemorrhagic complications and growth in the latter. A 52-year-old gentleman presented to us with a 17-year long history of simple motor seizures on the left faciobrachial region. On magnetic resonance imaging (MRI) of the head, a 1.5 cm × 1.5 cm CM without any evidence of recent hemorrhage was identified in the left high frontal premotor area. There was a linear enhancement in the adjoining superior frontal sulcus on contrast MRI. On intra-arterial angiogram, this hyperintensity was confirmed to be a venous channel draining into the superior sagittal sinus. Thus, a diagnosis of cavernoma associated with a DVA was made. The patient was advised conservative treatment and he was doing well at follow-up. Unless diligently looked for, DVA associated with CM may be easily missed. The coexistence has pathophysiological and management implications. Despite the reported aggressive natural history, there is a scope for conservative treatment for these complex vascular malformations.