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\begin{document}

\title{A small frontal lobe cavernoma presenting with headache mimicking
migraine and complex focal seizure: A Case report}



\author[1]{Prakriti Adhikari}%
\author[1]{Anil Nepali}%
\author[2]{Amit Shah}%
\author[2]{Shailes Paudel}%
\author[2]{Prakriti Bhandari}%
\author[3]{Prakash Nepali}%
\affil[1]{Kathmandu University School of Medical Sciences}%
\affil[2]{Patan Academy of Health Sciences}%
\affil[3]{Bhimad Primary Health Care Centre}%


\vspace{-1em}



  
  \date{May 28, 2024}


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Prakriti Adhikari\textsuperscript{1}, Anil Nepali\textsuperscript{1,2},
Amit Shah\textsuperscript{2}, Shailes Paudel\textsuperscript{2},
Prakriti Bhandari\textsuperscript{2}, and Prakash
Nepali\textsuperscript{3}

1 MBBS doctor, Kathmandu University School of Medical Sciences

2 MBBS doctor, Patan Academy of Health Sciences

3 MBBS doctor, Chitwan Medical College

Corresponding Author

Dr. Anil Nepali, Patan Academy of Health Sciences

dr.anilnepali1@gmail.com

\section*{Abstract}

{\label{abstract}}

Cavernoma, or cerebral cavernous angioma, are hamartomatous lesions
formed by sinusoidal vascular spaces without cerebral parenchyma in
between. Cavernoma is a rare disorder that is diagnosed infrequently and
incidentally, so it is called incidentaloma. However, cavernoma can
present with seizures, headaches, and other focal neurological deficits,
with seizures being the most frequent presentation. Cavernoma is
angiographically concealed, and its diagnosis is challenging. So, the
cavernoma is diagnosed based on an MRI. We present the rare case of a
patient who presented with a complex focal seizure and migraine-like
headache caused by a small frontal lobe cavernoma.

Keywords: frontal lobe, small cavernoma, complex focal seizure, headache

\section*{Introduction}

{\label{introduction}}

Cerebral cavernous angioma, or cavernoma, is an occult vascular
malformation of the central nervous system that frequently develops in
the brain parenchyma. It can develop in any age group, but it often
occurs between the ages of 30 and 40.\textbf{{[}1{]}} According to
reports, the annual incidence of cavernous malformations is 0.15--0.56
per 100,000 people, and the annual hemorrhage rate is 0.61--11\% per
patient-year, which is variable across populations.\textbf{{[}2{]}}

Almost 80\% of cerebral cavernomas are supratentorial, mainly affecting
the subcortical region of the frontal and temporal lobes. Seizures are
the most frequent clinical manifestation, mostly associated with
hemorrhages but may also be associated with headaches and other focal
neurological deficits.\textbf{{[}3{]}}

Only 30--50\% of lesions are detected by MRI, regardless of whether
contrast is administered, leading to an underdiagnosis of the disease.
The main imaging method for evaluating and diagnosing cavernomas is MRI,
which has a definite advantage over CT in terms of
sensitivity.\textbf{{[}3{]}}

In this case, we report on a patient who presented with a complex focal
seizure disorder associated with small frontal lobe cavernous
malformations detected by MRI.

\section*{Case report}

{\label{case-report}}

A 47-year-old female presented to the emergency department of our center
with a history of 1 episode of jerky movement of the left upper limb
following lip smacking lasting for about 15--30 seconds, followed by
loss of consciousness and post-ictal confusion. However, there is no
history of uprolling of the eyes, tongue biting, frothing of the mouth,
generalized tonic-clonic movement, and bowel or bladder incontinence.
Also, there was no history of fever, trauma, or previous seizure
disorder. She also complained of 6-7 episodes of headache mimicking
migraine from 1 year on and off, relieved by over-the-counter
medications. She had been diagnosed with hypothyroidism for 6 years and
is under levothyroxine. On examination, there were no signs of meningeal
irritation with normal systemic examination. Her vital signs were within
normal limits.

Neurological assessment was normal, along with unremarkable laboratory
findings. The EEG was done and showed no epileptiform discharge. The CT
head also shows no abnormality.

Thus, she was admitted for neurological monitoring and further
evaluation. An MRI of the brain was planned, which revealed a small
lobulated popcorn appearance lesion of size 10*9.5*8.5 mm with a central
high and peripheral low intensity rim in the right frontal lobe and
white matter showing tiny enhancing areas within, blooming in SWIs with
mixed bright and dark phase images (Figure 1: MRI of brain on right )and
altered low T2 signal intensity (Figure 1: MRI of brain on left ) around
them, suggestive of frontal lobe cavernoma.

Figure 1\selectlanguage{english}
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The patient was given injection levetiracetam 500mg twice daily, which
effectively controlled seizure activity. Also, the risk and benefits of
surgery were discussed with the patient and her family. However, the
patient denied surgery. Thus, he was discharged with oral levetiracetam
500mg twice daily and advised to follow up on a regular basis in
outpatient department. On follow up after 2, 4, and 6 months of
discharge, there was no repeat seizure activity.

\section*{Discussion}

{\label{discussion}}

Cavernoma is a benign low flow vascular malformation with an unknown
etiology. However, it has been linked to cranial radiation, coexisting
vascular malformations, genetic and hormonal variables, and other
causes.\textbf{{[}4{]}} The majority of cavernoma is supratentorial in
location, but it can also be found in spinal cord as well as the extra
axial region. Most of the cases of cavernoma are asymptomatic and
detected on autopsy incidentally. \textbf{{[}5{]}} In patients with
cerebral cavernous malformations (CCMs), epileptic seizures are the most
prevalent symptom. It has been suggested that repeated microhemorrhages
and hemosiderin deposits in the surrounding cortical tissue lead to
hyperexcitability because iron ions produce free radicals and lipid
peroxides. \textbf{{[}6{]}}

Cavernomas are angiographically concealed malformations; thus, the
identification of cavernomas is more challenging than that of other
vascular disorders. Some of the cutting-edge methods utilized for the
diagnosis of CMs include conventional T1- and T2-weighted MR imaging,
gradient echo sequences, high-field MRI, susceptibility-weighted
imaging, diffusion tensor imaging, and functional MRI.\textbf{{[}7{]}}In
our case, CT findings were insignificant, and cavernoma was diagnosed on
an MRI of the brain.

Antiepileptic medications are preferred as a first line of treatment in
CCM patients who have had a single episode rather than immediately doing
surgery, and antiepileptic medications were found to be 47--60\%
effective in controlling newly diagnosed cavernoma-related epilepsy. So,
routine follow-up with a neurologist is advised. Early surgery should be
taken into account for patients who have a significant risk of bleeding,
who are unable to adhere to AED therapy, and who have a strong desire to
finally cease using AEDs.{[}\textbf{8{]}} Our patient responded with
anti-epileptic drugs.

A similar case with seizures and migraine-like headaches was described
in a case report published in 2017 by Chirchiglia D et. al. We hereby
present the rare case of small frontal lobe cavernoma presented with
complex focal seizures and migraine like headaches that are effectively
controlled with antiepileptic medications.

\textbf{Conclusion:}

Even small cavernoma can cause seizures and headaches. Furthermore, In
some cases a headache can mimic migraine which leads to misdiagnosis.
Even on suspicion, diagnosis of cavernoma is challenging as it is
occultated on CT and angiography. MRI is a better diagnostic tool for
cavernoma.

Author Contribution

Prakriti Adhikari: Conceptualization; data curation; methodology;
writing -- original draft.

Anil Nepali: Conceptualization; supervision; validation; writing --
original draft; writing -- review and editing.

Amit Shah: Data curation; methodology; validation; writing -- original
draft; writing -- review and editing.

Shailes Paudel: Conceptualization; formal analysis; supervision;
validation; writing -- original draft; writing -- review and editing

Prakriti Bhandari: Conceptualization; data curation; validation; writing
-- original draft; writing -- review and editing.

Prakash Nepali: formal analysis; supervision; validation; writing --
review and editing

Acknowledgements

None.

Funding Information

None.

Conflict of Interest statement

None declared.

Ethics Statement

Ethical approval was not required for the case report as per the
country's guideline.

Informed Consent

Written informed consent was obtained from the patient to publish the
report.

\textbf{Data Availability Statement}

Data openly available in a public repository that issues datasets with
DOIs.

\section*{References}

{\label{references}}

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