What Is a Cavernoma?

A cavernoma (also termed cavernous malformation or cavernous haemangioma) is a cluster of abnormally enlarged, thin-walled blood vessels typically found within the brain or spinal cord. The vessels are packed closely together with no intervening normal neural tissue, creating a lesion that can range in size from a few millimetres to several centimetres. The vessel walls lack the normal structural layers of arteries and veins — they are thin, prone to small recurrent haemorrhages, and visually resemble a mulberry or raspberry on MRI imaging.

Cavernomas are present in approximately 0.5% of the general population, making them among the most common vascular malformations of the central nervous system. The majority are sporadic, but approximately 20% are familial — inherited in an autosomal dominant pattern with incomplete penetrance, associated with mutations in the KRIT1, CCM2, or PDCD10 genes. MRI with susceptibility-weighted imaging (SWI) is the most sensitive imaging modality for detection, revealing characteristic "popcorn" heterogeneous signal with a surrounding hemosiderin ring from prior microhaemorrhages.

Clinical Presentation

The clinical presentation of a cavernoma depends on its location within the neuraxis. A significant proportion — estimated at 30–50% — remain asymptomatic throughout life and are discovered incidentally on MRI performed for other indications. When symptomatic, the most common presentations include seizures (the most frequent symptom of supratentorial cavernomas), focal neurological deficits corresponding to the eloquent cortical or subcortical region involved, headache, and cognitive changes.

Cavernomas of the brainstem are anatomically compact and clinically treacherous — even small haemorrhages in this region can produce disproportionately severe deficits including cranial nerve palsies, hemiplegia, ataxia, and dysarthria. Spinal cavernomas typically present with progressive myelopathy or radiculopathy, often mimicking disc disease or tumour. The recognition that spinal cord cavernomas can present with musculoskeletal-appearing symptoms — back pain, limb weakness, altered reflexes — is clinically relevant for practitioners who may see such patients before a diagnosis is established.

Manual Therapy Relevance

Cavernomas are relevant to manual therapy practice primarily through the need to recognise neurological symptoms that may indicate cavernoma-related haemorrhage or expansion. New onset seizures, sudden onset focal neurological deficits, or rapidly progressive limb weakness in a patient presenting with neck or back pain should trigger urgent neurological referral rather than conservative treatment. Patients with known cavernomas may seek manual therapy for concurrent musculoskeletal conditions — in these cases, treatment of the musculoskeletal presentation is generally appropriate, but the treating therapist should be aware of the neurological history and maintain vigilance for any new or changing neurological symptoms.

Red flag: Any patient presenting with a new sudden-onset severe headache, focal neurological deficit, or first seizure requires emergency neurological assessment before any manual therapy is initiated.

References & Further Reading

  1. Akers A, et al. Synopsis of guidelines for the clinical management of cerebral cavernous malformations. Neurosurgery. 2017;80(5):665–680.
  2. Cavalcanti DD, et al. Cerebral cavernous malformations: a review of the genetic and molecular biology. Surg Neurol Int. 2012;3(Suppl 3):S168–S185.