Working Diagnosis:
Right occipital cavernous malformation with evidence of subacute hemorrhage.

Treatment:
Following the diagnosis of subacute hemorrhage of the cavernous malformation, the athlete was withheld from all sports participation and referred to Neurosurgery for definitive management. He subsequently underwent right occipital craniotomy and microsurgical resection of the vascular malformation. Postoperatively, he was managed conservatively with gradual progression of physical activity beginning with walking, light jogging, and resistance training.

Outcome:
The patient tolerated surgical intervention without postoperative complications. He gradually resumed activity and was ultimately cleared by Neurosurgery for unrestricted athletic participation. Long-term prognosis is considered favorable following complete resection. Surveillance brain MRI was planned for six months postoperatively and annually thereafter to monitor for recurrence or residual lesion.

Author's Comments:
This case highlights the diagnostic challenge of progressive nausea in an otherwise healthy collegiate athlete with a known cerebral cavernous malformation. Prior knowledge of the athlete's pre-existing lesion proved instrumental in guiding the clinical evaluation and maintaining concern for potential neurologic pathology despite an initially nonfocal presentation. Although the patient lacked focal neurologic deficits and initially presented with seemingly nonspecific gastrointestinal complaints, symptom progression ultimately reflected interval hemorrhage of a previously stable lesion. Cerebral cavernous malformations are low-flow vascular lesions composed of dilated capillary channels without intervening brain parenchyma and carry an annual hemorrhage risk estimated at approximately 0.5 1% per lesion-year, with increased risk following prior hemorrhage.

This case underscores the importance of maintaining a broad differential diagnosis in athletes presenting with evolving exertional symptoms, even in the absence of overt neurologic findings. Sports medicine physicians are often the first clinicians to evaluate subtle symptom progression in athletes, and timely recognition of red flag symptoms may expedite advanced imaging, multidisciplinary evaluation, and definitive management. Additionally, limited return-to-play guidance exists for athletes with cerebral cavernous malformations following hemorrhage and surgical resection, emphasizing the importance of individualized shared decision-making among athletes, sports medicine physicians, and neurosurgical teams.

Editor's Comments:
Cerebral cavernous malformations are clusters of dilated capillary channels without intervening neural parenchyma with incidence of 0.5% in the general population. These lesions are typically sporadic, although may be associated with germline loss of function mutations in 15-20% of cases. Per the New England Journal of Medicine, the risk of hemorrhage in incidentally found cerebral cavernous malformations ranges from 0.1-1% per year with the largest risk factor for hemorrhage being previous hemorrhage. Overall, in cases of known Cerebral cavernous malformations persistent nausea, headache or signs of focal/ localizing neurologic symptoms should warrant urgent brain MRI. As illustrated through this case, typically incidental imaging can reveal these lesions which are initially managed via observation, although if patients become symptomatic such as in this case surgical excision is considered with need for close follow up via MRI and Neurosurgery. Following surgical intervention it is imperative that athletes undergo a gradual return to play under supervision of Sports Medicine and Neurosurgery.

References:
Caton MT, et al. Cerebral Cavernous Malformations. StatPearls Publishing.

Smith ER. Cavernous Malformations of the Central Nervous System. N Engl J Med. 2024 Mar 14;390(11):1022-1028. doi: 10.1056/NEJMra2305116. PMID: 38477989.

Dulamea AO, Lupescu IC. Cerebral cavernous malformations - An overview on genetics, clinical aspects and therapeutic strategies. J Neurol Sci. 2024 Jun 15;461:123044. doi: 10.1016/j.jns.2024.123044. Epub 2024 May 12. PMID: 38749279.

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