Background and Purpose: Pregnancy as a hemorrhage risk factor in women with cavernous malformations (CMs) is controversial. We describe prospective hemorrhage risk in women who become pregnant after an established CM diagnosis. Methods: Beginning in 2015, we recruited consecutive patients with radiologically confirmed CM of the brain or spinal cord to participate in a prospective registry. Participants underwent a baseline and annual medical record review, imaging review, and annual surveys to ascertain pregnancies, deliveries, and neurological complications. We collected prospective hemorrhage data on reproductive age women. We calculated prospective hemorrhage rates on childbearing age patients based on the number of hemorrhages occurring post-CM diagnosis during pregnancy and nonpregnancy, divided by the years of follow-up and censored at last follow-up, age 46, or surgery in sporadic-form CM. The hemorrhage rates were compared and the 95% CI presented with a P value of <0.05. Results: Of 160 women, 90 presented with CM under the age of 46 (average age 31.6 years; 25.6% familial form; 46.7% with hemorrhage; 24.4% brain stem location). These 90 patients had 136 pregnancies before CM diagnosis; 36 pregnancies occurred at or after the diagnosis of CM. Four patients had a hemorrhage while pregnant or postpartum leading to the first CM diagnosis. During 402.6 years of follow-up while not pregnant, 42 hemorrhages occurred prospectively yielding a 10.4% per year (95% CI, 7.5–14.0) risk of hemorrhage while not pregnant. No hemorrhages occurred during 32 prospective pregnancies (26 live births including 1 twinset and 7 nonviable fetuses) after CM diagnosis during 26.9 years of pregnancy time yielding a rate of 0% per year (95% CI, 0–13.6). We found no statistical difference in the rates of hemorrhage during pregnant and nonpregnant time ( P =0.09). No hemorrhage occurred during delivery. Conclusions: Our prospective data suggest that pregnancy does not increase the risk of hemorrhage in women with a known brain or spinal cord CM and that vaginal delivery is safe in appropriate candidates.
Background: Cavernous malformations (CM) are low flow vascular malformations of the central nervous system. Brainstem location and prior hemorrhage increase the risk for future hemorrhage. Little is known about the influence of physical activity on increasing the risk of hemorrhage. Methods: Consecutive patients with radiologically confirmed CM were recruited to participate in a prospective registry beginning in 2015. A structured interview, survey, and examination were performed at baseline. Patients were asked if anything unusual occurred in the days leading to initial clinical presentation. Medical records and magnetic resonance imaging (MRI) studies were reviewed. Patients were surveyed about their involvement in select physical activity after the diagnosis of CM was made. Follow up surveys were sent annually to patients to ascertain new clinical hemorrhages. Follow up was censored at last follow up, hemorrhage, surgery, or death. Univariate analysis was performed to assess whether involvement in select physical activities increased the risk of prospective hemorrhage. Results: Of 195 patients, 117 (60 %) were female and the average age at diagnosis was 41 years (31-56 years). One hundred and three (52.8%) patients returned the survey about physical activity after diagnosis (cerebral n=100; spine n=3). Twenty-three patients had a prospective hemorrhage over 539.4 patient years. Five of these patients were removed from the analysis because they had less than 6 weeks of physical activity exposure before censor. Of 98 remaining patients, there was no difference in prospective hemorrhage risk in those patients participating 3 or more times monthly in walking, running, lifting more than 20 pound weights, lifting less than 20 pound weights, or participating in non-contact sports. Very few patients reported participation in contact sports (n=5), scuba diving (n=2) or high altitude climbing (n=1) more than 3 times monthly. Conclusion: Aerobic activity and non-contact sports do not increase the risk of hemorrhage in patients with cerebral CM and patients should not be restricted. Less information is known about contact sports, high altitude climbing or scuba diving and those with spinal cord CM.
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