Does conservative management for brain stem cavernomas have better long-term outcome?

Tarnaris, Andrew; Fernandes, Ritabelle; Kitchen, Neil

doi:10.1080/02688690802354210

Cited by 41 publications

(35 citation statements)

References 35 publications

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“…20 The percentage of improved or unchanged functional outcomes was retrospectively reported in relatively small cohorts and ranged from 46.7% to 95.7%. 10,16,23 This study demonstrated that an initial small lesion size, no prospective hemorrhage, and younger age contributed to promote complete recovery. These findings were interpreted as implying that a significant space-occupying effect, cumulative impairment caused by repeated hemorrhages, and advanced age with decreasing potential of rehabilitation or functional compensation would delay or even inhibit functional improvement.…”

Section: Functional Outcomesmentioning

confidence: 59%

Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations

Li¹,

Hao²,

Jia³

et al. 2014

JNS

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Object Cerebral cavernous malformations have been studied widely, but the natural history of brainstem cavernous malformations (CMs) is not well defined, and hemorrhages caused by brainstem CMs are devastating. The goal of this study was to quantify the hemorrhage risks and functional outcomes of patients with brainstem CMs. Methods This prospective, longitudinal, cohort study included patients with brainstem CMs diagnosed between 1985 and 2012. The clinical courses of all patients were recorded. Predictors of hemorrhage and the overall untreated outcomes were evaluated. Results A total of 331 patients (46.5% female) were included, with a mean follow-up duration of 6.5 years. The annual hemorrhage rates in patients initially presenting with hemorrhage with (n = 215) or without (n = 34) focal neurological deficits were 15.9% and 12.4%, respectively. However, the annual hemorrhage rate was 8.7% in patients initially presenting without hemorrhage (n = 82). The risk factors for hemorrhage were female sex (hazard ratio [HR] 1.445, p = 0.041), prior hemorrhage (HR 1.277, p = 0.029), and perilesional edema (HR 1.830, p = 0.002). Overall, neurological function at the most recent assessment was improved compared with neurological function at diagnosis. Additionally, 307 patients (92.7%) improved or stabilized, 268 (81.0%) lived independently, and 95 (28.7%) completely recovered. Predictors favoring complete recovery were no prospective hemorrhage (HR 1.958, p = 0.001), younger age (HR 1.268, p = 0.001), and small lesion size (HR 1.578, p = 0.004). Conclusions Patients' initial presentation predicts their prospective annual hemorrhage rate. This study suggests that several strong risk factors for hemorrhage and predictors of brainstem CM outcomes may enable clinicians to evaluate the potential hemorrhage risks of their patients and design personalized treatments.

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Section: Functional Outcomesmentioning

confidence: 59%

Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations

Li¹,

Hao²,

Jia³

et al. 2014

JNS

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“…In studies on the natural history of CMs (Table 9), the documented subdivided annual hemorrhage rates for brainstem CMs differed greatly and were noted to be 2.33% if retrospective 13 annual hemorrhage rate of 2.46%, a clinical event rate of 3.4%, and a rehemorrhage rate of 5.1%. Another study by Tarnaris et al 47 retrospectively cited a similar rehemorrhage rate of 5% in 21 cases of conservatively managed brainstem CMs. These diversities could be ascribed, as previously stated, to the limited number of patients, an insufficient followup duration, and the variance in individual study design.…”

Section: Hemorrhage Riskmentioning

confidence: 85%

“…10,11,14,19,22,30,34,37,38,42,47,51 Among these studies, Tarnaris et al 47 reported fairly poor outcomes, with 53.3% of patients exhibiting worsening conditions, and cited a neurological deterioration of 10% per patient year. An extremely malignant prognosis was reported with a mortality rate of 20%.…”

Section: Functional Outcomesmentioning

confidence: 99%

“…22 In contrast, acceptable outcomes were described in several series, stating that the natural history of brainstem CMs appeared to be more benign than previously believed. 14,19,30,34 Overall, in 7 series that provided detailed outcomes, 11,19,30,38,42,47,51 88 (71.5%) of 123 patients were improved/unchanged, 33 patients (26.8%) worsened, and the mortality rate due to rehemorrhage was 4.1% (9/218). Another series consisting exclusively of 13 pediatric brainstem CMs revealed no change in function in 8 patients (61.5%) and improvement in 4 patients (30.8%).…”

Section: Functional Outcomesmentioning

confidence: 99%

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Clinical course of untreated pediatric brainstem cavernous malformations: hemorrhage risk and functional recovery

Li¹,

Hao²,

Tang³

et al. 2014

PED

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Object The aim of this study was to investigate the clinical appearance of untreated pediatric brainstem cavernous malformations (CMs) and to identify the hemorrhage risks and functional outcomes. Methods All pediatric patients with a diagnosis of brainstem CM between 1985 and 2012 were registered. The clinical chart and radiographs were recorded, and follow-up evaluations were obtained prospectively. Results A total of 85 patients (69.4% male) were included with a mean age of 12.7 years. Sixty-seven patients (78.8%) had prior hemorrhage, and 6 patients (7.1%) were asymptomatic. There were 15 midbrain lesions, 53 pons lesions, and 17 medulla lesions. The mean lesion size was 1.9 cm. During a total of 401.6 patient-years of follow-up, 47 hemorrhages occurred in 37 patients, and the annual hemorrhage rate was 11.7% per patient-year. The mean hemorrhage interval was 47.8 months. The hemorrhage risk declined over time, especially after the first 2 years. Both a lesion size ≥ 2 cm (hazard ratio [HR] 2.122, p = 0.037) and the presence of perilesional edema (HR 2.192, p = 0.039) predicted future hemorrhage and were associated with a high annual hemorrhage rate. The hemorrhage-free survival at 6 months was 85.7%, and at 1, 5, 10, and 15 years was 71.5%, 49.4%, 27.5%, and 13.7%, respectively. At the most recent functional evaluation, 33 patients (38.8%) had improved, 32 (37.6%) had stabilized, and 20 (23.5%) had worsened, without any deaths. Twenty-two patients (25.9%) obtained a full recovery. Prospective hemorrhage (HR 0.191, p = 0.003) was the adverse predictor for full recovery. Full recovery primarily occurred within the first 12 months, after which the chance of full recovery decreased. The cumulative percentage of complete recovery at 6 months was 32.7%, and at 1, 3, and 5 years was 40.8%, 43.6%, and 49.2%, respectively. Conclusions In this study the hemorrhage rate was relatively high in pediatric brainstem CMs, although the functional outcome was acceptable. The decline in hemorrhage risk and the identified adverse predictors in this study were helpful for clinicians and patients when deciding on treatment. Referral bias and the insufficient follow-up period of the study were highlighted as limitations.

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“…13.5 mm 24.3 mm p 0.0001 p 0.9375 Fig. 3 undesirable events p 0.0040 21 Wang CW et al 25 Gross BA et al 8 Abla AA et al …”

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confidence: 96%

Natural History of Symptomatic Cavernous Malformations and Results of Surgery

et al. 2015

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Does conservative management for brain stem cavernomas have better long-term outcome?

Cited by 41 publications

References 35 publications

Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations

Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations

Clinical course of untreated pediatric brainstem cavernous malformations: hemorrhage risk and functional recovery

Natural History of Symptomatic Cavernous Malformations and Results of Surgery

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