Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations

Li, Da; Hao, Shuyu; Jia, Guijun; Wu, Zhen; Zhang, Liwei; Zhang, Junting

doi:10.3171/2014.3.jns132537

Cited by 68 publications

(77 citation statements)

References 27 publications

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“…Once cavernomas bleed, the rebleeding rate increases to 45% per person per year [3,5,16]. The optimal treatment for these lesions remains a matter of debate, and how to identify cavernomas that are at high risk of developing hemorrhage recurrences or producing severe neurological deficits remains unclear.…”

Section: Discussionmentioning

confidence: 99%

“…Recurrent hemorrhage was defined using the same criteria described before for the first episode of hemorrhage, but if the patient had a residual deficit of the first event, the worsening of this deficit was also included [5,14]. …”

Section: Methodsmentioning

confidence: 99%

“…The brain stem location makes surgical intervention difficult without significant postoperative morbidity, and there is currently no consensus regarding the best treatment [1,3,4]. Series that have examined the natural history of untreated BCMs have reported wide variations in the hemorrhage rate and rebleeding [1,5,6,7,8]. However, there is a relatively strong consensus that patients who present with significant neurological deficits should be surgically treated if the lesion comes to a surgical surface and patients with deep lesions are candidates for conservative treatment.…”

Section: Introductionmentioning

confidence: 99%

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Rebleeding and Outcome in Patients with Symptomatic Brain Stem Cavernomas

et al. 2017

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Purpose: We sought to evaluate the long-term functional outcomes and identify the potential risk factors for rebleeding in patients with brain stem cavernous malformations (BCMs) who presented with hemorrhages and were surgically or conservatively treated and prospectively monitored. Methods: From January 1990 to July 2015, we included patients with first hemorrhagic episodes secondary to single BCMs. Modified Rankin score (mRS) was used for neurological status assessment. Univariate and multivariate regression statistics were used to identify the risk factors for rebleeding. Results: A total of 99 patients with BCMs hemorrhages were included (59 [59.6%] women, mean age 37± 13 years). As initial treatments, 37 patients (37.4%) underwent surgery and 62 (62.6%) received conservative treatment. The median follow-up was 3.33 years (interquartile range 1.16-7 years; 408.3 patient/years). The rebleeding rate by patient/year was 10% in conservatively treated patients. Deterioration was significantly more frequent in patients with rebleeding (p = 0.0001). At the end of the follow-up, the mRS were favorable in 49 patients (65.3%) without rebleeding, whereas only 8 (33.3%) with rebleeding evolved to favorable outcomes (p = 0.006). Lesion size >18 mm (hazards ratio, HR 3.34, 95% CI 1.54-7.26; p = 0.0001) and ventral location or crossing the brain stem's midpoint (HR 2.5, 95% CI 1.14-5.46; p = 0.022) were associated with a major risk of rebleeding in the univariate analysis, but only a lesion >18 mm remained statistically significant (HR 2.7, 95% CI 1.2-6.21; p = 0.016) in the multivariate analysis. Conclusion: A lesion size >18 mm was the principal factor associated with hemorrhage recurrence. The overall functional outcome was good. However, significant morbidity was attributable to rebleeding.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Rebleeding and Outcome in Patients with Symptomatic Brain Stem Cavernomas

et al. 2017

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“…The estimated bleeding and rebleeding rates for brainstem CMs range from 0.5% to 6% and 5% to 60% per patient-year, respectively. 10,25,26,35 The management of brainstem CMs remains challenging due to a high degree of potential morbidity and mortality with and without treatment and specifically due to the eloquence of the perilesional anatomy. Resection is fraught with significant rates of permanent neurological deterioration, including for brainstem CMs reaching the pial surface.…”

mentioning

confidence: 99%

Longitudinal evaluation of corticospinal tract in patients with resected brainstem cavernous malformations using high-definition fiber tractography and diffusion connectometry analysis: preliminary experience

Faraji¹,

Kumar²,

Jarbo

et al. 2015

JNS

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abbreviatioNs ADL = activities of daily living; CC = corpus callosum; CM = cavernous malformation; CN = cranial nerve; CST = corticospinal tract; DSI = diffusion spectrum imaging; DTI = diffusion tensor imaging; FDR = false discovery rate; HDFT = high-definition fiber tractography; ICH = intracerebral hemorrhage; QA = quantitative anisotropy; ROI = region of interest; SRS = stereotactic radiosurgery. obJect Brainstem cavernous malformations (CMs) are challenging due to a higher symptomatic hemorrhage rate and potential morbidity associated with their resection. The authors aimed to preoperatively define the relationship of CMs to the perilesional corticospinal tracts (CSTs) by obtaining qualitative and quantitative data using high-definition fiber tractography. These data were examined postoperatively by using longitudinal scans and in relation to patients' symptomatology. The extent of involvement of the CST was further evaluated longitudinally using the automated "diffusion connectometry" analysis. methods Fiber tractography was performed with DSI Studio using a quantitative anisotropy (QA)-based generalized deterministic tracking algorithm. Qualitatively, CST was classified as being "disrupted" and/or "displaced." Quantitative analysis involved obtaining mean QA values for the CST and its perilesional and nonperilesional segments. The contralateral CST was used for comparison. Diffusion connectometry analysis included comparison of patients' data with a template from 90 normal subjects. results Three patients (mean age 22 years) with symptomatic pontomesencephalic hemorrhagic CMs and varying degrees of hemiparesis were identified. The mean follow-up period was 37.3 months. Qualitatively, CST was partially disrupted and displaced in all. Direction of the displacement was different in each case and progressively improved corresponding with the patient's neurological status. No patient experienced neurological decline related to the resection. The perilesional mean QA percentage decreases supported tract disruption and decreased further over the follow-up period (Case 1, 26%-49%; Case 2, 35%-66%; and Case 3, 63%-78%). Diffusion connectometry demonstrated rostrocaudal involvement of the CST consistent with the quantitative data. coNclusioNs Hemorrhagic brainstem CMs can disrupt and displace perilesional white matter tracts with the latter occurring in unpredictable directions. This requires the use of tractography to accurately define their orientation to optimize surgical entry point, minimize morbidity, and enhance neurological outcomes. Observed anisotropy decreases in the perilesional segments are consistent with neural injury following hemorrhagic insults. A model using these values in different CST segments can be used to longitudinally monitor its craniocaudal integrity. Diffusion connectometry is a complementary approach providing longitudinal information on the rostrocaudal involvement of the CST.

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“…Patients presenting with a hemorrhage have significantly higher rates of rehemorrhage compared to patients presenting due to incidental findings. 3,4 Flemming et al found that patients presenting with hemorrhage had an overall annual rate of hemorrhage of 6.19% compared to patients presenting without hemorrhage of 0.33%. With increasing use of MR imaging, the percentage of cavernous malformations found incidentally approaches 40%.…”

Section: Stereotactic Radiosurgery For Management Of Cavernous Malformentioning

confidence: 99%