Outcome after surgical or conservative management of cerebral cavernous malformations

Abstract

Objective: There have been few comparative studies of microsurgical excision vs conservative management of cerebral cavernous malformations (CCM) and none of them has reliably demonstrated a statistically and clinically significant difference. Methods:We conducted a prospective, population-based study to identify and independently validate definite CCM diagnoses first made in 1999-2003 in Scottish adult residents. We used multiple sources of prospective follow-up to assess adults' dependence and to identify and independently validate outcome events. We used univariate and multivariable survival analyses to test the influence of CCM excision on outcome, adjusted for prognostic factors and baseline imbalances.Results: Of 134 adults, 25 underwent CCM excision; these adults were younger (34 vs 43 years at diagnosis, p 5 0.004) and more likely to present with symptomatic intracranial hemorrhage or focal neurologic deficit than adults managed conservatively (48% vs 26%; odds ratio 2.7, 95% confidence interval [CI] 1.1-6.5). During 5 years of follow-up, CCM excision was associated with a deterioration to an Oxford Handicap Scale score 2-6 sustained over at least 2 successive years (adjusted hazard ratio [HR] 2.2, 95% CI 1.1-4.3) and the occurrence of symptomatic intracranial hemorrhage or new focal neurologic deficit (adjusted HR 3.6, 95% CI 1.3-10.0).Conclusions: CCM excision was associated with worse outcomes over 5 years compared to conservative management. Long-term follow-up will determine whether this difference is sustained over patients' lifetimes. Meanwhile, a randomized controlled trial appears justified. Classification of evidence:This study provides Class III evidence that CCM excision worsens shortterm disability scores and increases the risk of symptomatic intracranial hemorrhage and new focal neurologic deficits.

Rebleeding and Outcome in Patients with Symptomatic Brain Stem Cavernomas

“…Brain stem cavernous malformations (BCMs) represent 8-35% of intracranial cavernous malformations [1]. BCMs garner a particular interest because even mild or undetectable changes in the lesions can result in significant symptoms or deficits and they have an apparently higher rupture rate [2].…”

“…BCMs garner a particular interest because even mild or undetectable changes in the lesions can result in significant symptoms or deficits and they have an apparently higher rupture rate [2]. 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].…”

“…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.…”

“…Unfortunately, there are not well-defined factors for predicting the courses of individual patients or identifying patients with greater risks of possible devastating brain stem recurrent hemorrhages. Some series have identified female gender, age, larger lesions, non-lobar locations, and initial hemorrhages as risks factors for hemorrhage recurrence, but these studies have included patients with lesions along the central nervous system, which makes the results difficult to extrapolate to patients with sole BCMs [1,2,8,9,10,11,12]. The risk factors for rebleeding in patients with hemorrhagic BCMs and the long-term functional outcomes remain unclear.…”

Rho Kinase as a Target for Cerebral Vascular Disorders

“…The only management option that can be fully curative is surgical resection to remove the lesion [69]. However, the complications of this surgery include permanent or transient neurological morbidity and risk of serious systemic infection [70,71]. Given the risk-benefit considerations of surgical resection, identified lesions are typically monitored by MRI for signs of lesion expansion and hemorrhage and a resection is conducted only when the surgeon feels that the complications of the untreated lesion (e.g., intractable seizures, progressive neurological deficit) outweigh the surgical risks [72].…”