Rebleeding and Outcome in Patients with Symptomatic Brain Stem Cavernomas

Abstract

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.

Timing of surgery and surgical strategies in symptomatic brainstem cavernomas: Review of the literature

“…[3] Among these, the prevalence within the brainstem varies from 4% to 35%. [1567] Histopathologically, cavernomas are characterized by dilated, thin-walled sinusoidal vascular channels lined by a simple endothelium and thin fibrous adventitia, lacking in muscular and elastic layers, which predisposes to bleeding. These channels are filled with blood at various stages of thrombosis and organization.…”

“…Thus, promoting relentless efforts to improve microsurgical techniques and operative adjuncts such as intraoperative monitoring and neuronavigation to improve the postoperative outcome. [510] However, the selection of surgical approach, indications and the timing of intervention yet remains unclear owing to the limitations found in the knowledge about the natural history of the disease. [1410] In this article, we describe three cases of BSCs treated surgically at our institute along with an extensive review of natural history, clinical characteristics, radiology, timing of surgery, planning of a therapeutic approach, and intraoperative adjuncts used in the treatment of BSCs.…”

Update in Intracerebral Hemorrhages - Part 2: Patients at Risk Associated with Vascular Lesions

“…Three new original papers present information on three special groups - patients at very high risk of experiencing intraventricular hemorrhages (IVH) [6], children at risk of experiencing untreated brain arteriovenous malformations (bAVM) [7,] and patients with brain stem cavernoma [8] dealing with ICH due to vascular lesions.…”

“…Having addressed still devastating diseases with both examples, the third paper by Arauz et al [8] from Mexico deals with a subgroup of 99 patients at high risk for rebleeding from symptomatic brainstem cavernomas (BC) - an issue that was, more than 10 years ago, a matter of serious discussion worldwide with regard to whether or not surgical treatment can and should be performed or not. Today, albeit limited by the heterogeneity of reports and selection bias in many trials like the one by Arauz et al [8], there is now concrete evidence that prior hemorrhage is a key parameter for a worse prognosis, while age, gender, BC location, multiplicity and size are not [9,10].…”

“…Today, albeit limited by the heterogeneity of reports and selection bias in many trials like the one by Arauz et al [8], there is now concrete evidence that prior hemorrhage is a key parameter for a worse prognosis, while age, gender, BC location, multiplicity and size are not [9,10]. Neurosurgery performed with high expertise should be considered to improve outcome.…”