Natural history of intracranial cavernous malformations

Symptomatic cavernous malformations of the brainstem: functional outcome after microsurgical resection

Brainstem cavernous malformations are associated with a considerable risk of hemorrhage and subsequent morbidity. This study provides a detailed work-up of clinical and radiological outcome as well as identification of prognostic factors in patients who had suffered from symptomatic hemorrhages. Patients who had undergone surgery of symptomatic BSCMs were evaluated pre- and postoperatively both neurologically and neuroradiologically supplemented by telephone interviews. Additionally, patients were scored according to the Scandinavian Stroke Scale. Multiple uni- and multivariate analyses of possible clinical and radiological prognostic factors were conducted. The study population comprised 35 patients. Mean age at operation was 39.3 ± 13.0 years with microsurgical resection of a total of 37 different BSCMs between 2002 and 2011. Median clinical follow-up was 44.0 months (range 8-116 months). Postoperative MRI showed eventually complete resection of all BSCMs. Postoperative overall outcome revealed complete resolution of neurological symptoms for 5/35 patients, 14/35 improved and 9/35 remained unchanged. 7/35 suffered from a postoperative new and permanent neurological deficit, mostly affecting the facial nerve or hemipareses with mild impairment. Pre- and postoperative Scandinavian Stroke Scale scores were 11.0 ± 2.4 and 11.4 ± 2.2 (p = 0.55). None of the analyzed factors were found to significantly correlate with patients' clinical outcome. Complete resection of brainstem cavernous malformations can be achieved with an acceptable risk for long-term morbidity and surgery-related new deficits (~20 %). Neurological outcome is mainly determined within the first 6 months after surgery. Surgical treatment of brainstem cavernous malformations is recommended in symptomatic patients, in whom the lesion is accessible for surgery.

Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations

OBJECT

The aim of this study was to evaluate the pre- and postoperative rehemorrhage risk, neurological function outcome, and prognostic factors of surgically treated brainstem cavernous malformations (CMs) with long-term follow-up.

METHODS

The authors conducted a retrospective review of the clinical data from 242 patients with brainstem CMs that were surgically treated between 1999 and 2010. Patient charts, imaging findings, and outcomes were examined.

RESULTS

The study included 242 patients, with a male-to-female ratio of 1.3 and mean age of 32.6 years. The mean modified Rankin Scale scores on admission, at discharge, at 3 and 6 months after surgery, and at recent evaluation were 2.2, 2.6, 2.3, 1.8, and 1.5, respectively. The preoperative calculated annual hemorrhage and rehemorrhage rates were 5.0% and 60.9%, respectively. The complete resection rate was 95%. Surgical morbidity occurred in 112 patients (46.3%). Eighty-five patients (35.1%) demonstrated worsened condition immediately after surgery; 34 (41.0%) and 51 (61.4%) of these patients recovered to their baseline level within 3 and 6 months after surgery, respectively. At a mean follow-up of 89.4 months, the patients' condition had improved in 147 cases (60.7%), was unchanged in 70 cases (28.9%), and had worsened in 25 cases (10.3%). A total of 8 hemorrhages occurred in 6 patients, and the postoperative annual hemorrhage rate was 0.4%. Permanent morbidity remained in 65 patients (26.9%). The adverse factors for preoperative rehemorrhage were age ≥ 50 years, size ≥ 2 cm, and perilesional edema. The risk factors for postoperative hemorrhage were developmental venous anomaly and incomplete resection. The independent adverse factors for long-term outcome were increased age, multiple hemorrhages, ventral-seated lesions, and poor preoperative status. Favorable, complete improvement in the postoperative deficits over time was correlated with good preoperative neurological function and continuing improvement thereafter.

CONCLUSIONS

Favorable long-term outcomes and significantly low postoperative annual hemorrhage rates were achieved via surgery. Total resection should be attempted with an aim of minimal injury to neurological function; however, postoperative deficits can improve during the postoperative course. Close follow-up with radiological examination is proposed for patients with adverse factors predictive of rehemorrhage.

Stereotactic radiosurgery of intracranial cavernous malformations

Despite increasing worldwide experience, the role of stereotactic radiosurgery (SRS) in the management of cerebral cavernous malformations (CMs) remains controversial. Microsurgical excision of easily accessible CMs is typically safe; therefore, removal remains the gold standard for most of the symptomatic hemispheric lesions. However, there is now sufficient evidence supporting the use of SRS for the difficult cases. Waiting for the cumulative morbidity of the natural history to justify intervention does not serve the patient's interest, therefore, we argue for early radiosurgical intervention. Carefully designed randomized controlled trials might resolve controversies concerning the role of SRS in treating cerebral CMs.

Cavernous malformations of the basal ganglia in children

OBJECT

Cavernous malformations (CMs) of the basal ganglia are relatively rare lesions that can lead to considerable neurological impairment because of their eloquent location. The authors reviewed the clinical course and surgical outcome of a series of children with basal ganglia CMs.

METHODS

The authors retrospectively reviewed the operative experience of the senior author (R.M.S.) and the 1997-2011 database of Boston Children's Hospital for children with CM of the basal ganglia (which includes CM of the caudate and/or lentiform nucleus and excludes CM of the thalamus). They evaluated baseline demographics, presenting signs, operative outcomes, and condition at long-term follow-up visits and compared these characteristics among patients who underwent surgery and those who were observed.

RESULTS

Of 180 children with a diagnosis of CM, 11 (6%) had CM of the basal ganglia. The mean age at diagnosis was 9.3 years, and the male/female ratio was 1.8:1. Presenting signs were as follows: hemorrhage (8 children), incidental lesions (2), and seizures (1); 2 children had choreiform movement disorders. Treatment was observation or surgery. Observation was chosen for 5 children either because the lesions were asymptomatic (2 children) or because the risk for neurological dysfunction after attempted excision was believed to be high (3 children). These 5 children were observed over a combined total of 30.4 patient-years; none experienced neurological deterioration or symptomatic hemorrhage from their lesions. The other 6 children underwent microsurgical resection of the lesion because they were symptomatic from hemorrhage or increasing mass effect. All 6 of these children had hemorrhagic lesions, of which the smallest dimension was at least 1.5 cm. Of these 6 lesions, 5 were excised completely, and over a combined total of 46 patient-years of follow-up, no rebleeding or late neurological deterioration after surgery was reported.

CONCLUSIONS

In this patient population, the natural history of small and asymptomatic CMs of the basal ganglia was benign. The children with large (> 1.5 cm) symptomatic lesions underwent excision; neurological impairment was apparently minimal, and no hemorrhage or neurological deterioration occurred later.

Predictive Factors for Intracerebral Hemorrhage in Patients with Cavernous Angiomas

OBJECTIVES

Prediction of intracerebral hemorrhage (ICH) in patients with cavernous angiomas is not totally elucidated. The aims of our study were to determine the rate of cerebral hemorrhage, its associated factors, and the clinical outcome in patients with cavernous angiomas in a Hispanic population.

METHODS

We studied 133 patients with cavernous angiomas. The patients were classified into two groups depending on whether they presented an ICH. A comparative analysis of demographics and clinical data, neuroimaging characteristics, and prognosis was carried out in patients with and without hemorrhage. The hemorrhage rate (expressed as the percentage per patient per year) was also estimated.

RESULTS

Seventy-eight patients (59%) had hemorrhage. Non-lobar location of angiomas was associated with hemorrhage [OR 4.82 (CI 95% 2.17-10.73; p=<0.001)]. In contrast, factors associated with a decreased risk of hemorrhage were a family history of epilepsy [OR 0.30 (CI 95% 0.10-0.79; p=0.016)] and lobar location of the angiomas [OR 0.21 (CI 95% 0.09-0.46; p=<0.001)]. The hemorrhagic rate of 1.71% per patient per year was influenced by the location. It was only 1.22% per patient per year in lobar angiomas and 2.33, 2.39, and 2.82% per patient per year for brainstem, cerebellum, and deep hemispheric angiomas, respectively.

CONCLUSIONS

The non-lobar location of cavernous angiomas gives a higher risk of hemorrhage in our Mexican mestizo population, without the hemorrhage being related to either age or sex.

Cerebrovascular neurosurgery in 2012

Considerable advances in our understanding of the natural history and treatment of cerebrovascular disease were made in 2012. The landmark Unruptured Cerebral Aneurysm Study in Japan was published, illustrating a significantly greater rupture risk than previously reported for small anterior and posterior communicating artery aneurysms, those with daughter domes, and giant aneurysms. Results from the Cerecyte (DePuy Synthes, West Chester, PN, USA) coil trial did not demonstrate a statistically significant positive impact of these bioactive coils on angiographic occlusion rates or outcome. The Clazosentan to Overcome Neurological Ischemia and Infarct Occurring after Subarachnoid Hemorrhage study was also published and unfortunately did not demonstrate an overall favorable long-term functional outcome rate for patients with aneurysmal subarachnoid hemorrhage receiving clazosentan. Studies furthering our understanding of the natural history and treatment of vascular malformations were also published, including large prospective natural history studies of cavernous malformations from the Mayo Clinic and the Scottish Audit of Intracranial Vascular Malformations database. Although pregnancy was found to be a significant risk factor for arteriovenous malformation hemorrhage, several studies did not demonstrate pregnancy as a significant risk factor for cavernous malformation hemorrhage. Finally, prospective randomized control trials illustrated significantly improved angiographic and clinical outcome results for both the Solitaire (ev3 Endovascular, Plymouth, MN, USA; SWIFT trial) and Trevo (Concentric Medical, Mountainview, CA, USA; TREVO 2 trial) stent retrievers as compared to the Merci (Concentric Medical) clot retriever.

Comparative studies of the diagnosis and treatment of cerebral cavernous malformations in adults: systematic review

BACKGROUND

Cerebral cavernous malformation (CCM) management decisions are usually made after CCM diagnosis is suspected or definitively diagnosed on axial imaging by indirectly comparing a surgeon's estimate of operative morbidity and mortality against published estimates of CCM untreated clinical course.

METHODS

We used comprehensive electronic strategies to search OVID Medline and EMBASE for original studies published before 2011 of ≥20 adults with CCM that (a) evaluated diagnostic test accuracy, or (b) compared treatment with microsurgery or stereotactic radiosurgery against conservative management in a concurrent or historical control group and reported clinical outcome(s). We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group's approach to identify level 1 or level 2 studies according to the Oxford Centre for Evidence-Based Medicine's 2011 criteria.

RESULTS

We found one eligible diagnostic test accuracy study of 72 patients with brain masses accompanied by vasogenic edema and substantial amounts of blood, which found that hyperintense perilesional signal on T1-weighted magnetic resonance imaging could differentiate CCM from other causes with excellent specificity (98 %) and reasonable sensitivity (62 %). We found five potentially eligible observational studies of adults with a CCM that had already bled, but none met level 2 criteria for a "dramatic" effect (the conventionally calculated probability of the two groups of observations coming from the same population should be less than 0.01 and a rate ratio greater than 10). We found 11 potentially eligible observational studies of adults with CCM and epilepsy, but nine studies did not demonstrate dramatic effects and the remaining two studies showed dramatic effects, but they were at high risk of bias.

CONCLUSIONS

To address the absence of level 1 or 2 evidence to support CCM treatment decisions, there is a need for large studies of CCM treatment with a concurrent control group, ideally with randomized treatment allocation.

Hemorrhage of a cavernous malformation associated with accidental electrocution: Case report and review of the literature

BACKGROUND

Cavernous malformations (CMs) are the second most common intracranial vascular lesions. They typically present after hemorrhage or as incidental findings. Several risk factors have been identified for hemorrhage, however, electrocution as a cause has not been described. We performed a literature review of electrocution associated with CM hemorrhage and of the mechanisms of pathological injury in the central nervous system (CNS) secondary to electrocution. We found no cases of hemorrhage of CMs associated with electrocution.

CASE DESCRIPTION

A 19-year-old male electrician was accidentally electrocuted with 277 V of alternating current (AC) at a job site. He suffered no trauma or physical injuries and reported no immediate abnormal findings. He then experienced progressive nausea, emesis, and lethargy until he presented to the emergency department (ED) where it was discovered that he had a left thalamic/midbrain hemorrhage with hydrocephalus. His hydrocephalus was treated and he began to improve. Subsequent magnetic resonance imaging (MRI) of his head demonstrated characteristic features of a CM.

CONCLUSIONS

There are several proposed mechanisms in the literature by which electrocution may cause CNS damage. It is conceivable that given the pathology of CMs and the proposed mechanisms of electrical injury, these lesions may have an increased risk of hemorrhage as result of electrocution and we are reporting the first case of such an association.

Microsurgical or radiosurgical management of intracranial cavernomas

Cranial cavernous malformations (CCMs) constitute a heterogeneous group of lesions that tend to change dynamically over time with related periods of repeated exacerbation and alternating periods of remission. The decision on their management is based on estimating the inherent risk of further morbidity and the risk/benefit related to the particular treatment mode. Incidentally detected CCMs or lesions in asymptomatic patients presenting without major hemorrhage are best followed up. Complete resection of a CCM is the only healing option and is indicated for symptomatic or hemorrhagic lesions. In the large published series 83-92 % of the patients improved or remained unchanged after surgery, with only 8-11 % showing significant deterioration. For most patients, quality of life is improved. Analysis of the risk/benefit ratio for radiosurgery shows that it should not be regarded as an alternative option: It confers limited protection against bleeding and is related to a certain morbidity risk. In the subgroup of patients with symptomatic or hemorrhagic CCMs in locations that preclude surgical resection with acceptable risks, we recommend follow-up. The senior author is following a group of more than 80 such patients, and the vast majority remain free of hemorrhage and symptoms.

Risk for symptomatic hemorrhage of cerebral cavernous malformations during pregnancy

Object

The threat of symptomatic hemorrhage from cerebral cavernous malformations (CCMs) during pregnancy remains poorly understood. The authors undertook this study to better define the risk of pregnancy-related hemorrhage in this population.

Methods

The records of female patients with sporadic (isolated lesions and negative family history) and familial forms of CCM, which were collected as part of the Barrow Neurological Institute CCM natural history study, were examined. Clinical data related to pregnancy, including type of delivery (vaginal or cesarean section) and any change in neurological status, were obtained from chart reviews and patient interviews.

Results

There were 168 pregnancies among 64 female patients with CCM (28 sporadic and 36 familial). Assuming an average of 46 weeks per pregnancy (40 weeks of gestation and 6 weeks of puerperium), patients were at risk for hemorrhage for a total of 148.6 years. Symptomatic hemorrhage (defined as new-onset or exacerbation of seizure activity or any change in neurological status) occurred during 5 pregnancies, with the most common symptom being seizures (4 cases). The overall risk for symptomatic hemorrhage was 3% per pregnancy; the risk was 1.8% per pregnancy in the sporadic group and 3.6% per pregnancy in the familial patients.

There were 19 deliveries by cesarean section: 5 for obstetrical reasons, 8 for fear of possible hemorrhage, and 6 for unknown reasons. Vaginal delivery was performed without complications for the remaining 149 pregnancies.

Conclusions

The authors' experience suggests that the risk of symptomatic hemorrhage from a CCM during pregnancy is not increased and that a history of CCM is not a contraindication to pregnancy or vaginal delivery.

Antithrombotic therapy and bleeding risk in a prospective cohort study of patients with cerebral cavernous malformations

BACKGROUND AND PURPOSE

Cerebral cavernous malformations (CCMs) are one of the most frequently diagnosed vascular malformations of the brain and constitute a potential source of intracranial hemorrhage. In CCM patients suffering ischemic stroke or heart disease, the use of anticoagulants or antiplatelet therapy is generally avoided by fear of hemorrhagic complications, but no systematic studies exist to support this hypothesis.

METHODS

We prospectively followed-up consecutive patients with a diagnosis of one or more CCMs in a prospective database since 2008. Retrospective data collection was used for patients with a diagnostic event or imaging studies done before first assessment. Symptomatic hemorrhage and other focal neurological events during prospective follow-up were defined according to the current guidelines of the Angioma Alliance Scientific Advisory board.

RESULTS

A total of 87 patients were prospectively enrolled in our cohort [50 women (57%), mean age 44.8 years (SD±17.6), mean follow-up 3.9 years], harboring a total of 738 CCMs. Fifty-five patients (63%) had a single CCM, and 32 patients (37%) had multiple CCMs. Longitudinal follow-up included 16 (18%) patients receiving long-term antithrombotic therapy by antiplatelet treatment (n=11) or oral anticoagulants (n=5). During 5536 lesion-years of observation, none of the patients under antithrombotic therapy experienced CCM hemorrhage on follow-up.

CONCLUSIONS

Our observational data suggest that long-term antithrombotic treatment by antiplatelet drugs or warfarin does not increase the frequency of CCM-related hemorrhage. Patients harboring single or multiple CCMs suffering ischemic stroke or heart disease should not be withheld antithrombotic therapy.

Brainstem cavernomas: a surgical challenge

OBJECTIVE

The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review.

METHODS

From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications.

RESULTS

The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively.

CONCLUSIONS

Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.

Haemorrhagic Strokes in Pregnancy and Puerperium

There is an increased risk of strokes in pregnancy and puerperium. Intracranial haemorrhage is the rarer of the two stroke subtypes but carries a greater morbidity and mortality for both the mother and the child. This review highlights the causes of pregnancy-related intracranial haemorrhage and its management. The incidence varies from region to region with the highest being reported from China and Taiwan. Majority of these haemorrhages are secondary to hypertensive disorders of pregnancy with smaller proportions related to aneurysm and arteriovenous malformation rupture. A small but important contributor is cortical venous thrombosis which, although predominantly gives rise to ischaemic lesions, may lead to parenchymal haemorrhages as well. Presentation is usually with headaches or seizures, with or without focal deficits. Diagnosis requires brain imaging with computerized tomography or magnetic resonance imaging, and the necessity of investigation when this diagnosis is suspected supersedes the small risk of fetal malformation. Management follows the general management principles for intracranial haemorrhage management. Blood pressures need to be strictly monitored and medicines used for controlling them may differ slightly due to teratogenic effects. For preeclampsia, early but safe delivery is the best treatment. For cortical venous thrombosis, low-molecular-weight heparin is the preferred agent. Aneurysms and vascular malformations need to be definitively treated to prevent re-bleed and this can be achieved through surgical or endovascular procedures. The timing of surgery depends on neurosurgical considerations. However, the timing and mode of delivery are governed by obstetric factors. Risk of future haemorrhage depends on whether the underlying aetiology can be and has been definitively treated.

Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions

BACKGROUND

Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial.

METHODS

All eloquently located CMs (n = 45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n = 16; sensorimotor, n = 8; visual pathway, n = 7; cerebellum (deep nuclei and peduncles), n = 7; basal ganglia, n = 4, and language, n = 3. Follow-up data was available for 41 patients (91 %) with a median interval of 14 months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale.

RESULTS

Immediately after surgery, 47 % (n = 21) had a new deficit. At follow-up, 80 % (n = 36) recovered to at least preoperative status or were better than before surgery, 9 % (n = 4) exhibited a slight, and 7 % (n = 3) had a moderate neurological impairment. Only two cases (4 %) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients.

CONCLUSIONS

Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.

Petrosal approaches to brainstem cavernous malformations

Object

Although they provide excellent ventral and lateral exposure of the brainstem, petrosal approaches to brainstem cavernous malformations (CMs) are infrequently reported.

Methods

The authors reviewed their experience with petrosal approaches to brainstem CMs in combination with a comprehensive review of the literature to elucidate resection rates, complication rates, and outcomes.

Results

Including their own results, the authors found 65 cases in 20 reports of brainstem CMs treated with petrosal approaches. The specific approaches were posterior petrosal in 37 cases (57%), anterior petrosal in 17 (26%), extended posterior petrosal in 10 (15%), and a combined petrosal approach in 1 case (2%). For 50 cases in 16 reports with detailed outcome information, the overall complete resection rate was 90%, with early postoperative morbidity reported in 30% of cases and permanent morbidity in 14%. The rate of CSF leakage was 6%.

Conclusions

The versatile petrosal approaches to brainstem CMs are associated with good outcomes and an acceptable morbidity rate. More expansive lesions can be approached using a combination of the standard anterior and posterior petrosal approach, preserving hearing and avoiding the greater complication rates associated with extended posterior petrosal approaches.

The natural history of intracranial cavernous malformations

Literature reports on the natural history of cerebral cavernous malformations (CMs) are numerous, with considerable variability in lesion epidemiology, hemorrhage rates, and risk factors for hemorrhage. In this review, the authors performed a meta-analysis of 11 natural history studies. The overall male-to-female ratio was 1:1, and the mean age at presentation was 30.6 years. Overall, 37% of patients presented with seizures, 36% with hemorrhage, 23% with headaches, 22% with focal neurological deficits, and 10% were asymptomatic. Some patients had more than one symptom. Seizure presentation was most prevalent among supratentorial CMs, while focal neurological deficits were common in patients with infratentorial CMs. By location, CMs were in the cerebral hemispheres (66%), brainstem (18%), basal ganglia or thalamus (8%), cerebellum (6%), and other (2.5% [combined supra- and infratentorial, callosal or insular]). Overall, 19% of patients harbored multiple intracranial CMs, and 9% had radiographically apparent associated developmental venous anomalies. An overall annual hemorrhage rate of 2.4% per patient-year (range 1.6%-3.1%) was identified across 3 studies. Prior hemorrhage and female sex were risk factors for bleeding, while CM size and multiplicity did not affect hemorrhage rates. Although not impacting the hemorrhage rate itself, deep location was a risk factor for increased clinical aggressiveness.

Massive intracerebral hemorrhage caused by a cavernous malformation

We present a rare case of massive intracerebral hemorrhage resulting from a small, superficially-located supratentorial cavernous malformation, or cavernoma. These lesions rarely lead to massive, life-threatening intracerebral hemorrhages. A 17-year-old female presented with a 3-week history of declining mental status. Brain computed tomography and magnetic resonance imaging revealed a sizable intracranial hemorrhage, within the right occipital region, associated with a small nodule at the hematoma's posterior margin. An emergency operation removed the entire hematoma and nodule. Histological examination of the nodule was compatible with a diagnosis of cavernous malformation. The patient's post-operative course was uneventful.

Treatment strategies in cavernomas of the brain and spine

The management of brain and spinal cavernomas includes two main options: (i) conservative treatment or (ii) surgical removal. Clinical experience related to cavernoma patients falls into four major categories: the surgical or conservative treatment of incidental or symptomatic cavernomas. In many patients, cavernomas exist as fairly benign lesions, frequently remaining clinically silent for life. This observation argues against the active treatment of all cavernoma patients; rather for the meticulous selection of only those more likely to benefit from surgery. Thus, the most crucial task in successful management of cavernomas is appropriate patient selection. In this review, we present our institutional experience on cavernoma management supplemented with data from the literature.

Untreated clinical course of cerebral cavernous malformations: a prospective, population-based cohort study

BACKGROUND

Cerebral cavernous malformations (CCMs) are prone to bleeding but the risk of intracranial haemorrhage and focal neurological deficits, and the factors that might predict their occurrence, are unclear. We aimed to quantify these risks and investigate whether they are affected by sex and CCM location.

METHODS

We undertook a population-based study using multiple overlapping sources of case ascertainment (including a Scotland-wide collaboration of neurologists, neurosurgeons, stroke physicians, radiologists, and pathologists, as well as searches of registers of hospital discharges and death certificates) to identify definite CCM diagnoses first made in Scottish residents between 1999 and 2003, which study neuroradiologists independently validated. We used multiple sources of prospective follow-up both to identify outcome events (which were assessed by use of brain imaging, by investigators masked to potential predictive factors) and to assess adults' dependence. The primary outcome was a composite of intracranial haemorrhage or focal neurological deficits (not including epileptic seizure) that were definitely or possibly related to CCM.

FINDINGS

139 adults had at least one definite CCM and 134 were alive at initial presentation. During 1177 person-years of follow-up (completeness 97%), for intracranial haemorrhage alone the 5-year risk of a first haemorrhage was lower than the risk of recurrent haemorrhage (2·4%, 95% CI 0·0-5·7 vs 29·5%, 4·1-55·0; p<0·0001). For the primary outcome, the 5-year risk of a first event was lower than the risk of recurrence (9·3%, 3·1-15·4 vs 42·4%, 26·8-58·0; p<0·0001). The annual risk of recurrence of the primary outcome declined from 19·8% (95% CI 6·1-33·4) in year 1 to 5·0% (0·0-14·8) in year 5 and was higher for women than men (p=0·01) but not for adults with brainstem CCMs versus CCMs in other locations (p=0·17).

INTERPRETATION

The risk of recurrent intracranial haemorrhage or focal neurological deficit from a CCM is greater than the risk of a first event, is greater for women than for men, and declines over 5 years. This information can be used in clinical practice, but further work is needed to quantify risks precisely in the long term and to understand why women are at greater risk of recurrence than men.

FUNDING

UK Medical Research Council, Chief Scientist Office of the Scottish Government, and UK Stroke Association.

Gamma knife stereotactic radiosurgery for thalamic & brainstem cavernous angiomas

OBJECTIVE

To determine the safety and efficacy of Gamma Knife stereotactic radiosurgery (GKS) in the treatment of patients with symptomatic cavernous angiomas (CA) of the brainstem or thalamus, by comparing overall outcome to the natural history of the disease.

METHODS

Over 10 years a series of 16 consecutively presenting patients (M = 9, F = 7) with thalamic or brainstem CA were treated with GKS to a single lesion, specifically excluding the haemosiderin ring from the target. Within the year prior to treatment eight patients had suffered one symptomatic haemorrhage and eight had suffered more than one symptomatic haemorrhage. Mean age at treatment was 38.9 (15-55) years. Mean prescription dose 13.31 Gray (11.0 Gy-16.0 Gy). Patients were followed up radiologically and, more importantly, clinically for a mean period of 43.8 (11-101) months, median 36 months.

RESULTS

One patient suffered recurrent haemorrhage at 23 months post-GKS, but has not re-bled in the following 61 months. One patient died of thalamic haemorrhage from the treated lesion at 90 months. One patient was lost to follow up. There have been no other clinical episodes or radiological findings to suggest post-GKS haemorrhage in the remaining 13 patients, and no other complications were observed in the treated population. The annual haemorrhage rate within the first two years post GKS was 3.72% and the annual haemorrhage rate 2 years post GKS was 3.59% per annum.

CONCLUSION

With the dose regimens described, GKS is safe and effective in the treatment of thalamic and brainstem CA, as assessed by significant reduction in observed rate of re-haemorrhage over that expected from the known natural history of those CAs which have already demonstrated a tendency to haemorrhage in highly eloquent areas.

Management of incidentally discovered intracranial vascular abnormalities

With the widespread use of brain imaging studies, neurosurgeons have seen a marked increase in the number of incidental intracranial lesions, including vascular abnormalities. Specifically, the detection of incidentally discovered aneurysms, arteriovenous malformations, cavernous angiomas, developmental venous anomalies, and capillary telangiectasias has increased. The best management strategy for most of these lesions is controversial. Treatment options include observation, open surgery, endovascular procedures, and radiosurgery. Multiple factors should be taken into account when discussing treatment indications, including the natural history of the disease and the risk of the treatment. In this article, the authors focus on the natural history of these lesions and the risk of the treatment, and they give recommendations regarding the most appropriate management strategy based on the current evidence in the literature and their experience with intracranial vascular abnormalities.

Successful resection of the recurrence of a cavernous malformation of the optic chiasm

The case of a 33-year-old female who suffered from a recurrence of an intrachiasmatic cavernous malformation is presented. She had already undergone surgery in 1991 and 2001 and was admitted to our hospital with reduced vision in the right eye. After MRI, and diagnosis of recurrence of the cavernoma, a neurosurgical operation was performed using the pterional approach. The intraoperative situation was documented with micro photographs. The postoperative course was uneventful. The female described a minimal improvement of her vision. No postoperative complications were observed. To our knowledge, microsurgically complete extirpation of a recurrence of an intrachiasmatic cavernoma has not yet been reported in the literature.

Surgical strategies in treating brainstem cavernous malformations

BACKGROUND

Optimal therapy of brainstem cavernous malformations (BSCMs) remains controversial because their biological behavior is unpredictable and surgical removal is challenging.

OBJECTIVE

To analyze our experience with BSCMs and to conduct a review of the literature to identify a rational approach to the management of these lesions.

METHODS

Fifty-five patients harboring 57 BSCMs underwent surgery and 17 patients were treated conservatively during the 10-year period from 1999 to 2008. The operative strategy was to perform complete CM resection and to preserve any associated venous malformation with minimal functional brainstem tissue sacrificed. The National Institutes of Health Strength Scale (NIHSS) was used to assess neurological status.

RESULTS

The average hemorrhagic and rehemorrhagic rates were 4.7% and 32.7% per patient-year, respectively. Total lesional resection was achieved in all operated patients. Their mean NIHSS score was 4.6 after the first episode, 3.5 preoperatively, 3.2 at discharge, and 1.4 after a mean follow-up of 49 months. Complete recovery rates of motor deficits and sensory disturbances from the preoperative state were 70.4% and 51.7%, respectively. Complete recovery rates for cranial nerves III, V, VI, and VII and the lower group were 60%, 63.2%, 25%, 57.1%, and 80%, respectively. For the conservative patients, the mean NIHSS score was 5.9 after the first episode and 1.7 after a mean follow-up of 40 months.

CONCLUSION

NIHSS is optimal for evaluating the natural history and surgical effect of patients harboring BSCMs. Surgical resection remains the primary therapeutic option after careful patient screening and preoperative planning.

Spontaneous bleeding into a suprasellar cavernous angioma of a neonate: case report and literature review

INTRODUCTION

Cavernous angiomas (CA) are congenital intraparenchymal vascular malformations that contain sinusoidal spaces lined by a single-layer endothelium, separated by collagenous stroma with no intervening brain parenchyma. Despite the congenital origin of CA, they rarely present in the neonatal and prenatal period. In this paper, we present a case report of a neonatal suprasellar CA that presented with a bleed. We also present a literature review focusing on specific features of intracranial CA in the neonatal and fetal age groups.

CASE REPORT

A 27-day-old neonate presented with a left eye ptosis for 2 days, followed by a generalized seizure. A head computed tomography revealed a suprasellar hematoma with intraventricular and subarachnoid extension. Brain magnetic resonance imaging revealed hemorrhages of various ages. Magnetic resonance angiography did not reveal any vascular malformation. Surgical exploration of the suprasellar mass revealed a capsulated dense hematoma. Postoperatively, the neonate was weaned of artificial ventilation over a protracted period and remained hemiparetic with signs of third nerve palsy. Pathology revealed a CA. CA presenting as a suprasellar bleed with subarachnoid and intraventricular extension is very rare especially among neonates. To the best of our knowledge, 20 cases of CA have been reported in the neonatal and fetal period in the English literature. Neonatal CA in general and suprasellar location in particular are extremely rare lesions. Neonatal/fetal CA seems to present more aggressively and have a worse prognosis compared to those presenting at a later age.

Cavernous malformations

Cavernous malformations (CMs) are vascular lesions found in the central nervous system (CNS) and throughout the body and have been called cavernomas, cavernous angiomas, and cavernous hemangiomas. This article discusses the epidemiology, natural history, diagnosis, treatment and follow-up of children who are found to harbor these lesions. CMs affect children by causing hemorrhage, seizure, focal neurologic deficits, and headache. Diagnosis is best made with magnetic resonance imaging. Patients with multiple lesions should be referred for genetic evaluation and counseling. Individuals with symptomatic, growing, or hemorrhagic malformations should be considered for surgical resection. Close follow-up after diagnosis and treatment is helpful to identify lesion progression or recurrence.

Update on the natural history of cavernous malformations and factors predicting aggressive clinical presentation

Cavernous malformations (CMs) are angiographically occult, low-pressure neurovascular lesions with distinct imaging and clinical characteristics. They present with seizure, neurological compromise due to lesion hemorrhage or expansion, or as incidental findings on neuroimaging studies. Treatment options include conservative therapy, medical management of seizures, surgical intervention for lesion resection, and in select cases stereotactic radiosurgery. Optimal management requires a thorough understanding of the natural history of CMs including consideration of issues such as mode of presentation, lesion location, and genetics that may impact the associated neurological risk. Over the past 2 decades, multiple studies have been published, shedding valuable light on the clinical characteristics and natural history of these malformations. The purpose of this review is to provide the reader with a concise consolidation of this published material such that they may better understand the risks associated with CMs and their implications on patient treatment.

Operative management of brainstem cavernous malformations

Brainstem cavernous malformations (CMs) are complex lesions associated with hemorrhage and neurological deficit. In this review, the authors describe the anatomical nuances relating to the operative techniques for these challenging lesions. The resection of brainstem CMs in properly selected patients has been demonstrated to reduce the risk of rehemorrhage and can be achieved relatively safely in experienced hands.

Cerebral cavernous malformations as a disease of vascular permeability: from bench to bedside with caution

Tremendous insight into the molecular and genetic pathogenesis of cerebral cavernous malformations (CCMs) has been gained over the past 2 decades. This includes the identification of 3 distinct genes involved in familial CCMs. Still, a number of unanswered questions regarding the process from gene mutation to vascular malformation remain. It is becoming more evident that the disruption of interendothelial junctions and ensuing vascular hyperpermeability play a principal role. The purpose of this review is to summarize the current understanding of CCM genes, associated proteins, and functional pathways. Promising molecular and genetic therapies targeted at identified molecular aberrations are discussed as well.

Stereotactic radiosurgery for deep-seated cavernous malformations: a move toward more active, early intervention. Clinical article

OBJECT

The role of radiosurgery in the treatment of cavernous malformations (CMs) remains controversial. It is frequently recommended only for inoperable lesions that have bled at least twice. Rehemorrhage can carry a substantial risk of morbidity, however. The authors reviewed their practice of treating deep-seated inoperable CMs to assess the complication rate of radiosurgery, the impact that radiosurgery might have on rebleeding, and whether a more active, earlier intervention is justified in managing this condition.

METHODS

The authors performed a retrospective analysis of 113 patients with 79 brainstem and 39 thalamic/basal ganglia CMs treated with Gamma Knife surgery. Lesions were stratified into 2 groups: those that might be lower risk with no more than 1 symptomatic bleed before radiosurgical treatment and those deemed high risk with multiple symptomatic hemorrhages before treatment.

RESULTS

Forty-one CMs had multiple symptomatic hemorrhages before radiosurgery with a first-ever bleed rate of 2.9% per lesion per year, a rebleed rate of 30.5% per lesion per year, and a median time of 1.5 years between the first and second bleeds. In this group the rebleed rate decreased to 15% for the first 2 years after radiosurgery and declined further to 2.4% thereafter. Pretreatment multiple bleeds led to persistent deficits in 72% of the patients. Seventy-seven CMs had no more than 1 symptomatic bleed before radiosurgery, making for a lifetime bleed rate of 2.2% per lesion per year. The short period between the presenting bleed and treatment (median 1 year) makes the natural history in this group uncertain. The rate of hemorrhage in the first 2 years after treatment was 5.1%, and 1.3% thereafter. Pretreatment hemorrhages resulted in permanent deficits in 43% of the patients in this group, a rate significantly lower than in the multiple-bleeds group (p < 0.001). Posttreatment hemorrhages led to persistent deficits in only 7.3% of the patients. Permanent adverse radiation effects were rare (7.3%) and minor in both groups.

CONCLUSIONS

Stereotactic radiosurgery is a safe management strategy for CMs in eloquent sites with the marked advantage of reducing rebleed risks in patients with repeated pretreatment hemorrhages. The benefit in treating CMs with a single bleed is less clear. Note, however, that repeated hemorrhage carries a significant risk of increased morbidity far in excess of any radiosurgery-related morbidity, and the authors assert that this finding justifies the early active management of deep-seated CMs.

Surgical strategy for insular cavernomas

PURPOSE

Surgical treatment of cavernomas arising in the insula (especially in dominant cerebral hemisphere) is challenging in reason of the proximity to the internal capsule and lenticulostriate arteries. The advent of image guidance systems and intraoperative mapping of the subcortical language pathways has broadened the surgical indications for these lesions. In this work, we report four cases of insular cavernomas operated on, and we define a surgical strategy for these lesions.

METHODS

Between July 1997 and May 2007 in our department, four patients harboring an insular cavernoma were operated on by using image guidance system (neuronavigation in three cases, ultrasound in one case). Subcortical stimulations were used to preserve the functional language area in one case.

FINDINGS

The image guidance system determined the exact planning of the approach and determination of the ideal trajectory of insular cortex dissection. In a case of a deep left insular cavernoma, the shortest approach to remove the cavernoma was stopped in per-operative time because subcortical stimulation produced a speech inhibition, justifying another insular corticotomy. No surgical complications occurred, and the postoperative course was uneventful in all patients.

CONCLUSION

As it has been proposed by many authors, image guidance system is recommended in surgery of insular cavernomas. When the lesion is located in the dominant hemisphere, intraoperative mapping of the subcortical language pathways is also indicated to preserve the language functional areas.

De novo formation of orbital cavernous malformation 9 years after surgical management of dural arteriovenous fistula in the anterior middle fossa: case report

A 30-year-old man presented with recurrent dural arteriovenous fistula (dAVF) associated with de novo orbital cavernous malformation (CM), manifesting as progressive left visual disturbance. He had undergone transarterial embolization and subsequent surgical management for a left anterior middle fossa dAVF 9 years previously. External carotid angiography showed recurrence of the dAVF. Magnetic resonance imaging revealed a well delineated intraorbital mass lesion with hypointense signal rim by T(2)-weighted imaging, adjacent to the shunting point of the recurrent dAVF. Transcranial subtotal removal of the intraorbital mass lesion through the orbitopterional approach revealed continuity between the mass lesion and the draining vein of the recurrent dAVF. The histological diagnosis was CM. His symptom was relieved postoperatively, and no regrowth was seen during the follow-up period of one year. The coexistence of recurrent dAVF with newly formed orbital CM is extremely rare, but may indicate the underlying mechanism of the formation of CMs and recurrent dAVF.

Stereotactic radiosurgery for the treatment of symptomatic brainstem cavernous malformations

Object

The authors performed a retrospective review of prospectively collected data to evaluate the safety and efficacy of stereotactic radiosurgery (SRS) for the treatment of patients harboring symptomatic solitary cavernous malformations (CMs) of the brainstem that bleed repeatedly and are high risk for resection.

Methods

Between 1988 and 2005, 68 patients (34 males and 34 females) with solitary, symptomatic CMs of the brainstem underwent Gamma Knife surgery. The mean patient age was 41.2 years, and all patients had suffered at least 2 symptomatic hemorrhages (range 2–12 events) before radiosurgery. Prior to SRS, 15 patients (22.1%) had undergone attempted resection. The mean volume of the malformation treated was 1.19 ml, and the mean prescribed marginal radiation dose was 16 Gy.

Results

The mean follow-up period was 5.2 years (range 0.6–12.4 years). The pre-SRS annual hemorrhage rate was 32.38%, or 125 hemorrhages, excluding the first hemorrhage, over a total of 386 patient-years. Following SRS, 11 hemorrhages were observed within the first 2 years of follow-up (8.22% annual hemorrhage rate) and 3 hemorrhages were observed in the period after the first 2 years of follow-up (1.37% annual hemorrhage rate). A significant reduction (p < 0.0001) in the risk of brainstem CM hemorrhages was observed following radiosurgical treatment, as well as in latency period of 2 years after SRS (p < 0.0447). Eight patients (11.8%) experienced new neurological deficits as a result of adverse radiation effects following SRS.

Conclusions

The results of this study support a role for the use of SRS for symptomatic CMs of the brainstem, as it is relatively safe and appears to reduce rebleeding rates in this high-surgical-risk location.

Cavernous malformations of the optic pathway and hypothalamus: analysis of 65 cases in the literature

Object

Cavernous malformations (CMs) of the optic pathway and hypothalamus (OPH) are extremely rare. Patients with these lesions typically present with chiasmal apoplexy, characterized by sudden visual loss, acute headaches, retroorbital pain, and nausea. Surgical removal is the recommended treatment to restore or preserve vision and to eliminate the risk of future hemorrhage. However, the anatomical location and eloquence of nearby neural structures can make these lesions difficult to access and remove. In this study, the authors review the literature for reported cases of OPH CMs to analyze clinical and radiographic presentations as well as surgical approaches and neurological outcomes.

Methods

A MEDLINE/PubMed search was performed, revealing 64 cases of OPH CMs. The authors report an additional case in the study, making a total of 65 cases. Each case was analyzed for clinical presentation, lesion location, radiographic features, treatment method, and visual outcome.

Results

In 65 patients with OPH CMs, the optic chiasm was affected in 54 cases, the optic nerve(s) in 35, the optic tract in 13, and the hypothalamus in 5. Loss of visual field and acuity was the most common presenting symptom (98%), followed by headache (60%). The onset of symptoms was acute in 58% of patients, subacute in 15%, and chronic progressive in 26%. Computed tomography scans revealed hyperdense suprasellar lesions, with calcification visible in 56% of cases. Magnetic resonance imaging typically demonstrated a heterogeneous lesion with mixed signal intensities suggestive of blood of different ages. The lesion was often surrounded by a peripheral rim of hypointensity on T2-weighted images in 60% of cases. Minimal or no enhancement occurred after the administration of gadolinium. Hemorrhage was reported in 82% of cases. Most patients were surgically treated (97%) using gross-total resection (60%), subtotal resection (6%), biopsy procedure alone (6%), biopsy procedure with decompression (23%), and biopsy procedure followed by radiation (2%). Those patients who underwent gross-total resection had the highest rate of visual improvement (85%). Two patients were treated conservatively, resulting in complete blindness in 1 patient and spontaneous recovery of vision in the other patient.

Conclusions

Cavernous malformations of the OPH are rare and challenging lesions. Gross-total resection of these lesions is associated with favorable visual outcomes. Emergent surgery is warranted in patients presenting with chiasmal apoplexy to prevent permanent damage to the visual pathway.

Brainstem cavernous malformations: a review with two case reports

Central nervous system (CNS) cavernous malformations (CMs) are developmental malformations of the vascular bed with a highly variable clinical course due to their dynamic nature. We present one case of 'de novo' brainstem cavernous malformation after radiation therapy adding to the increasing number of reported cases in the medical literature, and the case of a pregnant patient with symptomatic intracranial hemorrhage related to brainstem CMs to illustrate the complex nature in management of these patients, followed by a review of clinical and radiographic characteristics. CMs account for 8-15% of all intracranial and intraspinal vascular malformations. Although traditionally thought to be congenital in origin, CMs may present as acquired lesions particularly after intracranial radiation therapy. Clinical manifestations are protean and surgical treatment should be considered for patients with progressive neurologic deficits.

Stereotactic radiosurgery for symptomatic solitary cerebral cavernous malformations considered high risk for resection

Object

A retrospective study was conducted to reassess the benefit and safety of stereotactic radiosurgery (SRS) in patients with solitary cerebral cavernous malformations (CCMs) that bleed repeatedly and are poor candidates for surgical removal.

Methods

Between 1988 and 2005 at the University of Pittsburgh, the authors performed SRS in 103 evaluable patients (57 males and 46 females) with solitary symptomatic CCMs. The mean patient age was 39.3 years. Ninety-eight percent of these patients had experienced 2 or more hemorrhages associated with new neurological deficits. Seventeen patients (16.5%) had undergone attempted resection before radiosurgery. Ninety-three CCMs were located in deep brain structures and 10 were in subcortical lobar areas of functional brain importance. The median malformation volume was 1.31 ml, and the median tumor margin dose was 16 Gy.

Results

The follow-up ranged from 2 to 20 years. The annual hemorrhage rate—that is, a new neurological deficit associated with imaging evidence of a new hemorrhage—before SRS was 32.5%. After SRS 22 hemorrhages were observed within 2 years (10.8% annual hemorrhage rate) and 4 hemorrhages were observed after 2 years (1.06% annual hemorrhage rate). The risk of hemorrhage from a CCM was significantly reduced after radiosurgery (p < 0.0001). Overall, new neurological deficits due to adverse radiation effects following SRS developed in 14 patients (13.5%), with most occurring early in our experience. Modifications in technique (treatment volume within the T2-weighted MR imaging–defined margin, use of MR imaging, and dose reduction for CCM in critical brainstem locations) further reduced risks after SRS.

Conclusions

Data in this study provide further evidence that SRS is a relatively safe procedure that reduces the rebleeding rate for CCMs located in high-surgical-risk areas of the brain.

Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques

This study reviewed surgical experience with brainstem cavernomas in an attempt to define optimal surgical approaches and risks associated with surgical management. Clinical courses were retrospectively reviewed for 36 consecutive patients (12 men, 24 women; mean age, 42 years) who underwent microsurgical resection of brainstem cavernomas between 1996 and 2006. Medical records, surgical records, and neuroimaging examinations were evaluated. All 36 patients presented with > or =1 hemorrhage from the cavernomas and preoperatively displayed some neurological symptoms. Surgical approach was midline suboccipital for 16 pontine and/or medullary cavernomas under the floor of the fourth ventricle, retrosigmoid for 10 lateral mesencephalic, pontine, and/or medullary cavernomas, occipital transtentorial for 2 thalamomesencephalic and 3 mesencephalic cavernomas, combined petrosal for 2 pontine cavernomas, and other for 3 cavernomas. Complete resection according to postoperative magnetic resonance imaging was achieved in 33 of 36 patients. No mortality was encountered in this study. New neurological deficit occurred in the early postoperative period for 18 patients, but was transient in 15 of these. Neurological state as of final follow-up was improved in 16 patients (44%), unchanged in 17 (47%), and worsened in 3 (8%) compared with preoperatively. In conclusion, symptomatic brainstem cavernomas should be considered for surgical treatment. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory.