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Calloni T, Carai A, Lioi F, Cavaliere M, DE Benedictis A, Rossi S, Randi F, Rossi Espagnet MC, Trivisano M, Cesario C, Pisaneschi E, Marasi A, Savioli A, Giussani CG, Marras CE. Surgical management of pediatric intracranial cerebral cavernous malformations: a 10-year single-center experience. J Neurosurg Sci 2024; 68:278-286. [PMID: 35416451 DOI: 10.23736/s0390-5616.22.05574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) are low-flow vascular malformations made up of dilated vascular spaces without intervening parenchyma that can occur throughout the central nervous system. CCMs can occur sporadically or in familial forms. Presentation is diverse, ranging from incidental discovery of asymptomatic CCMs to drug-resistant epilepsy and hemorrhages. METHODS We describe the surgical management of CCMs in pediatric patients at Bambino Gesù Children's Hospital in Rome over the last 10 years. The cases have been stratified based on the clinical presentation and the relevant literature is discussed accordingly. RESULTS We discuss the rationale and technique used in these cases based on their presentation, as well as the generally positive outcomes we achieved with early surgical management, use of intraoperative ultrasound (ioUS) and intraoperative neuromonitoring. CONCLUSIONS Surgical management of pediatric CCMs is a safe and effective strategy, low rates of postoperative morbidity and partial resection were observed.
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Affiliation(s)
- Tommaso Calloni
- Department of Medicine and Surgery, School of Medicine, University of Milan-Bicocca, Milan, Italy
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy -
| | - Francesco Lioi
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Marilou Cavaliere
- Department of Medicine and Surgery, School of Medicine, University of Milan-Bicocca, Milan, Italy
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandro DE Benedictis
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Sabrina Rossi
- Pathology Unit, Department of Laboratories, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Randi
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria C Rossi Espagnet
- Neuroradiology Unit, Imaging Department, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Marina Trivisano
- Neurology Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Claudia Cesario
- Translational Cytogenomics Research Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisa Pisaneschi
- Translational Cytogenomics Research Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Marasi
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Savioli
- Department of Anesthesia and Critical Care (ARCO), IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Carlo G Giussani
- Department of Medicine and Surgery, School of Medicine, University of Milan-Bicocca, Milan, Italy
- Neurosurgery Unit, Department of Neurosciences, San Gerardo Hospital, Monza, Italy
| | - Carlo E Marras
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Tailored Treatment Options for Cerebral Cavernous Malformations. J Pers Med 2022; 12:jpm12050831. [PMID: 35629253 PMCID: PMC9147523 DOI: 10.3390/jpm12050831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 11/19/2022] Open
Abstract
The diagnosis and treatment of cerebral cavernous malformations (CCMs), or cavernomas, continues to evolve as more data and treatment modalities become available. Intervention is necessary when a lesion causes symptomatic neurologic deficits, seizures, or has high risk of continued hemorrhage. Future medical treatment directions may specifically target the pathogenesis of these lesions. This review highlights the importance of individualized treatment plans based on specific CCM characteristics.
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Dziedzic TA, Koczyk K, Nowak A, Maj E, Marchel A. Long-Term Management of Seizures after Surgical Treatment of Supratentorial Cavernous Malformations : A Retrospective Single Centre Study. J Korean Neurosurg Soc 2022; 65:415-421. [PMID: 35508959 PMCID: PMC9082132 DOI: 10.3340/jkns.2020.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Seizure recurrence after the first-ever seizure in patients with a supratentorial cerebral cavernous malformation (CCM) is almost certain, so the diagnosis and treatment of epilepsy is justified. The optimal method of management of these patients is still a matter of debate. The aim of our study was to identify factors associated with postoperative seizure control and assess the surgical morbidity rate.
Methods We retrospectively analysed 45 consecutive patients with a supratentorial CCM and symptomatic epilepsy in a single centre. Pre- and postoperative epidemiological data, seizure-related patient histories, neuroimaging results, surgery details and outcomes were obtained from hospital medical records. Seizure outcomes were assessed at least 12 months after surgery.
Results Thirty-five patients (77.8%) were seizure free at the long-term follow-up (Engel class I); six (13,3%) had rare, nocturnal seizures (Engel class II); and four (8.9%) showed meaningful improvement (Engel class III). In 15 patients (33%) in the Engel I group; it was possible to discontinue antiepileptic medication. Although there was not statistical significance, our results suggest that patients can benefit from early surgery. No deaths occurred in our study, and mild postoperative neurologic deficits were observed in two patients (4%) at the long-term follow-up.
Conclusion Surgical resection of CCMs should be considered in all patients with a supratentorial malformation and epilepsy due to the favourable surgical results in terms of the epileptic seizure control rate and low postoperative morbidity risk, despite the use of different predictors for the seizure outcome.
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Phillips CM, Stamatovic SM, Keep RF, Andjelkovic AV. Cerebral Cavernous Malformation Pathogenesis: Investigating Lesion Formation and Progression with Animal Models. Int J Mol Sci 2022; 23:5000. [PMID: 35563390 PMCID: PMC9105545 DOI: 10.3390/ijms23095000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 02/01/2023] Open
Abstract
Cerebral cavernous malformation (CCM) is a cerebromicrovascular disease that affects up to 0.5% of the population. Vessel dilation, decreased endothelial cell-cell contact, and loss of junctional complexes lead to loss of brain endothelial barrier integrity and hemorrhagic lesion formation. Leakage of hemorrhagic lesions results in patient symptoms and complications, including seizures, epilepsy, focal headaches, and hemorrhagic stroke. CCMs are classified as sporadic (sCCM) or familial (fCCM), associated with loss-of-function mutations in KRIT1/CCM1, CCM2, and PDCD10/CCM3. Identifying the CCM proteins has thrust the field forward by (1) revealing cellular processes and signaling pathways underlying fCCM pathogenesis, and (2) facilitating the development of animal models to study CCM protein function. CCM animal models range from various murine models to zebrafish models, with each model providing unique insights into CCM lesion development and progression. Additionally, these animal models serve as preclinical models to study therapeutic options for CCM treatment. This review briefly summarizes CCM disease pathology and the molecular functions of the CCM proteins, followed by an in-depth discussion of animal models used to study CCM pathogenesis and developing therapeutics.
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Affiliation(s)
- Chelsea M. Phillips
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Svetlana M. Stamatovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Richard F. Keep
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Anuska V. Andjelkovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
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Earlier Age at Surgery for Brain Cavernous Angioma-Related Epilepsy May Achieve Complete Seizure Freedom without Aid of Anti-Seizure Medication. Brain Sci 2022; 12:brainsci12030403. [PMID: 35326359 PMCID: PMC8946282 DOI: 10.3390/brainsci12030403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
Background: The present study hypothesized that some factors may distinguish between patients with a brain cavernous angioma (BCA), who were free from anti-seizure medication (ASM), and patients who still required ASMs postoperatively. The purpose of the study was thus to identify factors associated with ceasing ASMs for patients with drug-resistant epilepsy secondary to BCA, who underwent BCA removal surgery. Methods: We divided patients into those with drug-resistant epilepsy secondary to BCA who achieved complete seizure freedom without ASMs a year after surgery (No-ASM group) (International League Against Epilepsy (ILAE) classification class I with no epileptiform discharges), and others (ASM group) (ILAE classification ≤ II and/or epileptiform discharges). We statistically compared groups in terms of: (1) age at operation; (2) history of epilepsy; (3) size of BCA; and (4) location of BCA. Results: Overall, a year after the surgery, the No-ASM group comprised 12 patients (48%), and the ASM group comprised 13 patients (52%). In both multi- and univariate logistic regression analyses, age at BCA removal surgery correlated significantly with the No-ASM group (p = 0.043, p = 0.019), but history of epilepsy did not (p = 0.581, p = 0.585). Conclusions: Earlier age at surgery for patients with drug-resistant epilepsy is encouraged to achieve complete seizure freedom without the need for ASMs when the cause of epilepsy is BCA.
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Gao X, Yue K, Sun J, Fang Z, Cao Y, Zhao B, Zhang H, Dai S, Zhang L, Luo P, Jiang X. A systematic review and meta-analysis of surgeries performed for cerebral cavernous malformation-related epilepsy in pediatric patients. Front Pediatr 2022; 10:892456. [PMID: 36147813 PMCID: PMC9485440 DOI: 10.3389/fped.2022.892456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The clinical benefit of surgery for the treatment of cerebral cavernous malformation (CCM)-related epilepsy in pediatric patients is still controversial. Although surgical treatment of CCM-related epilepsy in children is widely recognized, the clinical benefits of controlling the seizure rate must be balanced against the risk of leading to perioperative morbidity. METHODS We conducted a comprehensive search to identify relevant studies via Ovid Medline, Web of Science and PubMed (January 1995-June 2020). The following search terms were used: "hemangioma, cavernous, central nervous system," "brain cavernous hemangioma," "cerebral cavernous hemangioma," "CCM," "epilepsy," and "seizures." The seizure control rate and the risk of postoperative adverse outcomes along with their 95% confidence intervals (CIs) were calculated. RESULTS A total of 216 patients across 10 studies were included in meta-analysis. The results showed that the control rate of epilepsy was 88% (95% CI: 76-95%). Four percent (95% CI: 2-10%) of the patients experienced temporary symptomatic adverse effects following surgical resection, and 3% (95% CI: 0-26%) of the patients developed permanent symptomatic adverse effects in the long-term follow-up after surgical excision of the CCMs. None of the patients died as a result of the CCMs or surgical treatment. CONCLUSION Surgery is an effective and safe treatment for CCM -related epilepsy in pediatric patients with a low risk of postoperative complications and death.
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Affiliation(s)
- Xiangyu Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kangyi Yue
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jidong Sun
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zheng Fang
- Reproductive Medical Center, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yuan Cao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Boyan Zhao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Haofuzi Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shuhui Dai
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Luo
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaofan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Winter F, Blair L, Buchfelder M, Roessler K. Risk Factors for Poor Postoperative Outcome and Epileptic Symptoms in Patients Diagnosed with Cerebral Cavernous Malformations. J Neurol Surg A Cent Eur Neurosurg 2020; 82:59-63. [PMID: 33278828 DOI: 10.1055/s-0040-1715496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND STUDY OBJECTIVE Roughly 12 to 47% of individuals with cerebral cavernous malformations (CCM) are asymptomatic, while other people may present with symptoms such as epileptic seizures, neurologic deficits, and intracerebral hemorrhages (IH). The aim of this study was to report our experience of postoperative outcomes of patients diagnosed with CCMs. PATIENTS AND METHODS We present a series of consecutive patients who underwent surgical treatment for a diagnosed CCM between January 2003 and March 2014. Data were retrospectively analyzed with respect to preoperative visits, operating reports, patient admission charts, and postoperative follow-up visits. The Engel scale was used to evaluate the outcome of patients with epileptic seizures. RESULTS A total of 91 patients were included with a mean age of 38.8 ± 15 years (range: 2-72 years). Prior to surgery, 57 of these patients had epileptic seizures, while 25 patients recorded at least one episode of IH with a latency time of 6.7 ± 8.5 years (range: 3-240 months) in between hemorrhages. A CCM located within the brainstem was significantly associated with IH prior to surgery (p = 0.000). If the CCM was adjacent to an eloquent brain area, the postoperative outcome in terms of seizure control was significantly worse (p = 0.033). In addition, a trend for worsened outcomes according to the Engel scale was observed in patients with more than one seizure prior to surgery (p = 0.055). CONCLUSION Proximity of CCMs to eloquent brain areas is a risk factor for poor postoperative outcome with respect to a lower rate of medication reduction as well as a lower rate of epileptic seizure omission. This underlines the importance of patient-specific therapeutic approaches.
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Affiliation(s)
- Fabian Winter
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Lisa Blair
- Department of Neurosurgery, Erlangen University Hospital, Erlangen, Bayern, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Erlangen University Hospital, Erlangen, Bayern, Germany
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria.,Department of Neurosurgery, Erlangen University Hospital, Erlangen, Bayern, Germany
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Shang-Guan HC, Wu ZY, Yao PS, Chen GR, Zheng SF, Kang DZ. Is Extended Lesionectomy Needed for Patients with Cerebral Cavernous Malformations Presenting with Epilepsy? A Meta-Analysis. World Neurosurg 2018; 120:e984-e990. [DOI: 10.1016/j.wneu.2018.08.208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/28/2018] [Indexed: 11/16/2022]
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Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature. Childs Nerv Syst 2017. [PMID: 28634821 DOI: 10.1007/s00381-017-3429-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs. MATERIAL AND METHODS We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome. RESULTS A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14 years (3-18 years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6 cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162 months (mean 47.2 months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series. CONCLUSION Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.
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Dammann P, Wrede K, Jabbarli R, Neuschulte S, Menzler K, Zhu Y, Özkan N, Müller O, Forsting M, Rosenow F, Sure U. Outcome after conservative management or surgical treatment for new-onset epilepsy in cerebral cavernous malformation. J Neurosurg 2017; 126:1303-1311. [DOI: 10.3171/2016.4.jns1661] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The aim of this study was to determine seizure outcome, functional outcome, and the withdrawal of antiepileptic drugs (AEDs) after conservative or surgical treatment of patients with new-onset cavernoma-related epilepsy (CRE).
METHODS
The authors conducted a retrospective comparative observational study of 79 consecutive patients, each with a single sporadic cerebral cavernous malformation (CCM) and new-onset CRE.
RESULTS
Forty-one patients underwent initial surgery (IS), and 38 patients underwent initial conservative (IC) treatment. Of those in the latter group, 19 underwent delayed surgical (DS) treatment. At the last follow-up, 88%, 32%, and 79% of patients in the respective groups had been seizure free for at least 2 years (International League Against Epilepsy [ILAE] Class 1; IS vs IC, p < 0.0001) and 78%, 8%, and 58%, respectively, had been off AEDs (IS vs IC, p < 0.0001). The cumulative probability of staying seizure free (ILAE Class 1) during a 5-year period was 73% (mean seizure-free follow-up 49.8 ± 2.7 months, 95% CI 44.4–55.1 months) for the IS group, 22% (mean 31.8 ± 3.6 months, 95% CI 24.8–38.8 months) for the IC group, and 68% (mean 48.6 ± 4.3 months, 95% CI 40.1–57.1 months) for the DS group (IS vs IC p < 0.001). Long-term operative morbidity was 3%, and long-term morbidity in the conservatively treated group was also 3%.
CONCLUSIONS
Patients with CCM and new-onset CRE who underwent IS treatment showed better results in seizure control and the discontinuation of AEDs than the conservatively treated patients. Operative morbidity was comparable to the morbidity from symptomatic CCM hemorrhage in the conservative group. Half of the patients who started with conservative treatment underwent subsequent surgical treatment; however, a longer duration of epilepsy prior to surgery did not worsen postoperative seizure outcome.
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Affiliation(s)
- Philipp Dammann
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Karsten Wrede
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Ramazan Jabbarli
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Salome Neuschulte
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Katja Menzler
- 2Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main
- 3Epilepsy Center Hessen-Marburg, Department of Neurology, Philipps-University, Marburg
| | - Yuan Zhu
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Neriman Özkan
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Oliver Müller
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Michael Forsting
- 4Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Felix Rosenow
- 2Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main
- 3Epilepsy Center Hessen-Marburg, Department of Neurology, Philipps-University, Marburg
| | - Ulrich Sure
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
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Chávez CL, Yáñez G, Catroppa C, Rojas S, Escartin E, Hearps SJ, García A. Adolescents with vascular frontal lesion: A neuropsychological follow up case study. Neurocirugia (Astur) 2016; 27:136-43. [DOI: 10.1016/j.neucir.2015.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/11/2015] [Accepted: 09/19/2015] [Indexed: 10/22/2022]
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12
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Surgical Cavernous Malformations and Venous Anomalies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Vale FL, Vivas AC, Manwaring J, Schoenberg MR, Benbadis SR. Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes. Acta Neurochir (Wien) 2015; 157:1887-95; discussion 1895. [PMID: 26416611 DOI: 10.1007/s00701-015-2592-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/15/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCM) of the temporal lobe often present with seizures. Surgical resection of these lesions can offer durable seizure control. There is, however, no universally accepted methodology for assessing and surgically treating these patients. We propose an algorithm to maximize positive surgical outcomes (seizure control) while minimizing post-surgical neurological deficit. METHODS A retrospective review of 34 patients who underwent epilepsy surgery for radiographically proven temporal lobe CCM was conducted. Patients underwent a relatively standard work-up for seizure localization. In patients with mesial temporal lobe epilepsy (MTLE), a complete resection of the epileptogenic zone was performed including amygdalo-hippocampectomy in addition to a lesionectomy if not contraindicated by pre-operative work-up. Patients with neocortical epilepsy underwent intraoperative electrocorticography (ECoG)-guided lesionectomy. RESULTS Seizure-free rate for mesial and neocortical (anterior, lateral, and basal) location was 90 vs. 83 %, respectively. Complete resection of the lesion, irrespective of location, was statistically significant for seizure control (p = 0.018). There was no difference in seizure control based on disease duration or location (p > 0.05). Patients with mesial temporal CCM who presented with MTLE were presumed to also have mesial temporal sclerosis (MTS), or dual pathology. These patients underwent routine resection of the mesial structures. Interestingly, patients who had MTLE and basal (neocortical) lesions who underwent a mesial resection for suspected MTS were found not to have dual pathology. CONCLUSIONS Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.
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Affiliation(s)
- Fernando L Vale
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Andrew C Vivas
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jotham Manwaring
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mike R Schoenberg
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Selim R Benbadis
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Ruan D, Yu XB, Shrestha S, Wang L, Chen G. The Role of Hemosiderin Excision in Seizure Outcome in Cerebral Cavernous Malformation Surgery: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0136619. [PMID: 26305879 PMCID: PMC4548944 DOI: 10.1371/journal.pone.0136619] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 08/05/2015] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Whether the excision of hemosiderin surrounding cerebral cavernous malformations (CCMs) is necessary to achieve a seizure-free result has been the subject of debate. Here, we report a systematic review of related literature up to Jan 1, 2015 including 594 patients to assess the effect of hemosiderin excision on seizure outcome in patients with CCMs by meta-analysis. Methods Ten studies comparing extended hemosiderin excision with only lesion resection were identified by searching the English-language literature. Meta-analyses, subgroup analyses and sensitivity analysis were conducted to determine the association between hemosiderin excision and seizure outcome after surgery. Results Seizure outcome was significantly improved in the patients who underwent an extended excision of the surrounding hemosiderin (OR, 0.62; 95% CI: 0.42–0.91; P = 0.01). In subgroup analysis, studies from Asia (OR, 0.42; 95% CI: 0.25–0.71; P = 0.001), male-majority (female ratio < 50%) studies (OR, 0.56; 95% CI: 0.33–0.96; P = 0.04), low occurrence rate of multiple CCMs (OR, 0.37; 95% CI: 0.20–0.71; P = 0.003), cohort studies (OR, 0.44; 95% CI: 0.28–0.68; P = 0.78), longer duration of seizure symptoms (> 1 year) before surgery (OR, 0.43; 95% CI: 0.22–0.84; P = 0.01), lesion diameter > 2 cm (OR, 0.41; 95% CI: 0.19–0.87; P = 0.02) and short-term (< 3 years) follow-up (OR, 0.48; 95% CI: 0.29–0.80; P = 0.005) tended to correlate with a significantly favorable outcome. Conclusion Patients who underwent extended surrounding hemosiderin excision could exhibit significantly improved seizure outcomes compared to patients without hemosiderin excision. However, further well-designed prospective multiple-center RCT studies are still needed.
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Affiliation(s)
- Di Ruan
- Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, the People’s Republic of China
| | - Xiao-Bo Yu
- Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, the People’s Republic of China
| | - Sudeep Shrestha
- Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, the People’s Republic of China
| | - Lin Wang
- Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, the People’s Republic of China
| | - Gao Chen
- Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, the People’s Republic of China
- * E-mail:
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Moultrie F, Horne MA, Josephson CB, Hall JM, Counsell CE, Bhattacharya JJ, Papanastassiou V, Sellar RJ, Warlow CP, Murray GD, Al-Shahi Salman R. Outcome after surgical or conservative management of cerebral cavernous malformations. Neurology 2014; 83:582-9. [PMID: 24994841 DOI: 10.1212/wnl.0000000000000684] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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 = 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 short-term disability scores and increases the risk of symptomatic intracranial hemorrhage and new focal neurologic deficits.
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Affiliation(s)
- Fiona Moultrie
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Margaret A Horne
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Colin B Josephson
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Julie M Hall
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Carl E Counsell
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Jo J Bhattacharya
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Vakis Papanastassiou
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Robin J Sellar
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Charles P Warlow
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Gordon D Murray
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK
| | - Rustam Al-Shahi Salman
- From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
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Huang C, Chen MW, Si Y, Li JM, Zhou D. Factors associated with epileptic seizure of cavernous malformations in the central nervous system in West China. Pak J Med Sci 2013; 29:1116-21. [PMID: 24353703 PMCID: PMC3858921 DOI: 10.12669/pjms.295.3681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/18/2013] [Accepted: 07/25/2013] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To explore the factors associated with preoperative and postoperative epileptic seizure in patients with cavernous malformations (CMs). METHODS A total of 52 consecutive patients from January 2009 to June 2011 who underwent surgical treatment in West China Hospital of Sichuan University due to CMs and confirmed by histopathology were retrospectively reviewed.Patients were divided into two groups (epilepsy-group and non-epilepsy group) according to clinical presentation. Other clinical data, treatment procedure, and follow-up information were collected. Engel classification was used to evaluate seizure outcome. RESULTS Low birth weight, temporal lobe involvement and cortical lesion showed significant difference between two groups (p=0.017, 0.003 and 0.025 respectively). Cortical lesion highly increased risk for preoperative epileptic seizure (OR=10.48; 95% CI 1.61-68.23). After a mean follow-up of 2.1 years, 77.8% of epileptic patients achieved Engel class I. Temporal lobe involvement, lesion size < 2.5cm and surgery within one year of symptom onset were found associated with better seizure outcome (p=0.016, 0.012 and 0.050). Temporal lobe involvement significantly decreased the risk for postoperative epileptic seizure (OR=0.038; 95% CI 0.002-0.833). Application of ECoG made no significant difference to seizure outcome (p=0.430). Most patients need continuing medication therapy after surgery. CONCLUSION Surgical treatment of patient with CMs is satisfactory in most cases and temporal lobe involvement usually predict favourable postoperative seizure outcome whether under the monitoring of ECoG or not. Thus, epileptic patients with CMs should be considered for surgical treatment especially when cortical brain layer or temporal lobe was involved.
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Affiliation(s)
- Cheng Huang
- Cheng Huang, Department of Neurology, West China Hospital of Sichuan University, China
| | - Ming-Wan Chen
- Ming-Wan Chen, West China School of Medicine, Sichuan University, China
| | - Yang Si
- Yang Si, Department of Neurology, West China Hospital of Sichuan University, China
| | - Jin-Mei Li
- Jin-Mei Li, Department of Neurology, West China Hospital of Sichuan University, China
| | - Dong Zhou
- Dong Zhou, Department of Neurology, West China Hospital of Sichuan University, China
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Long-term seizure outcomes following resection of supratentorial cavernous malformations. Clin Neurol Neurosurg 2013; 115:2377-81. [PMID: 24075713 DOI: 10.1016/j.clineuro.2013.08.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 08/10/2013] [Accepted: 08/25/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Symptomatic supratentorial cavernous malformations may present with seizure, headache, neurological deficit, or a combination thereof. Factors that contribute to treatment algorithms commonly include patient age, lesion size and location, lesion multiplicity, hemorrhage history, and the ability to control seizure activity with medication. A better appreciation of the impact of patient and lesion characteristics on post-operative seizure control may provide insight into management strategies. To determine long-term seizure outcomes following surgical resection of supratentorial cavernous malformations, the predictive value of characteristics including seizure duration and number, presence of generalized seizures, and lesion multiplicity and size on seizure control rate was evaluated. METHODS We performed a single institution retrospective review of consecutive patients with supratentorial cavernous malformations presenting with at least one seizure between 1995 and 2008. Univariate and multivariate analyses were used to determine the influence of patient and lesion characteristics on postoperative seizure control. RESULTS Fifty-six patients met inclusion criteria. Mean follow-up duration was 87.9 months. At last follow-up there were 46 patients (82.1%) that were free from impairing seizures (Engel Class 1). Ten patients (17.9%) were classified as Engel Class 2-4. Univariate analysis demonstrated that only the presence of multiple cavernomas was associated with worse post-operative seizure outcome (p=0.006). Multivariate analysis demonstrated that multiple cavernomas remained a significant predictor for development of worse seizure outcome controlling for number and duration of seizures prior to operation, presence of generalized tonic-clonic seizures, and size (odds ratio, 0.17; 95% confidence interval, 0.03, 0.99). CONCLUSION Resection of supratentorial cavernomas is associated with a high rate of postoperative seizure freedom. The presence of multiple cavernomas is predictive of seizure persistence following surgery.
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Ebrahimi A, Etemadifar M, Ardestani PM, Maghzi AH, Jaffe S, Nejadnik H. Cavernous angioma: a clinical study of 35 cases with review of the literature. Neurol Res 2013; 31:785-93. [DOI: 10.1179/016164109x12445505689445] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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19
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Poorthuis M, Samarasekera N, Kontoh K, Stuart I, Cope B, Kitchen N, Al-Shahi Salman R. Comparative studies of the diagnosis and treatment of cerebral cavernous malformations in adults: systematic review. Acta Neurochir (Wien) 2013; 155:643-9. [PMID: 23371401 DOI: 10.1007/s00701-013-1621-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 01/10/2013] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Michiel Poorthuis
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, PO Box 85500, 3500 GA, Utrecht, The Netherlands
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20
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Surgical versus conservative treatment in patients with cerebral cavernomas and non refractory epilepsy. Seizure 2012; 21:785-8. [DOI: 10.1016/j.seizure.2012.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 09/01/2012] [Accepted: 09/03/2012] [Indexed: 11/19/2022] Open
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Al-Shahi Salman R. The outlook for adults with epileptic seizure(s) associated with cerebral cavernous malformations or arteriovenous malformations. Epilepsia 2012; 53 Suppl 4:34-42. [PMID: 22946719 DOI: 10.1111/j.1528-1167.2012.03611.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cerebral cavernous malformations (CCMs) and arteriovenous malformations (AVMs) are common: their asymptomatic prevalence on brain magnetic resonance imaging (MRI) is 1 in 625 and 1 in 2,000, respectively. The risk of epileptic seizure(s) for people with AVMs and CCMs affects their domestic, social, and professional lives, and may influence their decisions about treatment. This article summarizes the seizure risks for people with AVMs and CCMs, gleaned from published original articles indexed in OVID Medline and Embase before 1 January 2012. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, a population-based study in Scotland, United Kingdom, found that the 5-year risks of first seizure were 8% for AVM and 4% for CCM; presentation with intracranial hemorrhage or focal neurologic deficit raised this risk for AVM (23%) but not for CCM (6%). Features associated with the occurrence of epileptic seizures for CCM are lesion multiplicity and cortical CCM location, whereas for AVM the most consistently reported associations are younger age, temporal location, cortical involvement, and nidus diameter >3 cm. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, the 5-year risk of developing epilepsy following a first seizure is 58% for AVM and 94% for CCM, though there is no difference in the chance of achieving 2-year seizure freedom in this time frame (45% AVM vs. 47% CCM). Observational case series describe encouraging differences in seizure frequency before and after AVM and CCM treatment, but the shortage of studies demonstrating dramatic effects in comparison to concurrent control groups justifies the need for more controlled studies, ideally with randomized treatment allocation when the benefits of AVM or CCM treatment are uncertain.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom.
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Cortés Vela J, Concepción Aramendía L, Ballenilla Marco F, Gallego León J, González-Spínola San Gil J. Cerebral cavernous malformations: Spectrum of neuroradiological findings. RADIOLOGIA 2012. [DOI: 10.1016/j.rxeng.2011.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Cortés Vela JJ, Concepción Aramendía L, Ballenilla Marco F, Gallego León JI, González-Spínola San Gil J. Cerebral cavernous malformations: spectrum of neuroradiological findings. RADIOLOGIA 2011; 54:401-9. [PMID: 22197483 DOI: 10.1016/j.rx.2011.09.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 09/13/2011] [Accepted: 09/18/2011] [Indexed: 10/14/2022]
Abstract
Cavernous malformations (cavernomas) are hamartomatous lesions formed by sinusoidal vascular spaces, with no cerebral parenchyma between them. Seizures are the most usual clinical presentation. They are dynamic lesions, producing changes throughout their evolution. The majority are located in the supratentorial region, but up to 20% of cases they are found in the posterior fossa. In computed tomography (CT) and in magnetic resonance (MR) their typical presentation is as a well defined round or oval lesion, with or without a minimal mass effect or oedema, with little or no contrast enhancement. Their appearance in MRI will depend on the stage of the haemorrhage, a T2 echo gradient being the most sensitive sequence. Angiography do not usually detect cavernomas. However, it may demonstrate a venous developmental anomaly. Cavernomas may present with atypical characteristics, as regards their size, appearance, location and number.
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Affiliation(s)
- J J Cortés Vela
- Servicio de Radiodiagnóstico, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, España.
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Englot DJ, Han SJ, Lawton MT, Chang EF. Predictors of seizure freedom in the surgical treatment of supratentorial cavernous malformations. J Neurosurg 2011; 115:1169-74. [PMID: 21819194 DOI: 10.3171/2011.7.jns11536] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Seizures are the most common presenting symptom of supratentorial cerebral cavernous malformations (CCMs) and progress to medically refractory epilepsy in 40% of patients. Predictors of seizure freedom in the resection of CCMs are incompletely understood. METHODS The authors systematically reviewed the published literature on seizure freedom following the resection of supratentorial CCMs in patients presenting with seizures. Seizure outcomes were stratified across 12 potential prognostic variables. A total of 1226 patients with supratentorial CCMs causing seizures were identified across 31 predominantly retrospective studies; 361 patients had medically refractory epilepsy. RESULTS Seventy-five percent of the patients were seizure free after microsurgical lesion removal, whereas 25% continued to have seizures. All patients had had preoperative seizures and > 6 months of postoperative follow-up. Modifiable predictors of postoperative seizure freedom included gross-total resection (OR 36.6, 95% CI 8.5-157.5) and surgery within 1 year of symptom onset (OR 1.83, 95% CI 1.30-2.58). Additional prognostic indicators of a favorable outcome were a CCM size < 1.5 cm (OR 15.4, 95% CI 5.2-45.4), the absence of multiple CCMs (OR 2.02, 95% CI 1.13-3.60), medically controlled seizures (OR 2.38, 95% CI 1.29-4.39), and the lack of secondarily generalized seizures (OR 3.33, 95% CI 2.09-5.30). Other factors, including extended resection of the hemosiderin ring, were not significantly predictive. CONCLUSIONS In the surgical treatment of supratentorial CCMs, gross-total resection and early operative intervention may improve seizure outcome. While surgery should not be considered the first-line treatment for CCM-related epilepsy, it is important to understand the variables associated with seizure freedom in CCM resection given the considerable morbidity and diminished quality of life associated with epilepsy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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Kim W, Stramotas S, Choy W, Dye J, Nagasawa D, Yang I. Prognostic factors for post-operative seizure outcomes after cavernous malformation treatment. J Clin Neurosci 2011; 18:877-80. [DOI: 10.1016/j.jocn.2010.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 12/19/2010] [Indexed: 10/18/2022]
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Cerebral cavernous malformations and intractable epilepsy: the limited usefulness of current literature. Acta Neurochir (Wien) 2011; 153:249-59. [PMID: 21190120 DOI: 10.1007/s00701-010-0915-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) are known to be highly epileptogenic lesions. A number of studies on CCM surgery deal with CCM-associated seizures and/or epilepsy. In order to counsel patients with CCM-associated epilepsy, clear results from such studies would be highly useful. This study reviews the current literature with the aim to assess its usefulness for presurgical decision-making with emphasis on differentiating outcomes in different epilepsy types. METHODS A systematic Medline search identified 27 studies between 1991 and 2009 through the keywords "cavernomas, cavernous, hemangioma, AND epilepsy, AND surgery". They were analysed with regard to clarity of definition of epilepsy subtypes, precision of definition of drug-resistant epilepsy, information on surgical procedure and presurgical workup, seizure outcome and length of follow-up. RESULTS Twenty studies included only surgically treated patients. Three types of epilepsy were defined: drug-resistant epilepsy, epilepsy or single/sporadic seizures. In 12 of 27 studies, at least one of these categories remained unclear. The classic definition of drug-resistant epilepsy was not used in the vast majority of studies, with many groups using their own definition. In 30%, the surgical procedure was not described precisely, although 52% of studies used a differentiated preoperative evaluation. Seizure outcome was described using a widely accepted classification in only 48% of series, and in over half of the studies outcome results contained cases with insufficient length of follow-up. CONCLUSIONS A large proportion of recent studies on surgery for CCM-associated epilepsy are not using criteria and definitions for the classification of epilepsy and outcome that are commonly used by epileptologists or epilepsy surgeons. This results in the limited usefulness of a large part of the literature for the purpose of preoperative counselling a patient with CCM-associated epilepsy.
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Eddleman CS, Batjer HH, Awad IA. Cerebral Cavernous Malformations and Venous Anomalies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Yadla S, Jabbour PM, Shenkar R, Shi C, Campbell PG, Awad IA. Cerebral cavernous malformations as a disease of vascular permeability: from bench to bedside with caution. Neurosurg Focus 2010; 29:E4. [PMID: 20809762 DOI: 10.3171/2010.5.focus10121] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Sanjay Yadla
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Treatment and outcome of children with cerebral cavernomas: a survey on 32 patients. Neurol Sci 2009; 31:117-23. [DOI: 10.1007/s10072-009-0157-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
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31
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Chang EF, Gabriel RA, Potts MB, Garcia PA, Barbaro NM, Lawton MT. Seizure characteristics and control after microsurgical resection of supratentorial cerebral cavernous malformations. Neurosurgery 2009; 65:31-7; discussion 37-8. [PMID: 19574823 DOI: 10.1227/01.neu.0000346648.03272.07] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The optimal management of seizures associated with cerebral cavernous malformations (CCMs) is unclear. The aim of this study was to determine the efficacy of surgery in the management of CCM-associated seizures. METHODS We conducted a retrospective review with follow-up of 164 patients who underwent microsurgical resection of supratentorial CCMs. Clinical and radiographic data were collected and then analyzed to determine predictors of developing epilepsy and predictors of postoperative seizure control after microsurgical resection. RESULTS Of the patients, 61.5% presented with seizures, and 34.7% had clinically defined epilepsy. The development of epilepsy was associated with CCMs located in the temporal lobe and the absence of symptomatic hemorrhage. After microsurgical resection in 44 patients with intractable epilepsy, 72.7% were completely seizure-free (Engel class 1), 11.4% had rare seizures (Engel class 2), 4.5% had meaningful improvement (Engel class 3), and 11.4% had no improvement (Engel class 4). Predictors of complete seizure freedom were gross total resection, smaller CCMs, and the absence of secondary generalized seizures (94% of patients were seizure-free with all 3 predictors). CONCLUSION Surgery is a safe and effective treatment for seizures associated with CCMs.
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Affiliation(s)
- Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143, USA.
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Plotnik AN, Carney P, Schweder P, O'Brien TJ, Velakoulis D, Drummond KJ. Seizures initially diagnosed as panic attacks: case series. Aust N Z J Psychiatry 2009; 43:878-82. [PMID: 19670064 DOI: 10.1080/00048670903107674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Patrick Carney
- Department of Medicine, Austin and Northern Hospitals, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Terence J. O'Brien
- Departments of Neurology, Medicine and Surgery, Royal Melbourne Hospital, University of Melbourne
| | - Dennis Velakoulis
- Neuropsychiatry Unit, Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital and University of Melbourne
| | - Katharine J. Drummond
- Departments of Neurosurgery, Neurology, Medicine and Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Brunon J, Nuti C. Histoire naturelle des cavernomes du système nerveux central. Neurochirurgie 2007; 53:122-30. [PMID: 17507056 DOI: 10.1016/j.neuchi.2007.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 02/22/2007] [Indexed: 10/19/2022]
Abstract
We present a critical review of the literature on the central nervous system cavernomas in order to highlight their natural history and to define the most appropriate management of these rare lesions. The prevalence is now estimated from 0.3 to 0.7% in the general population without any significant difference by gender; 25% of cases are pediatric. Two forms of the disease can be described: sporadic forms in 80% of cases, characterized by isolated or rare lesions and familial dominant autosomic forms characterized by multiple and evolutive lesions. The incidence is not well known, the consultation of the French PMSI database suggests that 50 to 100 cases are operated on each year (1 to 2 per million). Cavernomas are dynamic lesions: growing in many cases, seldom remaining quiescent and disappearing in rare cases. The anatomical evolution is more pejorative in familial forms. "De novo" cases are now well known, either in familial or sporadic forms and after radiotherapy. Many lesions are totally asymptomatic, but the frequency of symptomatic forms is debated in the literature from 3 to 90%... The hemorrhagic risk is evaluated from 0,5 to 3% each year, depending on the localization, and the risk of rebleeding is more important but not well known. The epileptic risk is correlated to the localization, more frequent for temporal and frontal lesions from 4,5 to 11% each year, but these data are controversial. The natural history depends on the topography: hemispheric, deep-seated, brain stem, cerebellum or intramedullary and in pediatric situations. Each situation will be treated in this report.
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Affiliation(s)
- J Brunon
- Service de neurochirurgie, CHU de Saint-Etienne, 17 boulevard Pasteur, 42055 Saint-Etienne cedex 02, France.
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Brunon J, Nuti C. [Results of surgical treatment]. Neurochirurgie 2007; 53:256-61. [PMID: 17507053 DOI: 10.1016/j.neuchi.2007.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 03/06/2007] [Indexed: 11/21/2022]
Abstract
In this chapter we report the results of the main papers of the international literature, but it is difficult to make an objective synopsis because only the best results are published and failure and complications remain confidential. Few papers describe "general complications" as thrombo phlebitis, wound infection, cardio respiratory insufficiency... which are probably as frequent as for all intracranial or spinal surgical procedures. The postoperative neurological status depends essentially on the location of the lesion. In non eloquent area, the postoperative neurological status is almost always excellent. But in a hemispheric functional area, basal ganglia and brain stem it is frequent to observe neurological sequellae; in the better series of the literature, 80% of the patients achieve a good outcome equivalent to or better than before the operation, but 20% are worsened. It is important to remember this fact before discussing the surgical indication. The risk of hemorrhage disappears after total surgical resection; and it is one of the benefits of the treatment, but this objective can be reached only when the lesion is unique. The risk persists in multiple forms and "de novo" cavernomas are always possible especially in familial forms. The main benefit is the treatment of epilepsy for seizure control. In case of good concordance between the location of the cavernoma and the clinical and electrical data, lesionectomy alone or lesionectomy with resection of the perilesional hemosiderin ring provide good results. In the event of severe epilepsy without good concordance between the site of the cavernoma and symptoms, the surgical approach may be functional and outcome less satisfactory.
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Affiliation(s)
- J Brunon
- Service de neurochirurgie, hôpital de Bellevue, CHU de Saint-Etienne, 17 boulevard Pasteur, 42055 Saint-Etienne cedex 02, France.
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Mauguière F. [Epileptogenicity and evaluation of epileptic risk]. Neurochirurgie 2007; 53:156-62. [PMID: 17507046 DOI: 10.1016/j.neuchi.2007.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 03/22/2007] [Indexed: 11/18/2022]
Abstract
Epilepsy is the more frequent clinical manifestation of hemispheric cavernomas in 50 to 75% of symptomatic cases; the annual risk of a first seizure is evaluated from 1.5 to 2.5%. As for all epileptogenic lesions, many questions arise: Is the pathologic tissue or the perilesional cortex responsible for the epileptic symptoms? Is the risk related with the topography of the lesion? Is the prognosis of the epilepsy related with the number of seizures? Can the epilepsy become drug-resistant? Can surgical treatment cure the epilepsy? When surgery is indicated, should lesionectomy alone or lesionectomy plus perilesional tissue resection be performed? The iron and the hemosiderin deposits induce metabolic perturbations and tissue reorganization (gliosis and sclerosis) around the cavernoma. These cortical modifications seem to be responsible for the epileptic discharges but this is difficult to demonstrate. Epileptic discharges have been recorded in the perilesional tissue in only one study of the literature. Drug therapy can usually control the seizures, but it appears that surgery is more effective when the epilepsy is recent and the seizures are not too frequent. For these reasons it would appear licit to propose the resection of the lesion when the surgical risk is not too great. In case of drug-resistant epilepsy, the same function-targeted surgical strategy may be used as for the management of any severe epilepsy.
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Affiliation(s)
- F Mauguière
- Service de neurologie fonctionnelle et d'épileptologie, hôpital neurologique, groupement hospitalier Est, hospices civils de Lyon (HCL), 59 boulevard Pinel 69394, Lyon cedex 03, France.
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Baumann CR, Acciarri N, Bertalanffy H, Devinsky O, Elger CE, Lo Russo G, Cossu M, Sure U, Singh A, Stefan H, Hammen T, Georgiadis D, Baumgartner RW, Andermann F, Siegel AM. Seizure Outcome after Resection of Supratentorial Cavernous Malformations: A Study of 168 Patients. Epilepsia 2007; 48:559-63. [PMID: 17346251 DOI: 10.1111/j.1528-1167.2006.00941.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The optimal management of cerebral cavernous malformations (CCMs) with epileptic seizures is still a matter of debate. The aim of our study was to examine seizure outcome in the largest published series of surgically treated patients with epilepsy due to a supratentorial CCM, and to define predictors for good surgical outcome. METHODS We retrospectively studied 168 consecutive patients with a single supratentorial CCM and symptomatic epilepsy in a multicenter study. Pre- and postoperative clinical examinations, age at epilepsy onset, age at operation, type of symptoms due to the CCM (seizures, headache, hemorrhage, focal deficits), type and frequency of epileptic seizures, and the localization and size of the CCM were assessed. Seizure outcome was determined in the first, second, and third postoperative years. RESULTS The CCM was completely resected in all patients. More than two thirds of the patients were classified as seizure free in the first 3 postoperative years. Predictors for good seizure outcome were age older than 30 years at the time of surgery, mesiotemporal CCM localization, CCM size <1.5 cm, and the absence of secondarily generalized seizures. No mortality occurred in our series, but only mild postoperative neurologic deficits in 12 (7%) patients. CONCLUSIONS Considering the natural history of CCMs, the favorable neurologic and seizure outcome, surgical resection of CCMs should be considered in all patients with supratentorial CCMs and concomitant epilepsy, irrespective of the presence or absence of predictors for a favorable seizure outcome.
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D'Angelo VA, De Bonis C, Amoroso R, Cali A, D'Agruma L, Guarnieri V, Muscarella LA, Zelante L, Bisceglia M, Scarabino T, Catapano D. Supratentorial cerebral cavernous malformations: clinical, surgical, and genetic involvement. Neurosurg Focus 2006; 21:e9. [PMID: 16859262 DOI: 10.3171/foc.2006.21.1.10] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although there is general agreement on the methods of treatment for symptomatic supratentorial cerebral cavernous malformations (CMs) located in noneloquent areas, some controversy exists regarding the management of cerebral CMs that are asymptomatic and/or located in eloquent or deep areas. Moreover, recent advances in genetic findings could influence both standard clinical management and the follow-up strategy in affected individuals. Thus, the objective of this study was to develop, based on the authors' experience and a literature review, a management algorithm to deal with supratentorial cerebral CMs.
Methods
The authors retrospectively reviewed the clinical data related to 118 patients who underwent surgery for symptomatic supratentorial cerebral CMs at their institution. Twenty-eight of 118 patients harbored multiple lesions, and nine of these 28 patients had a clinically positive familial history. Genetic investigations were performed in 89 patients (75%).
Conclusions
Surgery for supratentorial cerebral CMs in noneloquent locations is safe and curative. In cerebral CMs located in deep and eloquent areas and with symptoms including progressive neurological deficits, evidence of hemorrhage, and uncontrolled seizures, surgical treatment according to an integrated plan based on frameless stereotactic guidance and functional magnetic resonance imaging is recommended and results in acceptably low morbidity. The data support the need for long-term imaging follow up in all patients, careful preoperative vascular studies to detect associated venous anomalies, and the importance of genetic mutational analysis. The DNA screening protocol will change the care of family members of patients with familial forms of cerebral CMs, because affected asymptomatic family members may benefit by early detection of lesions. At the same time, the exclusion of family members who are not carriers of the mutation as members of the population at risk reduces the economic and psychological burden of clinical and instrumental monitoring.
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Affiliation(s)
- Vincenzo Antonio D'Angelo
- Neurosurgical Operative Unit, Neuromed Institute, Medical Genetic Service, Pathology Service, and Radiology Service, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
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