Long-Term Outcomes of Surgical Treatment in 181 Patients with Supratentorial Cerebral Cavernous Malformation–Associated Epilepsy

Epilepsy associated with cerebral cavernous malformations managed with stereotactic radiosurgery: an international, multicenter study

OBJECTIVE

Stereotactic radiosurgery (SRS) has been proposed as an alternative to resection for epilepsy control in patients with cerebral cavernous malformations (CCM) located in critical areas.

METHODS

This multicentric, retrospective study evaluated seizure control in patients with a solitary CCM and a history of at least one seizure prior to SRS.

RESULTS

109 patients (median age at diagnosis 28.9 years, interquartile range (IQR) 16.4 years] were included. Prior to SRS, 2 (1.8%) were seizure-free without medication, 35 (32.1%) were seizure-free with antiseizure medications (ASM), 17 (15.6%) experienced an improvement of at least 50% in seizure frequency/intensity with ASM, and 55 (50.5%) experienced an improvement of less than 50% in seizure frequency/intensity with ASM. At a median follow-up of 3.5 years post-SRS (IQR: 4.9), 52 (47.7%) patients were Engel class I, 13 (11.9%) class II, 17 (15.6%) class III, 22 (20.2%) class IVA or IVB and 5 (4.6%) class IVC. For the 72 patients who had seizures despite medication prior to SRS, a delay > 1.5 years between epilepsy presentation and SRS decreased the probability to become seizure-free, HR 0.25 (95% CI 0.09-0.66), p = 0.006. The probability of achieving Engel I at the last follow-up was 23.6 (95% CI 12.7-33.1) and 31.3% (95% CI 19.3-50.8) at 2 and 5 years respectively. 27 patients were considered as having drug-resistant epilepsy. At a median follow-up of 3.1 years (IQR: 4.7), 6 (22.2%) of them were Engel I, 3 (11.1%) Engel II, 7 (25.9%) Engel III, 8 (29.6%) Engel IVA or IVB and 3 (11.1%) Engel IVC.

INTERPRETATION

47.7% of patients managed with SRS for solitary CCM presenting with seizures achieved Engel class I at the last follow-up.

Cavernoma-Related Epilepsy: Postoperative Epilepsy Outcome and Analysis of the Predictive Factors, Case Series

BACKGROUND

Epilepsy is common in patients harboring cavernous malformation, and surgery is reported to be an effective treatment. However, few patients still experience seizures after surgery. We analyzed the outcome and predictive factors after cavernoma-related epilepsy (CRE) surgery.

METHODS

A database was created for all patients with CRE treated surgically from 2003 to 2020 at a university hospital. A chart review, perioperative epilepsy workup, surgical strategies, and postoperative and follow-up notes were analyzed. Postoperative seizure outcome was evaluated according to the Engel classification.

RESULTS

Thirty-seven patients (40.5% women; mean age 39.1 ± 14.5 years) were studied. The mean follow-up time was 5.6 ± 3.9 years. Among 37 patients, 32 (86.5%) achieved Engel class I at the last follow-up. Engel class II was found in 1 (2.7%), Engel class III in 1 (2.7%), and Engel class IV in 3 (8.1%) cases. Engel class Ia was observed in 23 patients (62.2%). None of the patients had a worse seizure outcome after the operation (Engel class IVc). Univariate and multivariate analysis showed that short-standing, sporadic, or low-frequent (≤3) seizures were the only variables significantly associated with seizure freedom, whereas longstanding, drug-resistant, or high-frequent seizure history were associated with worse seizure outcomes.

CONCLUSIONS

Surgical treatment results in favorable seizure control in most patients after CRE surgery. Long duration of epilepsy before surgery, high seizure frequency, and drug-resistant epilepsy could have a negative effect on seizure outcome (Engel class II-IV). Therefore, early surgical resection of the cavernoma after careful presurgical planning is recommended to achieve an optimal result.

Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations

OBJECTIVE

The objective of this study was to analyze the impact of medication intake on hemorrhage risk in patients with familial cerebral cavernous malformation (FCCM).

METHODS

The authors' institutional database was screened for patients with FCCM who had been admitted to their department between 2003 and 2020. Patients with a complete magnetic resonance imaging (MRI) data set, evidence of multiple CCMs, clinical baseline characteristics, and follow-up (FU) examination were included in the study. The authors assessed the influence of medication intake on first or recurrent intracerebral hemorrhage (ICH) using univariate and multivariate logistic regression adjusted for age and sex. The longitudinal cumulative 5-year risk of hemorrhage was calculated by applying Kaplan-Meier and Cox regression analyses adjusted for age and sex.

RESULTS

Two hundred five patients with FCCMs were included in the study. Multivariate Cox regression analysis revealed ICH as a predictor for recurrent hemorrhage during the 5-year FU. The authors also noted a tendency toward a decreased association with ICH during FU in patients on statin medication (HR 0.22, 95% CI 0.03-1.68, p = 0.143), although the relationship was not statistically significant. No bleeding events were observed in patients on antithrombotic therapy. Kaplan-Meier analysis and log-rank test showed a tendency toward a low risk of ICH during FU in patients on antithrombotic therapy (p = 0.085), as well as those on statin therapy (p = 0.193). The cumulative 5-year risk of bleeding was 22.82% (95% CI 17.33%-29.38%) for the entire cohort, 31.41% (95% CI 23.26%-40.83%) for patients with a history of ICH, 26.54% (95% CI 11.13%-49.7%) for individuals on beta-blocker medication, 6.25% (95% CI 0.33%-32.29%) for patients on statin medication, and 0% (95% CI 0%-30.13%) for patients on antithrombotic medication.

CONCLUSIONS

ICH at diagnosis was identified as a risk factor for recurrent hemorrhage. Although the relationships were not statistically significant, statin and antithrombotic medication tended to be associated with decreased bleeding events.

Laser Interstitial Thermal Therapy for Cerebral Cavernous Malformations: A Systematic Review of Indications, Safety, and Outcomes

BACKGROUND

Cerebral cavernous malformations (CCM) in deep eloquent areas present a surgical challenge. Laser interstitial thermal therapy (LITT) may present itself as a safe minimally invasive treatment option.

OBJECTIVE

To systematically review the indications, safety, and outcomes of LITT for CCM.

METHODS

Electronic databases were searched from inception to October 7, 2021 for articles with CCM and LITT keywords. Studies describing CCMs treated with LITT were included.

RESULTS

A total of 32 patients with CCMs in lobar (79%), basal ganglia (12%), and brainstem (9%) locations were treated with LITT. Indications for LITT included drug-resistant seizures (75%), unacceptable surgical risk (22%), recurrent hemorrhage (16%), and early intervention to discontinue antiepileptic drugs (3%). No death or CCM-associated intracranial hemorrhage occurred intraoperatively or postoperatively, and most patients experienced no adverse effects or transient effects that resolved at follow-up (84%). Of those treated for CCM-associated epilepsy, 83% experienced Engel class I seizure freedom and most were class IA (61%). Most patients experienced symptomatic improvement (93%), and a decrease in antiepileptic drugs was reported in more than half of patients (56%), with 28% able to discontinue all antiepilepsy medications after LITT.

CONCLUSIONS

LITT seems to be a safe treatment for CCMs located in deep eloquent areas and in lesions presenting with medically refractory seizures or recurrent hemorrhages. Randomized studies are needed to further elucidate its efficacy in treating CCM.

Quality of life and mood assessment in conservatively treated cavernous malformation-related epilepsy

BACKGROUND

To estimate the quality of life, anxiety, depression, and illness perception in patients with medically treated cerebral cavernous malformation (CCM) and associated epilepsy.

METHODS

Nonsurgically treated patients with CCM-related epilepsy (CRE) were included. Demographic, radiographic, and clinical features were assessed. All participants received established questionnaires (short-form 36 health survey, SF-36; hospital anxiety and depression score, HADS-A/D; visual analogue scale score, VAS) assessing the functional and psychosocial burden of disease. To some extent, calculated values were compared with reference values from population-based studies. Test results were related to seizure control.

RESULTS

A total of 37 patients were included. Mean age was 45.8 ± 14.4 years, and 54.1% were female. Diagnosis of CRE was significantly associated with attenuated quality of life and increased level of anxiety, affecting physical and psychosocial dimensions. The assessment of illness perception identified considerable burden. HADS was significantly associated with VAS and SF-36 component scores. Efficacy of antiepileptic medication had no restoring impact on quality of life, anxiety, depression, or illness perception.

CONCLUSIONS

CRE negatively influences quality of life and mood, independent of seizure control due to antiepileptic medication. Screening for functional and psychosocial deficits in clinical practice might be useful for assessing individual burden and allocating surgical or drug treatment.

An iEEG Recording and Adjustable Shunt-Current Conduction Platform for Epilepsy Treatment

This paper proposes a compact bioelectronics sensing platform, including a multi-channel electrode, intracranial electroencephalogram (iEEG) recorder, adjustable galvanometer, and shunt-current conduction circuit pathway. The developed implantable electrode made of polyurethane-insulated stainless-steel materials is capable of recording iEEG signals and shunt-current conduction. The electrochemical impedance of the conduction, ground/reference, and working electrode were characterized in phosphate buffer saline solution, revealing in vitro results of 517.2 Ω@1 kHz (length of 0.1 mm, diameter of 0.8 mm), 1.374 kΩ@1 kHz (length of 0.3 mm, diameter of 0.1 mm), and 3.188 kΩ@1 kHz (length of 0.1 mm, diameter of 0.1 mm), respectively. On-bench measurement of the system revealed that the input noise of the system is less than 2 μVrms, the signal frequency bandwidth range is 1 Hz~10 kHz, and the shunt-current detection range is 0.1~3000 μA with an accuracy of above 99.985%. The electrode was implanted in the CA1 region of the right hippocampus of rats for the in vivo experiments. Kainic acid (KA)-induced seizures were detected through iEEG monitoring, and the induced shunt-current was successfully measured and conducted out of the brain through the designed circuit-body path, which verifies the potential of current conduction for the treatment of epilepsy.

Intra-operative electrocorticography results and postoperative pathological findings are associated with epileptic outcomes in patients with cerebral cavernous malformations presenting with epilepsy

OBJECTIVES

The purpose of this study was to determine whether intraoperative electrocorticography (ECoG) results and postoperative pathological findings are associated with long-term epileptic outcomes in patients with cerebral cavernous malformations (CCMs).

METHODS AND MATERIALS

To identify all consecutive patients with surgically treated CCM-related epilepsy (CRE) referred to our hospital, our prospectively maintained database of patients with CCM was reviewed (NCT03467295). For these patients, an ECoG-guided extended lesionectomy was performed, in which the CCM, surrounding hemosiderin, and detected epileptic foci were removed. Intraoperative ECoG results and postoperative pathological findings were documented in detail. Engel Class I was defined as a favorable outcome, while Engel Class II-IV was considered an unfavorable outcome. The patients were followed up for at least 2 years. The relationship between ECoG results, postoperative pathological findings, and epileptic outcomes was analyzed.

RESULTS

A total of 522 patients with CCM were reviewed, and 85 patients with epileptic CCM were enrolled in this study. At the last clinical visit, 83.5 % of the patients experienced favorable postoperative outcomes. Multivariate analysis revealed that residual epileptic waves detected by intraoperative ECoG (OR 13.64; Cl 2.13-87.11; p = 0.006) and concomitant focal cortical dysplasia (FCD) (OR 11.37; Cl 1.63-79.27; p = 0.014) were independent factors significantly correlated with long-term epileptic outcomes. Most (61; 93.8 %) of the 65 patients with CRE without FCD achieved favorable outcomes.

CONCLUSION

Residual epileptiform discharges after excision and concomitant FCD may be associated with poorer long-term epileptic outcomes in patients with CRE. Close follow-up and strict administration of oral antiepileptic drugs may be needed for these patients.

Cavernous Malformation Surgery in the United States: Validation of a Novel International Classification of Disease, 10th Edition, Clinical Modification Code Search Algorithm and Volume-Driven Surgical Outcomes

OBJECTIVE

The surgical decision-making process for cavernous malformation (CM) must weigh the risks of surgery against the burden of patient symptoms/hemorrhage and anticipated natural history. Here, we sought to internally validate an International Classification of Disease (ICD)-10 search algorithm for CM surgery to use to analyze a nationwide administrative database.

METHODS

Institutional records were accessed to test the validity of a novel ICD-10 search algorithm for CM surgery. The algorithm identified patients with positive predictive value (92%), specificity (100%), and sensitivity of 55%. The algorithm was applied to extract our target population from the Nationwide Readmissions Database. Univariate and multivariable analyses were used to identify factors influencing patient outcomes.

RESULTS

We identified 1235 operations for supratentorial (87%) or infratentorial (13%) CM surgery from the Nationwide Readmissions Database (2016-2017). The overall rate of adverse disposition and 30-day readmission were 19.7% and 7.5%, respectively. The rate of adverse disposition was significantly higher for infratentorial (vs. supratentorial cases) (34.3% vs. 17.6%, P = 0.001) and brainstem (vs. cerebellar) cases (55% vs. 28%, P = 0.03). Hospital case-volume percentile was associated with decreasing rates of adverse disposition (1-74th: 22%, 75th: 16%, 90th: 13%, 95th: 7%). Treatment at HVCs was also associated with shorter average length of stay (4.6 vs. 7.3 days, P < 0.001) without significant changes to average cost of hospitalization (P = 0.60).

CONCLUSIONS

Our ICD-10 coding algorithm reliably identifies CM surgery with minimal false positives. Outcomes were influenced by patient age, clinical presentation, location of CM, and experience of institution. Centralization of care may improve outcomes and warrants further investigation.

Treatment of Cerebral Cavernous Malformations Presenting With Seizures: A Systematic Review and Meta-Analysis

Background: Cerebral cavernous malformations (CCMs) presenting with seizures can be treated with neurosurgery or radiosurgery, but the ideal treatment remains unclear. Currently, there is no adequate randomized controlled trial comparing surgical treatment and radiotherapy for epileptogenic CCMs. Therefore, we conducted a systematic review and meta-analysis of available data from published literature to compare the efficacy and safety of neurosurgery and radiosurgery for epileptogenic CCMs. Methods: We performed a comprehensive search of the Ovid MEDLINE, Web of Science, PubMed, China Biological Medicine and China National Knowledge Infrastructure databases for studies published between January 1994 and October 2019. The search terms were as follows: "epilepsy," "seizures," "brain cavernous hemangioma," "cerebral cavernous malformation," "cerebral cavernous hemangioma," "hemangioma, cavernous, central nervous system." Two researchers independently extracted the data and reviewed all the articles. We compared the advantages and disadvantages of the two treatments. Results: A total of 45 studies were included in our analysis. Overall, the seizure control rate was 79% (95% CI: 75-83%) for neurosurgery and 49% (95% CI: 38-59%) for radiosurgery. In the neurosurgery studies, 4.4% of patients experienced permanent morbidity, while no patients in the radiotherapy studies had permanent morbidity. In addition, the results of subgroup analysis showed that ethnicity, CCMs location and average lesion number are likely significant factors influencing the seizure outcome following treatment. Conclusions: The epilepsy control rate after neurosurgery was higher than that after radiosurgery, but neurosurgery also had a relatively higher rate of permanent morbidity.

Seizure Outcome in Adult Patients with Supratentorial Cavernomas

Background  Cavernomas are usually found in the supratentorial area, and epileptic seizures are one of the presenting symptoms.

Objective  This study aims to provide the seizure outcome in adult patients who underwent surgical excision of single supratentorial cavernomas.

Materials and Methods  A total of 23 patients with single supratentorial cavernomas were operated between May 2011 and January 2019. Pre- and postoperative seizure semiology, clinical, and radiological findings were collected from medical records. At the last follow-up, each patient was seen during regular visits and clinical variables were noted.

Results  The mean age was 37.08 ± 10.5 years, and 11 (57.8%) and 12 (52.2%) were females and males, respectively. Headache (43.5%) and seizure (43.5%) were the most common presenting symptoms. Cavernomas were located on the right side in 13 and on the left side in 10 patients. The most common locations were the frontal (43.5%) and temporal (43.5%) lobes. The mean follow-up in this series was 41.4 ± 30.8 months. Our results showed that surgery was effective in seizure outcome, as almost 70% of patients who had seizure before surgery was seizure free after surgery, and the difference between those who had seizure pre- and postoperative periods was statistically significant ( p = 0.0001).

Conclusion  Surgery is safe and effective for supratentorial cavernomas. The excision of cavernoma together with the surrounding hemosiderin should be performed to obtain a satisfactory seizure outcome.

Trans-sulcal versus trans-parenchymal approach in supratentorial cavernomas. A multicentric experience

OBJECTIVES

Cavernous malformations (CM) are low-flow vascular lesions that can cause significant symptoms and neurological deficits. Different intraoperative surgical approaches have been developed. Aim of the present investigation is the comparison between the trans-sulcal approach (TS) and the trans-parenchymal neuronavigation-assisted approach (TPN) in a surgical series from two neurosurgical centers. The technique and clinical outcomes are discussed, with a specific focus on seizure outcome.

PATIENTS AND METHODS

Clinical and radiological data from two neurosurgical centers ("A. Gemelli" Hospital in Rome and A.O.U. Città della Salute e della Scienza in Turin) were retrospectively reviewed in order to evaluate the different outcome of TS and TPN approach for cavernous malformation treatment.

RESULTS

A total of 177 patients underwent surgical intervention for supratentorial CM, 130 patients with TPN approach and 47 with TS approach. TS approach was associated with higher rate of seizure in early post-operative period both in epileptic patients (p < 0,001) and in patients without history of seizures before surgery (p = 0,002). Moreover, length of incision (p < 0,001), area of craniotomy (p < 0,001) and corticectomy (p < 0,001) were bigger in TS than in TPN approach. Brain contusion (p < 0,001) and fluid collection (p < 0,001) were more likely to be discovered after TS approach.

CONCLUSIONS

TPN is a valuable approach for resection of CM. Minor complications are significantly lower in TPN approach when compared with TS approach. In addition, it is associated with lower rate of early post-operative seizure and shorter length of stay.

Natural History, Clinical, and Surgical Management of Cavernous Malformations

We describe Natural history, clinical and surgical management of cavernous malformation of the brain and spinal cord. Decision-making for treatment of cavernous malformations cannot ignore their natural history and risk of bleeding, which is different depending on the location. Surgical morbidity also depends on the position of the lesion. We performed a review of hemorrhage risk and clinical assessment of superficial and deep supratentorial, brainstem and intramedullary cavernous malformations.

Predictors of Epileptic Seizures and Ability to Work in Supratentorial Cavernous Angioma Located Within Eloquent Brain Areas

BACKGROUND

The postoperative outcomes and the predictors of seizure control are poorly studied for supratentorial cavernous angiomas (CA) within or close to the eloquent brain area.

OBJECTIVE

To assess the predictors of preoperative seizure control, postoperative seizure control, and postoperative ability to work, and the safety of the surgery.

METHODS

Multicenter international retrospective cohort analysis of adult patients benefitting from a functional-based surgical resection with intraoperative functional brain mapping for a supratentorial CA within or close to eloquent brain areas.

RESULTS

A total of 109 patients (66.1% women; mean age 38.4 ± 12.5 yr), were studied. Age >38 yr (odds ratio [OR], 7.33; 95% confidence interval [CI], 1.53-35.19; P = .013) and time to surgery > 12 mo (OR, 18.21; 95% CI, 1.11-296.55; P = .042) are independent predictors of uncontrolled seizures at the time of surgery. Focal deficit (OR, 10.25; 95% CI, 3.16-33.28; P < .001) is an independent predictor of inability to work at the time of surgery. History of epileptic seizures at the time of surgery (OR, 7.61; 95% CI, 1.67-85.42; P = .003) and partial resection of the CA and/or of the hemosiderin rim (OR, 12.02; 95% CI, 3.01-48.13; P < .001) are independent predictors of uncontrolled seizures postoperatively. Inability to work at the time of surgery (OR, 19.54; 95% CI, 1.90-425.48; P = .050), Karnofsky Performance Status ≤ 70 (OR, 51.20; 95% CI, 1.20-2175.37; P = .039), uncontrolled seizures postoperatively (OR, 105.33; 95% CI, 4.32-2566.27; P = .004), and worsening of cognitive functions postoperatively (OR, 13.71; 95% CI, 1.06-176.66; P = .045) are independent predictors of inability to work postoperatively.

CONCLUSION

The functional-based resection using intraoperative functional brain mapping allows safe resection of CA and the peripheral hemosiderin rim located within or close to eloquent brain areas.

Routinely Performed Serial Follow-Up Imaging in Asymptomatic Patients With Multiple Cerebral Cavernous Malformations Has No Influence on Surgical Decision Making

Background: The best strategy to perform follow-up of patients with multiple cerebral cavernous malformations (mCCM) is unclear due to the unpredictable clinical course. Still, serial radiological follow-up is often performed. The objective of this work was to critically question whether active follow-up by serial imaging is justified and has an impact on clinical decision making.

Methods: We included all consecutive patients with mCCM treated and followed at our Department between 2006 and 2016. Patient data were collected and analyzed retrospectively.

Results: From a total number of 406 patients with CCM, n = 73 [18.0%; mean age at first diagnosis 45.2 years (±2.4 SE); n = 42 male (57.5 %)] were found to harbor multiple lesions (≤5 CCM in 58.9%; 6–25 in 21.9%; ≥ 25 in 19.2%). All of them were followed for a mean of 6.8 years (±0.85 SE). Conservative treatment was suggested in 43 patients over the complete follow-up period. Thirty patients underwent surgical extirpation of at least one CCM lesion. Forty-three surgical procedures were performed in total. During 500.5 follow-up years in total, routinely performed follow-up MRI in asymptomatic patients lead to an indication for surgery in only two occasions and even those two were questionable surgical indications.

Conclusion: Routinely performed follow-up MRI in asymptomatic patients with mCCM is highly questionable as there is no evidence for therapeutic relevance.