Risk Factors for Poor Postoperative Outcome and Epileptic Symptoms in Patients Diagnosed with Cerebral Cavernous Malformations

Cavernous malformations of the central nervous system: An international consensus statement

Introduction

Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial.

Research question

A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs.

Material and methods

A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%.

Results

A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases.

Discussion and conclusion

Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.

Giant cerebral cavernous malformations: redefinition based on surgical outcomes and systematic review of the literature

OBJECTIVE

Giant cerebral cavernous malformations (GCCMs) are rare vascular malformations. Unlike for tumors and aneurysms, there is no clear definition of a "giant" cavernous malformation (CM). As a result of variable definitions, working descriptions and outcome data of patients with GCCM are unclear. A new definition of GCCM related to surgical outcomes is needed.

METHODS

An institutional database was searched for all patients who underwent resection of CMs > 1 cm in diameter. Patient information, surgical technique, and clinical and radiographic outcomes were assessed. A systematic review was performed to augment an earlier published review.

RESULTS

In the authors' institutional cohort of 183 patients with a large CM, 179 with preoperative and postoperative modified Rankin Scale (mRS) scores were analyzed. A maximum CM diameter of ≥ 3 cm was associated with greater risk of severe postoperative decline (≥ 2-point increase in mRS score). After adjustment for age and deep versus superficial location, size ≥ 3 cm was strongly predictive of severe postoperative decline (OR 4.5, 95% CI 1.2-16.9). A model with CM size and deep versus superficial location was developed to predict severe postoperative decline (area under the receiver operating characteristic curve 0.79). Thirteen more patients with GCCMs have been reported in the literature since the most recent systematic review, including some patients who were treated earlier and not discussed in the previous review.

CONCLUSIONS

The authors propose that cerebral CMs with a diameter ≥ 3 cm be defined as GCCMs on the basis of the inflection point for functional and neurological outcomes. This definition is in line with the definitions for other giant lesions. It is less exclusive than earlier definitions but captures the rarity of these lesions (approximately 1% incidence) and variation in outcomes. GCCMs remain operable with potentially favorable outcomes. The term "giant" is not meant to deter or contraindicate surgery.