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Li X, Jones P, Zhao M. Identifying potential (re)hemorrhage among sporadic cerebral cavernous malformations using machine learning. Sci Rep 2024; 14:11022. [PMID: 38745042 PMCID: PMC11094099 DOI: 10.1038/s41598-024-61851-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 05/10/2024] [Indexed: 05/16/2024] Open
Abstract
The (re)hemorrhage in patients with sporadic cerebral cavernous malformations (CCM) was the primary aim for CCM management. However, accurately identifying the potential (re)hemorrhage among sporadic CCM patients in advance remains a challenge. This study aims to develop machine learning models to detect potential (re)hemorrhage in sporadic CCM patients. This study was based on a dataset of 731 sporadic CCM patients in open data platform Dryad. Sporadic CCM patients were followed up 5 years from January 2003 to December 2018. Support vector machine (SVM), stacked generalization, and extreme gradient boosting (XGBoost) were used to construct models. The performance of models was evaluated by area under receiver operating characteristic curves (AUROC), area under the precision-recall curve (PR-AUC) and other metrics. A total of 517 patients with sporadic CCM were included (330 female [63.8%], mean [SD] age at diagnosis, 42.1 [15.5] years). 76 (re)hemorrhage (14.7%) occurred during follow-up. Among 3 machine learning models, XGBoost model yielded the highest mean (SD) AUROC (0.87 [0.06]) in cross-validation. The top 4 features of XGBoost model were ranked with SHAP (SHapley Additive exPlanations). All-Elements XGBoost model achieved an AUROCs of 0.84 and PR-AUC of 0.49 in testing set, with a sensitivity of 0.86 and a specificity of 0.76. Importantly, 4-Elements XGBoost model developed using top 4 features got a AUROCs of 0.83 and PR-AUC of 0.40, a sensitivity of 0.79, and a specificity of 0.72 in testing set. Two machine learning-based models achieved accurate performance in identifying potential (re)hemorrhages within 5 years in sporadic CCM patients. These models may provide insights for clinical decision-making.
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Affiliation(s)
- Xiaopeng Li
- Department of Neurology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Peng Jones
- Independent Researcher, Xinyang, Henan, China
| | - Mei Zhao
- Department of Neurology, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang, 330006, Jiangxi, China.
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Li Z, Lu J, Liu M, Ma L, Quan K, Zhang H, Liu P, Shi Y, Dong X, You C, Tian R, Zhu W. Association of hemorrhage-to-treatment time with outcomes in patients with brainstem cavernous malformations: a nationwide cohort study. Int J Surg 2024; 110:2217-2225. [PMID: 38668661 PMCID: PMC11020047 DOI: 10.1097/js9.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/09/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Brainstem cavernous malformations (BSCMs) often present with haemorrhage, but the optimal timing for microsurgical intervention remains unclear. This study aims to explore how intervention timing relates to neurological outcomes in haemorrhagic BSCM patients undergoing microsurgery, offering insights for clinical decisions. METHODS A total of 293 consecutive patients diagnosed with BSCMs, who underwent microsurgery were identified between March 2011 and January 2023 at two comprehensive centres in China, with a postoperative follow-up duration exceeding 6 months. Utilizing logistic regression models with restricted cubic splines, distinct time groups were identified. Subsequently, matching weight analysis compared these groups in terms of outcomes, new haemorrhage rates, cranial nerve deficits, and perioperative complications. The primary outcome was an unfavourable outcome, which was defined as a mRS score greater than 2 at the latest follow-up. RESULTS Among the 293 patients, 48.5% were female, median age was (39.9±14.3) years, and median haemorrhage-to-treatment time was 42 days. Patients were categorized into acute (≤21 days), subacute (22-42 days), and delay (>42 days) intervention groups. After matching, 186 patients were analyzed. Adjusted analysis showed lower unfavourable outcome rates for acute [adjusted odds ratio (OR), 0.73; 95% CI, 0.65-0.82; P<0.001] and subacute (adjusted OR, 0.83; 95% CI, 0.72-0.95; P=0.007) groups compared to the delay group. Subacute intervention led to fewer cranial nerve deficits (adjusted OR, 0.76; 95% CI, 0.66-0.88, P<0.001). New haemorrhage incidence didn't significantly differ among groups. CONCLUSIONS For haemorrhagic BSCMs patients, delayed microsurgical intervention that exceeded 42 days after a prior haemorrhage were associated with an increased risk of unfavourable neurological outcomes.
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Affiliation(s)
- Zongze Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingjian Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Hongfei Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Xuchen Dong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
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Piccirilli E, Sestieri C, Di Clemente L, Delli Pizzi A, Colasurdo M, Panara V, Caulo M. The effect of different brain lesions on the reorganization of language functions within the dominant hemisphere assessed with task-based BOLD-fMRI. LA RADIOLOGIA MEDICA 2023:10.1007/s11547-023-01642-5. [PMID: 37184809 DOI: 10.1007/s11547-023-01642-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND AND PURPOSE Language reorganization has been described in brain lesions with respect to their location and timing, but little is known with respect to their etiology. We used fMRI to investigate the effects of different types of left hemisphere lesions (GL = gliomas, TLE = temporal lobe epilepsy and CA = cavernous angioma) on the topographic intra-hemispheric language plasticity, also considering their location. METHODS Forty-seven right-handed patients with 3 different left hemisphere lesions (16 GL, 15 TLE and 16 CA) and 17 healthy controls underwent BOLD fMRI with a verb-generation task. Euclidean distance was used to measure activation peak shifts among groups with respect to reference Tailarach coordinates of Inferior Frontal Gyrus, Superior Temporal Sulcus and Temporo-Parietal Junction. Mixed-model ANOVAs were used to test for differences in activation peak shifts. RESULTS Significant activation peak shifts were found in GL patients with respect both to HC and other groups (TLA and CA). In addition, in the same group of patients a significant effect of tumor location (anterior or posterior) was detected. CONCLUSIONS We demonstrated that intra-hemispheric language plasticity is influenced by the type of lesion affecting the left hemisphere and that fMRI is especially valuable in the preoperative assessment of such reorganization in glioma patients.
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Affiliation(s)
- Eleonora Piccirilli
- Department of Neuroscience, Imaging and Clinical Sciences (DNISC), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, 66100, Chieti, Italy
- Institute for Advanced Biomedical Technologies (ITAB), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, Chieti, Italy
- Department of Imaging, Ospedale Pediatrico Bambino Gesù, IRCSS, Rome, Italy
| | - Carlo Sestieri
- Department of Neuroscience, Imaging and Clinical Sciences (DNISC), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, 66100, Chieti, Italy
- Institute for Advanced Biomedical Technologies (ITAB), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, Chieti, Italy
| | - Loris Di Clemente
- Institute for Advanced Biomedical Technologies (ITAB), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, Chieti, Italy
| | - Andrea Delli Pizzi
- Department of Innovative Technologies in Medicine and Dentistry, Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, Chieti, Italy
- Department of Radiology, SS. Annunziata University Hospital, Chieti, Italy
| | - Marco Colasurdo
- Department of Radiology, SS. Annunziata University Hospital, Chieti, Italy
| | - Valentina Panara
- Institute for Advanced Biomedical Technologies (ITAB), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, Chieti, Italy
- Department of Radiology, SS. Annunziata University Hospital, Chieti, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences (DNISC), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, 66100, Chieti, Italy.
- Institute for Advanced Biomedical Technologies (ITAB), Università Degli Studi Gabriele d'Annunzio Di Chieti Pescara, Chieti, Italy.
- Department of Radiology, SS. Annunziata University Hospital, Chieti, Italy.
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Shoubash L, Nowak S, Greisert S, Al Menabbawy A, Rathmann E, von Podewils F, Fleck S, Schroeder HHW. Cavernoma-Related Epilepsy: Postoperative Epilepsy Outcome and Analysis of the Predictive Factors, Case Series. World Neurosurg 2023; 172:e499-e507. [PMID: 36693619 DOI: 10.1016/j.wneu.2023.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Loay Shoubash
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany.
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Stephan Greisert
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Ahmed Al Menabbawy
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Eico Rathmann
- Department of Neuroradiology, University Medicine of Greifswald, Greifswald, Germany
| | - Felix von Podewils
- Department of Neurology, Epilepsy Center, University Medicine of Greifswald, Greifswald, Germany
| | - Steffen Fleck
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Henry H W Schroeder
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
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Chen B, Lahl K, Saban D, Lenkeit A, Rauschenbach L, Santos AN, Li Y, Schmidt B, Zhu Y, Jabbarli R, Wrede KH, Kleinschnitz C, Sure U, Dammann P. Effects of medication intake on the risk of hemorrhage in patients with sporadic cerebral cavernous malformations. Front Neurol 2023; 13:1010170. [PMID: 36686509 PMCID: PMC9847255 DOI: 10.3389/fneur.2022.1010170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/29/2022] [Indexed: 01/05/2023] Open
Abstract
Objective Recurrent intracerebral hemorrhage (ICH) poses a high risk for patients with cerebral cavernous malformations (CCMs). This study aimed to assess the influence of medication intake on hemorrhage risk in sporadic CCMs. Methods From a database of 1,409 consecutive patients with CCM (2003-2021), subjects with sporadic CCMs and complete magnetic resonance imaging data were included. We evaluated the presence of ICH as a mode of presentation, the occurrence of ICH during follow-up, and medication intake, including beta blockers, statins, antithrombotic therapy, and thyroid hormones. The impact of medication intake on ICH at presentation was calculated using univariate and multivariate logistic regression with age and sex adjustment. The longitudinal cumulative 5-year risk for (re-)hemorrhage was analyzed using the Kaplan-Meier curves and the Cox regression analysis. Results A total of 1116 patients with CCM were included. Logistic regression analysis showed a significant correlation (OR: 0.520, 95% CI: 0.284-0.951, p = 0.034) between antithrombotic therapy and ICH as a mode of presentation. Cox regression analysis revealed no significant correlation between medication intake and occurrence of (re-)hemorrhage (hazard ratios: betablockers 1.270 [95% CI: 0.703-2.293], statins 0.543 [95% CI: 0.194-1.526], antithrombotic therapy 0.507 [95% CI: 0.182-1.410], and thyroid hormones 0.834 [95% CI: 0.378-1.839]). Conclusion In this observational study, antithrombotic treatment was associated with the tendency to a lower rate of ICH as a mode of presentation in a large cohort of patients with sporadic CCM. Intake of beta blockers, statins, and thyroid hormones had no effect on hemorrhage as a mode of presentation. During the 5-year follow-up period, none of the drugs affected the further risk of (re-)hemorrhage.
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Affiliation(s)
- Bixia Chen
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany,*Correspondence: Bixia Chen ✉
| | - Kirstin Lahl
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Annika Lenkeit
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Alejandro N. Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Boerge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yuan Zhu
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten H. Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Santos AN, Rauschenbach L, Gull HH, Olbrich A, Lahl K, Darkwah Oppong M, Dinger TF, Rieß C, Chen B, Lenkeit A, Schmidt B, Li Y, Jabbarli R, Wrede KH, Sure U, Dammann P. Central nervous system cavernous malformations: cross-sectional study assessing rebleeding risk after a second haemorrhage. Eur J Neurol 2023; 30:144-149. [PMID: 36181703 DOI: 10.1111/ene.15574] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the 5-year risk of a third bleeding event in cavernous malformations (CMs) of the central nervous system. METHODS Patients with cerebral or spinal CMs treated between 2003 and 2021 were screened using our institutional database. Patients with a complete magnetic resonance imaging dataset, clinical baseline characteristics, and history of two bleeding events were included. Patients who underwent surgical CM removal were excluded. Neurological functional status was obtained using the modified Rankin Scale score at the second and third bleeding. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for a third haemorrhage. RESULTS Forty-two patients were included. Cox regression analysis adjusted for age and sex did not identify risk factors for a third haemorrhage. 37% of patients experienced neurological deterioration after the third haemorrhage (p = 0.019). The cumulative 5-year risk of a third bleeding was 66.7% (95% confidence interval [CI] 50.4%-80%) for the whole cohort, 65.9% (95% CI 49.3%-79.5%) for patients with bleeding at initial diagnosis, 72.7% (95% CI 39.3%-92.7%) for patients with a developmental venous anomaly, 76.9% (95% CI 55.9%-90.3%) for patients with CM localization to the brainstem and 75% (95% CI 50.6%-90.4%) for patients suffering from familial CM disease. CONCLUSIONS During an untreated 5-year follow-up after a second haemorrhage, a significantly increased risk of a third haemorrhage compared to the known risk of a first and second bleeding event was identified. The third bleeding was significantly associated with neurological deterioration. These findings may justify a surgical treatment after a second bleeding event.
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Affiliation(s)
- Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Hanah Hadice Gull
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Angelina Olbrich
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Kirstin Lahl
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Christoph Rieß
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Annika Lenkeit
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
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Li Z, Ma L, Quan K, Liu P, Shi Y, Liu Y, Zhu W. Rehemorrhage of brainstem cavernous malformations: a benchmark approach to individualized risk and severity assessment. J Neurosurg 2022:1-12. [PMID: 36585870 DOI: 10.3171/2022.11.jns222277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/29/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) represent a unique subgroup of cavernous malformations with more hemorrhagic presentation and technical challenges. This study aimed to provide individualized assessment of the rehemorrhage clustering risk of BSCMs after the first symptomatic hemorrhage and to identify patients at higher risk of neurological deterioration after new hemorrhage, which would help in clinical decision-making. METHODS A total of 123 consecutive BSCM patients with symptomatic hemorrhage were identified between 2015 and 2022, with untreated follow-up > 12 months or subsequent hemorrhage during the untreated follow-up. Nomograms were proposed to individualize the assessment of subsequent hemorrhage risk and neurological status (determined by the modified Rankin Scale [mRS] score) after future hemorrhage. The least absolute shrinkage and selector operation (LASSO) regression was used for feature screening. The calibration curve and concordance index (C-index) were used to assess the internal calibration and discrimination performance of the nomograms. Cross-validation was further performed to validate the accuracy of the nomograms. RESULTS Prior hemorrhage times (adjusted OR [aOR] 6.78 per ictus increase) and Zabramski type I or V (OR 11.04) were associated with rehemorrhage within 1 year. A lower mRS score after previous hemorrhage (aOR 0.38 for a shift to a higher mRS score), Zabramski type I or V (OR 3.41), medulla or midbrain location (aOR 2.77), and multiple cerebral cavernous malformations (aOR 11.76) were associated with worsened neurological status at subsequent hemorrhage. The nomograms showed good accuracy and discrimination, with a C-index of 0.80 for predicting subsequent hemorrhage within 1 year and 0.71 for predicting neurological status after subsequent hemorrhage, which were maintained in cross-validation. CONCLUSIONS An individualized approach to risk and severity assessment of BSCM rehemorrhage was feasible with clinical and imaging features.
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Affiliation(s)
- Zongze Li
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Li Ma
- 6Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Quan
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Peixi Liu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Yuan Shi
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Yingjun Liu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Wei Zhu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
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Santos AN, Rauschenbach L, Saban D, Chen B, Lenkeit A, Gull HH, Rieß C, Deuschl C, Schmidt B, Jabbarli R, Wrede KH, Zhu Y, Frank B, Sure U, Dammann P. Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations. J Neurosurg 2022; 137:1088-1094. [PMID: 35213840 DOI: 10.3171/2022.1.jns212724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Alejandro N Santos
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | | | - Dino Saban
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Bixia Chen
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Annika Lenkeit
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Hanah Hadice Gull
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Christoph Rieß
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Cornelius Deuschl
- 2Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen
| | - Börge Schmidt
- 3Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen; and
| | - Ramazan Jabbarli
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Karsten H Wrede
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Yuan Zhu
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Benedikt Frank
- 4Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Germany
| | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Philipp Dammann
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
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9
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Xu XY, Li D, Song LR, Liu PP, Wu ZY, Wang L, Zhang LW, Zhang JT, Wu Z. Nomogram for predicting an individual prospective hemorrhage risk in untreated brainstem cavernous malformations. J Neurosurg 2022; 138:910-921. [PMID: 36152323 DOI: 10.3171/2022.8.jns221228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
In this study, the authors aimed to create a nomogram for precisely predicting the 5-year prospective hemorrhage risk in brainstem cavernous malformations (BSCMs).
METHODS
Patients with confirmed BSCMs in a single-center prospective observational series from January 2012 to December 2016 were included in the present study for nomogram building and validation. The concordance index (C-index), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy, discriminative ability, and clinical usefulness of the nomogram. Then, a nomogram-based risk stratification model for untreated BSCMs was developed.
RESULTS
In total, 600 patients were included in the study; 417 patients who had been enrolled before July 2015 were divided into the training and validation cohorts, and 183 subsequently enrolled patients were used as the external validation cohort. By applying a backward stepwise procedure in the multivariable Cox model, variables, including prior hemorrhage (HR 1.69), hemorrhage on admission (HR 3.33), lesion size > 1.5 cm (HR 1.84), lesion depth (HR 2.35), crossing the axial midpoint (HR 1.94), and developmental venous anomaly (HR 2.62), were incorporated to develop a nomogram. The Harrell C-index values for a 5-year prospective hemorrhage were 0.752 (95% CI 0.687–0.816), 0.801 (95% CI 0.665–0.936), and 0.758 (95% CI 0.674–0.842) in the training, internal validation, and external validation cohorts, respectively. The nomogram performed well in terms of consistency between prediction and actual observation according to the calibration curve. The patients could be classified into three distinct (low, medium, and high) risk groups using the final score of this nomogram.
CONCLUSIONS
Independent predictors of the 5-year hemorrhage risk in untreated BSCMs were selected to create the first nomogram for predicting individual prospective hemorrhage. The nomogram was able to stratify patients into different risk groups and assist in clinical decision-making.
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Affiliation(s)
- Xiao-Ying Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Lai-Rong Song
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Pan-Pan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Ze-Yu Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
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10
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Huo R, Wang J, Sun YF, Weng JC, Li H, Jiao YM, Xu HY, Zhang JZ, Zhao SZ, He QH, Wang S, Zhao JZ, Cao Y. Simplex cerebral cavernous malformations with MAP3K3 mutation have distinct clinical characteristics. Front Neurol 2022; 13:946324. [PMID: 36090889 PMCID: PMC9458974 DOI: 10.3389/fneur.2022.946324] [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: 05/27/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To investigate the clinical characteristics of cerebral cavernous malformations (CCMs) with MAP3K3 somatic mutation. Methods We performed a retrospective review of our CCMs database between May 2017 and December 2019. The patients with simplex CCMs identified to harbor a MAP3K3 or CCM gene somatic mutation were included. Clinical characteristics were recorded. Univariate and multivariate logistic analyses were used to assess the risk factors associated with hemorrhage events of CCMs. To explore the underlying mechanism, we transfected MEKK3-I441M-overexpressing and CCM2-knockdown lentiviruses into human umbilical vein endothelial cells (HUVECs) and investigated thrombomodulin (TM) and tight junctions (TJs) protein expression by western blotting and immunofluorescence. Finally, immunohistochemistry was used to validate TM and TJs protein expression in surgical samples. Results Fifty simplex CCMs patients were included, comprising 38 MAP3K3 mutations and 12 CCM gene mutations. Nine (23.7%) patients with MAP3K3 mutations and 11(91.7%) patients with CCM gene mutations exhibited overt hemorrhage, respectively. Multivariate logistic analyses revealed that MAP3K3 mutation was associated with a lower risk of hemorrhage events. In the vitro experiments, ZO-1 expression was not reduced in MEKK3-I441M-overexpressing HUVECs compared with wild type, whereas it was significantly decreased in CCM2-knockdown HUVECs compared with control. In the MEKK3-I441M-overexpressing HUVECs, TM expression was increased, and the NF-κB pathway was significantly activated. After treatment with an NF-κB signaling inhibitor, TM expression was further upregulated. Meanwhile, TM expression was increased, but the NF-κB pathway was not activated in CCM2-knockdown HUVECs. Accordingly, immunohistochemistry showed that ZO-1 expression in the MAP3K3-mutant samples was significantly higher than that in the CCM-mutant samples. TM expression in the MAP3K3-mutant lesions was significantly lower than that in the CCM-mutant samples. Conclusion Simplex CCMs with MAP3K3 mutation occasionally present with overt hemorrhage, which is associated with the biological function of MAP3K3 mutation.
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Affiliation(s)
- Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ying-Fan Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jian-Cong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu-Ming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hong-Yuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun-Ze Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shao-Zhi Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qi-Heng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ji-Zong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- *Correspondence: Yong Cao
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11
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Five-year symptomatic hemorrhage risk of untreated brainstem cavernous malformations in a prospective cohort. Neurosurg Rev 2022; 45:2961-2973. [PMID: 35633420 DOI: 10.1007/s10143-022-01815-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/23/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
Hemorrhage of brainstem cavernous malformation (CM) would cause various symptoms and severe disability. The study aimed to elaborate on the 5-year actuarial cumulative hazard of symptomatic hemorrhage. Patients diagnosed in our institute between 2009 and 2013 were prospectively registered. All clinical data were obtained, follow-up was performed, and risk factors were evaluated. Four hundred sixty-eight patients (217 female, 46.4%) were included in the study with a median follow-up duration of 79.0 months. A total of 137 prospective hemorrhages occurred in 107 patients (22.9%) during 1854.0 patient-years. Multivariate Cox analysis found age ≥ 55 years (hazard ratio (HR) 2.166, p = 0.002), DVA (HR 1.576, p = 0.026), superficial-seated location (HR 1.530, p = 0.047), and hemorrhage on admission (HR 2.419, p = 0.026) as independent risk factors for hemorrhage. The 5-year cumulative hazard of hemorrhage was 30.8% for the overall cohort, 47.8% for 60 patients with age ≥ 55 years, 43.7% for 146 patients with DVA, 37.9% for 272 patients with superficial-seated lesions, and 37.2% for 341 patients with hemorrhage on admission. As a stratified analysis, within subcohort of 341 patients with a hemorrhagic presentation, age ≥ 55 years (HR 3.005, p < 0.001), DVA (HR 1.801, p = 0.010), and superficial-seated location (HR 2.276, p = 0.001) remained independently significant. The 5-year cumulative hazard of hemorrhage was 52.0% for 119 patients with both DVA and hemorrhagic presentation. The 5-year cumulative hemorrhagic risk was 30.8% and was higher in subgroups if harboring risk factors that helped to predict potential hemorrhagic candidates and were useful for treatment decision-making.Clinical Trial Registration-URL: http://www.chictr.org.cn Unique identifier: ChiCTR-POC-17011575.
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12
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Jeon JP, Kim S, Kim TY, Han SW, Lim SH, Youn DH, Kim BJ, Hong EP, Park CH, Kim JT, Ahn JH, Rhim JK, Park JJ, Kim HC, Kang SH. Association Between Copeptin and Six-Month Neurologic Outcomes in Patients With Moderate Traumatic Brain Injury. Front Neurol 2022; 12:749110. [PMID: 35547639 PMCID: PMC9081440 DOI: 10.3389/fneur.2021.749110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background Copeptin has been reported as a predictive biomarker for the prognosis after traumatic brain injury (TBI). However, most of them were in patients with severe TBI and limited value in predicting outcomes in patients with moderate TBI defined as Glasgow Coma Scale (GCS) score from 9 to 12. We aimed to investigate the predictive value of copeptin in assessing the neurologic outcome following moderate TBI. Methods Patients were prospectively enrolled between May 2017 and November 2020. We consecutively measured plasma copeptin within 24 h after trauma, days 3, 5, and 7 using ELISA. The primary outcome was to correlate plasma copeptin levels with poor neurologic outcome at 6 months after moderate TBI. The secondary outcome was to compare the prognostic accuracy of copeptin and C-reactive protein (CRP) in assessing the outcome of patient. Results A total of 70 patients were included for the final analysis. The results showed that 29 patients (41.4%) experienced a poor neurologic outcome at 6 months. Multivariable logistic regression analysis revealed that increased copeptin (odds ration [OR] = 1.020, 95% CI: 1.005–1.036), GCS score of 9 or 10 (OR = 4.507, 95% CI: 1.266–16.047), and significant abnormal findings on CT (OR = 4.770; 95% CI: 1.133–20.076) were independent risk factors for poor outcomes. Consecutive plasma copeptin levels were significantly different according to outcomes (p < 0.001). Copeptin on day 7 exhibited better prognostic performance than CRP with an area under receiver operating characteristic curve (AUROC) difference of 0.179 (95% CI: 0.032–0.325) in predicting 6-month poor outcomes. Conclusion Plasma copeptin level can be a useful marker in predicting 6-month outcomes in patients with moderate TBI.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Seonghyeon Kim
- Department of Orthopaedic Surgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Tae Yeon Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sung Woo Han
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Seung Hyuk Lim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Dong Hyuk Youn
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Eun Pyo Hong
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Chan Hum Park
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jong-Tae Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, South Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk Medical Center, Seoul, South Korea
| | - Heung Cheol Kim
- Department of Radioilogy, Hallym University College of Medicine, Chuncheon, South Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
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13
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Ren J, Jiang N, Bian L, Dmytriw AA, Zeng G, He C, Sun L, Li X, Ma Y, Yu J, Li G, Ye M, Hu P, Li J, Yang F, Li Q, Ling F, Zhang H, Hong T. Natural History of Spinal Cord Cavernous Malformations: A Multicenter Cohort Study. Neurosurgery 2022; 90:390-398. [PMID: 35049523 DOI: 10.1227/neu.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The natural history of spinal cord cavernous malformations (SCCMs) remains relatively unclear. OBJECTIVE To investigate the natural history for hemorrhagic risks and neurological outcomes, as well as relevant predicting factors, of SCCMs. METHODS All patients between 2002 and 2019 with diagnosis of SCCMs were identified retrospectively. An observational study of patients with conservative management was performed to reveal the natural history of SCCMs. RESULTS We identified 305 patients in the full cohort, including 126 patients who were conservatively treated for at least 6 months (median observational period, 24.0 months). Forty-five hemorrhage events occurred during 527 person-years of follow-up, yielding an annual hemorrhage rate of 8.5% per person-year. The 1-, 2-, and 5-year cumulative risks of hemorrhage were 13.9%, 26.1%, and 35.1%, respectively. Prior hemorrhage (hazard ratio [HR] = 12.948, P = .012) and pediatric patients (HR = 2.841, P = .031) were independent predictors of hemorrhage in the long-term follow-up. Familial form (adjusted odds ratio [OR] = 30.695, P = .010) and subsequent hemorrhage events (adjusted OR = 16.333, P = .000) were independent risk factors for worsening of neurological function, and baseline neurological status (adjusted OR = 78.984, P = .000) and presence of subsequent hemorrhage (adjusted OR = 9.611, P = .001) were significantly associated with neurological outcomes. CONCLUSION The natural history of SCCMs varies. Baseline characteristics, such as pediatric patients, familial form, and baseline neurological status, as well as prior and subsequent hemorrhagic events, significantly affect the natural history of the SCCMs, which prompts a differentiated treatment strategy.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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14
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Santos AN, Rauschenbach L, Saban D, Chen B, Darkwah Oppong M, Herten A, Hadice Gull H, Rieß C, Deuschl C, Schmidt B, Jabbarli R, Wrede KH, Zhu Y, Frank B, Sure U, Dammann P. Multiple Cerebral Cavernous Malformations – Clinical Course of Confirmed, Assumed and Non‐Familial Disease. Eur J Neurol 2022; 29:1427-1434. [DOI: 10.1111/ene.15253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Alejandro N. Santos
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Hanah Hadice Gull
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Christoph Rieß
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology University Hospital of Essen Essen Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Karsten H. Wrede
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Yuan Zhu
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Benedikt Frank
- Department of Neurology University Hospital Essen Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
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15
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Are radiation-induced cavernomas clinically relevant findings? Results from long-term follow-up with brain magnetic resonance imaging of childhood cancer survivors. Radiol Oncol 2021; 55:274-283. [PMID: 34384013 PMCID: PMC8366727 DOI: 10.2478/raon-2021-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/20/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Radiation-induced cavernomas (RIC) after cranial radiotherapy have an unknown risk of hemorrhage. Zabramski magnetic resonance imaging (MRI) classification is touted as being able to indicate non-radiation-induced cavernomas hemorrhage risk. The aim of our study was to assess the hemorrhage risk of RIC during long-term follow-up of childhood cancer survivors based on brain MRI examinations. PATIENTS AND METHODS We analyzed retrospectively long-term follow-up data of 36 childhood cancer survivors after initial diagnosis with acute leukemia (n = 18) or brain tumor (n = 18), all treated with cranial radiotherapy. Detected RIC in long-term follow-up brain MRI (1.5 or 3 Tesla) were classified following the Zabramski MRI classification and were categorized into "high" (Zabramski type I, II or V) or "low" (type III or IV) risk of hemorrhage. RESULTS 18 patients (50%) showed RIC with a significant relation to the original tumor entity (p = 0.023) and the cumulative radiation dose to the brain (p = 0.016): all 9 childhood cancer survivors diagnosed with medulloblastoma developed RIC. We classified RIC in only 3/36 childhood cancer survivors (8%) (1 patient with acute lymphoblastic leukemia [Zabramski type II] and 2 patients with medulloblastoma [type I and type II]) as high risk for hemorrhage, the remaining RIC were classified as Zabramski type IV with low risk for hemorrhage. None of the childhood cancer survivors with RIC showed symptomatic hemorrhages. CONCLUSIONS RIC are common late effects in childhood cancer survivors treated with cranial radiotherapy affecting half of these patients. However, only a few RIC (occurring in 8% of all reviewed childhood cancer survivors) were classified as high risk for hemorrhage and none of the childhood cancer survivors with RIC developed symptomatic hemorrhages. Thus, we conclude that RIC are low-risk findings in brain MRI and the course is mainly benign.
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16
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Application of Near-Infrared Spectroscopy for the Detection of Delayed Cerebral Ischemia in Poor-Grade Subarachnoid Hemorrhage. Neurocrit Care 2021; 35:767-774. [PMID: 33963480 PMCID: PMC8104035 DOI: 10.1007/s12028-021-01223-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 02/23/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND The objective of this study was to investigate the clinical feasibility of near-infrared spectroscopy (NIRS) for the detection of delayed cerebral ischemia (DCI) in patients with poor-grade subarachnoid hemorrhage (SAH) treated with coil embolization. METHODS Cerebral regional oxygen saturation (rSO2) was continuously monitored via two-channel NIRS for 14 days following SAH. The rSO2 levels according to DCI were analyzed by using the Mann-Whitney U-test. A receiver operating characteristic curve was generated on the basis of changes in rSO2 by using the rSO2 level on day 1 as a reference value to determine the optimal cutoff value for identifying DCI. RESULTS Twenty-four patients with poor-grade SAH were included (DCI, n = 8 [33.3%]; non-DCI, n = 16 [66.7%]). The rSO2 levels of patients with DCI were significantly lowered from 6 to 9 days compared with those in without DCI. The rSO2 level was 62.55% (58.30-63.40%) on day 6 in patients with DCI versus 65.40% (60.90-68.70%) in those without DCI. By day 7, it was 60.40% (58.10-61.90%) in patients with DCI versus 64.25% (62.50-67.10%) those without DCI. By day 8, it was 58.90% (56.50-63.10%) in patients with DCI versus 66.05% (59.90-69.20%) in those without DCI, and by day 9, it was 60.85% (58.40-65.20%) in patients with DCI versus 65.80% (62.70-68.30%) in those without DCI. A decline of greater than 14.5% in the rSO2 rate yielded a sensitivity of 92.86% (95% confidence interval: 66.1-99.8%) and a specificity of 88.24% (95% confidence interval: 72.5-96.7%) for identifying DCI. A decrease by more than 14.7% of the rSO2 level indicates a sensitivity of 85.7% and a specificity of 85.7% for identifying DCI. CONCLUSIONS Near-infrared spectroscopy shows some promising results for the detection of DCI in patients with poor-grade SAH. Further studies involving a large cohort of the SAH population are required to confirm our results.
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Dammann P, Saban DV, Herten A, Chen B, Zhu Y, Santos A, Rauschenbach L, Wrede K, Jabbarli R, Schmidt B, Jöckel KH, Kleinschnitz C, Forsting M, Sure U. Cerebral cavernous malformations: Prevalence of cardiovascular comorbidities and allergic diseases compared to the normal population. Eur J Neurol 2021; 28:2000-2005. [PMID: 33738912 DOI: 10.1111/ene.14833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND To determine the prevalence of cardiovascular comorbidities and allergic diseases in patients with cavernous malformations of the central nervous system compared to the normal population. METHODS Clinical and magnetic resonance imaging data of 1352 patients with cerebral cavernous malformations (CCM) from an observational, cross-sectional, single-institutional study were analyzed and compared to an age-and-gender stratified and matched sample from a population-based, epidemiological study assessing cardiovascular risk factors in the local normal population of the same area (RECALL study). RESULTS Of 1352 patients, 810 (60%) were female. Mean age was 40.4 ± 16 years. 221 patients (16%) suffered from familial disease. Presence of cardiovascular risk factors and intake of certain drugs in the overall cohort was mostly equal to the normal population reference sample (n = 786). The prevalence of allergic diseases was found to be significantly higher in all CCM patients compared to the normal population (30% vs. 20%, odds ratio [OR] 1.35 [1.12-1.63]) and in sporadic CCM cases compared to the normal population and familial cases (32% vs. 20% (OR 1.46 [1.19-1.78], p = 0.0001) and 22% vs. 20%, respectively). CONCLUSIONS We present novel data on CCM using a large single-institution and population-based setup. The study elaborates disease characteristics of CCM patients in detail. For the first time, evidence for an unexplained high prevalence of allergic diseases in this patient population is described (differing between sporadic and familial cases), supporting the hypothesis that immune response is involved in the pathogenesis of CCM.
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Affiliation(s)
- Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Dino Vitali Saban
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Yuan Zhu
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Alejandro Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Karsten Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | | | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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Rhim JK, Youn DH, Kim BJ, Kim Y, Kim S, Kim HC, Jeon JP. The Role of Consecutive Plasma Copeptin Levels in the Screening of Delayed Cerebral Ischemia in Poor-Grade Subarachnoid Hemorrhage. Life (Basel) 2021; 11:life11040274. [PMID: 33806226 PMCID: PMC8066417 DOI: 10.3390/life11040274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
The prognostic value of copeptin in subarachnoid hemorrhage (SAH) has been reported, but the prognosis was largely affected by the initial clinical severity. Thus, the previous studies are not very useful in predicting delayed cerebral ischemia (DCI) in poor-grade SAH patients. Here, we first investigated the feasibility of predicting DCI in poor-grade SAH based on consecutive measurements of plasma copeptin. We measured copeptin levels of 86 patients on days 1, 3, 5, 7, 9, 11, and 13 using ELISA. The primary outcome was the association between consecutive copeptin levels and DCI development. The secondary outcomes were comparison of copeptin with C-reactive protein (CRP) in predicting DCI. Additionally, we compared the prognostic value of transcranial Doppler ultrasonography (TCD) with copeptin using TCD alone to predict DCI. Increased copeptin (OR = 1.022, 95% CI: 1.008–1.037) and modified Fisher scale IV (OR = 2.841; 95% CI: 0.998–8.084) were closely related to DCI. Consecutive plasma copeptin measurements showed significant differences between DCI and non-DCI groups (p < 0.001). Higher CRP and DCI appeared to show a correlation, but it was not statistically significant. Analysis of copeptin changes with TCD appeared to predict DCI better than TCD alone with AUCROC differences of 0.072. Consecutive measurements of plasma copeptin levels facilitate the screening of DCI in poor-grade SAH patients.
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Affiliation(s)
- Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju 63243, Korea;
| | - Dong Hyuk Youn
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon 24252, Korea; (D.H.Y.); (B.J.K.); (Y.K.)
| | - Bong Jun Kim
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon 24252, Korea; (D.H.Y.); (B.J.K.); (Y.K.)
| | - Youngmi Kim
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon 24252, Korea; (D.H.Y.); (B.J.K.); (Y.K.)
| | - Sungeun Kim
- EMS Situation Management Center, Seoul Emergency Operation Center, Seoul Metropolitan Fire & Disaster Headquarters, Seoul 04628, Korea;
| | - Heung Cheol Kim
- Department of Radioilogy, Hallym University College of Medicine, Chuncheon 24252, Korea;
| | - Jin Pyeong Jeon
- Genetic and Research Inc., Chuncheon 24252, Korea
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon 24252, Korea
- Correspondence: ; Tel.: +82-33-240-5171; Fax: +82-33-240-9970
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Li D, Zheng JJ, Weng JC, Liu PP, Wu ZY, Zhang LW, Zhang JT, Wang L, Wu Z. Neurological outcomes of untreated brainstem cavernous malformations in a prospective observational cohort and literature review. Stroke Vasc Neurol 2021; 6:501-510. [PMID: 33737399 PMCID: PMC8717781 DOI: 10.1136/svn-2020-000608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Haemorrhages of brainstem cavernous malformations (CMs) can lead to neurological deficits, the natural history of which is uncertain. The study aimed to evaluate the neurological outcomes of untreated brainstem CMs and to identify the adverse factors associated with worsened outcomes. Methods From 2009 to 2015, 698 patients (321 women) with brainstem CMs were entered into the prospective cohort after excluding patients lost to follow-up (n=43). All patients were registered, clinical data were collected and scheduled follow-up was performed. Results After a median follow-up of 60.9 months, prospective haemorrhages occurred in 167 patients (23.9%). The mean modified Rankin Scale scores at enrolment and at censoring time were 1.6 and 1.2. Neurological status was improved, unchanged and worsened in 334 (47.9%), 293 (42.0%) and 71 (10.2%) patients, respectively; 233 (33.4%) recovered to normal levels. Lesions crossing the axial midpoint (relative risk (RR) 2.325, p=0.003) and developmental venous anomaly (DVA) (RR 1.776, p=0.036) were independently significantly related to worsened outcomes. The percentage of worsened outcomes was 5.3% (18 of 337) in low-risk patients (neither DVA nor crossing the axial point) and increased to 26.0% (13 of 50) in high-risk patients (with both DVA and crossing the axial point). The percentage of worsened outcomes significantly increased as the number of prospective haemorrhages increased (from 1.5% (8 of 531, if 0 prospective ictus) to 37.5% (48 of 128, if 1 ictus) and 38.5% (15 of 39, if >1 ictus)). Conclusions The neurological outcomes of untreated brainstem CMs were improved/unchanged in majority of patients (89.8%) with a fatality rate of 1.7% in our cohort, which seemed to be favourable. Radiological features significantly predicted worsened outcomes. Our results provide evidence for clinical consultation and individualised treatment. The referral bias of our cohort was underlined.
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Affiliation(s)
- Da Li
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing-Jie Zheng
- Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jian-Cong Weng
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pan-Pan Liu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ze-Yu Wu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Wei Zhang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun-Ting Zhang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Wang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Wu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Li D, Wu ZY, Liu PP, Ma JP, Huo XL, Wang L, Zhang LW, Wu Z, Zhang JT. Natural history of brainstem cavernous malformations: prospective hemorrhage rate and adverse factors in a consecutive prospective cohort. J Neurosurg 2021; 134:917-928. [DOI: 10.3171/2019.12.jns192856] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEGiven the paucity of data on the natural history of brainstem cavernous malformations (CMs), the authors aimed to evaluate the annual hemorrhage rate and hemorrhagic risk of brainstem CMs.METHODSNine hundred seventy-nine patients diagnosed with brainstem CMs were referred to Beijing Tiantan Hospital from 2006 to 2015; 224 patients were excluded according to exclusion criteria, and 47 patients were lost to follow-up. Thus, this prospective observational cohort included 708 cases (324 females). All patients were registered, clinical data were recorded, and follow-up was completed.RESULTSSix hundred ninety (97.5%) of the 708 patients had a prior hemorrhage, 514 (72.6%) had hemorrhagic presentation, and developmental venous anomaly (DVA) was observed in 241 cases (34.0%). Two hundred thirty-seven prospective hemorrhages occurred in 175 patients (24.7%) during 3400.2 total patient-years, yielding a prospective annual hemorrhage rate of 7.0% (95% CI 6.2%–7.9%), which decreased to 4.7% after the 1st year. Multivariate Cox regression analysis after adjusting for sex and age identified hemorrhagic presentation (HR 1.574, p = 0.022), DVA (HR 1.678, p = 0.001), mRS score ≥ 2 on admission (HR 1.379, p = 0.044), lesion size > 1.5 cm (HR 1.458, p = 0.026), crossing the axial midpoint (HR 1.446, p = 0.029), and superficially seated location (HR 1.307, p = 0.025) as independent adverse factors for prospective hemorrhage, but history of prior hemorrhage was not significant. The annual hemorrhage rates were 8.3% and 4.3% in patients with and without hemorrhagic presentation, respectively; the rate was 9.9%, 6.0%, and 1.0% in patients with ≥ 2, only 1, and 0 prior hemorrhages, respectively; and the rate was 9.2% in patients with both hemorrhagic presentation and focal neurological deficit on admission.CONCLUSIONSThe study reported an annual hemorrhage rate of 7.0% exclusively for brainstem CMs, which significantly increased if patients presented with both hemorrhagic presentation and focal neurological deficit (9.2%), or any other risk factor. Patients with a risk factor for hemorrhage needed close follow-up regardless of the number of prior hemorrhages. It should be noted that the referral bias in this study could have overestimated the annual hemorrhage rate. This study improved the understanding of the natural history of brainstem CMs, and the results are important for helping patients and physicians choose a suitable treatment option based on the risk factors and stratified annual rates.Clinical trial registration no.: ChiCTR-POC-17011575 (http://www.chictr.org.cn/).
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Affiliation(s)
- Da Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Ze-Yu Wu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Pan-Pan Liu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
- 2Department of Neurosurgery, The Municipal Hospital of Weihai, People’s Republic of China
| | - Jun-Peng Ma
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Xu-Lei Huo
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Liang Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Li-Wei Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Zhen Wu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Jun-Ting Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
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Chen B, Saban D, Rauscher S, Herten A, Rauschenbach L, Santos A, Li Y, Schmidt B, Zhu Y, Jabbarli R, Wrede KH, Kleinschnitz C, Sure U, Dammann P. Modifiable Cardiovascular Risk Factors in Patients With Sporadic Cerebral Cavernous Malformations: Obesity Matters. Stroke 2021; 52:1259-1264. [PMID: 33588600 DOI: 10.1161/strokeaha.120.031569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This study aims to assess the influence of modifiable cardiovascular risk factors on hemorrhage risk of sporadic cerebral cavernous malformations (CCMs). METHODS From 1219 consecutive CCM patients (2003-2018), adult subjects with sporadic CCM and complete magnetic resonance imaging were included. We evaluated presence of intracerebral hemorrhage (ICH) as mode of presentation, occurrence of ICH during follow-up and risk factors arterial hypertension, diabetes, hyperlipidemia, nicotine abuse, and obesity (body mass index >30 kg/m2). Impact of risk factors on ICH at presentation was calculated using univariate and multivariate logistic regression with age and sex adjustment. We performed Kaplan-Meier and Cox regression to analyze cumulative 5-year risk for (re)bleeding. RESULTS We included 682 patients with CCM. The univariate logistic regression showed a significant relationship (odds ratio=1.938 [95% CI, 1.120-3.353], P=0.018) between obesity and ICH as mode of presentation. Multivariate adjusted logistic regression confirmed significant correlation with odds ratio=1.902 (95% CI, 1.024-3.532, P=0.042). Cox regression did not identify predictors for occurrence of (re)hemorrhage (P>0.05; hazard ratios: arterial hypertension 1.112 [95% CI, 0.622-1.990], diabetes 0.850 [95% CI, 0.208-3.482], hyperlipidemia 0.719 [95% CI, 0.261-1.981], nicotine abuse 1.123 [95% CI, 0.591-2.134], and obesity 0.928 [95% CI, 0.416-2.070]). CONCLUSIONS This study provides evidence that obesity may be a risk factor for CCM hemorrhage. It was significantly associated with ICH as mode of presentation. Other risk factors (arterial hypertension, diabetes, hyperlipidemia, and current nicotine abuse) showed no such effect. None of the factors showed to be independent predictors for cumulative 5-year risk of (re)bleeding.
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Affiliation(s)
- Bixia Chen
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Steffen Rauscher
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Alejandro Santos
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology (Y.L.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Boerge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology (B.S.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Yuan Zhu
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology (C.K.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany
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Chen B, Herten A, Saban D, Rauscher S, Radbruch A, Schmidt B, Zhu Y, Jabbarli R, Wrede KH, Kleinschnitz C, Sure U, Dammann P. Hemorrhage from cerebral cavernous malformations. Neurology 2020; 95:e89-e96. [DOI: 10.1212/wnl.0000000000009730] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo determine the role of associated developmental venous anomalies (DVAs) in intracranial hemorrhage (ICH) caused by cerebral cavernous malformations (CCMs).MethodsWe analyzed patient registry data of 1,219 patients with cavernous malformations treated in our institution between 2003 and 2018. Patients with spinal and familial CCM and patients without complete MRI data were excluded. The impact of various variables on ICH as a mode of presentation was assessed with multivariate binary logistic regression analysis. Kaplan Meier/Cox regression analysis was performed to analyze cumulative 5-year-risk for (re)hemorrhage and to identify baseline predictors of this outcome.ResultsSeven hundred thirty-one patients with CCM were included. Multivariate logistic regression confirmed a statistically significant negative correlation with DVA (odds ratio [OR] 0.635 [95% confidence interval (CI) 0.459–0.878]) and positive correlation with brainstem localization (OR 6.277 [95% CI 4.287–9.191]) with ICH as the mode of presentation. Among 731 patients, 76 experienced (re)hemorrhage during 2,338 person-years of follow-up. Overall cumulative 5-year risk was 24.1% (95% CI 21.1%–27.5%). Cox regression analysis revealed initial presentation with ICH (hazard ratio [HR] 8.0 [95% CI 3.549–18.122]) and brainstem localization (HR 2.9 [95% CI 1.756–4.765]) as independent baseline predictors of (re)hemorrhage. Presence of DVA added no independent prognostic information (HR 1.1 [95% CI 0.717–1.885]).ConclusionPatients with CCM with associated DVA are at lower risk to present with ICH. During untreated 5-year follow-up, they showed equal (re)hemorrhage risk compared to patients with CCM without DVA.
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Zheng JJ, Liu PP, Wang L, Zhang LW, Zhang JT, Li D, Wu Z, Wu YM. Natural history of incidentally diagnosed brainstem cavernous malformations in a prospective observational cohort. Neurosurg Rev 2020; 44:1151-1164. [PMID: 32399728 DOI: 10.1007/s10143-020-01308-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/21/2020] [Accepted: 04/26/2020] [Indexed: 12/18/2022]
Abstract
There was a lack of natural history of incidental brainstem cavernous malformations (CMs), hemorrhage of which would lead to severe neuropathies. The study aimed to evaluate the prospective hemorrhage rate and neurological outcome of the disease. This prospective cohort included patients with incidental brainstem CMs referred to our institute from 2009 to 2015. The diagnosis was confirmed based on the patients' complain, physical examination, and radiographic evidence. Clinical data were collected, scheduled follow-up was performed, and the independent risk factors were identified by multivariate analysis. This cohort included 48 patients (22 female, 45.8%). The median follow-up duration was 60.7 months, and 13 prospective hemorrhages occurred within 244.0 patient-years yielding an annual hemorrhage rate of 5.3%. The hemorrhage-free survival at 1 and 5 years was 91.6% and 80.6%. Age ≥ 55 years (hazard ratio (HR) = 8.59, p = 0.003), lesion size (per 1-mm increase) (HR = 3.55, p = 0.041), developmental venous anomaly (HR = 10.28, p = 0.017), and perilesional edema (HR = 4.90, p = 0.043) were independent risk factors for hemorrhage. Seven patients (14.6%) received surgical resection, and the other 41 patients remained under observation. Neurological function was improved in 22 patients (45.8%), unchanged in 19 (39.6%), and worsened in 7 (14.6%). Prospective hemorrhage (odds ratio = 14.95, p = 0.037) was the only independent risk factor for worsened outcomes. The natural history of incidental brainstem CMs seemed to be acceptable with improved/unchanged outcomes in most patients (85.4%). These results improved our understanding of the disease, and the future study of a large cohort was required to verify our findings.
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Affiliation(s)
- Jing-Jie Zheng
- Department of Gynecologic Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Pan-Pan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
- Department of Neurosurgery, The Municipal Hospital of Weihai, No. 70 Heping Road, Huancui District, Weihai, People's Republic of China
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China.
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China.
| | - Yu-Mei Wu
- Department of Gynecologic Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China.
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Role of aspirin and statin therapy in patients with cerebral cavernous malformations. J Clin Neurosci 2020; 78:246-251. [PMID: 32340842 DOI: 10.1016/j.jocn.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/14/2020] [Accepted: 04/05/2020] [Indexed: 12/23/2022]
Abstract
Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.
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Hartley BR, Birnbaum C, Hoffman CE. Cavernous malformation hemorrhage due to trans-mural pressure alterations after cerebrospinal fluid diversion: a case report. BMC Neurol 2020; 20:131. [PMID: 32284039 PMCID: PMC7153234 DOI: 10.1186/s12883-020-01714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/01/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cavernous malformations are rare cerebral pseudo-vascular lesions with annualized bleeding rates of 0.5-3% in most studies. Of the various explored risk factors for bleeding to date, only prior hemorrhage has shown significant correlation. CASE PRESENTATION In this case, we describe a 65-year old man with a peri-ventricular atrial cavernous malformation that hemorrhaged after CSF diversion via ventriculoperitoneal shunting. Serial imaging showed that bleeding continued until the shunt was revised with a programmable valve set at maximum resistance with the addition of a gravitational unit, thereby lowering the trans-mural pressure differential across the cavernous malformation. CONCLUSIONS Given that other vascular lesions are subject to hemorrhage from alterations in trans-mural pressure dynamics, we hypothesize that cavernous malformations are similarly affected by trans-mural pressure gradients as they are composed of primitive vascular elements. This hypothesis is corroborated by the temporal correlation of interventions, imaging, and exam findings in the present case, and suggests a potentially important risk factor for hemorrhage in CM patients that affects prognostication and management.
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Affiliation(s)
- Benjamin R. Hartley
- Department of Neurosurgery, Weill-Cornell College of Medicine/New York Presbyterian Hospital, 525 East 68th Street, Box, New York, NY 99 USA
| | | | - Caitlin E. Hoffman
- Department of Neurosurgery, Weill-Cornell College of Medicine/New York Presbyterian Hospital, 525 East 68th Street, Box, New York, NY 99 USA
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Gomez-Paz S, Maragkos GA, Salem MM, Ascanio LC, Lee M, Enriquez-Marulanda A, Orrego-Gonzalez E, Kicielinski K, Moore JM, Ogilvy CS, Thomas AJ. Symptomatic Hemorrhage From Cerebral Cavernous Malformations: Evidence from a Cohort Study. World Neurosurg 2019; 135:e477-e487. [PMID: 31843731 DOI: 10.1016/j.wneu.2019.12.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Patients with a cerebral cavernous malformation (CCM) can have intracranial hemorrhages ranging from insignificant and chronic microbleeds to life-threatening hemorrhage. Management decisions and patient counseling are based on a heterogeneous body of evidence. We sought to improve the literature by providing our results based on the standardized definitions and aimed to delineate differences in the symptomatic burden for CCMs, based on their anatomic location and presence of developmental venous anomalies. This evidence will aid in clinical decision making and patient counseling. METHODS A retrospective cohort analysis between 1990 and 2018 was performed, including patients with a diagnosis of a CCM. The primary outcome was acute symptomatic hemorrhages. RESULTS We identified 438 patients harboring 632 CCMs. Mean age at diagnosis was 50 years (standard deviation ±17 years). Median follow-up was 26 months (interquartile range, 7-72 hours). Multiple lesions were encountered in 64 patients (15%). An initial symptomatic presentation was observed in 64% of the patients. There were 438 supratentorial lesions (69%) and 194 infratentorial lesions (31%). A symptomatic hemorrhage was observed in 25% of the supratentorial lesions and 29% of the infratentorial lesions (P < 0.001). A linear mixed-effects regression model showed a significant difference in developing a symptomatic hemorrhage at diagnosis or follow-up between CCMs with an infratentorial location and those with a supratentorial location (odds ratio, 1.81; 95% confidence interval, 1.17-2.81; P = 0.008). CONCLUSIONS Infratentorial cavernous malformations are more likely to present with symptomatic hemorrhages at diagnosis or during follow-up when accounting for size differences between lesions.
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Affiliation(s)
- Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Luis C Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Lee
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Eduardo Orrego-Gonzalez
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly Kicielinski
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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A rupture risk analysis of cerebral cavernous malformation associated with developmental venous anomaly using susceptibility-weighted imaging. Neuroradiology 2019; 62:39-47. [PMID: 31482190 DOI: 10.1007/s00234-019-02274-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To search for the risk factors closely related to cerebral cavernous malformation associated with developmental venous anomaly (CCM-DVA) lesions rupture, laying foundations for the development of reasonable individual treatment plans for patients. METHODS In this retrospective study, we collected CCM-DVA patients who met the inclusion criteria in our outpatient department from 2014 to 2017, MRI scans were performed including susceptibility-weighted imaging (SWI) and contrast-enhanced imaging, characteristics and basic clinical information were collected then statistically analyzed, CCM-DVA lesions were divided into 3 types according to the location and quantitative relationship between CCM and DVA. RESULTS A total number of 319 adult patients were identified with 41.2±11.9 years on average, though univariate and multivariate regression analysis, ruptured presentations were more common in patients with prior hemorrhage (p=0.003), type III CCM-DVA lesions (p=0.001), lesions volume>1 cm3 (p<0.001), infratentorial lesions especially located in midbrain (p=0.019), pontine (p=0.007), medulla (p=0.015). Caplan-Meier curve shows a lower Hemorrhage-free survival rate on patients with type III CCM-DVA lesions (log-rank, p=0.0222), functional area lesions (log-rank, p<0.001), lesions volume>1 cm3 (log-rank, p<0.001), infratentorial lesions (log-rank, p=0.0002). CONCLUSION The classification based on the relationship between CCM and DVA may be meaningful to predict the risk of lesion rupture and CCM lesions next to DVA distal branches showed a higher risk of rupture.
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Jacobs R, Kano H, Gross BA, Niranjan A, Monaco EA, Lunsford LD. Defining Long-Term Clinical Outcomes and Risks of Stereotactic Radiosurgery for Brainstem Cavernous Malformations. World Neurosurg 2018; 124:S1878-8750(18)32787-6. [PMID: 30529525 DOI: 10.1016/j.wneu.2018.11.226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND We evaluated clinical outcomes in patients with symptomatic brainstem cavernous malformations (CMs) treated by stereotactic radiosurgery (SRS). METHODS Between 1988 and 2016, Gamma Knife SRS was performed in 76 evaluable patients with solitary symptomatic brainstem CMs. Forty-nine (66%) were intrinsic (not reaching a pial or ependymal surface). Most patients (91%) had experienced 2 or more hemorrhages associated with new neurologic deficits. Fourteen patients (18%) underwent resection before radiosurgery. The median CM volume was 0.66 cm3 (range, 0.05-6.8), and the median margin dose was 15.0 Gy. RESULTS After SRS, 15 patients (20%) had an imaging confirmed new hemorrhage at a median follow-up of 48 months. The hemorrhage-free survival after SRS for brainstem CMs was 92% at 1 year, 87% at 3 years, and 85% at 5 years. The annual hemorrhage rate was 31% before and 4% after SRS. In univariate analysis, CM volume, previous surgical resection, and increased number of hemorrhages before SRS were significantly associated with a higher rate of hemorrhage after SRS. In multivariate analysis, only number of previous hemorrhages was significant (P < 0.0005; hazard ratio, 1.51, 95% confidence interval, 1.23-1.85). Symptomatic adverse radiation effects developed in 7 patients (9%). The rate of symptom deterioration related to hemorrhage or symptomatic adverse radiation effects was 10% at 1 year, 18% at 3 years, and 20% at 5 years. CONCLUSIONS Patients with an increased rate of hemorrhage before SRS had an increased risk of repeat hemorrhage and symptom deterioration rate after SRS. Intrinsic CM location did not significantly affect rates of symptom deterioration or rebleeding.
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Affiliation(s)
- Rachel Jacobs
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edward A Monaco
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Pichi F, Abboud EB, Sarraf D. Is the Association of Retinal Venous Malformations With Venous Malformations of the Brain Clinically Meaningful?-Reply. JAMA Ophthalmol 2018; 136:1425. [PMID: 30242351 DOI: 10.1001/jamaophthalmol.2018.4059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Francesco Pichi
- Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Emad B Abboud
- Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates
| | - David Sarraf
- Stein Eye Institute, University of California, Los Angeles.,Greater Los Angeles VA Healthcare Center, Los Angeles, California
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Nagy G, Burkitt W, Stokes SS, Bhattacharyya D, Yianni J, Rowe JG, Kemeny AA, Radatz MWR. Contemporary radiosurgery of cerebral cavernous malformations: Part 1. Treatment outcome for critically located hemorrhagic lesions. J Neurosurg 2018; 130:1817-1825. [PMID: 30052154 DOI: 10.3171/2017.5.jns17776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term benefits of radiosurgery (RS) applying modern protocols to treat cavernous malformations (CMs) remain unclear as critics may consider the decrease in the rebleed rate generally observed 2 years after RS as a reflection of the lesion's natural history. The authors adopted an early intention-to-treat attitude since rehemorrhage from deep-seated CMs ultimately leads to stepwise neurological deterioration. The safety of this early policy was previously demonstrated. Here, the authors revisit their current practice in a larger population with a longer follow-up time to assess the long-term effects of RS in the context of current knowledge on the natural history of CMs. METHODS The authors conducted a retrospective analysis of 210 patients with 210 hemorrhagic CMs located in the brainstem, thalamus, or basal ganglia and treated with Gamma Knife RS between 1995 and 2014. Two hundred six patients had available follow-up, which was a median of 5.5 years (range 1-20 years). The median age was 37 years (0.5-77 years) at presentation and 43 (2-78) at treatment. One hundred twenty-seven CMs had bled once and 83 had had multiple hemorrhages prior to treatment. RESULTS The lifetime annual bleed rate of CMs having a single hemorrhage prior to treatment was 2.4% per lesion. The hemorrhage rate stabilized at 1.1% after a temporary increase of 4.3% within the first 2 years after RS. The annual pretreatment hemorrhage rate was 2.8% for the lesions having multiple bleeds prior to RS with a pretreatment rebleed rate of 20.7% and with a modest gradual decrease within the first 5 years and remaining stable at 11.55% thereafter. The rebleed rate fell to 7.9% for the first 2 years after RS and declined further to 1.3% thereafter, which was significantly lower than the long-term pretreatment rebleed risk. The rate of hemorrhage-free survival remained 86.4% and 75.1% (1 patient each) at 20 years after RS in the single- and multiple-bleed groups, respectively.Pretreatment hemorrhages resulted in permanent deficits in 48.8% of the cases with a single bleed and in 77.1% of the cases with multiple bleeds. Both the rate and severity of deficits were significantly lower in the first group. Only mild and a low rate of permanent neurological deficits were caused either by posttreatment hemorrhages (7.4%) or by radiation (7.2%). The rate of persistent morbidity in the single-bleed group remained significantly lower at the end of the study than pretreatment morbidity in the multiple-bleed group (OR 2.9, 95% CI 1.6-5.3). Lesion-specific mortality was < 1%. CONCLUSIONS The hemorrhage rate of CMs after RS remained low after the first 2 years during the longer follow-up period. The benefit of early treatment appears to be confirmed by the study results as repeated hemorrhages carry the risk of significantly higher cumulative morbidity than the morbidity associated with RS.
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Affiliation(s)
- Gábor Nagy
- 1National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Wendy Burkitt
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
| | | | - Debapriya Bhattacharyya
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - John Yianni
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Jeremy G Rowe
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | | | - Matthias W R Radatz
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
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Kashefiolasl S, Bruder M, Brawanski N, Herrmann E, Seifert V, Tritt S, Konczalla J. A benchmark approach to hemorrhage risk management of cavernous malformations. Neurology 2018; 90:e856-e863. [DOI: 10.1212/wnl.0000000000005066] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/01/2017] [Indexed: 11/15/2022] Open
Abstract
ObjectiveDespite the low annual risk of hemorrhage associated with a cavernous malformation (CM) (0.6%–1.1% per year), the risk of rehemorrhage rate and severity of neurologic deficits is significantly higher; therefore, we aimed to evaluate the rupture risk of CMs depending on various factors.MethodsWe retrospectively analyzed medical records of all patients with CM admitted to our institution between 1999 and April 2016. Cavernoma volume, location of the lesion, existence of a developmental venous anomaly (DVA), number of cavernomas, and patient characteristics (sex, age, hypertension, and antithrombotic therapy) were assessed.ResultsOne hundred fifty-four patients with CM were included; 89 (58%) ruptured CMs were identified. In statistical univariable analysis, the existence of a DVA was significantly higher in the ruptured cavernoma group (p < 0.001; odds ratio [OR] 4.6). A multivariable analysis of all included independent risk factors designated young age (<45 years) (p < 0.05; OR 2.2), infratentorial location (p < 0.01; OR 2.9), and existence of a DVA (p < 0.0001; OR 4.7) with significantly higher risk of rupture in our patient cohort. A separate analysis of these anatomical locations, supratentorial vs infratentorial, indicated that the existence of a DVA (p < 0.01; OR 4.16) in ruptured supratentorial cases and CM volume (≥1 cm3) (p < 0.0001; OR 3.5) in ruptured infratentorial cases were significant independent predictors for hemorrhage.ConclusionsYoung age (<45 years), infratentorial location, and the presence of a DVA are associated with a higher hemorrhage risk. CM volume (≥1 cm3) and the existence of a DVA were independently in accordance with the anatomical location high risk factors for CM rupture.
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Lahti AM, Saloheimo P, Huhtakangas J, Salminen H, Juvela S, Bode MK, Hillbom M, Tetri S. Poststroke epilepsy in long-term survivors of primary intracerebral hemorrhage. Neurology 2017; 88:2169-2175. [PMID: 28476758 DOI: 10.1212/wnl.0000000000004009] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/20/2017] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To identify the incidence and predisposing factors for development of poststroke epilepsy (PSE) after primary intracerebral hemorrhage (PICH) during a long-term follow-up. METHODS We performed a retrospective study of patients who had had their first-ever PICH between January 1993 and January 2008 in Northern Ostrobothnia, Finland, and who survived for at least 3 months. These patients were followed up for PSE. The associations between PSE occurrence and sex, age, Glasgow Coma Scale (GCS) score on admission, hematoma location and volume, early seizures, and other possible risk factors for PSE were assessed using the Cox proportional hazards regression model. RESULTS Of the 615 PICH patients who survived for longer than 3 months, 83 (13.5%) developed PSE. The risk of new-onset PSE was highest during the first year after PICH with cumulative incidence of 6.8%. In univariable analysis, the risk factors for PSE were early seizures, subcortical hematoma location, larger hematoma volume, hematoma evacuation, and a lower GCS score on admission, whereas patients with infratentorial hematoma location or hypertension were less likely to develop PSE (all variables p < 0.05). In multivariable analysis, we found subcortical location (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.35-3.81, p < 0.01) and early seizures (HR 3.63, 95% CI 1.99-6.64, p < 0.01) to be independent risk factors, but patients with hypertension had a lower risk of PSE (HR 0.54, 0.35-0.84, p < 0.01). CONCLUSIONS Subcortical hematoma location and early seizures increased the risk of PSE after PICH in long-term survivors, while hypertension seemed to reduce the risk.
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Affiliation(s)
- Anna-Maija Lahti
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland.
| | - Pertti Saloheimo
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Juha Huhtakangas
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Henrik Salminen
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Seppo Juvela
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Michaela K Bode
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Matti Hillbom
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland
| | - Sami Tetri
- From the Departments of Neurosurgery (A.-M.L., H.S., S.T.), Neurology (P.S., J.H., M.H.), and Diagnostic Radiology (M.K.B.), Oulu University Hospital; and Department of Clinical Neurosciences (S.J.), University of Helsinki, Finland.
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Gross BA, Du R. Hemorrhage from cerebral cavernous malformations: a systematic pooled analysis. J Neurosurg 2017; 126:1079-1087. [DOI: 10.3171/2016.3.jns152419] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The aim of this paper is to define an overall cavernous malformation (CM) hemorrhage rate and risk factors for hemorrhage.
METHODS
The authors performed a systematic, pooled analysis via the PubMed database through October 2015 using the terms “cavernoma,” “cavernous malformation,” “natural history,” “bleeding,” and “hemorrhage.” English-language studies providing annual rates and/or risk factors for CM hemorrhage were included. Data extraction, performed independently by the authors, included demographic data, hemorrhage rates, and hemorrhage risk factors.
RESULTS
Across 12 natural history studies with 1610 patients, the mean age at presentation was 42.7 years old and 52% of patients (95% CI 49%–55%) were female. Presentation modality was seizure in 30% (95% CI 25%–35%), hemorrhage in 26% (95% CI 17%–37%), incidental in 17% (95% CI 9%–31%), and focal deficits only in 16% of cases (95% CI 11%–23%). CM location was lobar in 66% (95% CI 61%–70%), brainstem in 18% (95% CI 13%–24%), deep supratentorial in 8% (95% CI 6%–10%), and cerebellar in 8% (95% CI 5%–11%). Pooling 7 studies that did not assume CM presence since birth, the annual hemorrhage rate was 2.5% per patient-year over 5081.2 patient-years of follow-up (95% CI 1.3%–5.1%). Pooling hazard ratios across 5 studies that evaluated hemorrhage risk factors, prior CM hemorrhage was a significant risk factor for hemorrhage (HR 3.73, 95% CI 1.26–11.1; p = 0.02) while younger age, female sex, deep location, size, multiplicity, and associated developmental venous anomalies (DVAs) were not.
CONCLUSIONS
Although limited by the heterogeneity of incorporated reports and selection bias, this study found prior hemorrhage to be a significant risk factor for CM bleeding, while age, sex, CM location, size, multiplicity, and associated DVAs were not. Future natural history studies should compound annual hemorrhage rate with prospective seizure and nonhemorrhagic neurological deficit rates.
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Affiliation(s)
- Bradley A. Gross
- 1Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Rose Du
- 2Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Yang C, Nicholas VHL, Zhao J, Wu B, Zhong H, Li Y, Xu Y. A Novel CCM1/KRIT1 Heterozygous Nonsense Mutation (c.1864C>T) Associated with Familial Cerebral Cavernous Malformation: a Genetic Insight from an 8-Year Continuous Observational Study. J Mol Neurosci 2017; 61:511-523. [PMID: 28255959 DOI: 10.1007/s12031-017-0893-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
Abstract
Cerebral cavernous malformation (CCM) is a congenital vascular abnormality that predominantly affects the central nervous system, but that sometimes encroaches other vital tissues, including the retina, skin, and even liver. The familial form of CCM (FCCM) is considered to be an autosomal dominant disease with incomplete penetrance and variable expression, which is often attributed to mutations in three genes: CCM1, CCM2, and CCM3. We screened a Chinese family diagnosed with FCCM by using Sanger sequencing. A 29-year-old male proband with cutaneous angiomas was pathologically diagnosed but presented with an atypical form of CCM as revealed by magnetic resonance imaging (MRI) findings, prompting further clinical evaluation and genetic analyses of him and his immediate family. We performed continuous observation over an 8-year period using MRI gradient echo imaging and susceptibility-weighted imaging of these individuals. Sanger sequencing of the CCM1, CCM2, and CCM3 genes identified a novel heterozygous nonsense nucleotide transition (c.1864C>T; p.Gln622X) in exon 17 of the CCM1/KRIT1 gene; this mutation was predicted to cause a premature stop codon (TAG) at nucleotides 1864 to 1866 to generate a truncated Krev interaction trapped 1 (Krit1) protein of 621 amino acids. During this long-term observational study, one of the enrolled family members with neurological deficits progressed to a stage indicative of brain surgery. This study provides a new CCM gene mutation profile, which highlights the significance of genetic counseling for individuals suspected of having this condition.
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Affiliation(s)
- Chenlong Yang
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, 100050, China
| | - Van Halm-Lutterodt Nicholas
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, 100050, China
| | - Jizong Zhao
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, 100050, China
| | - Bingquan Wu
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Haohao Zhong
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Yan Li
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Yulun Xu
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, 100050, China.
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Bulwa ZB, Ward GC, Kramer ON, Rao B, Wichter M. Rapidly Sequential and Fatal Hemorrhaging in a Case of Cerebral Amyloid Angiopathy. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:860-863. [PMID: 27853131 PMCID: PMC5115614 DOI: 10.12659/ajcr.900498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 08/24/2016] [Indexed: 12/04/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is an increasingly recognized cause of lobar intracerebral hemorrhage (ICH) and cognitive impairment in the aging population. Magnetic resonance imaging (MRI) of cerebral microbleeds is the most reliable option for clinical diagnosis of suspected CAA. The pathophysiology of microbleeds and ICH in CAA is not well understood, but it is thought to be the result of vessel weakening and rupture secondary to amyloid deposition. Little evidence has been established pertaining to the time course of recurrent CAA-related microbleeds or larger hemorrhages. Although several risk factors have been associated with an increased risk of ICH in CAA, there are no current treatment guidelines for recurrent hemorrhaging in CAA. CASE REPORT We present a rare case of rapidly sequential and fatal lobar hemorrhaging in the setting of suspected CAA, diagnosed by numerous microbleeds on MRI, compounded by the use of subcutaneous heparin in a 63-year-old female patient. CONCLUSIONS This case broadens our understanding of a rarely identified progression of CAA and illustrates the need for further investigation of the use of subcutaneous heparin in the setting of probable CAA.
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Affiliation(s)
- Zachary B. Bulwa
- Department of Internal Medicine, University of Chicago – NorthShore University Health System, Evanston, IL, U.S.A
| | - G. Carter Ward
- Department of Family Medicine, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - Owen N. Kramer
- Department of Neurology, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Birju Rao
- Department of Neurology, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Melvin Wichter
- Department of Neurology, Advocate Christ Medical Center, Oak Lawn, IL, U.S.A
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Tian KB, Zheng JJ, Ma JP, Hao SY, Wang L, Zhang LW, Wu Z, Zhang JT, Li D. Clinical course of untreated thalamic cavernous malformations: hemorrhage risk and neurological outcomes. J Neurosurg 2016; 127:480-491. [PMID: 27834594 DOI: 10.3171/2016.8.jns16934] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The natural history of cerebral cavernous malformations (CMs) has been widely studied, but the clinical course of untreated thalamic CMs is largely unknown. Hemorrhage of these lesions can be devastating. The authors undertook this study to obtain a prospective hemorrhage rate and provide a better understanding of the prognosis of untreated thalamic CMs. METHODS This longitudinal cohort study included patients with thalamic CMs who were diagnosed between 2000 and 2015. Clinical data were recorded, radiological studies were extensively reviewed, and follow-up evaluations were performed. RESULTS A total of 121 patients were included in the study (56.2% female), with a mean follow-up duration of 3.6 years. The overall annual hemorrhage rate (subsequent to the initial presentation) was calculated to be 9.7% based on the occurrence of 42 hemorrhages over 433.1 patient-years. This rate was highest in patients (n = 87) who initially presented with hemorrhage and focal neurological deficits (FNDs) (14.1%) (χ2 = 15.358, p < 0.001), followed by patients (n = 19) with hemorrhage but without FND (4.5%) and patients (n = 15) without hemorrhage regardless of symptoms (1.2%). The initial patient presentations of hemorrhage with FND (hazard ratio [HR] 2.767, 95% CI 1.336-5.731, p = 0.006) and associated developmental venous anomaly (DVA) (HR 2.510, 95% CI 1.275-4.942, p = 0.008) were identified as independent hemorrhage risk factors. The annual hemorrhage rate was significantly higher in patients with hemorrhagic pres entation at diagnosis (11.7%, p = 0.004) or DVA (15.7%, p = 0.002). Compared with the modified Rankin Scale (mRS) score at diagnosis (mean 2.2), the final mRS score (mean 2.0) was improved in 37 patients (30.6%), stable in 59 patients (48.8%), and worse in 25 patients (20.7%). Lesion size (odds ratio [OR] per 0.1 cm increase 3.410, 95% CI 1.272-9.146, p = 0.015) and mRS score at diagnosis (OR per 1 point increase 3.548, 95% CI 1.815-6.937, p < 0.001) were independent adverse risk factors for poor neurological outcome (mRS score ≥ 2). Patients experiencing hemorrhage after the initial ictus (OR per 1 ictus increase 6.923, 95% CI 3.023-15.855, p < 0.001) had a greater chance of worsened neurological status. CONCLUSIONS This study verified the adverse predictors for hemorrhage and functional outcomes of thalamic CMs and demonstrated an overall annual symptomatic hemorrhage rate of 9.7% after the initial presentation. These findings and the mode of initial presentation are useful for clinicians and patients when selecting an appropriate treatment, although the tertiary referral bias of the series should be taken into account.
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Affiliation(s)
- Kai-Bing Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Jing-Jie Zheng
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jun-Peng Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Shu-Yu Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
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Horne MA, Flemming KD, Su IC, Stapf C, Jeon JP, Li D, Maxwell SS, White P, Christianson TJ, Agid R, Cho WS, Oh CW, Wu Z, Zhang JT, Kim JE, Ter Brugge K, Willinsky R, Brown RD, Murray GD, Al-Shahi Salman R. Clinical course of untreated cerebral cavernous malformations: a meta-analysis of individual patient data. Lancet Neurol 2016; 15:166-173. [PMID: 26654287 PMCID: PMC4710581 DOI: 10.1016/s1474-4422(15)00303-8] [Citation(s) in RCA: 215] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/26/2015] [Accepted: 10/20/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) can cause symptomatic intracranial haemorrhage (ICH), but the estimated risks are imprecise and predictors remain uncertain. We aimed to obtain precise estimates and predictors of the risk of ICH during untreated follow-up in an individual patient data meta-analysis. METHODS We invited investigators of published cohorts of people aged at least 16 years, identified by a systematic review of Ovid MEDLINE and Embase from inception to April 30, 2015, to provide individual patient data on clinical course from CCM diagnosis until first CCM treatment or last available follow-up. We used survival analysis to estimate the 5-year risk of symptomatic ICH due to CCMs (primary outcome), multivariable Cox regression to identify baseline predictors of outcome, and random-effects models to pool estimates in a meta-analysis. FINDINGS Among 1620 people in seven cohorts from six studies, 204 experienced ICH during 5197 person-years of follow-up (Kaplan-Meier estimated 5-year risk 15·8%, 95% CI 13·7-17·9). The primary outcome of ICH within 5 years of CCM diagnosis was associated with clinical presentation with ICH or new focal neurological deficit (FND) without brain imaging evidence of recent haemorrhage versus other modes of presentation (hazard ratio 5·6, 95% CI 3·2-9·7) and with brainstem CCM location versus other locations (4·4, 2·3-8·6), but age, sex, and CCM multiplicity did not add independent prognostic information. The 5-year estimated risk of ICH during untreated follow-up was 3·8% (95% CI 2·1-5·5) for 718 people with non-brainstem CCM presenting without ICH or FND, 8·0% (0·1-15·9) for 80 people with brainstem CCM presenting without ICH or FND, 18·4% (13·3-23·5) for 327 people with non-brainstem CCM presenting with ICH or FND, and 30·8% (26·3-35·2) for 495 people with brainstem CCM presenting with ICH or FND. INTERPRETATION Mode of clinical presentation and CCM location are independently associated with ICH within 5 years of CCM diagnosis. These findings can inform decisions about CCM treatment. FUNDING UK Medical Research Council, Chief Scientist Office of the Scottish Government, and UK Stroke Association.
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Affiliation(s)
- Margaret A Horne
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - I-Chang Su
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Christian Stapf
- Département Hospitalo-Universitaire (DHU) NeuroVasc, Hôpital Lariboisière, Paris, France
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Susanne S Maxwell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle-upon-Tyne, UK
| | | | - Ronit Agid
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Karel Ter Brugge
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Robert Willinsky
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Gordon D Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Deng X, Xu L, Zhang Y, Wang B, Wang S, Zhao Y, Cao Y, Zhang D, Wang R, Ye X, Wu J, Zhao J. Difference of language cortex reorganization between cerebral arteriovenous malformations, cavernous malformations, and gliomas: a functional MRI study. Neurosurg Rev 2015; 39:241-9; discussion 249. [PMID: 26564149 DOI: 10.1007/s10143-015-0682-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 07/05/2015] [Accepted: 08/09/2015] [Indexed: 11/29/2022]
Abstract
The authors attempted to demonstrate the difference in language cortex reorganization between cerebral malformations (AVMs), cavernous malformations (CMs), and gliomas by blood oxygen level-dependent (BOLD) functional magnetic resonance imaging. Clinical and imaging data of 27 AVM patients (AVM-L group), 29 CM patients (CM-L group), and 20 glioma patients (Glioma-L group) were retrospectively reviewed, with lesions overlying the left inferior frontal gyrus (Broca area). As a control, patients with lesions involving the right inferior frontal gyrus were also enrolled, including 14 AVM patients (AVM-R group), 20 CM patients (CM-R group), and 14 glioma patients (Glioma-R group). All patients were right-handed. Lateralization indices (LI) of BOLD signal activations were calculated separately for Broca and Wernicke areas. In AVM-L group, right-sided lateralization of BOLD signals was observed in 10 patients (37.0%), including 6 in the Broca area alone, 1 in the Wernicke area alone, and 3 in both areas. Three patients (10.3%) of CM-L group showed right-sided lateralization in both Broca and Wernicke areas, and 1 patient (5.0%) of Glioma-L group had right-sided lateralization in the Wernicke area alone. A significant difference of right-sided lateralization was observed between the AVM-L group and CM-L group (P = 0.018) and also between the AVM-L group and Glioma-L group (P = 0.027). No patient in AVM-R, CM-R, or Glioma-R groups showed right-sided lateralization. Language cortex reorganization may occur in AVM, CM, and glioma patients when the traditional language cortex was involved by lesions, but the potential of reorganization for CM and glioma patients seems to be insufficient compared with AVM patients.
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Affiliation(s)
- Xiaofeng Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Bo Wang
- State Key Laboratory of Brain and Cognitive Science, Beijing MRI Center for Brain Research, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China. .,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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39
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Nikoubashman O, Di Rocco F, Davagnanam I, Mankad K, Zerah M, Wiesmann M. Prospective Hemorrhage Rates of Cerebral Cavernous Malformations in Children and Adolescents Based on MRI Appearance. AJNR Am J Neuroradiol 2015; 36:2177-83. [PMID: 26272978 DOI: 10.3174/ajnr.a4427] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 03/17/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Current classifications of cerebral cavernous malformations focus solely on morphologic aspects. Our aim was to provide a morphologic classification that reflects hemorrhage rates. MATERIALS AND METHODS We retrospectively categorized 355 cavernous malformations of 70 children and adolescents according to their morphologic appearance on MR imaging and calculated prospective hemorrhage rates on the basis of survival functions for 255 lesions in 25 patients with a radiologic observation period of >180 days. RESULTS Overall, there were 199 MR imaging examinations with 1558 distinct cavernous malformation observations during a cumulative observation period of 1094.2 lesion-years. The mean hemorrhage rate of all 355 cavernous malformations was 4.5% per lesion-year. According to Kaplan-Meier survival models, Zabramski type I and II cavernous malformations had a significantly higher hemorrhage rate than type III and IV lesions. The presence of acute or subacute blood-degradation products was the strongest indicator for an increased hemorrhage risk (P = .036, Cox regression): The mean annual hemorrhage rate and mean hemorrhage-free interval for cavernous malformations with and without signs of acute or subacute blood degradation products were 23.4% and 22.6 months and 3.4% and 27.9 months, respectively. Dot-sized cavernous malformations, visible in T2* and not or barely visible in T1WI and T2WI sequences, had a mean annual hemorrhage rate of 1.3% and a mean hemorrhage-free interval of 37.8 months. CONCLUSIONS It is possible to predict hemorrhage rates based on the Zabramski classification. Our findings imply a tripartite classification distinguishing lesions with and without acute or subacute blood degradation products and dot-sized cavernous malformations.
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Affiliation(s)
- O Nikoubashman
- From the Department of Neuroradiology (O.N., M.W.), University Hospital Aachen, Aachen, Germany Institute for Neuroscience and Medicine 4 (O.N.), Science Centre Jülich, Jülich, Germany
| | - F Di Rocco
- Service de Neurochirurgie Pédiatrique (F.D.R., M.Z.), Hôpital Necker-Enfants Malades, Paris, France
| | - I Davagnanam
- Department of Neuroradiology (I.D.), National Hospital for Neurology and Neurosurgery, London, UK Brain Repair & Rehabilitation Unit (I.D.), UCL Institute of Neurology, London, UK
| | - K Mankad
- Department of Paediatric Neuroradiology (K.M.), Great Ormond Street Hospital, London, UK
| | - M Zerah
- Service de Neurochirurgie Pédiatrique (F.D.R., M.Z.), Hôpital Necker-Enfants Malades, Paris, France
| | - M Wiesmann
- From the Department of Neuroradiology (O.N., M.W.), University Hospital Aachen, Aachen, Germany
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40
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Wu H, Yu T, Wang S, Zhao J, Zhao Y. Surgical Treatment of Cerebellar Cavernous Malformations: A Single-Center Experience with 58 Cases. World Neurosurg 2015; 84:1103-11. [PMID: 26070634 DOI: 10.1016/j.wneu.2015.05.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 05/25/2015] [Accepted: 05/28/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The goal of this study was to discuss the surgical indications, surgical approaches, and prognostic factors of cerebellar cavernous malformation (CM). METHODS We retrospectively reviewed the presentation, surgery, and outcome of 58 consecutive patients who underwent resection of cerebellar CMs between 2009 and 2013 in our center. RESULTS The study population consisted of 31 males and 27 females, mean age 39.9 years. Fifty-eight patients experienced 67 symptomatic hemorrhages. The median diameter of all lesions was 2.2 ± 0.9 cm (range, 0.8-4.8 cm). The locations were classified into 3 groups: group 1, cerebellar hemisphere (17 cases, 29.3%); group 2, vermis (18 cases, 31.0%); and group 3, cerebellar peduncle (23 cases, 39.7%). Complete resection was achieved in all patients without surgical mortality. Postoperatively, 11 patients developed new surgical complications, including facial paralysis in 6 patients, ataxia in 2 patients, dizziness in 2 patients, and decrease in facial sensation in 1 patient. The mean modified Rankin Scale (mRS) at final follow-up was significantly improved compared with the preoperative score (0.5 ± 0.5 vs. 1.4 ± 0.7, P = 0.035). The symptoms and neurologic deficits improved in most patients. The lesion location was the only factor that predicted a worse outcome, and the mRS was significantly lower in group 3 than groups 1 and group 2 (P = 0.019). CONCLUSIONS Patients with cerebellar CMs usually achieve favorable outcomes via surgery. Cerebellar peduncle CMs cause significantly more neurologic deficits than other locations. A reasonable surgical approach and meticulous manipulation are necessary to prevent impairment of neurologic function.
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Affiliation(s)
- Hongji Wu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; Department of Neurosurgery, Baoding No. 1 Central Hospital, Hebei, People's Republic of China
| | - Tao Yu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China.
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