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Berber T, Celik SE, Aksaray F, Yoney A, Harmanci K, Tambas M, Yılmaz BD, Numanoglu C, Yolcu A, Açan Hİ, Dinçer ST, Yıldırım BA. Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas. JOURNAL OF RADIATION RESEARCH 2023; 64:133-141. [PMID: 36208871 PMCID: PMC9855324 DOI: 10.1093/jrr/rrac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Indexed: 06/16/2023]
Abstract
In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.
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Affiliation(s)
- Tanju Berber
- Corresponding author. Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Kaptan Pasa, SSK Okmeydani Hst. No: 25, 34384 Sisli/Istanbul, Turkey. Tel: +905324111202;
| | - Suat Erol Celik
- Department of Neurosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ferdi Aksaray
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Adnan Yoney
- Department of Internal Medicine, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Kemal Harmanci
- Department of Radiology, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Makbule Tambas
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Binnur Dönmez Yılmaz
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Cakir Numanoglu
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ahmet Yolcu
- Department of Radiation Oncology, Namık Kemal University Medical Faculty of Medicine, Tekirdag, Turkey
| | - Hilal İrem Açan
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Selvi Tabak Dinçer
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Berna Akkuş Yıldırım
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
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Surgical Management of Cavernous Malformations and Venous Anomalies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Poorthuis MHF, Rinkel LA, Lammy S, Al-Shahi Salman R. Stereotactic radiosurgery for cerebral cavernous malformations: A systematic review. Neurology 2019; 93:e1971-e1979. [PMID: 31659093 DOI: 10.1212/wnl.0000000000008521] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/26/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The efficacy of stereotactic radiosurgery (SRS) for the treatment of cerebral cavernous malformations (CCMs) is uncertain, so we set out to quantify clinical outcomes after SRS for CCM and compare them to microsurgical excision or conservative management. METHODS We searched Ovid Medline and Ovid EMBASE from inception until June 1, 2018, for peer-reviewed publications describing clinical outcomes after SRS for ≥10 people with CCM in cohorts with or without a comparison group treated with neurosurgical excision or conservative management. Two reviewers independently extracted data from the included studies to quantify cohort characteristics and the incidence of the primary outcome (death attributable to CCM or its treatment) and secondary outcomes (incident nonfatal symptomatic intracerebral hemorrhage [ICH] and incident nonhemorrhagic persistent focal neurologic deficit [FND]). We assessed whether comparative studies showed a dramatic association (meaning the conventionally calculated probability comparing 2 differently managed patient groups from the same population was <0.01 with a rate ratio greater than 10). RESULTS We included 30 cohort studies involving a total of 1,576 patients undergoing SRS for CCM. Four nonrandomized studies compared SRS to other treatment strategies, but did not demonstrate dramatic associations. During a median follow-up of 48 (interquartile range 35-62) months after SRS, the annual incidences (95% confidence interval) of outcomes were death 0.18% (0.10-0.31), ICH 2.40% (2.05-2.80), FND 0.71% (0.53-0.96), and the composite of death, ICH, or FND 3.63% (3.17-4.16). Outcomes did not differ by CCM location or type of SRS. CONCLUSION After SRS for CCM, the annual incidences of death, ICH, and FND are <5% and seem comparable to outcomes without SRS. A randomized trial of SRS for CCM is needed.
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Affiliation(s)
- Michiel H F Poorthuis
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK
| | - Leon A Rinkel
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK
| | - Simon Lammy
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK
| | - Rustam Al-Shahi Salman
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK.
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Willie JT, Malcolm JG, Stern MA, Lowder LO, Neill SG, Cabaniss BT, Drane DL, Gross RE. Safety and effectiveness of stereotactic laser ablation for epileptogenic cerebral cavernous malformations. Epilepsia 2019; 60:220-232. [PMID: 30653657 PMCID: PMC6365175 DOI: 10.1111/epi.14634] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/08/2018] [Accepted: 12/09/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Magnetic resonance (MR) thermography-guided laser interstitial thermal therapy, or stereotactic laser ablation (SLA), is a minimally invasive alternative to open surgery for focal epilepsy caused by cerebral cavernous malformations (CCMs). We examined the safety and effectiveness of SLA of epileptogenic CCMs. METHODS We retrospectively analyzed 19 consecutive patients who presented with focal seizures associated with a CCM. Each patient underwent SLA of the CCM and adjacent cortex followed by standard clinical and imaging follow-up. RESULTS All but one patient had chronic medically refractory epilepsy (median duration 8 years, range 0.5-52 years). Lesions were located in the temporal (13), frontal (five), and parietal (one) lobes. CCMs induced magnetic susceptibility artifacts during thermometry, but perilesional cortex was easily visualized. Fourteen of 17 patients (82%) with >12 months of follow-up achieved Engel class I outcomes, of which 10 (59%) were Engel class IA. Two patients who were not seizure-free from SLA alone became so following intracranial electrode-guided open resection. Delayed postsurgical imaging validated CCM involution (median 83% volume reduction) and ablation of surrounding cortex. Histopathologic examination of one previously ablated CCM following open surgery confirmed obliteration. SLA caused no detectable hemorrhages. Two symptomatic neurologic deficits (visual and motor) were predictable, and neither was permanently disabling. SIGNIFICANCE In a consecutive retrospective series, MR thermography-guided SLA was an effective alternative to open surgery for epileptogenic CCM. The approach was free of hemorrhagic complications, and clinically significant neurologic deficits were predictable. SLA presents no barrier to subsequent open surgery when needed.
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Affiliation(s)
- Jon T. Willie
- Department of Neurological Surgery, Emory University School
of Medicine. Atlanta, GA
- Department of Neurology, Emory University School of
Medicine. Atlanta, GA
| | - James G. Malcolm
- Department of Neurological Surgery, Emory University School
of Medicine. Atlanta, GA
| | - Matthew A. Stern
- Medical Scientist Training Program, Emory University School
of Medicine. Atlanta, GA
| | - Lindsay O. Lowder
- Department of Pathology, Emory University School of
Medicine. Atlanta, GA
| | - Stewart G. Neill
- Department of Pathology, Emory University School of
Medicine. Atlanta, GA
| | - Brian T. Cabaniss
- Department of Neurology, Emory University School of
Medicine. Atlanta, GA
| | - Daniel L. Drane
- Department of Neurology, Emory University School of
Medicine. Atlanta, GA
- Department of Pediatrics, Emory University School of
Medicine. Atlanta, GA
- Department of Neurology, University of Washington School of
Medicine, Seattle, WA
| | - Robert E. Gross
- Department of Neurological Surgery, Emory University School
of Medicine. Atlanta, GA
- Department of Neurology, Emory University School of
Medicine. Atlanta, GA
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5
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Surgical Cavernous Malformations and Venous Anomalies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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McCracken DJ, Willie JT, Fernald BA, Saindane AM, Drane DL, Barrow DL, Gross RE. Magnetic Resonance Thermometry-Guided Stereotactic Laser Ablation of Cavernous Malformations in Drug-Resistant Epilepsy: Imaging and Clinical Results. Oper Neurosurg (Hagerstown) 2015; 12:39-48. [PMID: 27959970 DOI: 10.1227/neu.0000000000001033] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgery is indicated for cerebral cavernous malformations (CCM) that cause medically refractory epilepsy. Real-time magnetic resonance thermography (MRT)-guided stereotactic laser ablation (SLA) is a minimally invasive approach to treating focal brain lesions. SLA of CCM has not previously been described. OBJECTIVE To describe MRT-guided SLA, a novel approach to treating CCM-related epilepsy, with respect to feasibility, safety, imaging, and seizure control in 5 consecutive patients. METHODS Five patients with medically refractory epilepsy undergoing standard presurgical evaluation were found to have corresponding lesions fulfilling imaging characteristics of CCM and were prospectively enrolled. Each underwent stereotactic placement of a saline-cooled cannula containing an optical fiber to deliver 980-nm diode laser energy via twist drill craniostomy. MR anatomic imaging was used to evaluate targeting prior to ablation. MR imaging provided evaluation of targeting and near real-time feedback regarding extent of tissue thermocoagulation. Patients maintained seizure diaries, and remote imaging (6-21 months post-ablation) was obtained in all patients. RESULTS Imaging revealed no evidence of acute hemorrhage following fiber placement within presumed CCM. MRT during treatment and immediate post-procedure imaging confirmed desired extent of ablation. We identified no adverse events or neurological deficits. Four of 5 (80%) patients achieved freedom from disabling seizures after SLA alone (Engel class 1 outcome), with follow-up ranging 12-28 months. Reimaging of all subjects (6-21 months) indicated lesion diminution with surrounding liquefactive necrosis, consistent with the surgical goal of extended lesionotomy. CONCLUSION Minimally invasive MRT-guided SLA of epileptogenic CCM is a potentially safe and effective alternative to open resection. Additional experience and longer follow-up are needed.
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Affiliation(s)
- D Jay McCracken
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jon T Willie
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.,Interventional MRI Program, Emory University Hospital, Atlanta, Georgia
| | | | - Amit M Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Daniel L Drane
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.,Interventional MRI Program, Emory University Hospital, Atlanta, Georgia.,Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
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Rosenow F, Alonso-Vanegas MA, Baumgartner C, Blümcke I, Carreño M, Gizewski ER, Hamer HM, Knake S, Kahane P, Lüders HO, Mathern GW, Menzler K, Miller J, Otsuki T, Özkara C, Pitkänen A, Roper SN, Sakamoto AC, Sure U, Walker MC, Steinhoff BJ. Cavernoma-related epilepsy: Review and recommendations for management-Report of the Surgical Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2013; 54:2025-35. [DOI: 10.1111/epi.12402] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Felix Rosenow
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Mario A. Alonso-Vanegas
- ABC Neurological Center & National Institute of Neurology and Neurosurgery; México City Mexico
| | - Christoph Baumgartner
- Second Neurological Department; Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology; General Hospital Hietzing with Neurological Center Rosenhügel; Vienna Austria
| | - Ingmar Blümcke
- Department of Neuropathology; University Hospitals Erlangen; Friedrich-Alexander University Erlangen-Nuremberg; Erlangen Germany
| | - Maria Carreño
- Neurology Service; Epilepsy Unit; Hospital Clinic of Barcelona; Barcelona Spain
| | - Elke R. Gizewski
- Department of Radiology; University Clinic for Neuroradiology; Medical University Innsbruck; Innsbruck Austria
| | - Hajo M. Hamer
- Department of Neurology; Epilepsy Center Erlangen; University Hospitals Erlangen; Friedrich-Alexander University Erlangen-Nuremberg; Erlangen Germany
| | - Susanne Knake
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Philippe Kahane
- Department of Neurology and GIN INSERM U836-UJF-CEA; University Hospital of Grenoble; Grenoble France
| | - Hans O. Lüders
- Department of Neurosurgery; Epilepsy Center; University Hospitals Case Medical Center/Case Western Reserve University; Cleveland Ohio U.S.A
| | - Gary W. Mathern
- Departments of Neurosurgery and Psychiatry & BioBehavioral Medicine; David Geffen School of Medicine; Mattel Children's Hospital; University of California; Los Angeles California U.S.A
| | - Katja Menzler
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Jonathan Miller
- Department of Neurosurgery; University Hospitals Case Medical Center/Case Western Reserve University; Cleveland Ohio U.S.A
| | - Taisuke Otsuki
- Epilepsy Center; National Center of Neurology and Psychiatry; Tokyo Japan
| | - Cigdem Özkara
- Cerrahpasa Medical Faculty; Istanbul University; Istanbul Turkey
| | - Asla Pitkänen
- A. I. Virtanen Institute for Molecular Sciences; University of Eastern Finland (UEF); Kuopio Finland
- Department of Neurology; Kuopio University Hospital; Kuopio Finland
| | - Steven N. Roper
- Department of Neurosurgery; University of Florida; Gainesville Florida U.S.A
| | - Americo C. Sakamoto
- Department of Neurosciences and Behavioral Science; Ribeirão Preto School of Medicine; University of São Paulo; São Paulo Brazil
| | - Ulrich Sure
- Department of Neurosurgery; University Hospital Essen; University of Duisburg-Essen; Essen Germany
| | - Matthew C. Walker
- Department of Clinical and Experimental Epilepsy; UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery; London United Kingdom
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von der Brelie C, Malter MP, Niehusmann P, Elger CE, von Lehe M, Schramm J. Surgical management and long-term seizure outcome after epilepsy surgery for different types of epilepsy associated with cerebral cavernous malformations. Epilepsia 2013; 54:1699-706. [DOI: 10.1111/epi.12327] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Michael P. Malter
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - Pitt Niehusmann
- Department of Neuropathology; University of Bonn Medical Centre; Bonn Germany
| | - Christian E. Elger
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - Marec von Lehe
- Department of Neurosurgery; University of Bonn Medical Centre; Bonn Germany
| | - Johannes Schramm
- Department of Neurosurgery; University of Bonn Medical Centre; Bonn Germany
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Abstract
Despite increasing worldwide experience, the role of stereotactic radiosurgery (SRS) in the management of cerebral cavernous malformations (CMs) remains controversial. Microsurgical excision of easily accessible CMs is typically safe; therefore, removal remains the gold standard for most of the symptomatic hemispheric lesions. However, there is now sufficient evidence supporting the use of SRS for the difficult cases. Waiting for the cumulative morbidity of the natural history to justify intervention does not serve the patient's interest, therefore, we argue for early radiosurgical intervention. Carefully designed randomized controlled trials might resolve controversies concerning the role of SRS in treating cerebral CMs.
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Poorthuis M, Samarasekera N, Kontoh K, Stuart I, Cope B, Kitchen N, Al-Shahi Salman R. Comparative studies of the diagnosis and treatment of cerebral cavernous malformations in adults: systematic review. Acta Neurochir (Wien) 2013; 155:643-9. [PMID: 23371401 DOI: 10.1007/s00701-013-1621-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 01/10/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebral cavernous malformation (CCM) management decisions are usually made after CCM diagnosis is suspected or definitively diagnosed on axial imaging by indirectly comparing a surgeon's estimate of operative morbidity and mortality against published estimates of CCM untreated clinical course. METHODS We used comprehensive electronic strategies to search OVID Medline and EMBASE for original studies published before 2011 of ≥20 adults with CCM that (a) evaluated diagnostic test accuracy, or (b) compared treatment with microsurgery or stereotactic radiosurgery against conservative management in a concurrent or historical control group and reported clinical outcome(s). We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group's approach to identify level 1 or level 2 studies according to the Oxford Centre for Evidence-Based Medicine's 2011 criteria. RESULTS We found one eligible diagnostic test accuracy study of 72 patients with brain masses accompanied by vasogenic edema and substantial amounts of blood, which found that hyperintense perilesional signal on T1-weighted magnetic resonance imaging could differentiate CCM from other causes with excellent specificity (98 %) and reasonable sensitivity (62 %). We found five potentially eligible observational studies of adults with a CCM that had already bled, but none met level 2 criteria for a "dramatic" effect (the conventionally calculated probability of the two groups of observations coming from the same population should be less than 0.01 and a rate ratio greater than 10). We found 11 potentially eligible observational studies of adults with CCM and epilepsy, but nine studies did not demonstrate dramatic effects and the remaining two studies showed dramatic effects, but they were at high risk of bias. CONCLUSIONS To address the absence of level 1 or 2 evidence to support CCM treatment decisions, there is a need for large studies of CCM treatment with a concurrent control group, ideally with randomized treatment allocation.
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Affiliation(s)
- Michiel Poorthuis
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, PO Box 85500, 3500 GA, Utrecht, The Netherlands
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11
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Al-Shahi Salman R. The outlook for adults with epileptic seizure(s) associated with cerebral cavernous malformations or arteriovenous malformations. Epilepsia 2012; 53 Suppl 4:34-42. [PMID: 22946719 DOI: 10.1111/j.1528-1167.2012.03611.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cerebral cavernous malformations (CCMs) and arteriovenous malformations (AVMs) are common: their asymptomatic prevalence on brain magnetic resonance imaging (MRI) is 1 in 625 and 1 in 2,000, respectively. The risk of epileptic seizure(s) for people with AVMs and CCMs affects their domestic, social, and professional lives, and may influence their decisions about treatment. This article summarizes the seizure risks for people with AVMs and CCMs, gleaned from published original articles indexed in OVID Medline and Embase before 1 January 2012. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, a population-based study in Scotland, United Kingdom, found that the 5-year risks of first seizure were 8% for AVM and 4% for CCM; presentation with intracranial hemorrhage or focal neurologic deficit raised this risk for AVM (23%) but not for CCM (6%). Features associated with the occurrence of epileptic seizures for CCM are lesion multiplicity and cortical CCM location, whereas for AVM the most consistently reported associations are younger age, temporal location, cortical involvement, and nidus diameter >3 cm. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, the 5-year risk of developing epilepsy following a first seizure is 58% for AVM and 94% for CCM, though there is no difference in the chance of achieving 2-year seizure freedom in this time frame (45% AVM vs. 47% CCM). Observational case series describe encouraging differences in seizure frequency before and after AVM and CCM treatment, but the shortage of studies demonstrating dramatic effects in comparison to concurrent control groups justifies the need for more controlled studies, ideally with randomized treatment allocation when the benefits of AVM or CCM treatment are uncertain.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom.
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12
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Kivelev J, Niemelä M, Hernesniemi J. Treatment strategies in cavernomas of the brain and spine. J Clin Neurosci 2012; 19:491-7. [PMID: 22325075 DOI: 10.1016/j.jocn.2011.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/25/2022]
Abstract
The management of brain and spinal cavernomas includes two main options: (i) conservative treatment or (ii) surgical removal. Clinical experience related to cavernoma patients falls into four major categories: the surgical or conservative treatment of incidental or symptomatic cavernomas. In many patients, cavernomas exist as fairly benign lesions, frequently remaining clinically silent for life. This observation argues against the active treatment of all cavernoma patients; rather for the meticulous selection of only those more likely to benefit from surgery. Thus, the most crucial task in successful management of cavernomas is appropriate patient selection. In this review, we present our institutional experience on cavernoma management supplemented with data from the literature.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, Helsinki 00260, Finland.
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Englot DJ, Han SJ, Lawton MT, Chang EF. Predictors of seizure freedom in the surgical treatment of supratentorial cavernous malformations. J Neurosurg 2011; 115:1169-74. [PMID: 21819194 DOI: 10.3171/2011.7.jns11536] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Seizures are the most common presenting symptom of supratentorial cerebral cavernous malformations (CCMs) and progress to medically refractory epilepsy in 40% of patients. Predictors of seizure freedom in the resection of CCMs are incompletely understood. METHODS The authors systematically reviewed the published literature on seizure freedom following the resection of supratentorial CCMs in patients presenting with seizures. Seizure outcomes were stratified across 12 potential prognostic variables. A total of 1226 patients with supratentorial CCMs causing seizures were identified across 31 predominantly retrospective studies; 361 patients had medically refractory epilepsy. RESULTS Seventy-five percent of the patients were seizure free after microsurgical lesion removal, whereas 25% continued to have seizures. All patients had had preoperative seizures and > 6 months of postoperative follow-up. Modifiable predictors of postoperative seizure freedom included gross-total resection (OR 36.6, 95% CI 8.5-157.5) and surgery within 1 year of symptom onset (OR 1.83, 95% CI 1.30-2.58). Additional prognostic indicators of a favorable outcome were a CCM size < 1.5 cm (OR 15.4, 95% CI 5.2-45.4), the absence of multiple CCMs (OR 2.02, 95% CI 1.13-3.60), medically controlled seizures (OR 2.38, 95% CI 1.29-4.39), and the lack of secondarily generalized seizures (OR 3.33, 95% CI 2.09-5.30). Other factors, including extended resection of the hemosiderin ring, were not significantly predictive. CONCLUSIONS In the surgical treatment of supratentorial CCMs, gross-total resection and early operative intervention may improve seizure outcome. While surgery should not be considered the first-line treatment for CCM-related epilepsy, it is important to understand the variables associated with seizure freedom in CCM resection given the considerable morbidity and diminished quality of life associated with epilepsy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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Kim W, Stramotas S, Choy W, Dye J, Nagasawa D, Yang I. Prognostic factors for post-operative seizure outcomes after cavernous malformation treatment. J Clin Neurosci 2011; 18:877-80. [DOI: 10.1016/j.jocn.2010.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 12/19/2010] [Indexed: 10/18/2022]
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Kivelev J, Laakso A, Niemelä M, Hernesniemi J. A Proposed Grading System of Brain and Spinal Cavernomas. Neurosurgery 2011; 69:807-13; discussion 813-4. [DOI: 10.1227/neu.0b013e31821ffbb5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Most cavernomas in the central nervous system are characterized by a benign natural course. Progressive symptoms warrant surgical removal. In the literature, the factors affecting long-term postoperative outcome are not statistically well confirmed.
OBJECTIVE:
To perform a multifactorial analysis of risk factors on a large patient series and to use the results to propose a simple grading scale to predict outcome.
METHODS:
We studied 303 consecutive patients with cavernomas treated surgically at our department from 1980 to 2009. Follow-up assessment was performed on average 5.7 years postoperatively (range, 0.2-36 years). The main outcome measure was the patients' condition at the last follow-up on Glasgow Outcome Scale. For statistical analysis, the outcome measure was dichotomized to favorable (Glasgow Outcome Scale 5) and unfavorable (Glasgow Outcome Scale 1–4). Binary logistic regression analysis was used to estimate the effect of age, sex, seizures, preexisting neurological deficits, hemorrhage, and size and location of cavernoma on long-term outcome.
RESULTS:
Infratentorial, basal ganglia, or spinal location and preexisting neurological deficit were the only independent risk factors for unfavorable outcome, with relative risks of 2.7 (P = .008) and 3.2 (P = .002), respectively. We formulated a grading system based on a score of 1 to 3. When applied to our series, the proposed grading system strongly correlated with outcome (P < .001, Pearson χ2 test). The risk for long-term unfavorable outcome was 13%, 22%, and 55% for grades 1 through 3, respectively.
CONCLUSION:
The proposed grading system showed a convincing correlation with postoperative outcome in surgically treated cavernoma patients.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
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16
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Cerebral cavernous malformations and intractable epilepsy: the limited usefulness of current literature. Acta Neurochir (Wien) 2011; 153:249-59. [PMID: 21190120 DOI: 10.1007/s00701-010-0915-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) are known to be highly epileptogenic lesions. A number of studies on CCM surgery deal with CCM-associated seizures and/or epilepsy. In order to counsel patients with CCM-associated epilepsy, clear results from such studies would be highly useful. This study reviews the current literature with the aim to assess its usefulness for presurgical decision-making with emphasis on differentiating outcomes in different epilepsy types. METHODS A systematic Medline search identified 27 studies between 1991 and 2009 through the keywords "cavernomas, cavernous, hemangioma, AND epilepsy, AND surgery". They were analysed with regard to clarity of definition of epilepsy subtypes, precision of definition of drug-resistant epilepsy, information on surgical procedure and presurgical workup, seizure outcome and length of follow-up. RESULTS Twenty studies included only surgically treated patients. Three types of epilepsy were defined: drug-resistant epilepsy, epilepsy or single/sporadic seizures. In 12 of 27 studies, at least one of these categories remained unclear. The classic definition of drug-resistant epilepsy was not used in the vast majority of studies, with many groups using their own definition. In 30%, the surgical procedure was not described precisely, although 52% of studies used a differentiated preoperative evaluation. Seizure outcome was described using a widely accepted classification in only 48% of series, and in over half of the studies outcome results contained cases with insufficient length of follow-up. CONCLUSIONS A large proportion of recent studies on surgery for CCM-associated epilepsy are not using criteria and definitions for the classification of epilepsy and outcome that are commonly used by epileptologists or epilepsy surgeons. This results in the limited usefulness of a large part of the literature for the purpose of preoperative counselling a patient with CCM-associated epilepsy.
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17
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Eddleman CS, Batjer HH, Awad IA. Cerebral Cavernous Malformations and Venous Anomalies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Pham M, Gross BA, Bendok BR, Awad IA, Batjer HH. Radiosurgery for angiographically occult vascular malformations. Neurosurg Focus 2009; 26:E16. [PMID: 19408994 DOI: 10.3171/2009.2.focus0923] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The use of radiosurgery for angiographically occult vascular malformations (AOVMs) is a controversial treatment option for those that are surgically inaccessible or located in eloquent brain. To determine the efficacy of this treatment, the authors reviewed the literature reporting hemorrhage rates, seizure control, and radiation-induced morbidity. They found overall hemorrhage rates of 2-6.4%, overall postradiosurgery hemorrhage rates of 1.6-8%, and stratified postradiosurgery hemorrhage rates of 7.3-22.4% in the period immediately to 2 years after treatment; these latter rates declined to 0.8-5.2% > 2 years after treatment. Of 291 patients presenting with seizure across 16 studies, 89 (31%) attained a seizure-free status and 102 (35%) had a reduction in seizure frequency after radiosurgery. Overall radiation-induced morbidity ranged from 2.5 to 59%, with higher complication rates in patients with brainstem lesion locations. Researchers applying mean radiation doses of 15-16.2 Gy to the tumor margin saw both low radiation-induced complication rates (0-9.1%) and adequate hemorrhage control (0.8-5.2% > 2 years after treatment), whereas mean doses >or= 16.5 Gy were associated with higher total radiation-induced morbidity rates (> 17%). Although the use of stereotactic radiosurgery remains controversial, patients with AOVMs located in surgically inaccessible areas of the brain may benefit from such treatment.
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Affiliation(s)
- Martin Pham
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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19
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Results of surgical treatment of patient with supratentorial cavenroma and epilepsy. ACTA ACUST UNITED AC 2008; 55:137-40. [DOI: 10.2298/aci0802137j] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In past, cavernoma was frequently cause of symptomatic epilepsy without pathological substrate. We present the group of the patient (32) whose illness were presented by epilepsy, and who were treated in Institute for Neurosurgery from 1998 to 2003. There is the good correlation between presentation of epilepsy and largeness of the cavernoma (Phi 0.683). In 22 patients the epilepsy was controlled by medicaments, and in other the seizures were uncontrolled. Cavernoma initially presented with seizures had no inclination for massive intralesional or parenhimal bleeding. After surgical extirpation of lesion, there was good outcome during the following period of 3 years.
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