1
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Catapano JS, Koester SW, Rumalla K, Lamorie-Foote K, Winkler EA, Benner D, Scherschinski L, Baranoski JF, Cole TS, Rudy RF, Graffeo CS, Srinivasan VM, Spetzler RF, Lawton MT. Microsurgical Resection of Brainstem Cavernous Malformations in Older Adults: A Multicenter, 30-Year Experience. Neurosurgery 2024; 95:669-675. [PMID: 38551352 DOI: 10.1227/neu.0000000000002928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/30/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Microsurgical resection is the only curative intervention for symptomatic brainstem cavernous malformations (BSCMs), but the management of these lesions in older adults (≥65 years) is not well described. This study sought to address this gap by examining the safety and efficacy of BSCM resection in a cohort of older adults. METHODS Records of patients who underwent BSCM resection over a 30-year period were reviewed retrospectively. Baseline characteristics and outcomes were compared between older (≥65 years) and younger (<65 years) patients. RESULTS Of 550 patients with BSCM who met inclusion criteria, 41 (7.5%) were older than 65 years. Midbrain (43.9% vs 26.1%) and medullary lesions (19.5% vs 13.6%) were more common in the older cohort than in the younger cohort ( P = .01). Components of the Lawton BSCM grading system (ie, lesion size, crossing axial midpoint, developmental venous anomaly, and timing of hemorrhage) were not significantly different between cohorts ( P ≥ .11). Mean (SD) Elixhauser comorbidity score was significantly higher in older patients (1.86 [1.06]) than in younger patients (0.66 [0.95]; P < .001). Older patients were significantly more likely than younger patients to have poor outcomes at final follow-up (28.9% vs 13.8%, P = .01; mean follow-up duration, 28.7 [39.1] months). However, regarding relative neurological outcome (preoperative modified Rankin Scale to final modified Rankin Scale), rate of worsening was not significantly different between older and younger patients (23.7% vs 14.9%, P = .15). CONCLUSION BSCMs can be safely resected in older patients, and when each patient's unique health status and life expectancy are taken into account, these patients can have outcomes similar to younger patients.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Krista Lamorie-Foote
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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2
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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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Santos AN, Rauschenbach L, Gull HH, Olbrich A, Dinger TF, Darkwah Oppong M, Rieß C, Chen B, Lenkeit A, Schmidt B, Li Y, Jabbarli R, Wrede KH, Siegel A, Sure U, Dammann P. Natural course of cerebral and spinal cavernous malformations: a complete ten-year follow-up study. Sci Rep 2023; 13:15490. [PMID: 37726391 PMCID: PMC10509233 DOI: 10.1038/s41598-023-42594-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 09/12/2023] [Indexed: 09/21/2023] Open
Abstract
Knowledge of the bleeding risk and the long-term outcome of conservatively treated patients with cavernous malformations (CM) is poor. In this work, we studied the occurrence of CM-associated hemorrhage over a 10-year period and investigated risk factors for bleeding. Our institutional database was screened for patients with cerebral (CCM) or intramedullary spinal cord (ISCM) CM admitted between 2003 and 2021. Patients who underwent surgery and patients without completed follow-up were excluded. Analyses were performed to identify risk factors and to determine the cumulative risk for hemorrhage. A total of 91 CM patients were included. Adjusted multivariate logistic regression analysis identified bleeding at diagnosis (p = 0.039) and CM localization to the spine (p = 0.010) as predictors for (re)hemorrhage. Both risk factors remained independent predictors through Cox regression analysis (p = 0.049; p = 0.016). The cumulative 10-year risk of bleeding was 30% for the whole cohort, 39% for patients with bleeding at diagnosis and 67% for ISCM. During an untreated 10-year follow-up, the probability of hemorrhage increased over time, especially in cases with bleeding at presentation and spinal cord localization. The intensity of such increase may decline throughout time but remains considerably high. These findings may indicate a rather aggressive course in patients with ISCM and may endorse early surgical treatment.
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Affiliation(s)
- Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Hanah H Gull
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Adrian Siegel
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, 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, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
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Ndandja DTK, Musa G, Nosov I, Chmutin GE, Livshitz MI, Annanepesov NS, Mwela BM. A rare case of rebleeding brainstem cavernoma in a 5-month-old-girl. Surg Neurol Int 2023; 14:227. [PMID: 37404517 PMCID: PMC10316179 DOI: 10.25259/sni_308_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023] Open
Abstract
Background Brainstem cavernomas (BSCs) are relatively rare intracranial vascular lesions that, if left untreated, can be devastating to the patient. The lesions are associated with a myriad of symptoms, depending on their size and location. However, medullary lesions present acutely with cardiorespiratory dysfunction. We present the case of a 5-month-old child with a BSC. Case Description A 5-month-old child presented for the 2nd time with sudden respiratory distress and excessive salivation. On the first presentation, brain magnetic resonance imaging (MRI) showed a 13 × 12 × 14 mm cavernoma at the pontomedullary junction. She was managed conservatively but presented 3 months later with tetraparesis, bulbar palsy, and severe respiratory distress. A repeat MRI showed enlargement of the cavernoma to 27 × 28 × 26 mm with hemorrhage in different stages. After hemodynamic stabilization, complete cavernoma resection was performed through the telovelar approach with neuromonitoring. Postoperatively, the child recovered motor function, but the bulbar syndrome persisted with hypersalivation. She was discharged on day 55 with a tracheostomy. Conclusion BSCs are rare lesions that are associated with severe neurological deficits due to the compactness of important cranial nerve nuclei and other tracts in the brainstem. Early surgical excision and hematoma evacuation for superficially presenting lesions can be lifesaving. However, the risk of postoperative neurological deficits is still a major concern in these patients.
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Affiliation(s)
- Dimitri T. K. Ndandja
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Gerald Musa
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Ilya Nosov
- Department of Neurosurgery, Morozov Children’s City Clinical Hospital, Center for the Treatment of Cerebrovascular Pathology in Children and Adolescents, Moscow, Russian Federation
| | - Gennady E. Chmutin
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Matvey I. Livshitz
- Department of Neurosurgery, Morozov Children’s City Clinical Hospital, Center for the Treatment of Cerebrovascular Pathology in Children and Adolescents, Moscow, Russian Federation
| | - Nazar S. Annanepesov
- Department of Neurological Diseases and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia
| | - Bupe Mumba Mwela
- Department of Pediatrics and Child Health, Peoples Friendship University of Russia (RUDN University), Moscow, Russian Federation
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Rauschenbach L, Santos AN, Gull HH, Rieß C, Deuschl C, Schmidt B, Darkwah Oppong M, Gembruch O, Özkan N, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional impact of multiple bleeding events in patients with conservatively treated spinal cavernous malformations. J Neurosurg Spine 2023; 38:405-411. [PMID: 36401548 DOI: 10.3171/2022.10.spine22940] [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: 08/19/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the functional outcome in spinal cavernous malformation (SCM) patients with single or multiple intramedullary hemorrhagic events. METHODS SCM patients who were conservatively treated between 2003 and 2021 and had complete clinical baseline characteristics, an MRI data set, at least one SCM-related intramedullary hemorrhage (IMH), and at least one follow-up examination were included in this study. Functional status was assessed using the modified McCormick Scale score at diagnosis, before and after each bleeding event, and at the last follow-up. RESULTS A total of 45 patients were analyzed. Univariate analysis identified multiple bleeding events as the only statistically significant predictor for an unfavorable functional outcome at the last follow-up (OR 15.28, 95% CI 3.22-72.47; p < 0.001). Patients significantly deteriorated after the first hemorrhage (29.0%, p = 0.006) and even more so after the second hemorrhage (84.6%, p = 0.002). Multiple bleeding events were significantly associated with functional deterioration at the last follow-up (76.9%, p = 0.003). The time between the last IMH and the last follow-up did not influence this outcome. CONCLUSIONS IMH due to SCM is linked to functional worsening. Such outcomes tend to improve after each hemorrhage, but the probability of full recovery declines with each bleeding event.
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Affiliation(s)
- Laurèl Rauschenbach
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Alejandro N Santos
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Hanah H Gull
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Christoph Rieß
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - 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
| | - Marvin Darkwah Oppong
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Oliver Gembruch
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Neriman Özkan
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Ramazan Jabbarli
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Karsten H Wrede
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
| | - Philipp Dammann
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
- 4Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany
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6
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Santos AN, Rauschenbach L, Gull HH, Dinger TF, Chihi M, Li Y, Tippelt S, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional outcome after initial and multiple intracerebral hemorrhages in children with cerebral cavernous malformations. Eur J Neurol 2023; 30:1364-1370. [PMID: 36789485 DOI: 10.1111/ene.15749] [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: 12/07/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to assess the course and predictors of functional outcome after single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs) and to conduct a risk assessment of a third bleed during the first follow-up year after second ICH. METHODS We included patients aged ≤18 years with complete baseline characteristics, a magnetic resonance imaging dataset, ≥1 CCM-related ICH and ≥1 follow-up examination, who were treated between 2003 and 2021. Neurological functional status was obtained using modified Rankin Scale scores at diagnosis, before and after each ICH, and at last follow-up. Kaplan-Meier analysis was performed to determine the cumulative 1-year risk of third ICH. RESULTS A total of 55 pediatric patients (median [interquartile range] age 12 [11] years) were analyzed. Univariate analysis identified brainstem cavernous malformation (BSCM; p = 0.019) as a statistically significant predictor for unfavorable outcome after second ICH. Outcome after second ICH was significantly worse in 12 patients (42.9%; p = 0.030) than after first ICH and in five patients (55.6%; p = 0.038) after a third ICH compared to a second ICH. Cumulative 12-month risk of rebleeding during the first year after a second ICH was 10.7% (95% confidence interval 2.8%-29.37%). CONCLUSIONS Pediatric patients with a BSCM have a higher risk of worse outcome after second ICH. Functional outcome improves over time after an ICH but worsens following each ICH compared to baseline or previous ICH. Second bleed was associated with neurological deterioration compared to initial ICH, and this deteriorated further after a third ICH.
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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
| | - Hannah 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
| | - Thiemo Florin 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
| | - Mehdi Chihi
- 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
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Pediatrics, University Hospital of Essen, 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.,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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7
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Cerebral cavernous malformation: Management, outcomes, and surveillance strategies - A single centre retrospective cohort study. Clin Neurol Neurosurg 2023; 225:107576. [PMID: 36608471 DOI: 10.1016/j.clineuro.2022.107576] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may undergo a period of clinical and/or radiographical surveillance that precedes or follows definitive treatment. There are no international guidelines on the optimal surveillance strategy. This study describes the surveillance strategies at our centre and explore the related clinical outcomes. METHODS We performed a retrospective study of adult patients with CCMs referred to a neurovascular service over an 8-year period, to determine the frequency and type of surveillance, intervention, and explore the associated outcomes. We report our findings adhering to STROBE guidelines. RESULTS 133 patients (Male:Female 73:60; men age 42 years; range 12-82) were included. CCMs were identified in patients first presenting with symptomatic intracerebral haemorrhage (42.11%); headache, focal neurological deficit, or seizure without haemorrhage (41.35%); or, as an incidental finding (16.54%). The most common CCM location was supratentorial (59.40%), followed by brain stem (21.80%), cerebellum (10.53%) and basal ganglia (6.02%). Of the 133 patients, 77 patients (57.89%) were managed conservatively, 49 patients (36.84%) were managed by surgical resection alone, and seven patients (5.26%) were managed with stereotactic radiosurgery (SRS). Patients follow-up had a mean duration of 65.94 months, and varied widely (SD = 52.59; range 0-265), for a total of 730.83 person-years of follow up. During surveillance, 16 patients suffered an ICH equating to a bleeding rate of 2.19 per 100 patient years. CCMs that increased in size had a higher bleeding rate (p = 8.58 ×10-4). There were 8 (6.02%) cases where routine clinic review or MRI resulted in a change in management. CONCLUSIONS Our single centre retrospective study supports existing literature relating to presentation and sequalae of CCM, with an increase in CCM size being associated with higher rates of detected bleeding. There remains heterogeneity, even within a single centre, on the frequency and modality of surveillance. Further, there are no international guidelines or high-quality data that recommends the optimal duration and frequency of surveillance, and its effect on clinical outcomes. This is a future research direction.
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8
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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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9
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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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10
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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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11
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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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12
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Bauman MMJ, Patra DP, Bendok BR. Commentary: Transcallosal Transchoroidal Approach to the Third Ventricle for Resection of a Thalamic Cavernoma-Anatomical Landmarks Review: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e211-e213. [PMID: 35972121 DOI: 10.1227/ons.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Megan M J Bauman
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA.,Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Devi P Patra
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
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13
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Orlev A, Feghali J, Kimchi G, Salomon M, Berkowitz S, Oxman L, Levitan I, Knoller N, Auriel E, Huang J, Tamargo RJ, Harnof S. Neurological event prediction for patients with symptomatic cerebral cavernous malformation: the BLED2 score. J Neurosurg 2022; 137:344-351. [PMID: 34920431 DOI: 10.3171/2021.8.jns211321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Retrospective patient cohort studies have identified risk factors associated with recurrent focal neurological events in patients with symptomatic cerebral cavernous malformations (CCMs). Using a prospectively maintained database of patients with CCMs, this study identified key risk factors for recurrent neurological events in patients with symptomatic CCM. A simple scoring system and risk stratification calculator was then created to predict future neurological events in patients with symptomatic CCMs. METHODS This was a dual-center, prospectively acquired, retrospectively analyzed cohort study. Adult patients who presented with symptomatic CCMs causing focal neurological deficits or seizures were uniformly treated and clinically followed from the time of diagnosis onward. Baseline variables included age, sex, history of intracerebral hemorrhage, lesion multiplicity, location, eloquence, size, number of past neurological events, and duration since last event. Stepwise multivariable Cox regression was used to derive independent predictors of recurrent neurological events, and predictive accuracy was assessed. A scoring system based on the relative magnitude of each risk factor was devised, and Kaplan-Meier curve analysis was used to compare event-free survival among patients with different score values. Subsequently, 1-, 2-, and 5-year neurological event rates were calculated for every score value on the basis of the final model. RESULTS In total, 126 (47%) of 270 patients met the inclusion criteria. During the mean (interquartile range) follow-up of 54.4 (12-66) months, 55 patients (44%) experienced recurrent neurological events. Multivariable analysis yielded 4 risk factors: bleeding at presentation (HR 1.92, p = 0.048), large size ≥ 12 mm (HR 2.06, p = 0.016), eloquent location (HR 3.01, p = 0.013), and duration ≤ 1 year since last event (HR 9.28, p = 0.002). The model achieved an optimism-corrected c-statistic of 0.7209. All factors were assigned 1 point, except duration from last event which was assigned 2 points. The acronym BLED2 summarizes the scoring system. The 1-, 2-, and 5-year risks of a recurrent neurological event ranged from 0.6%, 1.2%, and 2.3%, respectively, for patients with a BLED2 score of 0, to 48%, 74%, and 93%, respectively, for patients with a BLED2 score of 5. CONCLUSIONS The BLED2 risk score predicts prospective neurological events in symptomatic CCM patients.
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Affiliation(s)
- Alon Orlev
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Feghali
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gil Kimchi
- 3Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Ramat-Gan, Israel
| | - Moran Salomon
- 4St. Georges, University of London, Cranmer Terrace, London, United Kingdom; and
| | - Shani Berkowitz
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Liat Oxman
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Idan Levitan
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Nachshon Knoller
- 3Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Ramat-Gan, Israel
| | - Eitan Auriel
- 5Department of Neurology, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Judy Huang
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sagi Harnof
- 1Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
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14
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Bubenikova A, Skalicky P, Benes V, Benes V, Bradac O. Overview of cerebral cavernous malformations: comparison of treatment approaches. J Neurol Neurosurg Psychiatry 2022; 93:475-480. [PMID: 35273070 DOI: 10.1136/jnnp-2021-328658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/31/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The comparison of treatment efficacy for cerebral cavernous malformations (CCMs) has not yet been well researched. DESIGN PubMed, Cochrane Library, Science Direct, ISI Web of Science, Embase and additional sources were searched to identify cohort studies about the treatment of CCMs published between 1990 and 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed; the Newcastle-Ottawa Scale was used to assess the risk of bias and to evaluate limitations based on selection/outcome biases. The cumulative incidences with 95% CIs were calculated using the random effects model. The models of Poisson distribution were applied to evaluate risk factors of poorer treatment outcome by calculating rate ratios within 100 person-years with 95% CIs. RESULTS A total of 100 cohorts yielding 8994 patients treated for CCMs within 41 098 person-years of follow-up were analysed. The efficacy of ensuring the prevention of haemorrhage was 97% in surgical, 86% in radiosurgical and 77% in the conservative treatment. The lowest mortality (1%) was after radiosurgery, and the highest persistent morbidity (22%) was in natural history series. Deep-seated and brainstem CCMs were associated with higher bleeding rates. Lobar localisation was a protective factor in all analyses. Patients with history of previous haemorrhage were exposed to higher risk of rebleeding. Male gender was a protective factor associated with lower risk of post-treatment haemorrhage. CONCLUSIONS Surgical resection of CCM is effective in ensuring the prevention of haemorrhage with acceptable morbidity and mortality, but conservative and radiosurgical management is a justified treatment alternative. Brainstem and deep-seated CCMs are predominantly associated with higher haemorrhage rates.
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Affiliation(s)
- Adela Bubenikova
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Skalicky
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Bradac
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic .,Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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15
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Spînu A, Ionescu T, Cristea AA, Băilă M, Daia C, Andone I, Popescu C, Brumă E, Constantin E, Onose G. Case report and related comments in a relatively young male patient with right hemiplegia after left thalamo- mesencephalic hemorrhage and a consequent Parinaud syndrome – interdisci-plinary therapeutic – rehabilitative approach. BALNEO AND PRM RESEARCH JOURNAL 2022. [DOI: 10.12680/balneo.2022.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Thalamo- mesencephalic hemorrhage is a devasting event, with a increased morbidity and mor-tality rate. Parinaud’s syndrome, also known as the dorsal midbrain syndrome, is characterized by a supranuclear vertical gaze disturbing, resulting from an insult to the mesencephalic tectum. Matherial and Method. We report the case of a 45-year-old man with personal antecedents of ar-terial hypertension, obesity and type 2 Diabetus mellitus, who was first admitted in the Neuro-logy Clinic Division of the Teaching Emergency Hospital Bucharest with a sudden onset of com-plete right hemiplegia, mixed aphasia and right central– type facial palsy on 17.04.2021, being diagnosed – following complex paraclinic investigations -with a left thalamo- mesencephalic hemorrhage. Results and discusssion. The patient followed a neuro- muscular rehabilitation program in our Neuro- Rehabilitation Clinic Division with favorable outcomes, the case repre-senting a real challenge regarding the complexity of the factors involved. Conclusions. The cli-nical outcomes and the quality of life of patients suffering from thalamo- mesencephalic hemor-rhage depend both on the prompt diagnosis and the efficient treatment, followed by an appro-priate rehabilitation program.
Keywords: neuro-rehabilitation, thalamo-mesencephalic hemorrhage, Parinaud syndrome
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Affiliation(s)
- Aura Spînu
- 1 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Teaching Emergency Hospital „Bagdasar Arseni” (THEBA) Bucharest, Romania
| | - Theodora Ionescu
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Mihai Băilă
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Daia
- 1 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Teaching Emergency Hospital „Bagdasar Arseni” (THEBA) Bucharest, Romania
| | - Ioana Andone
- 1 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Teaching Emergency Hospital „Bagdasar Arseni” (THEBA) Bucharest, Romania
| | - Cristina Popescu
- Teaching Emergency Hospital „Bagdasar Arseni” (THEBA) Bucharest, Romania
| | - Elena Brumă
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Elena Constantin
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gelu Onose
- 1 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Teaching Emergency Hospital „Bagdasar Arseni” (THEBA) Bucharest, Romania
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16
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Munakomi S, Torregrossa F, Grasso G. Natural Course, Clinical Profile, and Treatment Strategies for Cerebral Cavernous Malformations. World Neurosurg 2022; 159:373-380. [DOI: 10.1016/j.wneu.2021.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 10/18/2022]
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17
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Yang Y, Velz J, Neidert MC, Lang W, Regli L, Bozinov O. The BSCM score: a guideline for surgical decision-making for brainstem cavernous malformations. Neurosurg Rev 2021; 45:1579-1587. [PMID: 34713352 PMCID: PMC8976795 DOI: 10.1007/s10143-021-01679-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
Microsurgical resection of brainstem cavernous malformations (BSCMs) can be performed today with acceptable morbidity and mortality. However, in this highly eloquent location, the indication for surgery remains challenging. We aimed to elaborate a score system that may help clinicians with their choice of treatment in patients with BSCMs in this study. A single-center series of 88 consecutive BSCMs patients with 272 follow-up visits were included in this study. Univariable and multivariable generalized estimating equations (GEE) were constructed to identify the association of variables with treatment decisions. A score scale assigned points for variables that significantly contributed to surgical decision-making. Surgical treatment was recommended in 37 instances, while conservative treatment was proposed in 235 instances. The mean follow-up duration was 50.4 months, and the mean age at decision-making was 45.9 years. The mean BSCMs size was 14.3 ml. In the multivariable GEE model, patient age, lesion size, hemorrhagic event(s), mRS, and axial location were identified as significant factors for determining treatment options. With this proposed score scale (grades 0–XII), non-surgery was the first option at grades 0–III. The crossover point between surgery and non-surgery recommendations lay between grades V and VI while surgical treatment was found in favor at grades VII–X. In conclusion, the proposed BSCM operating score is a clinician-friendly tool, which may help neurosurgeons decide on the treatment for patients with BSCMs.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland. .,Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland.
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
| | - Wei Lang
- Department of Geriatric Medicine, University Hospital Zurich, City Hospital Waid Zurich, Tiechestrasse 99, CH-8037, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
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Yang Y, Velz J, Neidert MC, Stienen MN, Regli L, Bozinov O. Natural History of Brainstem Cavernous Malformations: On the Variation in Hemorrhage Rates. World Neurosurg 2021; 157:e342-e350. [PMID: 34656794 DOI: 10.1016/j.wneu.2021.10.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hemorrhage rates of conservatively managed brainstem cavernous malformations (BSCMs) vary widely in the literature. We aimed to elucidate the reason for the variation and to add the results of our experience of BSCMs management over the past decade. METHODS We performed a review of consecutive patients with BSCMs referred to our department in the period 2006-2018. A hemorrhagic event was defined as a radiographically verified intralesional and extralesional hemorrhage. Both retrospective and prospective hemorrhage rates were calculated based on the patient age in years, counted either from birth or from the time of initial presentation until the last contact (or until surgical resection). In addition, we retrieved and reviewed publications with a clear definition of hemorrhagic event and a detailed description of BSCM hemorrhage rate. RESULTS In total, 118 patients with BSCMs were reviewed, and 78 patients (mean age on admission 45.9 years) were included in the final analysis. The retrospective and prospective hemorrhage rates were 1.9% (95% confidence interval 1.6%-2.3%) per year and 11.9% (95% confidence interval 7.5%-17.8%), respectively. The retrospective hemorrhage rate in the literature review ranged from 1.9% to 6.8% per year with a median value of 3.8%, whereas the prospective hemorrhage rate ranged between 4.1% and 21.5%, with a median value of 10.2%. CONCLUSIONS The reported hemorrhage rates are calculated in 2 different ways. In our patient cohort, both the retrospective and prospective hemorrhage rates were in accordance with those in the literature. The long-term hemorrhage rate lies between the prospective and retrospective rate.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Zurich, Switzerland; Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland.
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland
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Velz J, Neidert MC, Yang Y, Akeret K, Nakaji P, Regli L, Bozinov O. Mortality in Patients with Brainstem Cavernous Malformations. Cerebrovasc Dis 2021; 50:574-580. [PMID: 34134124 DOI: 10.1159/000516909] [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: 02/18/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCM)-associated mortality has been reported up to 20% in patients managed conservatively, whereas postoperative mortality rates range from 0 to 1.9%. Our aim was to analyze the actual risk and causes of BSCM-associated mortality in patients managed conservatively and surgically based on our own patient cohort and a systematic literature review. METHODS Observational, retrospective single-center study encompassing all patients with BSCM that presented to our institution between 2006 and 2018. In addition, a systematic review was performed on all studies encompassing patients with BSCM managed conservatively and surgically. RESULTS Of 118 patients, 54 were treated conservatively (961.0 person years follow-up in total). No BSCM-associated mortality was observed in our conservatively as well as surgically managed patient cohort. Our systematic literature review and analysis revealed an overall BSCM-associated mortality rate of 2.3% (95% CI: 1.6-3.3) in 22 studies comprising 1,251 patients managed conservatively and of 1.3% (95% CI: 0.9-1.7) in 99 studies comprising 3,275 patients with BSCM treated surgically. CONCLUSION The BSCM-associated mortality rate in patients managed conservatively is almost as low as in patients treated surgically and much lower than in frequently cited reports, most probably due to the good selection nowadays in regard to surgery.
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Affiliation(s)
- Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Peter Nakaji
- Department of Neurosurgery at Banner, University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
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20
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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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Cerebral cavernous malformation remnants after surgery: a single-center series with long-term bleeding risk analysis. Neurosurg Rev 2020; 44:2639-2645. [PMID: 33211201 PMCID: PMC8490209 DOI: 10.1007/s10143-020-01436-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/01/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022]
Abstract
AbstractThe aim of this work is to investigate the long-term bleeding risk of cerebral cavernous malformation (CCM) remnants. A review of clinical, radiological, operative, and post-operative data of a cerebral cavernous malformation (CCMs) prospective database was performed. Fisher’s exact test and Mann-Whitney U-test were used to assess differences between non-hemorrhagic and hemorrhagic CCM remnants for 14 variables. Recursive partitioning analysis was performed to assess the order of variables most associated with CCM remnant bleeding. Twenty-four patients out of 126 had a CCM post-surgical remnant. Of these, 7 had at least one post-operative hemorrhagic event. The mean follow-up was 80.7 months (range 12–144). CCM post-surgical remnant bleeding presented mostly with acute headache (50%) and focal neurological deficit (25%); in the remaining cases, the hemorrhage was asymptomatic. Retreatment was performed in two patients, with surgery and radiosurgery, respectively; no treatment was performed in the majority of cases. All patients ranked as non-II, according to Zabramski classification, did not show any post-surgical bleeding. The presence of a pre-operative perilesional hemosiderin ring was highly significant in predicting post-surgical bleeding (sensitivity = 0.94, specificity = 0.88) and incorrectly predicted bleeding in only two of the 24 patients. This study provides an evaluation of clinical and radiological factors influencing the bleeding risk of a CCM post-surgical remnant in a homogeneous population. Perilesional hemosiderin ring and Zabramski Type II appear to strongly condition the bleeding risk of a CCM post-surgical remnant.
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22
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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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23
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Yuen J, Whitfield PC. Brainstem cavernous malformations - no longer a forbidden territory? A systemic review of recent literature. Neurochirurgie 2020; 66:116-126. [PMID: 32112802 DOI: 10.1016/j.neuchi.2019.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/21/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND Due to its eloquent location and potentially devastating neurological consequences, the management of brainstem cavernous malformations (CCMs) attracts considerable debate. There is currently a paucity of Level 1 evidence for their management. The aim of this literature review is to explore the current evidence on the risk-benefit profile of different management options. METHODS A systemic literature search, following the PRISMA algorithm was performed on publications between 2010 and 2018 using the Pubmed database, with the relevant keywords. Only English articles were included. Articles focusing on spinal CCMs and studies with less than 30 participants were excluded. RESULTS A total of 222 search results were reviewed and after removal of duplicates and screening of abstracts, 28 clinical papers comprising 30 or more brainstem CCM cases were included in the study. The heterogeneity of the publications precluded a formal meta-analysis of results. The general consensus is that for CCMs presenting with severe symptoms and/or multiple haemorrhages that reach an accessible pial surface, surgery is considered to be the gold-standard treatment, with some authors suggesting the optimal timing to be within two to six weeks of ictus. For those patients with multiple, deep-seated CCM related haemorrhages that do not reach the pial surface, stereotactic radiosurgery (SRS) can be considered. Conservative treatment is generally considered in incidental cases. Management of brainstem cavernomas of other categories still remains controversial. CONCLUSIONS Due to their highly eloquent location, brainstem CCMs are challenging lesions to manage. Management must be balanced by the risk-benefit profile and tailored to the individual patients and their treating clinicians. This review provides a comprehensive reference considering all treatment options and provides a basis for evidence-based patient counselling.
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Affiliation(s)
- J Yuen
- South West Neurosurgery Centre, Derriford Hospital, Plymouth Devon, UK PL6 8DH.
| | - P C Whitfield
- South West Neurosurgery Centre, Derriford Hospital, Plymouth Devon, UK PL6 8DH
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Kaye J, Zeller S, Patel NV, Herschman Y, Jumah F, Nanda A. Presentation, Surgical Management, and Postoperative Outcome of a Fourth Ventricular Cavernous Malformation: Case Report and Review of Literature. World Neurosurg 2020; 137:78-83. [PMID: 32028002 DOI: 10.1016/j.wneu.2020.01.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Brainstem cavernous malformations (CMs) represent dangerous clinical entities associated with high rates of rebleeding and morbidity compared with those in other locations. Particularly rare are those located within the fourth ventricle. Although fourth ventricular CMs are favorable from a surgical standpoint, there are no defined guidelines on definitive indications and optimal timing of surgery. In addition, the surgical approaches, anatomic considerations, and general observations regarding these lesions are not well reported in the literature. CASE PRESENTATION A 27-year-old man with a known history of a CM on the floor of the fourth ventricle presented with new cranial nerve deficits and signs of increased intracranial pressure. Imaging revealed acute bleeding from a fourth ventricular CM. The patient was urgently taken to surgery for resection. Despite a noneventful surgery which resulted in gross total resection, the patient developed a unique constellation of cranial nerve deficits postoperatively, most notably of which was eight-and-a-half syndrome. CONCLUSIONS CMs of the fourth ventricle are rare clinical entities that can be treated successfully with surgery. The indications for surgery may not always be clear-cut; therefore, the neurosurgeon's decision to proceed with surgery must reside on a case-by-case basis using a multifactorial approach. The location of these lesions presents unique challenges given their proximity to vital structures and the technical difficulty required. For these reasons, the resection of these lesions often results in new or persistent neurologic deficits. However, despite the associated risks, the potential benefits of surgery oftentimes outweigh the risks of the alternative.
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Affiliation(s)
- Joel Kaye
- Robert Wood Johnson Medical School-Rutgers, New Brunswick, New Jersey, USA
| | - Sabrina Zeller
- Robert Wood Johnson Medical School-Rutgers, New Brunswick, New Jersey, USA
| | - Nitesh V Patel
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Yehuda Herschman
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Robert Wood Johnson Medical School-Rutgers, New Brunswick, New Jersey, USA; Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA.
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Sharma M, Lin JW, Andaluz N, Williams BJ. Trans-labyrinthine Infra-trigeminal Approach for Recurrent Pontomedullary Cavernoma: A Step-wise Technical Note. Cureus 2019; 11:e5853. [PMID: 31720129 PMCID: PMC6839969 DOI: 10.7759/cureus.5853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Recurrent brainstem cavernoma is a challenging lesion due to the neurological risks associated with different surgical approaches. In this technical report, we present a 35-year-old female with a history of multiple brain cavernomas. She underwent midline suboccipital craniotomy and trans-fourth ventricle approach for resection of the brain stem cavernoma following two major bleeding episodes, one year prior to the presentation. Following the trans-labyrinthine infra-trigeminal approach, the patient recovered well postoperatively with a baseline neuro exam and was discharged to acute rehab on postoperative day 5 (POD5). The translabyrinthine approach is a safe and effective corridor for pontine or pontomedullary lesions in carefully selected patients. Appropriate selection of surgical approach (based on location), meticulous surgical technique, and intraoperative neuromonitoring help in maximizing surgical resection while minimizing neurological deficits.
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Affiliation(s)
- Mayur Sharma
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Jerry W Lin
- Otolaryngology, University of Louisville School of Medicine, Louisville, USA
| | - Norberto Andaluz
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Brian J Williams
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
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Rajagopal N, Kawase T, Mohammad AA, Seng LB, Yamada Y, Kato Y. Timing of Surgery and Surgical Strategies in Symptomatic Brainstem Cavernomas: Review of the Literature. Asian J Neurosurg 2019; 14:15-27. [PMID: 30937003 PMCID: PMC6417313 DOI: 10.4103/ajns.ajns_158_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.
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Affiliation(s)
- Niranjana Rajagopal
- Department of Neurosurgery, Sathya Sai Institute of Higher Medical Science, Bengaluru, Karnataka, India
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | | | - Liew Boon Seng
- Department of Neurosurgery, Sungai Buloh Hospital, Selangor, Malaysia
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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Hennerici MG. Update in Intracerebral Hemorrhages - Part 2: Patients at Risk Associated with Vascular Lesions. Cerebrovasc Dis 2017; 43:I-II. [PMID: 28531890 DOI: 10.1159/000477194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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