1
|
Sandmann ACA, Kempeneers MA, van den Berg R, Verbaan D, Vandertop WP, Coutinho JM. Clinical course of patients with conservatively managed cerebral cavernous malformations. Eur Stroke J 2024; 9:667-675. [PMID: 38624046 DOI: 10.1177/23969873241246868] [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] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION There is uncertainty whether patients with a cerebral cavernous malformation (CCM) should undergo conservative or surgical treatment, resulting in practice variation among hospitals. Our objective was to report clinical outcomes of patients with primarily conservatively managed CCMs. PATIENTS AND METHODS This single-center cohort study included consecutive adult CCM patients, diagnosed in 2000-2023, who underwent conservative management as primary treatment strategy. Data were extracted from medical records, and we systematically conducted telephone and questionnaire follow-up. Functional status was assessed on the modified Rankin Scale (mRS). RESULTS Of 345 patients, we included 265 patients with a CCM (median age 46 years; 45% male). At baseline, 131 (49%) patients presented with symptomatic hemorrhage (SH), and 134 (51%) with other symptoms or asymptomatically. During 58 months (IQR 35-94) median follow-up, 51 (19%) patients experienced a SH, 33 (12%) a seizure, and 13 (5%) focal neurological deficits. Fourteen (5%) patients underwent intervention (surgery n = 11, radiosurgery n = 4). Presentation with SH was associated with higher annual bleeding rates (6.0% vs 1.5%, p < 0.001), and higher cumulative 5-/10-year bleeding risks (31%/41% vs 7%, p < 0.001). Brainstem CCM was associated with higher cumulative 5-/10-year bleeding risks (27%/38% vs 17%/21%, p = 0.038). Nineteen (7%) patients died; two (0.8%) directly attributable to CCM. Of 246 surviving patients, 205 (83%) completed the questionnaire. At follow-up, 172/224 (77%) patients were functionally independent (mRS score ⩽2). DISCUSSION AND CONCLUSION The majority of conservatively managed CCM patients remained free of a SH during follow-up. Few patients required intervention, and death attributable to the CCM was rare. These data may help patient counseling and treatment decisions.
Collapse
Affiliation(s)
| | | | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - William Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Dulamea AO, Lupescu IC. Cerebral cavernous malformations - An overview on genetics, clinical aspects and therapeutic strategies. J Neurol Sci 2024; 461:123044. [PMID: 38749279 DOI: 10.1016/j.jns.2024.123044] [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: 10/16/2023] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
Cerebral cavernous malformations (CCMs) are abnormally packed blood vessels lined with endothelial cells, that do not exhibit intervening tight junctions, lack muscular and elastic layers and are usually surrounded by hemosiderin and gliosis. CCMs may be sporadic or familial autosomal dominant (FCCMs) caused by loss of function mutations in CCM1 (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10) genes. In the FCCMs, patients have multiple CCMs, different family members are affected, and developmental venous anomalies are absent. CCMs may be asymptomatic or may manifest with focal neurological deficits with or without associated hemorrhage andseizures. Recent studies identify a digenic "triple-hit" mechanism involving the aquisition of three distinct genetic mutations that culminate in phosphatidylinositol-3-kinase (PIK3CA) gain of function, as the basis for rapidly growing and clinically symptomatic CCMs. The pathophysiology of CCMs involves signaling aberrations in the neurovascular unit, including proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammation and immune mediated processes, anticoagulant vascular domain, and gut microbiome-driven mechanisms. Clinical trials are investigating potential therapies, magnetic resonance imaging and plasma biomarkers for hemorrhage and CCMs-related epilepsy, as well as different techniques of neuronavigation and neurosonology to guide surgery in order to minimize post-operatory morbidity and mortality. This review addresses the recent data about the natural history, genetics, neuroimaging and therapeutic approaches for CCMs.
Collapse
Affiliation(s)
- Adriana Octaviana Dulamea
- Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; Fundeni Clinical Institute, Department of Neurology, 258 Fundeni Street, 022328 Bucharest, Romania.
| | - Ioan Cristian Lupescu
- Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; Fundeni Clinical Institute, Department of Neurology, 258 Fundeni Street, 022328 Bucharest, Romania
| |
Collapse
|
3
|
Eriksson M, Hayat R, Kinsella E, Lewis K, White DCS, Boyd J, Bullen A, Maclean M, Stoddart A, Phair S, Evans H, Noakes J, Alexander D, Keerie C, Linsley C, Milne G, Norrie J, Farrar N, Realpe AX, Donovan JL, Bunch J, Douthwaite K, Temple S, Hogg J, Scott D, Spallone P, Stuart I, Wardlaw JM, Palmer J, Sakka E, Mukerji N, Cirstea E, Davies S, Giannakaki V, Kadhim A, Kennion O, Islam M, Ferguson L, Prasad M, Bacon A, Richards E, Howe J, Kamara C, Gardner J, Roman M, Sikaonga M, Cahill J, Rossdeutsch A, Cahill V, Hamina I, Chaudhari K, Danciut M, Clarkson E, Bjornson A, Bulters D, Digpal R, Ruiz W, Taylor M, Anyog D, Tluchowska K, Nolasco J, Brooks D, Angelopoulou K, Welch B, Broomes N, Fouyas I, MacRaild A, Kaliaperumal C, Teasdale J, Coakley M, Brennan P, Sokol D, Wiggins A, MacDonald M, Risbridger S, Bhatt P, Irvine J, Majeed S, Williams S, Reid J, Walch A, Muir F, van Beijnum J, Leach P, Hughes T, Makwana M, Hamandi K, McAleer D, Gunning B, Walsh D, Wroe Wright O, Patel S, Gurusinghe N, Raza-Knight S, Cromie TL, Brown A, Raj S, Pennington R, Campbell C, Patel S, Colombo F, Teo M, Wildman J, Smith K, Goff E, Stephens D, Borislavova B, Worner R, Buddha S, Clatworthy P, Edwards R, Clayton E, Coy K, Tucker L, Dymond S, Mallick A, Hodnett R, Spickett-Jones F, Grover P, Banaras A, Tshuma S, Muirhead W, Scott Hill C, Shah R, Doke T, Hall R, Coskuner S, Aslett L, Vindlacheruvu R, Ghosh A, Fitzpatrick T, Harris L, Hayton T, Whitehouse A, McDarby A, Hancox R, Auyeung CK, Nair R, Thomas R, McLachlan H, Kountourgioti A, Orjales G, Kruczynski J, Hunter S, Bohnacker N, Marimon R, Parker L, Raha O, Sharma P, Uff C, Boyapati G, Papadopoulos M, Kearney S, Visagan R, Bosetta E, Asif H, Helmy A, Chapas L, Tarantino S, Caldwell K, Guilfoyle M, Agarwal S, Brown D, Holland S, Tajsic T, Fletcher C, Sebyatki A, Ushewokunze S, Ali S, Preston J, Chambers C, Patel M, Holsgrove D, McLaughlan D, Marsden T, Colombo F, Cawley K, Raffalli H, Lee S, Israni A, Dore R, Anderson T, Hennigan D, Mayor S, Glover S, Chavredakis E, Brown D, Sokratous G, Williamson J, Stoneley C, Brodbelt A, Farah JO, Illingworth S, Konteas AB, Davies D, Owen C, Kerr L, Hall P, Al-Shahi Salman R, Forsyth L, Lewis SC, Loan JJM, Neilson AR, Stephen J, Kitchen N, Harkness KA, Hutchinson PJA, Mallucci C, Wade J, White PM. Medical management and surgery versus medical management alone for symptomatic cerebral cavernous malformation (CARE): a feasibility study and randomised, open, pragmatic, pilot phase trial. Lancet Neurol 2024; 23:565-576. [PMID: 38643777 DOI: 10.1016/s1474-4422(24)00096-6] [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: 01/29/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The highest priority uncertainty for people with symptomatic cerebral cavernous malformation is whether to have medical management and surgery or medical management alone. We conducted a pilot phase randomised controlled trial to assess the feasibility of addressing this uncertainty in a definitive trial. METHODS The CARE pilot trial was a prospective, randomised, open-label, assessor-blinded, parallel-group trial at neuroscience centres in the UK and Ireland. We aimed to recruit 60 people of any age, sex, and ethnicity who had mental capacity, were resident in the UK or Ireland, and had a symptomatic cerebral cavernous malformation. Computerised, web-based randomisation assigned participants (1:1) to medical management and surgery (neurosurgical resection or stereotactic radiosurgery) or medical management alone, stratified by the neurosurgeon's and participant's consensus about the intended type of surgery before randomisation. Assignment was open to investigators, participants, and carers, but not clinical outcome event adjudicators. Feasibility outcomes included site engagement, recruitment, choice of surgical management, retention, adherence, data quality, clinical outcome event rate, and protocol implementation. The primary clinical outcome was symptomatic intracranial haemorrhage or new persistent or progressive non-haemorrhagic focal neurological deficit due to cerebral cavernous malformation or surgery during at least 6 months of follow-up. We analysed data from all randomly assigned participants according to assigned management. This trial is registered with ISRCTN (ISRCTN41647111) and has been completed. FINDINGS Between Sept 27, 2021, and April 28, 2023, 28 (70%) of 40 sites took part, at which investigators screened 511 patients, of whom 322 (63%) were eligible, 202 were approached for recruitment, and 96 had collective uncertainty with their neurosurgeon about whether to have surgery for a symptomatic cerebral cavernous malformation. 72 (22%) of 322 eligible patients were randomly assigned (mean recruitment rate 0·2 [SD 0·25] participants per site per month) at a median of 287 (IQR 67-591) days since the most recent symptomatic presentation. Participants' median age was 50·6 (IQR 38·6-59·2) years, 68 (94%) of 72 participants were adults, 41 (57%) were female, 66 (92%) were White, 56 (78%) had a previous intracranial haemorrhage, and 28 (39%) had a previous epileptic seizure. The intended type of surgery before randomisation was neurosurgical resection for 19 (26%) of 72, stereotactic radiosurgery for 44 (61%), and no preference for nine (13%). Baseline clinical and imaging data were complete for all participants. 36 participants were randomly assigned to medical management and surgery (12 to neurosurgical resection and 24 to stereotactic radiosurgery) and 36 to medical management alone. Three (4%) of 72 participants withdrew, one was lost to follow-up, and one declined face-to-face follow-up, leaving 67 (93%) retained at 6-months' clinical follow-up. 61 (91%) of 67 participants with follow-up adhered to the assigned management strategy. The primary clinical outcome occurred in two (6%) of 33 participants randomly assigned to medical management and surgery (8·0%, 95% CI 2·0-32·1 per year) and in two (6%) of 34 participants randomly assigned to medical management alone (7·5%, 1·9-30·1 per year). Investigators reported no deaths, no serious adverse events, one protocol violation, and 61 protocol deviations. INTERPRETATION This pilot phase trial exceeded its recruitment target, but a definitive trial will require extensive international engagement. FUNDING National Institute for Health and Care Research.
Collapse
|
4
|
Zhang H, Yu Q, Mao Z, Zhang L, Yu X. Outcomes after surgical and nonsurgical treatment of pediatric cerebral cavernous malformation. Pediatr Investig 2024; 8:126-134. [PMID: 38910851 PMCID: PMC11193375 DOI: 10.1002/ped4.12435] [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: 12/26/2023] [Accepted: 04/16/2024] [Indexed: 06/25/2024] Open
Abstract
Importance Pediatric cerebral cavernous malformation (CCM) is a rarely encountered vascular entity. Comparative study on surgical excision and nonsurgical management outcomes of CCM in pediatrics is limited. Objective To determine the demographic characteristics, hemorrhage rate, and long-term outcomes of pediatric patients with CCM. Methods A retrospective study of pediatric patients with CCM in Chinese PLA General Hospital was conducted between January 2004 and January 2019. We compared the clinical characteristics, radiological features, and outcomes of the surgical and nonsurgical groups. Results Seventy-nine children were included, with 69.6% being boys, and the average age was 11.8 ± 5.5 years. The annual retrospective hemorrhagic rate was 5.7% per patient per year. Fifty-six children (70.9%) underwent surgical excision, and they were more likely to present with seizure symptoms (P = 0.011), have a higher proportion of larger lesion size (P = 0.008), less likely to have durations ≤10 days (P = 0.048), and less likely to have supratentorial deep CCM (P = 0.014) compared to children who received nonsurgical management. Total resection was achieved in most surgical cases (55, 98.2%). During the 143.9 ± 50.8 months of follow-up, 44 patients (78.6%) achieved improvement, 12 patients (17.8%) remained the same, and two (3.6%) experienced worsening. In the nonsurgical management group, 14 children (60.9%) experienced symptom improvement, eight (34.8%) remained the same, and one (4.3%) worsened, with a re-hemorrhagic risk of 8.7%. Interpretation Surgical removal of pediatric CCM can eliminate the risk of hemorrhage and lead to satisfactory outcomes. For children undergoing nonsurgical management, long-term close monitoring is essential due to the life-long risk of hemorrhage.
Collapse
Affiliation(s)
- Haohao Zhang
- Medical School of Nankai UniversityTianjinChina
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
| | - Qishuai Yu
- Medical School of Nankai UniversityTianjinChina
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
| | - Zhiqi Mao
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
| | - Liang Zhang
- Department of NeurosurgeryNational Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xinguang Yu
- Medical School of Nankai UniversityTianjinChina
- Department of NeurosurgeryChinese PLA General HospitalBeijingChina
| |
Collapse
|
5
|
Fotakopoulos G, Georgakopoulou VE, Papalexis P, Spandidos DA, Trakas N, Sklapani P, Fountas KN. Management of intracranial cavernous malformations using conservative vs. surgical and/or radiosurgical treatment: A systematic review and meta‑analysis. Exp Ther Med 2024; 27:215. [PMID: 38590573 PMCID: PMC11000448 DOI: 10.3892/etm.2024.12503] [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: 11/20/2023] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
Intracranial cavernous malformations (CMs) are vascular lesions with a high bleeding rate. At present, the debate regarding their treatment is still ongoing. The present systematic review and meta-analysis aimed to evaluate the safety of surgery or radiosurgery (SRS) for the management of CMs and to determine their potential outcomes compared with conservative treatment. The present systematic review and meta-analysis investigated the relative articles involving the management of intracranial CMs, namely their natural history (conservative treatment) vs. surgical/SRS treatment through electronic databases until June, 2023. The collected variables included the first author's name, the study period covered, the year of publication, the total number of patients examined and their age, and the number of males. In total, six articles met the eligibility criteria. The total number of patients was 399 (157 in the surgery/SRS group and 242 in the conservative treatment group). The results revealed that surgical or SRS management is a safe procedure for CMs compared with conservative treatment. Notably, the use of hemosiderin in the pre-MRI, the free of seizures parameter and the neurological deficit parameters were associated with improved outcomes in the surgical or SRS group of patients.
Collapse
Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Petros Papalexis
- Unit of Endocrinology, First Department of Propedeutic and Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| |
Collapse
|
6
|
Meneghelli P, Pasqualin A, Musumeci A, Pinna G, Berti PP, Polizzi GMV, Sinosi FA, Nicolato A, Sala F. Microsurgical removal of supratentorial and cerebellar cavernous malformations: what has changed? A single institution experience. J Clin Neurosci 2024; 123:162-170. [PMID: 38581776 DOI: 10.1016/j.jocn.2024.04.001] [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: 12/21/2023] [Revised: 03/09/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Features associated with a safe surgical resection of cerebral cavernous malformations (CMs) are still not clear and what is needed to achieve this target has not been defined yet. METHODS Clinical presentation, radiological features and anatomical locations were assessed for patients operated on from January 2008 to January 2018 for supratentorial and cerebellar cavernomas. Supratentorial CMs were divided into 3 subgroups (non-critical vs. superficial critical vs. deep critical). The clinical outcome was assessed through modified Rankin Scale (mRS) and was divided into favorable (mRS 0-1) and unfavorable (mRS ≥ 2). Post-operative epilepsy was classified according to the Maraire Scale. RESULTS A total of 144 were considered eligible for the current study. At 6 months follow-up the clinical outcome was excellent for patients with cerebellar or lobar CMs in non-critical areas (mRS ≤ 1: 91.1 %) and for patients with superficial CMs in critical areas (mRS ≤ 1: 92.3 %). Patients with deep-seated suprantentorial CMs showed a favorable outcome in 76.9 %. As for epilepsy 58.5 % of patients presenting with a history of epilepsy were free from seizures and without therapy (Maraire grade I) at last follow-up (mean 3.9 years) and an additional 41.5 % had complete control of seizures with therapy (Maraire grade II). CONCLUSIONS Surgery is safe in the management of CMs in non-critical but also in critical supratentorial locations, with a caveat for deep structures such as the insula, the basal ganglia and the thalamus/hypothalamus.
Collapse
Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Angelo Musumeci
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Giampietro Pinna
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Pier Paolo Berti
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | | | | | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona
| |
Collapse
|
7
|
Fisher DG, Sharifi KA, Shah IM, Gorick CM, Breza VR, Debski AC, Hoch MR, Cruz T, Samuels JD, Sheehan JP, Schlesinger D, Moore D, Lukens JR, Miller GW, Tvrdik P, Price RJ. Focused Ultrasound Blood-Brain Barrier Opening Arrests the Growth and Formation of Cerebral Cavernous Malformations. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.31.577810. [PMID: 38352349 PMCID: PMC10862920 DOI: 10.1101/2024.01.31.577810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) are vascular lesions within the central nervous system, consisting of dilated and hemorrhage-prone capillaries. CCMs can cause debilitating neurological symptoms, and surgical excision or stereotactic radiosurgery are the only current treatment options. Meanwhile, transient blood-brain barrier opening (BBBO) with focused ultrasound (FUS) and microbubbles is now understood to exert potentially beneficial bioeffects, such as stimulation of neurogenesis and clearance of amyloid-β. Here, we tested whether FUS BBBO could be deployed therapeutically to control CCM formation and progression in a clinically-representative murine model. METHODS CCMs were induced in mice by postnatal, endothelial-specific Krit1 ablation. FUS was applied for BBBO with fixed peak-negative pressures (PNPs; 0.2-0.6 MPa) or passive cavitation detection-modulated PNPs. Magnetic resonance imaging (MRI) was used to target FUS treatments, evaluate safety, and measure longitudinal changes in CCM growth after BBBO. RESULTS FUS BBBO elicited gadolinium accumulation primarily at the perilesional boundaries of CCMs, rather than lesion cores. Passive cavitation detection and gadolinium contrast enhancement were comparable in CCM and wild-type mice, indicating that Krit1 ablation does not confer differential sensitivity to FUS BBBO. Acutely, CCMs exposed to FUS BBBO remained structurally stable, with no signs of hemorrhage. Longitudinal MRI revealed that FUS BBBO halted the growth of 94% of CCMs treated in the study. At 1 month, FUS BBBO-treated lesions lost, on average, 9% of their pre-sonication volume. In contrast, non-sonicated control lesions grew to 670% of their initial volume. Lesion control with FUS BBBO was accompanied by a marked reduction in the area and mesenchymal appearance of Krit mutant endothelium. Strikingly, in mice receiving multiple BBBO treatments with fixed PNPs, de novo CCM formation was significantly reduced by 81%. Mock treatment plans on MRIs of patients with surgically inaccessible lesions revealed their lesions are amenable to FUS BBBO with current clinical technology. CONCLUSIONS Our results establish FUS BBBO as a novel, non-invasive modality that can safely arrest murine CCM growth and prevent their de novo formation. As an incisionless, MR image-guided therapy with the ability to target eloquent brain locations, FUS BBBO offers an unparalleled potential to revolutionize the therapeutic experience and enhance the accessibility of treatments for CCM patients.
Collapse
Affiliation(s)
- Delaney G Fisher
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Khadijeh A Sharifi
- Department of Neuroscience, University of Virginia, Charlottesville, VA
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Ishaan M Shah
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Catherine M Gorick
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Victoria R Breza
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Anna C Debski
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Matthew R Hoch
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Tanya Cruz
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Joshua D Samuels
- Department of Neuroscience, University of Virginia, Charlottesville, VA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - David Schlesinger
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, VA
| | - David Moore
- Focused Ultrasound Foundation, Charlottesville, VA
| | - John R Lukens
- Department of Neuroscience, University of Virginia, Charlottesville, VA
| | - G Wilson Miller
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA
| | - Petr Tvrdik
- Department of Neuroscience, University of Virginia, Charlottesville, VA
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Richard J Price
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Loan JJM, Bacon A, van Beijnum J, Bhatt P, Bjornson A, Broomes N, Bullen A, Bulters D, Cahill J, Chavredakis E, Colombo F, Danciut M, Digpal R, Edwards RJ, Ferguson L, Forsyth L, Fouyas I, Ganesan V, Grover P, Gurusinghe N, Hall PS, Harkness K, Harris LS, Hayton T, Helmy A, Holsgrove D, Hutchinson PJ, Israni A, Kinsella E, Lewis S, Majeed S, Mallucci C, Mukerji N, Nair R, Neilson AR, Papadopoulos MC, Radatz M, Rossdeutsch A, Raza-Knight S, Stephen J, Stoddart A, Teo M, Turner C, Wade J, Walsh D, White D, White P, Wildman J, Wroe Wright O, Uff C, Ushewokunze S, Vindlacheruvu R, Kitchen N, Al-Shahi Salman R. Feasibility of comparing medical management and surgery (with neurosurgery or stereotactic radiosurgery) with medical management alone in people with symptomatic brain cavernoma - protocol for the Cavernomas: A Randomised Effectiveness (CARE) pilot trial. BMJ Open 2023; 13:e075187. [PMID: 37558454 PMCID: PMC10414059 DOI: 10.1136/bmjopen-2023-075187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/29/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION The top research priority for cavernoma, identified by a James Lind Alliance Priority setting partnership was 'Does treatment (with neurosurgery or stereotactic radiosurgery) or no treatment improve outcome for people diagnosed with a cavernoma?' This pilot randomised controlled trial (RCT) aims to determine the feasibility of answering this question in a main phase RCT. METHODS AND ANALYSIS We will perform a pilot phase, parallel group, pragmatic RCT involving approximately 60 children or adults with mental capacity, resident in the UK or Ireland, with an unresected symptomatic brain cavernoma. Participants will be randomised by web-based randomisation 1:1 to treatment with medical management and with surgery (neurosurgery or stereotactic radiosurgery) versus medical management alone, stratified by prerandomisation preference for type of surgery. In addition to 13 feasibility outcomes, the primary clinical outcome is symptomatic intracranial haemorrhage or new persistent/progressive focal neurological deficit measured at 6 monthly intervals. An integrated QuinteT Recruitment Intervention (QRI) evaluates screening logs, audio recordings of recruitment discussions, and interviews with recruiters and patients/parents/carers to identify and address barriers to participation. A Patient Advisory Group has codesigned the study and will oversee its progress. ETHICS AND DISSEMINATION This study was approved by the Yorkshire and The Humber-Leeds East Research Ethics Committee (21/YH/0046). We will submit manuscripts to peer-reviewed journals, describing the findings of the QRI and the Cavernomas: A Randomised Evaluation (CARE) pilot trial. We will present at national specialty meetings. We will disseminate a plain English summary of the findings of the CARE pilot trial to participants and public audiences with input from, and acknowledgement of, the Patient Advisory Group. TRIAL REGISTRATION NUMBER ISRCTN41647111.
Collapse
Affiliation(s)
- James J M Loan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | | | - Nicole Broomes
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | - Alistair Bullen
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Diederik Bulters
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | - Julian Cahill
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | | | - Ronneil Digpal
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | | | | | - Laura Forsyth
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Ioannis Fouyas
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Vijeya Ganesan
- Developmental Neurosciences Department, Great Ormond Street Hospital for Children, London, UK
| | - Patrick Grover
- The National Hospital for Neurology & Neurosurgery, London, UK
| | | | - Peter S Hall
- Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | | | - Tom Hayton
- Queen Elizabeth Hospital, Birmingham, UK
| | - Adel Helmy
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Daniel Holsgrove
- Centre for Clinical Neurosciences, Salford Royal Hospital Manchester, Salford, UK
| | - Peter J Hutchinson
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Anil Israni
- Alder Hey Children's Hospital, Liverpool, UK
| | - Elaine Kinsella
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | | | | | - Aileen R Neilson
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - Matthias Radatz
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Mario Teo
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Carole Turner
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Julia Wade
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Walsh
- King's College Hospital, London, UK
- Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | | | - Phil White
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Jack Wildman
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | | | | | | | | | - Neil Kitchen
- The National Hospital for Neurology & Neurosurgery, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Rauschenbach L, Santos AN, Dinger TF, Darkwah Oppong M, Li Y, Tippelt S, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional outcome after pediatric cerebral cavernous malformation surgery. Sci Rep 2023; 13:2286. [PMID: 36759693 PMCID: PMC9911771 DOI: 10.1038/s41598-023-29472-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
The purpose of this study was to investigate the functional outcome following surgical resection of cerebral cavernous malformations (CCM) in pediatric patients. We screened our institutional database of CCM patients treated between 2003 and 2021. Inclusion regarded individuals younger or equal than 18 years of age with complete clinical baseline characteristics, magnetic resonance imaging dataset, and postoperative follow-up time of at least three months. Functional outcome was quantified using the modified Rankin Scale (mRS) score and assessed at admission, discharge, and last follow-up examination. The primary endpoint was the postoperative functional outcome. As a secondary endpoint, predictors of postoperative functional deterioration were assessed. A total of 49 pediatric patients with a mean age of 11.3 ± 5.7 years were included for subsequent analyses. Twenty individuals (40.8%) were female. Complete resection of the lesion was achieved in 44 patients (89.8%), and two patients with incomplete resection were referred for successive remnant removal. The mean follow-up time after surgery was 44 months (IQR: 13 - 131). The mean mRS score was 1.6 on admission, 1.7 at discharge, and 0.9 at the latest follow-up. Logistic regression analysis adjusted to age and sex identified brainstem localization (aOR = 53.45 [95%CI = 2.26 - 1261.81], p = .014) as a predictor of postoperative deterioration. This study indicates that CCM removal in children can be regarded as safe and favorable for the majority of patients, depending on lesion localization. Brainstem localization implies a high risk of postoperative morbidity and indication for surgery should be balanced carefully. Minor evidence indicates that second-look surgery for CCM remnants might be safe and favorable.
Collapse
Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany. .,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany.
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| |
Collapse
|
13
|
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.
Collapse
|
14
|
Berber T, Celik SE, Aksaray F, Yoney A, Harmanci K, Tambas M, Yılmaz BD, Numanoglu C, Yolcu A, Açan Hİ, Dinçer ST, Yıldırım BA. Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas. JOURNAL OF RADIATION RESEARCH 2023; 64:133-141. [PMID: 36208871 PMCID: PMC9855324 DOI: 10.1093/jrr/rrac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Indexed: 06/16/2023]
Abstract
In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.
Collapse
Affiliation(s)
- Tanju Berber
- Corresponding author. Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Kaptan Pasa, SSK Okmeydani Hst. No: 25, 34384 Sisli/Istanbul, Turkey. Tel: +905324111202;
| | - Suat Erol Celik
- Department of Neurosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ferdi Aksaray
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Adnan Yoney
- Department of Internal Medicine, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Kemal Harmanci
- Department of Radiology, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Makbule Tambas
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Binnur Dönmez Yılmaz
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Cakir Numanoglu
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ahmet Yolcu
- Department of Radiation Oncology, Namık Kemal University Medical Faculty of Medicine, Tekirdag, Turkey
| | - Hilal İrem Açan
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Selvi Tabak Dinçer
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Berna Akkuş Yıldırım
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Ogasawara C, Watanabe G, Young K, Kwon R, Conching A, Palmisciano P, Kan P, de Oliveira Sillero R. Laser Interstitial Thermal Therapy for Cerebral Cavernous Malformations: A Systematic Review of Indications, Safety, and Outcomes. World Neurosurg 2022; 166:279-287.e1. [PMID: 35760323 DOI: 10.1016/j.wneu.2022.06.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) in deep eloquent areas present a surgical challenge. Laser interstitial thermal therapy (LITT) may present itself as a safe minimally invasive treatment option. OBJECTIVE To systematically review the indications, safety, and outcomes of LITT for CCM. METHODS Electronic databases were searched from inception to October 7, 2021 for articles with CCM and LITT keywords. Studies describing CCMs treated with LITT were included. RESULTS A total of 32 patients with CCMs in lobar (79%), basal ganglia (12%), and brainstem (9%) locations were treated with LITT. Indications for LITT included drug-resistant seizures (75%), unacceptable surgical risk (22%), recurrent hemorrhage (16%), and early intervention to discontinue antiepileptic drugs (3%). No death or CCM-associated intracranial hemorrhage occurred intraoperatively or postoperatively, and most patients experienced no adverse effects or transient effects that resolved at follow-up (84%). Of those treated for CCM-associated epilepsy, 83% experienced Engel class I seizure freedom and most were class IA (61%). Most patients experienced symptomatic improvement (93%), and a decrease in antiepileptic drugs was reported in more than half of patients (56%), with 28% able to discontinue all antiepilepsy medications after LITT. CONCLUSIONS LITT seems to be a safe treatment for CCMs located in deep eloquent areas and in lesions presenting with medically refractory seizures or recurrent hemorrhages. Randomized studies are needed to further elucidate its efficacy in treating CCM.
Collapse
Affiliation(s)
- Christian Ogasawara
- Division of Neurosurgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i, USA.
| | - Gina Watanabe
- Division of Neurosurgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i, USA
| | - Kurtis Young
- Division of Neurosurgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i, USA
| | - Royce Kwon
- Division of Neurosurgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i, USA
| | - Andie Conching
- Division of Neurosurgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | | |
Collapse
|
18
|
Dammann P, Santos AN, Wan XY, Zhu Y, Sure U. Cavernous Malformations. Neurosurg Clin N Am 2022; 33:449-460. [DOI: 10.1016/j.nec.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Tu T, Peng Z, Ren J, Zhang H. Cerebral Cavernous Malformation: Immune and Inflammatory Perspectives. Front Immunol 2022; 13:922281. [PMID: 35844490 PMCID: PMC9280619 DOI: 10.3389/fimmu.2022.922281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/18/2022] [Indexed: 12/03/2022] Open
Abstract
Cerebral cavernous malformation (CCM) is a type of vascular anomaly that arises due to the dyshomeostasis of brain capillary networks. In the past two decades, many advances have been made in this research field. Notably, as a more reasonable current view, the CCM lesions should be attributed to the results of a great number of additional events related to the homeostasis disorder of the endothelial cell. Indeed, one of the most fascinating concerns in the research field is the inflammatory perturbation in the immune microenvironment, which would affect the disease progression as well as the patients’ outcomes. In this work, we focused on this topic, and underlined the immune-related factors’ contribution to the CCM pathologic progression.
Collapse
Affiliation(s)
- Tianqi Tu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenghong Peng
- Health Management Department, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Hongqi Zhang,
| |
Collapse
|
21
|
Rauschenbach L, Bartsch P, Santos AN, Lenkeit A, Darkwah Oppong M, Wrede KH, Jabbarli R, Chmielewski WX, Schmidt B, Quesada CM, Forsting M, Sure U, Dammann P. Quality of life and mood assessment in conservatively treated cavernous malformation-related epilepsy. Brain Behav 2022; 12:e2595. [PMID: 35470577 PMCID: PMC9226805 DOI: 10.1002/brb3.2595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/03/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To estimate the quality of life, anxiety, depression, and illness perception in patients with medically treated cerebral cavernous malformation (CCM) and associated epilepsy. METHODS Nonsurgically treated patients with CCM-related epilepsy (CRE) were included. Demographic, radiographic, and clinical features were assessed. All participants received established questionnaires (short-form 36 health survey, SF-36; hospital anxiety and depression score, HADS-A/D; visual analogue scale score, VAS) assessing the functional and psychosocial burden of disease. To some extent, calculated values were compared with reference values from population-based studies. Test results were related to seizure control. RESULTS A total of 37 patients were included. Mean age was 45.8 ± 14.4 years, and 54.1% were female. Diagnosis of CRE was significantly associated with attenuated quality of life and increased level of anxiety, affecting physical and psychosocial dimensions. The assessment of illness perception identified considerable burden. HADS was significantly associated with VAS and SF-36 component scores. Efficacy of antiepileptic medication had no restoring impact on quality of life, anxiety, depression, or illness perception. CONCLUSIONS CRE negatively influences quality of life and mood, independent of seizure control due to antiepileptic medication. Screening for functional and psychosocial deficits in clinical practice might be useful for assessing individual burden and allocating surgical or drug treatment.
Collapse
Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Pauline Bartsch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Annika Lenkeit
- 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
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Witold X Chmielewski
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Carlos M Quesada
- Department of Neurology, Division of Epilepsy, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Zuurbier SM, Hickman CR, Rinkel LA, Berg R, Sure U, Al-Shahi Salman R. Association Between Beta-Blocker or Statin Drug Use and the Risk of Hemorrhage From Cerebral Cavernous Malformations. Stroke 2022; 53:2521-2527. [PMID: 35410492 PMCID: PMC9311291 DOI: 10.1161/strokeaha.121.037009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to determine the association between beta-blocker or statin drug use and the future risk of symptomatic intracranial hemorrhage or persistent/progressive focal neurological deficit from cerebral cavernous malformations (CCM). METHODS The population-based Scottish Audit of Intracranial Vascular Malformations prospectively identified adults resident in Scotland first diagnosed with CCM during 1999 to 2003 or 2006 to 2010. We compared the association between beta-blocker or statin drug use after first presentation and the occurrence of new intracranial hemorrhage or persistent/progressive focal neurological deficit due to CCM for up to 15 years of prospective follow-up. We confirmed proportional hazards and used survival analysis with multivariable adjustment for age, intracranial hemorrhage at CCM presentation, and brain stem CCM location. RESULTS Sixty-three (21%) of 300 adults used beta-blockers (27/63 [43%] used propranolol), and 73 (24%) used statin drugs over 3634 person-years of follow-up. At baseline, the only statistically significant imbalances in prespecified potential confounders were age by statin use and intracranial hemorrhage at presentation by beta-blocker use. Beta-blocker use was associated with a lower risk of new intracranial hemorrhage or persistent/progressive focal neurological deficit (adjusted hazard ratio, 0.09 [95% CI, 0.01-0.66]; P=0.018). Statin use was associated with a nonsignificant lower risk of intracranial hemorrhage or persistent/progressive focal neurological deficit (adjusted hazard ratio, 0.37 [95% CI, 0.01-1.07]; P=0.067). CONCLUSIONS Beta-blocker, but not statin, use was associated with a lower risk of intracranial hemorrhage or persistent/progressive focal neurological deficit in patients with CCM.
Collapse
Affiliation(s)
- Susanna M Zuurbier
- Department of Neurology, Amsterdam University Medical Center, The Netherlands (S.M.Z., L.A.R.)
| | - Charlotte R Hickman
- Edinburgh Medical School, College of Medicine and Veterinary Medicine (C.R.H.)
| | - Leon A Rinkel
- Department of Neurology, Amsterdam University Medical Center, The Netherlands (S.M.Z., L.A.R.)
| | - Rebecca Berg
- University of Edinburgh, United Kingdom. Department of Neurosurgery, University of Duisburg-Essen, Germany (R.B., U.S.)
| | - Ulrich Sure
- University of Edinburgh, United Kingdom. Department of Neurosurgery, University of Duisburg-Essen, Germany (R.B., U.S.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Usher Institute of Population Health Sciences and Informatics (R.A.-S.S.)
| | | |
Collapse
|
24
|
Santos AN, Rauschenbach L, Saban D, Chen B, Darkwah Oppong M, Herten A, Hadice Gull H, Rieß C, Deuschl C, Schmidt B, Jabbarli R, Wrede KH, Zhu Y, Frank B, Sure U, Dammann P. Multiple Cerebral Cavernous Malformations – Clinical Course of Confirmed, Assumed and Non‐Familial Disease. Eur J Neurol 2022; 29:1427-1434. [DOI: 10.1111/ene.15253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Alejandro N. Santos
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Hanah Hadice Gull
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Christoph Rieß
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology University Hospital of Essen Essen Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Karsten H. Wrede
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Yuan Zhu
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Benedikt Frank
- Department of Neurology University Hospital Essen Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| |
Collapse
|
25
|
Harris L, Poorthuis MHF, Grover P, Kitchen N, Al-Shahi Salman R. Surgery for cerebral cavernous malformations: a systematic review and meta-analysis. Neurosurg Rev 2021; 45:231-241. [PMID: 34191202 DOI: 10.1007/s10143-021-01591-5] [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: 11/19/2020] [Revised: 03/21/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND We sought to quantify the risks of neurosurgical excision of cerebral cavernous malformations (CCMs) in a systematic review of cohort studies. METHODS We updated our previous systematic review by searching OVID Medline, OVID EMBASE, and the Cochrane Library from 1 January 2013 to 30 April 2019. The primary outcome was a composite of death attributed to CCM or surgery, non-fatal symptomatic intracerebral haemorrhage (ICH), or new or worsened persistent non-haemorrhagic focal neurological deficit (FND). RESULTS We included 70 cohorts, 67 reporting surgery alone, and three compared surgery to conservative management. A total of 5,089 patients (median age 36 years, 52% female) underwent surgery (total follow-up 19,404 patient-years). The annual rate of the composite outcome was 4.2% (95% CI 2.9 to 5.7; 46 cohorts; I2 = 93%), which was higher in cohorts reporting exclusively brainstem CCM (6.0%, 95% CI 4.1-8.3; 25 cohorts, I2 = 92%) versus predominantly supratentorial CCM (2.4%, 95% CI 1.3-3.8, 21 cohorts, I2 = 86%, phet = 0.001). The annual rate of the composite outcome was higher in cohorts with > 95% presenting with ICH (6.1%, 95% CI 4.2-8.4; 23 cohorts, I2 = 93%) versus others (2.3%, 95% CI 1.2-3.7; 23 cohorts, I2 = 83%, phet = 0.001). The incidence of the composite outcome did not change over time in cohorts of exclusively brainstem CCM (p = 0.7) or predominantly supratentorial CCM (p = 0.5). CONCLUSIONS The risk of death, ICH, or FND after CCM excision is ~ 4%. This risk is higher for brainstem CCM and CCM that have caused ICH but has not changed over time. TRIAL REGISTRATION This systematic review was registered (PROSPERO CRD42019131246).
Collapse
Affiliation(s)
- Lauren Harris
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
| | - Michiel H F Poorthuis
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Patrick Grover
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Neil Kitchen
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | | |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Lin F, He Q, Gao Z, Yu L, Wang D, Zheng S, Lin Y, Kang D. Treatments and outcomes of untreated cerebral cavernous malformations in China: study protocol of a nationwide multicentre prospective cohort study. BMJ Open 2020; 10:e037957. [PMID: 33122314 PMCID: PMC7597476 DOI: 10.1136/bmjopen-2020-037957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The treatment decision and long-term outcomes of previously untreated cerebral cavernous malformation (U-CCM) are still controversial. Therefore, we are conducting a nationwide multicentre prospective registry study in China to determine the natural history and effect of surgical treatment on long-term outcomes in Chinese people with U-CCM. METHODS AND ANALYSIS This study was started on 1 January 2018 and is currently ongoing. It is a cohort follow-up study across a 5-year period. Patients will be followed up for at least 3 years after inception. Patients with U-CCM will be enrolled from 24 Grade III, level A hospitals distributed all over China. The cohort size is estimated to be 1200 patients. Patients are registered in surgically treated group and conservatively treated group. Clinical characteristics, radiology information and laboratory data are prospectively collected using an electronic case report form through an electronic data capture system. The primary outcome of this study is poor clinical outcome at the last follow-up (modified Rankin Scale score >2 lasting at least 1 year). The secondary outcome includes symptomatic haemorrhage, drug refractory epilepsy, focal neurological deficits, morbidity and all-cause mortality during follow-up. Univariate and multivariate regression analysis will be performed to determine the risk factors for poor outcomes in all patients, and to estimate the effect of surgery. Life tables, Kaplan-Meier estimates, log-rank test and proportional hazards Cox regression will be used to analyse the follow-up data of conservatively treated patients to determine the natural history of U-CCM. Initial presentation and location of U-CCM are prespecified subgroup factors. ETHICS AND DISSEMINATION The study protocol and informed consent form have been reviewed and approved by the Research Ethical Committee of First Affiliated Hospital of Fujian Medical University (FAHFMU-2018-003).Written informed consent will be obtained from each adult participant or from the guardian of each paediatric participant. The final results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03467295.
Collapse
Affiliation(s)
- Fuxin Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Qiu He
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Zhuyu Gao
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Lianghong Yu
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Dengliang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Shufa Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Fujian Neuromedicine Center, Fuzhou, China
| |
Collapse
|
28
|
Ma L, Zhang S, Li Z, Wu CX, Wang Z, Zhan L, Hao Q, Wang H, Ye X, Chen X, Liu YO, Wang S, Zhao YL. Morbidity After Symptomatic Hemorrhage of Cerebral Cavernous Malformation: A Nomogram Approach to Risk Assessment. Stroke 2020; 51:2997-3006. [PMID: 32951540 DOI: 10.1161/strokeaha.120.029942] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Symptomatic hemorrhage contributes to an increased risk of repeated bleeding and morbidity in cerebral cavernous malformation (CCM). A better understanding of morbidity after CCM hemorrhage would be helpful to identify patients of higher risk for unfavorable outcome and tailor individualized management. METHODS We identified 282 consecutive patients who referred to our institute from 2014 to 2018 for CCM with symptomatic hemorrhage and had an untreated follow-up period over 6 months after the first hemorrhage. The morbidity after hemorrhage was described in CCM of different features. Nomogram to predict morbidity was formulated based on the multivariable model of risk factors. The predictive accuracy and discriminative ability of nomogram were determined with concordance index (C-index) and calibration curve, and further validated in an independent CCM cohort of a prospective multicenter study from 2019 to 2020. RESULTS The overall morbidity of CCM was 26.2% after a mean follow-up of 1.9 years (range 0.5-3.5 years) since the first hemorrhage. The morbidity during untreated follow-up was associated with hemorrhage ictus (adjusted odds ratio per ictus increase, 4.17 [95% CI, 1.86-9.33]), modified Rankin Scale score at initial hemorrhage (adjusted odds ratio per point increase, 2.57 [95% CI, 1.82-3.63]), brainstem location (adjusted odds ratio, 2.93 [95% CI, 1.28-6.68]), and associated developmental venous anomaly (adjusted odds ratio, 2.21 [95% CI, 1.01-4.83]). Subgroup analysis revealed similar findings in brainstem and non-brainstem CCM. Nomogram was contracted based on these features. The calibration curve showed good agreement between nomogram prediction and actual observation. The C-index of nomogram predicting morbidity was 0.83 (95% CI, 0.77-0.88). In validation cohort, the nomogram maintained the discriminative ability (C-index, 0.87 [95% CI, 0.78-0.96]). CONCLUSIONS Multiple symptomatic hemorrhages, initial neurological function after hemorrhage, brainstem location, and associated developmental venous anomaly were associated with morbidity of CCM hemorrhage. The nomogram represented a practical approach to provide individualized risk assessment for CCM patients. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04076449.
Collapse
Affiliation(s)
- Li Ma
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.)
| | - Shuo Zhang
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.)
| | - Zongze Li
- Department of Neurosurgery, Peking University International Hospital, Beijing, China (Z.L.)
| | - Chun-Xue Wu
- Department of Radiology (C.-X.W., Z.W., Y.-O.L., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China
| | - Zhaozhao Wang
- Department of Radiology (C.-X.W., Z.W., Y.-O.L., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China
| | - Lei Zhan
- School of Nursing, The George Washington University, Washington, DC (L.Z.)
| | - Qiang Hao
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.)
| | - Hao Wang
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.)
| | - Xun Ye
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.).,Beijing Translational Engineering Center for 3D Print in Clinical Neuroscience, China (X.Y., S.W., Y.-L.Z.)
| | - Xiaolin Chen
- China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.)
| | - Ya-Ou Liu
- Department of Radiology (C.-X.W., Z.W., Y.-O.L., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.)
| | - Shuo Wang
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.).,Center of Stroke, Beijing Institute for Brain Disorders, China (S.W., Y.-L.Z.).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (S.W., Y.-L.Z.).,Beijing Translational Engineering Center for 3D Print in Clinical Neuroscience, China (X.Y., S.W., Y.-L.Z.)
| | - Yuan-Li Zhao
- Department of Neurosurgery (L.M., S.Z., Q.H., H.W., X.Y., X.C., S.W., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,Department of Radiology (C.-X.W., Z.W., Y.-O.L., Y.-L.Z.), Beijing Tiantan Hospital, Capital Medical University, PR China.,China National Clinical Research Center for Neurological Diseases, Beijing, China (L.M., S.Z., Q.H., H.W., X.Y., X.C., Y.-O.L., S.W., Y.-L.Z.).,Center of Stroke, Beijing Institute for Brain Disorders, China (S.W., Y.-L.Z.).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (S.W., Y.-L.Z.).,Beijing Translational Engineering Center for 3D Print in Clinical Neuroscience, China (X.Y., S.W., Y.-L.Z.)
| |
Collapse
|
29
|
Idiculla PS, Gurala D, Philipose J, Rajdev K, Patibandla P. Cerebral Cavernous Malformations, Developmental Venous Anomaly, and Its Coexistence: A Review. Eur Neurol 2020; 83:360-368. [PMID: 32731220 DOI: 10.1159/000508748] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) are intracranial vascular malformations that can exist as a single lesion or mixed vascular lesions. The most common mixed form is the coexistence of CCM with an associated developmental venous anomaly (DVA). In this paper, we aim to give a comprehensive review of CCM, DVA, and their coexistence as mixed lesions. A PubMed search using the keywords "Cerebral cavernous malformations, Developmental venous anomaly, Mixed Cerebral cavernous malformations with Developmental venous anomaly" was done. All studies in the English language in the past 10 years were analyzed descriptively for this review. SUMMARY The search yielded 1,249 results for "Cerebral cavernous malformations," 271 results for "Developmental venous anomaly," and 5 results for "Mixed Cerebral cavernous malformations with Developmental venous anomaly." DVA is the most common intracranial vascular malformation, followed by CCM. CCM can have a wide array of clinical presentations like hemorrhage, seizures, or focal neurological deficits or can also be an incidental finding on brain imaging. DVAs are benign lesions by nature; however, venous infarction can occur in a few patients due to acute thrombosis. Mixed CCM with DVA has a higher risk of hemorrhage. CCMs are angiographically occult lesion, and cerebral digital subtraction angiography is the gold standard for the diagnosis of DVA. Mixed lesions, on the other hand, are best diagnosed with magnetic resonance imaging, which has also been effective in detecting specific abnormalities. Asymptomatic lesions are treated through a conservative approach, while clinically symptomatic lesions need surgical management. CONCLUSION Individual CCM or DVA lesions have a benign course; however, when they coexist in the same individual, the hemorrhagic risk is increased, which prompts for rapid diagnosis and treatment.
Collapse
Affiliation(s)
| | - Dhineshreddy Gurala
- Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Jobin Philipose
- Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | | |
Collapse
|
30
|
Konovalov AN, Gavryushin AV, Khukhlaeva EA. [«Cavernous angiomas» of the brainstem. Clinical manifestations, diagnosis and treatment results]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:5-21. [PMID: 32412190 DOI: 10.17116/neiro2020840215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction In the current literature, brainstem hematomas and various types of vascular micromalformations are combined into the one group of diseases under the general name «cavernous angioma» (CA). This approach does not make it possible to accurately determine the indications for surgery and predict postoperative outcomes. Objective To analyze our own experience in the diagnosis and treatment of patients with the brainstem CA. Material and methods There were 515 patients with CA of the brainstem (surgery - 322, conservative treatment - 193 patients) with a follow-up period of more than 5 years. Follow-up survey implied neurological examination, analysis of Karnofsky score, MRI and CT data. Results We identified two main groups of patients after comparison of MRI data, intraoperative findings and biopsy data: group 1 - hematomas (191 patients, 59%), group 2 - CA (131 patients, 41%). Each group was characterized by own clinical and radiological features. Postoperative outcomes depended on the disease. Debridement of hematoma ensured early postoperative improvement in 63% of patients, no changes in 21% of cases and impairment in 16% of patients. Less favorable results were observed in patients with CA and no signs of hemorrhage. Clinical impairment occurred in 73% of cases, improvement - only in 5% of patients. The most significant regression of neurological symptoms in long-term postoperative period was observed in patients with hematomas (92% of patients). These ones noted much better clinical state compared with preoperative condition. Conclusions The type of brain lesion is an important predictor to determine treatment approach. Postoperative outcomes differ significantly in patients with the brainstem hematoma and CA.
Collapse
|
31
|
Lanfranconi S, Scola E, Bertani GA, Zarino B, Pallini R, d'Alessandris G, Mazzon E, Marino S, Carriero MR, Scelzo E, Faragò G, Castori M, Fusco C, Petracca A, d'Agruma L, Tassi L, d'Orio P, Lampugnani MG, Nicolis EB, Vasamì A, Novelli D, Torri V, Meessen JMTA, Al-Shahi Salman R, Dejana E, Latini R. Propranolol for familial cerebral cavernous malformation (Treat_CCM): study protocol for a randomized controlled pilot trial. Trials 2020; 21:401. [PMID: 32398113 PMCID: PMC7218540 DOI: 10.1186/s13063-020-4202-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/24/2020] [Indexed: 12/21/2022] Open
Abstract
Background Cerebral cavernous malformations (CCMs) are vascular malformations characterized by clusters of enlarged leaky capillaries in the central nervous system. They may result in intracranial haemorrhage, epileptic seizure(s), or focal neurological deficits, and potentially lead to severe disability. Globally, CCMs represent the second most common intracranial vascular malformation in humans, and their familial form (FCCMs) accounts for one-fifth of cases. Neurosurgical excision, and perhaps stereotactic radiosurgery, is the only available therapeutic option. Case reports suggest that propranolol might modify disease progression. Methods Treat_CCM is a prospective, randomized, open-label, blinded endpoint (PROBE), parallel-group trial involving six Italian clinical centres with central reading of brain magnetic resonance imaging (MRI) and adverse events. Patients with symptomatic FCCMs are randomized (2:1 ratio) either to propranolol (40–80 mg twice daily) in addition to standard care or to standard care alone (i.e. anti-epileptic drugs or headache treatments). The primary outcome is intracranial haemorrhage or focal neurological deficit attributable to CCMs. The secondary outcomes are MRI changes over time (i.e. de novo CCM lesions, CCM size and signal characteristics, iron deposition, and vascular leakage as assessed by quantitative susceptibility mapping and dynamic contrast enhanced permeability), disability, health-related quality of life, depression severity, and anxiety (SF-36, BDI-II, State-Trait Anxiety Inventory). Discussion Treat_CCM will evaluate the safety and efficacy of propranolol for CCMs following promising case reports in a randomized controlled trial. The direction of effect on the primary outcome and the consistency of effects on the secondary outcomes (even if none of them yield statistically significant differences) of this external pilot study may lead to a larger sample size in a definitive phase 2 trial. Trial registration ClinicalTrails.gov, NCT03589014. Retrospectively registered on 17 July 2018.
Collapse
Affiliation(s)
- Silvia Lanfranconi
- Department of Neurology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Padiglione Monteggia-piano 3, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Elisa Scola
- Department of Neuroradiology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Giulio Andrea Bertani
- Department of Neurosurgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Barbara Zarino
- Department of Neurosurgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Roberto Pallini
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Giorgio d'Alessandris
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Emanuela Mazzon
- IRCCS Centro Neurolesi "Bonino Pulejo", Contrada Casazza, 98124, Messina, Italy
| | - Silvia Marino
- IRCCS Centro Neurolesi "Bonino Pulejo", Contrada Casazza, 98124, Messina, Italy
| | - Maria Rita Carriero
- Cerebrovascular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Emma Scelzo
- Cerebrovascular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Giuseppe Faragò
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini 2, 71013, San Giovanni Rotondo, Italy
| | - Carmela Fusco
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini 2, 71013, San Giovanni Rotondo, Italy
| | - Antonio Petracca
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini 2, 71013, San Giovanni Rotondo, Italy
| | - Leonardo d'Agruma
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini 2, 71013, San Giovanni Rotondo, Italy
| | - Laura Tassi
- "Claudio Munari" Epilepsy Surgery Centre, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, 20162, Milan, Italy
| | - Piergiorgio d'Orio
- "Claudio Munari" Epilepsy Surgery Centre, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, 20162, Milan, Italy
| | - Maria Grazia Lampugnani
- Laboratory of Vascular Biology, IFOM, Firc Institute for Molecular Oncology, Via Adamello 16, 20139, Milan, Italy
| | - Enrico Bjorn Nicolis
- Laboratory of Cardiovascular Clinical Pharmacology, Mario Negri Institute for Pharmacological Research-IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Antonella Vasamì
- Laboratory of Cardiovascular Clinical Pharmacology, Mario Negri Institute for Pharmacological Research-IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Deborah Novelli
- Laboratory of Cardiovascular Clinical Pharmacology, Mario Negri Institute for Pharmacological Research-IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Valter Torri
- Laboratory of Research Methodology, Mario Negri Institute for Pharmacological Research-IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Jennifer Marie Theresia Anna Meessen
- Laboratory of Cardiovascular Clinical Pharmacology, Mario Negri Institute for Pharmacological Research-IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Little France Crescent 49, Edinburgh, EH16 4SB, UK
| | - Elisabetta Dejana
- Laboratory of Vascular Biology, IFOM, Firc Institute for Molecular Oncology, Via Adamello 16, 20139, Milan, Italy
| | - Roberto Latini
- Laboratory of Cardiovascular Clinical Pharmacology, Mario Negri Institute for Pharmacological Research-IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | | |
Collapse
|
32
|
Multiple Large-Size Cystic Cerebral Cavernomas. World Neurosurg 2020; 139:410-414. [PMID: 32376377 DOI: 10.1016/j.wneu.2020.04.189] [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: 04/03/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cerebral cavernomas are vascular malformations characterized by networks of abnormally dilated capillaries. They typically present as nodules with mixed signal intensity and a surrounding hemosiderin rim on magnetic resonance imaging. They may occur as multiple lesions in the autosomal-dominant familial form. In rare cases, cavernomas may form cystic masses, mimicking other pathologies. CASE DESCRIPTION A 35-year-old man presented with recurrent seizures, aphasia, and gait disturbance with onset at age 14 years. He had previously undergone surgical drainage of multiple cysts across the brain with suspected parasitic infection. On magnetic resonance imaging, 22 cystic lesions were seen across the brain. A large cyst was located in the midline cerebellum, compressing the fourth ventricle. Occipital craniotomy and transvermian dissection allowed total resection of the cyst along with its wall. The postoperative course was uneventful and symptoms progressively improved. Histological analysis revealed cavernoma. Three more surgeries were performed for removal of large supratentorial cavernomas. CONCLUSIONS In patients with cystic lesions of the brain, the neurosurgeon should consider the possibility of cavernoma. Total excision along with the cyst wall is crucial for timely diagnosis and therapy.
Collapse
|
33
|
Polster SP, Cao Y, Carroll T, Flemming K, Girard R, Hanley D, Hobson N, Kim H, Koenig J, Koskimäki J, Lane K, Majersik JJ, McBee N, Morrison L, Shenkar R, Stadnik A, Thompson RE, Zabramski J, Zeineddine HA, Awad IA. Trial Readiness in Cavernous Angiomas With Symptomatic Hemorrhage (CASH). Neurosurgery 2020; 84:954-964. [PMID: 29660039 DOI: 10.1093/neuros/nyy108] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/06/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Brain cavernous angiomas with symptomatic hemorrhage (CASH) are uncommon but exact a heavy burden of neurological disability from recurrent bleeding, for which there is no proven therapy. Candidate drugs to stabilize the CASH lesion and prevent rebleeding will ultimately require testing of safety and efficacy in multisite clinical trials. Much progress has been made in understanding the epidemiology of CASH, and novel biomarkers have been linked to the biological mechanisms and clinical activity in lesions. Yet, the ability to enroll and risk-stratify CASH subjects has never been assessed prospectively at multiple sites. Biomarkers and other outcomes have not been evaluated for their sensitivity and reliability, nor have they been harmonized across sites. OBJECTIVE To address knowledge gaps and establish a research network as infrastructure for future clinical trials, through the Trial Readiness grant mechanism, funded by National Institute of Neurological Disorders and Stroke/National Institutes of Health. METHODS This project includes an observational cohort study to assess (1) the feasibility of screening, enrollment rates, baseline disease categorization, and follow-up of CASH using common data elements at multiple sites, (2) the reliability of imaging biomarkers including quantitative susceptibility mapping and permeability measures that have been shown to correlate with lesion activity, and (3) the rates of recurrent hemorrhage and change in functional status and biomarker measurements during prospective follow-up. EXPECTED OUTCOMES We propose a harmonized multisite assessment of enrollment rates of CASH, baseline features relevant to stratification in clinical trials, and follow-up assessments of functional outcomes in relation to clinical bleeds. We introduce novel biomarkers of vascular leak and hemorrhage, with firm mechanistic foundations, which have been linked to clinical disease activity. We shall test their reliability and validity at multiple sites, and assess their changes over time, with and without clinical rebleeds, hence their fitness as outcome instruments in clinical trials. DISCUSSION The timing cannot be more opportune, with therapeutic targets identified, exceptional collaboration among researchers and the patient community, along with several drugs ready to benefit from development of a path to clinical testing using this network in the next 5 years.
Collapse
Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Timothy Carroll
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Kelly Flemming
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - James Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | | | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Leslie Morrison
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Joseph Zabramski
- Department of Neurological Surgery, The Barrow Neurological Institute, Phoenix, ArizonaAll except the first and final author are listed in alphabetic order
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| |
Collapse
|
34
|
Das KK, Singh S, Deora H, Khatri D, Mehrotra A, Srivastava AK, Jaiswal AK, Behari S. Microsurgical excision of giant dominant lobe insular cavernoma presenting acutely: Sometimes you win, sometimes you learn. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2019. [DOI: 10.1016/j.inat.2019.100475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
35
|
Poorthuis MHF, Rinkel LA, Lammy S, Al-Shahi Salman R. Stereotactic radiosurgery for cerebral cavernous malformations: A systematic review. Neurology 2019; 93:e1971-e1979. [PMID: 31659093 DOI: 10.1212/wnl.0000000000008521] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/26/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The efficacy of stereotactic radiosurgery (SRS) for the treatment of cerebral cavernous malformations (CCMs) is uncertain, so we set out to quantify clinical outcomes after SRS for CCM and compare them to microsurgical excision or conservative management. METHODS We searched Ovid Medline and Ovid EMBASE from inception until June 1, 2018, for peer-reviewed publications describing clinical outcomes after SRS for ≥10 people with CCM in cohorts with or without a comparison group treated with neurosurgical excision or conservative management. Two reviewers independently extracted data from the included studies to quantify cohort characteristics and the incidence of the primary outcome (death attributable to CCM or its treatment) and secondary outcomes (incident nonfatal symptomatic intracerebral hemorrhage [ICH] and incident nonhemorrhagic persistent focal neurologic deficit [FND]). We assessed whether comparative studies showed a dramatic association (meaning the conventionally calculated probability comparing 2 differently managed patient groups from the same population was <0.01 with a rate ratio greater than 10). RESULTS We included 30 cohort studies involving a total of 1,576 patients undergoing SRS for CCM. Four nonrandomized studies compared SRS to other treatment strategies, but did not demonstrate dramatic associations. During a median follow-up of 48 (interquartile range 35-62) months after SRS, the annual incidences (95% confidence interval) of outcomes were death 0.18% (0.10-0.31), ICH 2.40% (2.05-2.80), FND 0.71% (0.53-0.96), and the composite of death, ICH, or FND 3.63% (3.17-4.16). Outcomes did not differ by CCM location or type of SRS. CONCLUSION After SRS for CCM, the annual incidences of death, ICH, and FND are <5% and seem comparable to outcomes without SRS. A randomized trial of SRS for CCM is needed.
Collapse
Affiliation(s)
- Michiel H F Poorthuis
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK
| | - Leon A Rinkel
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK
| | - Simon Lammy
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK
| | - Rustam Al-Shahi Salman
- From the Department of Neurology and Neurosurgery (M.H.F.P.), Brain Center Rudolf Magnus, University Medical Center Utrecht; University Medical Centre Groningen (L.A.R.), University of Groningen, the Netherlands; Department of Neurosurgery (S.L.), Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow; and Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, UK.
| |
Collapse
|
36
|
Awad IA, Polster SP. Cavernous angiomas: deconstructing a neurosurgical disease. J Neurosurg 2019; 131:1-13. [PMID: 31261134 PMCID: PMC6778695 DOI: 10.3171/2019.3.jns181724] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 01/08/2023]
Abstract
Cavernous angioma (CA) is also known as cavernoma, cavernous hemangioma, and cerebral cavernous malformation (CCM) (National Library of Medicine Medical Subject heading unique ID D006392). In its sporadic form, CA occurs as a solitary hemorrhagic vascular lesion or as clustered lesions associated with a developmental venous anomaly. In its autosomal dominant familial form (Online Mendelian Inheritance in Man #116860), CA is caused by a heterozygous germline loss-of-function mutation in one of three genes-CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10-causing multifocal lesions throughout the brain and spinal cord.In this paper, the authors review the cardinal features of CA's disease pathology and clinical radiological features. They summarize key aspects of CA's natural history and broad elements of evidence-based management guidelines, including surgery. The authors also discuss evidence of similar genetic defects in sporadic and familial lesions, consequences of CCM gene loss in different tissues at various stages of development, and implications regarding the pathobiology of CAs.The concept of CA with symptomatic hemorrhage (CASH) is presented as well as its relevance to clinical care and research in the field. Pathobiological mechanisms related to CA include inflammation and immune-mediated processes, angiogenesis and vascular permeability, microbiome driven factors, and lesional anticoagulant domains. These mechanisms have motivated the development of imaging and plasma biomarkers of relevant disease behavior and promising therapeutic targets.The spectrum of discoveries about CA and their implications endorse CA as a paradigm for deconstructing a neurosurgical disease.
Collapse
|
37
|
Nagy G, Stokes SS, Erőss LG, Bhattacharyya D, Yianni J, Rowe JG, Kemeny AA, Radatz MWR. Contemporary radiosurgery of cerebral cavernous malformations: Part 2. Treatment outcome for hemispheric lesions. J Neurosurg 2019; 130:1826-1834. [PMID: 30052157 DOI: 10.3171/2018.2.jns171267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of radiosurgery (RS) in treating superficial cavernous malformations (CMs) is insufficiently studied in part because of the disappointing results of early experimental attempts as compared to the mostly safe and effective microsurgery. Nonetheless, because of lesion- or treatment-specific factors, a therapeutic alternative may be required. In this study, the authors aimed to assess the safety of RS in treating superficial CMs and to analyze its long-term effect on hemorrhage rates and epilepsy control. METHODS The authors conducted a retrospective analysis of 96 patients with 109 CMs located in the cerebral or cerebellar hemispheres and treated with RS between 1995 and 2014. A median of 15 Gy (range 10-25 Gy) was given to the 50% prescription isodose level, lesion volume was 604 mm3 (4-8300 mm3), and the prescription isodose volume was 638.5 mm3 (4-9500 mm3). Outcomes were compared to those of 206 deep-seated lesions reported on in another study. Ninety-five patients had available follow-up, which was a median of 7 years (1-21 years). Median patient age was 42 years (0.5-77) at presentation and 45 (3-80) at treatment. Seventy-one CMs presented with symptomatic hemorrhage, and 52 caused seizures. RESULTS In the nonhemorrhagic group (37 lesions), one bleed occurred during the follow-up period, for an annual bleed rate of 0.4% per lesion. The lifetime annual bleed rate of CMs having a single hemorrhage prior to treatment was 2.5%. The rebleed rate in the single-bleed group decreased from 1.8% within the first 2 years after RS to 0.7% thereafter. The pretreatment rebleed rate for lesions having multiple bleeds prior to RS was 14.15%, which fell to 3.85% for the first 2 years after RS and declined to 1.3% thereafter. Multivariate analysis showed younger age, deep lesion location, and multiple pretreatment hemorrhages as significant predictors of posttreatment hemorrhage.Pretreatment hemorrhages led to permanent deficits in 41.4% of the cases with a single bleed and in 46.1% of cases with multiple bleeds. Only mild (modified Rankin Scale score 1) and a low rate of permanent neurological deficits were caused either by posttreatment hemorrhages (4.3%) or by radiation (2%).The rate of improvement in epilepsy was 84.9% after RS in patients with at least one seizure prior to treatment, not depending on the presence of hemorrhage or the time interval between presentation and treatment. Favorable outcome occurred in 81% of patients whose seizures were not controlled with antiepileptic medication prior to RS. CONCLUSIONS Radiosurgery for superficial CMs is safe and appears to be effective, offering a real treatment alternative to surgery for selected patients. Given their relatively benign natural history, superficial CMs require further study to verify the long-term benefit of RS over the lesions' natural history.
Collapse
Affiliation(s)
- Gábor Nagy
- 1National Institute of Clinical Neurosciences, Budapest, Hungary
| | | | - Loránd G Erőss
- 1National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Debapriya Bhattacharyya
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - John Yianni
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Jeremy G Rowe
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | | | - Matthias W R Radatz
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| |
Collapse
|
38
|
Rinkel LA, Salman RAS, Rinkel GJE, Greving JP. Radiosurgical, neurosurgical, or no intervention for cerebral cavernous malformations: A decision analysis. Int J Stroke 2019; 14:939-945. [DOI: 10.1177/1747493019851290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction We aimed to evaluate the preferred treatment strategy for patients with symptomatic cerebral cavernous malformations (CCM). Methods In a decision model, we compared neurosurgical, radiosurgical, and conservative management. A literature review yielded the risks and outcomes of interventions, intracerebral hemorrhage (ICH), and seizures. Patients with CCM rated their quality of life to determine utilities. We estimated the expected number of quality-adjusted life years (QALYs) and the ICH recurrence risk over five years, according to mode of presentation and CCM location (brainstem vs. other). We performed analyses with a time horizon of five years. Results Using the best available data, the expected number of QALYs for brainstem CCM presenting with ICH or focal neurological deficit was 2.84 (95% confidence interval [CI]: 2.54–3.08) for conservative, 3.01 (95% CI: 2.86–3.16) for neurosurgical, and 3.03 (95% CI: 2.88–3.18) for radiosurgical intervention; those for non-brainstem CCM presenting with ICH or focal neurological deficit were 3.08 (95% CI: 2.85–3.31) for conservative, 3.21 (95% CI: 3.01–3.36) for neurosurgical, and 3.19 (95% CI: 2.98–3.37) for radiosurgical intervention. For CCM presenting with epilepsy, QALYs were 3.09 (95% CI: 3.03–3.16) for conservative, 3.33 (95% CI: 3.31–3.34) for neurosurgical, and 3.27 (95% CI: 3.24–3.30) for radiosurgical intervention. Discussion and conclusion For the initial five years after presentation, our study provides Class III evidence that for CCM presenting with ICH or focal neurological deficit conservative management is the first option, and for CCM presenting with epilepsy CCM intervention should be considered. More comparative studies with long-term follow-up are needed.
Collapse
Affiliation(s)
- Leon A Rinkel
- University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Gabriel JE Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
39
|
Zanello M, Meyer B, Still M, Goodden JR, Colle H, Schichor C, Bello L, Wager M, Smits A, Rydenhag B, Tate M, Metellus P, Hamer PDW, Spena G, Capelle L, Mandonnet E, Robles SG, Sarubbo S, Martino González J, Fontaine D, Reyns N, Krieg SM, Huberfeld G, Wostrack M, Colle D, Robert E, Noens B, Muller P, Yusupov N, Rossi M, Conti Nibali M, Papagno C, Visser V, Baaijen H, Galbarritu L, Chioffi F, Bucheli C, Roux A, Dezamis E, Duffau H, Pallud J. Surgical resection of cavernous angioma located within eloquent brain areas: International survey of the practical management among 19 specialized centers. Seizure 2019; 69:31-40. [PMID: 30959423 DOI: 10.1016/j.seizure.2019.03.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/02/2019] [Accepted: 03/27/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE The practical management of cavernous angioma located within eloquent brain area before, during and after surgical resection is poorly documented. We assessed the practical pre-operative, intra-operative, and post-operative management of cavernous angioma located within eloquent brain area. METHOD An online survey composed of 61 items was sent to 26 centers to establish a multicenter international retrospective cohort of adult patients who underwent a surgical resection as the first-line treatment of a supratentorial cavernous angioma located within or close to eloquent brain area. RESULTS 272 patients from 19 centers (mean 13.6 ± 16.7 per center) from eight countries were included. The pre-operative management varied significantly between centers and countries regarding the pre-operative functional assessment, the pre-operative epileptological assessment, the first given antiepileptic drug, and the time to surgery. The intra-operative environment varied significantly between centers and countries regarding the use of imaging systems, the use of functional mapping with direct electrostimulations, the extent of resection of the hemosiderin rim, the realization of a post-operative functional assessment, and the time to post-operative functional assessment. The present survey found a post-operative improvement, as compared to pre-operative evaluations, of the functional status, the ability to work, and the seizure control. CONCLUSIONS We observed a variety of practice between centers and countries regarding the management of cavernous angioma located within eloquent regions. Multicentric prospective studies are required to solve relevant questions regarding the management of cavernous angioma-related seizures, the timing of surgery, and the optimal extent of hemosiderin rim resection.
Collapse
Affiliation(s)
- Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; UMR 1266 INSERM, IMA-BRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich School of Medicine, Munich, Germany
| | - Megan Still
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; UMR 1266 INSERM, IMA-BRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France
| | - John R Goodden
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Henry Colle
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Christian Schichor
- Neurosurgical Clinic, University of Munich - Campus Grosshadern, Munich, Germany
| | - Lorenzo Bello
- Department of Neurosurgery, Humanitas Hospital, Milan, Italy
| | - Michel Wager
- Department of Neurosurgery, La Milétrie University Hospital, 86021 Poitiers, France
| | - Anja Smits
- Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden
| | - Matthew Tate
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, USA
| | - Philippe Metellus
- Department of Neurosurgery, Clairval Private Hospital, Marseille, France
| | - Philip De Witt Hamer
- Department of Neurosurgery, VU University Medical Center, Amsterdam, Netherlands
| | | | - Laurent Capelle
- Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Paris, France
| | | | - Santiago Gil Robles
- Department of Neurosurgery, Hospital Universitario Quironsalud, Madrid, Spain
| | - Silvio Sarubbo
- Department of Neurosurgery, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Juan Martino González
- Department of Neurosurgery, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Denys Fontaine
- Department of Neurosurgery, Nice University Hospital, Nice, France
| | - Nicolas Reyns
- Department of Neurosurgery, Roger-Salengro University Hospital, Lille, France
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich School of Medicine, Munich, Germany
| | - Gilles Huberfeld
- Department of Neurophysiology, Pitié-Salpêtrière Hospital, UPMC, Sorbonne Université, Paris, France; Infantile Epilepsy and Brain Plasticity, INSERM U1129 Paris Descartes University, PRES Sorbonne, Paris, France; Neuroglial Interactions in Cerebral Physiopathology, Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR 7241, INSERM U1050, Labex Memolife, PSL Research University, Paris, France
| | - Maria Wostrack
- Department of Neurosurgery, Technical University of Munich School of Medicine, Munich, Germany
| | - David Colle
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Erik Robert
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Bonny Noens
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Peter Muller
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Natan Yusupov
- Neurosurgical Clinic, University of Munich - Campus Grosshadern, Munich, Germany
| | - Marco Rossi
- Department of Neurosurgery, Humanitas Hospital, Milan, Italy
| | | | | | - Victoria Visser
- Department of Neurosurgery, VU University Medical Center, Amsterdam, Netherlands
| | - Hans Baaijen
- Department of Neurosurgery, VU University Medical Center, Amsterdam, Netherlands
| | - Lara Galbarritu
- Department of Neurosurgery, Hospital Universitario Quironsalud, Madrid, Spain
| | - Franco Chioffi
- Department of Neurosurgery, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Carlos Bucheli
- Department of Neurosurgery, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; UMR 1266 INSERM, IMA-BRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; UMR 1266 INSERM, IMA-BRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France
| | - Hugues Duffau
- Neurosurgery Department, Hôpital Gui-de-Chauliac, Montpellier University Medical Center, 34000 Montpellier, France
| | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; UMR 1266 INSERM, IMA-BRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France.
| |
Collapse
|
40
|
Karschnia P, Nishimura S, Louvi A. Cerebrovascular disorders associated with genetic lesions. Cell Mol Life Sci 2019; 76:283-300. [PMID: 30327838 PMCID: PMC6450555 DOI: 10.1007/s00018-018-2934-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 09/30/2018] [Accepted: 10/02/2018] [Indexed: 01/15/2023]
Abstract
Cerebrovascular disorders are underlain by perturbations in cerebral blood flow and abnormalities in blood vessel structure. Here, we provide an overview of the current knowledge of select cerebrovascular disorders that are associated with genetic lesions and connect genomic findings with analyses aiming to elucidate the cellular and molecular mechanisms of disease pathogenesis. We argue that a mechanistic understanding of genetic (familial) forms of cerebrovascular disease is a prerequisite for the development of rational therapeutic approaches, and has wider implications for treatment of sporadic (non-familial) forms, which are usually more common.
Collapse
Affiliation(s)
- Philipp Karschnia
- Departments of Neurosurgery and Neuroscience, Program on Neurogenetics, Yale School of Medicine, P.O. Box 208082, New Haven, CT, 06520-8082, USA
| | - Sayoko Nishimura
- Departments of Neurosurgery and Neuroscience, Program on Neurogenetics, Yale School of Medicine, P.O. Box 208082, New Haven, CT, 06520-8082, USA
| | - Angeliki Louvi
- Departments of Neurosurgery and Neuroscience, Program on Neurogenetics, Yale School of Medicine, P.O. Box 208082, New Haven, CT, 06520-8082, USA.
| |
Collapse
|
41
|
Bazarde HA, Wenz F, Hänggi D, Etminan N. Radiosurgery of Brain Arteriovenous and Cavernous Malformations. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_10-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
42
|
Navigation-assisted transcortical transventricular approach for paraventricular cavernoma: A technical note and review of the literature. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2018. [DOI: 10.1016/j.lers.2018.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
43
|
Hughes JD, Bond KM, Mekary RA, Dewan MC, Rattani A, Baticulon R, Kato Y, Azevedo-Filho H, Morcos JJ, Park KB. Estimating the Global Incidence of Aneurysmal Subarachnoid Hemorrhage: A Systematic Review for Central Nervous System Vascular Lesions and Meta-Analysis of Ruptured Aneurysms. World Neurosurg 2018; 115:430-447.e7. [DOI: 10.1016/j.wneu.2018.03.220] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 11/16/2022]
|
44
|
Affiliation(s)
- Christopher J Stapleton
- From the Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Fred G Barker
- From the Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston.
| |
Collapse
|
45
|
Zanello M, Wager M, Corns R, Capelle L, Mandonnet E, Fontaine D, Reyns N, Dezamis E, Matsuda R, Bresson D, Duffau H, Pallud J. Resection of cavernous angioma located in eloquent areas using functional cortical and subcortical mapping under awake conditions. Outcomes in a 50-case multicentre series. Neurochirurgie 2017; 63:219-226. [DOI: 10.1016/j.neuchi.2016.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/06/2016] [Accepted: 08/22/2016] [Indexed: 11/24/2022]
|
46
|
Akers A, Al-Shahi Salman R, A. Awad I, Dahlem K, Flemming K, Hart B, Kim H, Jusue-Torres I, Kondziolka D, Lee C, Morrison L, Rigamonti D, Rebeiz T, Tournier-Lasserve E, Waggoner D, Whitehead K. Synopsis of Guidelines for the Clinical Management of Cerebral Cavernous Malformations: Consensus Recommendations Based on Systematic Literature Review by the Angioma Alliance Scientific Advisory Board Clinical Experts Panel. Neurosurgery 2017; 80:665-680. [PMID: 28387823 PMCID: PMC5808153 DOI: 10.1093/neuros/nyx091] [Citation(s) in RCA: 287] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/09/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite many publications about cerebral cavernous malformations (CCMs), controversy remains regarding diagnostic and management strategies. OBJECTIVE To develop guidelines for CCM management. METHODS The Angioma Alliance ( www.angioma.org ), the patient support group in the United States advocating on behalf of patients and research in CCM, convened a multidisciplinary writing group comprising expert CCM clinicians to help summarize the existing literature related to the clinical care of CCM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and radiology standards, (4) neurosurgical considerations, and (5) neurological considerations. The group reviewed literature, rated evidence, developed recommendations, and established consensus, controversies, and knowledge gaps according to a prespecified protocol. RESULTS Of 1270 publications published between January 1, 1983 and September 31, 2014, we selected 98 based on methodological criteria, and identified 38 additional recent or relevant publications. Topic authors used these publications to summarize current knowledge and arrive at 23 consensus management recommendations, which we rated by class (size of effect) and level (estimate of certainty) according to the American Heart Association/American Stroke Association criteria. No recommendation was level A (because of the absence of randomized controlled trials), 11 (48%) were level B, and 12 (52%) were level C. Recommendations were class I in 8 (35%), class II in 10 (43%), and class III in 5 (22%). CONCLUSION Current evidence supports recommendations for the management of CCM, but their generally low levels and classes mandate further research to better inform clinical practice and update these recommendations. The complete recommendations document, including the criteria for selecting reference citations, a more detailed justification of the respective recommendations, and a summary of controversies and knowledge gaps, was similarly peer reviewed and is available on line www.angioma.org/CCMGuidelines .
Collapse
Affiliation(s)
| | | | - Issam A. Awad
- Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Kelly Flemming
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Blaine Hart
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | | | - Douglas Kondziolka
- Departments of Neurosurgery and Radiation Oncology, NYU Langone Medical Center, New York City, New York
| | | | - Leslie Morrison
- Departments of Neurology and Pediatrics, University of New Mexico, Albuquerque, New Mexico
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Tania Rebeiz
- Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Darrel Waggoner
- Department of Human Genetics and Pediatrics, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Kevin Whitehead
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| |
Collapse
|
47
|
Dammann P, Wrede K, Jabbarli R, Neuschulte S, Menzler K, Zhu Y, Özkan N, Müller O, Forsting M, Rosenow F, Sure U. Outcome after conservative management or surgical treatment for new-onset epilepsy in cerebral cavernous malformation. J Neurosurg 2017; 126:1303-1311. [DOI: 10.3171/2016.4.jns1661] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The aim of this study was to determine seizure outcome, functional outcome, and the withdrawal of antiepileptic drugs (AEDs) after conservative or surgical treatment of patients with new-onset cavernoma-related epilepsy (CRE).
METHODS
The authors conducted a retrospective comparative observational study of 79 consecutive patients, each with a single sporadic cerebral cavernous malformation (CCM) and new-onset CRE.
RESULTS
Forty-one patients underwent initial surgery (IS), and 38 patients underwent initial conservative (IC) treatment. Of those in the latter group, 19 underwent delayed surgical (DS) treatment. At the last follow-up, 88%, 32%, and 79% of patients in the respective groups had been seizure free for at least 2 years (International League Against Epilepsy [ILAE] Class 1; IS vs IC, p < 0.0001) and 78%, 8%, and 58%, respectively, had been off AEDs (IS vs IC, p < 0.0001). The cumulative probability of staying seizure free (ILAE Class 1) during a 5-year period was 73% (mean seizure-free follow-up 49.8 ± 2.7 months, 95% CI 44.4–55.1 months) for the IS group, 22% (mean 31.8 ± 3.6 months, 95% CI 24.8–38.8 months) for the IC group, and 68% (mean 48.6 ± 4.3 months, 95% CI 40.1–57.1 months) for the DS group (IS vs IC p < 0.001). Long-term operative morbidity was 3%, and long-term morbidity in the conservatively treated group was also 3%.
CONCLUSIONS
Patients with CCM and new-onset CRE who underwent IS treatment showed better results in seizure control and the discontinuation of AEDs than the conservatively treated patients. Operative morbidity was comparable to the morbidity from symptomatic CCM hemorrhage in the conservative group. Half of the patients who started with conservative treatment underwent subsequent surgical treatment; however, a longer duration of epilepsy prior to surgery did not worsen postoperative seizure outcome.
Collapse
Affiliation(s)
- Philipp Dammann
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Karsten Wrede
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Ramazan Jabbarli
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Salome Neuschulte
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Katja Menzler
- 2Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main
- 3Epilepsy Center Hessen-Marburg, Department of Neurology, Philipps-University, Marburg
| | - Yuan Zhu
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Neriman Özkan
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Oliver Müller
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Michael Forsting
- 4Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Felix Rosenow
- 2Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main
- 3Epilepsy Center Hessen-Marburg, Department of Neurology, Philipps-University, Marburg
| | - Ulrich Sure
- 1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| |
Collapse
|
48
|
Ding D, Starke RM, Crowley RW, Liu KC. Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem. J Cerebrovasc Endovasc Neurosurg 2017; 19:19-35. [PMID: 28503485 PMCID: PMC5426196 DOI: 10.7461/jcen.2017.19.1.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 01/04/2017] [Accepted: 02/18/2017] [Indexed: 11/27/2022] Open
Abstract
Objective Surgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem. Materials and Methods We reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated. Results A total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm3, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%. Conclusion Microneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.
Collapse
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University, Chicago, IL, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
49
|
Arauz A, Patiño-Rodriguez HM, Chavarria-Medina M, Becerril M, Longo GM, Nathal E. Rebleeding and Outcome in Patients with Symptomatic Brain Stem Cavernomas. Cerebrovasc Dis 2017; 43:283-289. [DOI: 10.1159/000463392] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/08/2017] [Indexed: 11/19/2022] Open
Abstract
Purpose: We sought to evaluate the long-term functional outcomes and identify the potential risk factors for rebleeding in patients with brain stem cavernous malformations (BCMs) who presented with hemorrhages and were surgically or conservatively treated and prospectively monitored. Methods: From January 1990 to July 2015, we included patients with first hemorrhagic episodes secondary to single BCMs. Modified Rankin score (mRS) was used for neurological status assessment. Univariate and multivariate regression statistics were used to identify the risk factors for rebleeding. Results: A total of 99 patients with BCMs hemorrhages were included (59 [59.6%] women, mean age 37± 13 years). As initial treatments, 37 patients (37.4%) underwent surgery and 62 (62.6%) received conservative treatment. The median follow-up was 3.33 years (interquartile range 1.16-7 years; 408.3 patient/years). The rebleeding rate by patient/year was 10% in conservatively treated patients. Deterioration was significantly more frequent in patients with rebleeding (p = 0.0001). At the end of the follow-up, the mRS were favorable in 49 patients (65.3%) without rebleeding, whereas only 8 (33.3%) with rebleeding evolved to favorable outcomes (p = 0.006). Lesion size >18 mm (hazards ratio, HR 3.34, 95% CI 1.54-7.26; p = 0.0001) and ventral location or crossing the brain stem's midpoint (HR 2.5, 95% CI 1.14-5.46; p = 0.022) were associated with a major risk of rebleeding in the univariate analysis, but only a lesion >18 mm remained statistically significant (HR 2.7, 95% CI 1.2-6.21; p = 0.016) in the multivariate analysis. Conclusion: A lesion size >18 mm was the principal factor associated with hemorrhage recurrence. The overall functional outcome was good. However, significant morbidity was attributable to rebleeding.
Collapse
|
50
|
Clinical outcome following medical treatment of cavernous malformation related epilepsy. Seizure 2016; 45:64-69. [PMID: 27936450 DOI: 10.1016/j.seizure.2016.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/05/2016] [Accepted: 11/14/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The study was conducted to assess the long-term outcome of antiepileptic drug (AED) treatment in drug-naïve patients with cavernous malformation (CM) related epilepsy (CRE). METHOD This is a retrospective, single-center, long-term observational study of 34 patients with previously untreated seizures related to CM. All patients were followed-up for at least two years. Drug resistant epilepsy (DRE) was defined as two or more seizures per year after trial of two appropriate AEDs. Patients who had only one seizure during the previous one year were assigned as "epilepsy with rare seizures (ERSs)". RESULTS Terminal 1-year seizure remission (1-YTR) was achieved in 22 (64.7%) patients, nine (26.5%) patients were diagnosed as DRE, and three (8.8%) patients were as ERSs. 1-YTR was achieved in 18 (52.9%) patients by the first drug regimen and in additional four (11.8%) patients by the second drug regimen. None of nine patients who failed to first two drug regimens did achieve 1-YTR. The location of CM in the temporal lobe was the only prognostic factor predicting a poor seizure outcome (p=0.012). CONCLUSION The outcome of AEDs therapy in patients who were presented with new onset of CRE was quite comparable with that of patients with newly diagnosed epilepsy. Failure to achieve seizure-free after adequate trials of two AEDs seems appropriate as the criteria for their referral to surgical treatment. For patients with temporal lobe CRE, earlier presurgical evaluation may be considered justifiable once they failed to an adequate trial of the first drug.
Collapse
|