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Central nervous system cavernous malformations: cross-sectional study assessing rebleeding risk after
Alejandro N Santos1,2, Laurèl Rauschenbach1,2, Hanah Hadice Gull1,2
1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.
Insights
Patients with central nervous system cavernous malformations (CMs) face a high 5-year risk of a third bleeding event. This increased risk of re-bleeding and associated neurological decline may warrant surgical intervention after a second hemorrhage.
Area of Science:
- Neurology
- Neurosurgery
- Vascular Malformations
Background:
- Cavernous malformations (CMs) are vascular anomalies in the central nervous system.
- Recurrent bleeding from CMs poses significant risks to patients.
Purpose of the Study:
- To determine the 5-year risk of a third bleeding event in patients with central nervous system cavernous malformations.
- To identify factors influencing the risk of recurrent hemorrhage in CMs.
Main Methods:
- Retrospective analysis of patients with cerebral or spinal CMs treated between 2003 and 2021.
- Inclusion criteria: complete MRI, baseline characteristics, and history of two bleeding events. Exclusion: prior surgical removal.
- Kaplan-Meier and Cox regression analyses were used to assess the 5-year risk of a third hemorrhage.
Main Results:
- The cumulative 5-year risk of a third bleeding event was 66.7% for the entire cohort.
- Neurological deterioration occurred in 37% of patients after the third hemorrhage (p=0.019).
- Specific subgroups, including brainstem or familial CMs, showed even higher 5-year risks (up to 76.9%).
Conclusions:
- Patients with central nervous system cavernous malformations have a significantly elevated risk of a third bleeding event within 5 years after a second hemorrhage.
- A third hemorrhage is associated with a higher likelihood of neurological deterioration.
- These findings suggest that surgical treatment might be considered after a second bleeding event in CM patients.
Background And Purpose:
The purpose of this study was to investigate the 5-year risk of a third bleeding event in cavernous malformations (CMs) of the central nervous system.
Methods:
Patients with cerebral or spinal CMs treated between 2003 and 2021 were screened using our institutional database. Patients with a complete magnetic resonance imaging dataset, clinical baseline characteristics, and history of two bleeding events were included. Patients who underwent surgical CM removal were excluded. Neurological functional status was obtained using the modified Rankin Scale score at the second and third bleeding. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for a third haemorrhage.
Results:
Forty-two patients were included. Cox regression analysis adjusted for age and sex did not identify risk factors for a third haemorrhage. 37% of patients experienced neurological deterioration after the third haemorrhage (p = 0.019). The cumulative 5-year risk of a third bleeding was 66.7% (95% confidence interval [CI] 50.4%-80%) for the whole cohort, 65.9% (95% CI 49.3%-79.5%) for patients with bleeding at initial diagnosis, 72.7% (95% CI 39.3%-92.7%) for patients with a developmental venous anomaly, 76.9% (95% CI 55.9%-90.3%) for patients with CM localization to the brainstem and 75% (95% CI 50.6%-90.4%) for patients suffering from familial CM disease.
Conclusions:
During an untreated 5-year follow-up after a second haemorrhage, a significantly increased risk of a third haemorrhage compared to the known risk of a first and second bleeding event was identified. The third bleeding was significantly associated with neurological deterioration. These findings may justify a surgical treatment after a second bleeding event.
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