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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Natural course of cerebral and spinal cavernous malformations: a complete ten-year follow-up study
Alejandro N Santos1,2, Laurèl Rauschenbach3,4, Hanah H Gull3,4
1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany. alejandro.santos@uk-essen.de.
Insights
Conservative treatment for cavernous malformations (CM) carries a significant bleeding risk. Intramedullary spinal cord CM and prior hemorrhage are key predictors of future bleeding events over 10 years.
Area of Science:
- Neurology
- Neurosurgery
- Vascular Malformations
Background:
- Limited understanding of bleeding risk and long-term outcomes for conservatively managed cavernous malformations (CM).
- Need for data on hemorrhage occurrence and risk factors in untreated CM patients.
Purpose of the Study:
- To investigate the 10-year hemorrhage risk in patients with cerebral (CCM) or intramedullary spinal cord (ISCM) CM managed conservatively.
- To identify independent predictors of (re)hemorrhage in this cohort.
Main Methods:
- Retrospective analysis of 91 patients with CCM or ISCM from an institutional database (2003-2021).
- Exclusion of surgically treated patients and those with incomplete follow-up.
- Multivariate logistic regression and Cox regression analyses to identify risk factors and cumulative hemorrhage risk.
Main Results:
- Bleeding at diagnosis and spinal CM localization were significant predictors of (re)hemorrhage.
- Cumulative 10-year bleeding risk was 30% overall, 39% for those with initial bleeding, and 67% for ISCM.
- Hemorrhage probability increased over time, particularly in ISCM and patients with prior bleeding.
Conclusions:
- Conservative management of CM carries a substantial long-term bleeding risk.
- Spinal CM localization and prior hemorrhage are critical risk factors.
- Findings suggest a potentially aggressive course for ISCM, supporting consideration for early surgical intervention.
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.
