gms | German Medical Science

Objective: Microsurgical excision of cerebral cavernous malformations (CCM) is often routinely performed in patients with related epilepsy or even in asymptomatic cases to prevent hemorrhage. Few prospective studies have reliably demonstrated that surgery can statistically and clinically improve the outcome in comparison with the natural history of the disease.

Method: We conducted in two Italian Centers (University of Brescia and Torino) a prospective, population-based study on adult patients harboring sporadic CCM. The follow-up period was 5 years both for surgically treated patients and for the conservative group. Patients with genetic related CCM were excluded. We used multiple sources of prospective follow-up to assess adults' dependence and to identify and independently validate outcome events. We used univariate and multivariable survival analyses to test the influence of CCM excision on outcome, adjusted for prognostic factors and baseline imbalances.

Results: Of 198 adults, 106 underwent CCM excision. The subjects in the operated group were younger (p = 0.01). All patients were operated on with neuronavigation and cerebral monitoring or awake surgery. Although there has been no mortality in the surgical group, surgical morbidity was 1.8%. Only one patient in the conservative group had a clinically relevant hemorrhage. Smoke abuse was independently related with bad outcome. During 5 years of follow-up, CCM excision was associated with a deterioration to an Oxford Handicap Scale score.

Conclusions: CCM excision was associated with worse outcomes over 5 years compared to conservative management. Long-term follow-up will determine whether this difference is sustained over patients' lifetimes. The advent of new medical therapies that may be effective in the treatment of the CCM, such as TEMPOL and vitamin D, may change the surgical indications for this disease.