gms | German Medical Science

Objective: Cavernous malformations (CMs) are low-flow vascular lesions of the brain with an incidence between 0.4 and 0.9%. Depending on their location and the extent of the hemorrhage, CMs present incidentally, with epileptic seizures or with neurological deficits. However, robust evidence on their natural course especially in case of a concomitant hemorrhage is still lacking. Therefore, our study aims to describe the clinical course of patients with CMs and assess possible risk factors which might serve as surrogate for the presence of a hemorrhage.

Methods: This retrospective study included cases with radiologically confirmed CMs, who were diagnosed between 2015 and 2020. Data regarding baseline characteristics and the treatment approach (conservative vs. surgical resection) were collected. A logistic regression model was performed to examine risk factors such as age, sex, location, multiplicity and developed venous anomaly (DVA) for the occurrence of hemorrhage.

Results: A total of 277 cases with a mean age of 43.2 years (SD 10.7) were included. 192 were treated conservatively, whereas 85 were converted to a microsurgical resection of the CM. The occurrence of an epileptic seizure and of gait disturbance was significantly more prevalent among the surgical cohort (30.6%; 14.1%) compared to the conservative one (12.9%; 4.7%; p<0.001). No significant differences were found between the groups concerning neurological deficits, the location, or the multiplicity. While almost all surgically treated cases suffered from prior hemorrhage, signs of a prior hemorrhage were still found in half of conservatively treated cases (94.1% vs. 55.7%, p<0.001). Reasons for conservative management were significantly fewer seizures and absence of symptoms in infratentorial CMs compared to surgically treated cases with prior hemorrhage (p<0.05). Above all, infratentorial location was a unique risk factor for experiencing hemorrhage (OR 1.9; 95% 1.0-3.6, p=0.04), while age, sex, DVA and multiplicity were not.

Conclusion: Our findings suggest that an infratentorial location, the occurrence of an epileptic seizure and cerebellar symptoms might serve as critical pillars for neurosurgical decision making. Closer evaluation of imaging surrogates for hemorrhage risk and their implications on surgical decision making in CMs should be pursued to improve comprehensive management in the future.