scholarly journals Influence of Pregnancy on Hemorrhage Risk in Women With Cerebral and Spinal Cavernous Malformations

Stroke ◽  
2021 ◽  
Vol 52 (2) ◽  
pp. 434-441
Author(s):  
Nycole K. Joseph ◽  
Shivram Kumar ◽  
Robert D. Brown ◽  
Giuseppe Lanzino ◽  
Kelly D. Flemming
Keyword(s):  
Spinal Cord ◽  
Neurological Complications ◽  
Reproductive Age ◽  
Childbearing Age ◽  
Cavernous Malformations ◽  
Familial Form ◽  
Hemorrhage Risk ◽  
Risk Of Hemorrhage ◽  
Record Review

Background and Purpose: Pregnancy as a hemorrhage risk factor in women with cavernous malformations (CMs) is controversial. We describe prospective hemorrhage risk in women who become pregnant after an established CM diagnosis. Methods: Beginning in 2015, we recruited consecutive patients with radiologically confirmed CM of the brain or spinal cord to participate in a prospective registry. Participants underwent a baseline and annual medical record review, imaging review, and annual surveys to ascertain pregnancies, deliveries, and neurological complications. We collected prospective hemorrhage data on reproductive age women. We calculated prospective hemorrhage rates on childbearing age patients based on the number of hemorrhages occurring post-CM diagnosis during pregnancy and nonpregnancy, divided by the years of follow-up and censored at last follow-up, age 46, or surgery in sporadic-form CM. The hemorrhage rates were compared and the 95% CI presented with a P value of <0.05. Results: Of 160 women, 90 presented with CM under the age of 46 (average age 31.6 years; 25.6% familial form; 46.7% with hemorrhage; 24.4% brain stem location). These 90 patients had 136 pregnancies before CM diagnosis; 36 pregnancies occurred at or after the diagnosis of CM. Four patients had a hemorrhage while pregnant or postpartum leading to the first CM diagnosis. During 402.6 years of follow-up while not pregnant, 42 hemorrhages occurred prospectively yielding a 10.4% per year (95% CI, 7.5–14.0) risk of hemorrhage while not pregnant. No hemorrhages occurred during 32 prospective pregnancies (26 live births including 1 twinset and 7 nonviable fetuses) after CM diagnosis during 26.9 years of pregnancy time yielding a rate of 0% per year (95% CI, 0–13.6). We found no statistical difference in the rates of hemorrhage during pregnant and nonpregnant time ( P =0.09). No hemorrhage occurred during delivery. Conclusions: Our prospective data suggest that pregnancy does not increase the risk of hemorrhage in women with a known brain or spinal cord CM and that vaginal delivery is safe in appropriate candidates.

Multimodality treatment of posterior fossa arteriovenous malformations

2008 ◽  
Vol 108 (6) ◽  
pp. 1152-1161 ◽  
Author(s):  
Michael E. Kelly ◽  
Raphael Guzman ◽  
John Sinclair ◽  
Teresa E. Bell-Stephens ◽  
Regina Bower ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Multimodality Treatment ◽  
Neurological Complications ◽  
Cure Rate ◽  
Complete Obliteration ◽  
The Mean ◽  
Risk Of Hemorrhage ◽  
Negative Predictor

Object Posterior fossa arteriovenous malformations (AVMs) are relatively uncommon and often difficult to treat. The authors present their experience with multimodality treatment of 76 posterior fossa AVMs, with an emphasis on Spetzler–Martin Grades III–V AVMs. Methods Seventy-six patients with posterior fossa AVMs treated with radiosurgery, surgery, and endovascular techniques were analyzed. Results Between 1982 and 2006, 36 patients with cerebellar AVMs, 33 with brainstem AVMs, and 7 with combined cerebellar–brainstem AVMs were treated. Natural history data were calculated for all 76 patients. The risk of hemorrhage from presentation until initial treatment was 8.4% per year, and it was 9.6% per year after treatment and before obliteration. Forty-eight patients had Grades III–V AVMs with a mean follow-up of 4.8 years (range 0.1–18.4 years, median 3.1 years). Fifty-two percent of patients with Grades III–V AVMs had complete obliteration at the last follow-up visit. Three (21.4%) of 14 patients were cured with a single radiosurgery treatment, and 4 (28.6%) of 14 with 1 or 2 radiosurgery treatments. Twenty-one (61.8%) of 34 patients were cured with multimodality treatment. The mean Glasgow Outcome Scale (GOS) score after treatment was 3.8. Multivariate analysis performed in the 48 patients with Grades III–V AVMs showed radiosurgery alone to be a negative predictor of cure (p = 0.0047). Radiosurgery treatment alone was not a positive predictor of excellent clinical outcome (GOS Score 5; p > 0.05). Nine (18.8%) of 48 patients had major neurological complications related to treatment. Conclusions Single-treatment radiosurgery has a low cure rate for posterior fossa Spetzler–Martin Grades III–V AVMs. Multimodality therapy nearly tripled this cure rate, with an acceptable risk of complications and excellent or good clinical outcomes in 81% of patients. Radiosurgery alone should be used for intrinsic brainstem AVMs, and multimodality treatment should be considered for all other posterior fossa AVMs.

Long-term Results after Stereotactic Radiosurgery for Patients with Cavernous Malformations

Neurosurgery ◽  
2002 ◽  
Vol 50 (6) ◽  
pp. 1190-1198 ◽  
Author(s):  
Toshinori Hasegawa ◽  
James McInerney ◽  
Douglas Kondziolka ◽  
John Y.K. Lee ◽  
John C. Flickinger ◽  
...  
Keyword(s):  
High Risk ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife Radiosurgery ◽  
Long Term Results ◽  
Major Hemorrhage ◽  
Cavernous Malformations ◽  
Before And After ◽  
Risk Of Hemorrhage

Abstract OBJECTIVE Stereotactic radiosurgery has been used for patients with high-risk cavernous malformations of the brain. We performed radiosurgery for patients with symptomatic, imaging-confirmed hemorrhages for which resection was believed to be associated with high risk. This study examines the long-term hemorrhage rate after radiosurgery. METHODS We reviewed data obtained before and after gamma knife radiosurgery on 82 patients treated between 1987 and 2000. Most patients had multiple hemorrhages from brainstem or diencephalic cavernous malformations. Follow-up data were examined to identify hemorrhages, and an overall hemorrhage rate was calculated. RESULTS Observation before treatment averaged 4.33 years (range, 0.17–18 yr) for a total of 354 patient-years. During this period, 202 hemorrhages were observed, for an annual hemorrhage rate of 33.9%, excluding the first hemorrhage. Temporal clustering of hemorrhages was not significant. After radiosurgery, patient follow-up averaged 5 years (range, 0.42–12.08 yr), for a total of 401 patient-years. During this period, 19 hemorrhages were identified, 17 in the first 2 years posttreatment and 2 after 2 years. The annual hemorrhage rate was 12.3% per year for the first 2 years after radiosurgery, followed by 0.76% per year from Years 2 to 12. Eleven patients had new neurological symptoms without hemorrhage after radiosurgery (13.4%). The symptoms were minor in six of these patients and temporary in five. CONCLUSION Radiosurgery confers a reduction in the risk of hemorrhage for high-risk cavernous malformations. Risk reduction, although in evidence during initial follow-up, is most pronounced after 2 years. Given the difficulty of identifying high-risk patients, treatment after one major hemorrhage should be considered in selected younger patients. Such a strategy warrants further investigation.

Intramedullary spinal cord cavernous malformations: clinical features and risk of hemorrhage

2003 ◽  
Vol 26 (4) ◽  
pp. 253-256 ◽  
Author(s):  
Ibrahim Erol Sandalcioglu ◽  
Helmut Wiedemayer ◽  
Thomas Gasser ◽  
Siamek Asgari ◽  
Tobias Engelhorn ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Clinical Features ◽  
Intramedullary Spinal Cord ◽  
Cavernous Malformations ◽  
Risk Of Hemorrhage

scholarly journals Cavernous Malformation of Brainstem, Thalamus, and Basal Ganglia

Neurosurgery ◽  
2012 ◽  
Vol 72 (4) ◽  
pp. 573-589 ◽  
Author(s):  
Paritosh Pandey ◽  
Erick M. Westbroek ◽  
Peter A. Gooderham ◽  
Gary K. Steinberg
Keyword(s):  
Basal Ganglia ◽  
Neurological Deficits ◽  
Term Outcome ◽  
Cavernous Malformations ◽  
Long Term Outcome ◽  
Brain Malformations ◽  
Hemorrhage Risk ◽  
Clinical Records

Abstract BACKGROUND: Cavernous malformations (CMs) in deep locations account for 9% to 35% of brain malformations and are surgically challenging. OBJECTIVE: To study the clinical features and outcomes following surgery for deep CMs and the complication of hypertrophic olivary degeneration (HOD). METHODS: Clinical records, radiological findings, operative details, and complications of 176 patients with deep CMs were reviewed retrospectively. RESULTS: Of 176 patients with 179 CMs, 136 CMs were in the brainstem, 27 in the basal ganglia, and 16 in the thalamus. Cranial nerve deficits (51.1%), hemiparesis (40.9%), numbness (34.7%), and cerebellar symptoms (38.6%) presented most commonly. Hemorrhage presented in 172 patients (70 single, 102 multiple). The annual retrospective hemorrhage rate was 5.1% (assuming CMs are congenital with uniform hemorrhage risk throughout life); the rebleed rate was 31.5%/patient per year. Surgical approach depended on the proximity of the CM to the pial or ependymal surface. Postoperatively, 121 patients (68.8%) had no new neurological deficits. Follow-up occurred in 170 patients. Delayed postoperative HOD developed in 9/134 (6.7%) patients with brainstem CMs. HOD occurred predominantly following surgery for pontine CMs (9/10 patients). Three patients with HOD had palatal myoclonus, nystagmus, and oscillopsia, whereas 1 patient each had limb tremor and hemiballismus. At follow-up, 105 patients (61.8%) improved, 44 (25.9%) were unchanged, and 19 (11.2%) worsened neurologically. Good preoperative modified Rankin Score (98.2% vs 54.5%, P = .001) and single hemorrhage (89% vs 77.3%, P &lt; .05) were predictive of good long-term outcome. CONCLUSION: Symptomatic deep CMs can be resected with acceptable morbidity and outcomes. Good preoperative modified Rankin Score and single hemorrhage are predictors of good long-term outcome.

scholarly journals Spinal intramedullary cavernomas. Personal experience reffering to six cases

2014 ◽  
Vol 21 (4) ◽  
pp. 407-415 ◽  
Author(s):  
G. Iacob ◽  
Angela Olarescu
Keyword(s):  
Spinal Cord ◽  
Dorsal Surface ◽  
Neurological Status ◽  
Duration Of Symptoms ◽  
Cavernous Malformations ◽  
Excellent Outcome ◽  
Presenting Symptoms ◽  
Asymptomatic Patients ◽  
Microsurgical Techniques

Abstract Despite cavernous malformations of the CNS are pathologically similar, intramedullary cavernous malformations are very rare lesions, increasingly recognized after introduction of magnetic resonance image, generating gradual neurological decline, with severe deficits or acute loss of spinal function. We report our experience on six patients with intramedullary cavernomas defining the spectrum of presenting symptoms and signs analyzing the role of surgery as a treatment for these lesions. We present our experience with 2 cervical and 4 thoracal spinal intramedullary cavernoma from 2010 to 2014 searching history, onset of clinical manifestation, neurological status, radiological findings, operation, and clinical outcome. Among 6 patients male were 2 cases; female 4 cases; mean age was 42 years (range 25-72 years); mean duration of symptoms were 1,5 years (range 5 days and 2 years) with slowly progressive neurological decline. In two cases there was acute onset of neurological compromise. In all cases diagnosis was made on MRI and lesions were possible to be radically excised and gently extracted from the hemosiderin-stained bed inside of the spinal cord via a laminectomy and midline myelotomy with microsurgical techniques. The surgical outcome on a mean duration of follow up of 12 months were: for 4 cases - the patients neurological conditions remarkably improved 1 month later, for 2 cases no improvement were remarked. No recurrent hemorrhages were recorded. A follow-up MRI examination was made in all cases to confirm complete removal of the cavernous angioma. Spinal intramedullary cavernoma should be early recognized by MRI, can be positioned in a precarious position and generate significant neurologic deficits than cranial cavernomas. For symptomatic intramedullary cavernous malformations extended to the dorsal surface of the spinal cord, total resection with microsurgical techniques can offer good or excellent outcome, restoring neurological status and to stop chronic deterioration and acute rebleeding. To asymptomatic patients with deeper lesions which entail a higher operative risk, but also a surgically manageable cause of myelopathy a closed observation is mandatory.

scholarly journals Antithrombotic medication and bleeding risk in patients with cerebral cavernous malformations: a cohort study

2019 ◽  
Vol 130 (6) ◽  
pp. 1922-1930
Author(s):  
David Bervini ◽  
Christian Jaeggi ◽  
Pasquale Mordasini ◽  
Philippe Schucht ◽  
Andreas Raabe
Keyword(s):  
Bleeding Risk ◽  
Cerebral Cavernous Malformations ◽  
Cavernous Malformations ◽  
Vascular Abnormalities ◽  
Increased Risk ◽  
Potential Risk Factors ◽  
Hemorrhagic Risk ◽  
Risk Of Hemorrhage ◽  
Antithrombotic Medication

OBJECTIVECerebral cavernous malformations (CCMs) are frequently diagnosed vascular abnormalities. The hemorrhagic risk associated with the use of long-term antithrombotic medication (ATM) in patients with CCMs is a matter of controversy. The aim of this study was to determine the hemorrhagic risk associated with ATM use in patients diagnosed with one or more CCMs.METHODSDemographic, clinical, treatment, and ATM-related information on patients diagnosed with one or more CCMs at a single institution over more than 34 years was retrospectively recorded. Univariate and multivariate descriptive and survival analyses were used to assess potential risk factors associated with CCM-related hemorrhage at presentation and during follow-up (first or subsequent hemorrhage).RESULTSA total of 408 patients were included in the analysis and 492 CCMs were followed up after diagnosis, for a total of 1616 lesion-years. Thirty-seven (7.5%) CCMs bled during follow-up, leading to an overall annual rate of CCM-related symptomatic hemorrhage of 2.3% (95% CI 1.7%–3.2%). Eighty-two patients harboring 91 CCMs (16.8%) were on ATM. When stratified for ATM, the annual rates of hemorrhage were 0.7% (95% CI < 0.01% to 4.2%) for the lesions in patients on ATM versus 2.5% (95% CI 1.8%–3.4%) for those not on ATM. ATM was not found to be associated with either an increased risk of CCM-related hemorrhage at presentation (p = 0.355) or an increased risk of CCM-related hemorrhage (first or subsequent hemorrhage) in multivariate descriptive (p = 0.912) and survival (p = 0.145) analyses.CONCLUSIONSThe use of ATM does not seem to be associated with an increased risk of hemorrhage in patients diagnosed with CCMs.

Clinical course of untreated pediatric brainstem cavernous malformations: hemorrhage risk and functional recovery

2014 ◽  
Vol 13 (5) ◽  
pp. 471-483 ◽  
Author(s):  
Da Li ◽  
Shu-Yu Hao ◽  
Jie Tang ◽  
Xin-Ru Xiao ◽  
Gui-Jun Jia ◽  
...  
Keyword(s):  
Complete Recovery ◽  
Lesion Size ◽  
Full Recovery ◽  
Functional Evaluation ◽  
Cavernous Malformations ◽  
Clinical Appearance ◽  
Perilesional Edema ◽  
Hemorrhage Risk ◽  
The Mean

Object The aim of this study was to investigate the clinical appearance of untreated pediatric brainstem cavernous malformations (CMs) and to identify the hemorrhage risks and functional outcomes. Methods All pediatric patients with a diagnosis of brainstem CM between 1985 and 2012 were registered. The clinical chart and radiographs were recorded, and follow-up evaluations were obtained prospectively. Results A total of 85 patients (69.4% male) were included with a mean age of 12.7 years. Sixty-seven patients (78.8%) had prior hemorrhage, and 6 patients (7.1%) were asymptomatic. There were 15 midbrain lesions, 53 pons lesions, and 17 medulla lesions. The mean lesion size was 1.9 cm. During a total of 401.6 patient-years of follow-up, 47 hemorrhages occurred in 37 patients, and the annual hemorrhage rate was 11.7% per patient-year. The mean hemorrhage interval was 47.8 months. The hemorrhage risk declined over time, especially after the first 2 years. Both a lesion size ≥ 2 cm (hazard ratio [HR] 2.122, p = 0.037) and the presence of perilesional edema (HR 2.192, p = 0.039) predicted future hemorrhage and were associated with a high annual hemorrhage rate. The hemorrhage-free survival at 6 months was 85.7%, and at 1, 5, 10, and 15 years was 71.5%, 49.4%, 27.5%, and 13.7%, respectively. At the most recent functional evaluation, 33 patients (38.8%) had improved, 32 (37.6%) had stabilized, and 20 (23.5%) had worsened, without any deaths. Twenty-two patients (25.9%) obtained a full recovery. Prospective hemorrhage (HR 0.191, p = 0.003) was the adverse predictor for full recovery. Full recovery primarily occurred within the first 12 months, after which the chance of full recovery decreased. The cumulative percentage of complete recovery at 6 months was 32.7%, and at 1, 3, and 5 years was 40.8%, 43.6%, and 49.2%, respectively. Conclusions In this study the hemorrhage rate was relatively high in pediatric brainstem CMs, although the functional outcome was acceptable. The decline in hemorrhage risk and the identified adverse predictors in this study were helpful for clinicians and patients when deciding on treatment. Referral bias and the insufficient follow-up period of the study were highlighted as limitations.

Aggressive course of multiple de novo cavernous malformations

2011 ◽  
Vol 115 (6) ◽  
pp. 1175-1178 ◽  
Author(s):  
Kelly D. Flemming ◽  
George K. Bovis ◽  
Fredric B. Meyer
Keyword(s):  
De Novo ◽  
Clinical Symptoms ◽  
Cavernous Malformation ◽  
Correct Diagnosis ◽  
Cavernous Malformations ◽  
History Of ◽  
Hemorrhage Risk ◽  
Hemorrhagic Lesion ◽  
One Year ◽  
Risk Of Hemorrhage

The risk of hemorrhage from an intracerebral cavernous malformation has been estimated at 2%–4% per year. In patients with multiple cavernous malformations, typically there are 1 or 2 dominant lesions that result in symptoms. This report highlights an unusual case of recurrent hemorrhage from de novo cavernous malformations. This 35-year-old man had a generalized seizure in 2007. Magnetic resonance imaging performed at the time showed multiple hemorrhagic lesions suggestive of cavernous malformations. Two years later, the patient had clinical symptoms referable to a midbrain hemorrhage. This lesion was not present on 2007 standard and gradient echo images. One year later, the patient had another clinical hemorrhage at the cervical medullary junction. This lesion was also not present on earlier imaging. Genetic testing was negative for the known familial types of cavernous malformation. A lesion was biopsied to ensure correct diagnosis, and the results were pathologically consistent with a cavernous malformation. The patient had a fourth clinical hemorrhage in 2011 from a separate lesion. All hemorrhage symptoms were mild, and he returned to normal functioning and work after each hemorrhage. This case highlights several unusual features of the known natural history of intracerebral cavernous malformations. In this case, resection of the hemorrhagic lesion would not have altered future hemorrhage risk since each new hemorrhage was from a de novo lesion.

scholarly journals Knowledge About Obstetric Hazard Signs and Associated Factors Among Reproductive Age Women in South Eastern Zone of Tigray 2021. Cross Sectional Study

2022 ◽  
Author(s):  
Berhane Teklay Asfaha ◽  
Shewit Hailu Gebremariam ◽  
Gebremedhin Kinfe Gebremariam ◽  
Ataklti Gebretsadik Weldemariam
Keyword(s):  
Developing Countries ◽  
Educational Status ◽  
Reproductive Age ◽  
Childbearing Age ◽  
Women Of Reproductive Age ◽  
Cross Sectional ◽  
History Of ◽  
Women's Knowledge ◽  
Women’S Knowledge

Abstract Background: Pregnancy complications are the biggest health problem for women in developing countries. Around 295,000 women worldwide die each year from pregnancy-related causes, and 86% of this maternal mortality occurs in developing countries.Objective: To assess knowledge about obstetric hazard signs among women of reproductive age living in the southeastern zone of the Tigray region, Ethiopia, 2021.Methods: A community-based quantitative cross-sectional survey was conducted in the southeastern zone of Tigray. A multi-level random sampling technique was implemented to select the total participants from 410 women of reproductive age. Two districts were selected at random and from these districts 12 Kebels were selected at random and the calculated sample size (410) was proportionally assigned to each Kebele selected. The data was collected through face-to-face / interview with a structured questionnaire from January 20 to February 20, 2021, after it had been ensured that all ethical requirements were met. The collected data was entered into Epidata version 4.2 and then exported to SPSS version 20 for analysis. Descriptive statistics with frequency, percentage, table and graph as well as crosstabs were used to present the results. Bivariate and multivariable analyses were used to examine the relationship. Odds ratios with 95% confidence intervals and P-values ​​<0.05 were used to determine the statistical association.Result: Four hundred and ten women of childbearing age participated in the study, which resulted in a response rate of 100%. Leakage of fluid per vagina was the most frequently cited obstetric hazard sign (61%). Overall, one hundred and seventy-two (42%) had a good knowledge of obstetric hazard signs. Educational status of the mother [AOR (95% CI = 2.7 (1.189–6.24)], place of birth [AOR (95% CI = 2.2 (1.6–3.432)] and with a history of ANC follow-up [AOR (95% CI = 2.4 (1.13–5.6)] were found to be independent predictors of women's knowledge of the obstetric hazard sign.Conclusion and recommendation: The mother's educational status, birth site and the history of ANC follow-up were independently related to the women's knowledge of obstetric hazard signs. Therefore, the provision of information, education and communication to women, families and the general community about obstetric hazard signs and related factors has been recommended.

The natural history of familial cavernous malformations: results of an ongoing study

1994 ◽  
Vol 80 (3) ◽  
pp. 422-432 ◽  
Author(s):  
Joseph M. Zabramski ◽  
Thomas M. Wascher ◽  
Robert F. Spetzler ◽  
Blake Johnson ◽  
John Golfinos ◽  
...  
Keyword(s):  
Natural History ◽  
Mr Imaging ◽  
Ongoing Study ◽  
Mr Images ◽  
Cavernous Malformations ◽  
Content Type ◽  
Imaging Characteristics ◽  
Familial Form ◽  
Fine Print

✓ Cavernous malformations are congenital abnormalities of the cerebral vessels that affect 0.5% to 0.7% of the population. They occur in two forms: a sporadic form characterized by isolated lesions, and a familial form characterized by multiple lesions with an autosomal dominant mode of inheritance. The management of patients with cavernous malformations, particularly those with the familial form of the disease, remains a challenge because little is known regarding the natural history. The authors report the results of an ongoing study in which six families afflicted by familial cavernous malformations have been prospectively followed with serial interviews, physical examinations, and magnetic resonance (MR) imaging at 6- to 12-month intervals. A total of 59 members of these six families were screened for protocol enrollment; 31 (53%) had MR evidence of familial cavernous malformations. Nineteen (61%) of these 31 patients were symptomatic, with seizures in 12 (39%), recurrent headaches in 16 (52%), focal sensory/motor deficits in three (10%), and visual field deficits in two (6%). Twenty-one of these 31 patients underwent at least two serial clinical and MR imaging examinations. A total of 128 individual cavernous malformations (mean 6.5 ± 3.8 lesions/patient) were identified and followed radiographically. During a mean follow-up period of 2.2 years (range 1 to 5.5 years), serial MR images demonstrated 17 new lesions in six (29%) of the 21 patients; 13 lesions (10%) showed changes in signal characteristics, and five lesions (3.9%) changed significantly in size. The incidence of symptomatic hemorrhage was 1.1% per lesion per year. The results of this study demonstrate that the familial form of cavernous malformations is a dynamic disease; serial MR images revealed changes in the number, size, and imaging characteristics of lesions consistent with acute or resolving hemorrhage. It is believed that the de novo development of new lesions in this disease has not been previously reported. These findings suggest that patients with familial cavernous malformations require careful follow-up monitoring, and that significant changes in neurological symptoms warrant repeat MR imaging. Surgery should be considered only for lesions that produce repetitive or progressive symptoms. Prophylactic resection of asymptomatic lesions does not appear to be indicated.

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