Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations

Anshit Goyal, Lorenzo Rinaldo, Redab Alkhataybeh, Panagiotis Kerezoudis, Mohammed Ali Alvi, Kelly Flemming, Lindsy Williams, Felix Diehn, Mohamad Bydon

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Objective There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management. Methods We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates. Results A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7%) patients underwent immediate surgical resection, 64 (75.3%) were initially managed conservatively. Among this latter group, 16 (25.0%) suffered a haemorrhage during follow-up and 11 (17.2%) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5% per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5% and 0.8%, respectively. Median time to haemorrhage was 2.3 years (0.1-12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013). Conclusion Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.

Original languageEnglish (US)
Pages (from-to)695-703
Number of pages9
JournalJournal of Neurology, Neurosurgery and Psychiatry
Volume90
Issue number6
DOIs
StatePublished - Jun 1 2019

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Natural History
Spinal Cord
Hemorrhage

Keywords

  • bleeding risk
  • cavernoma
  • cavernous malformation
  • hemorrhage
  • intramedullary
  • natural history
  • neurologic outcomes
  • spinal cord
  • surgical resection

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology
  • Psychiatry and Mental health

Cite this

Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations. / Goyal, Anshit; Rinaldo, Lorenzo; Alkhataybeh, Redab; Kerezoudis, Panagiotis; Alvi, Mohammed Ali; Flemming, Kelly; Williams, Lindsy; Diehn, Felix; Bydon, Mohamad.

In: Journal of Neurology, Neurosurgery and Psychiatry, Vol. 90, No. 6, 01.06.2019, p. 695-703.

Research output: Contribution to journalArticle

Goyal, Anshit ; Rinaldo, Lorenzo ; Alkhataybeh, Redab ; Kerezoudis, Panagiotis ; Alvi, Mohammed Ali ; Flemming, Kelly ; Williams, Lindsy ; Diehn, Felix ; Bydon, Mohamad. / Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations. In: Journal of Neurology, Neurosurgery and Psychiatry. 2019 ; Vol. 90, No. 6. pp. 695-703.
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abstract = "Objective There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management. Methods We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates. Results A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7{\%}) patients underwent immediate surgical resection, 64 (75.3{\%}) were initially managed conservatively. Among this latter group, 16 (25.0{\%}) suffered a haemorrhage during follow-up and 11 (17.2{\%}) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5{\%} per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5{\%} and 0.8{\%}, respectively. Median time to haemorrhage was 2.3 years (0.1-12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013). Conclusion Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.",
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T1 - Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations

AU - Goyal, Anshit

AU - Rinaldo, Lorenzo

AU - Alkhataybeh, Redab

AU - Kerezoudis, Panagiotis

AU - Alvi, Mohammed Ali

AU - Flemming, Kelly

AU - Williams, Lindsy

AU - Diehn, Felix

AU - Bydon, Mohamad

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N2 - Objective There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management. Methods We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates. Results A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7%) patients underwent immediate surgical resection, 64 (75.3%) were initially managed conservatively. Among this latter group, 16 (25.0%) suffered a haemorrhage during follow-up and 11 (17.2%) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5% per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5% and 0.8%, respectively. Median time to haemorrhage was 2.3 years (0.1-12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013). Conclusion Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.

AB - Objective There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management. Methods We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates. Results A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7%) patients underwent immediate surgical resection, 64 (75.3%) were initially managed conservatively. Among this latter group, 16 (25.0%) suffered a haemorrhage during follow-up and 11 (17.2%) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5% per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5% and 0.8%, respectively. Median time to haemorrhage was 2.3 years (0.1-12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013). Conclusion Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.

KW - bleeding risk

KW - cavernoma

KW - cavernous malformation

KW - hemorrhage

KW - intramedullary

KW - natural history

KW - neurologic outcomes

KW - spinal cord

KW - surgical resection

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