Synopsis of Guidelines for the Clinical Management of Cerebral Cavernous Malformations: Consensus Recommendations Based on Systematic Literature Review by the Angioma Alliance Scientific Advisory Board Clinical Experts Panel

Optimizing gamma knife radiosurgery for cerebral cavernous malformation: Analysis of 54 patients treated at our university center

BACKGROUND

We retrospectively analyzed the characteristics of patients affected by Cerebral Cavernous Malformations (CCMs) treated in our center with Leksell Gamma Knife Stereotactic Radiosurgery (LGKSRS) to identify subsets with better treatment response or greater risk of symptomatic Adverse Radiation Effects (AREs).

METHODS

The data of 54 patients (60 CCMs) treated in our Department with LGKSRS between January 2011 and January 2021 were retrieved (mean follow-up 4.8 years). All patients had at least 2 bleedings before treatment. Mean Prescription Dose (PD) was 15.4 Gy. In 20 cases (33 %) an associated Developmental Venous Anomaly (DVA) was identified; multiple CCMs were found in 17 cases (28 %).

RESULTS

After treatment occurred 8 bleedings and 5 out of 8 within the first 6 months of follow-up. The Annual Hemorrhage Rate dropped from 51.37 % (before treatment) to 4.2 % (within 2 years of treatment) and 1.84 % (beyond 2 years) (p < 0.00001). A statistically significant reduction in the mean number of hemorrhages per lesion was observed (2.08 before vs 0.12 after LGKSRS, p < 0.00001). A higher risk of post-treatment bleeding was significantly associated with age < 45 years at univariate analysis, but only PD lower than 15 Gy was significantly associated at the multivariate level; associated vascular malformations showed a trend toward significance (p = 0.08). Of note, AREs were more common in isolated CCMs (not associated with vascular malformations).

CONCLUSIONS

Given the association of the outcomes with baseline lesion and patient features, our findings showed that lesion and patient features at baseline can predict the outcomes and should guide treatment decision.

A case of spinal cord intramedullary cavernoma

Rare vascular abnormalities of the central nervous system, spinal intramedullary cavernomas make up fewer than 5% of all spinal cord lesions. Symptoms are vague, making diagnosis difficult. A fast and precise diagnosis is made possible by the early detection and characterization of these lesions, which is made possible by radiological imaging, especially MRI with contrast. A 45-year-old man who had intermittent neck discomfort and developed upper limb weakness also had motor and sensory difficulty. Diagnosis of a spinal canal intramedullary cavernoma was confirmed by an magnetic resonance imaging (MRI) showing a distinct intramedullary lesion. This case report focuses on managerial factors and diagnostic problems.

Guidelines for the Diagnosis and Clinical Management of Cavernous Malformations of the Brain and Spinal Cord: Consensus Recommendations Based on a Systematic Literature Review by the Alliance to Cure Cavernous Malformation Clinical Advisory Board Experts Panel

BACKGROUND AND OBJECTIVES

Despite many publications about cavernous malformations (CMs), controversy remains regarding diagnostic and management strategies. To update evidence-based guidelines for the clinical management of brain and spinal cord CMs.

METHODS

The Alliance to Cure CMs, the patient support group in the United States advocating on behalf of patients and research in CM, convened a multidisciplinary writing group comprising expert CM clinicians to help summarize the existing literature related to the clinical care of CM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and imaging standards, (4) neurosurgical considerations, and (5) neurological considerations. Building on prior evidence-based recommendations reflecting literature review through October 2014, the group conducted a systematic review of the more recent literature, identified references for mandatory citation, rated evidence, developed recommendations, and established consensus according to a prespecified protocol. Finally, the writing group outlined remaining knowledge gaps and controversies to guide future research.

RESULTS

From 2672 publications published between October 1, 2014, and March 15, 2023, and meeting key word criteria, 234 were selected based on prearticulated criteria for mandatory consideration in evidence-based recommendations. Topic authors used these and other supporting references to summarize current knowledge and arrive at 53 management recommendations, with unanimous consensus based on a Delphi process. These were rated by class (strength of recommendation) and level (quality of evidence) per the American Heart Association/American Stroke Association criteria. Eighteen recommendations were class 1 (34%), class 2 in 31 (58%), and class 3 in 4 (8%). Three were level A (6%), 19 (36%) were level B, and 31 (58%) were level C.

CONCLUSION

Current evidence supports prior and new recommendations for the management of CMs, but many reflect moderate classes and low levels, mandating further research to better inform clinical practice.

Focused ultrasound-microbubble treatment arrests the growth and formation of cerebral cavernous malformations

Cerebral cavernous malformations (CCMs) are vascular lesions within the central nervous system that cause debilitating neurological symptoms. Currently, surgical excision and stereotactic radiosurgery, the primary treatment options, pose risks to some patients. Here we tested whether pulsed, low intensity, focused ultrasound-microbubble (FUS-MB) treatments control CCM growth and formation in a clinically representative Krit1 null murine model. FUS-MB under magnetic resonance imaging (MRI) guidance opened the blood-brain barrier, with gadolinium contrast agent deposition most evident at perilesional boundaries. Longitudinal MRI revealed that, at 1 month after treatment, FUS-MB halted the growth of 94% of treated CCMs. In contrast, untreated CCMs grew ~7-fold in volume. FUS-MB-treated CCMs exhibited a marked reduction in Krit1 null endothelial cells. In mice receiving multiple FUS-MB treatments with fixed peak-negative pressures, de novo CCM formation was reduced by 81%, indicating a prophylactic effect. Our findings support FUS-MB as a minimally invasive treatment modality that can safely arrest murine CCM growth and prevent de novo CCM formation in mice. If proven safe and effective in clinical trials, FUS-MB treatment may enhance therapeutic options for CCM patients.

There Will Be Blood: Mapping Iron Deposition in Sporadic Cerebral Cavernous Malformation-Related Epilepsy using QSM Imaging

Quantitative susceptibility mapping of iron deposition in sporadic cerebral cavernous malformation-related epilepsy Zhang S, Liu Y, Ma L, Yuan J, Wu C, Wang S. Epilepsia . 2025 Jan 13. doi: 10.1111/epi.18263. Epub ahead of print. PMID: 39804066. Objective: To evaluate iron deposition patterns in patients with cerebral cavernous malformation-related epilepsy (CRE) using quantitative susceptibility mapping (QSM) for detailed analysis of iron distribution associated with a history of epilepsy and severity. Methods: This study is part of the Quantitative Susceptibility Biomarker and Brain Structural Property for Cerebral Cavernous Malformation-Related Epilepsy (CRESS) cohort, a prospective multicenter study. QSM was used to quantify iron deposition in patients with sporadic cerebral cavernous malformation (CCMs). Lesions were segmented into intralesional, perilesional, and extralesional areas, with mean susceptibility values calculated for each subregion and analyzed in relation to epilepsy severity and duration. Results: Among the 46 patients studied, those with a history of epilepsy had significantly higher iron deposition values in the perilesional (P  = .012) and extralesional areas (P  = .01), as well as a greater extent of iron deposition (P  < .001) compared to those without epilepsy. The extent of iron deposition effectively distinguished patients with and without epilepsy, with an area under the curve (AUC) of 0.901 (95% confidence interval [CI]: 0.816-0.985). Among patients with epilepsy, iron deposition in the extralesional area was positively correlated with the severity of epilepsy (r2 = 0.181, P  = .043), and the extent of iron deposition was positively correlated with the duration of epilepsy (r2 = .214, P  = .026). Significance: This study highlights QSM as a noninvasive tool for assessing iron deposition in CRE, identifying distinct subregional iron deposition patterns linked to epilepsy status and severity.

Management, and outcomes of pediatric cerebral cavernous malformations across age groups: A systematic review and meta-analysis of the literature

OBJECTIVE

Pediatric Cerebral Cavernous Malformations (CCM) are focal neuro-vascular lesions with highly variable symptomatic presentations and natural history. In this study, we explored clinical features, management decisions, and outcomes in specific pediatric CCM populations.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an exhaustive review of the literature was conducted using search strings on PubMed, SCOPUS, Google Scholar, Ovid Embase, and Cochrane databases to assess differences in patient demographics, treatment strategies and clinical outcomes specifically between National Institute of Health (NIH) and American Academic of Pediatrics (AAP)-defined age groups: infants (0-1 year), children (1-12 years), adolescents (12-17 years).

RESULTS

Data from 630 individual pediatric cases from 94 publications was analyzed, yielding 45 infants (median: 0.3 years), 280 children (median: 7.0 years), and 305 adolescents (median: 15 years). Comparatively, infants were more likely to present with signs of elevated ICP and isolated lesions than both the children and adolescents' group (p < 0.05). Infants presenting with multiple lesions had higher rates of conservative management than surgery (46.2 % vs. 24.30 %, p < 0.01). Children with isolated sensory deficits or asymptomatic at presentation were more likely to undergo conservative management (14.3 % vs. 3.70 %, p < 0.05; 20.0 % vs. 0 %, p < 0.001), while those who underwent surgery had higher rates of improvement (81.6 % vs. 51.4 %, p < 0.001) and were more often symptom-free at follow-up (48.2 % vs. 25.7 %, p < 0.05). In adolescents, seizures (47.1 % vs. 14.8 %, p < 0.01), supratentorial lesions (64.6.0 % vs. 45.2 %, p < 0.01), and isolated lesions (75.7 % vs. 53.8 %, p < 0.05) favored surgical management. With increasing age, headaches were more likely (OR:1.05, 95 % CI:1.01-1.10, p < 0.05), whereas motor deficits (OR:0.96, 95 % CI:0.93-0.99, p < 0.05) and signs of elevated intracranial pressure (OR:0.91, 95 % CI:0.87-0.95, p < 0.001) were less likely initial presentations. Furthermore, older patients were more likely to harbor multiple malformations (OR:1.04, 95 % CI:1.01-1.08, p < 0.05). Regardless of management strategy, there was no difference in long-term outcomes between age groups (p > 0.05).

CONCLUSION

Although presenting symptoms, specific lesion characteristics and symptoms varied with the age of presentation in pediatric CCM patients, there was no significant difference noted in outcomes or long-term follow-up between age groups.

Mesenchymal Nonmeningothelial Tumors of the CNS: Evolving Molecular Landscape and Implications for Neuroradiologists

The World Health Organization Classification of Tumors of the Central Nervous System, 5th edition (WHO CNS5) significantly revised the terminology and diagnostic criteria of "mesenchymal nonmeningothelial" tumors of CNS to better align with the classification of these soft tissue tumors outside the CNS. The CNS chapter only covers the entities with distinct histologic or molecular characteristics that occur exclusively or primarily in the CNS. These tumors usually arise from the meninges and are rarely intraparenchymal in origin, mainly in the supratentorial compartment. These tumors are grouped into 3 main categories: soft tissue, chondro-osseous, and notochordal. Soft tissue tumors, the largest group, are further divided into fibroblastic, vascular, and skeletal muscle subtypes. Notably, a new subcategory for "tumors of uncertain differentiation" has been introduced, encompassing 3 new histomolecular entities: FET::cAMP response element-binding protein (CREB) fusion-positive, Capicua transcriptional receptor (CIC)-rearranged sarcoma, and primary intracranial sarcoma, DICER1-mutant. Emerging entities like dural angioleiomyomas and spindle cell neoplasms with neurotrophic receptor kinase (NTRK) rearrangements have been reviewed, although not introduced in WHO CNS5. Given the often nonspecific histology and immunophenotype of mesenchymal nonmeningothelial tumors of uncertain differentiation, molecular techniques have become indispensable for accurate diagnosis. This review provides a comprehensive overview of primary mesenchymal nonmeningothelial CNS tumors, including their clinical, radiologic, histopathologic, and molecular characteristics and treatment strategies.

Genetic Insights Into Hemorrhagic Stroke and Vascular Malformations: Pathogenesis and Emerging Therapeutic Strategies

Brain arteriovenous malformations (AVMs), cerebral cavernous malformations (CCMs), and intracranial aneurysms are major causes of hemorrhagic stroke, yet noninvasive therapies to prevent growth or rupture are lacking. Understanding the genetic basis of these malformations is critical for uncovering underlying mechanisms, developing targeted prevention strategies, and identifying novel therapeutic targets. This review highlights the causal genes and signaling pathways in AVMs, CCMs, and intracranial aneurysms, noting both their commonalities and differences. For AVMs, somatic mutations in the RAS (rat sarcoma virus)/MAPK (mitogen-activated protein kinase) and MAPK/ERK (extracellular signal-regulated kinase) pathway are key, particularly in sporadic cases, whereas hereditary conditions like hereditary hemorrhagic telangiectasia and capillary malformation-AVM involve the TGF-β (transforming growth factor β), Ephrin receptor, and angiopoietin-VEGF (vascular endothelial growth factor) signaling pathways. In CCMs, pathways affecting endothelial junctions and vascular stability, such as the ROCK (RhoA/Rho-associated coiled-coil containing kinases) pathway, play a central role. Although the genetic drivers of intracranial aneurysms are more diverse and less clearly linked to specific pathways, there is some overlap with genes in the TGF-β and endothelial function pathways seen in AVMs and CCMs. Emerging therapies for AVMs and CCMs include MAPK/ERK inhibitors, anti-VEGF treatments, and RhoA/ROCK inhibitors, showing potential in preclinical models. Due to the genetic overlap, these advancements may also offer future therapeutic strategies for intracranial aneurysms. As personalized medicine progresses, the development of reliable biomarkers, such as the candidate biomarker VEGF for AVMs and CCMs, will be crucial for guiding treatment decisions. In conclusion, ongoing research into genetic pathways holds promise for novel therapeutic targets that could transform the management of vascular malformations and reduce the risk of hemorrhagic stroke.

Antithrombotic therapy and cavernoma bleeding: does vascular border zone localization matter?

Objective

Hemorrhagic events in cavernous malformations (CCMs) are linked to significant morbidity and mortality. Identifying factors contributing to bleeding is crucial for effective clinical and surgical management.

Methods

This retrospective, observational, single-center study assessed potential and known risk factors for bleeding in patients with cerebral cavernous malformations. We evaluated age, gender, smoking habits, arterial hypertension, antithrombotic medication, diabetes mellitus, cavernoma shape, size changes observed in follow-up MRIs, the occurrence of epileptic seizures, and the localization of the lesion in regard of cerebral vascular territories.

Results

We identified 143 patients (43.4% male, 45.5% with hemorrhagic events, and 19.6% with epileptic seizures). Antithrombotic medication was associated with a lower frequency of hemorrhage (p = 0.012). Arterial hypertension, diabetes mellitus, smoking habits and localization in the border zone of a vascular territory or seizures were not significantly associated with bleeding events. An increased rate of hemorrhagic events was found in cavernomas with irregular MRI shape (p = 0.001), or with changes in size during follow-up (p = 0.012). Multivariate analysis confirmed that antithrombotic therapy was associated with a reduced risk of hemorrhage (OR: 0.151, 95% CI: 0.041-0.552, p = 0.004), while male gender (OR: 2.114, 95% CI: 1.047-4.269, p = 0.037), irregular cavernoma shape (p = 0.001), and cavernoma growth (p = 0.002) were independently associated with a higher bleeding risk. Cavernoma localisation in the border zone between median and posterior arterial territories was associated with a significant lower rate of bleeding events compared to localisation in other watershed areas.

Conclusion

We observed a reduced percentage of bleeding in cavernoma patients utilizing antithrombotic agents, compared to patients without antithrombotic medication. Factors such as smoking habits, irregular cavernoma shape on MRI, and changes in size during follow-up were associated with a higher frequency of bleeding events.

Comparative Analysis of the Health-Related Quality of Life Between Patients with Familial and Sporadic Forms of Cerebral Cavernous Malformation

OBJECTIVE

To compare health-related quality of life (HRQoL) in patients with familial form of cerebral cavernous malformation (fCCM) versus those with sporadic form of cerebral cavernous malformation (sCCM).

METHODS

A cross-sectional observational study was conducted involving adult patients receiving outpatient care at a specialized referral center for cerebral cavernous malformation (CCM). In addition to clinic visits, demographic data and imaging were reviewed. Patients completed the Patient-Reported Outcome Measurements Information System, version 2.0 (PROMIS-29), and the EuroQol 5 dimensions 5 levels, version 3.1. Data were compared using a 2-tailed 2-sample t-test or Mann-Whitney test for continuous variables. Pearson χ2 or Fisher's exact test assessed the association between 2 categorical variables.

RESULTS

Eighty-three patients participated in the study over one year. The average age of the participants was 45.37 years (standard deviation = 14.75), with 53 (63.86%) being female. On average, patients had 12.48 years of education (standard deviation = 3.87), and 36 (43.37%) had the familial form of the disease. No significant differences in HRQoL were observed between patients with familial fCCM and sCCM. Among symptomatic patients, there were also no differences between the 2 groups in any domain of either assessment tool. However, within the fCCM group, symptomatic individuals reported worse HRQoL in the usual activities domain of the EuroQol 5 dimensions 5 levels (P = 0.014) and the physical function domain of the PROMIS-29 (P = 0.031) when compared to asymptomatic individuals.

CONCLUSIONS

This study found no significant differences in HRQoL between patients with fCCM and sCCM.

Natural history, management, and outcomes of cerebellar cavernous malformations: A retrospective study of 130 patients

OBJECTIVE

Data on the natural history and management of cerebellar cavernous malformations (CMs) is limited. This study aims to identify factors associated with hemorrhage risk, assess management strategies, and compare outcomes between conservative and surgical management in patients with cerebellar CMs.

METHODS

We retrospectively reviewed 130 patients with cerebellar CMs treated at our center (1990-2023). Data on clinical presentation, lesion characteristics, management strategies, and outcomes were analyzed. Annual hemorrhage risk was calculated. Surgical outcomes were assessed based on the persistence of CM-related symptoms and the presence of postoperative complications. Statistical analyses identified factors associated with hemorrhage, symptomatic presentation, and surgical outcomes.

RESULTS

Of 130 patients (53.8% female; median age of 48.5 years (IQR: 26.75)), 41 (31.5%) presented with hemorrhage, and 20 (15.4%) had focal neurological deficits. Median lesion size measured 12 mm (IQR 8 mm) in size and were primarily located in the hemispheres (n = 89, 68.5%), with fewer in the vermis (n = 21, 16.2%), peduncle (n = 20, 15.4%), and dentate nucleus (n = 9, 6.9%). The annual hemorrhage risk for incidental lesions was 1.19%, while rehemorrhage risk for initially hemorrhagic lesions was 8.35%. Surgery was performed in 31 patients (23.8%), mostly for hemorrhage (n = 15, 48.4%) or cerebellar symptoms (n = 7, 22.6%). Postoperative complications were reported in three patients. At a median follow-up of 1.11 years (IQR 5.15 years), 22 patients (18.2%) had persistent symptoms, two developed new symptoms, and two experienced worsening symptoms from hypertrophic olivary degeneration. There was no CM- related mortality, and only one patient experienced moderate CM-related disability (mRS = 3).

CONCLUSIONS

Cerebellar CMs generally have a benign course with hemorrhage risks compared to supratentorial and brainstem lesions. Conservative management is recommended for incidental lesions, while surgery should be reserved for symptomatic, accessible cases.

Radiosurgery versus observation for brainstem cavernous malformations: a 5-year multicentre cohort study

The role of radiosurgery in preventing haemorrhage in brainstem cavernous malformations remains a subject of debate. This study aimed to evaluate whether radiosurgery provides a protective benefit against haemorrhage in these patients. This multicentre, prospective observational study was conducted in 17 centres and enrolled eligible patients with brainstem cavernous malformations consecutively. Data collected included clinical baseline information, radiosurgery planning details, periodic follow-up evaluations and any adverse radiation effects. The primary outcome of the study was the incidence of first prospective haemorrhage, and the secondary outcome was the development of new or worsening neurological dysfunctions. The impact of radiosurgery was assessed using multivariate Cox regression analysis. From March 2016 to August 2018, the study enrolled 377 patients: 280 in the observation group receiving standard care alone and 97 in the radiosurgery group receiving both radiosurgery and standard care. The overall cohort consisted of 173 females (45.9%) with a mean age of 40.5 years (range, 18-68 years), and there were no significant differences in baseline characteristics between the two groups. After a median follow-up period of 70 months, haemorrhage occurred in 25.0% (n = 70) of patients in the observation group and 10.3% (n = 10) of patients in the radiosurgery group. Multivariate Cox regression analysis identified radiosurgery as an independent protective factor against haemorrhage (hazard ratio 0.379, 95% confidence interval 0.195-0.738, P = 0.004). Following 1:2 propensity score matching, the incidence of prospective haemorrhage was 24.9% (45/181) in the observation group compared with 10.3% (10/97) in the radiosurgery group (hazard ratio 0.379, 95% confidence interval 0.190-0.755, P = 0.006). Adverse radiation effects were observed in 12 patients (12.4%), with none being permanent. Additionally, new or worsening neurological dysfunctions were significantly more common in the observation group (28.9%) compared with the radiosurgery group (16.5%) (P = 0.016). These results suggest that radiosurgery is associated with a low rate of haemorrhage in patients with brainstem cavernous malformations and could provide a benefit in selected patients. However, further research is required to confirm these findings.

Safety and efficacy of atorvastatin for rebleeding in cerebral cavernous malformations (AT CASH EPOC): a phase 1/2a, randomised placebo-controlled trial

BACKGROUND

Cerebral cavernous malformations (CCMs) carry a high risk of rebleeding after symptomatic haemorrhage, with serious clinical sequelae. Atorvastatin was shown to prevent CCM growth and bleeding in animal models. We aimed to assess the safety and efficacy of atorvastatin on rebleeding in patients with CCMs after a symptomatic haemorrhage.

METHODS

We did a phase 1/2a randomised trial at the University of Chicago's CCM Center of Excellence. Patients aged 18-80 years with untreated CCMs who had had symptomatic bleeding from a CCM lesion within the previous year were eligible. Patients were randomly allocated (1:1) to oral atorvastatin (80 mg daily for 2 years) or matching placebo. Investigators, clinical staff, and participants were masked to the assigned treatment. The primary efficacy outcome was the percentage change in mean lesional iron deposition per year, measured by quantitative susceptibility mapping (QSM) on MRI and averaged over 2 years; a decrease would signal potential benefit and an increase a safety concern. The primary efficacy outcome was analysed in the modified intention-to-treat cohort, including patients with at least one annual paired QSM assessment. Safety outcomes included rates of bleeds and serious adverse events necessitating drug discontinuation. This trial is registered at ClinicalTrials.gov (NCT02603328) and is completed.

FINDINGS

Between July 25, 2018, and July 22, 2022, 326 patients were assessed for eligibility, and 80 patients were allocated either atorvastatin (n=41) or placebo (n=39). 29 (36%) patients were male and 51 (64%) were female. 64 (80%) patients (33 in the atorvastatin group and 31 in the placebo group) had at least one annual paired QSM assessment and were included in the modified intention-to-treat analyses. The mean annual percentage change in lesional QSM was 10·88 (SE 7·29) with atorvastatin versus 12·09 (SE 7·54) with placebo (treatment effect -1·22, 95% CI -22·25 to 19·81; p=0·91). Symptomatic haemorrhage was reported in six patients assigned atorvastatin and seven patients assigned placebo (relative risk 0·81, 95% CI 0·31 to 2·13). No patients had a serious adverse event requiring drug discontinuation and no deaths were recorded.

INTERPRETATION

For people with symptomatic haemorrhage caused by CCMs, atorvastatin did not affect the mean change in lesional iron deposition on brain MRI over 2 years when compared with placebo. Atorvastatin was well tolerated and no safety concerns were noted. The study provides a useful framework for biomarker driven drug assessment in a rare disease.

FUNDING

US National Institutes of Health.

Quantitative susceptibility mapping of iron deposition in sporadic cerebral cavernous malformation-related epilepsy

OBJECTIVE

To evaluate iron deposition patterns in patients with cerebral cavernous malformation-related epilepsy (CRE) using quantitative susceptibility mapping (QSM) for detailed analysis of iron distribution associated with a history of epilepsy and severity.

METHODS

This study is part of the Quantitative Susceptibility Biomarker and Brain Structural Property for Cerebral Cavernous Malformation Related Epilepsy (CRESS) cohort, a prospective multicenter study. QSM was used to quantify iron deposition in patients with sporadic cerebral cavernous malformation (CCMs). Lesions were segmented into intralesional, perilesional, and extralesional areas, with mean susceptibility values calculated for each subregion and analyzed in relation to epilepsy severity and duration.

RESULTS

Among the 46 patients studied, those with a history of epilepsy had significantly higher iron deposition values in the perilesional (p =.012) and extralesional areas (p =.01), as well as a greater extent of iron deposition (p <.001) compared to those without epilepsy. The extent of iron deposition effectively distinguished patients with and without epilepsy, with an area under the curve (AUC) of 0.901 (95% confidence interval [CI]: 0.816-0.985). Among patients with epilepsy, iron deposition in the extralesional area was positively correlated with the severity of epilepsy (r2 = 0.181, p =.043), and the extent of iron deposition was positively correlated with the duration of epilepsy (r2 =.214, p =.026).

SIGNIFICANCE

This study highlights QSM as a non-invasive tool for assessing iron deposition in CRE, identifying distinct subregional iron deposition patterns linked to epilepsy status and severity.

Hereditary Haemorrhagic Cerebrovascular Disease: Implications for Clinical Management

Background

At present, treatment of hereditary haemorrhagic cerebrovascular disease remains in the symptomatic stage. It is more important to provide strategies for developing rational treatment methods, expanding our understanding with regard to the pathophysiology in the context of familial diseases.

Summary

In this article, the combined data from the literature on diseases, including familial cerebral cavernous haemangiomas, hereditary cerebral haemorrhage with amyloidosis, familial intracranial aneurysms, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, were reviewed to manage the haemorrhagic diseases discussed through genetic counselling and early prevention and treatment of these patients and their families, the genetics, pathogenesis, clinical manifestations and treatment.

Key Messages

It is important to understand and treat hereditary haemorrhagic cerebrovascular disease through genetic treatment options.

Clinical, genomic, and histopathologic diversity in cerebral cavernous malformations

Cerebral cavernous malformations (CCMs) are hemorrhagic vascular disorders with varied clinical and radiological presentations, occurring sporadically due to MAP3K3 or PIK3CA mutations or through inherited germline mutations of CCM genes. This study aimed to clarify the clinical, genetic, and pathological features of CCMs using a multicenter cohort across three Chinese centers. We analyzed 290 surgical specimens from symptomatic CCM patients, utilizing whole-exome sequencing, droplet digital PCR, and targeted panel sequencing, alongside immunohistology to examine genotypic and phenotypic differences. Among 290 cases, 201 had somatic MAP3K3, PIK3CA, or germline CCM mutations, each associated with distinct clinical parameters: hemorrhage risk (P < 0.001), lesion size (P = 0.019), non-hemorrhagic epilepsy (P < 0.001), Zabramski classifications (P < 0.001), developmental venous anomaly presence (P < 0.001), and MRI-detected edema (P < 0.001). PIK3CA mutations showed a higher hemorrhage risk than MAP3K3 and combined MAP3K3 & PIK3CA mutations (P < 0.001). Within PIK3CA mutations, the p.H1047R variant correlated with higher bleeding risk than p.E545K (P = 0.007). For non-hemorrhagic epilepsy, patients with single MAP3K3 mutations or combined MAP3K3 & PIK3CA mutations were at greater risk than those with PIK3CA mutations alone. Histopathologically, lesions with PIK3CA mutations displayed cyst walls, pS6-positive dilated capillaries, and fresh blood cells, while MAP3K3 and double mutation lesions exhibited classic CCM pathology with SMA-positive and KLF4-positive vessels, collagen, and calcification. PIK3CA lesions had fewer KLF4-positive cells than double mutations lesions (P < 0.001), and EndMT (SMA-positive) cells compared to double mutation lesions (P < 0.05) and MAP3K3 mutations (P < 0.001), with more pS6 compared to MAP3K3 mutations (P < 0.05). This study underscores the diverse clinical, genomic, and histopathological characteristics in CCMs, suggesting potential predictive markers based on mutation subtypes and MRI features.

Circulating molecules reflect imaging biomarkers of hemorrhage in cerebral cavernous malformations

Increases in mean lesional iron content by quantitative susceptibility mapping (QSM) by ≥6% and/or vascular permeability by dynamic contrast enhanced quantitative perfusion (DCEQP) by ≥40% on MRI have been associated with new symptomatic hemorrhage (SH) in cerebral cavernous malformations (CCMs). It is not known if plasma biomarkers can reflect these changes within the lesion proper. This cohort study enrolled 46 CCM patients with SH in the prior year. Plasma samples, QSM and DCEQP were simultaneously acquired at the beginning and end of 60 one-year epochs of prospective follow-up. Plasma levels of 16 proteins and 12 metabolites linked to CCM hemorrhage were assessed by enzyme-linked immunosorbent assay and liquid-chromatography mass spectrometry, respectively. A weighted model combining the percent changes in plasma levels in roundabout guidance receptor-4, cluster of differentiation 14, thrombomodulin and acetyl-L-carnitine reflected a mean increase in QSM ≥ 6% (97.2% and 100% specificity/sensitivity, p = 3.1 × 10-13). A weighted combination of percent changes in plasma levels of endoglin, pipecolic acid, arachidonic acid and hypoxanthine correlated with an increase in mean DCEQP ≥40% (99.6% specificity and 100% sensitivity, p = 4.1 × 10-17). This is a first report linking with great accuracy changes of circulating molecules to imaging changes reflecting new SH during prospective follow-up of CCMs.

Genetic variants in FCGR2A, PTPN2, VDR as predictive signatures of aggressive phenotypes in cerebral cavernous malformation

OBJECTIVE

The biological behavior of Cerebral Cavernous Malformation (CCM) is still controversial, lacking a clear-cut signature for a mechanistic explanation of lesion aggressiveness. In this study, we evaluated the predictive capacity of genetic variants concerning the aggressive behavior of CCM and their implications in biological processes.

METHODS

We genotyped the variants in VDRrs7975232, VDRrs731236, VDRrs11568820, PTPN2rs72872125 and FCGR2Ars1801274 genes using TaqMan Genotyping Assays in a cohort study with 103 patients, 42 of whom had close follow-up visits for 4 years, focusing on 2 main aspects of the disease: (1) symptomatic events, which included both intracranial bleeding or epilepsy, and (2) the onset of symptoms. The genotypes were correlated with the levels of several cytokines quantified in peripheral blood, measured using the x-MAP method.

RESULTS

We report a novel observation that the PTPN2rs72872125 CT and the VDRrs7975232 CC genotype were independently associated with an asymptomatic phenotype. Additionally, PTPN2rs72872125 CC genotype and serum level of GM-CSF could predict a diagnostic association with symptomatic phenotype in CCM patients, while the FCGR2Ars1801274 GG genotype could predict a symptomatic event during follow-up. The study also found a correlation between VDRrs731236 AA and VDRrs11568820 CC genotype to the time to the first symptomatic event.

CONCLUSIONS

These genetic markers could pave the way for precision medicine strategies for CCM, enhancing patient outcomes by enabling customized therapeutic approaches.

Cerebral Cavernous Malformation: From Genetics to Pharmacotherapy

INTRODUCTION

Cerebral cavernous malformation (CCM) is a type of cerebrovascular abnormality in the central nervous system linked to both germline and somatic genetic mutations. Recent preclinical and clinical studies have shown that various drugs can effectively reduce the burden of CCM lesions. Despite significant progress, the mechanisms driving CCM remain incompletely understood, and to date, no drugs have been developed that can cure or prevent CCM. This review aims to explore the genetic mutations, molecular mechanisms, and pharmacological interventions related to CCM.

METHODS

Literatures on the genetic mechanisms and pharmacological treatments of CCM can be searched in PubMed and Web of Science.

RESULTS

Germline and somatic mutations mediate the onset and development of CCM through several molecular pathways. Medications such as statins, fasudil, rapamycin, and propranolol can alleviate CCM symptoms or hinder its progression by specifically modulating the corresponding targets.

CONCLUSIONS

Understanding the molecular mechanisms underlying CCM offers potential for targeted therapies. Further research into novel mutations and treatment strategies is essential for improving patient outcomes.

Neuroendoscopic Surgery for Intraventricular Cavernous Malformations: A Review on Indications and Surgical Considerations

BACKGROUND

Intraventricular cavernous malformations (IVCs) are rare vascular lesions of the central nervous system. Surgical resection remains a challenging endeavor, with conventional microsurgical techniques associated with morbidity due to direct brain tissue manipulation. Neuroendoscopic approaches offer a minimally invasive alternative, though their efficacy and safety in treating IVCs remain underexplored.

METHODS

A narrative review was conducted to analyze all documented cases of IVCs treated exclusively with endoscopic transventricular approaches. Reviews, original research papers, and case reports published from 1990 to May 2024 were included. When available, surgical videos were also reviewed.

RESULTS

Seventeen patients with IVCs primarily located in the foramen of Monro were identified. The mean size of the IVCs was 17 mm (range: 7-29 mm). Neuroendoscopic procedures achieved gross total resection in all cases, leading to the resolution of clinical symptoms. Except for one patient who experienced memory impairment postsurgery, no persistent neurological dysfunctions were observed. Intraoperative bleeding, a significant challenge in IVC resection, was managed with continuous warm irrigation and dedicated coagulation instruments. Additionally, 6 cases of neuroendoscopic procedures such as endoscopic third ventriculostomy and septum pellucidotomy were reported for managing hydrocephalus.

CONCLUSIONS

Neuroendoscopic surgery offers several advantages in treating IVCs, including minimally invasive access, precise visualization, and reduced brain tissue manipulation. Our findings support the efficacy and safety of endoscopic transventricular approaches, underscoring its potential as a valuable therapeutic strategy for selected IVCs.

Clinical and radiologic distinctions between familial cavernous malformation syndrome and cerebral amyloid angiopathy

PURPOSE

Familial cerebral cavernous malformation syndrome (FCCM) is characterized by multiple hemorrhagic lesions and is sometimes mistaken for cerebral amyloid angiopathy (CAA).

METHODS

We compared clinical and radiologic characteristics in patients with definite (N = 32) and presumed FCCM (n = 76) to patients with definite (N = 29) and probable CAA (N = 21).

RESULTS

Patients with CAA were older (78.6 years CAA vs. 43.4 FCCM; p < 0.0001), had cognitive complaints (66.0% CAA vs. 8.3% FCCM; p < 0.0001), and less likely to have a family history (4.0% CAA vs. 50.9% FCCM; p < 0.0001). FCCM patients were more likely to have at least 1 Zabramski type 2 lesion (0 CAA vs. 79.6% FCCM; p < 0.0001). Presence of any subcortical white matter hemorrhagic lesion (23.0% CAA vs. 99.1% FCCM; p < 0.0001), a lesion in either the basal ganglia, internal capsule or cerebellum (28.0% CAA vs 79.6% FCCM; p < 0.0001) and a subcortical white matter to cortical ribbon distribution of hemorrhagic lesions ≥ 1.0 was predictive of FCCM (6.0% CAA vs 83.9% FCCM; p < 0.0001). CAA patients more commonly had white matter disease, sulcal subarachnoid hemorrhage, and severely enlarged perivascular spaces in the centrum. However, none of the latter features were unique to CAA. FCCM patients meeting Boston 2.0 criteria for CAA (n = 14) had additional factors that helped distinguish them from CAA.

CONCLUSIONS

Patients with FCCM can be reliably distinguished from CAA by accurately applying the Boston 2.0 criteria, assessing hemorrhagic lesion distribution and types, and assessing for clinical features unique to FCCM. FCCM criteria are proposed. The frequent finding of leukoaraiosis and enlarged perivascular spaces in the centrum semiovale in FCCM patients deserves further investigation.

Benefits of early MR-Imaging in patients with acute spontaneous intracerebral hemorrhage: a retrospective study

BACKGROUND

Neuroimaging plays a vital role in the diagnosis of intracerebral hemorrhage (ICH) and in identifying the underlying etiology for appropriate therapeutic approach. This study aims to determine the significance and potential advantages of using early magnetic resonance imaging (MRI) as a diagnostic tool for ICH.

METHODS

This retrospective study included 359 patients with ICH treated at the Department of Neurology, Mannheim University Hospital between January 2017 and December 2021. Patient characteristics, stroke severity and imaging procedures were descriptively analyzed. Factors associated with the choice of imaging modalities were evaluated. The etiology of hemorrhage was retrospectively analyzed using the existing data. We recorded the reassignment of ICH etiology by comparing the assessment after first sole review of CT scan and then subsequent MRI review. The overall rate of reassignments and the reassignments per CT-based initial etiology were analyzed.

RESULTS

In the sample of 359 patients with ICH (mean age 73.1 years, 55.4% male), patients receiving an additional MRI were significantly younger (p < .001) and were less severely affected by stroke (median NIHSS score 5 vs. 15, p < .001). MRI was performed significantly less frequently in patients who died during hospitalization (11.7% vs. 63.9%, p < .001). MRI led to a reassignment of ICH etiology in 48.2% of cases (80/166), uncovering unknown underlying causes in 69% of cases (49/71). Reassignment occurred most frequently in patients with a CT-based diagnosis of hypertensive ICH (18/50). The most frequent reassigned etiologies after MR imaging were cerebral amyloid angiopathy (CAA; 36 patients) and secondary hemorrhage of an ischemic stroke (30 patients).

CONCLUSIONS

Early MR imaging in patients with ICH improves the determination of underlying etiology and the conception of an appropriate treatment approach, potentially contributing to better patient outcomes.

Patient-reported outcomes in conservatively managed cerebral cavernous malformations

BACKGROUND

There is a paucity of studies on patient-reported outcomes and quality of life (QoL) in conservatively managed patients with a cerebral cavernous malformation (CCM).

METHODS

This single-center observational study included consecutive adult CCM patients, diagnosed in 2000-2023, managed conservatively, and with at least 6 months of follow-up. Patients completed two validated patient-reported outcome measures (PROMs): EuroQol 5-dimensions 5-levels (EQ-5D-5L), and Patient-Reported Outcome Measurement Information System 29 (PROMIS-29). Results were compared with Dutch reference populations.

RESULTS

Of 246 eligible patients with a CCM, 205 (83%) completed the PROMs. Median age was 46 years and 45% were male. Ninety-six (47%) patients presented with symptomatic hemorrhage (SH), 49 (24%) with a seizure, and 51 (25%) had a brainstem CCM. Median follow-up was 62 months (IQR 38-97). CCM patients had lower utility-weighted EQ index scores than the reference population (0.79 versus 0.87, p < 0.001). Most PROMIS-29 domain scores showed no significant difference, but patients reported more anxiety/fear (54.1 versus 50.3, p < 0.001) and depression/sadness (52.4 versus 50.3, p = 0.005), and less pain (41.6 versus 55.6, p < 0.001). Patients who presented with SH or seizure, or who had a brainstem CCM reported significantly worse scores in several domains compared to those with other presentations, or without brainstem CCM.

CONCLUSIONS

Patients with conservatively managed CCMs reported lower overall health than the general population. Mental health was affected most, while other domains were largely comparable, and patients reported less pain. Presentation with SH, seizure, or brainstem CCM was associated with worse scores. These data can help patient counseling, suggesting guidance on mental health.

Cerebral cavernous malformation with prolonged postoperative paralysis due to perilesional inflammation: illustrative case

BACKGROUND

Postoperative symptom exacerbation after resection of cerebral cavernous malformations (CCMs) is usually due to surgical damage to the eloquent areas or venous outflow obstruction from injury to a developmental venous anomaly (DVA).

OBSERVATIONS

A 21-year-old right-handed female presented with headache, right limb weakness, and aphasia. Magnetic resonance imaging (MRI) revealed a 3.5-cm CCM with significant perilesional edema in the middle frontal gyrus. Despite medical treatment, her weakness worsened, necessitating emergency resection. Imaging revealed no DVA or venous obstructions. Histopathological examination revealed marked neutrophil infiltration, indicating noninfectious inflammation. One week postoperatively, MRI revealed increased edema around the resection site. Although the aphasia improved, paralysis (manual muscle testing grade 3) persisted, prompting betamethasone administration. The symptoms rapidly improved over 10 days, and the patient was discharged symptom free on day 20 with no recurrence thereafter.

LESSONS

Patients with prolonged postoperative deficits after CCM resection can experience noninfectious inflammation. Anti-inflammatory treatments such as corticosteroids may be necessary in similar cases with poor recovery from edema and symptoms. https://thejns.org/doi/10.3171/CASE24570.

Clinical features, hemorrhage risk and epilepsy outcomes of familial cerebral cavernous malformation: A 20-year observational pragmatic single-center study

INTRODUCTION

Familial Cerebral Cavernous Malformations (fCCMs) are rare, hereditary conditions characterized by multiple central nervous system lesions. Despite their rarity, CCMs can cause significant clinical challenges when symptomatic, manifesting as seizure and symptomatic hemorrhage (CASH). Guidelines suggest neurosurgical intervention for symptomatic or previously symptomatic lesions, while conservative management is recommended for new-onset epilepsy. However, the natural history and optimal management remain unclear, necessitating further research.

OBJECTIVE

This study aims to provide a comprehensive analysis of the clinical features, hemorrhage risk, and epilepsy outcomes in fCCM patients over an extended follow-up period, offering a more precise estimate of CASH and epilepsy rates in this population.

METHODS

This retrospective longitudinal cohort study included fCCM patients enrolled from 2001 to May 2024. Data collected included demographic information, new neurological symptoms, symptomatic hemorrhages, seizures, and modified Rankin Scale (mRS) scores. Incidence rates of first symptomatic events and Kaplan-Meier survival curves were calculated, with logistic and Cox-proportional hazard regression models used to evaluate outcomes.

RESULTS

A total of 47 patients were included in this study, with a mean age at diagnosis of 37.51 years. At diagnosis, 68 % were symptomatic, with 30 % having CASH and 36 % experiencing seizures without CASH. During a median follow-up of 126.0 months (interquartile range, 110.5 months), 17 % had a new CASH event, 20 % had seizures without CASH, and 60 % remained asymptomatic. The bleeding rate was 1.02 % per patient-year, with new focal neurological symptoms at 2.045 per 1000 patient-years and new CASH at 10.225 per 1000 patient-years. Most patients maintained minimal or no disability (mRS 0 or 1). Presenting with epilepsy at baseline significantly increased the odds of future seizures (OR 18.13, p = 0.001).

CONCLUSION

This study highlights the complex presentation and progression of fCCMs, emphasizing the necessity for long-term monitoring. Baseline epilepsy is a significant predictor of future seizures, underscoring the need for individualized management strategies. Future research with larger cohorts and standardized criteria is essential to refine the understanding and management of fCCMs.

Stereotactic Radiosurgery for Intracranial Cavernous Malformations: International Stereotactic Radiosurgery Society, Systematic Review, Meta-Analysis, and Practice Guidelines

OBJECTIVE

The International Stereotactic Radiosurgery Society aims to establish evidence-based guidelines for single-fraction stereotactic radiosurgery (SRS) in treating intracranial cavernous malformations.

METHODS

We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines, searching electronic databases up to January 2024 to assess SRS's impact on post-treatment hemorrhage rates. Pooled risk ratios (RRs) and confidence intervals were used to quantify this effect, along with assessments of lesion volume changes, seizure outcomes, and SRS-related adverse effects.

RESULTS

Our meta-analysis included 32 studies with 2672 patients. A significant decrease in annual hemorrhage rates was observed post-treatment (RR = 0.17), with rates of RR = 0.29 in the first 2 years and RR = 0.11 thereafter. Hemorrhage rates significantly differed before and after 2 years post-SRS (RR = 0.36). Among epileptic patients, 20.2% had epilepsy pretreatment, and 49.9% were seizure-free post-SRS, while 30.6% experienced reduced seizure frequency. Lesion volume changes showed a reduction in 46.9%, stability in 47.1%, and an increase in 6.7%. Symptomatic radiation effects affected 8% of patients. Subgroup analysis revealed symptomatic change rates of 6% at doses ≤13 Gy compared to 9% at doses >13 Gy. Permanent clinical deficits were rare (2%).

CONCLUSIONS

This meta-analysis suggests SRS is an effective intervention for intracranial cavernous malformations, significantly reducing hemorrhage rates and improving seizure outcomes. International Stereotactic Radiosurgery Society practice guidelines are provided.

Cavernous Malformation From Cranial Nerves: A Systematic Review With a Novel Classification and Patient-Level Analysis

BACKGROUND AND OBJECTIVES

Cavernous malformations (CMs) occurring in the cranial nerve (CN) are extremely rare, and there is currently no comprehensive review on CN CMs, leading to a lack of sufficient understanding of CN CMs. We aimed to systematically review all published CN CM cases; summarize the epidemiology, clinical manifestations, treatment, and prognosis of CN CMs; and identify factors influencing the prognosis of CN CMs.

METHODS

This systematic review identified all cases potentially diagnosed with CN CM through a systematic search of PubMed, SCOPUS, Web of Science, and Cochrane databases. This represents the most comprehensive systematic review to date. We classified CN CMs based on their anatomic origins. Patient characteristics, disease manifestations, treatment approaches, and prognosis were summarized descriptively. Further analysis was conducted to identify factors influencing the prognosis of CN CMs.

RESULTS

The final analysis included 108 articles (127 individual patient cases). The optic nerve (49/128, 38.3%) is the most commonly affected nerve. Notably, CN CMs can be categorized into 3 types: Intraneural, Perineural, and Extraneural. Preoperative nerve function status and novel classification were associated with the prognosis of CN CMs ( P = .001; P < .001). The postoperative neurological deterioration rate for the Intraneural type was 19/37 (51.4%); for the Extraneural type, it was 13/69 (18.8%); and for the Perineural type, it was 1/22 (4.5%) ( P < .001).

CONCLUSION

We reviewed all the published CN CMs to date, offering a comprehensive description of CN CMs for the first time and identifying prognostic factors. The classification of CN CMs proposed in this study could serve as guidance for the selection of intraoperative treatment regimens. The findings of this systematic review are expected to provide a foundation for clinical decision-making in this crucial rare disease and lay the groundwork for developing relevant clinical guidelines.

Cerebral vascular malformations: pathogenesis and therapy

Cerebral vascular malformations (CVMs), particularly cerebral cavernous malformations and cerebral arteriovenous malformations, pose significant neurological challenges due to their complex etiologies and clinical implications. Traditionally viewed as congenital conditions with structural abnormalities, CVMs have been treated primarily through resection, embolization, and stereotactic radiosurgery. While these approaches offer some efficacy, they often pose risks to neurological integrity due to their invasive nature. Advances in next-generation sequencing, particularly high-depth whole-exome sequencing and bioinformatics, have facilitated the identification of gene variants from neurosurgically resected CVMs samples. These advancements have deepened our understanding of CVM pathogenesis. Somatic mutations in key mechanistic pathways have been identified as causative factors, leading to a paradigm shift in CVM treatment. Additionally, recent progress in noninvasive and minimally invasive techniques, including gene imaging genomics, liquid biopsy, or endovascular biopsies (endovascular sampling of blood vessel lumens), has enabled the identification of gene variants associated with CVMs. These methods, in conjunction with clinical data, offer potential for early detection, dynamic monitoring, and targeted therapies that could be used as monotherapy or adjuncts to surgery. This review highlights advancements in CVM pathogenesis and precision therapies, outlining the future potential of precision medicine in CVM management.

Recent novelties in research and management of cerebrospinal cavernous malformations

In recent years, knowledge about cerebrospinal cavernomas has grown considerably, leading to the development of initial guidelines and treatment recommendations. However, due to the rarity and heterogeneity of the disease, the level of evidence remains limited, leaving many questions unanswered and subject to ongoing debate. Therefore, an up-to-date review of this field's latest developments and controversies is reasonable.

Comprehensive analysis of Novel mutations in CCM1/KRIT1 and CCM2/MGC4607 and their clinical implications in Cerebral Cavernous malformations

BACKGROUND

Cerebral Cavernous Malformations (CCM) is a genetic disease characterized by vascular abnormalities in the brain and spinal cord, affecting 0.4-0.5 % of the population. We identified two novel pathogenic mutations, CCM1/KRIT1 c.811delT (p.Trp271GlyfsTer5) and CCM2/MGC4607 c.613_614insGG p.Glu205GlyfsTer31), which disrupt crucial protein domains and potentially alter disease progression.

OBJECTIVE

The study aims to comprehensively analyze a Brazilian cohort of CCM patients, integrating genetic, clinical, and structural aspects. Specifically, we sought to identify novel mutations within the CCM complex, and explore their potential impact on disease progression.

METHODS

We conducted a detailed examination of neuroradiological and clinical features in both symptomatic and asymptomatic CCM patients, performing genetic analyses through sequencing of the CCM1/KRIT1, CCM2/MGC4607, and CCM3/PDCD10 genes In silico structural predictions were carried out using PolyPhen-2, SIFT, and Human Genomics Community tools. Protein-protein interactions and docking analyses were explored using the STRING database.

RESULTS

Genetic analysis identifies 6 pathogenic mutations, 4 likely pathogenic, 1 variants of uncertain significance, and 7 unclassified mutations, including the novel mutations in CCM1 c.811delT and CCM2 c.613_614insGG. In silico structural analysis revealed significant alterations in protein structure, supporting their pathogenicity. Protein-protein interaction analysis indicated nuanced impacts on cellular processes. Clinically, we observed a broad spectrum of symptoms, including seizures and focal neurological deficits. However, no statistically significant differences were found in lesion burden, age of first symptom onset, or sex between the identified CCM1/KRIT1 and CCM2/MGC4607 mutations among all patients studied.

CONCLUSION

This study enhances the understanding of CCM by linking clinical variability, genetic mutations, and structural effects. The identification of these novel mutations opens new avenues for research and potential therapeutic strategies.

Intracranial Vascular Malformations in Children

Intracranial vascular malformations (IVMs) represent a significant challenge in pediatric medicine due to their diagnostic and therapeutic complexity. Despite their rarity, the severity of potential neurologic outcomes necessitates a comprehensive understanding and approach to management. This article aims to provide an overview of pediatric IVMs, specifically nidal arteriovenous malformations, cavernous malformations, capillary telangiectasias, and developmental venous anomalies, and highlight the importance of advanced diagnostic imaging and therapeutic strategies in improving outcomes. Vein of Galen malformations, pial arteriovenous fistulas, dural sinus malformations, and intracranial venous malformations will be addressed in other articles. Following a discussion of imaging and clinical considerations within the field, novel imaging techniques will be discussed.

Midbrain Cavernous Malformation: Microsurgical Nuances and an Anatomoclinical Review 2-Dimensional Video

Midbrain cavernous malformations (MCMs) are rare and dangerous taken the important structures and tracts located in this segment of the brainstem. MCM treatment is still controversial, and surgical resection is basically indicated in cases of recurrent hemorrhage and progressive neurologic deterioration. The optimal moment to operate ruptured MCM is in the subacute stage. Once indicated for surgical resection, preoperative planning needs to be individualized. There are various ways to access midbrain lesions, depending on the extension and predominant location: lateral subtemporal, posterior transtentorial, interhemispheric transcallosal, and anterior temporopolar approaches, or some of the alternatives. The aim of this Video 1 case is to review the surrounding anatomic structures and demonstrate the advantages of the semisitting position and the viability of the supracerebellar infratentorial approach for a tegmental midbrain lesion.1-10 In this 2-dimensional video, we present an 18-year-old man with a 4-year history of diplopia and third nerve palsy, which worsened 10 days before admission. He underwent microsurgical total resection of this MCM via extreme lateral supracerebellar infratentorial approach in a semisitting position. At the end, the surgical site and surrounding structures were reviewed microscopically and endoscopically. The patient tolerated the surgery well, and the perioperative course was uneventful. His recovery was smooth but he maintained the previous oculomotor nerve palsy. We discuss important steps of the surgical approach, local neuroanatomy, and the microsurgical techniques for the resection of these challenging MCM. The goal is total resection of the MCM with the preservation of the developmental venous anomaly and the surrounding white fiber tracts.

Risk of Bleed During Pregnancy in Women with Epilepsy Due to Cerebral Vascular Malformations

BACKGROUND

Cerebral vascular malformations are rare but important causes of epilepsy in young women. The risk of bleed during pregnancy and delivery as well as the fetal outcomes are important concerns for women with epilepsy (WWE) due to cerebral vascular malformations (EVM).

OBJECTIVES

We compared the maternal and fetal outcomes of a cohort of EVM with women with focal epilepsy due to other causes (ENVM).

METHODS AND MATERIAL

We identified all EVMs in the Kerala Registry of Epilepsy and Pregnancy and compared their characteristics with that of a set of randomly selected ENVM in the same registry. The clinical characteristics, pregnancy outcome, and seizure risk during pregnancy from the vascular malformations were compared between the two groups with Chi-square test and multivariate logistic regression after adjustment for age, epilepsy classification, and AED usage.

RESULTS

There were 45 women with EVM (arteriovenous malformations: 25, cavernoma: 20) in this registry between 1998 and 2018. The EVM and ENVM groups (n = 96) had similar rates of seizure relapse during pregnancy (37.1% vs. 55.1%), fetal loss (11.4% vs. 13.5%), and fetal malformations (9.4% vs. 9%). The rate of delivery by cesarean section, adjusted for maternal age, was higher for the EVM group (61.2% vs. 39%, odds ratio = 2.79, 95% CI: 0.99-7.9, P = 0.05). AVM bled during pregnancy for three women (none of the cavernoma had bled during pregnancy).

CONCLUSIONS

Maternal and fetal outcomes were comparable for the EVM and ENVM groups, but the former had a higher rate of cesarean section. AVM bled during pregnancy for 15% of women.

Early and long-term outcome of surgical versus conservative management for intracranial cerebral cavernous malformation: Meta-analysis of reconstructed time-to-event data

BACKGROUND

Cerebral cavernous malformations (CCMs) present challenges in clinical management due to a lack of definitive evidence from clinical trials. Surgical intervention and observational management are commonly used, yet their efficacy and long-term outcomes remain controversial.

OBJECTIVE

This meta-analysis evaluates the effectiveness of surgical intervention versus conservative management in patients with symptomatic CCMs over various time frames to determine optimal treatment strategies.

METHODS

A systematic review and reconstructed time-to-event meta-analysis were conducted, following PRISMA guidelines. Data from selected studies comparing surgical intervention to conservative management for CCMs were analyzed using pooled patient data from Kaplan-Meier curves. New focal neurological deficit (FND) or intracranial hemorrhage (ICH) were the outcome metrics.

RESULTS

Four eligible studies, comprising 290 patients, were included. Surgical intervention showed 43 events over a mean time to FND/ICH of 6.372 years (95 % CI: 3.536-8.005), while observational management had 48 events with a significantly longer mean time of 10.992 years (95 % CI: 6.070-8.005). No significant difference was found at 2 years (p = 0.910), but at 5 and 10 years, surgical intervention had more events and shorter mean times (p < 0.0001). Sensitivity analysis for previously bleeding CCMs showed no significant difference in events (p = 0.131).

CONCLUSION

This meta-analysis suggests observational management may achieve favorable long-term outcomes for symptomatic CCMs. Despite ongoing controversies, the findings highlight the need for further research, particularly randomized controlled trials, to refine treatment strategies and optimize patient care.

Stereotactic radiosurgery (SRS) for patients with brainstem cerebral cavernous malformations (CCMs): an international, multicentric study

Brainstem cerebral cavernous malformations (CCM) are clinically more aggressive compared to superficial CCMs. Due to their location, resection can be challenging, making stereotactic radiosurgery (SRS) an attractive alternative for symptomatic patient. Brainstem CCM patients (n = 170) were treated with Gamma Knife SRS at 11 radiosurgical centers. Hemorrhagic risk reduction, risk factors of post-SRS hemorrhage, and clinical outcomes were retrospectively analyzed. Most patients had a single (165/170 patients) brainstem CCMs treated; the majority of CCMs (165/181) presented with bleeding. Single-session SRS decreased the risk of repeat hemorrhage in patients with hemorrhagic brainstem CCM (HR: 0.17, p < 0.001) using recurrent multivariate analysis. The annual hemorrhage rate decreased from 14.8 per 100 CCM-years before SRS to 2.3 after treatment. Using univariate Cox-analysis, the probability of a new hemorrhages after SRS was reduced for patient older than 35 years (HR = 0.21, p = 0.002) and increased with a margin dose > 13 Gy (HR = 2.57, p = 0.044). Adverse radiation effect (ARE) occurred in 9 patients (5.3%) and was symptomatic in four (2.4%). At a median follow-up of 3.4 years (Inter-quartile range: 5.4), 13 patients (8.0%) had a worsened clinical status, with the treated CCM being the cause in 5.6% (10) of the patients. Single-session SRS decreased the risk of repeat hemorrhage in patients with hemorrhagic brainstem CCM and conveyed this benefit with a low risk of advrse radiation effects (ARE) and worsening clinical status.

Tailored management of cavernous malformations in women: considerations and strategies-a review

Purpose of review

Cavernous malformations (CM) are vascular lesions in the brain and spinal cord, characterized by clusters of endothelial-lined caverns lacking proper tight junctions. These malformations may be discovered incidentally or present with symptoms such as headaches, focal neurologic deficits, or seizures, with or without hemorrhage. This review focuses on non-surgical management considerations important for women with CM, who face challenges related to pregnancy, exogenous hormone use, anticonvulsive therapy, bone health, and mental health.

Recent findings

Emerging evidence suggests that both estrogen and progesterone may influence CM lesion behavior. Exogenous hormones, including those in oral contraceptives and oral hormone replacement therapy, indicate an elevated risk of symptomatic hemorrhage (SH) and may also influence seizure frequency and severity, particularly in women taking antiseizure medications (ASMs). Data suggest that the risk of CM hemorrhage during pregnancy is similar to the risk when not pregnant, although limitations to these studies will be reviewed.

Summary

This review synthesizes the current literature on the interplay between estrogen and progesterone and CM lesion behavior, highlighting the importance of gender- and sex-specific factors in clinical decision-making. Special attention is given to the implications of exogenous hormone use, seizure management, and the psychological well-being of women with CM, underscoring the need for a multidisciplinary approach tailored to the unique needs of this patient population.

Tobacco use increases lesion burden in familial cerebral cavernous malformation syndrome

BACKGROUND

Familial cerebral cavernous malformation (CCM) syndrome is characterized by multiple, non-contiguous cavernous malformations. The lesion burden may affect morbidity. Our aim was to identify risk factors for high lesion burden in these patients.

METHODS

Patients with radiologically confirmed CCM were screened between 2015 and 2023. Only familial or presumed familial CCM patients were included. Demographic information and medical history at the time of diagnosis were evaluated. The first diagnostic MRI was used to determine T2 total and T2 large lesion (≥5 mm) count. Chi-square was used to determine risk factors for total T2 large lesion count ≥5.

RESULTS

Of 107 patients with familial or presumed familial CCM (55.1 % female, age 42.4 years), the median total T2 lesion count and large lesion count was 4 (range: 1-109) and 2 (range: 0-50) respectively. Current tobacco use was a risk factor for T2 large lesion count ≥5.

CONCLUSION

Further studies combining familial cohorts and assessing length of exposure may be useful to confirm tobacco as a risk factor for T2 large lesion formation in familial CCM.

Clinical course of patients with conservatively managed cerebral cavernous malformations

INTRODUCTION

There is uncertainty whether patients with a cerebral cavernous malformation (CCM) should undergo conservative or surgical treatment, resulting in practice variation among hospitals. Our objective was to report clinical outcomes of patients with primarily conservatively managed CCMs.

PATIENTS AND METHODS

This single-center cohort study included consecutive adult CCM patients, diagnosed in 2000-2023, who underwent conservative management as primary treatment strategy. Data were extracted from medical records, and we systematically conducted telephone and questionnaire follow-up. Functional status was assessed on the modified Rankin Scale (mRS).

RESULTS

Of 345 patients, we included 265 patients with a CCM (median age 46 years; 45% male). At baseline, 131 (49%) patients presented with symptomatic hemorrhage (SH), and 134 (51%) with other symptoms or asymptomatically. During 58 months (IQR 35-94) median follow-up, 51 (19%) patients experienced a SH, 33 (12%) a seizure, and 13 (5%) focal neurological deficits. Fourteen (5%) patients underwent intervention (surgery n = 11, radiosurgery n = 4). Presentation with SH was associated with higher annual bleeding rates (6.0% vs 1.5%, p < 0.001), and higher cumulative 5-/10-year bleeding risks (31%/41% vs 7%, p < 0.001). Brainstem CCM was associated with higher cumulative 5-/10-year bleeding risks (27%/38% vs 17%/21%, p = 0.038). Nineteen (7%) patients died; two (0.8%) directly attributable to CCM. Of 246 surviving patients, 205 (83%) completed the questionnaire. At follow-up, 172/224 (77%) patients were functionally independent (mRS score ⩽2).

DISCUSSION AND CONCLUSION

The majority of conservatively managed CCM patients remained free of a SH during follow-up. Few patients required intervention, and death attributable to the CCM was rare. These data may help patient counseling and treatment decisions.

An Illustrative Case of Cervical Spondylotic Myelopathy and Medullary Cavernoma: Which Should Be Treated First?

Cervical spondylotic myelopathy (CSM) and spinal cavernoma (SC) represent distinct yet challenging conditions. CSM manifests as progressive neurological dysfunction, whereas SC denotes a benign vascular lesion. The need for documented cases featuring CSM and SC highlights the absence of evidence-based management guidelines for such scenarios. CSM typically presents as a gradual neurological decline, predominantly afflicting middle-aged men. Pathophysiological mechanisms involve axonal stretching and ischemia. Classic symptoms encompass gait instability, bladder dysfunction, limb paresis, hyperreflexia, and somatic pain. Diagnostic complexities persist due to the weak correlation between radiological findings and clinical severity, complicating treatment decisions. In contrast, SC, although often asymptomatic, exhibits a preference for the thoracic and cervical segments and can mimic intramedullary tumors. Diagnosis typically relies on magnetic resonance imaging (MRI) due to the limitations of angiography. This case study of a 66-year-old male with concurrent CSM and SC sheds light on the diagnostic and treatment challenges encountered. Surgical intervention targeting CSM preceded SC resection, resulting in significant clinical improvement. In conclusion, managing patients with concurrent CSM and SC necessitates a tailored approach, considering each condition's distinct characteristics and treatment goals. Further research is warranted to establish standardized management algorithms for this complex clinical scenario.

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations

OBJECTIVE

Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR).

METHODS

This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD.

RESULTS

One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2 years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N = 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics.

CONCLUSIONS

Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

GNA14 and GNAQ somatic mutations cause spinal and intracranial extra-axial cavernous hemangiomas

Extra-axial cavernous hemangiomas (ECHs) are complex vascular lesions mainly found in the spine and cavernous sinus. Their removal poses significant risk due to their vascularity and diffuse nature, and their genetic underpinnings remain incompletely understood. Our approach involved genetic analyses on 31 tissue samples of ECHs employing whole-exome sequencing and targeted deep sequencing. We explored downstream signaling pathways, gene expression changes, and resultant phenotypic shifts induced by these mutations, both in vitro and in vivo. In our cohort, 77.4% of samples had somatic missense variants in GNA14, GNAQ, or GJA4. Transcriptomic analysis highlighted significant pathway upregulation, with the GNAQ c.626A>G (p.Gln209Arg) mutation elevating PI3K-AKT-mTOR and angiogenesis-related pathways, while GNA14 c.614A>T (p.Gln205Leu) mutation led to MAPK and angiogenesis-related pathway upregulation. Using a mouse xenograft model, we observed enlarged vessels from these mutations. Additionally, we initiated rapamycin treatment in a 14-year-old individual harboring the GNAQ c.626A>G (p.Gln209Arg) variant, resulting in gradual regression of cutaneous cavernous hemangiomas and improved motor strength, with minimal side effects. Understanding these mutations and their pathways provides a foundation for developing therapies for ECHs resistant to current therapies. Indeed, the administration of rapamycin in an individual within this study highlights the promise of targeted treatments in treating these complex lesions.

Giant Intracranial Cavernous Malformations: A Review on Magnetic Resonance Imaging Characteristics

Background  Intracranial cavernous malformations (CMs), commonly known as cavernomas or cavernous angiomas, are low-flow, well-circumscribed vascular lesions composed of sinusoidal spaces lined by a single layer of endothelium and separated by a collagenous matrix without elastin, smooth muscle, or other vascular wall elements. A diameter greater than 3 cm for a CM is unlikely. These lesions may have atypical appearances on magnetic resonance imaging (MRI). MRI with advanced techniques such as a susceptibility-weighted image or T2-gradient echo, a diffusion-weighted image and corresponding apparent diffusion coefficient map, and diffusion tensor tractography have revolutionized the diagnostic approach to these lesions. Materials and Method  The present study reviews the etiopathogenesis, clinical manifestations, MRI strategy, and MRI appearances of the CMs, with a few examples of the giant CMs from our archive. Results  Intracranial giant CMs may have unexpected locations, sizes, numbers, and varied imaging appearances due to repeated hemorrhages, unusual enhancement patterns, intense perifocal edema, and unusual associations, making the differential diagnosis difficult. Conclusion  Familiarity with the MRI appearances of the giant intracranial CMs and the differential diagnosis improves diagnostic accuracy and patient management.

Stereotactic radiosurgery for haemorrhagic cerebral cavernous malformation: a multi-institutional, retrospective study

BACKGROUND

Cerebral cavernous malformations (CCMs) frequently manifest with haemorrhages. Stereotactic radiosurgery (SRS) has been employed for CCM not suitable for resection. Its effect on reducing haemorrhage risk is still controversial. The aim of this study was to expand on the safety and efficacy of SRS for haemorrhagic CCM.

METHODS

This retrospective multicentric study included CCM with at least one haemorrhage treated with single-session SRS. The annual haemorrhagic rate (AHR) was calculated before and after SRS. Recurrent event analysis and Cox regression were used to evaluate factors associated with haemorrhage. Adverse radiation effects (AREs) and occurrence of new neurological deficits were recorded.

RESULTS

The study included 381 patients (median age: 37.5 years (Q1-Q3: 25.8-51.9) with 414 CCMs. The AHR from diagnosis to SRS excluding the first haemorrhage was 11.08 per 100 CCM-years and was reduced to 2.7 per 100 CCM-years after treatment. In recurrent event analysis, SRS, HR 0.27 (95% CI 0.17 to 0.44), p<0.0001 was associated with a decreased risk of haemorrhage, and the presence of developmental venous anomaly (DVA) with an increased risk, HR 1.60 (95% CI 1.07 to 2.40), p=0.022. The cumulative risk of first haemorrhage after SRS was 9.4% (95% CI 6% to 12.6%) at 5 years and 15.6% (95% CI% 9 to 21.8%) at 10 years. Margin doses> 13 Gy, HR 2.27 (95% CI 1.20 to 4.32), p=0.012 and the presence of DVA, HR 2.08 (95% CI 1.00 to 4.31), p=0.049 were factors associated with higher probability of post-SRS haemorrhage. Post-SRS haemorrhage was symptomatic in 22 out of 381 (5.8%) patients, presenting with transient (15/381) or permanent (7/381) neurological deficit. ARE occurred in 11.1% (46/414) CCM and was responsible for transient neurological deficit in 3.9% (15/381) of the patients and permanent deficit in 1.1% (4/381) of the patients. Margin doses >13 Gy and CCM volume >0.7 cc were associated with increased risk of ARE.

CONCLUSION

Single-session SRS for haemorrhagic CCM is associated with a decrease in haemorrhage rate. Margin doses ≤13 Gy seem advisable.

Cerebral cavernous malformations - An overview on genetics, clinical aspects and therapeutic strategies

Cerebral cavernous malformations (CCMs) are abnormally packed blood vessels lined with endothelial cells, that do not exhibit intervening tight junctions, lack muscular and elastic layers and are usually surrounded by hemosiderin and gliosis. CCMs may be sporadic or familial autosomal dominant (FCCMs) caused by loss of function mutations in CCM1 (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10) genes. In the FCCMs, patients have multiple CCMs, different family members are affected, and developmental venous anomalies are absent. CCMs may be asymptomatic or may manifest with focal neurological deficits with or without associated hemorrhage andseizures. Recent studies identify a digenic "triple-hit" mechanism involving the aquisition of three distinct genetic mutations that culminate in phosphatidylinositol-3-kinase (PIK3CA) gain of function, as the basis for rapidly growing and clinically symptomatic CCMs. The pathophysiology of CCMs involves signaling aberrations in the neurovascular unit, including proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammation and immune mediated processes, anticoagulant vascular domain, and gut microbiome-driven mechanisms. Clinical trials are investigating potential therapies, magnetic resonance imaging and plasma biomarkers for hemorrhage and CCMs-related epilepsy, as well as different techniques of neuronavigation and neurosonology to guide surgery in order to minimize post-operatory morbidity and mortality. This review addresses the recent data about the natural history, genetics, neuroimaging and therapeutic approaches for CCMs.

Modeling blood-brain barrier formation and cerebral cavernous malformations in human PSC-derived organoids

The human blood-brain barrier (hBBB) is a highly specialized structure that regulates passage across blood and central nervous system (CNS) compartments. Despite its critical physiological role, there are no reliable in vitro models that can mimic hBBB development and function. Here, we constructed hBBB assembloids from brain and blood vessel organoids derived from human pluripotent stem cells. We validated the acquisition of blood-brain barrier (BBB)-specific molecular, cellular, transcriptomic, and functional characteristics and uncovered an extensive neuro-vascular crosstalk with a spatial pattern within hBBB assembloids. When we used patient-derived hBBB assembloids to model cerebral cavernous malformations (CCMs), we found that these assembloids recapitulated the cavernoma anatomy and BBB breakdown observed in patients. Upon comparison of phenotypes and transcriptome between patient-derived hBBB assembloids and primary human cavernoma tissues, we uncovered CCM-related molecular and cellular alterations. Taken together, we report hBBB assembloids that mimic the core properties of the hBBB and identify a potentially underlying cause of CCMs.

Single-cell and bulk RNA-seq unveils the immune infiltration landscape associated with cuproptosis in cerebral cavernous malformations

BACKGROUND

Cerebral cavernous malformations (CCMs) are vascular abnormalities associated with deregulated angiogenesis. Their pathogenesis and optimal treatment remain unclear. This study aims to investigate the molecular signatures of cuproptosis, a newly identified type of cell death, associated with CCMs development.

METHODS

Bulk RNA sequencing (RNA-seq) from 15 CCM and 6 control samples were performed with consensus clustering and clustered to two subtypes based on expression levels of cuproptosis-related genes (CRGs). Differentially expressed genes and immune infiltration between subtypes were then identified. Machine learning algorithms including the least absolute shrinkage and selection operator and random forest were employed to screen for hub genes for CCMs associated with cuproptosis. Furthermore, Pathway enrichment and correlation analysis were used to explore the functions of hub genes and their association with immune phenotypes in CCMs. An external dataset was then employed for validation. Finally, employing the Cellchat algorithm on a single-cell RNA-seq dataset, we explored potential mechanisms underlying the participation of these hub genes in cell-cell communication in CCMs.

RESULTS

Our study revealed two distinct CCM subtypes with differential pattern of CRG expression and immune infiltration. Three hub genes (BTBD10, PFDN4, and CEMIP) were identified and validated, which may significantly associate with CCM pathogenesis. These genes were found to be significantly upregulated in CCM endothelial cells (ECs) and were validated through immunofluorescence and western blot analysis. Single-cell RNA-seq analysis revealed the cellular co-expression patterns of these hub genes, particularly highlighting the high expression of BTBD10 and PFDN4 in ECs. Additionally, a significant co-localization was also observed between BTBD10 and the pivotal cuproptosis gene FDX1 in Mki67+ tip cells, indicating the crucial role of cuproptosis for angiogenesis in CCMs. The study also explored the cell-cell communication between subcluster of ECs expressing these hub genes and immune cells, particularly M2 macrophages, suggesting a role for these interactions in CCM pathogenesis.

CONCLUSION

This study identifies molecular signatures linking cuproptosis to CCMs pathogenesis. Three hub genes-PFDN4, CEMIP, and BTBD10-may influence disease progression by modulating immunity. Further research is needed to understand their precise disease mechanisms and evaluate their potential as biomarkers or therapeutic targets for CCMs.

Hemorrhage of cerebral cavernous malformation in third trimester of pregnancy

Cerebral cavernous malformation is a rare but important cause of cerebral hemorrhage in pregnancy and puerperium. In pregnancy, cavernomas can more easily bleed as a result of increased female hormones and growth factors such as vascular endothelial growth factor. We present the case of a pregnant woman who had been diagnosed with a cerebral cavernoma about ten years previously, after repeated headache episodes; at the 28th week of pregnancy the woman was hospitalized for epileptic seizures and active bleeding from the anterior cerebral artery. We describe the management of the case, the decision for a preterm delivery and for a resolutive neurosurgical procedure.