title: Outcome after surgical or conservative management of cerebral cavernous malformations.
abstract: OBJECTIVE
  There have been few comparative studies of microsurgical excision vs conservative management of cerebral cavernous malformations (CCM) and none of them has reliably demonstrated a statistically and clinically significant difference.
  
  
  METHODS
  We conducted a prospective, population-based study to identify and independently validate definite CCM diagnoses first made in 1999-2003 in Scottish adult residents. We used multiple sources of prospective follow-up to assess adults' dependence and to identify and independently validate outcome events. We used univariate and multivariable survival analyses to test the influence of CCM excision on outcome, adjusted for prognostic factors and baseline imbalances.
  
  
  RESULTS
  Of 134 adults, 25 underwent CCM excision; these adults were younger (34 vs 43 years at diagnosis, p = 0.004) and more likely to present with symptomatic intracranial hemorrhage or focal neurologic deficit than adults managed conservatively (48% vs 26%; odds ratio 2.7, 95% confidence interval [CI] 1.1-6.5). During 5 years of follow-up, CCM excision was associated with a deterioration to an Oxford Handicap Scale score 2-6 sustained over at least 2 successive years (adjusted hazard ratio [HR] 2.2, 95% CI 1.1-4.3) and the occurrence of symptomatic intracranial hemorrhage or new focal neurologic deficit (adjusted HR 3.6, 95% CI 1.3-10.0).
  
  
  CONCLUSIONS
  CCM excision was associated with worse outcomes over 5 years compared to conservative management. Long-term follow-up will determine whether this difference is sustained over patients' lifetimes. Meanwhile, a randomized controlled trial appears justified.
  
  
  METHODS
  This study provides Class III evidence that CCM excision worsens short-term disability scores and increases the risk of symptomatic intracranial hemorrhage and new focal neurologic deficits.
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Moultrie
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Horne
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Colin B
authors.initials: CB
authors.lastname: Josephson
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Hall
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Carl E
authors.initials: CE
authors.lastname: Counsell
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Jo J
authors.initials: JJ
authors.lastname: Bhattacharya
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Vakis
authors.initials: V
authors.lastname: Papanastassiou
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Robin J
authors.initials: RJ
authors.lastname: Sellar
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Charles P
authors.initials: CP
authors.lastname: Warlow
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK.
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Murray
authors.affiliation: From the Division of Clinical Neurosciences, Centre for Clinical Brain Sciences (F.M., C.B.J., J.M.H., R.J.S., C.P.W., R.A.-S.S.), and Centre for Population Health Sciences (M.A.H., G.D.M.), University of Edinburgh; the Division of Applied Health Sciences (C.E.C.), University of Aberdeen; and the Institute of Neurological Sciences (J.J.B., V.P.), Southern General Hospital, Glasgow, UK. Rustam.Al-Shahi@ed.ac.uk.
authors.forename: Rustam
authors.initials: R
authors.lastname: Al-Shahi Salman
mesh_terms: D000328:Adult; D000367:Age Factors; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D020786:Hemangioma, Cavernous, Central Nervous System / Q000150:complications / Q000601:surgery* / Q000628:therapy*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000150:complications / Q000601:surgery / Q000628:therapy; D008297:Male; D008866:Microsurgery / Q000009:adverse effects*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011446:Prospective Studies; D012606:Scotland; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome