Tag: hemorrhage risk

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Natural History of Sporadic Cerebral Cavernous Malformations by Zabramski Classification: Hemorrhage Risk and Functional Outcomes Over 5 Years

Neurosurgery 98:376–383, 2026

This prospective cohort study examines sporadic cerebral cavernous malformations (CCMs) categorized by Zabramski MRI types I–IV, reporting lesion features, presentation, hemorrhage rates, and mRS outcomes over a mean follow-up of 4.7 years. Type I lesions had the highest symptomatic presentation, largest size, brainstem predominance, and elevated hemorrhage risks.

Functional outcomes improved for some patients, but Type I had the poorest outcomes. Severe symptomatic hemorrhage was the strongest predictor of sustained disability (mRS ≥3). Types III and IV had low hemorrhage rates and favorable prognoses, supporting conservative management and tailored follow-up imaging.

Zabramski Classification: Stratifies cerebral cavernous malformations (CCMs) into Types I–IV based on MRI features, which correlate with clinical presentation, hemorrhage risk, and functional outcomes.

Type I Lesions: Show the highest annual symptomatic hemorrhage (SH) rate (13.9%), a 5-year cumulative risk of 50.6%, are mostly symptomatic at presentation, often located in the brainstem, and have the poorest long-term functional outcomes (mRS ≥2 in 35.4% at last follow-up).

Type II and III Lesions: Exhibit lower annual hemorrhage rates (2.9% and 1.8%, respectively), more frequently present with seizures or focal neurological deficits rather than hemorrhage, and have better long-term functional outcomes (Type II: mRS ≥2 in 11.2%; Type III: mRS ≥2 in 7.5% at last follow-up).

Type IV Lesions: Are exclusively asymptomatic, detected incidentally, have no observed hemorrhagic events during follow-up, and show no functional impairment (no cases of mRS ≥2).

Severe Symptomatic Hemorrhage: Is the strongest independent predictor of poor functional outcome (mRS ≥3), outweighing lesion type, age, location, or surgical intervention in multivariate analysis (HR 10.88, P < .001).

Dynamic Lesion Evolution: Zabramski type can change over time, particularly for Type I lesions, highlighting the need for longitudinal imaging and dynamic risk assessment rather than reliance on a single timepoint classification.

Clinical Management Implications: Conservative management is appropriate for most Type III and IV lesions due to their benign natural history, while Type I lesions require closer monitoring and individualized intervention strategies due to higher risk.

Study Limitations: Small sample sizes for Types III and IV, potential MRI protocol variability, and single-center design may limit generalizability; multicenter studies are needed for broader validation.

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Conservative management of 661 patients with unruptured intracranial aneurysms: an observational study over 4 decades

J Neurosurg 143:641–653, 2025

This retrospective study of 661 patients with unruptured intracranial aneurysms found a 4.4% aneurysm-related mortality and 0.6% annual rupture rate. No ruptures occurred with PHASES <8 or ELAPSS <15, highlighting these thresholds for risk stratification and the importance of close follow-up, especially in the first 10 years.

• A retrospective study analyzed 661 patients with 767 unruptured intracranial aneurysms (UIAs) managed conservatively over 4 decades.

• The overall aneurysm-related mortality rate was 4.4%, with 3.5% of patients experiencing rupture; annual hemorrhage rate was 0.6%.

• Most ruptures (87%) occurred within the first 5 years after diagnosis; no ruptures were observed after 10 years.

• No ruptures or aneurysm-related deaths occurred in patients with PHASES score <8 or ELAPSS score <15.

• Independent predictors of rupture included aneurysm size, PHASES and ELAPSS scores, posterior circulation location, and age ≥70 years.

• Aneurysms <7 mm in diameter did not rupture in this cohort, but this may reflect selection bias.

• Lifelong regular follow-up is recommended for conservatively managed UIAs, especially in the first 10 years.

• PHASES and ELAPSS score thresholds can help identify high-risk patients who may benefit from treatment.

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Outcome of 107 conservatively managed unruptured brain arteriovenous malformations

J Neurosurg 139:1025–1035, 2023

Since the publication of A Randomized Trial of Unruptured Brain AVMs (ARUBA), the management of unruptured brain arteriovenous malformations (bAVMs) has been controversially discussed. Long-term follow-up data on the exclusively conservative management of unruptured bAVMs are scarce. The authors evaluated the long-term outcomes of patients with unruptured untreated bAVMs in a real-life cohort.

METHODS A retrospective observational cohort of 107 patients (of 897 bAVM patients referred to the authors’ institution) with a diagnosis of unruptured and conservatively managed bAVMs is presented. AVMs of all Spetzler-Martin grades were observed. The mean follow-up period was 84 months. In 44% of patients, a follow-up period of 5 years or longer was observed. A national death register comparison completed the outcome analysis.

RESULTS The median age at diagnosis, sex distribution, neurological presentation, and modified Rankin Scale score were comparable to the patients in the medical management arm of the ARUBA study. Patients were mainly young, predominantly male, and in good clinical condition. Similar to the ARUBA cohort, 77% of this study’s cohort presented in an excellent clinical status at the time of last follow-up. However, 17% of patients had at least one hemorrhage, resulting in an overall annual hemorrhage risk of 2.7% in the observation period. Moreover, the cumulative 1-, 5-, and 10-year overall hemorrhage rates were 3.0%, 11.3%, and 15.3%, respectively. Consequently, the long-term follow-up AVM-related mortality rate amounted to 8%. The estimated median overall survival after AVM diagnosis was 19.3 years (95% CI 14.024.6 years). A multivariate Cox regression model revealed temporal and deep-seated localization as an independent risk factor for AVM hemorrhage, while the presence of seizures reached borderline significance as a risk factor.

CONCLUSIONS The authors’ results represent the long-term course of unruptured untreated bAVMs. Their data support the conclusion that even in the post-ARUBA era, tailored active treatment options may be offered to patients with unruptured bAVMs. For patient counseling, individual risk factors should be weighed against the center’s treatmentspecific risks.

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