Departments of1Translational Medicine and.
2Department of Neurosurgery, University Hospital S. Anna of Ferrara.
Neurosurg Focus. 2023 Oct;55(4):E15. doi: 10.3171/2023.7.FOCUS23355.
Cerebral cavernous malformations (CCMs) are vascular lesions with an overall risk of rupture from 2% to 6% per year, which is associated with significant morbidity and mortality. The diagnostic incidence is increasing, so it is of paramount importance to stratify patients based on their risk of rupture. Data in the literature seem to suggest that specific medications, particularly antithrombotic and cardiovascular agents, are associated with a reduced risk of bleeding. However, the effect of the patient coagulative status on the cumulative bleeding risk remains unclear. The aim of this study was to assess the impact of different radiological, clinical, and pharmacological factors on the bleeding risk of CCMs and to assess the predictive power of an already validated scale for general bleeding risk, the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly).
This was a multicenter retrospective observational study. The authors collected imaging, clinical status, and therapy data on patients with bleeding and nonbleeding CCMs. Univariate analysis and subsequent multivariate logistic regression were performed between the considered variables and bleeding or nonbleeding status to identify potential independent predictors of bleeding.
The authors collected data on 257 patients (46.7% male, 25.3% with bleeding CCMs). Compared with patients with nonbleeding lesions, those with bleeding CCMs were younger, less frequently had hypertension, and less frequently required antiplatelet drugs and beta-blockers (all p < 0.05). Bleeding lesions, however, had significantly higher median volumes (1050 mm3 vs 523 mm3 , p < 0.001). On multivariate analyses, after adjusting for age, history of hypertension and diabetes, and use of antiplatelet drugs or beta-blockers, lesion volume ≥ 300 mm3 was the only significant predictor of bleeding (adjusted OR 3.11, 95% CI 1.09-8.86). When the diagnostic accuracy of different volume thresholds was explored, volume ≥ 300 mm3 showed a limited sensitivity (36.7%, 95% CI 24.6%-50.0%), but a high specificity 78.2% (95% CI 71.3%-84.2%), with an area under the curve of 0.57 (95% CI 0.51-0.64).
This study supports previous findings that the CCM volume is the only factor influencing the bleeding risk. Antithrombotic agents and propranolol seem to have a protective role against the bleeding events. A high HAS-BLED score was not associated with an increased bleeding risk. Further studies are needed to confirm these results.
脑动静脉畸形（CAVM）是一种血管病变，每年破裂的总体风险为 2%至 6%，这与显著的发病率和死亡率相关。诊断发病率在增加，因此基于破裂风险对患者进行分层至关重要。文献中的数据似乎表明，特定药物，特别是抗血栓和心血管药物，与出血风险降低相关。然而，患者凝血状态对累积出血风险的影响仍不清楚。本研究旨在评估不同的影像学、临床和药理学因素对 CAVM 出血风险的影响，并评估已经验证的一般出血风险量表（HAS-BLED，高血压、异常肾功能/肝功能、中风、出血史或倾向、不稳定的国际标准化比值、老年、同时使用药物/酒精）的预测能力。
这是一项多中心回顾性观察性研究。作者收集了出血和非出血性 CAVM 患者的影像学、临床状况和治疗数据。在考虑的变量与出血或非出血状态之间进行单因素分析和随后的多变量逻辑回归，以确定出血的潜在独立预测因素。
作者收集了 257 名患者（46.7%为男性，25.3%有出血性 CAVM）的数据。与非出血性病变患者相比，出血性 CAVM 患者更年轻，高血压发生率更低，抗血小板药物和β受体阻滞剂的使用率也更低（均 p<0.05）。然而，出血性病变的中位体积明显更高（1050mm3 与 523mm3 ，p<0.001）。多变量分析调整年龄、高血压和糖尿病病史以及抗血小板药物或β受体阻滞剂的使用后，病灶体积≥300mm3 是出血的唯一显著预测因素（调整比值比 3.11，95%可信区间 1.09-8.86）。当探讨不同体积阈值的诊断准确性时，体积≥300mm3 显示出有限的敏感性（36.7%，95%可信区间 24.6%-50.0%），但特异性较高（78.2%，95%可信区间 71.3%-84.2%），曲线下面积为 0.57（95%可信区间 0.51-0.64）。
本研究支持先前的发现，即 CAVM 体积是唯一影响出血风险的因素。抗血栓药物和普萘洛尔似乎对出血事件具有保护作用。高 HAS-BLED 评分与出血风险增加无关。需要进一步研究来证实这些结果。
