Cerebral cavernous malformation remnants after surgery: a single-center series with long-term bleeding risk analysis

Neurosurg Rev. 2021 Oct;44(5):2639-2645. doi: 10.1007/s10143-020-01436-7. Epub 2020 Nov 19.


The aim of this work is to investigate the long-term bleeding risk of cerebral cavernous malformation (CCM) remnants. A review of clinical, radiological, operative, and post-operative data of a cerebral cavernous malformation (CCMs) prospective database was performed. Fisher's exact test and Mann-Whitney U-test were used to assess differences between non-hemorrhagic and hemorrhagic CCM remnants for 14 variables. Recursive partitioning analysis was performed to assess the order of variables most associated with CCM remnant bleeding. Twenty-four patients out of 126 had a CCM post-surgical remnant. Of these, 7 had at least one post-operative hemorrhagic event. The mean follow-up was 80.7 months (range 12-144). CCM post-surgical remnant bleeding presented mostly with acute headache (50%) and focal neurological deficit (25%); in the remaining cases, the hemorrhage was asymptomatic. Retreatment was performed in two patients, with surgery and radiosurgery, respectively; no treatment was performed in the majority of cases. All patients ranked as non-II, according to Zabramski classification, did not show any post-surgical bleeding. The presence of a pre-operative perilesional hemosiderin ring was highly significant in predicting post-surgical bleeding (sensitivity = 0.94, specificity = 0.88) and incorrectly predicted bleeding in only two of the 24 patients. This study provides an evaluation of clinical and radiological factors influencing the bleeding risk of a CCM post-surgical remnant in a homogeneous population. Perilesional hemosiderin ring and Zabramski Type II appear to strongly condition the bleeding risk of a CCM post-surgical remnant.

Keywords: Bleeding risk analysis; Cerebral cavernous malformation; Post-surgical bleeding.

Publication types

  • Review

MeSH terms

  • Hemangioma, Cavernous, Central Nervous System* / diagnostic imaging
  • Hemangioma, Cavernous, Central Nervous System* / surgery
  • Hemorrhage
  • Hemosiderin
  • Humans
  • Radiosurgery*
  • Risk Assessment


  • Hemosiderin