Comparison of Surgical and Conservative Management of Cerebral Cavernous Malformations in Children: A Systematic Review and Meta-Analysis

Introduction: Pediatric Cerebral cavernous malformations (CCMs) are neurovascular lesions that can spontaneously hemorrhage or grow, leading to neurologic morbidity. Current treatments include conservative and surgical approaches, but there is a shortage of data, particularly from randomized control trials and multicenter studies, to guide clinical decision making. Our study assesses the efficacy of conservative versus surgical treatment for pediatric CCMs.

Methods: A systematic review of the literature using PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to identify predictive factors, patient demographics, and lesion characteristics related to treatment strategies, and to compare long-term patient outcomes.

Results: In our analysis, 105 articles met criteria, with 96 case reports/series (638 patient cases) and 9 retrospective studies. Surgical patients had higher rates of seizures (47% vs. 25%, p< 0.01) and hemorrhage on imaging (26% vs. 13%, p< 0.05) at presentation. Conversely, conservatively treated patients were more often asymptomatic (20% vs. 0.2%, p< 0.0000), had sensory deficits (11% vs. 4%, p< 0.05), and an increased family history of CCMs (29% vs. 12%, p< 0.001). Regression analysis indicated surgical management was more often utilized in patients presenting with seizures (OR: 2.47, 95%CI: 1.39-4.75, p< 0.01), hemorrhage (OR: 2.31, 95%CI: 1.13-5.21, p< 0.05), isolated CCM lesions (OR: 2.56, 95%CI: 1.45-4.47, p< 0.001), and large CCMs size (OR: 1.06, 95%CI: 1.01-1.06, p< 0.05), while surgery was less likely in asymptomatic presentations (OR: 0.01, 95%CI: 0.00-0.05, p< 0.000), patients with sensory deficits (OR: 0.31, 95%CI: 0.12-0.84, p< 0.05), and infratentorial location (OR: 0.50, 95%CI: 0.30-0.85, p< 0.01). At last follow-up, surgical management was associated with a higher percentage of symptom-free patients (51% vs. 29%, p< 0.001) and was significantly associated with improved outcomes (OR: 2.18, 95%CI: 1.15-4.01, p< 0.05).

Conclusion : Surgical intervention may be more beneficial for symptomatic patients, while conservative management can be considered for asymptomatic and infratentorial CCM.