Functional outcome after initial and multiple intracerebral hemorrhages in children with cerebral cavernous malformations

Background and purpose: We aimed to assess the course and predictors of functional outcome after single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs) and to conduct a risk assessment of a third bleed during the first follow -up year after second ICH. Methods: We included patients aged <= 18 years with complete baseline characteristics, a magnetic resonance imaging dataset, >= 1 CCM-related ICH and >= 1 follow -up examination, who were treated between 2003 and 2021. Neurological functional status was obtained using modified Rankin Scale scores at diagnosis, before and after each ICH, and at last follow -up. Kaplan- Meier analysis was performed to determine the cumulative 1-year risk of third ICH.Results: A total of 55 pediatric patients (median [interquartile range] age 12 [11] years) were analyzed. Univariate analysis identified brainstem cavernous malformation (BSCM; p = 0.019) as a statistically significant predictor for unfavorable outcome after second ICH. Outcome after second ICH was significantly worse in 12 patients (42.9%; p = 0.030) than after first ICH and in five patients (55.6%; p = 0.038) after a third ICH compared to a second ICH. Cumulative 12 -month risk of rebleeding during the first year after a second ICH was 10.7% (95% confidence interval 2.8%- 29.37%).Conclusions: Pediatric patients with a BSCM have a higher risk of worse outcome after second ICH. Functional outcome improves over time after an ICH but worsens following each ICH compared to baseline or previous ICH. Second bleed was associated with neurological deterioration compared to initial ICH, and this deteriorated further after a third ICH.

Automated summary

This study aimed to assess the functional outcome and predictors of single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs), and to evaluate the risk of a third bleed after the second ICH. The findings showed that brainstem cavernous malformation (BSCM) was associated with worse outcome after the second ICH. Functional outcome improved over time after an ICH, but worsened with each subsequent ICH compared to baseline or previous ICH. The second bleed was associated with neurological deterioration compared to the initial ICH, and this deterioration further worsened after a third ICH.