Influence of Pregnancy on Hemorrhage Risk in Women With Cerebral and Spinal Cavernous Malformations.

BACKGROUND AND PURPOSE: Pregnancy as a hemorrhage risk factor in women with cavernous malformations (CMs) is controversial. We describe prospective hemorrhage risk in women who become pregnant after an established CM diagnosis. METHODS: Beginning in 2015, we recruited consecutive patients with radiologically confirmed CM of the brain or spinal cord to participate in a prospective registry. Participants underwent a baseline and annual medical record review, imaging review, and annual surveys to ascertain pregnancies, deliveries, and neurological complications. We collected prospective hemorrhage data on reproductive age women. We calculated prospective hemorrhage rates on childbearing age patients based on the number of hemorrhages occurring post-CM diagnosis during pregnancy and nonpregnancy, divided by the years of follow-up and censored at last follow-up, age 46, or surgery in sporadic-form CM. The hemorrhage rates were compared and the 95% CI presented with a P value of <0.05. RESULTS: Of 160 women, 90 presented with CM under the age of 46 (average age 31.6 years; 25.6% familial form; 46.7% with hemorrhage; 24.4% brain stem location). These 90 patients had 136 pregnancies before CM diagnosis; 36 pregnancies occurred at or after the diagnosis of CM. Four patients had a hemorrhage while pregnant or postpartum leading to the first CM diagnosis. During 402.6 years of follow-up while not pregnant, 42 hemorrhages occurred prospectively yielding a 10.4% per year (95% CI, 7.5-14.0) risk of hemorrhage while not pregnant. No hemorrhages occurred during 32 prospective pregnancies (26 live births including 1 twinset and 7 nonviable fetuses) after CM diagnosis during 26.9 years of pregnancy time yielding a rate of 0% per year (95% CI, 0-13.6). We found no statistical difference in the rates of hemorrhage during pregnant and nonpregnant time (P=0.09). No hemorrhage occurred during delivery. CONCLUSIONS: Our prospective data suggest that pregnancy does not increase the risk of hemorrhage in women with a known brain or spinal cord CM and that vaginal delivery is safe in appropriate candidates.

The Influence of Physical Activity on Cavernous Malformation Hemorrhage.

BACKGROUND AND AIM: Cavernous malformations are low-flow vascular malformations of the central nervous system. Brainstem location and prior hemorrhage increase future hemorrhage risk. We sought to determine the influence of physical activity on hemorrhage risk. METHODS: Consecutive patients with radiologically confirmed cavernous malformations participated in a prospective registry with structured, baseline interviews, surveys, and examinations. Patients were asked about unusual events prior to initial clinical presentation. Medical records and MRIs were reviewed. Patients were surveyed about their physical activity after receiving their diagnosis. Annual follow-up surveys to patients ascertained new hemorrhages. Follow-up terminated at last follow-up, hemorrhage, surgery, or death. Univariate analysis assessed the risk of physical activities on prospective hemorrhage. RESULTS: Of 195 patients, 117 (60%) were female. Median diagnosis age was 41 years. After diagnosis, 103 (52.8%) patients returned the physical activity survey (cerebral n = 100; spine n = 3). Over 539.4 patient years, 23 had a prospective hemorrhage. Five patients were removed from analysis because they had less than 6 weeks of physical-activity exposure before censor. The remaining 98 had no difference in prospective hemorrhage risk than those patients participating greater than or equal to 3 times monthly in walking, running, greater than 20-pound or less than 20-pound weight lifting, or noncontact sports. Few (n = 5) reported contact-sport participation, scuba diving (n = 2), or high-altitude climbing (n = 1) greater than 3 times monthly. CONCLUSIONS: Aerobic activity and noncontact sports do not increase hemorrhage risk in cerebral cavernous malformation; patients should not be restricted. Less is known about contact sports, high-altitude climbing, scuba diving, and those with spinal-cord cavernous malformation.