Clinical Presentation, Management, and Outcomes of Cerebellar Cavernous Malformations: a retrospective Study of 130 Patients

Introduction: Data on the natural history and optimal management of cerebellar cavernous malformations (CMs) is limited. This study analyzes clinical characteristics, hemorrhage risk, management strategies, and outcomes in a large cohort of cerebellar CM patients.

Methods: A retrospective review of 130 patients with cerebellar CMs evaluated from 1990 to 2023 was conducted. Clinical presentation, lesion characteristics, hemorrhage risk, management, and outcomes were analyzed. Hemorrhage was defined by clinical symptoms and radiological evidence, with annual risk calculated as hemorrhagic events per total patient-years (censored at surgery or death). Surgical outcomes were assessed by persistence of CM-related symptoms at last follow-up. Statistical analyses included non-parametric tests for continuous variables, chi-square or Fisher’s exact tests for categorical variables, and Kaplan-Meier analysis for hemorrhage-free survival.

Results: Of the 130 patients (53.8% female; mean age 47.8 years), the most common presenting symptoms were hemorrhage (31.5%) and focal neurological deficits (15.4%). The mean lesion size was 13.4 mm, predominantly located in the hemispheres (68.5%), followed by vermis (16.2%), peduncle (15.4%), and dentate nucleus (6.9%). The annual hemorrhage risk for incidental lesions was 1.19%, while the rehemorrhage risk for initially hemorrhagic lesions was 8.35%. Surgery was performed in 23.8% of patients, mainly for hemorrhage at presentation (48.4%) or cerebellar symptoms (22.6%). Postoperative complications occurred in three patients. At follow-up (mean 3.62 years), 18.2% reported persistent CM-related symptoms. Two patients developed new symptoms and two had worsening symptoms due to hypertrophic olivary degeneration. Fourteen patients died during follow-up – none related to CM or surgery. At the end of follow-up, only one case of severe disability (mRS > 3) was directly related to cerebellar CM or surgery.

Conclusion : Cerebellar CMs generally have a benign clinical course, with hemorrhage risks similar to supratentorial lesions. Conservative management is advised for incidental lesions, while surgery should be reserved for symptomatic and accessible hemorrhagic cases.