Surgical versus Conservative Management of Pediatric Intracranial Cavernous Malformations: A Systematic Review and Comparative Meta-analysis

Introduction: Pediatric cavernous malformations (PCMs) pose challenges due to their unpredictability and risk of neurological deficits. This study examines management strategies, focusing on factors guiding the choice between conservative and surgical treatments.

Methods: A systematic review following PRISMA guidelines was conducted using PubMed, Google Scholar, Embase, and Web of Science. A comparative meta-analysis quantified patient demographics, diagnostics, treatments, and outcomes, comparing surgical and conservative management of PCMs.

Results: Thirteen comparative studies with 785 patients were included, with 55.8% (438 patients) in the surgically managed group and 44.2% (347 patients) conservatively managed. The mean Methodological Index for Nonrandomized Studies (MINORS) was 12.4 ± 3.3. More males were in both groups (surgical: 57.9%, conservative: 58.3%). The surgical group had a higher prevalence of seizures (51.3% vs. 20.4%), signs of elevated intracranial pressure(6.1% vs. 0.7%) and hemorrhages (65.9% vs. 28.8%), but similar rates of headaches and motor deficits compared to conservative. Seizures (OR: 3.9, 95% CI: 2.7-5.7, p< 0.001) and hemorrhages (OR: 4.6, 95% CI: 1.5-13.7, p< 0.001) were predictors for surgical management, while asymptomatic presentation decreased the likelihood of surgery (OR: 0.7, 95% CI: 0.4-0.9, p< 0.001). Lesion characteristics showed more isolated lesions (82.1% vs. 64.8%) and larger mean lesion sizes (2.1 cm vs. 1.4 cm) in the surgical group. Clinical improvement was reported in 83.8% of surgical and 70.4% of conservative patients (p=0.277) while 77.5% of surgical patients were symptom-free compared to 47.5% of conservative (p=0.033) at last follow-up. Univariate analysis showed 1.37 years mean difference in time to symptom recurrence (95% CI: 0.04-2.71, p=0.04) after surgical compared to conservative management. No deaths were reported in either group.

Conclusion : Surgical management is indicated in symptomatic CMs, especially those with seizures or hemorrhage, while conservative management is indicated in asymptomatic patients. Further research is needed to expand on the identified predictors of surgical management.