Supratentorial cavernous malformations

I have just read the article from Shih and Pan (2005) on management of supratentorial cavernous malformations (CMs).

Overview
It is a retrospective cohortstudy (evidence level 2) with 46 patients, separated in a group that was treated with conventional surgery (craniotomy) and gamma-knife radiosurgery (GKRS). The objective was to compare both strategies to determine the best treatment option, related to circumstances.

Strengths
Besides a nice general introduction, the authors provide clear data on presenting symptoms and post-treatment hemorrhage. Seizures are the most common presentation in patients with supratentorial CMs. All patients with deep-seated supratentorial CMs presented with bleeding. Patients with multiple or infratentorial CMs were excluded.
In the surgery group (n=16), 79% of patiens became seizure-free and no postoperative bleeding occurred. In the GKRS-group (n=30), only 25% of patients became seizure-free and 33% had a hemorrhagic complication.

Limitations
As the authors ackowledge, the retrospective design caused considerable selection bias. Patients in the craniotomy group had frontal or temporal lesions, accessible for surgery. The GKRS consisted mainly of patients with deep seated lesions. According to the authors they also used a lower mean marginal dose (13,3Gy) compared to 19,7Gy in other series.

My Interpretation
If possible, surgery is the first treatment choice. GKRS can be used for deep-seated lesions that are difficult to access. All patients with seizures should be routinely evaluated pre-surgically to identify a possible epileptogenic focus, regardless of which treatment modality is adopted.
Of course, this conclusion must be interpreted keeping the study’s limitations in mind.

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