Received: 10 January 2022 Revised: 3 March 2022 Accepted: 4 April 2022
Quality of life and mood assessment in conservatively treated
cavernous malformation-related epilepsy
Laurèl Rauschenbach1Pauline Bartsch1Alejandro N. Santos1
Annika Lenkeit1Marvin Darkwah Oppong1Karsten H. Wrede1
Ramazan Jabbarli1Witold X. Chmielewski1Börge Schmidt2Carlos M. Quesada3
Michael Forsting4Ulrich Sure1Philipp Dammann1
1Department of Neurosurgery and Spine
Surgery, University Hospital Essen, Essen,
2Institute for Medical Informatics, Biometry
and Epidemiology, University Hospital of
Essen, Essen, Germany
3Department of Neurology, Division of
Epilepsy, University Hospital Essen, Essen,
4Department of Diagnostic and Interventional
Radiology and Neuroradiology, University
Hospital Essen, Essen, Germany
Laurèl Rauschenbach, Department of
Neurosurgery and Spine Surgery, University
Hospital Essen, Hufelandstrasse 55, 45147
This article was presented at the Annual
Meeting German Society of Neurosurgery
Background: To estimate the quality of life, anxiety, depression, and illness perception
in patients with medically treated cerebral cavernous malformation (CCM) and associ-
Methods: Nonsurgically treated patients with CCM-related epilepsy (CRE) were
included. Demographic, radiographic, and clinical features were assessed. All partici-
pants received established questionnaires (short-form 36 health survey, SF-36; hospi-
tal anxiety and depression score, HADS-A/D; visual analogue scale score, VAS) assess-
ing the functional and psychosocial burden of disease. To some extent, calculated val-
ues were compared with reference values from population-based studies. Test results
were related to seizure control.
Results: A total of 37 patients were included. Mean age was 45.8 ±14.4 years, and
54.1% were female. Diagnosis of CRE was significantly associated with attenuated
quality of life and increased level of anxiety, affecting physical and psychosocial dimen-
sions. The assessment of illness perception identified considerable burden. HADS was
significantly associated with VAS and SF-36 component scores. Efficacy of antiepilep-
tic medication had no restoring impact on quality of life, anxiety, depression, or illness
Conclusions: CRE negatively influences quality of life and mood, independent of
seizure control due to antiepileptic medication. Screening for functional and psychoso-
cial deficits in clinical practice might be useful for assessing individual burden and allo-
cating surgical or drug treatment.
anxiety, cerebral cavernous malformation, depression, epilepsy, quality of life
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2022 The Authors. Brain and Behavior published by Wiley Periodicals LLC.
Brain Behav. 2022;e2595. wileyonlinelibrary.com/journal/brb3 1of9
2of9 RAUSCHENBACH ET AL.
Cerebral cavernous malformations (CCMs) are the second most com-
mon type of neurovascular malformation in the central nervous sys-
tem, representing between 10% and 15% of all vascular malformations
(Washington et al., 2010). Although there is low blood pressure and
slow blood flow within these lesions, CCMs carry considerable risk of
intracerebral hemorrhage (Taslimi et al., 2016). Irrespective of bleed-
ing occurrence, CCMs can implicate headaches, seizures, or focal neu-
rological deficits (Horne et al., 2016). CCM-related epilepsy (CRE) is
a common phenomenon in CCM, with an incidence of ≈30% (Al-Shahi
Salman et al., 2012; Dammann, Wrede, et al., 2017; Horne et al., 2016).
Even though the underlying mechanisms are poorly understood, few
studies identified associations between CRE and CCM multiplicity, cor-
tical involvement, or CCM-related hemosiderin deposition (Dammann,
Schaller, et al., 2017; He et al., 2017; Menzler et al., 2010; Moul-
trie et al., 2014). Notably, CCM treatment is still subject to debate.
Evidence-based treatment guidelines are scarce and decision-making
is often limited to clinical experience (Dammann et al., 2021; Rosenow
et al., 2013). Although lesion removal in CRE patients seems justi-
fied in selected cases, brain surgery remains a delicate procedure, and
noninvasive treatment approaches must be considered, particularly
in patients who have minor or no functional impairments (Dammann,
Wrede, et al., 2017).
Epileptic seizures can have a considerable impact on health-related
quality of life (HRQOL) (Mahrer-Imhof et al., 2013), and treatment
pathways should take into account not only neurological but also psy-
chosocial burden. While the vast majority of CCM studies focus on
different treatment strategies and risk factors leading to hemorrhage
(Al-Shahi Salman et al., 2016), literature reporting on HRQOL is rare
(Bicalho et al., 2017; Rinkel et al., 2019). Recently published data high-
light the impact of CCM disease on self-reported quality of life but
HRQOL and mood have never been studied exclusively in medically
treated CRE patients (Herten et al., 2021).
In this study, conservatively treated patients were screened for
disease-related functional and psychosocial burden. Moreover, the
results were compared to the average population and related to seizure
2.1 Study design
A prospective cross-sectional study was performed of all patients who
were admitted to our specialized outpatient clinic for CCM disease
between November 2017 and January 2020. During consultation, all
patients were given general information about diagnosis, treatment
strategies, and prognosis. Participants needed to fulfill the inclusion
criteria mentioned below. Informed consent was obtained from all
participants. The study was conducted in accordance with the princi-
ples expressed in the Declaration of Helsinki. A local ethics commit-
tee approved all procedures (Review Board Identification Number: 15-
6636-BO). The trial was performed in accordance with Strengthening
the Reporting of Observational Studies in Epidemiology protocol. Parts
of the data were published previously in a study, investigating HRQOL
in patients with untreated cavernous malformations of the central ner-
vous system (Herten et al., 2021).
2.2 Inclusion and exclusion criteria
We included patients aged between 18 and 80 years and diagnosed
with CRE according to the definition by Rosenow et al. (2013). CCM
diagnosis was based on magnetic resonance imaging (MRI) includ-
ing T1, T2, contrast-enhanced, and susceptibility-weighted or T2*-
weighted gradient echo imaging. Patients were treated conservatively.
Individuals who received invasive treatment and were hospitalized
within 3 months prior to study were excluded. Patients required suf-
ficient knowledge of the German language to cope with the testing.
2.3 Data collection
Clinical data and imaging data were assessed prospectively and in
accordance with CCM reporting standards (Al-Shahi Salman et al.,
2008). An experienced neuroradiologist evaluated imaging data. The
following clinical and radiological features were assessed: age, sex,
number of CCMs, lesion localization, occurrence of CCM-related hem-
orrhage (Taslimi et al., 2016), physical or psychiatric comorbidities,
epilepsy semiology, number of seizures, antiepileptic medication, time
between first and last CCM-related seizure, time between first CCM-
related seizure and neuropsychological testing, and time between last
CCM-related seizure and neuropsychological testing. The degree of
disability was determined using the modified Rankin Scale (mRS). Out-
come was considered favorable if the patient had a mRS less than or
equal to 2 and unfavorable if the mRS was greater than 2. HRQOL
was assessed in a standardized interview using the German version of
the 36-item short form health survey (SF-36). Depression and anxiety
were addressed using the hospital anxiety and depression rating scale
(HADS-A/D). Moreover, subjective perception of disease and burden of
CRE were evaluated using a visual analog scale (VAS). Testing was con-
ducted by one interviewer to avoid interobserver effects.
The SF-36 questionnaire addresses two main domains comprised
of 8 subdomains with 36 questions items: physical functioning (PF),
social functioning (SF), role limitations due to physical problems (RP),
role limitations due to emotional problems (RE, three items), men-
tal health (MH, 5 items), vitality (VT, four items), bodily pain (BP, two
items), and general health perceptions (GH, five items). Additionally,
we determined two overall component scores: physical health compo-
nent score (PCS) and mental health component score (MCS). For each
subdomain, an overall score was assessed (0 =worst subjective health
state; 100 =best subjective health state). The HADS-A/D scaleconsists
of a questionnaire containing 14 questions, with 7 referring to anxiety
and seven referring to depression. With the VAS score, the individual
patient burden was determined. This psychometric scale ranges from 1
(no burden) to 10 (maximum burden).
RAUSCHENBACH ET AL.3of9
SF-36 and HADS-A/D scores were compared with data from Ger-
man reference population studies. For SF-36 testing, the reference
data were provided by the population-based Heinz Nixdorf Recall
Study and the associated MultiGeneration study (Schmermund et al.,
2002). Participants were randomly selected from three German cities
(i.e., Essen, Bochum, and Mülheim a.d. Ruhr). Individual matching (1:3)
was applied to ensure that CCM cases and population-based controls
had the same distribution over strata defined by age (5-year groups)
and sex. For HADS-A/D testing, reference values were derived from a
large population-based investigation (Hinz & Brähler, 2011).
2.4 Statistical analyses
Statistical analysis was performed using SPSS version 22 (IBM Corp.).
Data were tested for normal distribution by performing a Shapiro-
Wilk test. For interval-scaled data, mean values, and standard deviation
were calculated, while absolute numbers and valid percent were used
for nominal data. The unpaired t-test (normally distributed data) or the
Mann-Whitney U test (non-normally distributed data) were used to
compare continuous variables. Effect size was reported using Cohen’s
d, and values were categorized according to an established classifica-
tion system: small effect (>0.2), medium effect (>0.5), and large effect
(>0.8) (Rice & Harris, 2005). The degree of correlation was calculated
using the Spearman’s rank correlation test. For linear regression anal-
yses, R2values were determined. All tests were two tailed, and p-
values <.05 were defined as significant.
3.1 Patient demographics
A total of 37 patients were included in this study. Mean age was
45.8 ±14.4 years, and 20 participants (54.1%) were female. Six
patients (16.2%) exhibited multiple CCMs. Lesions were most com-
monly located in the temporal lobe. CCM-related hemorrhage was a
common phenomenon and affected 18 (48.6%) individuals. The major-
ity of patients (97.3%) were in good clinical condition (mRS≤2). Fif-
teen participants (40.4%) had diseases that were not related to CCM
disease, including 13 patients (35.1%) suffering from physical and two
patients (5.4%) from psychiatric comorbidities. Detailed information
on demographic, anatomic, and clinical data is provided in Table 1.
3.2 Cavernoma-related epilepsy
At the time of testing, all participants had experienced at least one
epileptic seizure. Most patients (64.9%) had a history of one single
seizure, but several individuals (35.1%) were admitted with a history
of recurrent seizures. In the majority of cases (75.7%), anticonvulsant
treatment was administered at the time of testing, mainly consisting
of one single drug. According to treatment guidelines, the most com-
TAB LE 1 Demographic, anatomic, and clinical characteristics
Total number of patients with CRE, n37
Age, years, mean ±SD 45.8 ±14.4
Male 17 (45.9)
Female 20 (54.1)
CCM number, n(%)
Solitary (1 CCM) 31 (83.8)
Multiple (≥2 CCM) 6 (16.2)
CCM localization, n(%)
Frontal lobe 9 (24.3)
Parietal lobe 5 (13.5)
Temporal lobe 10 (27)
Occipital lobe 3 (8.1)
Multiple lobes 7 (18.9)
Subcortical 3 (8.1)
CCM-related hemorrhage, n(%) 18 (48.6)
0 2 (5.4)
1 31 (83.8)
2 3 (8.1)
3 1 (2.7)
Physical comorbidities 13 (35.1)
Psychiatric comorbidities 2 (5.4)
CRE semiology, n(%)
Focal epilepsy 11 (29.7)
Generalized epilepsy 23 (62.2)
Absence epilepsy 3 (8.1)
No. of seizures, n(%)
1 CCM-related seizure 24(64.9)
≥2 CCM-related seizures 13 (35.1)
Antiepileptic treatment, n(%)
No treatment 9 (24.3)
Monotherapy (1 drug) 22 (59.3)
Combination therapy (2 drugs) 6 (16.2)
Antiepileptic medication, n(%)
Carbamazepine 1 (2.9)
Clonazepam 1 (2.9)
Lacosamide 1 (2.9)
Lamotrigine 5 (14.7)
Levetiracetam 19 (55.9)
Oxcarbazepine 1 (2.9)
Pregabalin 1 (2.9)
Valproate 3 (8.8)
Zonisamide 2 (5.9)
4of9 RAUSCHENBACH ET AL.
TAB LE 1 (Continued)
Time between first and last CCM-related
seizure, months, mean ±SD
Time between first CCM-related seizure and
survey,months, mean ±SD
Time between last CCM-related seizure and
survey,months, mean ±SD
Abbreviations: CCM: cerebral cavernous malformation; CRE: cavernoma-
related epilepsy; mRS: modified Rankin Scale; n: number; n/a:not applicable;
SD: standard deviation.
mon medication was levetiracetam (55.9%) and lamotrigen (14.7%).
Patients with multiple seizures featured a relatively low seizure fre-
quency. At admission, these patients had a history of 33.2 ±88.7
months between first and last seizure. In the total cohort, participants
were interviewed 60.1 ±101.5 months after their first seizure and 28.9
±59.6 months after their last seizure. Detailed information on clinical
data is provided in Table 1.
3.3 Health-related quality of life
HRQOL was assessed using the German version of the SF-36. The
results for CRE patients and for the age- and gender-matched German
reference population are presented in Figure 1. Compared to the ref-
erence population, CCM patients with CRE had decreased scores in all
domains and component scores. In 18 patients (48.6%), the PCS was
2 points lower than the mean score of the average population. Thirty-
three participants (89.2%) experienced a similar decrease in the MCS.
Notably, a two-point decrease is regarded as relevant (McHorney &
Ware, 1995; Ware et al., 1995). Statistical testing demonstrated signif-
icantly impaired scores in overall mental health score and in six addi-
tional subdomains (p<.001). Patients experienced limitations in usual
role activities due to physical impairment (RP, p=.0001), attenuated
general health (GH, p=.0001), decreased vitality (VT, p=.0001), limita-
tions in social activities because of physical or emotional problems (SF,
p=.0001), limitations in usual role activities due to emotional problems
(RE, p=.0001) and worsened mental health (MH, p=.0001). Detailed
analyses are provided in Table 2. Further investigation revealed dif-
ferences in physical health component scores of patients with single
(52.0 ±7.7) or multiple (39.9 ±13.8) CCM (p=.004), and differences
in mental health component scores of patients with (37.7 ±11.6) or
without (44.9 ±8.9) history of CCM-related hemorrhage (p=.039).
Notably, there were no differences in test performance between male
and female individuals.
3.4 Perception of illness, anxiety, and depression
Subjective perception of illness and burden of CRE were evaluated
using a visual analog scale (VAS). The mean VAS score was 5.4 ±
FIGURE 1 Short Form-36 (SF-36) domains including physical
health, mental health, and component scores. Physical functioning
(PF), social functioning (SF), role limitations due to physical problems
(RP), role limitations due to emotional problems (RE), mental health
(MH), vitality (VT), bodily pain (BP), and general health perceptions
(GH), physical health score (PCS), mental health score (MCS).
Asterisks indicate statistical significance compared to reference
2.3, indicating considerable symptom severity. Depression and anxiety
were determined using the hospital anxiety and depression rating scale
(HADS-A/D). In the CRE population, the mean HADS-A score was 7.9 ±
4.4 with 19 patients (51.4%) revealing a score more than or equal to 8,
indicating relevant levels of anxiety. Compared to the average German
population, values were considerably elevated (Hinz & Brähler, 2011).
In contrast to anxiety, depression was less common in CRE patients.
The mean HADS-D score was 5.6 ±4.2 with 10 patients (27%) scor-
ing 8 or more. These values were comparable to data derived from the
German reference population (Hinz & Brähler, 2011). Detailed analy-
ses are listed in Table 3. Notably, HADS-A, HADS-D, and VAS scores
demonstrated a high degree of concordance among each other, indi-
cating a correlation between the level of anxiety, depression, and per-
ception of illness. Moreover, HADS-A and HADS-D were significantly
associated with SF-36 component scores (p≤.003), except for HADS-
D and PCS. Detailed analyses are provided in Table S1. Subsequent
analyses demonstrated differences in HADS-D scores of patients with
RAUSCHENBACH ET AL.5of9
TAB LE 2 HRQOL testing in CRE and healthy populations
mean ±SD pa
Physical health subdomains
PF 86.2 ±19.6 91.6 ±13.5 .0638 0.40 +
RP 67.6 ±39.0 89.3 ±25.4 .0001 0.85 +++
BP 75.9 ±26.8 81.7 ±22.3 .1954 0.26 +
GH 58.1 ±21.8 72.5 ±15.5 .0001 2.62 +++
VT 53.0 ±20.4 67.1 ±17.2 .0001 0.82 +++
Mental health subdomains
SF 67.9 ±26.4 95.9 ±10.8 .0001 2.59 +++
RE 65.7 ±37.8 94.5 ±22.9 .0001 1.26 +++
MH 61.4 ±19.9 80.8 ±13.8 .0001 1.42 +++
PCS 49.9 ±9.9 52.8 ±17.1 .3302 0.17 +
MCS 41.7 ±10.8 55.2 ±18.1 .0001 0.75 ++
Age (y), mean ±SD 45.8 ±14.4 45.8 ±14.3 n/a n/a n/a
Male 17 (45.9%) 51 (45.9%) n/a n/a n/a
Female 20 (54.1%) 60 (54.1%)
Note: Control-to-case ratio was 3:1. Significant p-values are in bold font.
Abbreviations: BP, bodily pain; CRE, cavernoma-related epilepsy; GH, general health perception; MCS, mental health score; MH, Mental health; n/a, data not
available; PCS, physical health score; PF, physical functioning; RE, role emotional; RP, role physical; SF, social functioning; VT, vitality.
aTwo-tailed Student’s t-test.
bInterpretation of d according to Cohen: 0.2– 0.5 small effect size (+), 0.5–0.8 medium effect size (++), >0.8 large effect size (+++).
TAB LE 3 Anxiety, depression, and subjective disease burden in CRE, CCM, and healthy populations
HADS-A HADS-D VAS
Tota l <8≥8Total<8≥8Total
Mean ±SD n(%) n(%) Mean ±SD n(%) n(%) Mean ±SD
CRE (n=37) 7.9 ±4.4 18 (48.6) 19 (51.4) 5.6 ±4.2 27 (73.0) 10 (27.0) 5.4 ±2.3
Male 4.4 ±3.3 1580 (81.9) 349 (18.1) 4.8 ±4.0 1468 (76.1) 461 (23.9) n/a
Female 5.0 ±3.6 1905 (76.8) 576 (23.2) 4.7 ±3.9 1898 (76.5) 583 (23.5) n/a
Abbreviations: CRE, cavernoma-related epilepsy; HADS, hospital anxiety and depression rating scale; n/a, not available; VAS, visual analogue scale.
aData on normative values of the German population according to Hinz & Brähler (2011).
(7.3 ±4.9) or without (4.3 ±3.2) history of CCM-related hemor-
rhage (p=.030). Again, there were no differences in test performance
between male and female individuals.
3.5 Seizure control and seizure frequency
In the majority of cases, anticonvulsant medication resulted in suf-
ficient seizure control, but some patients experienced pharmacore-
sistant epilepsy. We thus investigated the impact of seizure control
on HRQOL, anxiety, depression, and perception of illness. Compar-
ison between patients with good seizure control for more or less
than 6, 12, or 24 months demonstrated no significant differences
in SF-36 component scores (p>.05), HADS-A/D scores (p>.05),
or VAS scores (p>.05), indicating minor impact of seizure con-
trol on quality of life, mood, and illness perception. Detailed val-
ues are presented in Figure 2a. Comparable with seizure control,
frequency of experienced seizures had no influence on psychomet-
ric test results. Values for HRQOL, anxiety, depression, and percep-
tion of illness revealed no differences between patients who had
experienced one or multiple seizures. The results are provided in
6of9 RAUSCHENBACH ET AL.
FIGURE 2 Short Form-36 (SF-36) component score, hospital anxiety, and depression rating scale (HADS-A/D) score and visual analogue scale
(VAS) score assessment in patients with seizure control for (A1) 6, (A2) 12, or (A3) 24 or in patients with (B) seizure multiplicity. Unpaired t-test
Abbreviations: MCS, mental health score; ns, not significant; PCS, physical health score
3.6 Time since diagnosis
Due to the cross-sectional design of this study, patients were examined
at different time points. Accordingly, time between first seizure and
testing was referred to SF-36 component scores, HADS-A/D scores,
and VAS scores. Data were visualized in scattered plots, and linear
regression analyses revealed low R2values, indicating that none of the
variance in test results was explained by the time between first seizure
and testing. The results are illustrated in Figure 3.
In this cross-sectional study, we investigated the impact of medically
treated CRE on quality of life and mood in a subset of patients who
were not referred to surgery for various reasons. Patient-reported sur-
veys were used to assess data, and results were related to seizure
Although seizure diseases are one of the most common presenta-
tions in CCM patients (Rosenow et al., 2013), functional and psychoso-
cial burden is rarely discussed. Moreover, literature dealing with qual-
ity of life in CRE is exclusively limited to studies investigating the out-
come after CCM removal (Dammann, Wrede, et al., 2017; Ruan et al.,
2015; Van Gompel et al., 2010). Since treatment is often personal-
ized, particularly in the case of CRE, patients and surgeons often face
the difficult question of whether to opt for surgery or continue drug
treatment (Dammann et al., 2021). Recently published data have high-
lighted the value of open and minimally invasive surgery for epilepto-
genic CCM lesions, including pediatric and adult patients (Dammann,
Wrede, et al., 2017; Kapadia et al., 2021; Lee et al., 2017; Lin et al.,
2018; Ozlen et al., 2021; Satzer et al., 2020;Schussetal.,2020; Willie
et al., 2019). Nevertheless, although early CCM removal is often fea-
sible and effective, this topic is still a matter of debate, and high-
quality evidence-based recommendations are missing (Awad & Polster,
2019; Zanello et al., 2019). In this scenario, clinical decision-making
should not only rely on neurological assessment, due to the following
Recently, Herten et al. (2021) tested quality of life in noninvasively
treated patients and concluded that CCM strongly decreases HRQOL,
even in the absence of functional impairment or neurological symp-
toms. Moreover, while numerous authors have described the negative
impact of epileptic seizures on quality of life (Mahrer-Imhof et al., 2013;
Villanueva et al., 2013), the impact of CRE in CCM patients has yet not
been considered. To this end, we present a novel study investigating
quality of life, anxiety, depression, and illness perception in medically
treated CRE patients. In this trial, we were able to confirm the negative
impact of epileptic seizures on quality of life and mood, even though
the rating of burden showed pronounced interindividual differences.
RAUSCHENBACH ET AL.7of9
FIGURE 3 Correlation between time since epilepsy onset and testing and Short Form-36 (SF-36) component scores, hospital anxiety, and
depression rating scale (HADS-A/D) scores or visual analogue scale (VAS) scores. Linear regression analyses were applied
Abbreviations: MCS, mental health score; PCS, physical health score
Furthermore, the calculated effect sizes ranged from small to large,
underlining the high degree of heterogeneity in patient burden. Inter-
estingly, neither the number of seizures experienced nor the length of
time with sufficient seizure control had an influence on the patient-
reported outcome. One might speculate that it is the diagnosis of
CRE, but not the extent of neurological impairment, which is the most
important contributing factor to the reduced quality of life and mood
observed in our study.
In light of the promising seizure outcome after surgery for CRE
(Dammann, Wrede, et al., 2017; Rosenow et al., 2013) and the increas-
ing HRQOL after CCM removal in general (Cornelius et al., 2016;
Dukatz et al., 2011), one might hypothesize that patients with strongly
decreased quality of life could be eligible for lesionectomy. Patient-
reported outcome parameters, for example, testing with SF-36 or
HADS-A/D, could be used as benchmarks to assess the individual
degree of functional and psychosocial deficits and to improve clinical
The shortcomings of this study are mainly related to the small sam-
ple size, the missing disease specificity of test instruments, and the
reporting on data of a previously published patient cohort. Since symp-
tomatic CCMs are often referred to surgery, the number of drug-
treated CRE patients remains low. However, compared to large stud-
ies on CCM, our cohort exhibits typical characteristics with similar
baseline data (Al-Shahi Salman et al., 2012; Horne et al., 2016). Thus,
patients included in this study can be regarded as a representative sam-
ple of CCM patients, increasing the external validity of our reported
results. Notably, SF-36, HADS-A/D, and VAS scores were not estab-
lished to assess burden in CCM or CRE patients, limiting the specificity
and sensitivity of testing. Nevertheless, disease-specific test instru-
ments are missing, and SF-36, HADS-A/D, and VAS are established, val-
idated, and convenient. These parameters might reflect disease bur-
den beyond neurological impairment or seizures, making them use-
ful for clinical application. Since parts of the data were published
previously in a trial investigating HRQOL in patients with untreated
8of9 RAUSCHENBACH ET AL.
cavernous malformations of the central nervous system, novelty of
data is limited.
Our report uncovers previously unrecognized functional and psy-
chosocial deficits in medically treated CRE patients and highlights the
clinical importance of psychometric testing. Seizure control had no
restoring effect on outcome, underlining the value of surgical CCM
removal irrespective of sufficient anticonvulsant treatment. A system-
atic analysis in a larger cohort is warranted.
The authors thank PD Dr. phil. Bernd-Otto Hütter for supporting neu-
CONFLICT OF INTEREST
The authors have declared that no competing interest.
Laurèl Rauschenbach: responsible for designing the study protocol,
summarized data, provided data, conducted data analysis, interpreted
results, created figures and tables, wrote the manuscript, and reviewed
the manuscript. Pauline Bartsch: summarized data, provided data, con-
ducted data analysis, created figures and tables, and reviewed the
manuscript. Alejandro N. Santos: summarized data, provided data, and
reviewed the manuscript. Annika Lenkeit: summarized data, provided
data, and reviewed the manuscript. Marvin Darkwah Oppong:sum-
marized data, provided data, interpreted results, and reviewed the
manuscript. Karsten H. Wrede: responsible for designing the study
protocol and reviewed the manuscript. Ramazan Jabbarli: responsible
for designing the study protocol and reviewed the manuscript. Witold
X. Chmielewski: responsible for designing the study protocol, con-
ducted data analysis, interpreted results, and reviewed the manuscript.
Börge Schmidt: responsible for designing the study protocol, con-
ducted data analysis, interpreted results, and reviewed the manuscript.
Carlos M. Quesada: interpreted results and reviewed the manuscript.
Michael Forsting: provided data, reviewed the manuscript. Ulrich
Sure: responsible for designing the study protocol, provided data,
interpreted results, and reviewed the manuscript. Philipp Dammann:
responsible for designing the study protocol, summarized data, pro-
vided data, interpreted results, wrote the manuscript and reviewed the
The authors of this study thank the anonymous reviewers for their
careful reading and improving this work. The peer review history for
this article is available at https://publons.com/publon/10.1002/brb3.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available in the sup-
plementary material of this article and from the corresponding author
upon reasonable request.
Laurèl Rauschenbach https://orcid.org/0000-0001- 8348-4298
Alejandro N. Santos https://orcid.org/0000-0002-6616-5313
Marvin Darkwah Oppong https://orcid.org/0000-0003- 1021-5024
Karsten H. Wrede https://orcid.org/0000-0001-7076- 3503
Al-Shahi Salman, R., Berg, M. J., Morrison, L., & Awad, I. A. (2008). Hemor-
rhage from cavernous malformations of the brain: Definition and report-
ing standards. Angioma Alliance Scientific Advisory Board. Stroke; A Jour-
nal of Cerebral Circulation,39, 3222–3230.
Al-Shahi Salman, R., Kitchen, N., Thomson, J., Ganesan, V., Mallucci, C., &
Radatz, M. (2016). Top ten research priorities for brain and spine cav-
ernous malformations. Lancet Neurology,15, 354–355.
Al-Shahi Salman, R., Hall, J. M., Horne, M. A., Moultrie, F., Josephson, C.
B., Bhattacharya, J. J., Counsell, C. E., Murray, G. D., Papanastassiou, V.,
Ritchie, V., Roberts, R. C., Sellar, R. J., & Warlow, C. P. (2012). Untreated
clinical course of cerebral cavernous malformations: A prospective,
population-based cohort study. Lancet Neurology,11, 217–224.
Awad, I. A., & Polster, S. P. (2019). Cavernous angiomas: Deconstructing a
neurosurgical disease. Journal of Neurosurgery,131, 1–13.
Bicalho, V. C., Bergmann, A., Domingues, F., Frossard, J. T., & de Souza, J.
(2017). Cerebral cavernous malformations: patient-reported outcome
validates conservative management. Cerebrovascular Diseases,44, 313–
Cornelius, J. F., Kürten, K., Fischer, I., Hänggi, D., & Steiger, H. J.(2016). Qual-
ity of life after surgery for cerebral cavernoma: Brainstem versus non-
brainstem location. World Neurosurgery,95, 315–321.
Dammann, P., Abla, A. A., Al-Shahi Salman, R., Andrade-Barazarte, H., Benes,
V., Cenzato, M., Connolly, E. S., Cornelius, J. F., Couldwell, W. T., Sola,
R. G., Gomez-Paz, S., Hauck, E., Hernesniemi, J., Kivelev, J., Lanzino, G.,
MacDonald, R. L., Morcos, J. J., Ogilvy, C. S., .. . Sure, U. (2021). Surgical
treatment of brainstem cavernous malformations: An international Del-
phi consensus. Journal of Neurosurgery, 1–11.
Dammann, P., Schaller, C., & Sure, U. (2017). Should we resect peri-lesional
hemosiderin deposits when performing lesionectomy in patients with
cavernoma-related epilepsy (CRE)? Neurosurgical Review,40, 39–43.
Dammann, P., Wrede, K., Jabbarli, R., Neuschulte, S., Menzler, K., Zhu, Y.,
Özkan, N., Müller, O., Forsting, M., Rosenow, F., & Sure, U. (2017). Out-
come after conservative management or surgical treatment for new-
onset epilepsy in cerebral cavernous malformation. Journal of Neuro-
Dukatz, T., Sarnthein, J., Sitter, H., Bozinov, O., Benes, L., Sure, U., &
Bertalanffy, H. (2011). Quality of life after brainstem cavernoma surgery
in 71 patients. Neurosurgery,69, 689–695.
He, K., Jiang, S., Song, J., Wu, Z., Chen, L., & Mao, Y. (2017). Long-term out-
comes of surgical treatment in 181 patients with supratentorial cerebral
cavernous malformation-associated epilepsy. World Neurosurgery,108,
Herten, A., Chen, B., Saban, D., Santos, A., Wrede, K., Jabbarli, R., Zhu, Y.,
Schmidt, B., Kleinschnitz, C., Forsting, M., Sure, U., & Dammann, P. (2021).
Health-related quality of life in patients with untreated cavernous mal-
formations of the central nervous system. European Journal of Neurology,
Hinz, A., & Brähler, E. (2011). Normative values for the hospital anxiety and
depression scale (HADS) in the general German population. Journal of
Psychosomatic Research,71, 74–78.
Horne, M. A., Flemming, K. D., Su, I. C., Stapf, C., Jeon, J. P., Li, D., Maxwell,
S. S., White, P., Christianson, T. J., Agid, R., Cho, W. S., Oh, C. W., Wu,
Z., Zhang, J. T., Kim, J. E., Ter Brugge, K., Willinsky, R., Brown, R. D. Jr.,
Murray, G. D., & Al-Shahi Salman, R. (2016). Clinical course of untreated
cerebral cavernous malformations: A meta-analysis of individual patient
data. Lancet Neurology,15, 166–173.
RAUSCHENBACH ET AL.9of9
Kapadia, M., Walwema, M., Smith, T. R., Bellinski, I., Batjer, H., Getch, C.,
Rosenow, J. M., Bendok, B. R., & Schuele, S. U. (2021). Seizure outcome
in patients with cavernous malformation after early surgery. Epilepsy &
Lee, Y., Cho, K. H., Kim, H. I., Lee, S. K., Cho, Y. J., Heo, K., & Lee, B. I. (2017).
Clinical outcome following medical treatment of cavernous malforma-
tion related epilepsy. Seizure: The Journal of the British Epilepsy Association,
Lin, Q., Yang,P.F., Jia, Y.Z., Pei, J. S., Xiao, H., Zhang, T.T., Zhong, Z. H., & Wang,
S. S. (2018). Surgical treatment and long-term outcome of cerebral cav-
ernous malformations-related epilepsy in pediatric patients. Neuropedi-
Mahrer-Imhof, R., Jaggi, S., Bonomo, A., Hediger, H., Eggenschwiler, P.,
Krämer, G., & Oberholzer, E. (2013). Quality of life in adult patients
with epilepsy and their family members. Seizure: The Journal of the British
Epilepsy Association,22, 128–135.
McHorney, C. A., & Ware, J. E. Jr. (1995). Construction and validation of an
alternate form general mental health scale for the Medical Outcomes
Study Short-Form 36-Item Health Survey. Medical Care,33, 15–28.
Menzler, K., Chen, X., Thiel, P., Iwinska-Zelder, J., Miller, D., Reuss, A., Hamer,
H. M., Reis, J., Pagenstecher, A., Knake, S., Bertalanffy, H., Rosenow, F., &
Sure, U. (2010). Epileptogenicity of cavernomas depends on (archi-) cor-
tical localization. Neurosurgery,67, 918–924.
Moultrie, F., Horne, M. A., Josephson, C. B., Hall, J. M., Counsell, C. E.,
Bhattacharya, J. J., Papanastassiou, V., Sellar, R. J., Warlow, C. P., Murray,
G. D., & Al-Shahi Salman, R. (2014). Outcome after surgical or conser-
vative management of cerebral cavernous malformations. Neurology,83,
Ozlen, F., Isler, C., Akgun, M. Y., Ozkara, C., Karabacak, M., Delil, S., Yilmaz
Oz, B., Tahmazoglu, B., & Uzan, M. (2021). Factors affecting seizure
outcomes after surgery for cavernoma related epilepsy. Tur kish Ne u-
rosurgery, Advance online publication. https://doi.org/10.5137/1019-
Rice, M. E., & Harris, G. T. (2005). Comparing effect sizes in follow-up stud-
ies: ROC area, Cohen’s d, and r. Law and Human Behavior,29, 615–620.
Rinkel, L. A., Al-Shahi Salman, R., Rinkel, G. J., & Greving, J. P. (2019). Radio-
surgical, neurosurgical, or no intervention for cerebral cavernousmalfor-
mations: A decision analysis. International Journal of Stroke: Official Journal
of the International Stroke Society,14, 939–945.
Rosenow, F., Alonso-Vanegas, M. A., Baumgartner, C., Blümcke, I., Carreño,
M., Gizewski, E. R., Hamer, H. M., Knake, S., Kahane, P., Lüders, H.
O., Mathern, G. W., Menzler, K., Miller, J., Otsuki, T., Ozkara, C.,
Pitkänen, A., Roper, S. N., Sakamoto, A. C., Sure, U., .. . Steinhoff, B. J.
(2013). Cavernoma-related epilepsy: Review and recommendations for
management—Report of the Surgical Task Force of the ILAE Commission
on Therapeutic Strategies. Epilepsia,54, 2025–2035.
Ruan, D., Yu, X. B., Shrestha, S., Wang, L., & Chen, G. (2015). The role of
hemosiderin excision in seizure outcome in cerebral cavernous malfor-
mation surgery: A systematic review and meta-analysis. Plos One,10,
Satzer, D., Tao, J. X., Issa, N. P., Chen, Z., Wu, S., Rose, S., Collins, J., Awad,
I. A., & Warnke, P. C. (2020). Stereotactic laser interstitial thermal ther-
apy for epilepsy associated with solitary and multiple cerebral cavernous
malformations. Neurosurgical Focus,48, E12.
Schmermund, A., Möhlenkamp, S., Stang, A., Grönemeyer, D., Seibel, R.,
Hirche, H., Mann, K., Siffert, W., Lauterbach, K., Siegrist, J., Jöckel, K.
H., & Erbel, R. (2002). Assessment of clinically silent atherosclerotic dis-
ease and established and novel risk factors for predicting myocardial
infarction and cardiac death in healthy middle-aged subjects: Rationale
and design of the Heinz Nixdorf RECALL Study. Risk Factors, Evaluation
of Coronary Calcium and Lifestyle. American Heart Journal,144, 212–
Schuss, P., Marx, J., Borger, V., Brandecker, S., Güresir, Á., Hadjiathanasiou,
A., Hamed, M., Schneider, M., Surges, R., Vatter, H., & Güresir, E. (2020).
Cavernoma-related epilepsy in cavernous malformations located within
the temporal lobe: Surgical management and seizure outcome. Neurosur-
Taslimi, S., Modabbernia, A., Amin-Hanjani, S., Barker, F. G. 2nd, &
MacDonald, R. L. (2016). Natural history of cavernous malformation:
Systematic review and meta-analysis of 25 studies. Neurology,86, 1984–
Van Gompel, J. J., Marsh, W. R., Meyer,F. B., & Worrell, G. A. (2010). Patient-
assessed satisfaction and outcome after microsurgical resection of cav-
ernomas causing epilepsy. Neurosurgical Focus,29, E16.
Villanueva, V., Girón, J. M., Martín, J., Hernández-Pastor, L. J., Lahuerta, J.,
Doz, M., Cuesta, M., & Lévy-Bachelot, L. (2013). Quality of life and eco-
nomic impact of refractory epilepsy in Spain: The ESPERA study. Neurolo-
Ware, J. E. Jr., Kosinski, M., Bayliss, M. S., McHorney, C. A., Rogers, W. H.,
& Raczek, A. (1995). Comparison of methods for the scoring and statis-
tical analysis of SF-36 health profile and summary measures: Summary
of results from the Medical Outcomes Study. Medical Care,33, As264–
Washington, C. W., McCoy, K. E., & Zipfel, G. J. (2010). Update on the natu-
ral history of cavernous malformations and factors predicting aggressive
clinical presentation. Neurosurgical Focus,29,E7.
Willie, J. T., Malcolm, J. G., Stern, M. A., Lowder, L. O., Neill, S. G., Cabaniss, B.
T., Drane, D. L., & Gross, R. E. (2019). Safety and effectiveness of stereo-
tactic laser ablation for epileptogenic cerebral cavernous malformations.
Zanello, M., Meyer, B., Still, M., Goodden, J. R., Colle, H., Schichor, C., Bello,
L., Wager, M., Smits, A., Rydenhag, B., Tate, M., Metellus, P., Hamer,
P. W., Spena, G., Capelle, L., Mandonnet, E., Robles, S. G., Sarubbo, S.,
Martino González, J., ..., & Pallud, J. (2019). Surgical resection of cav-
ernous angioma located within eloquent brain areas: International sur-
vey of the practical management among 19 specialized centers. Seizure:
The Journal of the British Epilepsy Association,69, 31–40.
Additional supporting information may be found in the online version
of the article at the publisher’s website.
How to cite this article: Rauschenbach, L., Bartsch, P., Santos,
A. N., Lenkeit, A., Darkwah Oppong, M., Wrede, K. H., Jabbarli,
R., Chmielewski, W. X., Schmidt, B., Quesada, C. M., Forsting,
M., Sure, U., & Dammann, P. (2022). Quality of life and mood
assessment in conservatively treated cavernous
malformation-related epilepsy. Brain and Behavior, e2595.