A comparison of the clinical profile of cavernous malformations with and without associated venous malformations

OBJECTIVE

Little is known about the clinical behavior of cavernous malformations (CMs) associated with venous malformations (VMs) of the brain. The aim of this study is to compare the clinical profile of patients harboring CMs with and without associated VMs.

METHODS

A retrospective analysis of 55 consecutive patients harboring CMs of the brain who presented to a single neurovascular team during a 4-year period was performed. Forty-two patients (76%) had CMs alone (CM group), and 13 patients (24%) had CMs associated with VMs (CM + VM group). Detailed clinical information regarding each patient was gathered. Statistical analysis was performed using Fisher's exact test for binary variables and Mann-Whitney U test for continuous variables.

RESULTS

The lesion location was infratentorial for 19 of the 70 CMs (27%) in the CM group and for 14 of the 21 CMs (67%) in the CM + VM group (P = 0.001). Familial histories of CMs were documented for 7 of the 42 patients (17%) in the CM group and none of the 13 patients in the CM + VM group. There was a female-to-male gender bias of 1.6:1 in the CM group and 3.3:1 in the CM + VM group. Sixteen of the 42 patients (38%) in the CM group and 8 of the 13 patients (62%) in the CM + VM group presented with symptomatic hemorrhage. Seizure presentation was documented in 11 of the 42 patients (26%) in the CM group and in 1 of the 13 patients (8%) in the CM + VM group. Repeated symptomatic hemorrhage was diagnosed in 4 of the 42 patients (9.5%) in the CM group and in 3 of the 13 patients (23%) in the CM + VM group. There were no apparent differences in the mean age at presentation, lesion size, or multiplicity between the two groups.

CONCLUSION

Patients with CMs associated with VMs are more likely to be female patients, have associated symptomatic hemorrhage, have lesions in the posterior fossa (statistically significant), suffer from repeated symptomatic hemorrhage, and are less likely to present with seizures or to have familial histories when compared with patients with CMs alone. The possible mechanisms for these apparent differences in clinical profile are discussed.

Hereditary cerebral cavernous angiomas: clinical and genetic features in 57 French families. Société Française de Neurochirurgie

BACKGROUND

Cavernous angiomas, which are vascular malformations mostly located in the central nervous system, may be inherited as an autosomal dominant disorder known as familial cerebral cavernoma (FCC). FCC has been studied in Hispanoamerican families, in which a strong founder effect was shown. We studied the families of 57 non-Hispanic patients with cavernous angiomas.

METHODS

All 28 neurosurgery centres in France collaborated in the study. Inclusion criteria were: families of index patients known to have at least one clinically affected relative, and families of index patients with multiple cavernous angiomas who initially presented as sporadic cases. Clinical and cerebral magnetic resonance imaging (MRI) investigations were done in all patients and in other at-risk individuals who consented to take part.

FINDINGS

On MRI, 16 of 22 sporadic index patients had relatives with cavernous angiomas. 51 multiple-case families, including 100 patients with symptoms and 164 symptom-free individuals had MRI lesions. Most FCC patients had multiple lesions and there was a strong correlation between number of lesions and age (p<0.01). The sensitivity of gradient-echo sequences was higher than that of standard MRI for detection of small cavernous angiomas. Pattern of inheritance was autosomal dominant, with incomplete clinical penetrance. The occurrence of de-novo mutations was strongly suggested in some families.

INTERPRETATION

Neuroimaging penetrance of FCC is much higher than clinical penetrance. 75% of sporadic cases with multiple lesions are in fact familial cases. The proportion of patients developing clinical symptoms is higher in the hereditary form than in the sporadic form of the disorder.

Anticipation in familial cavernous angioma: ascertainment bias or genetic cause

OBJECTIVES

Anticipation has been linked to unstable trinucleotide repeats in many neurological disorders. We examined the hypothesis of genetic anticipation in familial cavernous angioma (FCA) of the central nervous system.

MATERIAL AND METHODS

The mean ASO of affected individuals was compared between successive generations in 55 families. Intergenerational pair-wise comparisons were employed to avoid several ascertainment biases. Regarding severity of disease both type of manifestation and number of cavernous angiomas were compared between generations.

RESULTS

The mean ASO decreased significantly both from the first to the second generation (31.6 vs 17.8 years; P = 0.000) and from the second to the third generation (17.8 vs 6.7 years; P = 0.002). The pair-wise comparisons also showed significantly earlier ASO. No clear evidence for anticipation with regard to severity of disease was found.

CONCLUSIONS

Molecular genetic studies will determine whether trinucleotide repeats are the underlying mechanism for our observation of anticipation in FCA.

[Familial cerebral cavernomatosis associated with cutaneous angiomas]

OBJECTIVE, PATIENTS AND METHOD: We present a genealogical study of a person with familial cerebral cavernomatosis (CCF) discovered following study of a man who presented with status epilepticus at the age of 35 years. This had also affected another three members of the family consisting of a total of 43 persons, studied over six generations.

RESULTS

In the family members studied we did not find cavernomas at other sites but there were dermatological lesions whose relation to cerebral cavernomas (CC) is discussed. CCs are the second commonest type of cerebral vascular malformations. Their major clinical features are epilepsy and cerebral haemorrhage. There are two forms of CC: a sporadic form with single lesions and a familial form with multiple lesions. Although the condition has been recognized since 1854, very little is known about it. Recently a gene causing the familial form has been found on chromasome 7.

CONCLUSIONS

We discuss the clinical findings in this family with relation to descriptions in the literature. We emphasize the importance of MR in diagnosis of the condition and for detection of asumptomatic carriers. We consider a possible relationship between these findings and genes which have been mapped, and in view of recent genetic data, the hypothesis of a possible Spanish ancestor with the condition.

Familial cavernous angiomas masquerading as multiple sclerosis

We report here two cases of cavernous angioma, in the proband and her father, with quite different clinical presentations. The proband presented with a brainstem syndrome, mimicking multiple sclerosis, while the father had a history of mild epilepsy. Both patients were managed conservatively. The cases also demonstrate the utility of magnetic resonance imaging in the diagnosis of cavernous angioma.

[Familial giant hemangiomas of the liver. Study of a family and review of the literature]

In this report we present for the first time strong evidence for autosomal-dominant inheritance of grant liver hemangiomas. Furthermore, we review the current literature about incidence, pathogenesis, clinics, as well as diagnostic and therapeutic aspects of LH. A large family of Italian origin is described where three female patients in three successive generations suffered from large symptomatic LH. In addition, two other female relatives exhibited asymptomatic LH on sonographic scans. The restriction of the disease to the female gender could be explained by a sex-dependent difference in penetrance or expressivity of a presumable "liver-hemangioma" gene, or by known proliferative factors such as female sex hormones. We also observed an increased incidence of adenomas of the thyroidea among members with or without LH of the presented family. This uncommon familial association has also not yet been described and its genetic aspects are discussed.

[Familial clustering of cerebrovascular anomalies]

The authors report mother and her daughter affected with intracranial aneurysm and arteriovenous malformation. The anomalies of cerebral vascular system, as intracranial aneurysms, cavernous hemangiomas and arteriovenous malformations are considered to originate from congenital maldevelopments of the brain vessels. The importance of the early diagnosis in the familial cases and the prevention due to surgery and genetic counselling are stressed.

Independent segregation of von Hippel-Lindau disease and cerebral cavernomas

A probable diagnosis of von Hippel-Lindau disease was made in a two generation family in which the proband had a phaeochromocytoma, renal cysts, and multiple cerebral cavernomas. His sister had multiple similar cerebral vascular lesions and his father died from renal carcinoma aged 42. Although the family did not satisfy the conventional diagnostic criteria for von Hippel-Lindau disease, an underlying germline mutation in the von Hippel-Lindau disease tumour suppressor gene was identified in the proband. Molecular genetic analysis not only confirmed the putative diagnosis of the disease in the proband but also showed that the cerebral vascular lesions segregated independently from the von Hippel-Lindau disease mutation. This report exemplifies how molecular genetic investigations can enhance the diagnosis and management of families with suspected von Hippel-Lindau disease, particularly when the manifestations, as in this family, are not typical.

[Cerebral cavernomas--clinical aspects and therapy]

Cavernomas are congenital cerebrovascular hamartomas which occur sporadic or familial. They are comprised of multiple sinusoidal spaces, filled with blood, without enlarged arterial feeders and draining veins. They occur in an estimated 0.4 to 0.5% of the population, with male and female patients equally affected and all ages represented. Lesions are singular or multiple (up to 20%) in the same patient and occur all over the central nervous system. Clinical representation is characterized by cross intracranial hemorrhage, seizures and focal neurological deficits. Unspecific symptoms, like headaches, vertigo and tinnitus were present in 25 to 30% of the patients. Asymptomatic cavernomas could be detected in up to 20% of the cases. The natural course revealed an annual risk of bleeding (0.6%) and a risk of developing epilepsy (1.5%). Microsurgical resection of a symptomatic lesion is the first choice of treatment. There is no mortality and the morbidity after resection of superficial cavernomas is below 5%. Deep seated cavernomas revealed a higher risk of postoperative neurological deficit. Therefore indication of operative removal in deep seated cavernomas should be carefully weighted up to the risk of natural course and generally neurological and radiological control is favoured. Radiosurgery is only indicated in progressively symptomatic cases which are surgical inaccessible.

Early fatal rebleeding from a cerebellar cavernous malformation--case report

A 25-year-old female patient presented with hemorrhage from a cerebellar cavernous malformation manifesting as headache and vomiting. She died of massive rebleeding within 1 week of the previous hemorrhage. The natural history of cavernous malformations was considered relatively benign, with significant hemorrhage being uncommon. The present case suggests that emergency surgery should be performed for patients with unstable clinical conditions and/or those with a significant mass effect in the cerebellum or the brainstem.

[Familial multiple cavernomatosis]

We present a family study of multiple cavernomatosis which affected a boy of six, his mother and two brothers. It was seen clinically as epileptic crises, focal neurological defects and frequent headaches. In our case, the condition started as a syndrome of intracranial hypertension with progressive headache and vomiting. During the illness, localizing neurological signs due to bleeding were seen. Amongst these were acute left hemiparesia and paralysis of vertical gaze. Other members of the family remain symptom-free. In a search for angiomas at other sites none were found in the patient or his family. Recently the gene giving rise to the familial cerebral cavernosa malformation has been found to be a locus on chromosome 7. We discuss the findings on neuro-imaging, emphasizing the importance of magnetic resonance (MR) both in diagnosis and finding affected asymptomatic family members, because of its great sensitivity and specificity. Angiography is not a suitable technique for this since they behave as hidden malformations. We also point out its importance as a way of following-up the illness and for evaluation of possible complications due to progressive growth or sudden haemorrhage, which may indicate the need for treatment. Finally we emphasize the different characteristics of MR signals in this type of lesion since cavernomatasa malformations are dynamic lesions.

Linkage of the locus for cerebral cavernous hemangiomas to human chromosome 7q in four families of Mexican-American descent

OBJECTIVE

To determine with greater precision the map location of the locus associated with familial cavernous hemangiomas.

BACKGROUND

Cavernous malformations of the brain are a significant cause of seizures, progressive or apoplectic neurologic deficit, and headache. Prevalence estimates from autopsy series vary from 0.39 to 0.9%. This disorder (OMIM #116860) can be inherited as an autosomal dominant trait with variable penetrance. Linkage to markers on the long arm of chromosome 7 was recently reported in separate reports in three apparently unrelated Hispanic kindreds as well as in two kindreds of non-Hispanic descent.

DESIGN/METHODS

We examined clinically, by MRI scanning, and by pathologic examination of surgical specimens, members of four large Mexican-American families segregating cavernous hemangiomas of the brain. Linkage analysis was performed with use of blood specimens from morphologically proven cases. Two-point linkage analysis was performed with the MLINK program of the LINKAGE package. Multipoint analysis was performed between two markers and the disease locus with LINKMAP in the FASTLINKAGE package. Allele frequencies were set as described by the Genome Database (GDB). Maximum penetrance for the disease allele was set to 0.75.

RESULTS

The highest lod score was observed for marker D7S652 with Zmax = 6.66 at theta(max) = 0.00. Multipoint LOD score analysis placed the disease locus in the 11 cM interval between markers D7S630 and D7S527 with Zmax = 9.19. Haplotype analysis is in agreement with the placement of the disease gene between D7S630 and D7S527 and further shows a minimal shared region within this interval, indicating a founder effect in the establishment of the mutation in these families.

CONCLUSIONS

We confirmed the linkage of cavernous hemangioma to markers on the long arm of chromosome 7q, and the estimate of the map location has been refined to a region of shared haplotype between markers D7S630 and D7S527 in four Mexican-American families who may be descended from a common ancestor in Sonora County, Mexico.

[Familial cavernous angioma. Report in 3 generations]

Cavernous angioma is a vascular malformation that affect 0.5 to 0.7% of the population making up 8 to 15% of cerebrovascular malformations. It is the second vascular malformation in frequency of the central nervous system, supplanted only by classic arteriovenous malformation. It may occur in two forms: a sporadic form characterized by isolated lesions: and a familial form characterized by multiple lesions with an autosomal dominant mode of inheritance with high penetrance and varied expressivity in the proportion M1:F1. Symptoms related to cavernous angioma are seizures, headache or progressive neurologic deficit. The authors present a Chinese family with familial cavernous angioma. Manifestations of the disease occurred in three generations affecting only females. Clinical, neuroimage, pathological, natural course and genetical aspects of the disease are discussed.

[Familial cerebral cavernous angiomatosis]

Two patient with familial cavernous angiomatosis presenting with long lasting variable epilepsy with a poor therapeutic response and variable neurologic impairments are presented here. One of the numerous cavernous angiomas was resected in one case. This last patient remains asymptomatic. Familial cerebral cavernous angiomas are often numerous and disseminated in the brain, therefore clinical manifestations are very polymorphous. Moreover the course of these lesions is variable. Therefore MRI should be performed to every patient presenting with poorly understood neurological symptoms, focal or generalized epileptic seizures or absence in order to look for potentially imputable brain lesions. A reliable genetic marker might be helpful for diagnosis of this disease with a variable penetrance and autosomal dominant inheritance. Then a neurosurgical treatment should be carefully discussed if lesions are accessible and medications are poorly efficient with recurrent neurologic impairments or epilepsy.

Hereditary neurocutaneous angiomatosis. Report of four cases

The authors report the coexistence of vascular nevi (hemangiomas and arteriovenous malformations (AVMs) of the skin) with AVMs and venous malformations of the brain in male siblings from two related but nonconsanguineous families of three generations. The proband, his siblings, parents, aunts, uncles, and cousins were examined, underwent magnetic resonance (MR) imaging and MR angiography, and when appropriate, cerebral angiography. A father had vascular nevi and a mother, his sister, had an azygos anterior cerebral artery. No other cutaneous or cerebrovascular malformations were present in the parents. Each of the two families had two boys and one girl, 9 to 18 years of age. All the children had vascular nevi and all of the boys had coexisting cerebrovascular malformations: AVMs in three, and a venous malformation in another. One boy had three cerebral AVMs. Two boys had a cerebral hemorrhage, and one also had focal motor seizures. The skin lesions were not those of the Sturge-Weber-Dimitri, Rendu-Osler-Weber, or Wybum-Mason syndromes. The association of cutaneous and cerebrovascular malformations was seen only in males in these families. but females have also been reported in the literature. The results obtained in these families and three other families reported from Western and Central Europe indicate that the association of cerebral and cutaneous vascular hamartomas constitutes a distinct, hereditary clinicopathological entity with autosomal dominant inheritance and variable penetrance. The clinical manifestations of this syndrome are visible, painful vascular nevi, epilepsy, cerebral hemorrhage, and focal neurological deficits. The preponderance of male patients with the full expression of the syndrome suggests a possible hormonal influence on the expression of the gene.

[Familial multiple cavernous angioma in the brain and spinal cord]

We reported two patients from the same family underwent operation for neurological symptoms due to vascular lesions that were proved on pathological examination to be cavernous angiomas. Case 1, a 64-year-old woman was admitted to our hospital because of paraparesis. MRI revealed a mass lesion with high signal intensity in T1 and T2 weighted images at T3-4 level. Complete excision was carried out and diagnosis of cavernous angioma was made. Three years later, she experienced a mild headache and dizziness. CT scan demonstrated a subcortical hematoma in the right frontal lobe. Postoperative pathological diagnosis was cavernous angioma. Case 2, a 65-year-old woman (younger sister of case 1) was operated for the tumor of spinal cord, and diagnosed as a cavernous angioma. Two years later, she developed diplopia and ataxic gait. MRI showed multiple cavernous angioma in the brain including pons. Pontine lesion which was responsible for this episode was removed, and diagnosis was a cavernous angioma histopathologically.

Familial presumed cerebral cavernous angiomas diagnosed by MRI: three generations

Familial cerebral cavernous angiomas are rare, with an autosomal dominant pattern of inheritance. To our knowledge, 25 families with this disorder have been described. We report three family members in a direct line of descent, who all brain had lesions typical of cavernous angiomas on MRI.

De novo familial cavernous malformation presenting with hemorrhage 12.5 years after the initial hemorrhagic Ictus: natural history of an infantile form

Cerebral cavernous malformations are congenital, non-neoplastic lesions, but they are known for their potential for growth. De novo lesion genesis is exceptional and occurs more commonly with the familial form of the disease. We report the case of a 13-year-old Caucasian boy with a positive family history, who underwent surgery for a left parietal hemorrhage during the 1st year of life and who recently presented with a new hemorrhage in the left temporal lobe quite distant from the previous hematoma bed. Both hemorrhages were caused by cavernous malformations. Sequential magnetic resonance scans prior to the recent presentation failed to disclose the growth of the new lesion. We reviewed the literature for mechanisms of new lesion formation.

Familial cavernous hemangioma with atypical neuroimaging

Three members of the same family were studied, all of whom had multiple intracerebral cavernous angiomas for which a dominant autosomal inheritance was hypothesised. The proband suffered from headaches, and physical examination revealed evident right hemiparesis. The second case started with a hemorrhagic cerebral stroke and the third was asymptomatic on neurological examination. Nuclear magnetic resonance (NMR), performed in two of the three cases, showed lesions whose number and extent were not radiologically characteristic of cavernous angioma. A cerebral biopsy of the proband enabled the diagnosis to be made. Despite the recent introduction of NMR, the nosological classification of familial forms can be difficult when the radiological lesions are atypical. In such cases, cerebral biopsy is not only a valid diagnostic aid, but is also indispensable for obtaining adequate genetic information.

Familial cerebral cavernous angioma: a gene localized to a 15-cM interval on chromosome 7q

Cerebral cavernous angiomas are collections of closely clustered vessels without intervening normal brain parenchyma, with microscopic evidence of hemorrhage, frequently multiple; they are best visualized with magnetic resonance imaging. Familial cerebral cavernous angioma occurs as an autosomal dominant disorder, although carriers of the gene are often asymptomatic. Recently, a gene responsible for familial cerebral cavernous angioma in a large Hispanic kindred was mapped to human chromosome 7q11-22, representing a large segment of DNA containing approximately 33 cM (about 33 million base pairs). This distance did not allow more restricted isolation of the region containing the familial cerebral cavernous angioma gene. In this report, we present a large white kindred with familial cerebral cavernous angioma and confirm the mapping to 7q11-22, including the genetic markers D7S558/D7S1789 and D7S804. Recombination between several markers in the region suggests that the candidate region is distal to D7S804. Combining our results with those previously published, we suggest that the gene is likely to reside within a 15-cM region bounded by markers D7S660 and D7S558/D7S1789. These results should assist the further refinement of the candidate region for familial cerebral cavernous angioma and facilitate the search for the gene.

Genetic heterogeneity of inherited cerebral cavernous malformation

OBJECTIVE

Cerebral cavernous malformation (CCM) is frequently an inherited disorder showing autosomal dominant transmission. Genetic analysis has localized a gene causing CCM to a segment of the long arm of human chromosome 7 (7q). This evidence derives from investigation of a small number of families, mostly of Hispanic American descent. In this study, we have tested whether inherited CCM is always due to mutation in this 7q gene, or whether mutation in other genes can cause CCM.

METHODS

We have studied subjects from two non-Hispanic families with inherited CCM. The clinical features of CCM in these families are indistinguishable from those in kindreds in which CCM is due to mutation in the 7q gene. To test whether CCM in these kindreds is caused by a mutation on 7q, we compared the inheritance of CCM to the inheritance of genetic markers on 7q.

RESULTS

Genetic analysis demonstrates independent inheritance of CCM and markers on 7q in both families studied. This evidence excludes mutation in the 7q gene as the cause of CCM in these families, with odds against CCM being due to mutation in 7q in each family of more than 100,000:1 and 100:1, respectively.

CONCLUSION

These findings demonstrate that inherited CCM is not always caused by a mutant gene on 7q, indicating the presence of at least a second gene in which mutation can cause CCM. These results have implications for genetic testing and the pathogenesis of this disorder.

A founder mutation as a cause of cerebral cavernous malformation in Hispanic Americans

BACKGROUND

Cerebral cavernous malformation is a vascular disease of the brain causing headaches, seizures, and cerebral hemorrhage. Familial and sporadic cases are recognized, and a gene causing familial disease has been mapped to chromosome 7. Hispanic Americans have a higher prevalence of cavernous malformation than do other ethnic groups, raising the possibility that affected persons in this population have inherited the same mutation from a common ancestor.

METHODS

We compared the segregation of genetic markers and clinical cases of cavernous malformation in Hispanic-American kindreds with familial disease; we also compared the alleles for markers linked to cavernous malformation in patients with familial and sporadic cases.

RESULTS

All kindreds with familial disease showed linkage of cavernous malformation to a short segment of chromosome 7 (odds supporting linkage, 4X10(10).1). Forty-seven affected members of 14 kindreds shared identical alleles for up to 15 markers linked to the cavernous-malformation gene, demonstrating that they had inherited the same mutation from a common ancestor. Ten patients with sporadic cases also shared these same alleles, indicating that they too had inherited the same mutation. Thirty-three asymptomatic carriers of the disease gene were identified, demonstrating the variability and age dependence of the development of symptoms and explaining the appearance of apparently sporadic cases.

CONCLUSIONS

Virtually all cases of familial and sporadic cavernous malformation among Hispanic Americans of Mexican descent are due to the inheritance of the same mutation from a common ancestor.

[Familial occurrence of intracerebral cavernous angioma: report of cases in brothers]

Familial occurrence of intracerebral cavernous angioma has been rarely reported. We report two histologically verified cases of cavernous angioma among brothers and review relevant cases in the literature. Case 1 is that of a 3-year-old boy who suffered front acute onset of headache, vomiting, and tonic-clonic type seizure. CT revealed a well-demarcated tumor with partial hemorrhage in the left frontal lobe which was strongly enhanced with contrast Medium. Complete excision was carried out and the patient had a satisfactory clinical course and was able to be followed up for 13 years after the Surgery. Case 2 is that of a 17-year-old boy who was the elder brother of case 1 and presented with gradually increasing episodes of a psychomotor seizure which started at the age of 16. CT and MRI revealed a well-demarcated tumor in the left subcortical temporal lobe and an asymptomatic small calcified lesion in the left subcortical parietal lobe. The temporal tumor was totally excised and histologically diagnosed as cavernous angioma. The seizures gradually decreased and eventually disappeared one year after the surgery. This report reviews 13 previously reported cases, and surgical indication for asymptomatic cases.

Refined localization of the cerebral cavernous malformation gene (CCM1) to a 4-cM interval of chromosome 7q contained in a well-defined YAC contig

Cerebral cavernous malformations (CCM) are vascular lesions present in some 20 million people worldwide that are responsible for seizures, migraine, hemorrhage, and other neurologic problems. Familial cases ofCCM can be inherited as an autosomal dominant disorder with variable expression. A gene for CCM (CCM/)was recently mapped to a 33-cM segment of chromosome 7q in a large Hispanic family (Dubovsky et al.1995). Here, the collection of several new short tandem repeat polymorphisms (STRPs) within the region of interest on 7q and the refinement of the marker order in this region using both linkage analysis in CEPH families and especially YAC-based STS content mapping are described. Affected members of three Hispanic families share allele haplotypes indicating a common ancestral mutation within these families. Using the shared haplotype information along with analysis of crossovers in affected individuals from both the Hispanic and Caucasian families, the region likely to contain the CCMI gene has been reduced to a 4-cM segment of 7q between D7S2410 and D7S689. All markers within the refined chromosomal segment were located on a single YAC contig estimated to be approximately 2 Mb in size. Four potential candidate genes have been mapped to this region.

A locus for cerebral cavernous malformations maps to chromosome 7q in two families

Cavernous malformations (angiomas) affecting the central nervous system and retina can be inherited in autosomal dominant pattern (OMIM 116860). These vascular lesions may remain clinically silent or lead to a number of neurological symptoms including seizure, intracranial hemorrhage, focal neurological deficit, and migraine. We have mapped a gene for this disorder in two families, one of Italian-American origin and one of Mexican-American origin, to markers on proximal 7q, with a combined maximum lod score of 3.92 (theta of zero) with marker D7S479. Haplotype analysis of these families places the locus between markers D7S502 proximally and D7S515 distally, an interval of approximately 41 cM. The location distinguishes this disorder from an autosomal dominant vascular malformation syndrome where lesions are primarily cutaneous and that maps to 9p21.

Mapping a gene causing cerebral cavernous malformation to 7q11.2-q21

Cerebral cavernous malformation is a common disease of the brain vasculature of unknown cause characterized by dilated thin-walled sinusoidal vessels (caverns); these lesions cause varying clinical presentations which include headache, seizure, and hemorrhagic stroke. This disorder is frequently familial, with autosomal dominant inheritance. Using a general linkage approach in two extended cavernous malformation kindreds, we have identified linkage of this trait to chromosome 7q11.2-q21. Multipoint linkage analysis yields a peak logarithm of odds (lod) score of 6.88 with zero recombination with locus D7S669 and localizes the gene to a 7-cM region in the interval between loci ELN and D7S802.

Familial cerebral cavernous angioma: clinical analysis of a family and phenotypic classification

Only a few large families with cerebral cavernous angiomas (CCA) have been reported. We studied 47 members of a four-generation kindred with familial CCA. Thirteen members are affected; of these, eleven (85%) have epilepsy, five (38%) have hearing loss, three (23%) have clinically significant cerebral hemorrhages, one has dementia and progressive pseudobulbar palsy, one has a compressive myelopathy, one has asymptomatic cerebral cavernous angiomas identified by MRI, and another has an adrenal angioma found at autopsy. We developed a phenotypic classification to be used in future gene mapping studies. This classification is based on clinical symptoms, age at onset, concurrent diagnoses, and magnetic resonance imaging (MRI) findings. In the context of this family, this system assigns each member a probability of affectedness that can be used for linkage analysis. We suggest that patients with epilepsy may experience transient poor seizure control due to bleeding from an angioma, and drugs that may induce bleeding from the angiomas, such as valproic acid, should be avoided.

Familial cerebral cavernous angiomas: clinical and radiologic studies

Cavernous angiomas are well-circumscribed cerebrovascular malformations whose natural history is poorly understood. We reviewed 5,000 cranial MRI reports of studies performed between 1986 and 1993 and retrospectively evaluated the histories and imaging studies of 29 patients whose lesions were suggestive of cavernous angiomas. Patients ranged from 3 to 66 years and 27 were of Hispanic origin. The number of malformations per patient ranged from one to 30, and 24 patients had more than one lesion. In our series, the number of lesions per patient increased at a rate of one lesion per decade of age, but the mean size of the lesions was smaller with advancing decade (p < 0.05). All patients had MRI evidence of old or recent hemorrhage confined only to the malformation and adjacent brain. In only one patient was it deemed necessary to remove the malformation. Two excluded patients with typical lesions on MRI had small arteriovenous malformations found at surgery. Thus, MRI or CT cannot identify cavernous angiomas with certainty. This study supports studies that propose that cavernous angioma-like lesions, as identified by MRI or CT, are more common in Hispanics. It is possible that patients may not be born with MRI-identifiable malformations, but with advancing age the malformations become MRI-visible through malformation growth, hemorrhage, or both. The declining size by decade favors hemorrhage rather than growth. Cavernous angiomas may be more benign than previously thought.

A gene responsible for cavernous malformations of the brain maps to chromosome 7q

Cavernous malformations of the brain are vascular lesions which are present in up to 0.4% of all individuals and which are often accompanied by seizures, migraine, hemorrhage and other neurologic problems. Using linkage analysis and a set of short tandem repeat polymorphisms, a gene responsible for cavernous malformations in a large Hispanic kindred was mapped to the q11-q22 region of chromosome 7. A maximum pairwise lod score of 4.2 was obtained at zero recombination with marker PY5-18 at locus D7S804. Lod scores in excess of 3.0 were obtained with four additional markers closely linked to PY5-18. A broad chromosome 7q haplotype of 33 cM length on the sex average map was shared by all affected individuals indicating that the gene lies between loci D7S502 and D7S479.

Multiple familial cavernous malformations evaluated over three generations with MR

MR imaging was used to determine the presence or absence of cavernous malformations in three generations of family members. The presenting child (proband) had sustained a symptomatic hemorrhage. Multiple malformations were identified in his father, in an older sibling, and in an asymptomatic grandfather. The father's brother had died from cavernous malformation-related intracerebral hemorrhage. Increasing numbers of malformations were found with increasing patient age, suggesting that MR-apparent lesions may grow in number as a result of repetitive small hemorrhages over time.

Gonadal mixed germ cell tumor combined with a large hemangiomatous lesion in a patient with Turner's syndrome and 45,X/46,X, +mar karyotype

In this report, we describe bilateral gonadal tumors with characteristic histopathological findings in a patient with Turner's syndrome who had 45,X/46,X, +mar mosaicism. The left gonad contained a gonadoblastoma and a remnant of streak gonad. The right gonad was entirely replaced by a 15x11x7-cm solid and cystic tumor, which was revealed to be a combination of a mixed germ cell tumor and a cavernous hemangiomatous lesion. The latter occupied approximately half of the entire tumor volume, and there was an incomplete boundary between it and the mixed germ cell tumor lesion. To our knowledge, this is the first reported case of Turner's syndrome with a combination of a mixed germ cell tumor and a hemangiomatous lesion in the gonad.

Familial cerebral, hepatic, and retinal cavernous angiomas: a new syndrome

New, non-invasive neuroradiological techniques [computed tomography (CT) and magnetic resonance (MR)] have led to reassessment of the incidence of cavernous angioma of the brain (CCA), which is sometimes multiple and associated with cavernomas in other organs. CCA is known to be familial, with dominant autosomal transmission. This paper concerns a family with multiple CCA, sometimes in association with liver angiomas, in ten members belonging to four different generations. These malformations can vary in clinical expression: no neurological symptoms have been detected in subjects from the first or second generations, but they were found in adult age in subjects from the third generation; two fourth-generation patients came under our observation at 2.5 years of age. Symptoms include partial epileptic fits, which sometimes become generalized later and which are generally controlled adequately by therapy. Patients also present paresthesia and occasional motor deficiencies corresponding to CCA bleeding episodes; these symptoms have always abated with medical treatment alone. None of the patients are mentally retarded or restricted in their daily lives. Neuroradiological investigations (CT, MR, angiography) reveal typical multiple brain lesions in all patients. Given the first-generation patient's clinical history of symptomatic hepatomegaly and the postmortem finding of multiple liver and brain cavernomas, liver ultrasonography was performed on all members of the family. Liver angioma was detected in two subjects from the second and third generations. Retinal angioma was detected in one patient with quadrantanopsia.(ABSTRACT TRUNCATED AT 250 WORDS)

The natural history of familial cavernous malformations: results of an ongoing study

Cavernous malformations are congenital abnormalities of the cerebral vessels that affect 0.5% to 0.7% of the population. They occur in two forms: a sporadic form characterized by isolated lesions, and a familial form characterized by multiple lesions with an autosomal dominant mode of inheritance. The management of patients with cavernous malformations, particularly those with the familial form of the disease, remains a challenge because little is known regarding the natural history. The authors report the results of an ongoing study in which six families afflicted by familial cavernous malformations have been prospectively followed with serial interviews, physical examinations, and magnetic resonance (MR) imaging at 6- to 12-month intervals. A total of 59 members of these six families were screened for protocol enrollment; 31 (53%) had MR evidence of familial cavernous malformations. Nineteen (61%) of these 31 patients were symptomatic, with seizures in 12 (39%), recurrent headaches in 16 (52%), focal sensory/motor deficits in three (10%), and visual field deficits in two (6%). Twenty-one of these 31 patients underwent at least two serial clinical and MR imaging examinations. A total of 128 individual cavernous malformations (mean 6.5 +/- 3.8 lesions/patient) were identified and followed radiographically. During a mean follow-up period of 2.2 years (range 1 to 5.5 years), serial MR images demonstrated 17 new lesions in six (29%) of the 21 patients; 13 lesions (10%) showed changes in signal characteristics, and five lesions (3.9%) changed significantly in size. The incidence of symptomatic hemorrhage was 1.1% per lesion per year. The results of this study demonstrate that the familial form of cavernous malformations is a dynamic disease; serial MR images revealed changes in the number, size, and imaging characteristics of lesions consistent with acute or resolving hemorrhage. It is believed that the de novo development of new lesions in this disease has not been previously reported. These findings suggest that patients with familial cavernous malformations require careful follow-up monitoring, and that significant changes in neurological symptoms warrant repeat MR imaging. Surgery should be considered only for lesions that produce repetitive or progressive symptoms. Prophylactic resection of asymptomatic lesions does not appear to be indicated.

Cavernous angiomatosis of the central nervous system: usefulness of screening the family

A 23-year-old woman presented with cerebellar hemorrhage from a cavernous angioma (CA). A history of spinal hemorrhage and a supratentorial calcified lesion on CT and MRI suggested cavernous angiomatosis of the CNS. Familial investigation in 20 relatives revealed 4 additional patients with symptomatic CA and one person with asymptomatic CA. In the symptomatic patients, CA had not been recognized as the cause of their neurologic symptoms prior to our investigation. The number of CA lesions in asymptomatic relatives was low. This study shows that, when a patient with cavernous angiomatosis of the CNS is encountered, systematic clinical and MRI investigations in other family members with a history or symptoms of neurologic disorder should be carried out.

Oculomotor nerve cavernous angioma in a patient with Roberts syndrome

A 25-year-old man with Roberts Syndrome (SC-phocomyelia) is described who presented with an acute onset of a complete right third nerve palsy. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated an enhancing lesion in the region of the right third nerve with bony erosion of the posterior clinoid process. At exploration, the lesion proved to be a cavernous angioma arising from the substance of the third nerve. Three other cases of third nerve cavernous angioma have been reported. One of these lesions also occurred in a patient with this unusual genetic syndrome. The surgical management and possible role of the genetic defect in the pathogenesis of this lesion are discussed.

Aicardi syndrome, metastatic angiosarcoma of the leg, and scalp lipoma

An infant girl with Aicardi syndrome, scalp lipomas, and angiosarcoma of a limb is reported. The cavernous hemangioma of the leg was benign when biopsied at age 5 months but became malignant at 11 months. Angiosarcoma caused multiple distant metastases which were evident at autopsy at age 19 months. This is the first case of Aicardi syndrome associated with lipoma and metastatic angiosarcoma.

Familial cavernous angiomas of the brain: observations in a four generation family

A family with a history of cavernous angiomas of the brain was investigated by MRI. The disease was present in four generations of the family and is consistent with autosomal dominant inheritance. Among affected individuals, there was considerable variability in the extent of intraparenchymal cavernomas and neurological symptoms as a result of bleeding events. Three siblings manifested with seizures, two affected persons were symptom free at the time of investigation, and one sibling had neurological symptoms without certain correlation with cavernomas. The disease appeared to have an earlier onset in younger generations.

[Familial cavernous angioma of the central nervous system--report of a family and review of literature]

In this paper we reported a familially occurred cavernous angiomas (CA) of the central nervous system (CNS). Case 1 was a 14-year-old female with an initial symptom of transient motor and sensory disorders of the right upper extremity. On examination she had a cutaneous angioma and no neurological deficit. CT and MRI revealed two lesions in the brain. These lesions were removed surgically and were diagnosed histologically as CA. Case 2 was a 45-year-old female, the mother of case 1, with a long standing headache. She had a cutaneous angioma and no neurological deficit. CT and MRI revealed a CA in the brain and a one in the cervical cord. Case 3 was an 11-year-old female, the cousin of case 1, with an initial symptom of left hemiparesis. On examination, she had a cutaneous angioma and left hemiparesis. CT revealed two lesions in the brain. These lesions were removed surgically and were diagnosed histologically as CA. Familial CA of the CNS is relatively rare and the reported cases were 24 families consisted of 70 cases. We analyzed the reported cases to clarify the specificities of the familial cases. In the familial cases, CAs were apt to be multiple and were located more frequently in the posterior fossa than in the non-familial cases. In some familial cases, the vascular anomalies of the CNS other than CA or CA of the skin or retina were also revealed. Because of high incidence (89%) of the hemorrhage from the histologically verified CA, operation should be carried out even in the cases of CA with mild or no symptom, if the lesion is accessible surgically.

Terminal transverse limb defects associated with familial cavernous angiomatosis

Terminal transverse limb defects rarely are reported as familial. Multiple pathogenetic mechanisms, including vascular disruption, have been proposed to account for these defects. We report on a family followed over the past 6 years known to have familial cavernous angiomatosis in which 2 relatives have similar terminal transverse defects at the mid-forearm. Multiple relatives have had episodic bleeding from intracranial cavernous angiomas, a distinct finding in this disorder. Other findings in this family include retinal cavernous angiomas (2 patients), a high incidence of skin angiomas (12 patients), cavernous angiomas of the soft tissue (2 patients), and a hepatic angioma (one patient). One of the 2 individuals with the limb defect was evaluated extensively. Magnetic resonance imaging of the forearm with the terminal transverse defect using gadolinium-DTPA enhancement showed abrupt termination of all structures distal to the normal radial and ulnar heads. We propose that familial cavernous angiomatosis may be a new cause of vascular disruption resulting in terminal transverse limb defects.

A family with hereditary intracerebral cavernous angiomas

There are a very few reports in literature of inherited intracerebral cavernous angiomas. The majority of them are Mexican-American families. In some of the reported families autosomal dominant transmission is suggested. We report a family in which three members of three consecutive generations were proven to have multiple intracerebral cavernous malformations, without involvement of skin, eyes, or other viscera. An autosomal dominant mode of inheritance is clearly suggested.