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Beslow LA, Krings T, Kim H, Hetts SW, Lawton MT, Ratjen F, Whitehead KJ, Gossage JR, McCulloch CE, Clancy M, Bagheri N, Faughnan ME. De Novo Brain Vascular Malformations in Hereditary Hemorrhagic Telangiectasia. Pediatr Neurol 2024; 155:120-125. [PMID: 38631080 PMCID: PMC11102835 DOI: 10.1016/j.pediatrneurol.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/26/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Approximately 10% of people with hereditary hemorrhagic telangiectasia (HHT) have brain vascular malformations (VMs). Few reports describe de novo brain VM formation. International HHT Guidelines recommend initial brain VM screening upon HHT diagnosis in children but do not address rescreening. We aimed to confirm whether brain VMs can form de novo in patients with HHT. METHODS The Brain Vascular Malformation Consortium HHT project is a 17-center longitudinal study enrolling patients since 2010. We analyzed the database for de novo VMs defined as those detected (1) on follow-up neuroimaging in a patient without previous brain VMs or (2) in a location distinct from previously identified brain VMs and reported those in whom a de novo VM could be confirmed on central neuroimaging review. RESULTS Of 1909 patients enrolled, 409 (21%) had brain VMs. Seven patients were recorded as having de novo brain VMs, and imaging was available for central review in four. We confirmed that three (0.7% of individuals with brain VMs) had de novo brain VMs (two capillary malformations, one brain arteriovenous malformation) with intervals of six, nine, and 13 years from initial imaging. Two with de novo brain VMs were <18 years. The fourth patient, a child, did not have a de novo brain VM but had a radiologically confirmed increase in size of an existing brain arteriovenous malformation. CONCLUSIONS Brain VMs can, albeit rarely, form de novo in patients with HHT. Given the potential risk of hemorrhage from brain VMs, regular rescreening in patients with HHT may be warranted.
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Affiliation(s)
- Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Helen Kim
- Department of Anesthesia, University of California - San Francisco, San Francisco, California
| | - Steven W Hetts
- Division of Neurointerventional Radiology, University of California - San Francisco, San Francisco, California
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Felix Ratjen
- Department of Paediatrics, Division of Paediatric Respiratory Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Kevin J Whitehead
- Departments of Internal Medicine and Pediatrics, The University of Utah, Salt Lake City, Utah
| | - James R Gossage
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California - San Francisco, San Francisco, California
| | | | - Negar Bagheri
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
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Beslow LA, White AJ, Krings T, Hammill AM, Lang SS, Baba A, Clancy MS, Olitsky SE, Hetts SW. Current Practice: Rationale for Screening Children with Hereditary Hemorrhagic Telangiectasia for Brain Vascular Malformations. AJNR Am J Neuroradiol 2024:ajnr.A8195. [PMID: 38816017 DOI: 10.3174/ajnr.a8195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/08/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia is an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectasias, recurrent epistaxis, and organ vascular malformations including in the brain, which occur in about 10% of patients. These brain vascular malformations include high-flow AVMs and AVFs as well as low-flow capillary malformations. High-flow lesions can rupture, causing neurologic morbidity and mortality. STATE OF PRACTICE International guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia recommend screening children for brain vascular malformations with contrast enhanced MR imaging at hereditary hemorrhagic telangiectasia diagnosis. Screening has not been uniformly adopted by some practitioners who contend that screening is not justified. Arguments against screening include application of short-term data from the adult A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial of unruptured sporadic brain AVMs to children with hereditary hemorrhagic telangiectasia as well as concerns about administration of sedation or IV contrast and causing patients or families increased anxiety. ANALYSIS In this article, a multidisciplinary group of experts on hereditary hemorrhagic telangiectasia reviewed data that support screening guidelines and counter arguments against screening. Children with hereditary hemorrhagic telangiectasia have a preponderance of high-flow lesions including AVFs, which have the highest rupture risk. The rupture risk among children is estimated at about 0.7% per lesion per year and is additive across lesions and during a lifetime. ARUBA, an adult clinical trial of expectant medical management versus treatment of unruptured brain AVMs, favored medical management at 5 years but is not applicable to pediatric patients with hereditary hemorrhagic telangiectasia given the life expectancy of a child. Additionally, interventional, radiosurgical, and surgical techniques have improved with time. Experienced neurovascular experts can prospectively determine the best treatment for each child on the basis of local resources. The "watch and wait" approach to imaging means that children with brain vascular malformations will not be identified until a potentially life-threatening and deficit-producing intracerebral hemorrhage occurs. This expert group does not deem this to be an acceptable trade-off.
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Affiliation(s)
- Lauren A Beslow
- From the Division of Neurology (L.A.B.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Departments of Neurology and Pediatrics (L.A.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J White
- Department of Pediatrics (A.J.W.), St. Louis University School of Medicine, St. Louis, Missouri
| | - Timo Krings
- Division of Neuroradiology (T.K.), Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Adrienne M Hammill
- Cancer and Blood Diseases Institute (A.M.H.), Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pediatrics (A.M.H.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shih Shan Lang
- Division of Neurosurgery (S.S.L.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Neurosurgery (S.S.L.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Atsuko Baba
- Department of Anesthesia (A.B.), University of California San Francisco, San Francisco, California
| | | | | | - Steven W Hetts
- Departments of Radiology & Biomedical Imaging and Neurological Surgery and Division of Neuroendovascular Surgery (S.W.H.), University of California San Francisco, San Francisco, California
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Cheng HC, Faughnan ME, terBrugge KG, Liu HM, Krings T. Prevalence and Characteristics of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia. AJNR Am J Neuroradiol 2023; 44:1367-1372. [PMID: 38050014 PMCID: PMC10714847 DOI: 10.3174/ajnr.a8058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND PURPOSE The association between hereditary hemorrhagic telangiectasia and intracranial aneurysms remains controversial. This study evaluated the prevalence and characteristics of intracranial aneurysms in patients with hereditary hemorrhagic telangiectasia with brain vascular malformations. MATERIALS AND METHODS Between 2007 and 2021, patients enrolled in the Brain Vascular Malformation Consortium with definite hereditary hemorrhagic telangiectasia, the presence of brain vascular malformations, and available angiographic studies of the brain were retrospectively reviewed. Angiographic features of intracranial aneurysms and their relationship to coexisting brain vascular malformations were analyzed. We also examined the association between baseline clinical features and the presence of intracranial aneurysms. RESULTS One hundred eighty patients were included. A total of 14 intracranial aneurysms were found in 9 (5%) patients, and 4 intracranial aneurysms were considered flow-related aneurysms. Patients with intracranial aneurysms were significantly older than patients without intracranial aneurysms (mean, 48.1 [SD, 18.2] years versus 33.5 [SD, 21.0] years; P = .042). If we excluded flow-related intracranial aneurysms, the prevalence of intracranial aneurysms was 3.3%. All intracranial aneurysms were in the anterior circulation, were unruptured, and had an average maximal diameter of 3.9 (SD, 1.5) mm. No intracranial aneurysms were found in pediatric patients with hereditary hemorrhagic telangiectasia. No statistically significant correlation was observed among other baseline demographics, hereditary hemorrhagic telangiectasia features, and the presence of intracranial aneurysms. CONCLUSIONS The prevalence of intracranial aneurysms in this large cohort study is comparable with that in the general population and might be increased slightly due to hemodynamic factors associated with shunting brain vascular malformations.
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Affiliation(s)
- How-Chung Cheng
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery (H.-C.C.), Department of Surgery, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Marie E Faughnan
- Toronto HHT Centre (M.E.F.), St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Division of Respirology (M.E.F.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karel G terBrugge
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hon-Man Liu
- Department of Medical Imaging (H.-M.L.), Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Timo Krings
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Kilian A, Latino GA, White AJ, Ratjen F, McDonald J, Whitehead KJ, Gossage JR, Krings T, Lawton MT, Kim H, Faughnan ME. Comparing Characteristics and Treatment of Brain Vascular Malformations in Children and Adults with HHT. J Clin Med 2023; 12:2704. [PMID: 37048789 PMCID: PMC10094792 DOI: 10.3390/jcm12072704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterized by the development of vascular malformations (VMs) in organs such as the brain and lungs, as well as telangiectases on mucosal surfaces. Prophylactic treatment of organ VMs may prevent potential complications, such as hemorrhage. However, brain VM treatment-surgical resection, embolization, and/or radiosurgery-is not recommended for all patients due to the associated risks. Given the scarcity of data regarding HHT-related brain VM presentation and treatment trends in pediatric patients, we aim to describe the clinical presentations and the patterns of treatment of HHT-related brain VMs in a pediatric cohort, and compare pediatric trends to those of adults. Demographic and clinical data were analyzed in 114 pediatric patients with HHT-related brain VMs and compared with a cohort of 253 adult patients enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. Our data demonstrated that a higher proportion of pediatric patients with HHT-related brain VMs were symptomatic at presentation (p = 0.004). Moreover, a higher proportion of pediatric patients presented with intracranial hemorrhage (p < 0.001) and seizure (p = 0.002) compared to adult patients. Surgical resection was the most common brain VM treatment modality in both children and adults. We conclude that pediatric patients may be more likely to present with symptoms and complications from brain VMs, supporting the case for screening for brain VMs in children with HHT.
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Affiliation(s)
- Alexandra Kilian
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
| | - Giuseppe A. Latino
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, ON M2K 1E1, Canada
| | - Andrew J. White
- Department of Pediatrics, St Louis University, St. Louis, MO 63103, USA
| | - Felix Ratjen
- Division of Respiratory Medicine and Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, UT 84132, USA
| | - Kevin J. Whitehead
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT 84132, USA
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT 84132, USA
| | - James R. Gossage
- Department of Medicine, Augusta University, Augusta, GA 30912, USA
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94110, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Marie E. Faughnan
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
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Hereditary Hemorrhagic Telangiectasia in Pediatric Age: Focus on Genetics and Diagnosis. Pediatr Rep 2023; 15:129-142. [PMID: 36810341 PMCID: PMC9944132 DOI: 10.3390/pediatric15010011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) or Rendu-Osler-Weber Syndrome (ROW) is an autosomal dominant vascular disease, with an estimated prevalence of 1:5000. Genes associated with HHT are ACVRL1, ENG, SMAD4, and GDF2, all encoding for proteins involved in the TGFβ/BMPs signaling pathway. The clinical diagnosis of HHT is made according to the "Curaçao Criteria," based on the main features of the disease: recurrent and spontaneous epistaxis, muco-cutaneous telangiectases, arteriovenous malformations in the lungs, liver, and brain, and familiarity. Since the clinical signs of HHT can be misinterpreted, and the primary symptom of HHT, epistaxis, is common in the general population, the disease is underdiagnosed. Although HHT exhibits a complete penetrance after the age of 40, young subjects may also present symptoms of the disease and are at risk of severe complications. Here we review the literature reporting data from clinical, diagnostic, and molecular studies on the HHT pediatric population.
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Drapé E, Anquetil T, Larrivée B, Dubrac A. Brain arteriovenous malformation in hereditary hemorrhagic telangiectasia: Recent advances in cellular and molecular mechanisms. Front Hum Neurosci 2022; 16:1006115. [PMID: 36504622 PMCID: PMC9729275 DOI: 10.3389/fnhum.2022.1006115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/27/2022] [Indexed: 11/25/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder characterized by vessel dilatation, such as telangiectasia in skin and mucosa and arteriovenous malformations (AVM) in internal organs such as the gastrointestinal tract, lungs, and brain. AVMs are fragile and tortuous vascular anomalies that directly connect arteries and veins, bypassing healthy capillaries. Mutations in transforming growth factor β (TGFβ) signaling pathway components, such as ENG (ENDOGLIN), ACVRL1 (ALK1), and SMAD4 (SMAD4) genes, account for most of HHT cases. 10-20% of HHT patients develop brain AVMs (bAVMs), which can lead to vessel wall rupture and intracranial hemorrhages. Though the main mutations are known, mechanisms leading to AVM formation are unclear, partially due to lack of animal models. Recent mouse models allowed significant advances in our understanding of AVMs. Endothelial-specific deletion of either Acvrl1, Eng or Smad4 is sufficient to induce AVMs, identifying endothelial cells (ECs) as primary targets of BMP signaling to promote vascular integrity. Loss of ALK1/ENG/SMAD4 signaling is associated with NOTCH signaling defects and abnormal arteriovenous EC differentiation. Moreover, cumulative evidence suggests that AVMs originate from venous ECs with defective flow-migration coupling and excessive proliferation. Mutant ECs show an increase of PI3K/AKT signaling and inhibitors of this signaling pathway rescue AVMs in HHT mouse models, revealing new therapeutic avenues. In this review, we will summarize recent advances and current knowledge of mechanisms controlling the pathogenesis of bAVMs, and discuss unresolved questions.
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Affiliation(s)
- Elise Drapé
- Centre de Recherche, CHU St. Justine, Montréal, QC, Canada,Département de Pharmacologie et de Physiologie, Université de Montréal, Montréal, QC, Canada
| | - Typhaine Anquetil
- Centre de Recherche, CHU St. Justine, Montréal, QC, Canada,Département De Pathologie et Biologie Cellulaire, Université de Montréal, Montréal, QC, Canada
| | - Bruno Larrivée
- Département d’Ophtalmologie, Université de Montréal, Montréal, QC, Canada,Centre De Recherche, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada,*Correspondence: Bruno Larrivée,
| | - Alexandre Dubrac
- Centre de Recherche, CHU St. Justine, Montréal, QC, Canada,Département De Pathologie et Biologie Cellulaire, Université de Montréal, Montréal, QC, Canada,Département d’Ophtalmologie, Université de Montréal, Montréal, QC, Canada,Alexandre Dubrac,
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7
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Vetiska S, Wälchli T, Radovanovic I, Berhouma M. Molecular and genetic mechanisms in brain arteriovenous malformations: new insights and future perspectives. Neurosurg Rev 2022; 45:3573-3593. [PMID: 36219361 DOI: 10.1007/s10143-022-01883-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/30/2022] [Accepted: 10/05/2022] [Indexed: 10/17/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are rare vascular lesions made of shunts between cerebral arteries and veins without the interposition of a capillary bed. The majority of bAVMs are asymptomatic, but some may be revealed by seizures and potentially life-threatening brain hemorrhage. The management of unruptured bAVMs remains a matter of debate. Significant progress in the understanding of their pathogenesis has been made during the last decade, particularly using genome sequencing and biomolecular analysis. Herein, we comprehensively review the recent molecular and genetic advances in the study of bAVMs that not only allow a better understanding of the genesis and growth of bAVMs, but also open new insights in medical treatment perspectives.
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Affiliation(s)
- Sandra Vetiska
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Thomas Wälchli
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Group of CNS Angiogenesis and Neurovascular Link, Neuroscience Center Zurich, and Division of Neurosurgery, University and University Hospital Zurich, and Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland.,Division of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Ivan Radovanovic
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Moncef Berhouma
- Department of Neurosurgery, University Hospital of Dijon Bourgogne, Dijon, France. .,CREATIS Lab, CNRS UMR 5220, INSERM U1294, Lyon 1, University, Lyon, France.
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Yamada H, Akiyama T, Kamamoto D, Yoshida K, Fukumura M, Toda M. Combined transarterial and transvenous embolization of multi-hole pial arteriovenous fistula with large varix. Neuroradiol J 2022; 35:640-646. [PMID: 35477369 PMCID: PMC9513922 DOI: 10.1177/19714009221096829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pial arteriovenous fistula (AVF) is a vascular fistulous disease in which the cerebral pial artery and vein are directly connected without the intervening nidus within a sub-pial space. Multi-hole pial AVFs, wherein multiple feeders flow into one drainer, are usually formed with complex angioarchitecture and are difficult to treat. METHODS A rare case of an adult patient with hereditary hemorrhagic telangiectasia and multi-hole pial AVF was described. A 23-year-old woman was referred to our hospital. She was previously diagnosed with left cerebellar pial AVF with multiple feeders (bilateral superior cerebellar artery and common trunk of the left anterior inferior cerebellar artery and posterior inferior cerebellar) and large varix that had been untreated for 9 years. The enlargement of the large varix with the new second varix formation was revealed by angiography. Although asymptomatic, considered to be a risk for future hemorrhage was the continuous high hemodynamic stress. RESULTS Endovascular embolization was performed by securing safe transarterial n-butyl-2-cyanoacrylate injection by transarterial and transvenous coil placement to the shunt points and feeders, resulting in total occlusion of the fistula without any complications. Extensive transvenous coil placement inside the varix allowed safe embolization of the entire fistula with multiple high-flow feeders. Moreover, bidirectional (transarterial and transvenous) retrograde coil embolization enabled firm obliteration of the shunt points. CONCLUSIONS Performing combined transarterial and transvenous embolization in a well-balanced manner was considered to treat multi-hole pial AVF to provide a safe and effective embolization.
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Affiliation(s)
- Hiroki Yamada
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Takenori Akiyama
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Dai Kamamoto
- Department of Neurosurgery, Tokyo Dental College Ichikawa General
Hospital, Chiba, Japan
| | - Keisuke Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mariko Fukumura
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Sârbu F, Oprea VD, Tatu AL, Polea Drima E, Bojincă VC, Romila A. Hereditary Hemorrhagic Telangiectasia Associating Neuropsychiatric Manifestations with a Significant Impact on Disease Management-Case Report and Literature Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071059. [PMID: 35888148 PMCID: PMC9320563 DOI: 10.3390/life12071059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022]
Abstract
(1) Background: Genetic hereditary hemorrhagic telangiectasia (HHT) is clinically diagnosed. The clinical manifestations and lack of curative therapeutic interventions may lead to mental illnesses, mainly from the depression–anxiety spectrum. (2) Methods: We report the case of a 69-year-old patient diagnosed with HHT and associated psychiatric disorders; a comprehensive literature review was performed based on relevant keywords. (3) Results: Curaçao diagnostic criteria based the HHT diagnosis in our patient case at 63 years old around the surgical interventions for a basal cell carcinoma, after multiple episodes of epistaxis beginning in childhood, but with a long symptom-free period between 20 and 45 years of age. The anxiety–depressive disorder associated with nosocomephobia resulted in a delayed diagnosis and low adherence to medical monitoring. A comprehensive literature review revealed the scarcity of publications analyzing the impact of psychiatric disorders linked to this rare condition, frequently associating behavioral disengagement as a coping strategy, psychological distress, anxiety, depression, and hopelessness. (4) Conclusions: As patients with HHT face traumatic experiences from disease-related causes as well as recurring emergency hospital visits, active monitoring for mental illnesses and psychological support should be considered as part of the initial medical approach and throughout the continuum of care.
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Affiliation(s)
- Fabiola Sârbu
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “Elisabeta Doamna” Psychiatric Hospital, 800179 Galati, Romania
| | - Violeta Diana Oprea
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania
- Correspondence: (V.D.O.); (A.L.T.)
| | - Alin Laurențiu Tatu
- Clinical, Medical Department, Dermatology, ReForm UDJ, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania
- Dermatology Department, Clinical Hospital of Infectious Diseases Saint Parascheva, 800179 Galati, Romania
- Correspondence: (V.D.O.); (A.L.T.)
| | - Eduard Polea Drima
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “Elisabeta Doamna” Psychiatric Hospital, 800179 Galati, Romania
| | - Violeta Claudia Bojincă
- Internal Medicine Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy in Bucharest, 020021 Bucharest, Romania;
- Department of Internal Medicine and Rheumatology, “Sf. Maria” Hospital, 011172 Bucharest, Romania
| | - Aurelia Romila
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania
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Perez Akly MS, Vazquez C, Besada CH, Rodriguez MJ, Conde MF, Cajal AR, Peuchot VA, Dardik D, Baccanelli MM, Serra MM. Prevalence of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia: Report from a Single Reference Center. AJNR Am J Neuroradiol 2022; 43:844-849. [PMID: 35589139 DOI: 10.3174/ajnr.a7505] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/17/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Neurologic manifestations in hereditary hemorrhagic telangiectasia include an increased incidence of brain abscesses and ischemic strokes due to paradoxic embolization in addition to a wide spectrum of symptoms and complications due to typical brain vascular malformations. Intracranial aneurysms are not part of this brain vascular malformation spectrum. The aim of this study was to determine their prevalence in patients with hereditary hemorrhagic telangiectasia. MATERIALS AND METHODS This was a single-center, retrospective study. Adult patients from the institutional Hereditary Hemorrhagic Telangiectasia registry with a definitive diagnosis of hereditary hemorrhagic telangiectasia and an available report or angiographic imaging study were included and reviewed to determine the intracranial aneurysm prevalence. In addition, the morphologic characteristics of intracranial aneurysms and possible associated risk factors were collected. RESULTS Two hundred twenty-eight patients were analyzed. Thirty-seven aneurysms in 33 patients (14.5%; 95% CI, 9.9%-19%) were found. The median diameter of intracranial aneurysms was 3.2 mm (interquartile range, 2.6-4.4 mm). No association between intracranial aneurysm and sex, age, or genetic background was noted. There were no subarachnoid hemorrhagic events due to intracranial aneurysm rupture. CONCLUSIONS Due to the high prevalence of intracranial aneurysms in adult patients with hereditary hemorrhagic telangiectasia, further studies regarding bleeding risks and monitoring should be addressed.
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Affiliation(s)
- M S Perez Akly
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
| | - C Vazquez
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Department of Internal Medicine (C.V., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
| | - C H Besada
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
| | - M J Rodriguez
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M F Conde
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A R Cajal
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
- Translational Medicine and Biomedical Engineering Institute (A.R.C.), Buenos Aires, Argentina
- University Institute (A.R.C., M.M.B., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
| | - V A Peuchot
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Internal Medicine Research Area (V.A.P.), Hospital Italiano, Buenos Aires, Argentina
| | - D Dardik
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- From the Department of Radiology (D.D.), Clínica Instituto de Diagnóstico Sociedad Anónima (INDISA), Santiago, Chile
| | - M M Baccanelli
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Department of Neurosurgery (M.M.B.), Hospital Italiano, Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
- University Institute (A.R.C., M.M.B., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
| | - M M Serra
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Department of Internal Medicine (C.V., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
- University Institute (A.R.C., M.M.B., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
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Neurovascular Manifestations in Pediatric Patients With Hereditary Haemorrhagic Telangiectasia. Pediatr Neurol 2022; 129:24-30. [PMID: 35176532 DOI: 10.1016/j.pediatrneurol.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a multiorgan vascular dysplasia with limited data regarding its neurovascular manifestations and genotype-phenotype correlation in children. The objective of this study was to describe the neurovascular findings in a large cohort of children with HHT and correlate between phenotype and genotype. METHODS This retrospective study was conducted on 221 children (<18 years) with a definite or possible diagnosis of HHT based on Curacao criteria, or with positive genetics for the mutated genes of ENG, ACVRL-1, and SMAD-4, who also underwent brain MRI and/or conventional angiography. Demographic and clinical information, imaging findings, and follow up information were gathered. RESULTS Two hundred twenty-one children with HHT (70.6% genetically confirmed, and 99.5% positive family history) were included, with a median age of 7 years (interquartile range: 3 to 11 years) and 58.8% male predominance. Neurovascular lesions were found in 64 of 221 (28.9%), with 3.1% prevalence of intracranial hemorrhage. The most commonly observed vascular malformations were developmental venous anomalies (48.5%) and brain arteriovenous malformations (AVMs) (31.2%), followed by capillary malformations (14.1%). Multiple AVMs were seen in 10.0% of the cohort. We found no instances of de novo AVM (1281.8 patient-years).A significantly higher proportion of patients with ENG mutations (19.7%) had brain AVM than those with ACVRL-1 (4.9%) and SMAD-4 (0%) mutations (P < 0.01). There was no significant difference in the hemorrhagic risk of shunting lesions associated with ENG (35.3%) or ACVRL-1 (33.3%) positivity (P = 0.9). CONCLUSIONS We describe the neurovascular imaging and genetic findings from a large pediatric cohort of HHT, to enhance clinical awareness and guide management of patients with HHT.
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12
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Nicholson P, Krings T. Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00069-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Tessier S, Lipton BA, Ido F, Longo S, Nanda S. Pathogenesis and therapy of arteriovenous malformations: A case report and narrative review. Int J Crit Illn Inj Sci 2021; 11:167-176. [PMID: 34760664 PMCID: PMC8547675 DOI: 10.4103/ijciis.ijciis_127_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins that lack intervening capillary beds. They have been described in almost every organ in the body, emerging sporadically or as part of well-described syndromes. Hereditary hemorrhagic telangiectasia (HHT) is a rare, progressive, and lifelong disease characterized by AVMs and recurrent hemorrhaging. In the last 2 decades, significant advances have been made in understanding the pathogenesis of this condition. The accumulation of knowledge has led to a natural evolution of therapy, from open surgery to endovascular procedures, and now to a role for medications in certain AVMs. Here, we review a case of HHT and describe the most up-to-date clinical practice, including diagnosis of HHT, subtypes of HHT, and medical therapy.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Brooke A Lipton
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Sudip Nanda
- Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
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14
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Mizutani K, Consoli A, Maria FD, Condette Auliac S, Boulin A, Coskun O, Gratieux J, Rodesch G. Intradural spinal cord arteriovenous shunts in a personal series of 210 patients: novel classification with emphasis on anatomical disposition and angioarchitectonic distribution, related to spinal cord histogenetic units. J Neurosurg Spine 2021:1-11. [PMID: 33799293 DOI: 10.3171/2020.9.spine201258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Few classifications of intradural spinal arteriovenous shunts (ID-SAVSs) have considered their anatomical localization in relation to their phenotype and angioarchitectonics. The authors propose another vision of ID-SAVSs allowing a reappraised classification based on analysis of the anatomical disposition, angioarchitecture, and histogenetic location of these vascular malformations. METHODS The radiological and clinical records of 210 patients with ID-SAVSs were retrospectively reviewed, considering their localization, vascular architectonics, and correlation with the 5 histogenetic units of the spinal cord. Among these, 183 files with complete data allowed precise analysis of the ID-SAVSs. RESULTS Among these 183 files (162 and 21 cases with single and multiple lesions, respectively), different entities were identified: 13 pial macro arteriovenous fistulas (MAVFs), 92 pial micro arteriovenous fistulas (mAVFs), 33 superficial pial niduses, and 69 intramedullary niduses. Thirteen sulcal shunts (either fistulas or niduses) were considered subtypes of pial lesions. Among the 21 multiple cases, 11 were monomyelomeric while 10 were multimyelomeric. Pial lesions, either fistulas or niduses, were dominantly vascularized by pial arteries (anterior or posterior depending on the localization of the shunt) and occasionally (except for MAVFs) by transmedullary arteries. Pial niduses occasionally extended into the funiculus by recruiting intrinsic veins or by extension of the nidus itself inside the white matter. Intramedullary niduses were always vascularized by both centrifugal and centripetal feeders, respectively, from sulcal arteries (SAs) and pial arteries. Sulcal lesions are pial lesions located within the ventral median sulcus and vascularized by SAs and veins. Single or multiple ID-SAVSs can be part of various syndromes such as hereditary hemorrhagic telangiectasia, Parkes-Weber, RASA1, CLOVES, and spinal arteriovenous metameric syndromes. Histogenetic analyses revealed a specific distribution of each ID-SAVS in the 5 histogenetic units of the spinal cord: intramedullary niduses were found almost equally from cervical to thoracic units, while MAVFs and mAVFs were mostly found from thoracic to postcrural ones. Pial niduses showed intermediate features between intramedullary and fistulous lesions and were mostly distributed from brachial to crural segments. CONCLUSIONS Precise analysis of the anatomical disposition of ID-SAVSs in relation to functional histogenetic units allows a better understanding of these lesions and improved therapeutic management.
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Affiliation(s)
- Katsuhiro Mizutani
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France.,2Department of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo; and.,3Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Arturo Consoli
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Federico Di Maria
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Stéphanie Condette Auliac
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Anne Boulin
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Oguzhan Coskun
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Julie Gratieux
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Georges Rodesch
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
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15
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Kilian A, Clancy MS, Olitsky S, Gossage JR, Faughnan ME. Screening for pulmonary and brain vascular malformations is the North American standard of care for patients with hereditary hemorrhagic telangiectasia (HHT): A survey of HHT Centers of Excellence. Vasc Med 2020; 26:53-55. [PMID: 33375920 PMCID: PMC7879226 DOI: 10.1177/1358863x20974452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexandra Kilian
- Department of Medicine, Division of Respirology, Toronto HHT Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | - James R Gossage
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Augusta University, Augusta, GA, USA
| | - Marie E Faughnan
- Department of Medicine, Division of Respirology, Toronto HHT Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute and the Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
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16
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Faughnan ME, Mager JJ, Hetts SW, Palda VA, Lang-Robertson K, Buscarini E, Deslandres E, Kasthuri RS, Lausman A, Poetker D, Ratjen F, Chesnutt MS, Clancy M, Whitehead KJ, Al-Samkari H, Chakinala M, Conrad M, Cortes D, Crocione C, Darling J, de Gussem E, Derksen C, Dupuis-Girod S, Foy P, Geisthoff U, Gossage JR, Hammill A, Heimdal K, Henderson K, Iyer VN, Kjeldsen AD, Komiyama M, Korenblatt K, McDonald J, McMahon J, McWilliams J, Meek ME, Mei-Zahav M, Olitsky S, Palmer S, Pantalone R, Piccirillo JF, Plahn B, Porteous MEM, Post MC, Radovanovic I, Rochon PJ, Rodriguez-Lopez J, Sabba C, Serra M, Shovlin C, Sprecher D, White AJ, Winship I, Zarrabeitia R. Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia. Ann Intern Med 2020; 173:989-1001. [PMID: 32894695 DOI: 10.7326/m20-1443] [Citation(s) in RCA: 202] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
DESCRIPTION Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications. METHODS The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved. RECOMMENDATIONS The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.
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Affiliation(s)
- Marie E Faughnan
- St. Michael's Hospital, Li Ka Shing Knowledge Institute, and University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | | | - Steven W Hetts
- University of California, San Francisco, San Francisco, California (S.W.H., M.C.)
| | | | | | | | - Erik Deslandres
- Centre Hospitalier de l'Université de Montréal, Hôtel-Dieu, Montreal, Quebec, Canada (E.D.)
| | - Raj S Kasthuri
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (R.S.K., J.D.)
| | - Andrea Lausman
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.L., R.P.)
| | - David Poetker
- Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin (D.P., P.F.)
| | - Felix Ratjen
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada (F.R.)
| | - Mark S Chesnutt
- VA Portland Health Care System and Oregon Health & Science University, Portland, Oregon (M.S.C.)
| | | | - Kevin J Whitehead
- University of Utah Medical Center, Salt Lake City, Utah (K.J.W., J.M.)
| | - Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A.)
| | - Murali Chakinala
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Miles Conrad
- University of California, San Francisco, San Francisco, California (S.W.H., M.C.)
| | - Daniel Cortes
- St. Michael's Hospital and Unity Health Toronto, Toronto, Canada (D.C.)
| | | | - Jama Darling
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (R.S.K., J.D.)
| | | | | | | | - Patrick Foy
- Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin (D.P., P.F.)
| | - Urban Geisthoff
- University Hospital of Marburg and Phillips University Marburg, Marburg, Germany (U.G.)
| | | | - Adrienne Hammill
- Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, Ohio (A.H.)
| | - Ketil Heimdal
- Oslo University Hospital, Rikshospitalet, Oslo, Norway (K.H.)
| | | | | | | | | | - Kevin Korenblatt
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Jamie McDonald
- University of Utah Medical Center, Salt Lake City, Utah (K.J.W., J.M.)
| | | | - Justin McWilliams
- University of California, Los Angeles, Los Angeles, California (J.M.)
| | - Mary E Meek
- University of Arkansas for Medical Sciences, Little Rock, Arkansas (M.E.M.)
| | - Meir Mei-Zahav
- Schneider Children's Medical Center of Israel and Sackler School of Medicine of Tel Aviv University, Tel Aviv, Israel (M.M.)
| | | | | | - Rose Pantalone
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.L., R.P.)
| | - Jay F Piccirillo
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | | | | | - Marco C Post
- St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht, the Netherlands (M.C.P.)
| | - Ivan Radovanovic
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada (I.R.)
| | - Paul J Rochon
- University of Colorado Hospital, Aurora, Colorado (P.J.R.)
| | | | | | - Marcelo Serra
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (M.S.)
| | | | | | - Andrew J White
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Ingrid Winship
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia (I.W.)
| | - Roberto Zarrabeitia
- Hospital Sierrallana (Servicio Cántabro de Salud), Torrelavega, Spain (R.Z.)
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Beslow LA, Breimann J, Licht DJ, Waldman J, Fallacaro S, Pyeritz RE, Goldmuntz E, Vossough A. Cerebrovascular Malformations in a Pediatric Hereditary Hemorrhagic Telangiectasia Cohort. Pediatr Neurol 2020; 110:49-54. [PMID: 32718529 DOI: 10.1016/j.pediatrneurol.2020.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND We determined the frequency of cerebrovascular malformations in a pediatric cohort with hereditary hemorrhagic telangiectasia. METHODS Retrospective cohort study of 54 children diagnosed with hereditary hemorrhagic telangiectasia at a tertiary care center. All neuroimaging was reviewed to assess for number and types of cerebrovascular malformations and for intracerebral hemorrhage and arterial ischemic stroke. Clinical charts were reviewed for clinical manifestations, genetic mutation, and clinically evident intracerebral hemorrhages and arterial ischemic strokes. RESULTS Among 54 children with hereditary hemorrhagic telangiectasia with a median age of 3.5 years (interquartile range 0.4 to 7.9 years) at diagnosis, neuroimaging was performed in 52 (96.3%) at a median age of 5.2 years (interquartile range 1.8 to 9 years). Fourteen of 52 imaged children (26.9%) had cerebrovascular malformations. Cerebrovascular malformations included arteriovenous malformations, arteriovenous fistulas, vein of Galen malformations, and developmental venous anomalies. Six of the 14 children with cerebrovascular malformations (42.9%) had multiple malformations. Three children developed new cerebral arteriovenous malformations over time. Six children (11.1%) had clinically evident intracerebral hemorrhage, arterial ischemic stroke, or transient ischemic attack. The three children with intracerebral hemorrhage presented at young ages (4.3 to 7.7 years). CONCLUSIONS More than a quarter of children with hereditary hemorrhagic telangiectasia who were imaged had cerebrovascular malformations, and overt stroke occurred in more than 10%. Intracerebral hemorrhages can occur in pediatric hereditary hemorrhagic telangiectasia patients at young ages, and new cerebral arteriovenous malformations may develop over time. Early screening with neuroimaging including neurovascular imaging as well as repeat neuroimaging may be warranted in children with hereditary hemorrhagic telangiectasia.
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Affiliation(s)
- Lauren A Beslow
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Jake Breimann
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jake Waldman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samantha Fallacaro
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Reed E Pyeritz
- Department of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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18
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Genotype-Phenotype Correlations in Children with HHT. J Clin Med 2020; 9:jcm9092714. [PMID: 32842615 PMCID: PMC7565052 DOI: 10.3390/jcm9092714] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), a rare autosomal dominant disease mostly caused by mutations in three known genes (ENG, ACVRL1, and SMAD4), is characterized by the development of vascular malformations (VMs). Patients with HHT may present with mucocutaneous telangiectasia, as well as organ arteriovenous malformations (AVMs) of the central nervous system, lungs, and liver. Genotype-phenotype correlations have been well described in adults with HHT. We aimed to investigate genotype-phenotype correlations among pediatric HHT patients. Demographic, clinical, and genetic data were collected and analyzed in 205 children enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. A chi-square test was used to determine the association between phenotypic presentations and genotype. Among 205 patients (age range: 0-18 years; mean: 11 years), ENG mutation was associated with the presence of pulmonary AVMs (p < 0.001) and brain VM (p < 0.001). The presence of a combined phenotype-defined as both pulmonary AVMs and brain VMs-was also associated with ENG mutation. Gastrointestinal bleeding was rare (4.4%), but was associated with SMAD4 genotype (p < 0.001). We conclude that genotype-phenotype correlations among pediatric HHT patients are similar to those described among adults. Specifically, pediatric patients with ENG mutation have a greater prevalence of pulmonary AVMs, brain VMs, and a combined phenotype.
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Eker OF, Boccardi E, Sure U, Patel MC, Alicante S, Alsafi A, Coote N, Droege F, Dupuis O, Fialla AD, Jones B, Kariholu U, Kjeldsen AD, Lefroy D, Lenato GM, Mager HJ, Manfredi G, Nielsen TH, Pagella F, Post MC, Rennie C, Sabbà C, Suppressa P, Toerring PM, Ugolini S, Buscarini E, Dupuis-Girod S, Shovlin CL. European Reference Network for Rare Vascular Diseases (VASCERN) position statement on cerebral screening in adults and children with hereditary haemorrhagic telangiectasia (HHT). Orphanet J Rare Dis 2020; 15:165. [PMID: 32600364 PMCID: PMC7322871 DOI: 10.1186/s13023-020-01386-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/22/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia inherited as an autosomal dominant trait. Approximately 10 % of patients have cerebral vascular malformations, a proportion being cerebral arteriovenous malformations (AVMs) and fistulae that may lead to potentially devastating consequences in case of rupture. On the other hand, detection and treatment related-risks are not negligible, and immediate. While successful treatment can be undertaken in individual cases, current data do not support the treatment of unruptured AVMs, which also present a low risk of bleeding in HHT patients. Screening for these AVMs is therefore controversial. Structured discussions, distinctions of different cerebrovascular abnormalities commonly grouped into an “AVM” bracket, and clear guidance by neurosurgical and neurointerventional radiology colleagues enabled the European Reference Network for Rare Vascular Disorders (VASCERN-HHT) to develop the following agreed Position Statement on cerebral screening: 1) First, we emphasise that neurological symptoms suggestive of cerebral AVMs in HHT patients should be investigated as in general neurological and emergency care practice. Similarly, if an AVM is found accidentally, management approaches should rely on expert discussions on a case-by-case basis and individual risk-benefit evaluation of all therapeutic possibilities for a specific lesion. 2) The current evidence base does not favour the treatment of unruptured cerebral AVMs, and therefore cannot be used to support widespread screening of asymptomatic HHT patients. 3) Individual situations encompass a wide range of personal, cultural and clinical states. In order to enable informed patient choice, and avoid conflicting advice, particularly arising from non-neurovascular interpretations of the evidence base, we suggest that all HHT patients should have the opportunity to discuss knowingly brain screening issues with their healthcare provider. 4) Any screening discussions in asymptomatic individuals should be preceded by informed pre-test review of the latest evidence regarding preventative and therapeutic efficacies of any interventions. The possibility of harm due to detection of, or intervention on, a vascular malformation that would not have necessarily caused any consequence in later life should be stated explicitly. We consider this nuanced Position Statement provides a helpful, evidence-based framework for informed discussions between healthcare providers and patients in an emotionally charged area.
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Affiliation(s)
- Omer F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - Edoardo Boccardi
- Niguarda Hospital, Milan, Italy and VASCERN HHT Reference Centre, Crema, Italy
| | - Ulrich Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Maneesh C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Saverio Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Ali Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Nicola Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Freya Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Olivier Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France
| | - Annette Dam Fialla
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Bryony Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Ujwal Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Anette D Kjeldsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - David Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Gennaro M Lenato
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Hans Jurgen Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Troels H Nielsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Fabio Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Marco C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Catherine Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Carlo Sabbà
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy.
| | - Patrizia Suppressa
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Pernille M Toerring
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Sara Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | | | - Claire L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK and Imperial College London, London, UK.
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Venous pathologies in paediatric neuroradiology: from foetal to adolescent life. Neuroradiology 2019; 62:15-37. [PMID: 31707531 DOI: 10.1007/s00234-019-02294-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
The interpretation of cerebral venous pathologies in paediatric practice is challenging as there are several normal anatomical variants, and the pathologies are diverse, involving the venous system through direct and indirect mechanisms. This paper aims to provide a comprehensive review of these entities, as their awareness can avoid potential diagnostic pitfalls. We also propose a practical classification system of paediatric cerebral venous pathologies, which will enable more accurate reporting of the neuroimaging findings, as relevant to the underlying pathogenesis of these conditions. The proposed classification system comprises of the following main groups: arterio-venous shunting-related disorders, primary venous malformations and veno-occlusive disorders. A multimodal imaging approach has been included in the relevant subsections, with a brief overview of the modality-specific pitfalls that can also limit interpretation of the neuroimaging. The article also summarises the current literature and international practices in terms of management options and outcomes in specific disease entities.
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21
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Klostranec JM, Chen L, Mathur S, McDonald J, Faughnan ME, Ratjen F, Krings T. A theory for polymicrogyria and brain arteriovenous malformations in HHT. Neurology 2019; 92:34-42. [PMID: 30584075 DOI: 10.1212/wnl.0000000000006686] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/14/2018] [Indexed: 01/11/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is generally considered a disorder of endothelial dysfunction, characterized by the development of multiple systemic arteriovenous malformations (AVMs), including within the brain. However, there have recently been a number of reports correlating HHT with malformations of cortical development, of which polymicrogyria is the most common type. Here we present 7 new cases demonstrating polymicrogyria in HHT, 6 of which demonstrate a brain AVM (bAVM) in close spatial proximity, with the aim of providing a common origin for the association. Upon reviewing patient genetics and imaging data and comparing with previously reported findings, we form 2 new conclusions: (1) polymicrogyria in HHT appears exclusively associated with a subset of mutations in the transmembrane protein endoglin that is involved with blood flow-related mechanotransduction signaling during angiogenesis and (2) the polymicrogyria is characteristically unilateral, typically focal, and correlates with vascular regions experiencing low fluid shear stress during corticogenesis in utero. Integrating these with findings in the literature from genetics and molecular biology experiments, we propose a theory suggesting haploinsufficient endoglin mutations, especially those that are dominant-negative, may predispose focal, aberrant hypersprouting angiogenesis during corticogenesis that leads to the production of polymicrogyria. This hypoxic insult may further serve as the revealing trigger for later development of a spatially coincident bAVM. This hypothesis suggests an essential role for endoglin-mediated hemodynamic mechanotransduction in normal corticogenesis.
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Affiliation(s)
- Jesse M Klostranec
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Long Chen
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Shobhit Mathur
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Jamie McDonald
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Marie E Faughnan
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Felix Ratjen
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Timo Krings
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada.
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22
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Kim D, Seo EJ, Song YS, Suh CH, Kim JW, Kim DJ, Suh DC. Current Status of Clinical Diagnosis and Genetic Analysis of Hereditary Hemorrhagic Telangiectasia in South Korea: Multicenter Case Series and a Systematic Review. Neurointervention 2019; 14:91-98. [PMID: 31455059 PMCID: PMC6736501 DOI: 10.5469/neuroint.2019.00150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/18/2019] [Indexed: 01/28/2023] Open
Abstract
Purpose Hereditary hemorrhagic telangiectasia (HHT), a rare genetic vascular disorder, has been rarely reported in South Korea. We investigated the current prevalence and presenting patterns of genetically confirmed HHT in South Korea. Materials and Methods We defined HHT patients as those with proven mutations on known HHT-related genes (ENG, ACVRL1, SMAD4, and GDF2) or those fulfilling 3 or 4 of the Curaçao criteria. A computerized systematic search was performed in PubMed and KoreaMed using the following search term: (“hereditary hemorrhagic telangiectasia” AND “Korea”) OR (“Osler-Weber-Rendu” AND “Korea”). We also collected government health insurance data. HHT genetic testing results were collected from three tertiary hospitals in which the genetic tests were performed. We integrated patient data by analyzing each case to obtain the prevalence and presenting pattern of HHT in South Korea. Results We extracted 90 cases from 52 relevant articles from PubMed and KoreaMed. An additional 22 cases were identified from the three Korean tertiary hospitals after excluding seven cases that overlapped with those in the published articles. Finally, 112 HHT patients were identified (41 males and 71 females, aged 4–82 years [mean±standard deviation, 45.3±20.6 years]). The prevalence of HHT in South Korea is about 1 in 500,000, with an almost equal prevalence among men and women. Forty-nine patients underwent genetic testing, of whom 28 had HHT1 (ENG mutation) and 19 had HHT2 (ACVRL1 mutation); the other two patients were negative for ENG, ACVRL1, and SMAD4 mutations. Conclusion The prevalence of HHT is underestimated in Korea. The rate of phenotypic presentation seems to be similar to that found worldwide. Korean health insurance coverage is limited to representative genetic analysis to detect ENG and ACVRL1 mutations. Further genetic analyses to detect HHT3, HHT4, and other forms of HHT should be implemented.
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Affiliation(s)
- Donghyun Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eul-Ju Seo
- Department of Laboraory Medicines, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Yun Sun Song
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chong Hyun Suh
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Won Kim
- Department of Laboraory Medicines, Samsung Medical Center, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Morii K, Uematsu R, Yamamoto T, Nakamura S, Okushin H, Nishiwaki N, Watanabe T, Kai K, Sato S. Hepatocellular Carcinoma in a Patient with Hereditary Hemorrhagic Telangiectasia. Intern Med 2018; 57:3545-3549. [PMID: 30146556 PMCID: PMC6355409 DOI: 10.2169/internalmedicine.1056-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 76-year-old woman with hereditary hemorrhagic telangiectasia (HHT) showed elevated serum hepatobiliary enzyme levels, and abdominal imaging studies revealed a hepatic tumor. Her serum alpha-fetoprotein level was 759.5 ng/mL. A pathological examination after hepatectomy confirmed a diagnosis of hepatocellular carcinoma (HCC). An examination of the surrounding liver revealed dilated vessels and thickened endothelial cells without inflammations. HHT patients without other risk factors (like this patient) reportedly have a lower incidence of common cancers, including HCC, in comparison to the unaffected population. One intriguing hypothesis that might explain the hepatocarcinogenesis in this situation is the ischemic liver cirrhosis theory, which suggests that chronic ischemia may cause parenchymal strain and promote inappropriate hepatocyte proliferation.
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Affiliation(s)
- Kazuhiko Morii
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | - Riku Uematsu
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | - Takeharu Yamamoto
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | | | - Hiroaki Okushin
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | - Noriyuki Nishiwaki
- Department of Hepatobiliary and Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Takanori Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Japanese Red Cross Society Himeji Hospital, Japan
| | - Kyohei Kai
- Department of Hepatobiliary and Pancreatic Surgery, Japanese Red Cross Society Himeji Hospital, Japan
| | - Shiso Sato
- Department of Hepatobiliary and Pancreatic Surgery, Japanese Red Cross Society Himeji Hospital, Japan
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Fatania G, Gilson C, Glover A, Alsafi A, Jackson JE, Patel MC, Shovlin CL. Uptake and radiological findings of screening cerebral magnetic resonance scans in patients with hereditary haemorrhagic telangiectasia. Intractable Rare Dis Res 2018; 7:236-244. [PMID: 30560015 PMCID: PMC6290842 DOI: 10.5582/irdr.2018.01103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) results in arteriovenous malformations (AVMs), most commonly in the lungs, liver and brain. Discussion of cerebral vascular malformations is an important element of patient management. The current study objectives were to examine uptake and results of screening cerebral magnetic resonance (MR) scans, excluding symptomatic patients requiring neurological investigations. The remaining non-symptomatic individuals received formal pretest counselling that differed according to family history. For the 603 patients with no neurological symptoms of concern, screening scan uptake was higher after publication of the ARUBA trial. Patients with a family history of cerebral haemorrhage were 4 to 14-fold more likely to have a screening scan than patients with no such family history. For patients without neurological symptoms suggesting cerebral AVMs, none of the 59 screening scans performed at our institution demonstrated a cerebral AVM. Four scans (6.8%) demonstrated small aneurysms. The most common abnormality was cerebral infarction (20/59, 33.9%), predominantly identified in patients with pulmonary AVMs. Of 29 pulmonary AVM patients with no previous history of clinical stroke, 16 (55.2%) had between one and five silent infarcts. For HHT patients with pulmonary AVMs, the most frequently affected sites were the cerebellum (40%) and thalamus (14.3%), and the age-adjusted odds ratio for an infarct was 21.6 (95% confidence intervals 3.7, 126), p = 0.001. We concluded that for cerebral screening programmes in HHT, the findings support informed patient choice incorporating understanding that cerebral AVMs are rare in non-symptomatic HHT patients, but that screening scans commonly detect silent cerebral infarction due to pulmonary AVMs.
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Affiliation(s)
- Gavin Fatania
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Clare Gilson
- NHLI Cardiovascular Sciences, Imperial College London, London, UK
| | - Alan Glover
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Ali Alsafi
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
- VASCERN HHT European Reference Centre, Imperial College Healthcare NHS Trust, London, UK
| | - James E Jackson
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
- VASCERN HHT European Reference Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Maneesh C Patel
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
- VASCERN HHT European Reference Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Claire L. Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK
- VASCERN HHT European Reference Centre, Imperial College Healthcare NHS Trust, London, UK
- Address correspondence to:Claire L. Shovlin, Professor of Practice (Clinical and Molecular Medicine), NHLI Cardiovascular Sciences, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK. E-mail:
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25
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Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT), or Osler Weber-Rendu disease, is a rare inherited disorder of fibrovascular tissue affecting various organs. Epistaxis is the most common symptom of HHT but as the disease affects multiple organs, a multisystem and multidisciplinary approach to management is required. The purpose of this article is to provide an overview of the multidisciplinary approach to HHT for the otolaryngologist and to discuss the current pharmacologic and procedural treatment options available for HHT-related epistaxis. RECENT FINDINGS Multidisciplinary expert guidelines have better defined what screening tests are advised for the multisystem evaluation of the HHT patient. New pharmacologic therapies including bevacizumab (Avastin) used submucosally or topically have shown promise as in-office treatment modalities. Sclerotherapy of telangiectasia, including in-office applications, has recently proven safe and effective. SUMMARY HHT remains a difficult disease to treat. Being aware of the common organ systems involved by the disease will help the practicing otolaryngologist to ensure the patient receives appropriate multidisciplinary care. For HHT-related epistaxis, new medical and surgical options allow for a wider range of treatments than were previously available.
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Tan AP, Svrckova P, Cowan F, Chong WK, Mankad K. Intracranial hemorrhage in neonates: A review of etiologies, patterns and predicted clinical outcomes. Eur J Paediatr Neurol 2018; 22:690-717. [PMID: 29731328 DOI: 10.1016/j.ejpn.2018.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/31/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022]
Abstract
Intracranial hemorrhage (ICH) in neonates often results in devastating neurodevelopmental outcomes as the neonatal period is a critical window for brain development. The neurodevelopmental outcomes in neonates with ICH are determined by the maturity of the brain, the location and extent of the hemorrhage, the specific underlying etiology and the presence of other concomitant disorders. Neonatal ICH may result from various inherited and acquired disorders. We classify the etiologies of neonatal ICH into eight main categories: (1) Hemorrhagic stroke including large focal hematoma, (2) Prematurity-related hemorrhage, (3) Bleeding diathesis, (4) Genetic causes, (5) Infection, (6) Trauma-related hemorrhage, (7) Tumor-related hemorrhage and (8) Vascular malformations. Illustrative cases showing various imaging patterns that can be helpful to predict clinical outcomes will be highlighted. Potential mimics of ICH in the neonatal period are also reviewed.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd 119228, Singapore.
| | - Patricia Svrckova
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Frances Cowan
- Dept. of Neonatology, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, SW10 9NH, UK.
| | - Wui Khean Chong
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
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27
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Meybodi AT, Kim H, Nelson J, Hetts SW, Krings T, terBrugge KG, Faughnan ME, Lawton MT. Surgical Treatment vs Nonsurgical Treatment for Brain Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia: A Retrospective Multicenter Consortium Study. Neurosurgery 2018; 82:35-47. [PMID: 28973426 DOI: 10.1093/neuros/nyx168] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 05/24/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebral arteriovenous malformations (AVMs) are common in patients with hereditary hemorrhagic telangiectasia (HHT). However, due to the rarity of HHT and little published evidence of outcomes from management of brain AVMs in this disease, current international HHT guidelines recommend an individualized approach. Specifically, the outcomes for surgical vs nonsurgical management of these lesions have not been reported to date. OBJECTIVE To report long-term outcomes of surgical resection of brain AVMs in HHT patients compared to outcomes in nonsurgically treated patients. METHODS From the database of the Brain Vascular Malformation Consortium HHT project, 19 patients with 20 resected AVMs (group 1) and 22 patients with 33 AVMs who received nonsurgical treatment (group 2) were studied. The groups were retrospectively reviewed for changes in functional status (modified Rankin Scale score) during the follow-up period. RESULTS During the follow-up period, 9% of patients in group 1 suffered from worsening of functional status, whereas this figure was 16% for group 2 (P > .05). Functional outcomes were not statistically different between the 2 groups at the latest follow-up (P > .05). CONCLUSION HHT patients treated surgically for brain AVMs appear to have long-term functional outcomes comparable to nonsurgical (including observational) therapy with fewer unfavorable outcomes. It is therefore reasonable to consider surgical resection as a management option in the multidisciplinary team's individualized treatment strategy for HHT patients with brain AVMs.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Steven W Hetts
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Timo Krings
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karel G terBrugge
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
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Clinical presentation and treatment paradigms in patients with hereditary hemorrhagic telangiectasia and spinal vascular malformations. J Clin Neurosci 2018; 50:51-57. [PMID: 29398197 DOI: 10.1016/j.jocn.2018.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/05/2018] [Indexed: 11/23/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that causes angiodysplasia and results in mucocutaneous telangiectasias and arteriovenous malformations of organs. Although central nervous system vascular malformations can occur anywhere along the neuraxis, spinal vascular malformations are rare. We present our experience with the presentation and management of spinal vascular malformations in patients with HHT. Of the more than 800 patients with the diagnosis of HHT screened at our institution from 1995 through 2017, four patients with spinal vascular malformations (age range 1 month-77 years; 2 male, 2 female) were identified, three of whom came to clinical attention after significant neurological deterioration from previously unknown malformations. A review of the literature including our patients demonstrated 29 total spinal arteriovenous fistulas (AVFs) in 28 HHT patients (69% male). The lesions were located predominantly in the thoracic spine (65.5%). Three lesions were not treated, 17 were treated with embolization, 6 were surgically resected, and 3 were treated with embolization and surgery. In 14 cases, the patients presented with hemorrhage of the AVF. Overall, 79% of patients achieved complete or near-complete occlusion, with 75% reporting improvement in neurological function. Discovery of spinal lesions often occurs after neurological decline because current screening protocols do not include evaluation of the patient for spinal lesions. Most patients benefit from intervention, which is tailored to the characteristics of the patient and their malformation. Given the often-severe neurological deficit encountered at presentation, we favor a protocol that screens HHT patients for spinal vascular malformations.
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Saliou G, Eyries M, Iacobucci M, Knebel J, Waill M, Coulet F, Ozanne A, Soubrier F. Clinical and genetic findings in children with central nervous system arteriovenous fistulas. Ann Neurol 2017; 82:972-980. [DOI: 10.1002/ana.25106] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/26/2017] [Accepted: 11/19/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Guillaume Saliou
- Department of NeuroradiologyCentre Hospitalier Universitaire VaudoisLausanne Switzerland
- Department of NeuroradiologyBicêtre HospitalLe Kremlin Bicêtre France
| | - Mélanie Eyries
- Department of geneticsHopital Pitié‐SalpêtrièreParis France
- UMR‐S 1166‐ICAN; INSERM and UPMC Sorbonne UniversityParis France
| | - Marta Iacobucci
- Department of NeuroradiologyBicêtre HospitalLe Kremlin Bicêtre France
| | - Jean‐François Knebel
- département de Radiologie, Centre d'Imagerie Biomédicale, Hôpital Nestlé, CHUVLausanne Switzerland
| | | | | | - Augustin Ozanne
- Department of NeuroradiologyBicêtre HospitalLe Kremlin Bicêtre France
| | - Florent Soubrier
- Department of geneticsHopital Pitié‐SalpêtrièreParis France
- UMR‐S 1166‐ICAN; INSERM and UPMC Sorbonne UniversityParis France
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Abstract
This article describes three hereditary conditions known to be associated with arteriovenous malformation (AVM), along with their clinical and imaging features and angiographic angioarchitecture. Hereditary hemorrhagic telangiectasia, capillary malformation-AVM (CM-AVM), and PTEN tumor hamartoma syndrome are conditions with autosomal dominant inheritance, caused by mutations in different molecular pathways, which frequently present with symptomatic AVMs. Imaging biomarkers, including sites of predilection, angioarchitecture, and tissue overgrowth patterns, are helpful in identifying these patients and selecting appropriate treatment.
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Affiliation(s)
- Patricia E Burrows
- Department of Radiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Rattani A, Dewan MC, Hannig V, Naftel RP, Wellons JC, Jordan LC. Cerebral hemorrhage in monozygotic twins with hereditary hemorrhagic telangiectasia: case report and hemorrhagic risk evaluation. J Neurosurg Pediatr 2017; 20:164-169. [PMID: 28524787 DOI: 10.3171/2017.3.peds16587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a case of monozygotic twins with hereditary hemorrhagic telangiectasia (HHT) who experienced cerebral arteriovenous malformation (AVM) hemorrhage at a very young age. The clinical variables influencing HHT-related AVM rupture are discussed, and questions surrounding the timing of screening and intervention are explored. This is only the second known case of monozygotic HHT twins published in the medical literature, and the youngest pair of first-degree relatives to experience AVM-related cerebral hemorrhage. Evidence guiding the screening and management of familial HHT is lacking, and cases such as this underscore the need for objective and validated protocols.
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Affiliation(s)
- Abbas Rattani
- School of Medicine, Meharry Medical College, Nashville
| | - Michael C Dewan
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, and
| | - Vickie Hannig
- Divisions of 3 Medical Genetics and Genomic Medicine and
| | - Robert P Naftel
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, and
| | - John C Wellons
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, and
| | - Lori C Jordan
- Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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McGurgan IJ, Lonergan R, Killeen R, McGuigan C. Cervical spine arteriovenous fistula associated with hereditary haemorrhagic telangiectasia. BMJ Case Rep 2017; 2017:bcr2016218172. [PMID: 28174188 PMCID: PMC5307285 DOI: 10.1136/bcr-2016-218172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 11/03/2022] Open
Abstract
Reported is a case of a man aged 55 years who presented with progressive spastic paraparesis. Examination demonstrated multiple cutaneous telangiectases. Subsequent development of upper limb weakness, acute urinary retention and eventual respiratory compromise resulted in the requirement for intensive care unit admission and mechanical ventilation. MRI spine revealed diffuse T2 hyperintensity in the cervical cord with enhancement and cord expansion. Immunomodulatory therapy for a presumed diagnosis of transverse myelitis yielded no response, so a vascular aetiology was suspected. Spinal angiography demonstrated an arteriovenous fistula involving the upper cervical cord. Endovascular embolisation was successfully performed and a marked clinical improvement was achieved. Cervical arteriovenous fistulas can cause progressive myelopathy, subarachnoid haemorrhage and brainstem dysfunction. Management typically comprises endovascular embolisation or surgical interruption. A clinical diagnosis of hereditary haemorrhagic telangiectasia was also made in this case, and spinal arteriovenous fistula formation has been associated with this condition.
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Affiliation(s)
- Iain John McGurgan
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - Roisin Lonergan
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - Ronan Killeen
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
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Brinjikji W, Iyer VN, Wood CP, Lanzino G. Prevalence and characteristics of brain arteriovenous malformations in hereditary hemorrhagic telangiectasia: a systematic review and meta-analysis. J Neurosurg 2016; 127:302-310. [PMID: 27767404 DOI: 10.3171/2016.7.jns16847] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Patients with hereditary hemorrhagic telangiectasia (HHT) are known to suffer from high rates of cerebral arteriovenous malformations (AVMs). The authors performed a systematic review and meta-analysis of the literature examining prevalence rates, characteristics, and clinical presentation of cerebral AVMs in the HHT population. METHODS To identify studies on AVM prevalence and characteristics in the HHT population, 4 databases (MEDLINE, EMBASE, Scopus and Web of Science) were searched by a reference librarian with over 30 years experience in systematic reviews and meta-analysis. The search period was January 1, 1990-March 2016. The following search terms were used: hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome, AVM, brain AVM, arteriovenous malformation, arteriovenous fistula, prevalence, and epidemiology. The authors identified studies that examined the prevalence rates, characteristics, and clinical presentation of cerebral AVMs in patients with HHT. They assessed overall AVM prevalence rates as well as prevalence rates by age, sex, HHT type, and country/region. They also systematically reviewed the characteristics of AVMs, including rupture status, location, clinical presentation, angioarchitecture, and Spetzler-Martin grade. Data were analyzed using a random-effects meta-analysis model. RESULTS Thirty-nine studies were included in this meta-analysis. Thirty studies examined brain AVM prevalence rates in various HHT patient populations, and 18 studies examined AVM clinical and angiographic characteristics (9 studies examined both prevalence rates and AVM characteristics). The prevalence of brain AVMs in HHT patients was 10.4% (95% CI 7.9%-13.0%) with no significant difference between males (8.5%, 95% CI 4.9%-12.0%) and females (11.0%, 95% CI 5.9%-16.1%). Patients with HHT Type 1 (HHT1) had a significantly higher brain AVM prevalence (13.4%, 95% CI 9.5%-17.4%) compared with those with HHT Type 2 (HHT2) (2.4%, 95% CI 1.0%-3.8%) (p < 0.0001). In 55.2% (95% CI 38.3%-72.1%) of cases, the AVMs were symptomatic. Spetzler-Martin grade was 2 or less in 86.9% (95% CI 67.5%-95.2%) of patients. CONCLUSIONS The prevalence of brain AVMs in the HHT population is about 10%. HHT1 patients are significantly more likely to have brain AVMs than HHT2 patients. Most AVMs in the HHT population are symptomatic. The Spetzler-Martin grade for these lesions is 2 or less in nearly 90% of patients.
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Robaina Cabrera DM, Verde González MP, Tarazona Chocano B, Amado Fernández C, Zarrabeitia Puente R. Telangiectasia hemorrágica hereditaria: enfermedad de Rendu-Osler-Weber. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.fmc.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kim HM, Cho JH, Kim KH. Onyx Embolization of Intracranial Pial Arteriovenous Fistula. J Cerebrovasc Endovasc Neurosurg 2016; 18:291-295. [PMID: 27847777 PMCID: PMC5104858 DOI: 10.7461/jcen.2016.18.3.291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/05/2016] [Accepted: 09/12/2016] [Indexed: 11/23/2022] Open
Abstract
Intracranial pial arteriovenous fistulas (AVFs) are rare cerebrovascular lesions consisting of one or more arterial connections to a single venous channel without an intervening nidus. Because of the location and high flow dynamics of these lesions, neurosurgeons may have a difficulty deciding between endovascular treatment and open surgical treatment. We report on a patient who underwent endovascular treatment with liquid embolic agent. A 50-year-old man with a decreased mental state and a tonic seizure event was brought to our hospital. Computed tomography (CT) of the brain showed a subcortical hematoma in the right temporoparietal lobe. On three-dimensional cerebral artery CT, there was no evidence of definite cerebrovascular abnormality. Cerebral angiography showed a pial AVF supplied by the right middle cerebral artery with early drainage into the right superior cerebral vein. The patient was treated with Onyx embolization for definitive closure of the fistula. The patient was transferred to the department of rehabilitation medicine two weeks later with grade 4 left hemiparesis. The application of advanced equipment, such as the latest angiography and endovascular tools, will facilitate the correct diagnosis and delicate treatment of pial AVF.
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Affiliation(s)
- Hae-Min Kim
- Department of Neurosurgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jae-Hoon Cho
- Department of Neurosurgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Ki-Hong Kim
- Department of Neurosurgery, Daegu Catholic University School of Medicine, Daegu, Korea
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Brinjikji W, Iyer VN, Yamaki V, Lanzino G, Cloft HJ, Thielen KR, Swanson KL, Wood CP. Neurovascular Manifestations of Hereditary Hemorrhagic Telangiectasia: A Consecutive Series of 376 Patients during 15 Years. AJNR Am J Neuroradiol 2016; 37:1479-86. [PMID: 27012295 DOI: 10.3174/ajnr.a4762] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 01/28/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia is associated with a wide range of neurovascular abnormalities. The aim of this study was to characterize the spectrum of cerebrovascular lesions, including brain arteriovenous malformations, in patients with hereditary hemorrhagic telangiectasia and to study associations between brain arteriovenous malformations and demographic variables, genetic mutations, and the presence of AVMs in other organs. MATERIALS AND METHODS Consecutive patients with definite hereditary hemorrhagic telangiectasia who underwent brain MR imaging/MRA, CTA, or DSA at our institution from 2001 to 2015 were included. All studies were re-evaluated by 2 senior neuroradiologists for the presence, characteristics, location, and number of brain arteriovenous malformations, intracranial aneurysms, and nonshunting lesions. Brain arteriovenous malformations were categorized as high-flow pial fistulas, nidus-type brain AVMs, and capillary vascular malformations and were assigned a Spetzler-Martin score. We examined the association between baseline clinical and genetic mutational status and the presence/multiplicity of brain arteriovenous malformations. RESULTS Three hundred seventy-six patients with definite hereditary hemorrhagic telangiectasia were included. One hundred ten brain arteriovenous malformations were noted in 48 patients (12.8%), with multiple brain arteriovenous malformations in 26 patients. These included 51 nidal brain arteriovenous malformations (46.4%), 58 capillary vascular malformations (52.7%), and 1 pial arteriovenous fistula (0.9%). Five patients (10.4%) with single nidal brain arteriovenous malformation presented with hemorrhage. Of brain arteriovenous malformations, 88.9% (88/99) had a Spetzler-Martin score of ≤2. Patients with brain arteriovenous malformations were more likely to be female (75.0% versus 57.6%, P = .01) and have a family history of hereditary hemorrhagic telangiectasia (95.8% versus 84.8%, P = .04). The prevalence of brain arteriovenous malformation was 19.7% in endoglin (ENG) mutations and 12.5% in activin receptor-like kinase (1ACVRL1) mutations. CONCLUSIONS Our study of 376 patients with hereditary hemorrhagic telangiectasia demonstrated a high prevalence of brain arteriovenous malformations. Nidal brain arteriovenous malformations and capillary vascular malformations occurred in roughly equal numbers.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
| | - V N Iyer
- Pulmonary and Critical Care Medicine (V.N.I., V.Y.)
| | - V Yamaki
- Pulmonary and Critical Care Medicine (V.N.I., V.Y.)
| | - G Lanzino
- Neurosurgery (G.L.), Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
| | - K R Thielen
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
| | - K L Swanson
- Department of Pulmonary and Critical Care Medicine (K.L.S.), Mayo Clinic, Scottsdale, Arizona
| | - C P Wood
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
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Shovlin C, Awan I, Cahilog Z, Abdulla F, Guttmacher A. Reported cardiac phenotypes in hereditary hemorrhagic telangiectasia emphasize burdens from arrhythmias, anemia and its treatments, but suggest reduced rates of myocardial infarction. Int J Cardiol 2016; 215:179-85. [DOI: 10.1016/j.ijcard.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/02/2016] [Indexed: 01/17/2023]
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Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an underrecognized and underdiagnosed autosomal-dominant angiodysplasia that has an estimated prevalence of 1 in 5000 individuals, with variable clinical presentations even within family members with identical mutations. The most common manifestations are telangiectasias of the skin and nasal mucosa. However, HHT can often be complicated by the presence of arteriovenous malformations and telangiectasias in the lungs, brain, gastrointestinal tract, and liver that are often silent and can lead to life-threatening complications of stroke and hemorrhage. This article reviews HHT for the pulmonologist, who is not uncommonly the first practitioner to encounter these patients.
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Brinjikji W, Iyer VN, Lanzino G, Thielen KR, Wood CP. Natural history of brain capillary vascular malformations in hereditary hemorrhagic telangiectasia patients. J Neurointerv Surg 2016; 9:26-28. [PMID: 26919971 DOI: 10.1136/neurintsurg-2015-012252] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE Brain capillary vascular malformations (CVMs) are known to occur with relatively high frequency in hereditary hemorrhagic telangiectasia (HHT) patients. These lesions are thought to have a benign natural history but this has not been systematically studied. The purpose of our study was to examine the natural history of CVMs in a consecutive series of HHT patients. MATERIALS AND METHODS Consecutive patients with untreated CVMs receiving serial imaging were included. Baseline data including demographics, HHT gene mutations, and Curacao diagnostic criteria were collected. The primary outcome was rupture on follow-up. A secondary outcome was new focal neurological deficit or seizure related to the lesion. RESULTS 22 patients with 42 CVMs were included. Mean age was 45.9±16.9 years. 18 patients (81.8%) were women and 4 (18.2%) were men. 19 patients (86.4%) had definite HHT and 3 patients (13.6%) had probable HHT. Mean follow-up was 4.6±3.7 years. There were a total of 100.2 patient years of follow-up and 222.5 lesion years. No lesions ruptured on follow-up and no patient had focal neurological deficits or seizures related to the lesions. CONCLUSIONS Our study found that CVMs in HHT patients have a benign natural history as no patients had hemorrhage or other symptoms related to these lesions. These findings should be confirmed in additional multicenter longitudinal studies.
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Affiliation(s)
| | - Vivek N Iyer
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Thielen
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Brinjikji W, Nasr DM, Cloft HJ, Iyer VN, Lanzino G. Spinal arteriovenous fistulae in patients with hereditary hemorrhagic telangiectasia: A case report and systematic review of the literature. Interv Neuroradiol 2016; 22:354-61. [PMID: 26823330 DOI: 10.1177/1591019915623560] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 11/22/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although rare, spinal arteriovenous malformations (AVMs) are thought to be more prevalent in the hereditary Hereditary Hemorrhagic Telangiectasia (HHT) population. METHODS We report a case of a spinal AVM in a 37-year-old female with HHT treated with endovascular embolization. In addition, we report findings from a systematic review of the literature on the clinical characteristics, angioarchitecture, and clinical outcomes of HHT patients with spinal AVMs. RESULTS The patient is a 37 year-old female with definite HHT who presented with a one-year history of progressive gait difficulty. The spinal fistula was incidentally detected on chest computed tomography (CT). Spinal angiography demonstrated a large perimedullary arteriovenous fistula was supplied by a posterolateral spinal artery. The fistula was treated with detachable coils. The patient made a complete neurological recovery. Our systematic review yielded 25 additional cases of spinal AVMs in HHT patients. All fistulae were perimedullary (100.0%). Treatments were described in 24 of the 26 lesions. Endovascular-only treatment was performed in 16 cases (66.6%) and surgical-only treatment was performed in five cases (20.8%). Complete or near-complete occlusion rates were 86.7% (13/15) for endovascular treated cases, 100.0% (4/4) for surgery and 66.6% (2/3) for combined treatments. Overall, 80.0% of patients (16/20) reported improvement in function following treatment, 100.0% (5/5) in the surgery group and 84.6% (11/13) reported improvement in the endovascular group. CONCLUSIONS Spinal fistulae in HHT patients are usually type IV perimedullary fistulae. Both endovascular and surgical treatments appeared to be effective in treating these lesions. However, it is clear that endovascular therapy has become the preferred treatment modality.
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Affiliation(s)
| | | | | | - Vivek N Iyer
- Department of Pulmonology and Critical Care Medicine, Mayo Clinic, USA
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41
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Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00067-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Brinjikji W, Iyer VN, Sorenson T, Lanzino G. Cerebrovascular Manifestations of Hereditary Hemorrhagic Telangiectasia. Stroke 2015; 46:3329-37. [PMID: 26405205 DOI: 10.1161/strokeaha.115.010984] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 08/28/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Waleed Brinjikji
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN.
| | - Vivek N Iyer
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN
| | - Thomas Sorenson
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN
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Abstract
Cerebrospinal vascular malformations are a group of anomalies affecting the arterial wall, the capillary arteriovenous interface, or the venous and lymphatic structures. Heritability and family studies allow identification of mutations in single genes associated with rare familial conditions causing cerebral or spinal vascular malformations, as is the case in hemorrhagic hereditary telangiectasia diseases. This article reviews the genetic and epigenetic influences increasingly reported in recent years as causal factors or triggers involved in the formation and growth of cerebromedullary vascular malformations.
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Affiliation(s)
- Hortensia Alvarez
- Interventional Neuroradiology, UNC at Chapel Hill, Chapel Hill, NC 27516, USA
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44
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Kim H, Nelson J, Krings T, terBrugge KG, McCulloch CE, Lawton MT, Young WL, Faughnan ME. Hemorrhage rates from brain arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia. Stroke 2015; 46:1362-4. [PMID: 25858236 DOI: 10.1161/strokeaha.114.007367] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 03/12/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia (HHT) is a systemic disease characterized by mucocutaneous telangiectasias, epistaxis, and arteriovenous malformations (AVMs). Intracranial hemorrhage (ICH) rates in this population are not well described. We report ICH rates and characteristics in HHT patients with brain AVMs (HHT-BAVMs). METHODS We studied the first 153 HHT-BAVM patients with follow-up data enrolled in the Brain Vascular Malformation Consortium HHT Project. We estimated ICH rates after BAVM diagnosis. RESULTS The majority of patients were women (58%) and white (98%). The mean age at BAVM diagnosis was 31±19 years (range, 0-70), with 61% of cases diagnosed on asymptomatic screening. Overall, 14% presented with ICH; among symptomatic cases, 37% presented ruptured. During 493 patient-years of follow-up, 5 ICH events occurred yielding a rate of 1.02% per year (95% confidence interval, 0.42-2.44%). ICH-free survival differed significantly by ICH presentation (P=0.003); ruptured cases had a higher ICH rate (10.07%; 95% confidence interval, 3.25-31.21%) than unruptured cases (0.43%; 95% confidence interval, 0.11-1.73%). CONCLUSIONS Patients with HHT-BAVM who present with hemorrhage are at a higher risk for rehemorrhage compared with patients with BAVM detected presymptomatically.
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Affiliation(s)
- Helen Kim
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.).
| | - Jeffrey Nelson
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Timo Krings
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Karel G terBrugge
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Charles E McCulloch
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Michael T Lawton
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - William L Young
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Marie E Faughnan
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
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Ladner TR, Mahdi J, Attia A, Froehler MT, Le TM, Lorinc AN, Mocco J, Naftel RP, Newton AT, Pruthi S, Tenenholz T, Vance EH, Wushensky CA, Wellons JC, Jordan LC. A multispecialty pediatric neurovascular conference: a model for interdisciplinary management of complex disease. Pediatr Neurol 2015; 52:165-73. [PMID: 25693581 DOI: 10.1016/j.pediatrneurol.2014.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/02/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In 2013, our institution established a multidisciplinary pediatric neurovascular conference for coordination of care. Here, we review our initial experience. METHODS Clinical and demographic data were obtained from medical records for patients presented to the pediatric neurovascular conference from April 2013 to July 2014. Patient descriptive characteristics were described by mean and standard deviation for continuous measures and by number and percent for categorical measures. Patients were secondarily stratified by lesion/disease type, and descriptive statistics were used to measure demographic and clinical variables. RESULTS The pediatric neurovascular conference met 26 times in the study period. Overall, 75 children were presented to the conference over a 15-month period. The mean age was 9.8 (standard deviation, 6.3) years. There were 42 (56%) male patients. These 75 children were presented a total of 112 times. There were 28 (37%) patients with history of stroke. Complex vascular lesions were the most frequently discussed entity; of 62 children (83%) with a diagnosed vascular lesion, brain arteriovenous malformation (29%), cavernous malformation (15%), and moyamoya (11%) were most common. Most discussions were for review of imaging (35%), treatment plan formulation (27%), the need for additional imaging (25%), or diagnosis (13%). Standardized care protocols for arteriovenous malformation and moyamoya were developed. CONCLUSION A multidisciplinary conference among a diverse group of providers guides complex care decisions, helps standardize care protocols, promotes provider collaboration, and supports continuity of care in pediatric neurovascular disease.
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Affiliation(s)
- Travis R Ladner
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jasia Mahdi
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael T Froehler
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Truc M Le
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda N Lorinc
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Mocco
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allen T Newton
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sumit Pruthi
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Tenenholz
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Haley Vance
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Curtis A Wushensky
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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Krings T, Kim H, Power S, Nelson J, Faughnan ME, Young WL, terBrugge KG. Neurovascular manifestations in hereditary hemorrhagic telangiectasia: imaging features and genotype-phenotype correlations. AJNR Am J Neuroradiol 2015; 36:863-70. [PMID: 25572952 DOI: 10.3174/ajnr.a4210] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/08/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia is an autosomal dominant disease that presents in 10%-20% of patients with various brain vascular malformations. We aimed to report the radiologic features (phenotype) and the genotype-phenotype correlations of brain vascular malformations in hereditary hemorrhagic telangiectasia. MATERIALS AND METHODS Demographic, clinical, genotypic, and imaging information of 75 patients with hereditary hemorrhagic telangiectasia with brain arteriovenous malformations enrolled in the Brain Vascular Malformation Consortium from 2010 to 2012 were reviewed. RESULTS Nonshunting, small, superficially located conglomerates of enhancing vessels without enlarged feeding arteries or draining veins called "capillary vascular malformations" were the most commonly observed lesion (46 of 75 patients; 61%), followed by shunting "nidus-type" brain AVMs that were typically located superficially with a low Spetzler-Martin Grade and a small size (32 of 75 patients; 43%). Direct high-flow fistulous arteriovenous shunts were present in 9 patients (12%). Other types of vascular malformations (dural AVF and developmental venous anomalies) were present in 1 patient each. Multiplicity of vascular malformations was seen in 33 cases (44%). No statistically significant correlation was observed between hereditary hemorrhagic telangiectasia gene mutation and lesion type or lesion multiplicity. CONCLUSIONS Depending on their imaging features, brain vascular malformations in hereditary hemorrhagic telangiectasia can be subdivided into brain AVF, nidus-type AVM, and capillary vascular malformations, with the latter being the most common phenotype in hereditary hemorrhagic telangiectasia. No genotype-phenotype correlation was observed among patients with this condition.
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Affiliation(s)
- T Krings
- From the Division of Neuroradiology (T.K., S.P., K.G.t.B.), Department of Medical Imaging Division of Neurosurgery (T.K.), Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - H Kim
- Department of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Center for Cerebrovascular Research Department of Epidemiology and Biostatistics (H.K.), University of California San Francisco, San Francisco, California
| | - S Power
- From the Division of Neuroradiology (T.K., S.P., K.G.t.B.), Department of Medical Imaging
| | - J Nelson
- Department of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Center for Cerebrovascular Research
| | - M E Faughnan
- Division of Respirology (M.E.F.), Department of Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada Division of Respirology (M.E.F.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - W L Young
- Department of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Center for Cerebrovascular Research
| | - K G terBrugge
- From the Division of Neuroradiology (T.K., S.P., K.G.t.B.), Department of Medical Imaging
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Garg N, Khunger M, Gupta A, Kumar N. Optimal management of hereditary hemorrhagic telangiectasia. J Blood Med 2014; 5:191-206. [PMID: 25342923 PMCID: PMC4206399 DOI: 10.2147/jbm.s45295] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known by the eponym Osler-Weber-Rendu syndrome, is a group of related disorders inherited in an autosomal dominant fashion and characterized by the development of arteriovenous malformations (AVM) in the skin, mucous membranes, and/or internal organs such as brain, lungs, and liver. Its prevalence is currently estimated at one in 5,000 to 8,000. Most cases are due to mutations in the endoglin (HHT1) or ACVRLK1 (HHT2) genes. Telangiectasias in nasal and gastrointestinal mucosa generally present with recurrent/chronic bleeding and iron deficiency anemia. Larger AVMs occur in lungs (~40%-60% of affected individuals), liver (~40%-70%), brain (~10%), and spine (~1%). Due to the devastating and potentially fatal complications of some of these lesions (for example, strokes and brain abscesses with pulmonary AVMs), presymptomatic screening and treatment are of utmost importance. However, due to the rarity of this condition, many providers lack an appreciation for the whole gamut of its manifestations and complications, age-dependent penetrance, and marked intrafamilial variation. As a result, HHT remains frequently underdiagnosed and many families do not receive the appropriate screening and treatments. This article provides an overview of the clinical features of HHT, discusses the clinical and genetic diagnostic strategies, and presents an up-to-date review of literature and detailed considerations regarding screening for visceral AVMs, preventive modalities, and treatment options.
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Affiliation(s)
- Neetika Garg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Monica Khunger
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Arjun Gupta
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nilay Kumar
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
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