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Thrash GW, Hale AT, Feldman MJ, Saccomano BW, Barrett DJ, Malenkia PD, Das S, Tsemo GB, Blount JP, Rocque BG, Rozzelle CJ, Johnston JM, Jones JG. Pediatric non-galenic pial arteriovenous fistula's characteristics and outcomes: a systematic review. Childs Nerv Syst 2024; 40:1721-1729. [PMID: 38506930 PMCID: PMC11111522 DOI: 10.1007/s00381-024-06352-5] [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: 01/10/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Pediatric non-galenic pial arteriovenous fistulas (pAVFs) are rare vascular malformations that are characterized by a pial arterial-venous connection without an intervening capillary bed. Outcomes and treatment strategies for pAVFs are highly individualized, owing to the rarity of the disease and lack of large-scale data guiding optimal treatment approaches. METHODS We performed a systematic review of pediatric patients (< 18 years at diagnosis) diagnosed with a pAVF by digital subtraction angiogram (DSA). The demographics, treatment modalities, and outcomes were documented for each patient and clinical outcome data was collected. Descriptive information stratified by outcome scores were classified as follows: 1 = excellent (no deficit and full premorbid activity), 2 = good (mild deficit and full premorbid activity), 3 = fair (moderate deficit and impaired activity), 4 = poor (severe deficit and dependent on others), 5 = death. RESULTS A total of 87 studies involving 231 patients were identified. Median age at diagnosis was 3 years (neonates to 18 years). There was slight male preponderance (55.4%), and 150 subjects (81.1%*) experienced excellent outcomes after treatment. Of the 189 patients treated using endovascular approaches, 80.3% experienced excellent outcomes and of the 15 patients surgically treated subjects 75% had an excellent outcome. The highest rate of excellent outcomes was achieved in patients treated with Onyx (95.2%) and other forms of EvOH (100%). High output heart failure and comorbid vascular lesions tended to result in worse outcomes, with only 54.2% and 68% of subjects experiencing an excellent outcome, respectively. *Outcomes were reported in only 185 patients. CONCLUSION pAVFs are rare lesions, necessitating aggregation of patient data to inform natural history and optimal treatment strategies. This review summarizes the current literature on pAVF in children, where children presenting with heart failure as a result of high flow through the lesion were less likely to experience an excellent outcome. Prospective, large-scale studies would further characterize pediatric pAVFs and enable quantitative analysis of outcomes to inform best treatment practices.
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Affiliation(s)
- Garrett W Thrash
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA.
| | - Michael J Feldman
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin W Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - D Jonah Barrett
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pedram D Malenkia
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Somnath Das
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James M Johnston
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G Jones
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
- Department of Diagnostic Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Kaplan JS, Dardanelli EP, Requejo F, Mackintosh C, Lipsich JE. Use of greyscale and Doppler ultrasound in initial evaluation and follow-up of neurovascular malformations in children. Pediatr Radiol 2024; 54:347-356. [PMID: 38191809 DOI: 10.1007/s00247-023-05846-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/10/2024]
Abstract
Pediatric intracranial arteriovenous shunts are rare vascular malformations that can be diagnosed prenatally or postnatally, as an incidental finding or due to complications. We propose a review of cerebral vascular malformations in newborns and infants with special emphasis on neurosonography and Doppler ultrasound as the first diagnostic method. Sonography can thus contribute in the planning of further studies that are always necessary, and in post-therapy follow-up.
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Affiliation(s)
- Julio S Kaplan
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina.
| | - Esteban P Dardanelli
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
| | - Flavio Requejo
- Department of Neuroradiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
| | - Cecilia Mackintosh
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
| | - José E Lipsich
- Department of Radiology, Hospital de Pediatría J.P. Garrahan, Combate de los Pozos 1881 (C 1425 AAM), Buenos Aires, Argentina
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Sabrina C, Laura M, Sabrina S, Giacomo T, Nicoletta M, Elena P, Francesco C, Eugenio B. Expect the unexpected: a case of spontaneous thrombosis of a pial arteriovenous fistula in a preterm newborn with review of the literature. Childs Nerv Syst 2023; 39:793-799. [PMID: 36161521 PMCID: PMC10024657 DOI: 10.1007/s00381-022-05652-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pial arteriovenous fistulas (pAVF) are rare vascular malformations, especially in children and newborns. In neonates, the most common symptom is congestive heart failure. CASE PRESENTATION We report a case of an asymptomatic preterm newborn incidentally diagnosed with pAVF during a routine cranial ultrasound (cUS) on the third day of life. Cerebral magnetic resonance (MRI) confirmed the diagnosis. A wait-and-see approach was chosen by the multidisciplinary team. The cUS and the MRI on day 14 of life showed the spontaneous resolution of the lesion. CONCLUSIONS This case underlines the challenges in identifying pAVF in the first weeks of life and demonstrates a possible positive outcome for affected neonates.
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Affiliation(s)
- Congedi Sabrina
- University of Padua, Department of Women's and Children's Health, Padova University Hospital, Unit of Neonatal Intensive Care Unit, Division Women's and Children's Health , Padua, Italy.
| | - Moschino Laura
- University of Padua, Department of Women's and Children's Health, Padova University Hospital, Unit of Neonatal Intensive Care Unit, Division Women's and Children's Health , Padua, Italy
| | - Salvadori Sabrina
- University of Padua, Department of Women's and Children's Health, Padova University Hospital, Unit of Neonatal Intensive Care Unit, Division Women's and Children's Health , Padua, Italy
| | - Talenti Giacomo
- Neuroradiology Unit, Padova University Hospital, Padua, Italy
| | - Mainini Nicoletta
- University of Padua, Department of Women's and Children's Health, Padova University Hospital, Unit of Neonatal Intensive Care Unit, Division Women's and Children's Health , Padua, Italy
| | - Priante Elena
- University of Padua, Department of Women's and Children's Health, Padova University Hospital, Unit of Neonatal Intensive Care Unit, Division Women's and Children's Health , Padua, Italy
| | - Causin Francesco
- Interventional Neuroradiology, Padova University Hospital, Padua, Italy
| | - Baraldi Eugenio
- University of Padua, Department of Women's and Children's Health, Padova University Hospital, Unit of Neonatal Intensive Care Unit, Division Women's and Children's Health , Padua, Italy
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Younger DS. Spinal cord motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:3-42. [PMID: 37620076 DOI: 10.1016/b978-0-323-98817-9.00007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Spinal cord diseases are frequently devastating due to the precipitous and often permanently debilitating nature of the deficits. Spastic or flaccid paraparesis accompanied by dermatomal and myotomal signatures complementary to the incurred deficits facilitates localization of the insult within the cord. However, laboratory studies often employing disease-specific serology, neuroradiology, neurophysiology, and cerebrospinal fluid analysis aid in the etiologic diagnosis. While many spinal cord diseases are reversible and treatable, especially when recognized early, more than ever, neuroscientists are being called to investigate endogenous mechanisms of neural plasticity. This chapter is a review of the embryology, neuroanatomy, clinical localization, evaluation, and management of adult and childhood spinal cord motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Savage C, Hale AT, Parr MS, Hedaya A, Saccomano BW, Tsemo GB, Hafeez MU, Tanweer O, Kan P, Solomon LJ, Meila D, Dirks PB, Blount JP, Johnston JM, Rocque BG, Rozzelle CJ, Bhatia K, Muthusami P, Krings T, Jones J. Outcomes of endovascular embolization for Vein of Galen malformations: An individual participant data meta-analysis. Front Pediatr 2022; 10:976060. [PMID: 36245731 PMCID: PMC9561813 DOI: 10.3389/fped.2022.976060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Understanding outcomes after Vein of Galen malformation (VOGM) embolization has been limited by small sample size in reported series and predominantly single center studies. To address these limitations, we perform an individual-participant meta-analysis (IPMA) to identify risk factors associated with all-cause mortality and clinical outcome after VOGM endovascular embolization. Methods We performed a systematic review and IPMA of VOGM endovascular outcomes according to PRISMA guidelines. Individual patient characteristics including demographic, intra/post-operative adverse events, treatment efficacy (partial or complete occlusion), and clinical outcome were collected. Mixed-effects logistic regression with random effects modeling and Bonferroni correction was used (p ≤ 0.003 threshold for statistical significance). The primary and secondary outcomes were all-cause mortality and poor clinical outcome (moderate/severe developmental delay or permanent disabling injury), respectively. Data are expressed as (mean ± standard deviation (SD)) or (odds ratio (OR), 95% confidence interval (CI), I 2, p-value). Results Thirty-five studies totaling 307 participants quantifying outcomes after endovascular embolization for VOGM were included. Follow up time was 42 (±57) months. Our analysis contained 42% neonates (<1 month) at first embolization, 45% infants (1 month ≤2 years), and 13% children (>2 years). Complete occlusion was reported in 48% of participants. Overall all-cause mortality was 16%. Overall, good clinical outcome was achieved in 68% of participants. First embolization as a neonate [OR = 6.93; 95% CI (1.99-24.08); I 2 < 0.01; p < 0.001] and incomplete embolization [OR = 10.87; 95% CI (1.86-63.55); I 2 < 0.01; p < 0.001] were associated with mortality. First embolization as a neonate [OR = 3.24; 95% CI (1.47-7.15); I 2 < 0.01; p < 0.001], incomplete embolization [OR = 5.26; 95% CI (2.06-13.43); I 2 < 0.01; p < 0.001], and heart failure at presentation [OR = 3.10; 95% CI (1.03-9.33); I 2 < 0.01; p = 0.002] were associated with poor clinical outcomes. Sex, angioarchitecture of lesion, embolization approach (transvenous vs. transarterial), and single or multistage embolization were not associated with mortality or clinical outcome. Conclusions We identify incomplete VOGM embolization independently associated with mortality and poor clinical outcome. While this study provides the highest level of evidence for VOGM embolization to date, prospective multicenter studies are needed to understand the optimal treatment strategies, outcomes, and natural history after VOGM embolization.
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Affiliation(s)
- Cody Savage
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew T. Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew S. Parr
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Alexander Hedaya
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Benjamin W. Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Muhammad U. Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston TX, United States
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Laurent J. Solomon
- Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants, Paris, France
| | - Dan Meila
- Department of Interventional Radiology, Helois Klinikum Krefeld, Johanna-Etienne Hospital Neuss, Neuss, Germany
| | - Peter B. Dirks
- Division of Pediatric Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeffrey P. Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M. Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brandon G. Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Curtis J. Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kartik Bhatia
- Department of Medical Imaging, Sydney Children’s Hospital Network, Westmead, NSW, Australia
| | - Prakash Muthusami
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Timo Krings
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Jesse Jones
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
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Bankole N, Janot K, Listrat A, Travers N, Maldonado I, Velut S. Child pial arteriovenous fistula of the conus medullaris presenting with spinal cord venous congestion: Case report and literature review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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7
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Giant dural arteriovenous fistula in a pediatric patient: positive outcome following surgical treatment. Childs Nerv Syst 2021; 37:2063-2068. [PMID: 33108519 DOI: 10.1007/s00381-020-04923-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Our purpose is to present an atypical case of a 4-month-old patient with a giant dural arteriovenous fistula (DAVF). METHODS Presentation of a case report and review of the literature. RESULTS The DAVF arterial supply was through the middle meningeal artery bilaterally and the anterior and middle cerebral arteries on the right hemisphere. The venous drainage was through the posterior two-thirds of the superior sagittal sinus. The endovascular team performed an embolization to reduce the flow of the lesion, and finally, the surgical team completed the excision of the residual venous sac, without causing any significant neurological deficit. We used a double surgical approach done with two surgical teams in order to optimize the hemostasis control and reduce morbidity and mortality. CONCLUSION Midline DAVF usually has devastating consequences in children. Endovascular treatment is the first choice since it has lower mortality. Nevertheless, it requires multiple interventions, and the cure of the disease may not be achieved. We believe that joint endovascular and surgical treatment, supported by a reliable multidisciplinary medical team, is a good option for this type of lesions.
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8
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Ghali MGZ, Arborelius UP, Veznedaroglu E, Spetzler RF, Yaşargil MG, Marchenko V. Galenic Pial Arteriovenous Fistulas in Adults. J Neurol Sci 2020; 416:117014. [PMID: 32652360 DOI: 10.1016/j.jns.2020.117014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/30/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Vein of Galen aneurysmal malformations (VOGMs) are pial arteriovenous fistulas possessing Galenic venous drainage most commonly presenting during the neonatal period and infancy, with initial discovery during adulthood quite rare. OBJECTIVES AND METHODS We conducted a literature survey of the PubMed database in order to identify Galenic pial arteriovenous fistulas (GPAVFs) with major manifestation or initial presentation during adulthood. Inclusionary criteria included pial AVFs with Galenic drainage with major manifestation or initial presentation at, or older than, 18 years. Exclusionary criteria included exclusive pediatric onset of symptomatology attributable to GPAVFs without a new onset major presentation during adulthood, exclusive or major dural arterial supply, arteriovenous malformations with Galenic drainage, developmental venous anomalies with Galenic drainage, isolated varices or anomalies of the vein of Galen, and any lesions with uncertainty regarding true GPAVF nature. RESULTS Our search generated 1589 articles. Excluding duplicates, 26 cases met criteria for evaluation. Mean age was 34.1 +/- 2.53 years. Clinical presentations of GPAVFs among adults included headache, intracranial hemorrhage, seizures, and focal neurologic deficits. Management strategies included observation (n = 5), emergent ventriculostomy or Torkildsen shunt (n = 3), cerebrospinal fluid diversion via ventriculoperitoneal shunting (n = 4), microsurgical obliteration or thrombectomy (n = 4), transarterial and/or transvenous embolotherapeutic obliteration (n = 7), and concurrent embolotherapy and radiosurgical irradiation (n = 1). CONCLUSIONS GPAVFs in adults often present with symptomatology of mild severity and may be effectively managed conservatively, though occasionally present catastrophically or may be treated via cerebrospinal fluid diversion, microsurgical obliteration, or endovascular embolization. Severity sufficient to require emergent intervention portended a poor outcome.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurological Surgery Karolinska Institutet, Nobels väg 6, Solna and Alfred Nobels Allé 8, Huddinge SE-171 77, Stockholm, Sweden; Centrum för traumaforskning Karolinska Institutet, Nobels väg 6, Solna and Alfred Nobels Allé 8, Huddinge SE-171 77, Stockholm, Sweden.
| | - Ulf P Arborelius
- Department of Neurological Surgery Karolinska Institutet, Nobels väg 6, Solna and Alfred Nobels Allé 8, Huddinge SE-171 77, Stockholm, Sweden; Centrum för traumaforskning Karolinska Institutet, Nobels väg 6, Solna and Alfred Nobels Allé 8, Huddinge SE-171 77, Stockholm, Sweden
| | - Erol Veznedaroglu
- Director of the Drexel Neurosciences Institute, Robert A. Groff Chairman in Neurosurgery, Global Neurosciences Institute, Mercerville, NJ 08619, United States of America
| | - Robert F Spetzler
- Department of Neurological Surgery, Barrow Neurological Institute, 350 W Thomas Rd, Phoenix, AZ 85013, Phoenix, AZ 85013, United States of America
| | - M Gazi Yaşargil
- Department of Neurosurgery, Department of Neurophysiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Vitaliy Marchenko
- Institut Fiziologii imeni O O Bogomolca Nacional'na akademia nauk Ukraini, Bogomoletz str. 4, Kiev 01024, Ukraine
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Brinjikji W, Krings T, Murad MH, Rouchaud A, Meila D. Endovascular Treatment of Vein of Galen Malformations: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2017; 38:2308-2314. [PMID: 28982789 DOI: 10.3174/ajnr.a5403] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes after endovascular embolization of vein of Galen malformations remain relatively poorly described. PURPOSE We performed a systematic review of the literature to determine outcomes and predictors of good outcomes following endovascular treatment of vein of Galen malformations. DATA SOURCES We used Ovid MEDLINE, Ovid Embase, and the Web of Science. STUDY SELECTION Our study consisted of all case series with ≥4 patients receiving endovascular treatment of vein of Galen malformations published through January 2017. DATA ANALYSIS We studied the following outcomes: complete/near-complete occlusion rates, technical complications, perioperative stroke, perioperative hemorrhage, technical mortality, all-cause mortality, poor neurologic outcomes, and good neurologic outcomes. Outcomes were stratified by age-group (neonate, infant, child). A random-effects meta-analysis was performed. DATA SYNTHESIS A total of 27 series with 578 patients were included; 41.9% of patients were neonates, 45.0% of patients were infants, and 13.1% of patients were children. All-cause mortality was 14.0% (95% CI, 8.0%-22.0%). Overall good neurologic outcome rates were 62.0% (95% CI, 57.0%-67.0%). Overall poor neurologic outcome rates were 21.0% (95% CI, 17.0%-26.0%). Neonates were significantly less likely to have good neurologic outcomes than infants (48.0%; 95% CI, 35.0%-62.0% versus 77.0%; 95% CI, 70.0%-84.0%; P < .01). Treatment indications following the Bicêtre neonatal evaluation score resulted in significantly higher rates of good neurologic outcome (P = .04). Patients with congestive heart failure had significantly lower rates of good neurologic outcome (OR, 0.50; 95% CI, 0.28-0.88; P = .01). LIMITATIONS Limitations were selection and publication biases. CONCLUSIONS Patients receiving endovascular embolization of vein of Galen malformations experienced good long-term clinical outcomes in >60% of cases. Appropriate patient selection is key as treatment guided by the Bicêtre neonatal evaluation score was associated with improved neurologic outcomes.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B.)
- Neurosurgery, (W.B.)
- Division of Neuroradiology and Neurosurgery (W.B., T.K.), University of Toronto, Toronto Western Hospital and University Health Network, Toronto, Ontario, Canada
| | - T Krings
- Division of Neuroradiology and Neurosurgery (W.B., T.K.), University of Toronto, Toronto Western Hospital and University Health Network, Toronto, Ontario, Canada
| | - M H Murad
- Center for the Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | - A Rouchaud
- Neuroradiology Service (A.R.), Centre Hospitalier Universitaire Bicêtre, Le Kremlin Bicêtre, France
| | - D Meila
- Department of Radiology and Neuroradiology (D.M.), Klinikum Duisburg, Duisburg, Germany
- Department of Diagnostic and Interventional Neuroradiology (D.M.), Medical School Hannover, Hannover, Germany
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Hewitt AL, Morrical BD, Cetta F. Cerebral Arteriovenous Malformation Detected by Newborn Congenital Heart Disease Screen with Echocardiography. ACTA ACUST UNITED AC 2017; 1:242-244. [PMID: 30062291 PMCID: PMC6058347 DOI: 10.1016/j.case.2017.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CCHD screening may produce “false-positive” results due to extracardiac causes. Cerebral arteriovenous malformations can cause increased cerebral venous return. The anterior fontanelle provides a unique ultrasound window in newborns. Echocardiography detected a cerebral AVM in a newborn with a failed CCHD screen.
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Affiliation(s)
- Angela L Hewitt
- Department of Child Neurology, Mayo Clinic, Rochester, Minnesota
| | - Brandon D Morrical
- Department of Pediatrics, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Frank Cetta
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.,Department of Pediatrics, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
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Pedicelli A, Iacobucci M, Frassanito P, Lozupone E, Masselli G, Di Rocco C, Colosimo C. Prenatal Diagnosis and Multimodal Neonatal Treatment of a Rare Pial Arteriovenous Fistula: Case Report and Review of the Literature. World Neurosurg 2017; 104:1050.e13-1050.e18. [PMID: 28559076 DOI: 10.1016/j.wneu.2017.05.121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intracranial pial arteriovenous fistulas (PAVFs) are direct communications between the arterial and venous system of the brain, with the characteristic absence of a plexiform nidus, as seen in the classic cerebral arteriovenous malformations. These vascular malformations, usually occurring in the pediatric population, very rarely are diagnosed in utero, because of a lack of understanding of the condition and because they may be hard to visualize. CASE DESCRIPTION We report a rare case of a mass-effect PAVF diagnosed with fetal magnetic resonance imaging, involving the right cerebral hemisphere, fed by a pericallosal artery and associated with a giant venous dilatation. The PAVF initially was managed by the endovascular embolization. The recruitment of a middle cerebral artery feeder and the rapidly enlarging size of the venous pouch with mass effect required subsequent surgery. CONCLUSIONS The 2-stage multimodal treatment resulted in complete disappearance of the PAVF without complications.
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Affiliation(s)
- Alessandro Pedicelli
- Department of Radiology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Marta Iacobucci
- Department of Radiology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.
| | - Paolo Frassanito
- Pediatric Neurosurgery, Catholic University of Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Emilio Lozupone
- Department of Radiology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | | | - Concezio Di Rocco
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Cesare Colosimo
- Department of Radiology, Catholic University of Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Morales-Gómez JA, Garza-Oyervides VV, Arenas-Ruiz JA, Mercado-Flores M, Elizondo-Riojas CG, Boop FA, de León ÁMP. Hydrocephalus in a patient with an unruptured pial arteriovenous fistula: hydrodynamic considerations, endovascular treatment, and clinical course. J Neurosurg Pediatr 2017; 19:307-311. [PMID: 28059677 DOI: 10.3171/2016.9.peds16458] [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
Intracranial pial arteriovenous fistulas, also known as nongalenic fistulas, are rare vascular malformations affecting predominantly the pediatric population. Hydrocephalus is an unusual presentation in which the exact pathophysiology is not fully understood. The aim of treatment in these cases is occlusion of the fistula prior to considering ventricular shunting. Here, the authors describe the hydrodynamic considerations of the paravascular pathway and the resolution of hydrocephalus with endovascular treatment of the fistula.
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Affiliation(s)
| | | | | | - Mariana Mercado-Flores
- Centro Universitario de Imagen Diagnóstica, Hospital Universitario "Dr. José Eleuterio González," Monterrey, Nuevo León, México; and
| | - C Guillermo Elizondo-Riojas
- Centro Universitario de Imagen Diagnóstica, Hospital Universitario "Dr. José Eleuterio González," Monterrey, Nuevo León, México; and
| | - Frederick A Boop
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
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13
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Yan J, Gopaul R, Wen J, Li XS, Tang JF. The natural progression of VGAMs and the need for urgent medical attention: a systematic review and meta-analysis. J Neurointerv Surg 2016; 9:564-570. [PMID: 27091749 DOI: 10.1136/neurintsurg-2015-012212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 03/20/2016] [Accepted: 03/25/2016] [Indexed: 11/04/2022]
Abstract
BackgroundVein of Galen aneurysmal malformations (VGAMs) are congenital disorders that may require emergency treatment and some may cause sudden death before medical attention is provided. Some patients also have a spontaneous thrombosis.ObjectiveTo understand the natural progression of VGAMs through a systematic literature review.MethodsWe examined PubMed to identify studies published between July 1973 and March 2015. We determined the proportion of patients with VGAM who died before receiving medical attention, who received emergency treatment, or had a spontaneous thrombosis. We pooled estimates of proportions with corresponding 95% CIs calculated using the raw (ie, untransformed) proportions.ResultsThe 31 studies obtained described the outcome of 754 patients with VGAM. The probability of sudden death risk was 4% (95% CI 1% to 7%; I2=51.6%); of an emergency operation was 46% (95% CI 34% to 58%; I2=93.2%); and of spontaneous thromboses 1% (95% CI 0% to 2%; I2=0%) of cases. Differences between age and clinical outcomes of patients with spontaneous thromboses were significant according to the rank test (Mann–Whitney U test, Z=−2.398, p=0.016), both having a linear correlation (χ2 test, p=0.022).ConclusionsOver time, the rate of preoperative sudden death in patients with VGAM gradually declined and the rate of emergency operations gradually increased. The outcome of patients with early spontaneous thromboses was good. Our study provides a definitive description of the natural progression of VGAMs and the need for urgent medical attention.
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Affiliation(s)
- Jun Yan
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Guilin Medical University, Guilin City, Guangxi Zhuang Autonomous Region, China
| | - Roodrajeetsing Gopaul
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Jing Wen
- Department of Rheumatism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xi-Sheng Li
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Jing-Feng Tang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Guilin Medical University, Guilin City, Guangxi Zhuang Autonomous Region, China
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14
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Danon E, Weisz B, Achiron R, Pretorius DH, Weissmann-Brenner A, Gindes L. Three-dimensional ultrasonographic depiction of fetal brain blood vessels. Prenat Diagn 2016; 36:407-17. [DOI: 10.1002/pd.4791] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 01/03/2016] [Accepted: 01/30/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Eran Danon
- Department of Obstetrics and Gynecology; Chaim Sheba Medical Center (Affiliated to the Sackler School of Medicine, Tel-Aviv University); Ramat Gan Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology; Chaim Sheba Medical Center (Affiliated to the Sackler School of Medicine, Tel-Aviv University); Ramat Gan Israel
| | - Reuven Achiron
- Department of Obstetrics and Gynecology; Chaim Sheba Medical Center (Affiliated to the Sackler School of Medicine, Tel-Aviv University); Ramat Gan Israel
| | - Dolores H. Pretorius
- Department of Radiology; University of California, San Diego, Thornton Hospital; San Diego CA USA
| | - Alina Weissmann-Brenner
- Department of Obstetrics and Gynecology; Chaim Sheba Medical Center (Affiliated to the Sackler School of Medicine, Tel-Aviv University); Ramat Gan Israel
| | - Liat Gindes
- Department of Obstetrics and Gynecology; Chaim Sheba Medical Center (Affiliated to the Sackler School of Medicine, Tel-Aviv University); Ramat Gan Israel
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15
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Yan J, Wen J, Gopaul R, Zhang CY, Xiao SW. Outcome and complications of endovascular embolization for vein of Galen malformations: a systematic review and meta-analysis. J Neurosurg 2015; 123:872-90. [PMID: 26230476 DOI: 10.3171/2014.12.jns141249] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECT There have been many multidisciplinary approaches to the treatment of vein of Galen malformations. Endovascular embolization is the first option for treatment. However, the effects of the treatment remain controversial. The aim of this study is to assess the efficacy and safety of endovascular embolization to treat patients with vein of Galen malformations. METHODS This paper includes a retrospective analysis of a sample of 667 patients who underwent endovascular embolization to treat vein of Galen malformations. The data were obtained through a literature search of PubMed databases. The authors also evaluate the efficacy and safety of the treatment. Mortality within the follow-up period is analyzed. Pooled estimates of proportions with corresponding 95% CIs were calculated using raw (i.e., untransformed) proportions (PRAW). RESULTS In the 34 studies evaluated, neonates accounted for 44% of the sample (95% CI 31%-57%; I(2) = 92.5%), infants accounted for 41% (95% CI 30%-51%; I(2) = 83.3%), and children and adults accounted for 12% (95% CI 7%-16%; I(2) = 52.9%). The meta-analysis revealed that complete occlusion was performed in 57% (95% CI 48%-65%; I(2) = 68.2%) of cases, with partial occlusion in 43% (95% CI 34%-51%; I(2) = 70.7%). The pooled proportion of patients showing a good outcome was 68% (95% CI 61%-76%; I(2) = 77.8%), while 31% showed a poor outcome (95% CI 24%-38%; I(2) = 75.6%). The proportional meta-analysis showed that postembolization mortality and complications were reported in 10% (95% CI 8%-12%; I(2) = 42.8%) and 37% (95% CI 29%-45%; I(2) = 79.1%), respectively. Complications included cerebral hemorrhage, cerebral ischemia, hydrocephalus, leg ischemia, and vessel perforation. CONCLUSIONS The successful treatment of vein of Galen malformations remains a complex therapeutic challenge. The authors' analysis of clinical history and research literature suggests that vein of Galen malformations treated with endovascular embolization can result in an acceptable mortality rate, complications, and good clinical outcome. Future large-scale, multicenter, randomized trials are necessary to confirm these findings.
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Affiliation(s)
- Jun Yan
- Departments of 1 Neurosurgery and
| | - Jing Wen
- Rheumatism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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16
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Jagadeesan BD, Grande AW, Guillaume DJ, Nascene DR, Tummala RP. The role of percutaneous embolization techniques in the management of dural sinus malformations with atypical angioarchitecture in neonates: report of 2 cases. J Neurosurg Pediatr 2015; 16:74-9. [PMID: 25910034 DOI: 10.3171/2014.12.peds145] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dural sinus malformations (DSMs) are rare congenital malformations that can be midline or lateral in location. Midline DSMs have been reported to have a worse prognosis than lateral DSMs and have traditionally been more difficult to manage. The authors report 2 unusual manifestations of midline DSMs and their management with percutaneous transfontanelle embolization. The first patient (Case 1) presented at 21 days of life with a large midline DSM and multiple highflow dural and pial arteriovenous shunts. The child developed congestive cardiac failure and venous congestion with intracranial hemorrhage and seizures within a few weeks. The second patient (Case 2) presented with a large midline DSM found on prenatal imaging that was determined to be a purely venous malformation on postnatal evaluation. This large malformation resulted in consumptive coagulopathy and apneic episodes from brainstem compression. The patient in Case 1 was treated initially with endovascular embolization and eventually with curative percutaneous-transfontanelle embolization. The patient in Case 2 was treated with percutaneous transfontanelle embolization in combination with posterior fossa decompression and cranial expansion surgery.
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Affiliation(s)
| | - Andrew W Grande
- Department of Radiology.,Department of Neurosurgery, and.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Ramachandra P Tummala
- Department of Radiology.,Department of Neurosurgery, and.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota
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Madsen PJ, Lang SS, Pisapia JM, Storm PB, Hurst RW, Heuer GG. An institutional series and literature review of pial arteriovenous fistulas in the pediatric population: clinical article. J Neurosurg Pediatr 2013; 12:344-50. [PMID: 23909618 DOI: 10.3171/2013.6.peds13110] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Pial arteriovenous fistulas (PAVFs) are a rare form of cerebrovascular disease that tend to be overrepresented in the pediatric population. There have been limited studies of the clinical features and outcomes in this group of patients. Here, the authors attempt to better delineate this clinical entity with institutional cases and a review of the literature. METHODS A retrospective review of cases at our institution was performed to identify all pediatric patients treated for a PAVF between 2000 and 2012. RESULTS Five patients treated for a PAVF were identified. Patients had a mean age of 1.9 years at diagnosis, and the most common presenting symptoms were seizure and macrocephaly. Patients were treated primarily with embolization, and 3 patients required both N-butyl cyanoacrylate (NBCA) glue and coiling. Four of the patients had complete obliteration of the PAVF and had a pediatric overall performance category score of either 1 (n = 3) or 2 (n = 1) at follow-up. There was 1 death due to heart failure. Analysis of the literature review suggested that a younger age or presence of intracerebral hemorrhage (ICH) or congestive heart failure (CHF) at presentation likely predicts a worse prognosis. Older patients presented more often with ICH, whereas younger patients presented significantly more often in CHF. The majority of pediatric patients reported on in the literature were treated with endovascular embolization, most commonly with NBCA glue alone. Most patients (65.4%) in the literature had an excellent outcome without neurological deficit. CONCLUSIONS Pial AVFs represent a serious yet rare form of cerebrovascular disease. Pediatric patients with ICH or CHF at presentation or those who are very young are likely to have a worse prognosis. Endovascular management of these patients has greatly changed the natural history of this disease, but the complication and mortality rates suggest the need for continued insights and advances in treatment.
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Abstract
Abstract
BACKGROUND:
Demographics, hemorrhage risk, and results of surgical and endovascular treatment of spinal pial (type IV) arteriovenous fistulae (AVFs) across a large patient group have not been previously reported.
OBJECTIVE:
To report demographics, hemorrhage rates, and treatment results for these AVFs.
METHODS:
We performed a pooled analysis via the PubMed and Embase databases through November 2012. Individualized patient data were extracted and analyzed using Cox proportional hazards regression to obtain hazard ratios for hemorrhage risk factors and pooled for baseline demographics and treatment results.
RESULTS:
We extracted information on 213 patients from 28 studies. Only 1% of lesions were incidental; 93% of patients presented with neurologic deficits and 36% with hemorrhage. Patients with type IVa lesions were significantly older (mean age, 46.9 years) and demonstrated a male sex predilection (68% male). Patients with type IVc lesions were significantly younger (mean age, 18.7 years), had no sex predilection, and had the highest prevalence of syndromic conditions (29% of cases). The annual hemorrhage rate was 2.5% (95% confidence interval [CI]: 1.4%-4.7%), increasing to 5.6% for hemorrhagic fistulae (95% CI: 3.0%-10.7%; hazard ratio: 6.31; 95% CI: 0.69-57.4; P = .10). Patient sex, fistula location, and fistula subclass were not significant risk factors for hemorrhage. The surgical obliteration rate was 88%; 68% of patients improved, 26% were the same, and 6% were worse. The endovascular obliteration rate was 74%; 75% of patients improved, 14% were the same, and 11% were worse.
CONCLUSION:
We demonstrate the utility of the Anson-Spetzler a-c subclassification and underscore the efficacy of surgical and endovascular spinal AVF treatment.
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Affiliation(s)
- Bradley A. Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Gross BA, Orbach DB. Addressing challenges in 4 F and 5 F arterial access for neurointerventional procedures in infants and young children. J Neurointerv Surg 2013; 6:308-13. [PMID: 23468537 DOI: 10.1136/neurintsurg-2012-010610] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Among the technical challenges involved in safely performing neuroendovascular procedures in infants are limitations on the size of femoral arterial access catheters. Restricting groin access to 4 F and 5 F systems constrains the range of procedures that can potentially be performed. METHODS AND RESULTS We present here a consecutive series of transfemoral angiographic procedures in children with no permanent and one transient case of groin morbidity related to femoral access. We illustrate two strategies for using 4 F and 5 F systems for interventions in a manner that enables such techniques as balloon assisted coil embolization and the deployment of triaxial catheter systems to be used. CONCLUSIONS Extremely low groin morbidity is achievable using rigorous parameters around femoral catheterization in children. With creative approaches to working within the limitations of the access vessel size, complex endovascular neurointerventions are possible, even in the youngest infants.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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20
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Cohen JE, Gomori JM, Benifla M, Itshayek E, Moscovici S. Endovascular management of sigmoid sinus dural arteriovenous fistula associated with sinus stenosis in an infant. J Clin Neurosci 2012; 20:168-70. [PMID: 23010427 DOI: 10.1016/j.jocn.2012.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 06/06/2012] [Indexed: 11/17/2022]
Abstract
A 4-month-old female presented with a dural arteriovenous fistula (DAVF), which was successfully managed using endovascular techniques. There are very few case series reporting DAVF in infants younger than 12 months and, to our knowledge, only 60 pediatric patients with DAVF have been reported to date. Although most DAVF have a benign course, they can result in life-threatening hemorrhage. Endovascular therapies are usually indicated in the management of these neurosurgical vascular malformations. Endovascular therapy of DAVF in neonatal patients presents some major issues. Gaining arterial access may be problematic in femoral arteries too small for the introduction of a sizeable guiding catheter. The volumes of contrast and infused fluids must be carefully monitored to prevent fluid overload. Radiation exposure should be restricted as far as possible. This report contributes to the limited body of evidence on neonatal DAVF and its endovascular management.
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Affiliation(s)
- José E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.
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21
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Squier W. The "Shaken Baby" syndrome: pathology and mechanisms. Acta Neuropathol 2011; 122:519-42. [PMID: 21947257 DOI: 10.1007/s00401-011-0875-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/09/2011] [Accepted: 09/11/2011] [Indexed: 01/01/2023]
Abstract
The "Shaken Baby" syndrome (SBS) is the subject of intense controversy; the diagnosis has in the past depended on the triad of subdural haemorrhage (SDH), retinal haemorrhage and encephalopathy. While there is no doubt that infants do suffer abusive injury at the hands of their carers and that impact can cause catastrophic intracranial damage, research has repeatedly undermined the hypothesis that shaking per se can cause this triad. The term non-accidental head injury has therefore been widely adopted. This review will focus on the pathology and mechanisms of the three physiologically associated findings which constitute the "triad" and are seen in infants suffering from a wide range of non-traumatic as well as traumatic conditions. "Sub" dural bleeding in fact originates within the deep layers of the dura. The potential sources of SDH include: the bridging veins, small vessels within the dura itself, a granulating haemorrhagic membrane and ruptured intracranial aneurysm. Most neuropathologists do not routinely examine eyes, but the significance of this second arm of the triad in the diagnosis of Shaken Baby syndrome is such that it merits consideration in the context of this review. While retinal haemorrhage can be seen clinically, dural and subarachnoid optic nerve sheath haemorrhage is usually seen exclusively by the pathologist and only rarely described by the neuroradiologist. The term encephalopathy is used loosely in the context of SBS. It may encompass anything from vomiting, irritability, feeding difficulties or floppiness to seizures, apnoea and fulminant brain swelling. The spectrum of brain pathology associated with retinal and subdural bleeding from a variety of causes is described. The most important cerebral pathology is swelling and hypoxic-ischaemic injury. Mechanical shearing injury is rare and contusions, the hallmark of adult traumatic brain damage, are vanishingly rare in infants under 1 year of age. Clefts and haemorrhages in the immediate subcortical white matter have been assumed to be due to trauma but factors specific to this age group offer other explanations. Finally, examples of the most common causes of the triad encountered in clinical diagnostic and forensic practice are briefly annotated.
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Affiliation(s)
- Waney Squier
- Department of Neuropathology, West Wing, John Radcliffe Hospital, Oxford, UK.
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Al-Tamimi YZ, Sinha P, Johnson E, Turner L, Pollard N, Goddard A, Chumas PD, Tyagi AK. Case series of atypical high flow arterio-venous malformations in children. Childs Nerv Syst 2011; 27:1493-8. [PMID: 21842349 DOI: 10.1007/s00381-011-1477-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Accepted: 05/02/2011] [Indexed: 12/01/2022]
Abstract
Arteriovenous malformations (AVM) constitute a clinically significant form of vascular malformations in children. We present three cases of paediatric AVMs that demonstrated unusual features of high flow and significant shunting of blood without a clearly demonstrable nidus. Venous malformations were associated with the lesions. A discussion of the concepts underlying AVM physiology and how these case reports contradict these is included.
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