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Brake A, Fry L, Chatley KS, Peterson J, Stepp T, Wang F, Ebersole K. Volume staged stereotactic radiosurgery and endovascular embolization in the treatment of cerebral proliferative angiopathy: lessons learned. Br J Neurosurg 2024; 38:1047-1051. [PMID: 34894924 DOI: 10.1080/02688697.2021.2013437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/21/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
Purpose of the ArticleCerebral proliferative angiopathy (CPA) is a rare and recently characterized vascular malformation that is often mistaken for a large, diffuse arteriovenous malformation (AVM). However, distinguishing the two entities is critical, as while the diseases may appear similar on imaging, they are completely different entities. The most distinguishing features of CPA compared to AVM are the presence of normal functioning brain within the 'nidus' of the abnormality and the proliferative nature of the nidus. While the management of AVM is considered well understood, the management of CPA is unclear. Typical treatment may include conservative management, targeted embolization, and/or surgical revascularization.Materials and MethodsHere, we present a patient who was initially diagnosed with a large, diffuse AVM in the posterior fossa. Initially managed conservatively, the development of progressive, debilitating neurologic symptoms prompted treatment. We pursued staged endovascular intervention and improved her initial outlook. Thereafter, volume-staged stereotactic radiosurgery (VS-SRS) was pursued to attempt to achieve a definitive treatment.Results and ConclusionsUltimately, while the treatment proved successful clinically and radiographically, the post-treatment course was exceptionally challenging. In retrospect, it is clear the working diagnosis was incorrect, and CPA was the true diagnosis. To our knowledge, this is the first known application of this treatment approach for CPA. However, the post-treatment course and final clinical outcome likely reflect the important differences between AVM and CPA. For these reasons, we are cautious to recommend the treatment course as prescribed in this case but hope to highlight important lessons learned in managing this rare condition.
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Affiliation(s)
- Aaron Brake
- School of Medicine, The University of Kansas, Kansas City, KS, USA
| | - Lane Fry
- School of Medicine, The University of Kansas, Kansas City, KS, USA
| | - Kevin S Chatley
- Department of Neurosurgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Jeremy Peterson
- Department of Neurosurgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Timothy Stepp
- Department of Neurosurgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Fen Wang
- Department of Radiation Oncology, The University of Kansas Health System, Kansas City, KS, USA
| | - Koji Ebersole
- Department of Neurosurgery, The University of Kansas Health System, Kansas City, KS, USA
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Zedde M, Grisendi I, Assenza F, Napoli M, Moratti C, Lara B, Di Cecco G, D’Aniello S, Pavone C, Pezzella FR, Candelaresi P, Andreone V, Valzania F, Pascarella R. Neurovascular Issues in Antiphospholipid Syndrome: Arterial Vasculopathy from Small to Large Vessels in a Neuroradiological Perspective. J Clin Med 2024; 13:3667. [PMID: 38999233 PMCID: PMC11242764 DOI: 10.3390/jcm13133667] [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: 05/01/2024] [Revised: 06/10/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune prothrombotic condition characterized by venous thromboembolism, arterial thrombosis, and pregnancy morbidity. Among neurological manifestations, arterial thrombosis is only one of the possible associated clinical and neuroradiological features. The aim of this review is to address from a neurovascular point of view the multifaceted range of the arterial side of APS. A modern neurovascular approach was proposed, dividing the CNS involvement on the basis of the size of affected arteries, from large to small arteries, and corresponding clinical and neuroradiological issues. Both large-vessel and small-vessel involvement in APS were detailed, highlighting the limitations of the available literature in the attempt to derive some pathomechanisms. APS is a complex disease, and its neurological involvement appears multifaceted and not yet fully characterized, within and outside the diagnostic criteria. The involvement of intracranial large and small vessels appears poorly characterized, and the overlapping with the previously proposed inflammatory manifestations is consistent.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Federica Assenza
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Manuela Napoli
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
| | - Claudio Moratti
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
| | - Bonacini Lara
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
| | - Giovanna Di Cecco
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
| | - Serena D’Aniello
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
| | - Claudio Pavone
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
| | | | - Paolo Candelaresi
- Neurology and Stroke Unit, AORN Antonio Cardarelli, 80131 Naples, Italy; (P.C.); (V.A.)
| | - Vincenzo Andreone
- Neurology and Stroke Unit, AORN Antonio Cardarelli, 80131 Naples, Italy; (P.C.); (V.A.)
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (B.L.); (G.D.C.); (S.D.); (C.P.); (R.P.)
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Luo FR, Zhou Y, Wang Z, Liu QY. Cerebral proliferative angiopathy in pediatric age presenting as neurological disorders: A case report. World J Clin Cases 2023; 11:8071-8077. [DOI: 10.12998/wjcc.v11.i33.8071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare subtype of arteriovenous malformation. It is extremely rare in pediatric patients and has serious implications for developing children. However, reports of these disorders worldwide are limited, and no uniform reference for diagnosis and treatment options exists. We report the case of a 6-year-old with CPA having predominantly neurological dysfunction and review the literature on pediatric CPA.
CASE SUMMARY We report the case of a pediatric patient with CPA analyzed using digital subtraction angiography (DSA) who presented initially with a neurological disorder as the main manifestation. This case is the basis for further discussion of the clinical presentation, pathogenesis, diagnosis, and treatment of CPA in children. After the cerebral DSA, the patient was treated conservatively with sedation, fluid replacement, and blood anticoagulation. She could not cooperate with the follow-up magnetic resonance imaging examination because of her young age, and her family declined further treatment because of the surgery’s high risk. She was followed up for 3 months; her symptoms did not worsen.
CONCLUSION This report of rare pediatric CPA can inform and advance clinical research on congenital cerebrovascular diseases.
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Affiliation(s)
- Fu-Ren Luo
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Ying Zhou
- Department of Radiology, Mianyang Central Hospital, Mianyang 621000, Sichuan Province, China
| | - Zhong Wang
- Department of Radiology, Mianyang Central Hospital, Mianyang 621000, Sichuan Province, China
| | - Qi-Yu Liu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
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Srivastava T, Gandhi A, Kumar R. Clinico-radiological features of cerebral proliferative angiopathy: A large case series from India. Neuroradiol J 2022; 35:742-750. [PMID: 35614873 PMCID: PMC9626836 DOI: 10.1177/19714009221096816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Based on angiographic features, a rare subgroup, different from classical brain AVMs, called cerebral proliferative angiopathy (CPA) was suggested by Lasjaunias et al. in 1989. There are only few reports of CPA described from Asia. Liu et al. has described 5 cases of CPA from China. The objective of study was to evaluate the clinico-radiological features of patients with CPA in our cohort and to find out the differences between our study and the study by Lasjaunias and Liu et al. METHODS We retrospectively analysed cases of CPA from March 2012 to April 2020. All radiological images of the patients with AVMs were studied and findings suggestive of CPA were identified. We found 10 patients with CPA out of 272 cases of AVM (10/272) and described the various demographic and clinico-radiological features. RESULTS The age of the patients with CPA in our series varied from 14 to 53 years and the mean age was 28.6 years. There was male preponderance (60%) with male to female ratio of 3:2. The most common presentation was seizure (70%). Intracranial haemorrhage was present in five patients. One patient had cerebral infarction. CONCLUSIONS There were substantial differences in clinico-radiological profile of patients with CPA in our cohort as compared to the study by Lasjaunias et al. and Liu et al. in form of male dominance, higher rate of ICH and seizure. In our knowledge, this is the second largest series of CPA worldwide and the first largest series in Asia.
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Affiliation(s)
| | - Ashok Gandhi
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, India
| | - Rahul Kumar
- GS Neuroscience Clinic and Reasearch
Centre, Patna, India
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Use of beta-blocker in cerebral proliferative angiopathy: a case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Ito S, Kanagaki M, Yoshimoto N, Hijikata Y, Shimizu M, Kimura H. Cerebral proliferative angiopathy depicted by four-dimensional computed tomographic angiography: A case report. Radiol Case Rep 2022; 17:2332-2336. [PMID: 35570862 PMCID: PMC9095649 DOI: 10.1016/j.radcr.2022.03.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/30/2022] [Indexed: 11/18/2022] Open
Abstract
Cerebral proliferative angiopathy is a rare cerebrovascular disorder characterized by diffuse abnormal vessels with intermingled brain parenchyma fed by many arteries and draining into many veins without high-flow arteriovenous shunts, which is usually confirmed by conventional digital subtraction angiography. However, dilution of the contrast medium due to the markedly increased blood flow and volume in cerebral proliferative angiopathy leads to low-contrast angiography. We report a 53-year-old man with cerebral proliferative angiopathy who underwent CT, MR imaging, MR angiography, digital subtraction angiography and 4D-CTA. The 4D-CTA exhibited abnormal vessels without early venous filling between the atrophic brain parenchyma in higher contrast than the angiography due to high spatial and time resolution, whereas the left external carotid angiography visualized the characteristic transdural supply more clearly than the 4D-CTA due to high vascular selectivity. Therefore, novel 4D-CTA and conventional angiography plays a complementary role in the accurate diagnosis of cerebral proliferative angiopathy. Taking invasiveness into account, 4D-CTA may be advantageous for the diagnosis of cerebral proliferative angiopathy based on the characteristic imaging findings.
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Hess RM, Zhang JF, Cappuzzo JM, Bregy A, Levy EI. Cerebral Proliferative Angiopathy Presenting as Subdural Hematoma: A Case Report and Systematic Literature Review. World Neurosurg 2022; 164:281-289. [PMID: 35636668 DOI: 10.1016/j.wneu.2022.05.096] [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: 04/03/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
Cerebral proliferative angiopathy (CPA) is a rare cerebrovascular pathology that presents with unique clinical features due to distinct histologic, angiographic, and pathophysiologic characteristics that separate it from classical arteriovenous malformation. The disorder is characterized by uncontrolled angiogenesis in which functional brain parenchyma is interspersed with abnormal vascular channels without a distinct nidus. Common presenting symptoms include headache, seizures, and stroke-like symptoms. Hemorrhagic presentations are rare in contrast to the typical presentations of classical arteriovenous malformation. Here, we report a young woman with a history of a suspected connective tissue disorder who presented to the emergency department with worsening headaches in a delayed fashion after experiencing minor head trauma and was found to have a left-sided subdural hematoma. Angiography confirmed a diagnosis of CPA after abnormal cortical vasculature was noted during the patient's craniotomy. A systematic review of CPA cases described in the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with the findings discussed.
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Affiliation(s)
- Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jeff F Zhang
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Amade Bregy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA.
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8
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Hemorrhagic cerebral proliferative angiopathy in two pediatric patients: case reports. Childs Nerv Syst 2022; 38:789-794. [PMID: 33956211 DOI: 10.1007/s00381-021-05181-0] [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: 10/30/2020] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Cerebral proliferative angiopathy (CPA) is an infrequent vascular malformation. It is composed of a nidus, arterial feeders, and venous drainage. Some special features differentiate it from the common arteriovenous malformations (AVM). The nidus has normal cerebral tissue intermingled and occupies a large portion of the brain. There is a frequent transdural arterial supply. Arterial feeders and draining veins are of small caliber concerning the nidus size. Ischemic strokes are the most common clinical event. Intracranial bleeding when occurs has a worse prognosis due to its high recurrence rate. We have presented two cases of CPA in pediatric patients who required surgical resolution of their acute episode.
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Engin EF, Polat B, Ertan Akan G, Akgül E. Cerebral proliferative angiopathy accompanied by cerebral cavernous malformation: A case report. Clin Neurol Neurosurg 2021; 210:107011. [PMID: 34741975 DOI: 10.1016/j.clineuro.2021.107011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/28/2022]
Abstract
Cerebral Proliferative Angiopathy (CPA) is a rare vascular malformation that is distinguished from classical brain arteriovenous malformations (AVM) in its imaging findings and clinical progression but more importantly in its pathophysiology. Here we report the case of a 37-year-old male patient with CPA accompanied by Cerebral Cavernous Malformation (CCM) in hopes to expand the inquiry into the pathophysiology of this rare lesion. A patient with progressive headache, right-sided weakness, and impaired speech were evaluated at our medical center. Neuroimaging studies were performed, and the patient was diagnosed with CPA. The patient has been followed up with conservative management and periodic neuroradiological evaluation for 5 years. Digital subtraction angiography (DSA) showed a vascular malformation diffusely covering the left hemisphere that is consistent with CPA. In addition, 2 sequential CCMs were detected in the right hemisphere. Also, the patients' familial history included two brothers with CCMs. The coexistence of CPA with CCM and patients' familial history of CCM could suggest the possibility of a common pathophysiological element.
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Affiliation(s)
- Eyüp Furkan Engin
- Medical Directory, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Burcu Polat
- Department of Neurology, Istanbul Medipol University, Istanbul, Turkey
| | - Gülhan Ertan Akan
- Department of Radiology, Istanbul Medipol University, Istanbul, Turkey
| | - Erol Akgül
- Interventional Neuroradiology Section, Radiology Department, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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Xia Y, Yu XF, Ma ZJ, Sun ZW. Hemorrhagic transformation of ischemic cerebral proliferative angiopathy: A case report. World J Clin Cases 2021; 9:5730-5736. [PMID: 34307632 PMCID: PMC8281439 DOI: 10.12998/wjcc.v9.i20.5730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/06/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare vascular disease characterized by the presence of diffuse vascular proliferation, progressive vascular hyperflow and vasodilation of multiple vessels in the normal brain parenchyma. Unlike cerebral arteriovenous malformations, CPA has a mixed appearance between that of lesions with cell proliferation and endothelial proliferation. To date, the pathogenesis of CPA is unclear, in which changes induced by cortical ischemia in the elastic layer of the blood supply artery and smooth muscle cells may be involved.
CASE SUMMARY In this article, we retrospectively analyzed a case of hemorrhagic transformation of ischemic CPA diagnosed by digital subtraction angiography and reviewed the related literature for further exploration of its pathogenesis, diagnosis and treatment.
CONCLUSION The information in the present case report may facilitate further clinical research on this cerebrovascular disease.
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Affiliation(s)
- Yu Xia
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Xian-Feng Yu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Zhen-Juan Ma
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Zhong-Wu Sun
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
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