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Calloni T, Carai A, Lioi F, Cavaliere M, DE Benedictis A, Rossi S, Randi F, Rossi Espagnet MC, Trivisano M, Cesario C, Pisaneschi E, Marasi A, Savioli A, Giussani CG, Marras CE. Surgical management of pediatric intracranial cerebral cavernous malformations: a 10-year single-center experience. J Neurosurg Sci 2024; 68:278-286. [PMID: 35416451 DOI: 10.23736/s0390-5616.22.05574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) are low-flow vascular malformations made up of dilated vascular spaces without intervening parenchyma that can occur throughout the central nervous system. CCMs can occur sporadically or in familial forms. Presentation is diverse, ranging from incidental discovery of asymptomatic CCMs to drug-resistant epilepsy and hemorrhages. METHODS We describe the surgical management of CCMs in pediatric patients at Bambino Gesù Children's Hospital in Rome over the last 10 years. The cases have been stratified based on the clinical presentation and the relevant literature is discussed accordingly. RESULTS We discuss the rationale and technique used in these cases based on their presentation, as well as the generally positive outcomes we achieved with early surgical management, use of intraoperative ultrasound (ioUS) and intraoperative neuromonitoring. CONCLUSIONS Surgical management of pediatric CCMs is a safe and effective strategy, low rates of postoperative morbidity and partial resection were observed.
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Affiliation(s)
- Tommaso Calloni
- Department of Medicine and Surgery, School of Medicine, University of Milan-Bicocca, Milan, Italy
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy -
| | - Francesco Lioi
- Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Marilou Cavaliere
- Department of Medicine and Surgery, School of Medicine, University of Milan-Bicocca, Milan, Italy
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandro DE Benedictis
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Sabrina Rossi
- Pathology Unit, Department of Laboratories, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Randi
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria C Rossi Espagnet
- Neuroradiology Unit, Imaging Department, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Marina Trivisano
- Neurology Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Claudia Cesario
- Translational Cytogenomics Research Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisa Pisaneschi
- Translational Cytogenomics Research Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Marasi
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Savioli
- Department of Anesthesia and Critical Care (ARCO), IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Carlo G Giussani
- Department of Medicine and Surgery, School of Medicine, University of Milan-Bicocca, Milan, Italy
- Neurosurgery Unit, Department of Neurosciences, San Gerardo Hospital, Monza, Italy
| | - Carlo E Marras
- Neurosurgery Unit, Department of Neurosciences, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Szczygieł-Pilut E, Pilut D, Korostynski M, Kopiński P, Potaczek DP, Wypasek E. The First Potentially Causal Genetic Variant Documented in a Polish Woman with Multiple Cavernous Malformations of the Brain. Genes (Basel) 2023; 14:1535. [PMID: 37628586 PMCID: PMC10454152 DOI: 10.3390/genes14081535] [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: 06/29/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
Cerebral cavernous malformations (CCMs) are relatively common in the central nervous system. They occur in two forms, sporadic and familial (FCCMs). Three genes are recognized to be associated with FCCM, including CCM1, CCM2, and CCM3, the latter also called PDCD10. In this article, we describe a single-nucleotide variant in the PDCD10 gene in a 23-year-old Polish female with CCM. The NM_007217.4 (PDCD10): c.395+1G>A variant destroys the canonical splice donor site following exon 6. This is the first reported genetically characterized case of CCM (FCCM) in Poland.
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Affiliation(s)
- Elżbieta Szczygieł-Pilut
- Department of Neurology with the Stroke Unit and Sub-Department of Neurological Rehabilitation, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Psychology and Psychopathology of Human Development, Faculty of Philosophy, John Paul II Pontifical University, 31-002 Krakow, Poland
| | - Daniel Pilut
- Individual Clinical Practice, 31-534 Krakow, Poland;
| | - Michal Korostynski
- Laboratory of Pharmacogenomics, Department of Molecular Neuropharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 31-343 Krakow, Poland;
| | - Piotr Kopiński
- Department of Lung Diseases, Cancer and Tuberculosis, Collegium Medicum, Nicolaus Copernicus University, 85-067 Bydgoszcz, Poland;
- Krakow Center for Medical Research and Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Daniel P. Potaczek
- Translational Inflammation Research Division & Core Facility for Single Cell Multiomics, Medical Faculty, Philipps University Marburg, 35043 Marburg, Germany
- Center for Infection and Genomics of the Lung (CIGL), Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
- Bioscientia MVZ Labor Mittelhessen GmbH, 35394 Giessen, Germany
| | - Ewa Wypasek
- Krakow Center for Medical Research and Technology, John Paul II Hospital, 31-202 Krakow, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Kraków, Poland
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Goyal A, Fernandes-Torres J, Flemming KD, Williams LN, Daniels DJ. Clinical presentation, natural history, and outcomes for infantile intracranial cavernous malformations: case series and systematic review of the literature. Childs Nerv Syst 2023; 39:1545-1554. [PMID: 36917267 DOI: 10.1007/s00381-023-05903-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Intracranial cavernous malformations (CMs) are rare vascular malformations of the central nervous system in children. Infantile patients, being a developmentally vulnerable age group, pose a special challenge for management of these lesions. We pooled data from infantile patients diagnosed at our institution and individual cases published in the literature to provide input towards therapeutic decision-making. METHODS A systematic search of PubMed, MEDLINE, Embase, and Scopus was performed in accordance with PRISMA guidelines to identify all reported cases of intracranial CMs in the literature for infantile patients aged ≤ 2 years. In addition, cases from our institution diagnosed between 2010 and 2020 were also included. Individual cases were pooled and analyzed for clinical presentation, natural history, and outcomes from conservative and surgical management. RESULTS A total of 36 cases were included, of which 32 were identified from the literature. Median age at presentation was 14 months (range: 2 days to 24 months) months; 53% (n = 19) were females. Most cavernomas (64%, 23/36) were supratentorial, while 30% (n = 11) were located in brainstem and 5.5% (n = 2) in the cerebellum. With the exception of one patient, all cases were reported to be symptomatic; seizures (n = 15/31, 48.3%) and motor deficits (n = 13/31, 42%) were the most common symptom modalities. A total of 13 patients were managed conservatively upon initial presentation. No symptomatic hemorrhages were observed during 26 total person-years of follow-up. A total of 77% (28/36) underwent surgery; either upfront (23/28, 82%) at initial presentation or following conservative management. Among 12 patients who had preoperative seizures, 11/12 (91.6%) achieved seizure freedom post-resection. Among 7 patients who presented with hemiparesis preoperatively, 5 (71%) demonstrated some improvement, while 1 remained unchanged, and another patient with a brainstem cavernous malformation had worsening of motor function postoperatively. Postoperative recurrence was noted in 3 cases (3/27, 11%). CONCLUSION Annual risk of repeat hemorrhage may be low for infantile patients with intracranial cavernous malformations; however, better follow-up rates and higher number of cases are needed to make a definitive assertion. Surgical resection may be associated with high rates of epilepsy cure and provide improvement in neurological function in a select number of cases.
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Affiliation(s)
- Anshit Goyal
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jenelys Fernandes-Torres
- City University of New York School of Medicine, New York, NY, USA.,Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - David J Daniels
- City University of New York School of Medicine, New York, NY, USA.
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4
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Santos AN, Rauschenbach L, Gull HH, Dinger TF, Chihi M, Li Y, Tippelt S, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional outcome after initial and multiple intracerebral hemorrhages in children with cerebral cavernous malformations. Eur J Neurol 2023; 30:1364-1370. [PMID: 36789485 DOI: 10.1111/ene.15749] [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: 12/07/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to assess the course and predictors of functional outcome after single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs) and to conduct a risk assessment of a third bleed during the first follow-up year after second ICH. METHODS We included patients aged ≤18 years with complete baseline characteristics, a magnetic resonance imaging dataset, ≥1 CCM-related ICH and ≥1 follow-up examination, who were treated between 2003 and 2021. Neurological functional status was obtained using modified Rankin Scale scores at diagnosis, before and after each ICH, and at last follow-up. Kaplan-Meier analysis was performed to determine the cumulative 1-year risk of third ICH. RESULTS A total of 55 pediatric patients (median [interquartile range] age 12 [11] years) were analyzed. Univariate analysis identified brainstem cavernous malformation (BSCM; p = 0.019) as a statistically significant predictor for unfavorable outcome after second ICH. Outcome after second ICH was significantly worse in 12 patients (42.9%; p = 0.030) than after first ICH and in five patients (55.6%; p = 0.038) after a third ICH compared to a second ICH. Cumulative 12-month risk of rebleeding during the first year after a second ICH was 10.7% (95% confidence interval 2.8%-29.37%). CONCLUSIONS Pediatric patients with a BSCM have a higher risk of worse outcome after second ICH. Functional outcome improves over time after an ICH but worsens following each ICH compared to baseline or previous ICH. Second bleed was associated with neurological deterioration compared to initial ICH, and this deteriorated further after a third ICH.
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Affiliation(s)
- Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Hannah Hadice Gull
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Pediatrics, University Hospital of Essen, Essen, Germany
| | | | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
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5
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Rauschenbach L, Santos AN, Dinger TF, Darkwah Oppong M, Li Y, Tippelt S, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional outcome after pediatric cerebral cavernous malformation surgery. Sci Rep 2023; 13:2286. [PMID: 36759693 PMCID: PMC9911771 DOI: 10.1038/s41598-023-29472-5] [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: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
The purpose of this study was to investigate the functional outcome following surgical resection of cerebral cavernous malformations (CCM) in pediatric patients. We screened our institutional database of CCM patients treated between 2003 and 2021. Inclusion regarded individuals younger or equal than 18 years of age with complete clinical baseline characteristics, magnetic resonance imaging dataset, and postoperative follow-up time of at least three months. Functional outcome was quantified using the modified Rankin Scale (mRS) score and assessed at admission, discharge, and last follow-up examination. The primary endpoint was the postoperative functional outcome. As a secondary endpoint, predictors of postoperative functional deterioration were assessed. A total of 49 pediatric patients with a mean age of 11.3 ± 5.7 years were included for subsequent analyses. Twenty individuals (40.8%) were female. Complete resection of the lesion was achieved in 44 patients (89.8%), and two patients with incomplete resection were referred for successive remnant removal. The mean follow-up time after surgery was 44 months (IQR: 13 - 131). The mean mRS score was 1.6 on admission, 1.7 at discharge, and 0.9 at the latest follow-up. Logistic regression analysis adjusted to age and sex identified brainstem localization (aOR = 53.45 [95%CI = 2.26 - 1261.81], p = .014) as a predictor of postoperative deterioration. This study indicates that CCM removal in children can be regarded as safe and favorable for the majority of patients, depending on lesion localization. Brainstem localization implies a high risk of postoperative morbidity and indication for surgery should be balanced carefully. Minor evidence indicates that second-look surgery for CCM remnants might be safe and favorable.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany. .,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany.
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
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6
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Chowdhury SS, See AP, Eriksson LP, Boulouis G, Lehman LL, Hararr DB, Zabih V, Dlamini N, Fox C, Waak M. Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review. Semin Pediatr Neurol 2022; 43:101001. [PMID: 36344021 DOI: 10.1016/j.spen.2022.101001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma >2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).
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Affiliation(s)
| | | | | | | | | | | | - Veda Zabih
- The Hospital for Sick Children, Toronto, Canada
| | | | | | - Michaela Waak
- The University of Queensland, Australia; Children's Health Queensland Hospital, Brisbane, Australia
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7
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Bauman MMJ, Patra DP, Bendok BR. Commentary: Transcallosal Transchoroidal Approach to the Third Ventricle for Resection of a Thalamic Cavernoma-Anatomical Landmarks Review: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e211-e213. [PMID: 35972121 DOI: 10.1227/ons.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Megan M J Bauman
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA.,Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Devi P Patra
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Samanci Y, Ardor GD, Peker S. Management of pediatric cerebral cavernous malformations with gamma knife radiosurgery: a report of 46 cases. Childs Nerv Syst 2022; 38:929-938. [PMID: 35275282 DOI: 10.1007/s00381-022-05485-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pediatric cerebral cavernous malformations (CCMs) are commonly treated vascular anomalies with different clinical characteristics than their adult counterparts. Outcomes of Gamma Knife Radiosurgery (GKRS) for pediatric CCMs have not explicitly been reported. This paper reports our experience in managing pediatric CCMs with GKRS. METHODS We retrospectively reviewed the clinical features, GKRS parameters, and clinical and radiological outcomes of 46 children with 64 CCMs. RESULTS A total of 46 children, including 19 girls and 27 boys, with a median age of 16 years (3-17 years), were enrolled in the study. The median age at first CCM diagnosis was 13 years (range, 2-17 years). Twenty-two patients (47.8%) had more than one neurological symptom at the time of diagnosis, and the most common presenting symptom was seizure (28.3%). The most common location was supratentorial superficial (53.1%), and 17.4% of patients had multiple CCMs. A developmental venous anomaly was detected in 5 patients (10.9%). During a total of 52.4 retrospective patient-years in patients with > 1 hemorrhage episode, the calculated annual hemorrhage rate was 40.1%. The median post-GKRS follow-up was 79 months (range, 19-175 months), with an overall 306.2 prospective patient years. The annual hemorrhage rate (AHR) during the first 2 years after GKRS and after the initial 2 years was 1.11% and 0.46%, respectively. Regarding clinical factors and GKRS parameters, univariate analysis revealed a significant association with post-GKRS AHR and volume (p = 0.023) only. Patients with pre-GKRS seizures showed favorable seizure control (Engel class I and II) in 8 children (61.5%). There was no mortality in our series. CONCLUSION Low AHR following GKRS with no radiation-induced toxicity makes GKRS a therapeutic alternative for pediatric CCMs.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey.,Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey
| | - Gokce Deniz Ardor
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey. .,School of Medicine, Department of Neurosurgery, Koç University, Davutpasa Caddesi No: 4, 34010, Zeytinburnu, Istanbul, Turkey.
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9
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Catapano JS, Rutledge C, Rumalla K, Raygor KP, Srinivasan VM, Koester SW, Kimata AR, Ma KL, Labib MA, Spetzler RF, Lawton MT. External validation of the Lawton brainstem cavernous malformation grading system in a cohort of 277 microsurgical patients. J Neurosurg 2022; 136:1231-1239. [PMID: 34598133 DOI: 10.3171/2021.3.jns204291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The brainstem cavernous malformation (BSCM) grading system predicts neurological outcomes associated with microsurgical resection and assists neurosurgeons in selecting patients for treatment. The predictive accuracy of the BSCM grading system should be validated in a large cohort from high-volume centers to generalize its use. METHODS An external validation cohort comprised patients with a BSCM resected by the senior author (M.T.L.) since the publication of the BSCM grading system and those resected by another neurosurgeon (R.F.S.) over a 16-year period. Size, crossing the axial midpoint, the presence of a developmental venous anomaly, patient age, and timing of last hemorrhage were used to assign BSCM grades from 0 to VII. Poor neurological outcomes were recorded as modified Rankin Scale scores > 2 at last follow-up examination. RESULTS A total of 277 patients were included in the study. The average BSCM grade was 3.9, and the majority of BSCMs (181 patients, 65%) were intermediate grade (grades III-V). Outcomes were predicted by BSCM grade, with good outcomes observed in 47 of 54 patients (87%) with low-grade BSCMs, in 135 of 181 patients (75%) with intermediate-grade BSCMs, and in 21 of 42 patients (50%) with high-grade BSCMs. Conversely, proportions of patients with neurological deterioration increased with increasing BSCM grade, with worsening observed in 2 of 54 patients (4%) with low-grade BSCMs, in 29 of 181 patients (16%) with intermediate-grade BSCMs, and in 17 of 42 patients (40%) with high-grade BSCMs. In the chi-square analysis, high-grade BSCMs were associated with increased odds of neurological worsening compared to low- and intermediate-grade BSCMs (OR 5.0, 95% CI 2.4-10.4; p < 0.001). The receiver operating characteristic analysis demonstrated acceptable discrimination for predicting unfavorable functional outcomes (modified Rankin Scale score > 2) with an area under the curve of 0.74 (95% CI 0.68-0.80; p < 0.001). CONCLUSIONS This study validates the BSCM grading system in a large cohort of patients from two high-volume surgeons. BSCM grade predicted neurological outcomes with accuracy comparable to that of other grading systems in widespread use. The BSCM grading system establishes categories of low-, intermediate-, and high-grade BSCMs and a boundary or cutoff for surgery at BSCM grade V. BSCM grading guides the analysis of a particular patient's condition, but treatment recommendations must be individualized, and neurosurgeons must calibrate BSCM grading to their own outcome results, unique abilities, and practices.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Caleb Rutledge
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kavelin Rumalla
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kunal P Raygor
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Visish M Srinivasan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Stefan W Koester
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Anna R Kimata
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kevin L Ma
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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10
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Patel M, Mahajan U, Pace J, Rothstein B. Presentation and management of nervous system cavernous malformations in children: A systematic review and case report. Brain Circ 2022; 8:121-126. [PMID: 36267435 PMCID: PMC9578313 DOI: 10.4103/bc.bc_26_22] [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: 05/25/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022] Open
Abstract
Cerebral cavernous malformations (CMs) are slow-flow vascular lesions that affect up to 0.5% of the pediatric population. These lesions are at risk for hemorrhage, causing seizures, and leading to neurological deficits. Here, we conduct a literature review and then present a report of a supratentorial CM in a 2-year-old patient with no significant past medical history who presented at our institution with 1 month of eye twitching. We performed a literature search of five databases of all articles published before 2020. Our inclusion criteria included cohort and case series of children with mean age under 12 years. Our search yielded 497 unique articles, of which 16 met our inclusion criteria. In our pooled literature analysis, a total of 558 children were included, 8.3% of which had a positive family history and 15.9% had multiple CMs. About 46.1% of the children had seizures, and 88.4% of those who underwent surgery had a total resection. About 85.1% of those with epilepsy were Engel Class 1 postsurgery. Over a mean follow-up of 4.1 years, 3.4% of patients had additional neurological deficits, including paresis and speech deficits. Our analysis of published literature shows surgical intervention should be considered first-line therapy for patients who are symptomatic from CM, present with seizure, and have surgically accessible lesions. Additional work is needed on outcomes and long-term effects of minimally invasive treatments, including radiosurgery and laser ablation, in pediatric populations.
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11
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Gao X, Yue K, Sun J, Fang Z, Cao Y, Zhao B, Zhang H, Dai S, Zhang L, Luo P, Jiang X. A systematic review and meta-analysis of surgeries performed for cerebral cavernous malformation-related epilepsy in pediatric patients. Front Pediatr 2022; 10:892456. [PMID: 36147813 PMCID: PMC9485440 DOI: 10.3389/fped.2022.892456] [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: 03/09/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The clinical benefit of surgery for the treatment of cerebral cavernous malformation (CCM)-related epilepsy in pediatric patients is still controversial. Although surgical treatment of CCM-related epilepsy in children is widely recognized, the clinical benefits of controlling the seizure rate must be balanced against the risk of leading to perioperative morbidity. METHODS We conducted a comprehensive search to identify relevant studies via Ovid Medline, Web of Science and PubMed (January 1995-June 2020). The following search terms were used: "hemangioma, cavernous, central nervous system," "brain cavernous hemangioma," "cerebral cavernous hemangioma," "CCM," "epilepsy," and "seizures." The seizure control rate and the risk of postoperative adverse outcomes along with their 95% confidence intervals (CIs) were calculated. RESULTS A total of 216 patients across 10 studies were included in meta-analysis. The results showed that the control rate of epilepsy was 88% (95% CI: 76-95%). Four percent (95% CI: 2-10%) of the patients experienced temporary symptomatic adverse effects following surgical resection, and 3% (95% CI: 0-26%) of the patients developed permanent symptomatic adverse effects in the long-term follow-up after surgical excision of the CCMs. None of the patients died as a result of the CCMs or surgical treatment. CONCLUSION Surgery is an effective and safe treatment for CCM -related epilepsy in pediatric patients with a low risk of postoperative complications and death.
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Affiliation(s)
- Xiangyu Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kangyi Yue
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jidong Sun
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zheng Fang
- Reproductive Medical Center, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yuan Cao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Boyan Zhao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Haofuzi Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shuhui Dai
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Luo
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaofan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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12
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Consales A, Cognolato E, Pacetti M, Mancardi MM, Tortora D, Di Perna G, Piatelli G, Nobili L. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy (MR-gLiTT) in Pediatric Epilepsy Surgery: State of the Art and Presentation of Giannina Gaslini Children's Hospital (Genoa, Italy) Series. Front Neurol 2021; 12:739034. [PMID: 34764929 PMCID: PMC8577648 DOI: 10.3389/fneur.2021.739034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Magnetic resonance-guided laser interstitial thermal therapy (MR-gLiTT) is a novel minimally invasive treatment approach for drug-resistant focal epilepsy and brain tumors. Using thermal ablation induced by a laser diode implanted intracranially in a stereotactic manner, the technique is highly effective and safe, reducing the risk associated with more traditional open surgical approaches that could lead to increased neurological morbidity. Indications for MR-gLiTT in pediatric epilepsy surgery include hypothalamic hamartoma, tuberous sclerosis complex, cavernoma-related epilepsy, SEEG-guided seizure onset zone ablation, corpus callosotomy, periventricular nodular heterotopia, mesial temporal lobe epilepsy, and insular epilepsy. We review the available literature on the topic and present our series of patients with drug-resistant epilepsy treated by MR-gLiTT. Our experience, represented by six cases of hypothalamic hamartomas, one case of tuberous sclerosis, and one case of dysembryoplastic neuroepithelial tumor, helps to confirm that MR-gLiTT is a highly safe and effective procedure for several epilepsy conditions in children.
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Affiliation(s)
- Alessandro Consales
- Unit of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Erica Cognolato
- DINOGMI, University of Genoa, Genoa, Italy.,Unit of Child Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Mattia Pacetti
- Unit of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy.,DINOGMI, University of Genoa, Genoa, Italy
| | - Maria Margherita Mancardi
- Unit of Child Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Unit of Neuroradiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Azienda Ospedaliera Universitaria (AOU) Città della Scienza e della Salute, University of Turin, Turin, Italy
| | - Gianluca Piatelli
- Unit of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Lino Nobili
- DINOGMI, University of Genoa, Genoa, Italy.,Unit of Child Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
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13
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Santos AN, Rauschenbach L, Saban D, Chen B, Herten A, Dinger TF, Li Y, Tippelt S, Della Marina A, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Natural Course of Cerebral Cavernous Malformations in Children: A Five-Year Follow-Up Study. Stroke 2021; 53:817-824. [PMID: 34706565 DOI: 10.1161/strokeaha.121.035338] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the natural course of cerebral cavernous malformations (CCM) in the pediatric population, with special emphasis on the risk of first and recurrent bleeding over a 5-year period. METHODS Our institutional database was screened for patients with CCM treated between 2003 and 2020. Patients ≤18 years of age with complete magnetic resonance imaging data set, clinical baseline characteristics, and ≥1 follow-up examination were included. Surgically treated individuals were censored after CCM removal. We assessed the impact of various parameters on first or recurrent intracerebral hemorrhage (ICH) at diagnosis using univariate and multivariate logistic regression adjusted for age and sex. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for (re)hemorrhage. RESULTS One hundred twenty-nine pediatric patients with CCM were analyzed. Univariate logistic regression identified brain stem CCM (odds ratio, 3.15 [95% CI, 1.15-8.63], P=0.026) and familial history of CCM (odds ratio, 2.47 [95% CI, 1.04-5.86], P=0.041) as statistically significant predictors of ICH at diagnosis. Multivariate logistic regression confirmed this correlation (odds ratio, 3.62 [95% CI, 1.18-8.99], P=0.022 and odds ratio, 2.53 [95% CI, 1.07-5.98], P=0.035, respectively). Cox regression analysis identified ICH as mode of presentation (hazard ratio, 14.01 [95% CI, 1.80-110.39], P=0.012) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of (re)bleeding was 15.9% (95% CI, 10.2%-23.6%) for the entire cohort, 30.2% (20.2%-42.3%) for pediatric patients with ICH at diagnosis, and 29.5% (95% CI, 13.9%-51.1%) for children with brain stem CCM. CONCLUSIONS Pediatric patients with brain stem CCM and familial history of CCM have a higher risk of ICH as mode of presentation. During untreated 5-year follow-up, they revealed a similar risk of (re)hemorrhage compared to adult patients. The probability of (re)bleeding increases over time, especially in cases with ICH at presentation or brain stem localization.
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Affiliation(s)
- Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany. (Y.L.)
| | - Stephan Tippelt
- Department of Pediatrics, University Hospital Essen, Germany. (S.T., A.D.M., C.D.-S.)
| | - Adela Della Marina
- Department of Pediatrics, University Hospital Essen, Germany. (S.T., A.D.M., C.D.-S.)
| | | | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Germany. (B.S.)
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
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14
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Are radiation-induced cavernomas clinically relevant findings? Results from long-term follow-up with brain magnetic resonance imaging of childhood cancer survivors. Radiol Oncol 2021; 55:274-283. [PMID: 34384013 PMCID: PMC8366727 DOI: 10.2478/raon-2021-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/20/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Radiation-induced cavernomas (RIC) after cranial radiotherapy have an unknown risk of hemorrhage. Zabramski magnetic resonance imaging (MRI) classification is touted as being able to indicate non-radiation-induced cavernomas hemorrhage risk. The aim of our study was to assess the hemorrhage risk of RIC during long-term follow-up of childhood cancer survivors based on brain MRI examinations. PATIENTS AND METHODS We analyzed retrospectively long-term follow-up data of 36 childhood cancer survivors after initial diagnosis with acute leukemia (n = 18) or brain tumor (n = 18), all treated with cranial radiotherapy. Detected RIC in long-term follow-up brain MRI (1.5 or 3 Tesla) were classified following the Zabramski MRI classification and were categorized into "high" (Zabramski type I, II or V) or "low" (type III or IV) risk of hemorrhage. RESULTS 18 patients (50%) showed RIC with a significant relation to the original tumor entity (p = 0.023) and the cumulative radiation dose to the brain (p = 0.016): all 9 childhood cancer survivors diagnosed with medulloblastoma developed RIC. We classified RIC in only 3/36 childhood cancer survivors (8%) (1 patient with acute lymphoblastic leukemia [Zabramski type II] and 2 patients with medulloblastoma [type I and type II]) as high risk for hemorrhage, the remaining RIC were classified as Zabramski type IV with low risk for hemorrhage. None of the childhood cancer survivors with RIC showed symptomatic hemorrhages. CONCLUSIONS RIC are common late effects in childhood cancer survivors treated with cranial radiotherapy affecting half of these patients. However, only a few RIC (occurring in 8% of all reviewed childhood cancer survivors) were classified as high risk for hemorrhage and none of the childhood cancer survivors with RIC developed symptomatic hemorrhages. Thus, we conclude that RIC are low-risk findings in brain MRI and the course is mainly benign.
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15
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Cerebral cavernous malformation presenting in childhood: a single-centered surgical experience of 29 cases. Clin Neurol Neurosurg 2020; 194:105830. [DOI: 10.1016/j.clineuro.2020.105830] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/21/2022]
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16
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Gewiss C, Hagel C, Krajewski K. Cerebral cavernomas in adults and children express relaxin. J Neurosurg Pediatr 2019; 25:144-150. [PMID: 31756710 DOI: 10.3171/2019.9.peds19333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To shed light on the role of relaxin in cerebral cavernous malformations (CCMs) in adults and children, the authors investigated endothelial cell (EC) expression of relaxin 1, 2, and 3; vascular endothelial growth factor receptor-1 and -2 (VEGFR-1 and -2); Ki-67; vascular geometry; and hemorrhage, as well as the clinical presentation of 32 patients with surgically resected lesions. METHODS Paraffin-embedded sections of 32 CCMs and 5 normal nonvascular lesion control (NVLC) brain tissue samples were immunohistochemically stained with antibodies to relaxin 1, 2, and 3; angiogenesis growth factor receptors Flt-1 (VEGFR-1) and Flk-1 (VEGFR-2); and proliferation marker Ki-67. For morphometric analysis, Elastica van Gieson stain was used, and for hemorrhage demonstration, Turnbull stain was used. Data from the pediatric and adult CCMs were compared with each other and with those obtained from the NVLCs. Statistical analyses were performed with Fisher's exact test, the chi-square test, the phi correlation coefficient, and the Student t-test. A p value < 0.05 was considered significant. RESULTS Pediatric and adult cavernoma vessels did not significantly differ in diameter. Hemorrhage was observed in CCMs but not in NVLC samples (p < 0.05). There was no difference in expression of Ki-67, VEGFR-1 and -2, and relaxin 1, 2, and 3 in the ECs of pediatric and adult CCMs. The ECs of CCMs were largely negative for relaxin 3 compared to NVLCs (p < 0.05), whereas CCMs, compared to control brain tissue samples, more frequently expressed Flt-1 and relaxin 2 (p < 0.05). Ki-67 was not expressed in the NVLCs, but the difference was not statistically significant. Relaxin 1 and 2 expression and increased expression of VEGFR-1 were associated with a supra- versus infratentorial location (p < 0.05). CONCLUSIONS Relaxin 1 and 2 and VEGFR-1 play a role in supratentorial cavernomas. Relaxin 3 may play a physiological role in normal brain vasculature. Relaxin 1 and 3 are also found in normal cerebral vasculature. Relaxin 1, 2, and 3 are associated with increased VEGFR-1 expression.
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Affiliation(s)
- Caroline Gewiss
- 1Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg; and
| | - Christian Hagel
- 1Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg; and
| | - Kara Krajewski
- 2Department of Neurosurgery, University of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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17
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Wen R, Shi Y, Gao Y, Xu Y, Xiong B, Li D, Gong F, Wang W. The Efficacy of Gamma Knife Radiosurgery for Cavernous Malformations: A Meta-Analysis and Review. World Neurosurg 2018; 123:371-377. [PMID: 30583131 DOI: 10.1016/j.wneu.2018.12.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This meta-analysis is to evaluate the clinical efficacy of gamma knife radiosurgery (GKRS) for treating cavernous malformations. METHODS PubMed, Ovid Embase, and Ovid Medline electronic databases were searched. The primary outcome is hemorrhage rate and this meta-analysis is performed. RESULTS Nine studies are included in this meta-analysis. The overall risk ratio (RR) of hemorrhage rate of pre-GKRS and post-GKRS is 6.08 (95% confidence interval [CI], 5.04-7.35). The overall RR is 3.03 (95% CI, 2.65-4.11) between the hemorrhage rate of pre-GKRS and the first 2 years postradiosurgery, and the overall RR is 12.13 (95% CI, 1.73-85.07) comparing pre-GKRS with 2 years after GKRS. There is no significant difference of the hemorrhage rate between the first 2 years postradiosurgery and 2 years after GKRS (RR = 2.81; 95% CI, 0.20-13.42). The neurologic deficiency is the most common radiosurgery-related complication. CONCLUSIONS Patients with cerebral cavernous malformations, especially ones that were deep seated and surgically inaccessible, seem to benefit from GKRS owing to a reduction of annual hemorrhage rate in the first 2 years and 2 years after, despite several cases that suffer from negative side effects of radiation.
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Affiliation(s)
- Rong Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yifeng Shi
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yuan Gao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yangyang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Botao Xiong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Denghui Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Feilong Gong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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18
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Tinsa F, Bel Hadj I, Riant F, Ben Romdhane M, Brini I, Tournier-Lasserve E, Louati H, Abdelhak S, Hamouda S, Boussetta K. A novel large deletion in CCM1 gene in a Tunisian family. Rev Neurol (Paris) 2018; 175:194-197. [PMID: 30314744 DOI: 10.1016/j.neurol.2018.04.013] [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: 02/09/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 10/28/2022]
Abstract
Familial CCM is a rare entity associated with the mutation of three genes: CCM1 (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10). We report here the first description of a Tunisian familial CCMs composed of six members. The father and two daughters were affected and symptomatic. The two other kindred were healthy. Surgical treatment was performed in only one affected patient. Molecular analysis of KRIT1, MGC4607 and PDCD10 genes identified a large KRIT1 deletion of the first ten exons. To the best of our knowledge, this large deletion has never been reported before.
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Affiliation(s)
- F Tinsa
- Department of pediatrics B, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary Bab Saadoun, Tunis, Tunisia; University of medicine, Tunis El Manar, Tunisia; Laboratory of biomedical genomics and oncogenetics (LR11IPT05), university of Tunis El Manar, Pasteur Institut of Tunis, Tunis, Tunisia.
| | - I Bel Hadj
- Department of pediatrics B, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary Bab Saadoun, Tunis, Tunisia; University of medicine, Tunis El Manar, Tunisia
| | - F Riant
- Service de génétique moléculaire neurovasculaire, centre de référence des maladies vasculaires rares du cerveau et de l'oeil (CERVCO), AP-HP, groupe hospitalier Saint-Louis Lariboisière-Fernand-Widal, 75010 Paris, France
| | - M Ben Romdhane
- Department of pediatrics B, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary Bab Saadoun, Tunis, Tunisia; University of medicine, Tunis El Manar, Tunisia
| | - I Brini
- Department of pediatrics B, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary Bab Saadoun, Tunis, Tunisia
| | - E Tournier-Lasserve
- Service de génétique moléculaire neurovasculaire, centre de référence des maladies vasculaires rares du cerveau et de l'oeil (CERVCO), AP-HP, groupe hospitalier Saint-Louis Lariboisière-Fernand-Widal, 75010 Paris, France; UMR-S1161, université Paris-Diderot, Sorbonne-Paris-Cité, 75010 Paris, France; Inserm UMR-S1161, génétique et physiopathologie des maladies cérébro-vasculaires, 75010 Paris, France
| | - H Louati
- Department of pediatric radiology, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary, Bab Saadoun, Tunis, Tunisia
| | - S Abdelhak
- Laboratory of biomedical genomics and oncogenetics (LR11IPT05), university of Tunis El Manar, Pasteur Institut of Tunis, Tunis, Tunisia
| | - S Hamouda
- Department of pediatrics B, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary Bab Saadoun, Tunis, Tunisia; University of medicine, Tunis El Manar, Tunisia
| | - K Boussetta
- Department of pediatrics B, children's hospital Bechir Hamza, boulevrad 9 avril, 1007 Jabbary Bab Saadoun, Tunis, Tunisia; University of medicine, Tunis El Manar, Tunisia
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19
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Wang C, Zhao M, Wang J, Wang S, Jiang Z, Zhao J. Frontal Lobe Cavernous Malformations in Pediatric Patients: Clinical Features and Surgical Outcomes. J Child Neurol 2018; 33:512-518. [PMID: 29697019 DOI: 10.1177/0883073818768156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study is to investigate the clinical manifestations, surgical treatment, and neurologic outcomes of frontal lobe cavernous malformations in children. A retrospective analysis of 23 pediatric frontal lobe cavernous malformation patients who underwent surgical treatment in Beijing Tiantan Hospital was performed. The case series included 16 boys and 7 girls. Gross total removal without surgical mortality was achieved in all patients. The mean follow-up period after surgery was 33.1 months. Two patients who left hospital with motor deficits gradually recovered after rehabilitative treatment, and other patients were considered to be in excellent clinical condition. For symptomatic frontal lobe cavernous malformations, neurosurgical management should be the treatment of choice. Conservative treatment may be warranted in asymptomatic frontal lobe cavernous malformations, especially the deep-seated or eloquently located cases.
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Affiliation(s)
- Chengjun Wang
- 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Meng Zhao
- 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jia Wang
- 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhongli Jiang
- 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature. Childs Nerv Syst 2017. [PMID: 28634821 DOI: 10.1007/s00381-017-3429-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs. MATERIAL AND METHODS We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome. RESULTS A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14 years (3-18 years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6 cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162 months (mean 47.2 months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series. CONCLUSION Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.
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Akers A, Al-Shahi Salman R, A. Awad I, Dahlem K, Flemming K, Hart B, Kim H, Jusue-Torres I, Kondziolka D, Lee C, Morrison L, Rigamonti D, Rebeiz T, Tournier-Lasserve E, Waggoner D, Whitehead K. Synopsis of Guidelines for the Clinical Management of Cerebral Cavernous Malformations: Consensus Recommendations Based on Systematic Literature Review by the Angioma Alliance Scientific Advisory Board Clinical Experts Panel. Neurosurgery 2017; 80:665-680. [PMID: 28387823 PMCID: PMC5808153 DOI: 10.1093/neuros/nyx091] [Citation(s) in RCA: 282] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/09/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite many publications about cerebral cavernous malformations (CCMs), controversy remains regarding diagnostic and management strategies. OBJECTIVE To develop guidelines for CCM management. METHODS The Angioma Alliance ( www.angioma.org ), the patient support group in the United States advocating on behalf of patients and research in CCM, convened a multidisciplinary writing group comprising expert CCM clinicians to help summarize the existing literature related to the clinical care of CCM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and radiology standards, (4) neurosurgical considerations, and (5) neurological considerations. The group reviewed literature, rated evidence, developed recommendations, and established consensus, controversies, and knowledge gaps according to a prespecified protocol. RESULTS Of 1270 publications published between January 1, 1983 and September 31, 2014, we selected 98 based on methodological criteria, and identified 38 additional recent or relevant publications. Topic authors used these publications to summarize current knowledge and arrive at 23 consensus management recommendations, which we rated by class (size of effect) and level (estimate of certainty) according to the American Heart Association/American Stroke Association criteria. No recommendation was level A (because of the absence of randomized controlled trials), 11 (48%) were level B, and 12 (52%) were level C. Recommendations were class I in 8 (35%), class II in 10 (43%), and class III in 5 (22%). CONCLUSION Current evidence supports recommendations for the management of CCM, but their generally low levels and classes mandate further research to better inform clinical practice and update these recommendations. The complete recommendations document, including the criteria for selecting reference citations, a more detailed justification of the respective recommendations, and a summary of controversies and knowledge gaps, was similarly peer reviewed and is available on line www.angioma.org/CCMGuidelines .
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Affiliation(s)
| | | | - Issam A. Awad
- Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Kelly Flemming
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Blaine Hart
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | | | - Douglas Kondziolka
- Departments of Neurosurgery and Radiation Oncology, NYU Langone Medical Center, New York City, New York
| | | | - Leslie Morrison
- Departments of Neurology and Pediatrics, University of New Mexico, Albuquerque, New Mexico
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Tania Rebeiz
- Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Darrel Waggoner
- Department of Human Genetics and Pediatrics, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Kevin Whitehead
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
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22
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Genetic Screening of Pediatric Cavernous Malformations. J Mol Neurosci 2016; 60:232-8. [DOI: 10.1007/s12031-016-0806-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
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Knerlich-Lukoschus F, Steinbok P, Dunham C, Cochrane DD. Cerebellar cavernous malformation in pediatric patients: defining clinical, neuroimaging, and therapeutic characteristics. J Neurosurg Pediatr 2015; 16:256-66. [PMID: 26053436 DOI: 10.3171/2015.1.peds14366] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebellar cavernous malformations (CCMs) have not been specifically described in the pediatric age group. Authors of this study, after considering the published literature, describe the characteristic clinical, radiological, and surgical features of CCM in children. METHOSDS: Patients younger than 18 years of age who were known to have CCM and had undergone surgery between 1992 and 2014 at the authors' institution were reviewed. Pediatric CCM cases reported in the literature (case reports and cases included in series on CMs in the pediatric age group) were also analyzed for specific features of this entity. RESULTS Four male patients and 1 female patient (2.5-14 years of age) with CCM presented acutely with severe headache followed by cerebellar dysfunction. In all patients, neuroimaging (cranial CT and MRI) demonstrated hemorrhagic cerebellar lesions with heterogeneous T1 and T2 signal intensities and hyperintense blooming on susceptibility-weighted imaging. The lesions reached large sizes exhibiting spherical, cystic, and often "pseudotumoral" morphology. In 3 patients, developmental venous anomalies (DVAs) were found. In 4 of the 5 patients, the CCMs and hematomas were totally removed. All patients had a clinically excellent functional outcome without surgical complication and with complete resolution of their presenting symptoms. CONCLUSIONS Cerebellar CMs occur in all pediatric age groups and display characteristic clinical and imaging features. In children, CCMs reach large sizes and can result in massive hemorrhage, often leading to a possible diagnosis of hemorrhage into a tumor. An associated DVA is quite common. Surgery is a safe and efficient treatment option with excellent outcomes in patients.
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Affiliation(s)
- Friederike Knerlich-Lukoschus
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital and Department of Surgery, University of British Columbia;,Department of Neurosurgery, University Hospital of Schleswig-Holstein Campus Kiel, Germany
| | - Paul Steinbok
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital and Department of Surgery, University of British Columbia
| | - Christopher Dunham
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - David Douglas Cochrane
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital and Department of Surgery, University of British Columbia
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Cavernous malformations of the central nervous system (CNS) in children: clinico-radiological features and management outcomes of 36 cases. Childs Nerv Syst 2014; 30:1355-66. [PMID: 24879529 DOI: 10.1007/s00381-014-2442-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cavernous malformations (CMs) of the central nervous system (CNS) are angiographically occult vascular lesions that affect approximately 0.5 % of the general population, and one quarter of all CMs occurs in children. METHODS We retrospectively analyzed demographic, clinical, radiological, management, and follow-up data of 36 pediatric patients with CMs from a single institution. RESULTS The mean age of the children at first presentation and at operation was 8.7 and 9.6 years, respectively. However, a bimodal age distribution was found with peak under 4 years and above 12 years. Seizure was the most common single presenting symptom (38.9 %), and 61.1 % of patients had at least one seizure before the admission. Focal neurological deficits (410.7 %), intracranial hypertension (27.8 %), and headache (2.8 %) were the other manifestations. Acute/subacute hemorrhage was evident at presentation in 63.9 %. The patients under 6 years of age were found to have significantly more giant cavernomas (69 vs 20 %; p = 0.011), and more overt hemorrhages (81 vs 47 %; p = 0.065) at diagnosis than those patients above 12 years. Surgery was performed in 31 patients (32 CMs), with 26 total and 6 incomplete resections. Mean follow-up duration was 6.9 ± 4.1 years. Of all patients, 63.8 % had excellent and 30.5 % had good clinical outcomes, and also 90.9 % of the epileptic patients were seizure-free (Engel Class I) at the last follow-up. CONCLUSIONS Younger children tend to harbor larger CMs and present with hemorrhage more frequently than older ones. Microsurgical resection should be the treatment of choice in symptomatic and accessible CMs.
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Li D, Hao SY, Tang J, Xiao XR, Jia GJ, Wu Z, Zhang LW, Zhang JT. Surgical management of pediatric brainstem cavernous malformations. J Neurosurg Pediatr 2014; 13:484-502. [PMID: 24679081 DOI: 10.3171/2014.2.peds13536] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to evaluate surgical outcomes of pediatric brainstem cavernous malformations (CMs) and identify the risk factors associated with postoperative full recovery and rebleeding. METHODS The clinical charts and radiographs from a series of 52 pediatric patients (37 male and 15 female; mean age 12.2 years; range 1-17 years) who underwent surgery for brainstem CMs between 1996 and 2011 were reviewed. Follow-up evaluation measures were obtained retrospectively. Neurological function was evaluated using the modified Rankin Scale (mRS) score. RESULTS The lesion locations among the 52 patients included the midbrain (n = 7, 13.5%), pons (n = 38, 73.1%), and medulla (n = 7, 13.5%). The mean duration of symptoms was 18.5 months, and the preoperative annual hemorrhage and rebleeding rates were 12.3% and 32.5% per patient-year, respectively. The mean lesion size was 2.1 cm. Gross-total resection without surgery-related death was achieved in 49 patients (94.2%). Immediate postoperative reduced neurological function was observed in 17 patients (32.7%). Surgical morbidities developed in 25 patients (48.1%) and remained in 11 patients (21.2%) after 7.9 years of follow-up. The mean mRS scores at admission, discharge after surgery, 3 and 6 months postsurgery, and recent evaluation were 2.0, 2.3, 2.0, 1.5, and 1.0, respectively. The postoperative mRS scores at 6 months (p < 0.001) and on recent evaluation (p < 0.001) were significantly lower than those at admission. Postoperative rebleeding occurred in 2 patients, and the postoperative annual rebleeding rate was 0.5% per patient-year. By the most recent evaluation, 10 patients (19.2%) had achieved full recovery and all patients were either improved (n = 32, 61.5%) or unchanged (n = 20, 38.5%). The adverse predictors for full recovery included age ≥ 12 years (HR 0.230, p = 0.021), ≥ 2 preoperative hemorrhages (HR 0.124, p = 0.048), and poor preoperative status (HR 0.197, p = 0.040). An HR < 1 predicted poor complete recoveries. The single risk factor predicting postoperative rebleeding was incomplete resection (χ2 = 4.340, p = 0.037). CONCLUSIONS Fair outcomes for pediatric brainstem CMs could be obtained through surgery, but only a few patients achieved full recovery. Thus, to minimize surgical morbidity, surgical planning must be tailored to individual patients in all cases in which an operation is warranted. Complete resection must be attempted to reduce the risk of postoperative rebleeding. The predictors associated with complete postoperative recovery were referential for determining treatment.
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Affiliation(s)
- Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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Di Giannatale A, Morana G, Rossi A, Cama A, Bertoluzzo L, Barra S, Nozza P, Milanaccio C, Consales A, Garrè ML. Natural history of cavernous malformations in children with brain tumors treated with radiotherapy and chemotherapy. J Neurooncol 2014; 117:311-20. [PMID: 24515423 DOI: 10.1007/s11060-014-1390-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
Abstract
Cavernous malformations (CM) are cerebral irradiation-related late complications. Little is known about their natural history and the pathogenetic role of concomitant chemotherapy. We present a retrospective, single-institution study of 108 children affected with medulloblastoma, ependymoma, or germinoma treated with radio- and chemotherapy. The frequency, clinical and radiological presentations, and outcomes were analyzed to investigate the relationship among radiation dose, associated chemotherapy, age, latency and localization of radiation-induced CM. 100 out of 108 children were treated with radiotherapy for primary brain tumor; 34 (27 with medulloblastoma and 7 with other histologies) out of 100 patients developed CM. No significant relationship was found between CM and gender (p = 0.70), age (p = 0.90), use of specific chemotherapy (standard versus high-dose, p = 0.38), methotrexate (p = 0.49), and radiation dose (p = 0.45). However, CM developed more frequently and earlier when radiotherapy was associated with methotrexate (70 % of cases). Radiation-induced CM prevailingly occurred in the cerebral hemispheres (p = 0.0001). Only 3 patients (9 %) were symptomatic with headache. Three patients underwent surgery for intra- or extra-lesional hemorrhage. CM was confirmed by histopathology for all 3 patients. The vast majority of radiation-induced CM is asymptomatic, and macro-hemorrhagic events occur rarely. Concomitant therapy with methotrexate seems to favor their development. We recommend observation for asymptomatic lesions, while surgery should be reserved to symptomatic growth or hemorrhage.
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Gross BA, Smith ER, Goumnerova L, Proctor MR, Madsen JR, Scott RM. Resection of supratentorial lobar cavernous malformations in children: clinical article. J Neurosurg Pediatr 2013; 12:367-73. [PMID: 23971633 DOI: 10.3171/2013.7.peds13126] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors present a series of children with supratentorial lobar cavernous malformations (CMs). Current imaging and operative techniques along with long-term follow-up were incorporated to characterize the response to surgical treatment in this pediatric population. METHODS The senior author's operative experience was reviewed retrospectively along with a review of the Boston Children's Hospital database from 1997 to 2011 for children with supratentorial lobar CMs. Lobar CM was defined as having a supratentorial location but not involving the thalamus/hypothalamus or basal ganglia. Baseline patient demographics, pertinent radiographic findings, operative outcomes, and long-term results were evaluated and compared between patients managed operatively and those who were managed nonoperatively. RESULTS Of 238 CMs identified, 181 (76%) were lobar. Compared with patients managed with observation only, those selected for surgery were older (p = 0.03), more likely to have symptomatic lesions (p < 0.001), and had larger lesions (p < 0.001). Of the 83 CMs selected for surgery, 98% were completely resected. Over a total of 384.5 patient-years of follow-up after surgery (mean 4.6 years; median 2.7 years; range 0.1-22.3 years), there were no subsequent hemorrhages in any patient undergoing complete resection; 1 of the 2 incompletely resected lesions rebled during the follow-up period. Radiographically, there was 1 recurrence (1.2%) in a child with multiple CMs; there were no recurrences of completely resected single lesions. Of the 48 patients who presented with seizures (acute or chronic), 46 (96%) were seizure free at follow-up. The permanent neurological complication rate of surgery was 5%; these complications were limited to those patients whose lesions were in eloquent locations. CONCLUSIONS Pediatric patients with symptomatic supratentorial lobar CMs are ideal candidates for surgery, for which there are high complete resection rates, rewarding long-term seizure outcomes, and low operative morbidity. Observation may be warranted in smaller asymptomatic lesions located within eloquent cortex.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Brainstem Cavernous Malformations: 1390 Surgical Cases from the Literature. World Neurosurg 2013; 80:89-93. [DOI: 10.1016/j.wneu.2012.04.002] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 04/03/2012] [Indexed: 11/23/2022]
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Amato MCM, Madureira JFG, Oliveira RSD. Intracranial cavernous malformation in children: a single-centered experience with 30 consecutive cases. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:220-8. [DOI: 10.1590/0004-282x20130006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 10/26/2012] [Indexed: 11/21/2022]
Abstract
Objectives: To determine the clinical presentation and treatment outcome of pediatric intracranial cavernous malformation (CM) in a single-centered institution. Methods: Clinical data review of 30 patients under 18 years-old who had undergone surgery for cavernous malformation from January 1993 to December 2011. Results: The Study Group included 18 males and 12 females (mean age: 8.7 years-old). Symptoms at presentation were seizures (16/30, 53.3%), headache (15/30, 50.0%), and focal neurological deficits (11/30, 36.6%). Multiple cavernous malformations were found in 5/30 (16.6%). According to location, patients were classified in groups: (G1) brain-steam in 5/30 (16.6%), (G2) cerebellum in 2/30 (6.6%), (G3) supratentorial associated with seizures in 16/30 (53.3%), and (G4) supratentorial without seizures in 7/30 (23.3%). Surgical resection was performed in 26 out of 30 (86.6%) patients. The mean follow-up period was 4.1 years. Of 15 children followed-up with preoperative seizures, all were rendered seizure-free after surgery. Conclusions: For symptomatic solitary cavernous malformation, the treatment of choice is complete microsurgical excision preceded by careful anatomical and functional evaluation. For multiple cavernous malformation or asymptomatic patients, the treatment modalities must be cautiously considered.
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Kivelev J, Niemelä M, Hernesniemi J. Characteristics of cavernomas of the brain and spine. J Clin Neurosci 2012; 19:643-8. [DOI: 10.1016/j.jocn.2011.08.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 08/18/2011] [Accepted: 08/19/2011] [Indexed: 01/05/2023]
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Kim YS, Lee JI, Choi CH, Ko JK. Massive intracerebral hemorrhage caused by a cavernous malformation. J Korean Neurosurg Soc 2012; 51:37-9. [PMID: 22396841 PMCID: PMC3291704 DOI: 10.3340/jkns.2012.51.1.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 05/19/2011] [Accepted: 12/05/2011] [Indexed: 11/29/2022] Open
Abstract
We present a rare case of massive intracerebral hemorrhage resulting from a small, superficially-located supratentorial cavernous malformation, or cavernoma. These lesions rarely lead to massive, life-threatening intracerebral hemorrhages. A 17-year-old female presented with a 3-week history of declining mental status. Brain computed tomography and magnetic resonance imaging revealed a sizable intracranial hemorrhage, within the right occipital region, associated with a small nodule at the hematoma's posterior margin. An emergency operation removed the entire hematoma and nodule. Histological examination of the nodule was compatible with a diagnosis of cavernous malformation. The patient's post-operative course was uneventful.
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Affiliation(s)
- Young Soo Kim
- Department of Neurosurgery, Medical Reserch Institute, Pusan National University Hospital, Busan, Korea
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Kivelev J, Niemelä M, Hernesniemi J. Treatment strategies in cavernomas of the brain and spine. J Clin Neurosci 2012; 19:491-7. [PMID: 22325075 DOI: 10.1016/j.jocn.2011.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/25/2022]
Abstract
The management of brain and spinal cavernomas includes two main options: (i) conservative treatment or (ii) surgical removal. Clinical experience related to cavernoma patients falls into four major categories: the surgical or conservative treatment of incidental or symptomatic cavernomas. In many patients, cavernomas exist as fairly benign lesions, frequently remaining clinically silent for life. This observation argues against the active treatment of all cavernoma patients; rather for the meticulous selection of only those more likely to benefit from surgery. Thus, the most crucial task in successful management of cavernomas is appropriate patient selection. In this review, we present our institutional experience on cavernoma management supplemented with data from the literature.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, Helsinki 00260, Finland.
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Abstract
INTRODUCTION Pediatric stroke, while increasingly recognized among practitioners as a clinically significant, albeit infrequent entity, remains challenging from the viewpoint of clinicians and researchers. DISCUSSION Advances in neuroimaging have revealed a higher prevalence of pediatric stroke while also provided a safer method for evaluating the child's nervous system and vasculature. An understanding of pathogenic mechanisms for pediatric stroke requires a division of ages (perinatal and childhood) and a separation of mechanism (ischemic and hemorrhagic). This article presents a review of the current literature with the recommended divisions of age and mechanism. CONCLUSION Guidelines for treatment, though limited, are also discussed.
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Englot DJ, Han SJ, Lawton MT, Chang EF. Predictors of seizure freedom in the surgical treatment of supratentorial cavernous malformations. J Neurosurg 2011; 115:1169-74. [PMID: 21819194 DOI: 10.3171/2011.7.jns11536] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Seizures are the most common presenting symptom of supratentorial cerebral cavernous malformations (CCMs) and progress to medically refractory epilepsy in 40% of patients. Predictors of seizure freedom in the resection of CCMs are incompletely understood. METHODS The authors systematically reviewed the published literature on seizure freedom following the resection of supratentorial CCMs in patients presenting with seizures. Seizure outcomes were stratified across 12 potential prognostic variables. A total of 1226 patients with supratentorial CCMs causing seizures were identified across 31 predominantly retrospective studies; 361 patients had medically refractory epilepsy. RESULTS Seventy-five percent of the patients were seizure free after microsurgical lesion removal, whereas 25% continued to have seizures. All patients had had preoperative seizures and > 6 months of postoperative follow-up. Modifiable predictors of postoperative seizure freedom included gross-total resection (OR 36.6, 95% CI 8.5-157.5) and surgery within 1 year of symptom onset (OR 1.83, 95% CI 1.30-2.58). Additional prognostic indicators of a favorable outcome were a CCM size < 1.5 cm (OR 15.4, 95% CI 5.2-45.4), the absence of multiple CCMs (OR 2.02, 95% CI 1.13-3.60), medically controlled seizures (OR 2.38, 95% CI 1.29-4.39), and the lack of secondarily generalized seizures (OR 3.33, 95% CI 2.09-5.30). Other factors, including extended resection of the hemosiderin ring, were not significantly predictive. CONCLUSIONS In the surgical treatment of supratentorial CCMs, gross-total resection and early operative intervention may improve seizure outcome. While surgery should not be considered the first-line treatment for CCM-related epilepsy, it is important to understand the variables associated with seizure freedom in CCM resection given the considerable morbidity and diminished quality of life associated with epilepsy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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Treatment strategies and outcome of pediatric cerebral cavernomas. Neurol Sci 2010; 32:735. [PMID: 20596740 DOI: 10.1007/s10072-010-0366-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 06/22/2010] [Indexed: 10/19/2022]
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