Neuroimaging of Cavernous Malformations

Plasma water T2 detects age-stratified differences in cardiometabolic health among familial CCM patients with Hispanic CCM1 mutation

Cerebral cavernous malformations (CCMs) are abnormal clusters of capillaries in the nervous system. This pilot study analyzed the cardiometabolic health status of individuals with familial CCMs caused by a rare mutation in the CCM1 gene (fCCM1). The aim was to compare plasma water T2 values from individuals with fCCM1 with values from metabolically unhealthy and healthy individuals with no known CCM mutations. This observational, cross-sectional study included 75 participants: 11 fCCM1 patients, 24 metabolically unhealthy and 40 metabolically healthy individuals. Plasma water T2, an early, global and practical marker of cardiometabolic health, was measured in the time domain using benchtop magnetic resonance relaxometry. The results were stratified by age (equal to or less than 45 vs. older than 45 years). Group means were compared using Welch's one-way ANOVA and post hoc Tukey-Kramer tests. Multivariable linear regression, with T2 as the outcome variable, was used to explore associations with age, gender, Hispanic ethnicity and fCCM1 status. In the younger age stratum, the fCCM1 group had a mean plasma water T2 value comparable to the metabolically healthy group (p = 0.6388), but higher than the unhealthy group (p < 0.0001). By contrast, in the older stratum, the mean plasma water T2 value for the fCCM1 group was comparable to the metabolically unhealthy group (p = 0.7819) and lower than the healthy group (p = 0.0005). Multivariable linear regression revealed that age and the interaction between age and fCCM1 status were significant predictors of T2, even after adjusting for gender and Hispanic ethnicity. Plasma water T2 shows potential as a biomarker for assessing the health status of individuals with fCCM1. Further research is needed to validate these preliminary observations and elucidate the association between CCMs and cardiometabolic health.

Plasma water T2 detects age-stratified differences in cardiometabolic health among familial CCM patients with Hispanic CCM1 mutation

Introduction

Cerebral cavernous malformations (CCMs) are abnormal clusters of capillaries in the nervous system. This pilot study analyzed the cardiometabolic health status of individuals with familial CCMs caused by a rare mutation in the CCM1 gene (fCCM1). The aim was to compare plasma water T2 values from individuals with fCCM1 with values from metabolically unhealthy and healthy individuals with no known CCM mutations.

Design

This observational, cross-sectional study included 75 participants: 11 fCCM1 patients, 24 metabolically unhealthy and 40 metabolically healthy individuals. Plasma water T2, an early, global and practical marker of cardiometabolic health, was measured in the time domain using benchtop magnetic resonance relaxometry. The results were stratified by age (equal to or less than 45 vs. older than 45 years). Group means were compared using Welch's one-way ANOVA and post hoc Tukey-Kramer tests. Multivariable linear regression, with T2 as the outcome variable, was used to explore associations with age, gender, Hispanic ethnicity and fCCM1 status.

Results

In the younger age stratum, the fCCM1 group had a mean plasma water T2 value comparable to the metabolically healthy group (p=0.6388), but higher than the unhealthy group (p<0.0001). By contrast, in the older stratum, the mean plasma water T2 value for the fCCM1 group was comparable to the metabolically unhealthy group (p=0.7819) and lower than the healthy group (p=0.0005). Multivariable linear regression revealed that age and the interaction between age and fCCM1 status were significant predictors of T2, even after adjusting for gender and Hispanic ethnicity.

Conclusion

Plasma water T2 shows potential as a biomarker for assessing the health status of individuals with fCCM1. Further research is needed to validate these preliminary observations and elucidate the association between CCMs and cardiometabolic health.

Plasma water T2 detects age-stratified differences in cardiometabolic health among familial CCM patients with Hispanic CCM1 mutation

Introduction

Cerebral cavernous malformations (CCMs) are abnormal clusters of capillaries in the nervous system. This pilot study analyzed the cardiometabolic health status of individuals with familial CCMs caused by a rare mutation in the CCM1 gene (fCCM1). The aim was to compare plasma water T2 values from individuals with fCCM1 with values from metabolically unhealthy and healthy individuals with no known CCM mutations.

Design

This observational, cross-sectional study included 75 participants: 11 fCCM1 patients, 24 metabolically unhealthy and 40 metabolically healthy individuals. Plasma water T2, an early, global and practical marker of cardiometabolic health, was measured in the time domain using benchtop magnetic resonance relaxometry. The results were stratified by age (≤ 45 vs. >45 years). Group means were compared using Welch's one-way ANOVA and post hoc Tukey-Kramer tests. Multivariable linear regression, with T2 as the outcome variable, was used to explore associations with age, gender, Hispanic ethnicity and fCCM1 status.

Results

In the younger age stratum, the fCCM1 group had a mean plasma water T2 value comparable to the metabolically healthy group (p=0.6388), but higher than the unhealthy group (p<0.0001). By contrast, in the older stratum, the mean plasma water T2 value for the fCCM1 group was comparable to the metabolically unhealthy group (p=0.7819) and lower than the healthy group (p=0.0005). Multivariable linear regression revealed that age and the interaction between age and fCCM1 status were significant predictors of T2, even after adjusting for gender and Hispanic ethnicity.

Conclusion

Plasma water T2 shows potential as a biomarker for assessing the health status of individuals with fCCM1. Further research is needed to validate these preliminary observations and elucidate the association between CCMs and cardiometabolic health.

Surgical resection of intracranial cavernous hemangioma located at uncommon location: Clinical presentation and management

Background

Intracranial cavernous hemangiomas (CHs) usually originate from the cerebral and cerebellar hemispheres, while the clinical features and optimum treatment of CHs that originate from atypical locations remain unclear.

Methods

We conducted a retrospective analysis of CHs that originated from the sellar, suprasellar, or parasellar region, the ventricular system, the cerebral falx, or the meninges in patients who underwent surgery from 2009 to 2019 in our department.

Results

In our study, fourteen patients with pathologically confirmed CHs in uncommon locations (UCHs) were enrolled; 5 were located at the sellar or parasellar region, 3 at the suprasellar region, 3 at the ventricular system, 2 at the cerebral falx, and 1 originated from parietal meninges. The most common symptoms were headache and dizziness (10/14); however, none presented with seizures. All UCHs located in the ventricular systems and 2 of the 3 UCHs located in the suprasellar region manifested as hemorrhagic lesions and shared similar radiological features compared with axial CHs; other locations of UCHs did not have a "popcorn" appearance on T2-weighted image. Nine patients achieved GTR, 2 achieved STR, and 3 achieved PR. Four out of five patients who received incomplete resection underwent adjuvant gamma-knife radiosurgery. During the average follow-up of 71.1 ± 43.3 months, no patient died and one patient encountered recurrence and de novo formation of midbrain CH. Most patients had an excellent KPS score of 90-100 (9 of 14) or a good KPS score of 80 (1 of 14).

Conclusion

We suggest that surgery is the optimum therapeutic method for UCHs located at the ventricular system, dura mater, and cerebral falx. Stereotactic radiosurgery plays an important role in the treatment of UCHs located at the sellar or parasellar region and remnant UCHs. Favorable outcomes and lesion control could be achieved by surgery.

Management of Central Nervous System Cavernomas: An Experience of the Department of Neurosurgery at the Ibn Tofail Hospital, Mohammed VI University Hospital

INTRODUCTION

Central nervous system cavernomas are congenital vascular anomalies posing a challenge not only in their diagnosis but also in their therapeutic management. The latter depends largely on their natural evolution and specifically their hemorrhagic potential.

MATERIAL AND METHODS

This paper reports the experience of the Department of Neurosurgery at the Ibn Tofail Hospital, Mohammed VI University Hospital at Marrakech in the management of central nervous system cavernomas from January 2011 to December 2018. We collected and analyzed epidemiological, clinical, radiological, therapeutic, and evolution data from 16 cases of central nervous cavernomas using a pre-established sheet.  Results: Sixteen cases of cavernomas were treated in a period of eight years; 14 patients had cerebral cavernomas and two had brainstem cavernomas. The sex ratio was 1.66 with a male predominance, and the mean age of our patients was 42 years. The clinical presentation was dominated by epileptic seizures. Cerebral MRI was performed on all our patients. In all 16 cases, the cavernomas were solitary with the majority being supra-tentorial (13 cases) and bleeding was apparent on imaging in one case. Microsurgery was performed in 13 cases, while three patients benefited from stereotactic radiosurgery. Complete resection was obtained in all patients and pathology examination showed a radio-histological correlation in 87.5% of cases. The overall evolution in operated patients was favorably marked by neurological improvement in 87.5% of cases, deterioration in 6.2% of cases, and no clinical improvement in 6.2% of the cases.

CONCLUSION

Early diagnosis coupled with macroscopically complete resection and long-term follow-up with MRI are all crucial steps to ensure the proper management of central nervous cavernomas, especially considering their risk of recurrence.

Atlas of Nervous System Vascular Malformations: A Systematic Review

Vascular malformations are frequent in the head and neck region, affecting the nervous system. The wide range of therapeutic approaches demand the correct anatomical, morphological, and functional characterization of these lesions supported by imaging. Using a systematic search protocol in PubMed, Google Scholar, Ebsco, Redalyc, and SciELO, the authors extracted clinical studies, review articles, book chapters, and case reports that provided information about vascular cerebral malformations, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 385,614 articles were grouped; using the inclusion and exclusion criteria, three of the authors independently selected 51 articles about five vascular cerebral malformations: venous malformation, brain capillary telangiectasia, brain cavernous angiomas, arteriovenous malformation, and leptomeningeal angiomatosis as part of Sturge–Weber syndrome. We described the next topics—“definition”, “etiology”, “pathophysiology”, and “treatment”—with a focus on the relationship with the imaging approach. We concluded that the correct anatomical, morphological, and functional characterization of cerebral vascular malformations by means of various imaging studies is highly relevant in determining the therapeutic approach, and that new lines of therapeutic approaches continue to depend on the imaging evaluation of these lesions.

[Cerebral and spinal cavernomas]

CLINICAL/METHODICAL ISSUE

Cavernous malformations or cavernomas belong to the angiodysplasias. They may be sporadic or familial and cause symptoms (epilepsy) despite the absence of a left-to-right shunt. In addition to intracranial locations, spinal cavernomas are also found.

STANDARD RADIOLOGICAL METHODS

Magnetic resonance imaging (MRI) and computed tomography (CT) are used for diagnosis PERFORMANCE: MRI, except for acutely or subacutely hemorrhaged cavernomas, is superior to CT for lesion detection.

ACHIEVEMENTS

CT is reserved for acute diagnosis. MRI, especially susceptibility-sensitive gradient echo sequences, can also detect cavernomas without (sub-)acute hemorrhage or calcifications.

PRACTICAL RECOMMENDATIONS

MRI is also useful for differentiating the familial form vs. sporadic form. Digital subtraction angiography (DSA) is used for differential diagnosis in rare cases, as cavernomas show no correlate here.

Role of i-CT, i-US, and Neuromonitoring in Surgical Management of Brain Cavernous Malformations and Arteriovenous Malformations: A Case Series

OBJECTIVE

We retrospectively reviewed the institutional experience in patients who underwent microsurgical resection of cavernous malformations (CMs) or arteriovenous malformations (AVMs) using a multimodal intraoperative protocol including neuronavigation, intraoperative ultrasound (i-US), computed tomography (i-CT), and neuromonitoring.

METHODS

Twenty-four patients (14 male), with a mean age of 47.5 years (range 27-73), have been included: 20 of them suffered from CMs and 4 suffered from AVMs. Neuromonitoring was used in 18 cases, when lesions were located in eloquent areas; 2 patients underwent awake craniotomy. First, an i-CT scan with and without contrast was acquired after patient positioning. Navigated B-mode ultrasound acquisition was carried out after dural opening to identify the lesion (CMs or AVMs nidus). Following identification and resection of vascular lesions, postcontrast i-CT (or CT-angio) was performed to detect and localize any small or calcified remnant (in cases of CMs) or residual vessels feeding the nidus (in cases of AVMs).

RESULTS

In 5 cases of CMs and in 1 case of AVM, i-CT identified small residual lesions. In these cases, new i-CT images were uploaded into the navigation system and used for further resection. i-US was useful before starting transsulcal or transcortical approach to identify the lesions and guide the trajectory of the approach. However, several artifacts were observed during subsequent steps of dissection, making image interpretation difficult.

CONCLUSIONS

The combination of different intraoperative real-time imaging modalities (i-CT and i-US), coupled with neuromonitoring, in the surgical management of vascular lesions, particularly if located in eloquent areas, has a positive impact on clinical outcome.

Developments in distinguishing secondary vascular headache from primary headache disorders in clinical practice

INTRODUCTION

Vascular headaches are secondary headache disorders with potentially devastating consequences if missed. Clinicians often struggle to distinguish these from primary headache disorders whereby there is no underlying structural pathology. Here, the authors describe the advancement in our understanding of vascular headache disorders, their clinical presentation and the developments in neuroimaging that facilitate diagnosis.

AREAS COVERED

Here the authors discuss the definition of primary and secondary headache disorders. They review the literature on the presentation, choice of neuroimaging and diagnostic tools that can be used to diagnose specific vascular headaches including Carotid or Vertebral artery dissection, Stroke, Temporal Arteritis, subarachnoid hemorrhage, cerebral venous thrombosis, Reversible Cerebral Vasoconstriction syndrome, Primary angiitis, AV malformation and Genetic vasculopathy. The authors discuss the influence of Covid-19 on the management of patients with headache.

EXPERT OPINION

Whilst developments in neuroimaging have been of paramount importance in the diagnosis of vascular headache disorders, there is no substitute for meticulous history taking and examination. Research has aided our understanding of clinical presentation, however further studies are needed as well as increased education of neurologists and acute physicians.

Measurement of Endothelial Barrier Function in Mouse Models of Cerebral Cavernous Malformations Using Intravital Microscopy

Vascular permeability is a major function of the microvasculature that is regulated by multiple factors including blood pressure, blood viscosity, and endothelial barrier function. Intravital microscopy has been used to directly assess vascular permeability in vivo, which allows for the accurate measurement of endothelial barrier function in a truly physiological hemodynamic context. Here, we describe the procedure for measuring endothelial barrier function in mouse models of cerebral cavernous malformations, including micropipette preparation, anesthesia, tracheotomy, jugular catheterization, cremaster dissection, imaging, and data analysis. These animals exhibit an increase in microvessel permeability and abnormal vessel morphology, which require special consideration.