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Koester SW, Rhodenhiser EG, Dabrowski SJ, Benner D, Rumalla K, Scherschinski L, Catapano JS, Graffeo CS, Srinivasan VM, Lawton MT. Radiation-Induced Cerebral Cavernous Malformations: A Single-Center Experience and Systematic Literature Review. World Neurosurg 2023; 179:222-232.e2. [PMID: 37595838 DOI: 10.1016/j.wneu.2023.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE Radiation was first demonstrated to be associated with cavernomagenesis in 1992. Since then, a growing body of literature has shown the unique course and presentation of radiation-induced cavernous malformations (RICMs). This study summarizes the literature on RICMs and presents a single-center experience. METHODS A prospectively maintained single institution vascular malformation database was searched for all cases of intracranial cavernous malformation (January 1, 1997-December 31, 2021). For patients with a diagnosis of RICM, information on demographic characteristics, surgical treatments, radiation, and surgical outcomes was obtained and analyzed. A comprehensive literature search was conducted using PubMed, Embase, Cochrane, and Web of Science databases for all reported cases of RICM. RESULTS A retrospective review of 1662 patients treated at a single institution yielded 10 patients with prior radiation treatment in the neck or head region and a subsequent diagnosis of intracranial RICM. The median (interquartile range) latency between radiation and presentation was 144 (108-192) months. Nine of 10 patients underwent surgery; symptoms improved for 5 patients, worsened for 3, and were stable for 1. The systematic literature review yielded 64 publications describing 248 patients with RICMs. Of the 248 literature review cases, 71 (28.6%) involved surgical resection. Of 39 patients with reported surgical outcomes, 32 (82%) experienced improvement. CONCLUSIONS RICMs have a unique course and epidemiology. RICMs should be considered when patients with a history of radiation present with neurologic impairment. When RICMs are identified, symptomatic patients can be treated effectively with surgical excision and close follow-up.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Emmajane G Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Snellings DA, Hong CC, Ren AA, Lopez-Ramirez MA, Girard R, Srinath A, Marchuk DA, Ginsberg MH, Awad IA, Kahn ML. Cerebral Cavernous Malformation: From Mechanism to Therapy. Circ Res 2021; 129:195-215. [PMID: 34166073 PMCID: PMC8922476 DOI: 10.1161/circresaha.121.318174] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cerebral cavernous malformations are acquired vascular anomalies that constitute a common cause of central nervous system hemorrhage and stroke. The past 2 decades have seen a remarkable increase in our understanding of the pathogenesis of this vascular disease. This new knowledge spans genetic causes of sporadic and familial forms of the disease, molecular signaling changes in vascular endothelial cells that underlie the disease, unexpectedly strong environmental effects on disease pathogenesis, and drivers of disease end points such as hemorrhage. These novel insights are the integrated product of human clinical studies, human genetic studies, studies in mouse and zebrafish genetic models, and basic molecular and cellular studies. This review addresses the genetic and molecular underpinnings of cerebral cavernous malformation disease, the mechanisms that lead to lesion hemorrhage, and emerging biomarkers and therapies for clinical treatment of cerebral cavernous malformation disease. It may also serve as an example for how focused basic and clinical investigation and emerging technologies can rapidly unravel a complex disease mechanism.
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Affiliation(s)
- Daniel A Snellings
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC (D.A.S., D.A.M.)
| | - Courtney C Hong
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (C.C.H., A.A.R., M.L.K.)
| | - Aileen A Ren
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (C.C.H., A.A.R., M.L.K.)
| | - Miguel A Lopez-Ramirez
- Department of Medicine (M.A.L.-R., M.H.G.), University of California, San Diego, La Jolla
- Department of Pharmacology (M.A.L.-R.), University of California, San Diego, La Jolla
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Abhinav Srinath
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Douglas A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC (D.A.S., D.A.M.)
| | - Mark H Ginsberg
- Department of Medicine (M.A.L.-R., M.H.G.), University of California, San Diego, La Jolla
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (C.C.H., A.A.R., M.L.K.)
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TAKAYAMA Y, JIN K, OSAWA SI, IWASAKI M, UKISHIRO K, KAKISAKA Y, TOMINAGA T, YAMAMOTO T, NAKASATO N. Epilepsy in Five Long-term Survivors of Pineal Region Tumors. NMC Case Rep J 2021; 8:773-780. [PMID: 35079547 PMCID: PMC8769476 DOI: 10.2176/nmccrj.cr.2021-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/23/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Yutaro TAKAYAMA
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kazutaka JIN
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shin-ichiro OSAWA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Masaki IWASAKI
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Kazushi UKISHIRO
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yosuke KAKISAKA
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tetsuya YAMAMOTO
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Nobukazu NAKASATO
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Cacho-Díaz B, Salmerón-Moreno K, Lorenzana-Mendoza N, Reyes A, Valdés-Ferrer SI, Gómez-Ahumada G, Reyes-Soto G, Herrera-Gómez Á. Radiotherapy induced cavernomas in adult cancer patients. Radiother Oncol 2018; 127:287-291. [DOI: 10.1016/j.radonc.2018.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Abou-Al-Shaar H, Bahatheq A, Takroni R, Al-Thubaiti I. Optic chiasmal cavernous angioma: A rare suprasellar vascular malformation. Surg Neurol Int 2016; 7:S523-6. [PMID: 27583178 PMCID: PMC4982351 DOI: 10.4103/2152-7806.187495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/27/2016] [Indexed: 11/10/2022] Open
Abstract
Background: Suprasellar cavernous malformation in the optic pathway is not commonly encountered. To date, there are only few reports present in the literature. Case Description: The authors report a rare case of suprasellar optic pathway cavernous malformation in a 33-year-old female who presented with progressive visual loss. Her imaging revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure, causing mass effect on the adjacent hypothalamus and third ventricle displacing these structures. Gross total resection of the lesion was achieved utilizing a right frontal craniotomy approach. Histopathological examination confirmed the diagnosis of suprasellar chiasmal cavernous malformation. Conclusion: Although visual pathway cavernous malformation is a rare event, it should be included in the differential diagnosis of lesions occurring suprasellarly in the visual pathway and hypothalamus.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Department of Neurosciences, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ayman Bahatheq
- Department of Neurosciences, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Radwan Takroni
- Department of Neurosciences, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ibrahim Al-Thubaiti
- Department of Neurosciences, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Passos J, Nzwalo H, Marques J, Azevedo A, Netto E, Nunes S, Salgado D. Late Cerebrovascular Complications After Radiotherapy for Childhood Primary Central Nervous System Tumors. Pediatr Neurol 2015; 53:211-5. [PMID: 26302700 DOI: 10.1016/j.pediatrneurol.2015.05.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/26/2015] [Accepted: 05/28/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Brain radiotherapy plays a central role in the treatment of certain types of childhood primary central nervous system tumors. However, damage to surrounding normal brain tissue causes different acute and chronic medical and neurological complications. Despite the expected increase in number of childhood primary central nervous system tumor survivors, studies assessing the occurrence of late cerebrovascular complications, such as cavernoma, moyamoya, microbleeds, superficial siderosis, and stroke are sparse. METHODS We undertook a retrospective consecutive case series review describing the occurrence and characteristics of late cerebrovascular complications in 100 survivors of childhood primary central nervous system tumors treated with radiotherapy. Demographic, clinical, and radiological findings including gradient echo brain magnetic resonance data were retrieved. RESULTS Late cerebrovascular complications were found in 36 (36%) of the patients included in the study. Mean age at radiotherapy was 8.6 years (3-17) and at diagnosis was 23.9 years (3-38). The majority were males (21; 58%). The most common complications were microbleeds (29/36; 80.6%) and cavernomas 19 (52.8%). In seven (19.4%), late cerebrovascular complications were symptomatic: epilepsy (two), motor and language deficit (two), and sensorineural hearing loss and progressive ataxia (three) associated with cavernomas, stroke, and superficial siderosis, respectively. Follow-up length was associated with an increased diagnosis of late cerebrovascular complications (P < 0.0001). Late cerebrovascular complications occurred more commonly in children treated with whole-brain radiation therapy (P = 0.046). Factors such as sex, chemotherapy, and histological type of tumor were not correlated with the occurrence of late cerebrovascular complications. CONCLUSION Although not usually symptomatic, late cerebrovascular complications occur frequently in survivors of childhood primary central nervous system tumors treated with radiotherapy. Prolonged follow-up increases the probability of diagnosis. The impact and prognostic value of these late cerebrovascular complications is yet to be clarified.
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Affiliation(s)
- João Passos
- Department of Neurology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Hipólito Nzwalo
- Neurology Department, Centro Hospitalar do Algarve, Algarve, Portugal.
| | - Joana Marques
- Department of Neurology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Ana Azevedo
- Department of Neurology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Eduardo Netto
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Sofia Nunes
- Department of Pediatric Neuro-Oncology, Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Duarte Salgado
- Departments of Neurology and Pediatric Neuro-Oncology, Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
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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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Detection of irreversible changes in susceptibility-weighted images after whole-brain irradiation of children. Neuroradiology 2013; 55:853-9. [PMID: 23588615 DOI: 10.1007/s00234-013-1185-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 03/29/2013] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Whole-brain irradiation is part of the therapy protocol for patients with medulloblastomas. Side effects and complications of radiation can be detected by follow-up magnetic resonance imaging (MRI). Susceptibility-weighted images (SWI) can detect even very small amounts of residual blood that cannot be shown with conventional MRI. The purpose of this study was to determine when and where SWI lesions appear after whole-brain irradiation. METHODS MRI follow-up of seven patients with medulloblastoma who were treated with whole-brain irradiation were analyzed retrospectively. SWI were part of the initial and follow-up MRI protocol. De novo SWI lesions, localization, and development over time were documented. RESULTS At time of irradiation, mean age of the patients was 13 years (±4 years). Earliest SWI lesions were detected 4 months after radiation treatment. In all patients, SWI lesions accumulated over time, although the individual number of SWI lesions varied. No specific dissemination of SWI lesions was observed. CONCLUSION Whole-brain irradiation can cause relatively early dot-like SWI lesions. The lesions are irreversible and accumulate over time. Histopathological correlation and clinical impact of these SWI lesions should be investigated.
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Menon RN, Baheti NN, Cherian A, Rathore C, Iyer RS, Radhakrishnan A. Post-irradiation "acquired cavernous angiomas" with drug resistant seizures. Epilepsy Res 2011; 96:161-5. [PMID: 21680152 DOI: 10.1016/j.eplepsyres.2011.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 05/03/2011] [Accepted: 05/19/2011] [Indexed: 10/18/2022]
Abstract
Cavernomas are well-known congenital vascular lesions with presumably high epileptogenicity. We report two patients who developed cavernomas; both were in remission from childhood acute lymphoblastic leukemia following standard chemo-radiotherapy. They developed drug-resistant focal epilepsy secondary to cavernomas and were subjected to surgical/medical management. This report highlights the ictogenesis of radiation-induced "acquired" cavernous angiomatosis in the brain. Appropriate treatment, including resection of these lesions in selected cases, improves the quality of life in such patients.
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Affiliation(s)
- Ramshekhar N Menon
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India.
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Spontaneous bleeding into a suprasellar cavernous angioma of a neonate: case report and literature review. Childs Nerv Syst 2011; 27:303-11. [PMID: 20419304 DOI: 10.1007/s00381-010-1161-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 04/15/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Cavernous angiomas (CA) are congenital intraparenchymal vascular malformations that contain sinusoidal spaces lined by a single-layer endothelium, separated by collagenous stroma with no intervening brain parenchyma. Despite the congenital origin of CA, they rarely present in the neonatal and prenatal period. In this paper, we present a case report of a neonatal suprasellar CA that presented with a bleed. We also present a literature review focusing on specific features of intracranial CA in the neonatal and fetal age groups. CASE REPORT A 27-day-old neonate presented with a left eye ptosis for 2 days, followed by a generalized seizure. A head computed tomography revealed a suprasellar hematoma with intraventricular and subarachnoid extension. Brain magnetic resonance imaging revealed hemorrhages of various ages. Magnetic resonance angiography did not reveal any vascular malformation. Surgical exploration of the suprasellar mass revealed a capsulated dense hematoma. Postoperatively, the neonate was weaned of artificial ventilation over a protracted period and remained hemiparetic with signs of third nerve palsy. Pathology revealed a CA. CA presenting as a suprasellar bleed with subarachnoid and intraventricular extension is very rare especially among neonates. To the best of our knowledge, 20 cases of CA have been reported in the neonatal and fetal period in the English literature. Neonatal CA in general and suprasellar location in particular are extremely rare lesions. Neonatal/fetal CA seems to present more aggressively and have a worse prognosis compared to those presenting at a later age.
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Thakar S, Furtado SV, Ghosal N, Hegde AS. A peri-trigonal giant tumefactive cavernous malformation: case report and review of literature. Childs Nerv Syst 2010; 26:1819-23. [PMID: 20665038 DOI: 10.1007/s00381-010-1237-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 07/15/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Giant cavernous malformations (GCMs) constitute an uncommon entity in the diagnostic armamentarium of the neurosurgeon. We report a 3-year-old boy with a GCM in the peri-trigonal region and review 13 other paediatric cases previously reported in literature. CASE A 3-year-old boy presented with right-sided hemiparesis and features of raised intracranial pressure of short duration. Computed tomography showed a large left peri-trigonal mass with a bleed. Magnetic resonance imaging showed associated perilesional edema and mass effect, rendering the lesion a tumefactive appearance. He underwent total excision of the lesion, with subsequent recovery of hemiparesis. Histopathology was reported as a cavernoma. DISCUSSION The clinico-radiological presentation of GCM is discussed based on a case report and relevant cases in literature. Good surgical outcome can be expected with total microsurgical excision. CONCLUSION A giant cavernous malformation should be one of the differentials of a lesion with a tumefactive clinico-radiological presentation in children. There should be a high index of suspicion for such a diagnosis, especially when the lesion does not enhance with contrast. This is the third case report in paediatric literature describing a periventricular location of this unusual lesion.
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Affiliation(s)
- Sumit Thakar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India.
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