Segmental hemangioma of infancy complicated by life-threatening arterial bleed

Large, ulcerated infantile hemangioma of the chest wall complicated by life-threatening hemorrhage: Case report and literature review

While ulceration is one of the most common infantile hemangioma (IH) complications, severe bleeding is a rare consequence, with a paucity of patients reported. We report a 5-month-old girl with a very large, mixed, partial segmental IH of the upper chest wall who, despite medical intervention, developed severe ulceration and multiple episodes of life-threatening bleeding that ultimately led to hemorrhagic shock. Experience in our patient and a review of six previous reports shows that severe bleeding is a risk when ulceration extends directly into an arterial feeding vessel that is often visible clinically. Other potential predictors for severe bleeding include large to very large IH size with extension of the tumor into underlying structures, segmental or partial segmental patterning, mixed and bulky morphology, and white discoloration as a sign of impending or worsening ulceration.

Preoperative administration of propranolol reduced the surgical risks of PHACES syndrome in a 14-month-old girl

PHACES syndrome is an uncommon neurocutaneous disorder first identified in 1996. Patients with PHACES syndrome often require surgical treatment for their anomalies, including intracranial vasculopathy, coarctation/interruption of the aorta, intracardiac defects, glaucoma/cataract and sternal defects. Risk factors associated with the symptoms of intraoperative/perioperative management include ischaemic stroke due to the cerebral vasculopathy, airway obstruction due to the subglottic/tracheal haemangiomas and massive bleeding due to the large haemangiomas. Recently, propranolol is considered as first-line therapy for patients with infantile haemangiomas (IHs). However, until now, there have been no reported cases of PHACES syndrome treated by propranolol to reduce the surgical risks associated with IH. In this report, we describe a case of a 14-month-old Japanese girl with PHACES syndrome treated by propranolol for IH before surgical closure of the ventricular septum defect. Oral administration of propranolol was effective in decreasing the size of IH, leading to the uneventful perioperative course.

Vascular tumors in infants and adolescents

Malignant vascular tumors as part of the vascular anomalies spectrum are extremely rare in children and young adults. Instead, benign vascular neoplasias are frequently encountered in the pediatric patient population. While vascular malformations are congenital vascular lesions, originating from a mesenchymal stem cell defect, vascular tumors are neoplastic transformations of endothelial and other vascular cells. The appropriate differential diagnosis and nomenclature according to the classification of the International Society for the Study of Vascular Anomalies (ISSVA) is decisive to initiate correct therapy. While infantile hemangioma can be routinely diagnosed by clinical means and rarely require therapy, more rare vascular tumors are frequently difficult to diagnose, require dedicated cross-sectional imaging, and benefit from an interdisciplinary treatment approach. The focus of this review is to provide an overview over the spectrum of vascular tumors, typical imaging characteristics, and summarize treatment options including interventional radiology approaches.

Clinical Practice Guideline for the Management of Infantile Hemangiomas

Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.

Current perspectives on the optimal management of infantile hemangioma

Infantile hemangiomas (IHs) are the most common benign tumor of infancy. As our understanding of their pathobiology has evolved, treatment has become more focused and tailored to specifically treat IH while minimizing adverse effects. Propranolol has gained FDA approval as the first medical therapy for a traditionally surgical disease. This review provides readers with an overview of IH, treatment modalities, and addresses specific considerations in IH disease management.

Scalp Infantile Hemangioma Complicated by Life-Threatening Bleeding

We report on an 8-month-old girl with an ulcerated occipital infantile hemangioma resulting in significant hemorrhage. The hemangioma responded rapidly to systemic propranolol and prednisolone, and we believe that describing her atypical clinical course would be helpful for others managing complicated scalp hemangiomas.

The changing face of complicated infantile hemangioma treatment

Infantile hemangiomas are the most common vascular tumors of infancy. A multidisciplinary approach including dermatologists, otolaryngologists, plastic surgeons, hematologists/oncologists and interventional/diagnostic radiologists is crucial for appropriate management of children with complicated infantile hemangiomas. Since its unforeseen discovery in 2008, propranolol has become the first-line treatment for infantile hemangiomas, eclipsing systemic corticosteroids and radiologic intervention. There are still, however, uncommon indications for more aggressive interventional management. We review the 2014-updated International Society for the Study of Vascular Anomalies (ISSVA) classification for vascular anomalies. Additionally, we suggest management algorithms for complicated lesions, including recommendations for radiologic and surgical intervention.

Surgical management of vascular anomalies in children at a tertiary care hospital in a resource-limited setting: a Tanzanian experience with 134 patients

BACKGROUND

Vascular anomalies pose major diagnostic and therapeutic challenges among pediatricians and pediatric surgeons practicing in resource limited countries. There is paucity of published data regarding this subject in Tanzania and Bugando Medical Centre in particular. This study describes our experiences on the challenges and outcome of surgical management of childhood vascular anomalies in our environment.

METHODS

Between January 2009 and December 2013, a prospective study on the surgical management of vascular anomalies was undertaken at Bugando Medical Centre.

RESULTS

A total of 134 patients (M; F = 1:2.5) were studied. The median age at presentation was 6 years. Of the 134 patients, 101 (75.4%) were diagnosed as having vascular tumors and 33 (24.6%) had vascular malformations. The head and the neck were the most frequent anatomical site recorded as having a tumor (56.7% of patients). Out of 134 patients, 129 (96.3%) underwent surgical treatment. Failure to respond to non-operative treatment (86.8%), huge disfiguring/obstructing mass (4.7%), infection (3.1%), ulceration (3.1%) and hemorrhage (2.3%) were indications for surgical intervention. Tumor excision and primary wound closure was the most common type of surgical procedure performed in 80.6% of patients. Surgical site infection was the most frequent complications accounting for 33.8% of cases. Mortality rate was 1.5%. Tumor excision and primary wound closure gave better outcome compared with other surgical options (p < 0.001). Outcome of injection sclerotherapy in 3 (3.7%) children, serial ligation of feeder vessels employed in 2 (1.6%), and conservative treatment in 5 (3.7%), were poor and required conversion to surgical excision. Despite low mortality rate recorded in this study, but ugly scar, 14 (20.6%) and limb deformity, 6 (8.8%) were problems. The overall result of surgical treatment at the end of follow up period was excellent in 108 (87.1%) patients.

CONCLUSION

Surgical excision and primary wound closure gave good outcome which could be employed in complicated and vascular anomalies which failed to respond to other treatment in regions with limited resources.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Complications of infantile hemangiomas

Most infantile hemangiomas have a spontaneous and uneventful involution and, hence, may be treated expectantly. Others, however, will present some complication along their evolution that may require prompt therapeutic interventions. Ulceration is the most common complication, and amblyopia is frequently associated with periocular tumors. Airways hemangiomas may be life-threatening, and disfigurement can heavily impact the patient's quality of life.

Update on pediatric extracranial vascular anomalies of the head and neck

PURPOSE

Vascular anomalies most frequently present at birth or in early childhood, and the craniofacial region is the most common site of involvement. A long history of misleading nomenclature born of confusion about the presentation and natural history of various vascular anomalies has made appropriate diagnosis difficult. The present article emphasizes the importance of clarity of nomenclature for proper diagnosis, both clinically and radiographically, to guide appropriate therapy. In addition, updates on clinical concepts, imaging, and treatment strategies will be discussed. Pediatric vascular anomalies can be divided into two broad categories: vascular tumors and vascular malformations. This biologic classification is based on differences in natural history, cellular turnover, and histology. An updated classification was introduced in 1996 by the International Society for the Study of Vascular Anomalies (ISSVA) to include infantile hemangioma variants, other benign vascular tumors, and combined lesions. Widespread confusion propagated throughout the literature and in clinical practice stems from the continued improper use of many of the terms used to describe vascular tumors and malformations ignoring their pathophysiology. This leads to errors in diagnosis and the dissemination of misinformation to patients and clinicians. Certain terms should be abandoned for more appropriate terms. The clinical presentation usually identifies what general type of vascular anomaly is present, either vascular tumor or vascular malformation. Imaging provides crucial information about the initial diagnosis and aids in follow-up.

CONCLUSIONS

Adoption and use of uniform nomenclature in the ISSVA classification system is the first vital step in correct diagnosis and treatment of often complicated vascular tumors and vascular malformations. A multidisciplinary team approach is necessary to provide optimal care for patients, and the necessity for specialists in all areas to communicate using standardized terminology cannot be overemphasized.

Update on vascular tumors of infancy

PURPOSE OF REVIEW

Advances have been made in the pathogenesis, diagnosis and management of vascular tumors of infancy in the past year. Propranolol therapy for infantile hemangiomas (IH) is now being used widely, and case reports, series, and adverse effects are reviewed. Kaposiform hemangioendothelioma and tufted angioma are less common than IH but more often associated with coagulopathy (Kasabach-Merritt phenomenon).

RECENT FINDINGS

Recent work suggests that stem cells, mediated by the Notch signaling pathway, may become proliferating endothelial cells that comprise IH. Large, segmental IH are more likely to develop complications that can include life-threatening bleeds; however, solitary large IH do not appear to increase the risk of hepatic IH. Segmental IH may herald underlying structural anomalies of the brain, cerebral, and cardiac vessels (PHACE syndrome--Posterior fossa defects, Hemangiomas, Arterial anomalies, Cardiac defects and Coarctation of the aorta, Eye anomalies), and new criteria aid in diagnosis. Propranolol therapy is effective in life-threatening IH and appears to stop growth and hasten involution in proliferative and plateau phase IH. Adverse effects include bradycardia, hypotension, hypoglycemia, and bronchospasm. A recent review of kaposiform hemangioendothelioma finds that an associated coagulopathy (Kasabach-Merritt phenomenon) occurs in 72%.

SUMMARY

Propranolol appears to be tremendously efficacious with fewer side effects than systemic corticosteroids, but its proper place in the therapeutic algorithm for IH and other vascular tumors awaits controlled study.