Congenital intracranial vascular malformations in children

Endovascular Treatment of Congenital External Carotid-Jugular Fistula: Case Report and Review of the Literature

Congenital vascular malformation (CVM) between the external carotid artery and the internal jugular vein is a rare disease, it originates as a consequence of arrested development during various stages of embryogenesis. The natural history of CMVs is progressive growth, it can remain clinically silent until it progresses causing local swelling accompanied by symptoms and signs of arteriovenous shunting, mass effect, ischemic insult with ulceration of skin or bleeding. In literature only few cases of CMVs have been reported, therefore there is still no consensus about the correct surgical approach to this pathology. We report an uncomplicated case of CVMs in a 15-year-old female successfully treated with coils embolization. To our knowledge, this is the eighth reported case in the literature review.

Arteriovenous fistula with associated aneurysms coexisting with dural arteriovenous malformation of the anterior inferior falx. Case report and review of the literature

This 24-year-old man presented with an unusual case of a high-flow arteriovenous fistula (AVF). This lesion was similar to giant AVFs in children that have been previously described in the literature. In patients in whom abnormalities of the vein of Galen have been excluded and in whom presentation occurs after 20 years of age, a diagnosis of congenital AVF is quite unusual. The fistula in this case originated in an enlarged callosomarginal artery and drained into the superior sagittal sinus via a saccular vascular abnormality. Two giant aneurysmal dilations of the fistula were present. In an associated finding, a small falcine dural arteriovenous malformation (AVM) was also present. Arterial supply to the AVM arose from both external carotid arteries and the left vertebral artery, with drainage through an aberrant vein in the region of the inferior sagittal sinus into the vein of Galen. Craniotomy with exposure and trapping of the AVF was performed, with subsequent radiosurgical (linear accelerator) treatment of the dural AVM. Through this combination of microsurgical trapping of the AVF and radiotherapy of the dural AVM, an excellent clinical outcome was achieved.

Clinical studies of de novo aneurysms

Although multiple cerebral aneurysms ae well recognized, a new aneurysm has only rarely been documented after successful treatment for an aneurysm elsewhere. In our consecutive series of 986 patients with intracranial saccular arterial aneurysm collected from 1975 to 1990, nine patients who had previously unverified (hence, de novo) intracranial aneurysms and ruptures at intervals of 4 to 7.5 years after clipping of an initial aneurysm are presented here. All nine had undergone successful treatment of a previous aneurysm; preoperative and postoperative angiography showed not only successful clipping of the first aneurysm but also no incidence of multiple aneurysms. These patients had suffered from hypertension before their second admission. Seven of the nine patients were treated surgically. All patients had experienced angiographical or symptomatic vasospasm after the first subarachnoid hemorrhage. In the second admission however, seven patients who underwent the surgery for a new aneurysm suffered from no vasospasm in spite of the prominent second subarachnoid hemorrhage. Two of the nine patients died of primary brain damage due to the hemorrhage and underwent necropsy. A histological study of a new aneurysm demonstrated the same findings as that of a usual saccular aneurysm. This clinical study of our patients suggests that it is important to control blood pressure for protection against a new aneurysm formation.

A study on the venous drainage of 150 cerebral arteriovenous malformations as related to haemorrhagic risks and size of the lesion

In this paper we study the venous drainage of 150 cerebral arteriovenous malformations (AVM), correlating the number of efferent veins with the symptoms of clinical onset and with the size of the lesions. Statistical analysis demonstrates that those AVM's which in the angiograms show only one draining vein have a high risk of haemorrhage. As the number of drainage veins increases, this bleeding risk decreases, becoming quite low in angiomas with multiple drainage veins, which we denominate "medusa-head angiomas". Statistics also demonstrate that small angiomas (less than 2 centimeter on diameter) usually have only one drainage vein, thus carrying a high risk of haemorrhage. As their size increase, so do the number of veins, and the possibility of haemorrhage decreases.

Hemorrhagic stroke in infancy, childhood, and adolescence

The authors report on factors influencing the outcome after hemorrhagic strokes in infants, children, and adolescents over a period of 14 years. Their series comprised primary hemorrhage in 24 cases (46.2%), including 5 cases of vitamin K deficiency; arteriovenous malformation in 20 cases (38.5%); intracranial aneurysm and moya-moya disease in 3 cases (5.7%) each; and spinal angioma in 2 cases (3.9%). Ten of 52 patients with juvenile hemorrhagic strokes died despite surgical treatment. These fatal cases involved an intraparenchymal hematoma with ventricular casts, and unilateral hydrocephalus suggesting acute, uncontrollable intracranial hypertension. The "child's biologic plasticity" plays an important role in the favorable prognosis in infants, children, and adolescents with hemorrhagic strokes. On the contrary, cases with intraventricular hemorrhage due to any pathologic condition have an unfavorable prognosis.

Vascular malformations of the central nervous system: a morphological overview

Vascular malformations of the central nervous system (C.N.S.) are classified by size, location, and morphologic type, distinguishing capillary telangiectasias, cavernous malformations, venous angiomas, arteriovenous malformations (AVMs) including varix of the great vein of Galen, and other vascular malformations (e.g. Sturge-Weber syndrome). The morphology and predominant location pattern of the different types of vascular malformations in the brain and spinal cord, and their embryology are reviewed. In the brain and its coverings, all types mainly AVMs and venous angiomas do occur, representing 5-9% of all intracranial space-occupying lesions and 20-40% of the sources of surgically treated intracranial hemorrhages. 50-80% of the angiomas are located in the cerebral hemispheres, 10-18% in central brain areas (basal ganglia, internal capsule, choroid plexus), and 10-30% in the posterior fossa. The major types of cerebral vascular malformations are described with reference to their anatomical features, location, chief arterial and venous supply, and prominent complications. Spinal vascular malformations, accounting for 3 to 12% of spinal space-occupying lesions, include vertebral, extradural, dural, subpial and intramedullary angiomas which occur as isolated or complex vascular anomalies and may involve various covering layers at the same level. The preferential occurrence of angiomas on the dorsal surface of the cord and in the caudal regions is related to the embryologic development of spinal vasculature. Frequent association of spinal angiomas (20-25%) with other vascular anomalies and dysplasias emphasizes their hamartomatous nature and developmental origin. Spinal angiomas include capillary telangiectasias with extra- or intradural and, rarely, intramedullary location, cavernomas, mainly arising in vertebral bodies, venous angiomas, mainly located in vertebral bodies and in the extradural space, and AVMs constituting the commonest type, that may affect both the pial and radicular vessels and can penetrate into the cord. They present as simple AV fistulas, cirsoid angiomas with localized vascular plexuses and large complex convolutions ("juvenile" type). The complications of spinal angiomas include subarachnoid hemorrhage, rare epidural hematoma, hematomyelia, compression lesions of the cord and roots, and ischemic changes causing chronic progressive radiculomyelopathy, previously referred to as Foix-Alajouanine syndrome. Chronic damage to the cord and spinal roots results from pressure effects, thrombosis of the abnormal vessels, disorders of venous drainage, and "steal" phenomena related to the vascular anomalies.

Cerebral arteriovenous malformations in children. Clinical features and outcome of treatment in children and in adults

A study of 19 children with cerebral arteriovenous malformation (AVM) is reported; these children represent 12% of 161 patients with this disease at the Rome University Institute of Neurosurgery. The published data on intracranial arteriovenous malformations in children and in adults are reviewed and the clinical features and results of treatment in the two age groups compared. The results of surgical removal seem to be better in children while the follow-up mortality with conservative treatment is higher. The last point receives indirect confirmation from a study of the risk of bleeding in which the patients of our series were compared by age at clinical onset, viz. those under 15 years of age and those over 15 years. After an average follow-up of slightly over 10 years, the risk of bleeding is higher with onset before the age 15 years and significantly higher if the onset is nonhemorrhagic.

Arteriovenous malformations of the brain: a teratologic challenge

Congenital arteriovenous malformations of the brain are lesions which are well-known to neurologists and neurosurgeons but are puzzling to teratologists because they occur sporadically and are unassociated with congenital malformations outside the central nervous system. They are recommended to teratologists as a field of etiologic and pathogenetic research.

Intracranial venous aneurysms: vein of Galen and other similar vascular anomalies

Aneurysmal dilatation of the vein of Galen is peculiar to arteriovenous malformation around the midbrain. Similar venous aneurysms may rarely occur in other regions. This paper deals with the radiographic findings in three cases of vascular malformation associated with giant venous aneurysms. The pathophysiology resulting in aneurysmal venous dilatation is discussed based on our material and those previously reported.

Aneurysms of the vein of Galen. Experience at The Hospital for Sick Children, Toronto

✓ A study of the literature published between 1937 and 1981 revealed 128 aneurysms of the vein of Galen. Their clinical course and management are reviewed. During the years 1950 to 1980, 29 patients with an aneurysm of the vein of Galen were seen at The Hospital for Sick Children. In 14 of these patients surgical obliteration of their aneurysm was attempted, and in six this proved successful.

Aneurysms of the vein of Galen in infants aged 2 to 15 months. Diagnosis and natural evolution

This is a report of seven cases of aneurysm of the vein of Galen (AVG) with a review of the clinical and radiological aspects of 48 cases in the literature. The natural evolution and pathophysiology of this vascular malformation are discussed. The clinical signs of this condition are often misleading. The appearance of AVG on CT is pathognomic. Surveillance of the vascular malformation and associated cerebral lesions can be maintained with subsequent CT. Spontaneous thrombosis of the aneurysm was observed in three cases. The diagnosis of thrombosis of the AVG was always made at operation or by histological examination. The radiological appearance of a thrombosed aneurysm is typical.

Arteriovenous malformations. Summary of 100 consecutive supratentorial cases

One hundred cases of macroscopic supratentorial arteriovenous malformations are studied, along with the significant literature. On the basis of morphology, they are subdivided into straight-line, single-unit, multiple-unit, intra- and extracranial, venous-wall types, and one other of questionable type. The study does not confirm a relationship of pregnancy to bleeding. It does confirm the absence of vasospasm in association with these lesions, the increasing tendency of the lesion to bleed the smaller it is, the equal sex distribution, the peak incidence in the patient's fourth decade, the lack of significance of family history, and the lack of associated vascular lesions. The study stresses the advantages of preopertive three-dimensional angiography, surgical magnification, and intraoperative serial angiography. It is emphasized again that the fistula itself must be removed or obliterated.

Causes of spontaneous subarachnoid hemorrhage in Thai infants and children. A study of 56 patients

The authors report 56 cases of spontaneous subarachnoid hemorrhage in Thai infants and children. The causes were: hemorrhagic disorders in 22 cases, arteriovenous malformations and aneurysms in 18, gnathostomiasis in nine, bleeding tumors in four, hypernatremia in one, and undertermined causes in two cases. Coagulation studies and cerebrospinal fluid examination for eosinophils are recommended before further invasive studies in such cases.

Malformation of the great vein of Galen with neonatal heart failure. Report of two cases

The clinical and patholgoical findings in two neonates with the malformation of the great vein of Galen are given. They both reported with serious neonatal heart failure suggesting congenital heart disease. In one of them cardiac catheterization revealed a foetal pattern of circulation causing cyanosis. A bruit and in one of them a thrill over the skull gave the clinical diagnosis of an intracranial arteriovenous aneurysm. They died 48 and 144 hours after birth in spite of medical treatment. The outlook for patients having malformation of the great vein of Galen and suffering neonatal heart failure treated conservatively, seems hopeless.

Intracranial arteriovenous malformations in childhood

During the 13-year period 1964 through 1976, 37 patients less than 20 years with an intracranial, parenchymal arteriovenous fistula were seen at the Mayo Clinic. The most frequent mode of presentation was hemorrhage or seizure. Other than angiography, computed tomography with contrast enhancement was the most helpful diagnostic test. Surgery was restricted to patients with intraparenchymal hematomas, intractable seizures, or subarachnoid hemorrhage with accessible lesions and to 1 infant with a massive, sumptomatic malformation. Surgery generally was tolerated well, with reversal of most acute focal neurological deficits related to hematomas. In the nonsurgical group, follow-up revealed a fairly stable neurological status during the period of the study.

The haemodynamic effect of an intracranial arteriovenous anomaly. A Doppler-haematotachographic study

Determination of the mean blood flow velocity by means of Doppler haematotachography is suggested as an aid in evaluating the haemodynamic changes associated with an intracranial arteriovenous anomaly. A Doppler haematotachogram (HTG) was obtained in 13 patients with a radiologically diagnosed arteriovenous anomaly, with marked interindividual variations in dimensions and blood supply; in 6 of these patients the Doppler HTG was obtained before and after total neurosurgical extirpation. The large majority of the patients showed a significant increase in diastolic, and to a lesser degree in systolic flow velocity at the level of the common carotid artery. In most cases the flow velocity curve of the ophthalmic artery showed a decrease in amplitude. These are the most useful parameters in evaluating the haemodynamic effect of an intracranial arteriovenous anomaly. After the surgical removal of the anomaly, the carotid flow velocity decreased significantly. In the internal and external jugular veins, Doppler-haematotachographic pulse waves were registered for the first time. These may have been conducted from the internal carotid artery to the jugular veins via the arteriovenous anomaly. The usefulness of this parameter is reduced because of the cumbersome calculations required to determine the time within which an arterial pulse wave conducted via the arteriovenous anomaly reaches the jugular vein. Registration of this unusual pulse wave is solely of theoretical value.

Intracranial hemorrhage in infants due to acquired prothrombin complex deficiency

✓ The authors report eight infants who had acute intracranial bleeding after the third week of life, in the absence of known trauma. When first seen each was moribund, pale, and had a tense anterior fontanel; half of the cases had associated ecchymoses. Spinal and subdural taps yielded large amounts of bloody fluid. Coagulation studies indicated a severe lack of factors involved in prothrombin complex formation. The clotting indices were sufficiently low to account for spontaneous bleeding. Satisfactory clinical and laboratory results were demonstrated after subdural and spinal taps combined with intravenous vitamin K and fresh blood transfusion to correct the coagulation defect and anemia.

Intracranial hemorrhage in children and adolescents

✓ The authors report their experience with 124 cases of intracranial hemorrhage in children and adolescents; the study includes 25 cases first reported in 1958. Fifty aneurysms with a mortality rate of 28% and 33 arteriovenous malformations with a mortality rate of 21% are included; 32 cases had no angiographically demonstrable lesion, six had miscellaneous lesions, and three primary cerebral hemorrhage. Specific programs for therapeutic management based on this experience are discussed.