Guidelines and parameters: percutaneous sclerotherapy for the treatment of head and neck venous and lymphatic malformations

Attempted ablation of an orbital cyst in a dog with 1% polidocanol using fluoroscopy and contrast cystography

A 4-year-old female spayed mixed-breed dog received enucleation surgery of the right eye in 2018 following the diagnosis of glaucoma. The patient was presented in 2021 for recurrent swelling of the right orbit. Ultrasound confirmed the presence of a cystic structure, and chemical ablation with 1% polidocanol (compounded, Stokes Pharmacy, Mt. Laurel, NJ) and contrast cystography was elected for treatment. Iodinated contrast was injected under fluoroscopy and after no leakage was noted, the contrast was aspirated from the orbital cyst and immediately followed by an injection of 1% polidocanol solution. The orbital cyst collapsed within 24 h but returned 25 days post-injection. A second attempt was made for chemical cyst wall ablation with 1% polidocanol foam and ultrasound guidance. The orbital cyst returned 12 weeks post 1% polidocanol foam injection, and the patient presented for surgical removal. Histopathology revealed an orbital conjunctival inclusion cyst associated with granulomatous and lymphoplasmacytic inflammation. Histopathology confirmed that the draining cyst was lined by conjunctiva and likely represented conjunctival remnants from the previous enucleation. This report describes fluoroscopic guidance for sclerotherapy in the treatment of a post-enucleation orbital cyst in a dog. Contrast cystography may be useful to verify catheter position and demonstrate cyst margins prior to injection. This case report highlights the importance of complete conjunctival excision during enucleation.

A rare pediatric case: Mesenteric cystic hygroma in a 5-year-old child

INTRODUCTION AND SIGNIFICANCE

Lymphangiomas are benign vascular malformations commonly found in the head and neck region, although they can occur elsewhere. Clinical manifestations vary based on location and size. Surgical resection remains the primary treatment modality.

CASE PRESENTATION

A male child presented with progressive abdominal distension without associated symptoms. Emergency department evaluation revealed a palpable abdominal mass. Abdominal ultrasound and computed tomography (CT) scans confirmed a large abdominal cyst. The cyst was surgically removed, and pathological examination diagnosed mesenteric lymphangioma.

CLINICAL DISCUSSION

Despite their infrequent occurrence, mesenteric cysts should be included in the differential diagnosis of pediatric abdominal masses.

CONCLUSION

Complete surgical resection is essential for the definitive management of mesenteric lymphangioma. Partial resection or aspiration should be avoided due to the risk of complications and potential recurrence.

Effectiveness of polidocanol sclerotherapy in alleviating symptoms in patients with venous malformations

OBJECTIVE

The objective of this study was to retrospectively evaluate the effectiveness of polidocanol in managing pain, swelling, functional limiting and cosmetic disorders in patients with venous malformations (VMs).

METHODS

This retrospective study included patients who underwent sclerotherapy with polidocanol for VMs between 2020 and 2022. Patient records, imaging findings, and evaluation questionnaires used in the preprocedure and follow-up phases were reviewed. After sclerotherapy, patients were followed up at 1, 2, 3, and 6 months. During these visits, the previously used 11-point verbal numerical rating scale (from 0 [no pain] to 10 [worst pain thinkable]) was used to evaluate the severity of symptoms such as pain, swelling, cosmetic discomfort, and functional limitation, and patients were asked to report the number of days per week they experienced these symptoms owing to the VM.

RESULTS

A total of 194 sclerotherapy procedures (mean, 1.6 ± 0.3 procedures) in 84 patients (55 female and 29 male patients; mean age, 22.45 ± 11.83 years) were conducted. The majority of these malformations (81%, or 68 patients) were located in the extremities. We found a significant decrease in pain, swelling, functional limitation, cosmetic appearance, and number of painful days between all time points, except for the comparison between months 3 and 6 (P < .001) CONCLUSIONS: Polidocanol sclerotherapy is a safe and effective treatment for VMs that significantly decreases patient complaints and has a very low complication rate. Particularly, following patients at short intervals and administering additional sclerotherapy sessions when necessary will significantly increase patient satisfaction.

A rare case of a large mesenteric lymphangioma in a 2-year-old child: Case report and review of the literature

INTRODUCTION AND SIGNIFICANCE

Lymphangiomas are benign tumors that are typically found in the neck and armpit region but can also occur in other locations. The clinical presentation varies depending on their location and size, and surgical resection is the primary treatment option.

CASE PRESENTATION

We present the case of a child who presented with a painless and non-obstructing abdominal mass. The mass was diagnosed and underwent complete surgical resection. Subsequent tissue analysis confirmed that the cyst was a lymphangioma.

CLINICAL DISCUSSION

These tumors should be considered in the differential diagnosis of cystic lesions in the abdomen, and the importance of performing complete surgical resection is emphasized.

CONCLUSION

The importance of complete surgical resection for mesenteric lymphangioma must be emphasized. Partial resection or aspiration should not be performed due to the risk of complications associated with these procedures and the increased risk of recurrence.

Percutaneous sclerotherapy for head and neck lymphatic malformations in neonates and infants ≤12 months of age

BACKGROUND

Percutaneous sclerotherapy is an effective treatment for lymphatic malformations (LM) of the head and neck in adults. The purpose of this study was to examine the indications and efficacy of sclerotherapy for head/neck LM in the neonate and infant population.

METHODS

We retrospectively reviewed patients treated with percutaneous sclerotherapy for LM of the head/neck at age ≤12 months at a single vascular anomalies clinic. The clinical, anatomic, and technical aspects of each treatment, complications, and post-treatment clinical and imaging outcomes were analyzed.

RESULTS

22 patients underwent 36 treatments during the first year of life. Median age at first treatment was 6.2 months (range 2-320 days). Severe airway compromise was the most frequent indication for treatment (31.8%). Sclerosants included doxycycline (80.5%), sodium tetradecyl sulfate (55.5%), bleomycin (11.1%) and ethanol (2.8%). There were no immediate procedure-related complications; sclerosant-related laboratory complications included transient metabolic acidosis (8.3%) and hemolytic anemia (5.5%). Median follow-up was 3.7 years (IQR 0.6-4.8). 47.6% of patients showed >75% lesion size reduction and 19.0% showed minimal response (<25% improvement). At last follow-up, 71.4% of children were developmentally normal and asymptomatic, 23.8% had recurring symptoms, and 4.8% required permanent tracheostomy. Patients with ongoing symptoms or limited response to percutaneous sclerotherapy (33.3%) were treated with long-term sirolimus.

CONCLUSIONS

Percutaneous sclerotherapy is a safe and effective treatment for symptomatic LM of the head and neck in neonates and infants. Treatment strategy and management of recurrent symptoms requires consensus from an experienced, multidisciplinary team.

Management of prenatally diagnosed multiple giant cystic lymphangioma with combination of surgery and intralesional bleomycin injection: A case report

INTRODUCTION AND IMPORTANCE

Giant cystic lymphangioma was a congenital lymphatic system malformation. Although it is benign, it can cause some complications requiring prompt treatment. The selection of therapy was challenging because none of them is perfect. In this report, we presented a case of multiple giant cystic lymphangiomas in an infant treated with stepwise surgeries combined with intralesional bleomycin injection.

CASE PRESENTATION

A two-day-old infant presented with multiple, soft, skin-colored tumors on the right side of the neck, thoracoabdominal region, axilla, and upper extremity which on pre-natal MRI appeared as heterogeneous masses with septate cystic components infiltrating upper chest cavity and compressing subclavian and carotid arteries. The patient was treated successfully with stepwise surgeries followed by intralesional bleomycin injections.

CLINICAL DISCUSSION

Cystic lymphangioma is a benign malformation of lymphatic vessels with the neck and axillar region being the most common site. There are several options for treatment modalities. Surgery has been the mainstay of treatment, but other treatment modes are getting more popular. A combination of surgery and sclerotherapy has shown satisfying results.

CONCLUSION

In large and infiltrative lymphangioma cases, staged surgery followed by intralesional bleomycin injection can be a treatment approach to minimize morbidity and mortality.

French national diagnosis and care protocol (PNDS, protocole national de diagnostic et de soins): cystic lymphatic malformations

Cystic lymphatic malformations (LMs) are rare chronic conditions which management differs according to the type (macrocystic LMs, microcystic LMs or both). Studies are lacking due to rarity of the pathology. We aimed to establish a French National Diagnosis and Care Protocol (PNDS: Protocole National de Diagnostic et de Soins), to provide health professionals with free open access synthesis on optimal management and care of patients with LMs ( https://www.has-sante.fr/upload/docs/application/pdf/2021-03/malformations_lymphatiques_kystiques_-_pnds.pdf ). The process included a critical review of the literature and multidisciplinary expert consensus. LMs are congenital but are not always discovered at birth. Nearly 75% of them are located in the head and neck because of the highly dense lymphatic system in this region. Physical examination (showing painless masses with normal skin color and depressible consistency, or cutaneous/mucosal lymphangiectasia) and color Doppler ultrasonography, usually allow for diagnosis. MRI (involving T2 sequences with fat saturation in at least two spatial planes) is the tool of choice for evaluating anatomical extension, characterizing lesions (microcystic and macrocystic), and before considering therapeutic management. A biopsy, coupled to a blood sample, can also be used for molecular biology analyses, to search for activating mutations of the PIK3CA gene, particularly with LM integrating in a syndromic form (CLOVES or Klippel-Trenaunay syndrome) but also in certain isolated (or common) LMs. The spontaneous evolution of LMs, in particular microcystic forms, is often toward progressive aggravation, with an increase in the number of vesicles, thickening, increased oozing and bleeding, while pure macrocystic LMs may regress due to "natural sclerosis", i.e. fibrosis secondary to an inflammatory reorganization after common infantile infections. In case of voluminous LMs or syndromic forms, functional and psychological repercussions can be major, deteriorating the patient's quality of life. LMs must be treated by physicians integrated in multidisciplinary teams, and be personalized. Management is a life-long process that involves one or several of these therapies: conservative management, physical therapy (compression), sclerotherapy, surgery, drugs such as mTOR inhibitors (sirolimus), that has shown efficacy in decreasing the volume of LMs, and, more recently, PI3K-inhibitors in syndromic forms. Psychological and social support is necessary, taking into account the patient and his family.

A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation

OBJECTIVE

Sclerotherapy for venous malformation has been widely used; however, no guidelines are available to assess the effectiveness of different sclerotherapy agents. We conducted a systematic review and network meta-analysis to investigate the effectiveness of sclerotherapy agents for venous malformations.

METHODS

Three electronic databases were searched from their inception (1950) to April 29, 2021. Studies comparing the effectiveness of different sclerotherapy agents were included. The risk of bias within and across studies was assessed. Pairwise meta-analyses were conducted, followed by a network meta-analysis. We also assessed inconsistency and publishing bias using various approaches.

RESULTS

Seven studies with 547 patients in six arms were included in the present study. We defined the response and complete response as two separate outcomes. Significant differences were observed in four comparisons with respect to the response (ethanol vs bleomycin, ethanol vs polidocanol, ethanol vs sodium tetradecyl sulfate, polidocanol vs sodium tetradecyl sulfate). No statistically significant differences were found in the other comparisons. The evidence network revealed that for the response outcome, ethanol ranked first, followed by pingyangmycin, polidocanol, sodium morrhuate, bleomycin, and, finally, sodium tetradecyl sulfate. For the complete response outcome, pingyangmycin had the best results, followed by sodium morrhuate, polidocanol, ethanol, bleomycin, and, finally, sodium tetradecyl sulfate. Major complications, such as facial nerve palsy, serious local swelling, and necrosis, had occurred mostly in the ethanol group and rarely in the other groups. Because of the limited data, no further analysis of major complications was conducted. Our confidence in the comparisons and rankings was low. We found no verified inconsistency or publishing bias in the present study using the existing approaches.

CONCLUSIONS

Ethanol showed a significantly better response statistically compared with the other agents. However, ethanol had also resulted in the highest incidence of complications. Pingyangmycin showed the second-best response, best complete response, and a low rate of complications, respectively. Overall, pingyangmycin achieved excellent performance and balance in terms of the different outcomes. However, they could not be adequately recommended from the available data. More superior trials, especially randomized controlled trials, are needed in the future.

Cystic lymphangioma of the upper limb: Clinical case and literature review

We report an observation of a macro- and microcystic lymphatic malformation located in the right upper limb. This was a 5-year-old girl with no previous pathological history, followed since the age of 11 months for a congenital subcutaneous, painless and soft swelling of the right upper limb.

Ultrasound of the soft tissue and magnetic resonance imaging (MRI) allowed the diagnosis of macro- and microcystic lymphatic malformation of the right upper limb.

There is little epidemiological data on cystic lymphatic malformations (CLM). Superficial MLKs are more numerous than deep MLKs; of the superficial MLKs, nearly 75% are located in the head and neck, with an estimated incidence of 1.2 to 2.8 per 1000 births, and in the axillary hollows in 20% of cases. They affect equally males and females and different ethnic backgrounds. Involvement of the upper limb and particularly the arm is very rare.

MRI plays an important role in the diagnosis and assessment of the tumor’s boundaries.

Treatment can be difficult because of the location of the tumor and its extension into the surrounding tissue.

Polidocanol monotherapy for a superficial orbital venous malformation in a horse

OBJECTIVE

To describe the use of 1% polidocanol as the sole treatment for a superficial orbital venous malformation in a horse.

ANIMAL

A 23-year-old Welsh Cobb cross gelding with a distensible swelling affecting the left lower eyelid, and secondary palpebral margin abnormalities and superficial keratitis.

PROCEDURE

Color flow Doppler ultrasonography revealed non-pulsatile blood flow within the tortuous vascular network most consistent with a superficial orbital venous malformation appearing to involve the lateral palpebral and transverse facial veins. An intravenous catheter was placed within the lateral aspect of the venous malformation, and agitated saline was slowly injected into the vessel while simultaneously ultrasound imaging the medial aspect in which the bubbles were observed coursing across, consistent with lateral to medial flow. Contrast venography confirmed a corkscrew vessel along the ventral aspect of the orbital rim. Under standing sedation, 1% polidocanol solution was administered slowly through the intravenous catheter while manual pressure was applied on the medial and lateral aspects of the venous malformation.

RESULTS

Ultrasonography performed immediately after administration of polidocanol confirmed venous stasis, and formation of a thrombus. No adverse side effects were noted. The venous malformation and associated palpebral margin abnormalities and superficial keratitis resolved at the time of re-examination at 4 months.

CONCLUSION AND CLINICAL RELEVANCE

Polidocanol as the sole treatment for a superficial orbital venous malformation in a horse was well tolerated and led to clinical resolution. Sclerosant monotherapy may be a safe treatment option for superficial orbital venous malformations.

A Novel Drug Self-Delivery System from Fatty Alcohol Esters of Tranexamic Acid for Venous Malformation Sclerotherapy

Venous malformation (VM), which causes severe damage to patients' appearance and organ function, is one of the most common vascular malformations. At present, many drugs in clinical treatment cause various adverse reactions. Herein, we synthesized cationic amphiphilic gelators (TA6, TA8, and TA9) by introducing saturated carbon chains of different lengths to tranexamic acid (TA), which could self-assemble into low-molecular-weight gels (LMWGs) as drug delivery carriers by hydrogen bonds, van der Waals forces, and hydrophobic interactions. The rheological properties, gelation driving force and drug release profiles of TA6, TA8, and TA9 hydrogels were characterized, and the results indicated that the hydrogels prepared in this study possessed the typical characteristics of a gel and could release drugs slowly. More importantly, the TA9 gelator showed significant pharmacological activity, in that it served as both an active drug compound and a drug carrier. The in vitro experiments demonstrated that TA9 induced HUVECs death and hemolysis by destroying cell membranes in a dose-dependent manner, and caused cell death and hemolysis at a concentration of 0.09 µM/mL. Meanwhile, we found TA9 could interact not only with fibrinogen, but also with other endogenous molecules in the blood. After the administration of TA9 hydrogel for 15 days, macroscopic imaging and histological evaluation in mice and rabbits displayed obvious thrombi, inflammatory reactions, and venous embolization, indicating that the mechanism of the TA9 hydrogel in treating VM was involved in two processes. Firstly, the TA9 hydrogel relied on its mechanical strength to physically block veins and continuously release TA9, in situ, for targeted therapy. Then, TA9 destroyed endothelial cells and damaged venous walls critically, causing thrombi. Most excitingly, TA9 was hydrolyzed to TA by enzymes that inhibited the degradation of thrombi by plasmin to prolong the embolization time and to promote venous fibrosis. Compared with other clinically available sclerosants, the degradation of TA9 also empowered a better biocompatibility and biodegradability for the TA9 hydrogel. In conclusion, we synthesized a potentially safe and effective derivative of TA and developed a low-molecular-weight gel as a self-delivery system for TA in treating VM.

A somatic mutation in PIK3CD unravels a novel candidate gene for lymphatic malformation

Background

Lymphatic malformations (LMs) are benign congenital malformations that stem from the abnormal development of the lymphatic vessels during early embryogenesis. Somatic PIK3CA gene mutations are conventional cause leading to LMs. Both macrocystic and microcystic LMs arise due to lymphatic endothelial cell-autonomous defects, depending on the time in development at which PIK3CA gene mutation occurs. Recent study finds a PIK3CA mutation in 79% of LMs. However, discovering new genetic events in this disease is crucial to identify the molecular mechanism of the pathogenesis and further develop new targeted therapies.

Results

Here, we initially performed whole-exome sequencing in six children with LMs to find a new causal gene. Somatic mutations in PIK3CA (c.1633G > A [p. E545K] and PIK3CD (c.1997T > C [p.L666P]) were discovered in two different individuals. In vitro functional studies were conducted to demonstrate the pathogenicity of the novel mutation c.1997T > C in PIK3CD. We found that L666P promoted the cell proliferation and migration of human umbilical vein endothelial cells (HUVECs) and induced hyperactivation of the mTOR pathway. These findings indicate that the PIK3CD mutation affects downstream signalling in endothelial cells, which may impair normal lymphangiogenesis.

Conclusions

This study reveals a novel candidate gene associated with the development of LMs, which is consistent with previous researches. These findings in our study may offer a novel gene target for developing therapies, which acts in tight interaction with the previously known PIK3CA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01782-9.

Management of disseminated intravascular coagulation associated with aortic aneurysm and vascular malformations

Aortic aneurysms and vascular malformations are sometimes associated with disseminated intravascular coagulation (DIC). A typical blood coagulation test shows decrease in platelet count and fibrinogen, and increases in fibrin/fibrinogen degradation products (FDP) and D-dimer. The coagulation activation marker thrombin-antithrombin complex (TAT) and the fibrinolysis activation marker plasmin-α₂ plasmin inhibitor (PIC) are significantly increased. α₂ plasmin inhibitor (α₂PI) is significantly reduced. Since no prolongation of prothrombin time (PT) is noticeable and activated partial thromboplastin time (APTT) is shortened in some cases, DIC cannot be diagnosed or ruled out by PT and APTT alone. The cornerstone of treatment for DIC is to treat the underlying disease. However, surgery is not possible in some cases. Follow-up may be appropriate in patients with abnormal results from coagulation tests and no bleeding. However, pharmacotherapy is often required in cases with bleeding. Unfractionated heparin, low molecular weight heparin, protease inhibitors, recombinant thrombomodulin, direct oral anticoagulants, and factor XIII preparations are effective. If PIC is significantly increased and α₂PI is significantly decreased, or if the bleeding is severe, tranexamic acid is used as an antifibrinolytic therapy with anticoagulant therapy. In such cases, attention should be paid not only to TAT but also changes in PIC.

Effectiveness of sirolimus in the treatment of complex lymphatic malformations: Single center report of 56 cases

BACKGROUND

Lymphatic malformations are common congenital vascular lesions. Neither surgical resection nor other surgical treatments have been found to be effective for invasive cases. Recent research has suggested that sirolimus is effective in treating complex lymphatic malformations (LMs). We aimed to evaluate the effectiveness and safety of oral sirolimus for children living with LMs in our hospital.

METHODS

Fifty-six cases of complex LMs treated with sirolimus were collected from Shanghai Children's Medical Centre between June 2016 and March 2019. All cases were confirmed either by pathology (44) or enhanced MRI (12). Following informed consent, sirolimus 0.8 mg/m² bid was administered orally to participants and maintained at a trough concentration of 10-15 ng/ml. Children's ages at diagnosis were neonate to 16 years (mean 44.3 months). All children were followed up for 5 to 30 months, with a mean of 16.8 months.

RESULTS

During the follow-up period, blood, liver and kidney function as well as disseminated intravascular coagulation was regularly reviewed in all 56 children. Enhanced MRI was regularly performed to evaluate therapeutic effects. Total effective rate (complete response or partial response) of LMs was 89.3% (50/56). No serious adverse reactions were found.

CONCLUSION

This study suggests that sirolimus is effective and tolerable for decreasing lesions in children with complex LMs, leading to fewer and more tolerable side effects. There is no need to pursue an excision rate to reduce unnecessary operative complications since adjuvant sirolimus therapy modifies the complex LMs clinical appearance and alleviates their symptoms.

TYPE OF STUDY

Clinical research.

LEVEL OF EVIDENCE

Level IV.

Contrast-enhanced ultrasound with perfusion analysis in patients with venous malformations before and after percutaneous treatment with ethanol-gel

INTRODUCTION

Percutaneous sclerotherapy is a well-established treatment option for venous malformations (VM). A recently established sclerosing agent is ethanol-gel. Aim of this study was to identify, if contrast-enhanced ultrasound (CEUS) with an integrated perfusion analysis allows for differentiation between untreated VM, healthy tissue, and with gelified ethanol treated malformation tissue.

MATERIAL AND METHODS

In this institutional review board approved prospective study symptomatic VM patients underwent CEUS at exactly the same position before and after sclerotherapy with ethanol-gel. Two experienced sonographers performed all examinations after the bolus injection of microbubbles using a multi-frequency probe with 6 -9 MHz of a high-end ultrasound machine. An integrated perfusion analysis was applied in the center of the VM and in healthy, surrounding tissue. For both regions peak enhancement (peak), time to peak (TTP), area under the curve (AUC), and mean transit time (MTT) were evaluated. Wilcoxon signed rank test was executed; p-values <0.05 were regarded statistically significant.

RESULTS

In 23 patients including children (mean age 25.3 years, 19 females) before treatment all identified parameters were significantly higher in the VM center compared to healthy tissue (peak: p < 0.01; TTP: p < 0.01; AUC: p < 0.01; MTT: p < 0.01). Comparing the VM center before and after treatment, TTP (p < 0.02) and MTT (p < 0.01) reduced significantly after sclerotherapy. In surrounding tissue only peak changed after treatment in comparison to pre-treatment results (p = 0.04). Comparing data in the VM center with surrounding tissue after sclerotherapy, results still differed significantly for peak (p < 0.01), TTP (p < 0.01), and AUC (p < 0.01), but assimilated for MTT (p = 0.07).

CONCLUSION

All with CEUS identified parameters seem to be excellent tools for differentiating between VM and healthy tissue. TTP and MTT could distinguish between with ethanol-gel sclerotized VM portions and untreated malformation parts and thereby might assist the monitoring of sclerotherapy with ethanol-gel.

A Novel Compound Sclerosant: Polidocanol-Bleomycin Foam

BACKGROUND

Foam sclerotherapy is an effective treatment strategy for venous malformations. Both polidocanol (POL) and bleomycin are effective sclerosants; however, no studies have reported POL-bleomycin foam.

OBJECTIVE

To introduce a method for producing POL-bleomycin foam and evaluate the stability of POL-bleomycin foam with bleomycin concentrations.

MATERIALS AND METHODS

Group A: 2 mL of 1% POL + 8 mL of air; Group B: 2 mL of 1% POL + 3 U bleomycin + 8 mL of air; Group C: 2 mL of 1% POL + 6 U bleomycin + 8 mL of air; Group D: 2 mL of 1% POL + 12 U bleomycin + 8 mL of air. Tessari method was used for foam generation. The foam half-life time (FHT) was used to evaluate foam stability. Five recordings were made for each group.

RESULTS

The FHT was 148.6 ± 2.9 seconds in Group A, 148.8 ± 4.0 seconds in Group B, 148.4 ± 2.6 seconds in Group C, and 148.8 ± 1.6 seconds in Group D. The FHT in different groups showed no significant differences.

CONCLUSION

The POL-bleomycin foam was prepared successfully and its FHT was as long as the POL foam.

Interventional Neuroradiology: A Review

Interventional neuroradiology (INR) has evolved from a hybrid mixture of daring radiologists and iconoclastic neurosurgeons into a multidisciplinary specialty, which has become indispensable for cerebrovascular and neurological centers worldwide. This manuscript traces the origins of INR and describes its evolution to the present day. The focus will be on cerebrovascular disorders including aneurysms, stroke, brain arteriovenous malformations, dural arteriovenous fistulae, and atherosclerotic disease, both intra- and extracranial. Also discussed are cerebral vasospasm, venolymphatic malformations of the head and neck, tumor embolization, idiopathic intracranial hypertension, inferior petrosal venous sinus sampling for Cushing's disease, and spinal interventions. Pediatric INR has not been included and deserves a separate, dedicated review.

The Efficacy of Absolute Ethanol and Polidocanol in the Treatment of Venous Malformations

INTRODUCTION

Using meta-analysis to evaluate the efficacy of absolute ethanol and polidocanol in the treatment of venous malformations.

MATERIALS AND METHODS

A systematic search of the English literature was conducted in April 2019 including PubMed, Embase and Web of Science. Article selection was based on preset criteria. The included literature was scored on the MINORS scale, and the meta-analysis and the forest plot were made using the R 3.5.1 software for efficiency.

RESULTS

Ten articles were included in the meta-analysis. Absolute ethanol response rate ranged between 79% and 92% with a pooled rate of 85%, and polidocanol response rate ranged between 63% and 94% with a pooled rate of 77%.

DISCUSSION

Although sclerotherapy is effective in most studies, a large number of randomized controlled trials are still needed to confirm the best treatment options at different sites.

Effects of sclerosing agents on head and neck hemangiomas: A systematic review

Background

The aim of this study was to systematically review the literature for studies that investigated the effects of sclerosing agents on head and neck hemangiomas.

Material and Methods

Clinical trials, cohort studies, and descriptive studies were considered eligible and selected in a two-phase process. Six main electronic databases, in addition to three grey literature databases, were searched. Risk of bias (RoB) was assessed using the “Meta-Analysis of Statistics Assessment and Review Instrument” checklist. From fifty-six considered eligible, five were finally included.

Results

One article were judged at low, one at moderate, and three at high RoB. The sclerosing agents investigated were sodium tetradecyl sulphate (n=2), ethanolamine oleate (n=1), pingyangmycin (n=1) and bleomycin (n=1). Overall, good results were achieved on the treatment of head and neck hemangiomas with intralesional sclerotherapy. Most commonly reported adverse effects included pain, swelling, fever, necrosis, transient facial palsy, and anorexia.

Conclusions

Considering the limited number of included studies, intralesional sclerotherapy on the management of HN hemangiomas presented overall good results with minor adverse reactions, especially in regards to smaller lesions.

Key words:Sclerotherapy, sclerosing solutions, vascular neoplasms, hemangioma.

Treatment of Head and Neck Venous Malformations with Sodium Tetradecyl Sulfate

Objective

The purpose of this study was to discuss the clinical outcomes and complications of treating venous malformations with sclerotherapy, with sodium tetradecyl sulfate as the sclerosing agent.

Study Design

Case series with planned data collection.

Setting

Amiralam Hospital—a referral otolaryngology–head and neck surgery hospital affiliated with Tehran University of Medical Sciences.

Subjects and Methods

A total of 345 patients with venous malformations were treated with sclerotherapy with sodium tetradecyl sulfate 3% (1 mL for every 1 cm³ of the lesion). The venous malformation location, treatments before the current sclerotherapy with sodium tetradecyl sulfate, the number of sclerotherapy sessions, and complications resulting from sclerotherapy were recorded. Follow-up assessments were done for a minimum of 1 year following the procedure. A favorable outcome was defined as a 50% decrease in the lesion size based on clinical and radiologic assessments.

Results

A total of 759 injection sessions were documented, ranging from 1 to 6 injections per patient (mean = 3.1). The follow-up duration ranged from 12 to 84 months (mean = 55 months). Based on clinical assessment, a 50% reduction of size was reported for 95.6% of the patients. According to the imaging before and after the procedures, a 50% reduction of size was seen among 67.3% of the patients.

Conclusion

The results of the study showed that the use of sodium tetradecyl sulfate as a sclerosing substance can effectively reduce the size of venous malformation lesions.

Bleomycin sclerotherapy for eyelid venous malformations as an alternative to surgery or laser therapy

PURPOSE

To evaluate the clinical outcome of patients with venous malformation (VM) involving the eyelid treated with bleomycin sclerotherapy.

METHODS

A retrospective review was performed of 18 consecutive patients with VM involving the eyelid who underwent bleomycin sclerotherapy. Patients' clinical presentation, details of sclerotherapy, and post-sclerotherapy resolution of the lesion as well as any procedure-related complications were evaluated.

RESULTS

Twelve women and six men of mean age 34.3±20.4 years underwent sclerotherapy with bleomycin. Chief complaints were cosmetic disfigurations with or without hemifacial deformity (n=2), pain in engorgement area (n=2), pain and swelling from venous thrombosis (n=2), swelling or engorgement obstructing their eyesight (n=2), or eyelid dysfunction (n=1). The lesions were only in the eyelid in three patients; otherwise they were extended out of the eyelid either superiorly (n=3), laterally (n=8), inferiorly (n=8), and/or posteriorly to the orbit (n=8) to various extents. Conjunctival involvement was present in 13 patients. 14 patients had received prior treatments including surgery, laser therapy, or non-bleomycin sclerotherapy. With an average three sessions of bleomycin sclerotherapy (average total dose 34.5 mg), more than 80% shrinkage was observed in seven patients (38.9%), 50-80% shrinkage in eight patients (44.4%), and 30-50% shrinkage in two patients (11.1%). One patient had recurrence, which was successfully treated again with bleomycin. No procedure-related complications were noted.

CONCLUSIONS

The use of bleomycin appears to be a simple, safe, and effective treatment for venous malformations involving the eyelid, avoiding more elaborate and challenging surgical or laser interventions, and is even effective in full thickness lesions.

Ethanol-Gel Sclerotherapy of Venous Malformations: Effectiveness and Safety

OBJECTIVE

In the treatment of venous malformations, ethanol may be administered in a gelified form to increase local effects and reduce systemic ones. The purpose of this prospective study was to evaluate the efficacy and safety of a commercially available viscous ethanol gel in the treatment of venous malformations.

SUBJECTS AND METHODS

Thirty-one patients (mean age, 23.4 years; age range, 6.6-46.5 years) with venous malformations were prospectively scheduled for two ethanol-gel sclerotherapy sessions. Venous malformations were located at the lower extremity (n = 18), the upper extremity (n = 9), and the face (n = 4). Questionnaires to assess pain, clinical examinations, professional photographs, and contrast-enhanced MRI of the venous malformations were performed before and after therapy to measure therapy-induced changes. Two experienced radiologists blinded to the examination date and clinical status compared photographs and MR images before and after treatment.

RESULTS

A mean of 4.2 mL of ethanol gel were administered per session. The technical success rate was 100%. Clinical success, defined as improvement or resolution of symptoms, was noted in 81% of patients. Mean pain score decreased, and the difference was statistically significant (3.9 vs 3.1, p = 0.005). In 54 treatment sessions where follow-up was available, four minor complications occurred. Comparison of photographs and MR images before and after treatment showed improvement in 35% and 93% of patients, respectively.

CONCLUSION

Ethanol gel is an effective and safe sclerosing agent in the treatment of venous malformations.