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Demir MK, Kılıc D, Zorlu E, Kılıc T. Giant Intracranial Cavernous Malformations: A Review on Magnetic Resonance Imaging Characteristics. Indian J Radiol Imaging 2024; 34:511-521. [PMID: 38912256 PMCID: PMC11188748 DOI: 10.1055/s-0044-1779587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Background Intracranial cavernous malformations (CMs), commonly known as cavernomas or cavernous angiomas, are low-flow, well-circumscribed vascular lesions composed of sinusoidal spaces lined by a single layer of endothelium and separated by a collagenous matrix without elastin, smooth muscle, or other vascular wall elements. A diameter greater than 3 cm for a CM is unlikely. These lesions may have atypical appearances on magnetic resonance imaging (MRI). MRI with advanced techniques such as a susceptibility-weighted image or T2-gradient echo, a diffusion-weighted image and corresponding apparent diffusion coefficient map, and diffusion tensor tractography have revolutionized the diagnostic approach to these lesions. Materials and Method The present study reviews the etiopathogenesis, clinical manifestations, MRI strategy, and MRI appearances of the CMs, with a few examples of the giant CMs from our archive. Results Intracranial giant CMs may have unexpected locations, sizes, numbers, and varied imaging appearances due to repeated hemorrhages, unusual enhancement patterns, intense perifocal edema, and unusual associations, making the differential diagnosis difficult. Conclusion Familiarity with the MRI appearances of the giant intracranial CMs and the differential diagnosis improves diagnostic accuracy and patient management.
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Affiliation(s)
- Mustafa Kemal Demir
- Clinic of Radiology, Bahcesehir University Goztepe Medical Park Hospital, Istanbul, Turkey
| | - Deniz Kılıc
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
| | - Emre Zorlu
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
| | - Turker Kılıc
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
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Jagtiani P, Rumalla K, Roy JM, Bhalla S, Covell MM, Bowers CA. Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations. World Neurosurg 2024:S1878-8750(24)01114-8. [PMID: 38960310 DOI: 10.1016/j.wneu.2024.06.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR). METHODS This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD. RESULTS One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2 years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N = 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics. CONCLUSIONS Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.
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Affiliation(s)
- Pemla Jagtiani
- School of Medicine, SUNY Downstate Health Sciences University, New York, NY, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
| | - Kranti Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Joanna M Roy
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA; Topiwala National Medical College, Mumbai, India
| | - Shubhang Bhalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA; Texas Tech University Health Sciences Center School of Medicine, El Paso, Texas
| | - Michael M Covell
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA; School of Medicine, Georgetown University, Washington, DC, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA.
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Yang K, Fang S, Zhang X, Wang T, Feng Y, Jiao L, Yan Y. In-stent restenosis after vertebral artery origin stenosis stenting: a nomogram for risk assessment. J Neurointerv Surg 2023; 15:e41-e45. [PMID: 35896318 DOI: 10.1136/neurintsurg-2022-019091] [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: 04/27/2022] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To propose a nomogram for individual risk assessment of in-stent restenosis (ISR) after vertebral artery origin stenosis (VAOS) stenting. METHODS We included 793 patients with VAOS treated with stenting from October 2006 to May 2013, with a median follow-up of 27.8 months. Cox regression and the least absolute shrinkage and selection operator (LASSO) regression were adopted for variable selection. The nomogram was formulated and validated by concordance indexes (C-indexes) and calibration curves. An in-stent restenosis risk table (ISR-RT) was subsequently generated for risk stratification. Differences between low-, intermediate-, and high-risk levels were shown by Kaplan-Meier curves and compared by log-rank test. RESULTS The training and validation set included 594 and 199 patients, with a mean ISR rate of 37.2% and 35.2%, respectively. Stent type (HR=1.64, 95% CI 1.26 to 2.14), stent diameter (HR=2.48, 95% CI 1.77 to 3.48), history of peripheral vascular disease (HR=2.17, 95% CI 1.17 to 4.00), history of transit ischemic attack (HR=1.45, 95% CI 1.05 to 2.14), and left-side involvement (HR=1.33, 95% CI 1.04 to 1.69) were included in the nomogram. The C-indexes at 6 and 12 months were 0.650 and 0.611 in the training set, and 0.713 and 0.603 in the validation set, respectively. Compared with low-risk patients, the intermediate- and high-level group had 1.46 (95% CI 1.05 to 2.04; p=0.0235) and 2.28 (95% CI 1.64 to 3.17; p<0.0001) higher chances of developing ISR in 2 years, respectively. CONCLUSIONS A nomogram and a risk evaluation table were developed with good predictive ability for in-stent restenosis among patients with VAOS, which could serve as a practical approach for individualized risk evaluation.
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Affiliation(s)
- Kun Yang
- Department of Epidemiology and Biostatistics, Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University School of Public Health, Beijing, China
- Evidence-based Medicine Center, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Shiyuan Fang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yiding Feng
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Yuxiang Yan
- Department of Epidemiology and Biostatistics, Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University School of Public Health, Beijing, China
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4
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Hage S, Hagan M, Bi D, Stadnik A, Lee J, Romanos S, Srinath A, Shenkar R, Lee C, Horowitz PM, Girard R, Awad IA. Impact of socioeconomics and race on clinical follow-up and trial enrollment and adherence in cerebral cavernous malformation. J Stroke Cerebrovasc Dis 2023; 32:107167. [PMID: 37146402 PMCID: PMC10201538 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES Cerebral cavernous malformation (CCM) affects more than a million Americans but advanced care for symptomatic lesions and access to research studies is largely limited to referral academic centers MATERIALS AND METHODS: A cohort of CCM patients screened for research studies at an accredited center of excellence for CCM was analyzed. Demographics, lesion location, history of hemorrhage, insurance type and area of deprivation index (ADI) were collected. Primary outcomes were clinical follow-up within a year from initial evaluation, and enrollment and adherence in clinical trials among eligible subjects RESULTS: A majority (52.8%) of CCM patients evaluated had a high socioeconomic status (SES) (ADI 1-3), and only 11.5% were African American. Patients who had a symptomatic bleed were more likely to follow-up (p=0.01), and those with brainstem lesion were more likely to enroll/adhere in a clinical trial (p=0.02). Rates of clinical follow-up were similar across different ADI groups, insurance coverage and race. Patients who were uninsured/self-paying, and African Americans were more likely to decline/drop from clinical trials (OR 2.4, 95% CI 0.46-10.20 and OR 2.2, 95% CI 0.33-10.75, respectively), but differences were not statistically significant CONCLUSIONS: Access of disadvantaged patients to center of excellence care and research remains limited despite geographic proximity to their community. Patients with lower SES and African Americans are as likely to follow-up clinically, but there were trends of differences in enrollment/adherence in clinical trials. Mitigation efforts should target systemic causes of low access to specialized care among uninsured and African American patients.
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Affiliation(s)
- Stephanie Hage
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Matthew Hagan
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Dehua Bi
- Department of Public Health Sciences, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Justine Lee
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Robert Shenkar
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Cornelia Lee
- Alliance to Cure Cavernous Malformations, Charlottesville, Virginia, USA.
| | - Peleg M Horowitz
- Neurotrauma Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Issam A Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
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5
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Li Z, Ma L, Quan K, Liu P, Shi Y, Liu Y, Zhu W. Rehemorrhage of brainstem cavernous malformations: a benchmark approach to individualized risk and severity assessment. J Neurosurg 2022:1-12. [PMID: 36585870 DOI: 10.3171/2022.11.jns222277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/29/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) represent a unique subgroup of cavernous malformations with more hemorrhagic presentation and technical challenges. This study aimed to provide individualized assessment of the rehemorrhage clustering risk of BSCMs after the first symptomatic hemorrhage and to identify patients at higher risk of neurological deterioration after new hemorrhage, which would help in clinical decision-making. METHODS A total of 123 consecutive BSCM patients with symptomatic hemorrhage were identified between 2015 and 2022, with untreated follow-up > 12 months or subsequent hemorrhage during the untreated follow-up. Nomograms were proposed to individualize the assessment of subsequent hemorrhage risk and neurological status (determined by the modified Rankin Scale [mRS] score) after future hemorrhage. The least absolute shrinkage and selector operation (LASSO) regression was used for feature screening. The calibration curve and concordance index (C-index) were used to assess the internal calibration and discrimination performance of the nomograms. Cross-validation was further performed to validate the accuracy of the nomograms. RESULTS Prior hemorrhage times (adjusted OR [aOR] 6.78 per ictus increase) and Zabramski type I or V (OR 11.04) were associated with rehemorrhage within 1 year. A lower mRS score after previous hemorrhage (aOR 0.38 for a shift to a higher mRS score), Zabramski type I or V (OR 3.41), medulla or midbrain location (aOR 2.77), and multiple cerebral cavernous malformations (aOR 11.76) were associated with worsened neurological status at subsequent hemorrhage. The nomograms showed good accuracy and discrimination, with a C-index of 0.80 for predicting subsequent hemorrhage within 1 year and 0.71 for predicting neurological status after subsequent hemorrhage, which were maintained in cross-validation. CONCLUSIONS An individualized approach to risk and severity assessment of BSCM rehemorrhage was feasible with clinical and imaging features.
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Affiliation(s)
- Zongze Li
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Li Ma
- 6Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Quan
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Peixi Liu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Yuan Shi
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Yingjun Liu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Wei Zhu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
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6
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Gamma Knife® stereotactic radiosurgery for intracranial cavernous malformations. J Clin Neurosci 2022; 106:96-102. [DOI: 10.1016/j.jocn.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/11/2022]
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Xu XY, Li D, Song LR, Liu PP, Wu ZY, Wang L, Zhang LW, Zhang JT, Wu Z. Nomogram for predicting an individual prospective hemorrhage risk in untreated brainstem cavernous malformations. J Neurosurg 2022; 138:910-921. [PMID: 36152323 DOI: 10.3171/2022.8.jns221228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
In this study, the authors aimed to create a nomogram for precisely predicting the 5-year prospective hemorrhage risk in brainstem cavernous malformations (BSCMs).
METHODS
Patients with confirmed BSCMs in a single-center prospective observational series from January 2012 to December 2016 were included in the present study for nomogram building and validation. The concordance index (C-index), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy, discriminative ability, and clinical usefulness of the nomogram. Then, a nomogram-based risk stratification model for untreated BSCMs was developed.
RESULTS
In total, 600 patients were included in the study; 417 patients who had been enrolled before July 2015 were divided into the training and validation cohorts, and 183 subsequently enrolled patients were used as the external validation cohort. By applying a backward stepwise procedure in the multivariable Cox model, variables, including prior hemorrhage (HR 1.69), hemorrhage on admission (HR 3.33), lesion size > 1.5 cm (HR 1.84), lesion depth (HR 2.35), crossing the axial midpoint (HR 1.94), and developmental venous anomaly (HR 2.62), were incorporated to develop a nomogram. The Harrell C-index values for a 5-year prospective hemorrhage were 0.752 (95% CI 0.687–0.816), 0.801 (95% CI 0.665–0.936), and 0.758 (95% CI 0.674–0.842) in the training, internal validation, and external validation cohorts, respectively. The nomogram performed well in terms of consistency between prediction and actual observation according to the calibration curve. The patients could be classified into three distinct (low, medium, and high) risk groups using the final score of this nomogram.
CONCLUSIONS
Independent predictors of the 5-year hemorrhage risk in untreated BSCMs were selected to create the first nomogram for predicting individual prospective hemorrhage. The nomogram was able to stratify patients into different risk groups and assist in clinical decision-making.
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Affiliation(s)
- Xiao-Ying Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Lai-Rong Song
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Pan-Pan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Ze-Yu Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
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Five-year symptomatic hemorrhage risk of untreated brainstem cavernous malformations in a prospective cohort. Neurosurg Rev 2022; 45:2961-2973. [PMID: 35633420 DOI: 10.1007/s10143-022-01815-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/23/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
Hemorrhage of brainstem cavernous malformation (CM) would cause various symptoms and severe disability. The study aimed to elaborate on the 5-year actuarial cumulative hazard of symptomatic hemorrhage. Patients diagnosed in our institute between 2009 and 2013 were prospectively registered. All clinical data were obtained, follow-up was performed, and risk factors were evaluated. Four hundred sixty-eight patients (217 female, 46.4%) were included in the study with a median follow-up duration of 79.0 months. A total of 137 prospective hemorrhages occurred in 107 patients (22.9%) during 1854.0 patient-years. Multivariate Cox analysis found age ≥ 55 years (hazard ratio (HR) 2.166, p = 0.002), DVA (HR 1.576, p = 0.026), superficial-seated location (HR 1.530, p = 0.047), and hemorrhage on admission (HR 2.419, p = 0.026) as independent risk factors for hemorrhage. The 5-year cumulative hazard of hemorrhage was 30.8% for the overall cohort, 47.8% for 60 patients with age ≥ 55 years, 43.7% for 146 patients with DVA, 37.9% for 272 patients with superficial-seated lesions, and 37.2% for 341 patients with hemorrhage on admission. As a stratified analysis, within subcohort of 341 patients with a hemorrhagic presentation, age ≥ 55 years (HR 3.005, p < 0.001), DVA (HR 1.801, p = 0.010), and superficial-seated location (HR 2.276, p = 0.001) remained independently significant. The 5-year cumulative hazard of hemorrhage was 52.0% for 119 patients with both DVA and hemorrhagic presentation. The 5-year cumulative hemorrhagic risk was 30.8% and was higher in subgroups if harboring risk factors that helped to predict potential hemorrhagic candidates and were useful for treatment decision-making.Clinical Trial Registration-URL: http://www.chictr.org.cn Unique identifier: ChiCTR-POC-17011575.
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Qin L, Zhang H, Li B, Jiang Q, Lopez F, Min W, Zhou JH. CCM3 Loss-Induced Lymphatic Defect Is Mediated by the Augmented VEGFR3-ERK1/2 Signaling. Arterioscler Thromb Vasc Biol 2021; 41:2943-2960. [PMID: 34670407 PMCID: PMC8613000 DOI: 10.1161/atvbaha.121.316707] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCMs) can happen anywhere in the body, although they most commonly produce symptoms in the brain. The role of CCM genes in other vascular beds outside the brain and retina is not well-examined, although the 3 CCM-associated genes (CCM1, CCM2, and CCM3) are ubiquitously expressed in all tissues. We aimed to determine the role of CCM gene in lymphatics. Approach and Results: Mice with an inducible pan-endothelial cell (EC) or lymphatic EC deletion of Ccm3 (Pdcd10ECKO or Pdcd10LECKO) exhibit dilated lymphatic capillaries and collecting vessels with abnormal valve structure. Morphological alterations were correlated with lymphatic dysfunction in Pdcd10LECKO mice as determined by Evans blue dye and fluorescein isothiocyanate(FITC)-dextran transport assays. Pdcd10LECKO lymphatics had increased VEGFR3 (vascular endothelial growth factor receptor-3)-ERK1/2 (extracellular signal-regulated kinase 1/2) signaling with lymphatic hyperplasia. Mechanistic studies suggested that VEGFR3 is primarily regulated at a transcriptional level in Ccm3-deficient lymphatic ECs, in an NF-κB (nuclear factor κB)-dependent manner. CCM3 binds to importin alpha 2/KPNA2 (karyopherin subunit alpha 2), and a CCM3 deletion releases KPNA2 to activate NF-κB P65 by facilitating its nuclear translocation and P65-dependent VEGFR3 transcription. Moreover, increased VEGFR3 in lymphatic EC preferentially activates ERK1/2 signaling, which is critical for lymphatic EC proliferation. Importantly, inhibition of VEGFR3 or ERK1/2 rescued the lymphatic defects in structure and function. CONCLUSIONS Our data demonstrate that CCM3 deletion augments the VEGFR3-ERK1/2 signaling in lymphatic EC that drives lymphatic hyperplasia and malformation and warrant further investigation on the potential clinical relevance of lymphatic dysfunction in patients with CCM.
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MESH Headings
- Animals
- Apoptosis Regulatory Proteins/genetics
- Cells, Cultured
- Endothelial Cells/physiology
- Endothelium, Lymphatic/pathology
- Endothelium, Lymphatic/physiopathology
- Female
- Gene Deletion
- Hemangioma, Cavernous, Central Nervous System/pathology
- Hemangioma, Cavernous, Central Nervous System/physiopathology
- Hyperplasia
- MAP Kinase Signaling System/physiology
- Male
- Mice, Inbred Strains
- Models, Animal
- NF-kappa B/genetics
- Translocation, Genetic
- Vascular Endothelial Growth Factor Receptor-3/metabolism
- Mice
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Affiliation(s)
- Lingfeng Qin
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Haifeng Zhang
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Busu Li
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Quan Jiang
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Francesc Lopez
- Yale Center for Genome Analysis, Cancer Department of Genetics, Yale University School of Medicine, New Haven, CT
| | - Wang Min
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Jenny Huanjiao Zhou
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, CT
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10
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Tao C, Xu P, Yao Y, Zhu Y, Li R, Li J, Luo W, Hu W. A Prospective Study to Investigate Controlling Blood Pressure Under Transcranial Doppler After Endovascular Treatment in Patients With Occlusion of Anterior Circulation. Front Neurol 2021; 12:735758. [PMID: 34659095 PMCID: PMC8511455 DOI: 10.3389/fneur.2021.735758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/26/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: The objective of this study was to evaluate the effect of blood pressure (BP) management with transcranial Doppler (TCD) guidance in patients with large-vessel occlusion in the anterior circulation after endovascular thrombectomy (EVT) on the long-term prognosis. Methods: This was a prospective study; 232 patients were nonrandomized assigned to TCD-guided BP management (TBM) group or non-TCD-guided BP management (NBM) group. In the TBM group, BP was controlled according to TCD showing cerebral blood flow fluctuation. In the NBM group, BP was controlled according to the guidelines. The primary endpoint was a modified Rankin scale (mRS) score of 2 or lower at 90 days. The safety outcomes were the rates of symptomatic or any intracerebral hemorrhage (ICH) and mortality at 90 days. Results: One hundred sixty-three patients were assigned to the TBM group, and 69 were assigned to the NBM group. In the propensity score-matched cohort (65 matches in both groups), there was significant difference in the proportion of participants with mRS 0–2 at 90 days according to BP management (adjusted odds ratio 3.34, 95% CI 1.36 to 8.22). There was no difference in the rates of symptomatic or any ICH and mortality between two groups. In inverse probability-weighted regression adjustment analysis, mortality decreased significantly in the TBM group than in the NBM group (adjusted odds ratio 0.86, 95% CI 0.76–0.99, p = 0.03). Conclusion: In patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation, BP management under TCD was superior to NBM in improving the clinical outcomes at 90 days. Clinical Trial Registration: (URL: https://www.chictr.org.cn/showproj.aspx?proj=55484; Identifier: ChiCTR2000034443.
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Affiliation(s)
- Chunrong Tao
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Pengfei Xu
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Yang Yao
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Yajuan Zhu
- Division of Life Sciences and Medicine, Department of Ultrasound, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Rui Li
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Jie Li
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Wenwu Luo
- Department of pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Hu
- Division of Life Sciences and Medicine, Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
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11
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Rahman MM, Nabi Khan SK, Khan RA, Garcia-Ballestas E, Moscote-Salazar LR, Rahman S. Surgical outcome and technical issues in symptomatic brainstem cavernous malformations. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Peng M, Chen Y, Geng G. Cystatin C and intravenous thrombolysis. Eur J Neurol 2021; 28:e28. [PMID: 33421235 DOI: 10.1111/ene.14722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Meidi Peng
- School of Medicine (School of Nursing), Nantong University, Nantong, China
| | - Yupei Chen
- School of Medicine (School of Nursing), Nantong University, Nantong, China
| | - Guiling Geng
- School of Medicine (School of Nursing), Nantong University, Nantong, China
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