Intracranial Vascular Malformations in Children

Intracranial vascular malformations (IVMs) represent a significant challenge in pediatric medicine due to their diagnostic and therapeutic complexity. Despite their rarity, the severity of potential neurologic outcomes necessitates a comprehensive understanding and approach to management. This article aims to provide an overview of pediatric IVMs, specifically nidal arteriovenous malformations, cavernous malformations, capillary telangiectasias, and developmental venous anomalies, and highlight the importance of advanced diagnostic imaging and therapeutic strategies in improving outcomes. Vein of Galen malformations, pial arteriovenous fistulas, dural sinus malformations, and intracranial venous malformations will be addressed in other articles. Following a discussion of imaging and clinical considerations within the field, novel imaging techniques will be discussed.

KTWS (Klippel-Trenaunay-Weber syndrome): A systematic presentation of a rare disease

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare disease with a wide range of manifestations. KTWS is characterized by a clinical triad of varicosities of the extremities, cutaneous vascular malformations, and hypertrophy of soft tissues and long bones. The diagnosis is made clinically supplemented with magnetic resonance imaging and computed tomography.

AIM

Hereby we aim to highlight the significance of the possible life-threatening first-time presentations associated with the GI system in previously undiagnosed KTWS patients.

PATIENT

We report the case of a 47-year-old male with KTWS, who presented with various symptoms such as rectorrhagia since childhood, digestive problems and abnormal lateral vascular malformations of the left buttock which extended all the way to the leg, vascular malformations of the left fourth and fifth toes as well as soft tissue swelling of the left foot. There was no evidence of other clinical presentations. The patient was hospitalized with severe rectorrhagia and a hemoglobin level of 3/9. Physical examination revealed a blood pressure of 85/55 and pulse rate of 115. Ruptured aneurysm of the superior mesenteric artery was found on angiography and subsequently treated with embolization. Dermatologic evaluation showed pitting edema of the left leg and foot and multiple vascular lesions. Thus a diagnosis of KTWS was established. Pulsed dye laser therapy and compression bandage was performed for the patient. The patient's follow-up was done 3 months after discharge for which the patient was again consulted by a dermatologist and gastroenterologist. Lymphedema of the left leg had improved to a great extend so treatment with compression bandage was continued. Colonoscopy was repeated for the patient to evaluate and control possible active sources of bleeding, due to potential life-threating complications.

RESULTS

According to previous findings, there have been few case reports of KTWS presenting with gastrointestinal manifestations, fewer of which have covered acute life-threatening bleedings associated with this system.

Rare Presentation of the Vein of Servelle in a Case of Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular syndrome involving bone and soft tissue hypertrophy of the involved limb and vascular malformations of the lymphatic, capillary, and venous systems. It is often confused with Parkes-Weber syndrome (PWS). KTS is characterized by a triad of capillary malformation in the form of port wine stains, bone or limb hypertrophy, and varicose veins. The vein of Servelle, also known as the lateral marginal vein, is one of the two persisting embryonic veins of the leg, the persistent sciatic vein being the other. Truncal vascular malformation can be a complication of failure of obliteration of these veins. We present a case of a 24-year-old male of KTS who had varicose veins in his right lower limbs since five years of age and macrodactyly with a synchronous presentation of the vein of Servelle.

Klippel-Trenaunay Syndrome: To Be or Not to Be Afraid

Klippel-Trenaunay syndrome (KTS) is a rare genetic syndrome comprising an abnormal development of soft tissues and the lymphovascular system with bony overgrowth, venous malformation, and port wine stains. We present an interesting case of a three-year-old child brought to our hospital with a swollen limb and raised skin lesions associated with bleeding from minor trauma. Most of the clinical characteristics of KTS were seen in our patient, including arteriovenous, soft tissue, capillary, and lymphatic abnormalities. The diagnosis of KTS is based on clinical examinations and imaging investigations. He had gross hypertrophy of the left lower limb with measurable lengthening compared to the opposite limb. Ultrasonography of the left limb revealed soft tissue hypertrophy with abnormal venous communication. The management of KTS is mainly symptomatic and should be approached conservatively if the patient has functional limbs without edema, bleeding, ulceration, or pain.

Klippel-Trenaunay Syndrome, Segmental/Focal Overgrowth Malformations: A Review

Klippel-Trenaunay syndrome is an uncommon, infrequent, congenital disorder characterized by a triad of capillary malformation, varicosities, and tissue and bone hypertrophy. The presence of two of these three signs is enough to obtain the diagnosis. Capillary malformations are usually present at birth, whereas venous varicosities and limb hypertrophy become more evident later. The syndrome has usually a benign course, but serious complications involving various organs, such as gastrointestinal and genitourinary organs, as well as the central nervous system, may be observed. Recently, Klippel-Trenaunay syndrome has been included in the group of PIK3CA-related overgrowth spectrum (PROS) disorders. In terms of this disorder, new results in etiopathogenesis and in modalities of treatment have been advanced. We report here a review of the recent genetic findings, the main clinical characteristics and related severe complications, differential diagnoses with a similar disorder, and the management of patients with this complex and uncommon syndrome.

Treatment of venous malformations in pediatric population – three- year experience

Venous malformations (VMs) are a type of vascular malformations that result in abnormal development of veins that become extensible over time due to an error in vascular morphogenesis. They usually appear in newborns or in early adulthood as a bluish, soft, swollen and eventually painful skin formation. Treatment includes conservative therapy, sclerotherapy and surgical excision. Aim of the paper is to evaluate the therapeutic effect of scleraotherapy in pediatric patients with venous malformations. Material and methods: In a three-year period, from 2019 to 2021, venous malformation was found in 33 patients aged 4 to 14 years (average age: 8 years). Pain as a symptom occurred in 8 patients. Two patients had lesions measuring up to 5 cm and 5 cm respectively, while in the remaining subjects the lesion was over 5 cm. Ultrasound was performed routinely in all subjects, and MRI in two patients. Conservative treatment was instituted in 13 patients with venous malformations of the extremities, surgical excision with local reconstruction was performed in 11 patients, and sclerotherapy with bleomycin under general anesthesia was performed in 8 patients. Combined treatment was used in one patient that presented with venous malformation of the upper arm that underwent partial sclerotherapy with subsequent operative excision due to a phlebolith. Follow-up examinations revealed regression of the change not only from functional but from aesthetic aspect as well. Conclusion: Sclerotherapy is the established golden standard, first-line treatment for venous malformations. Excellent results were achieved as the reduction of the lesions was below 50% of the initial size. However, the modality of treatment should be individualized to each patient as it can sometimes require a combination of more than one treatment option. Venous malformations are best treated early, but they usually recur over time. Treatment helps relieve symptoms and control the growth of vascular malformations.

Evaluation and management of the lateral marginal vein in Klippel-Trénaunay and other PIK3CA-related overgrowth syndromes

The lateral marginal vein is an anomalous clinical entity found in association with Klippel-Trénaunay and other PIK3CA-related overgrowth syndromes. Although it is reported to affect <20% of patients with Klippel-Trénaunay syndrome, this venous anomaly has been associated with significant morbidity and mortality attributable to venous hypertension and potentially lethal thromboembolic events. Limited literature exists on the diagnosis and management of this rare anomaly, with most of the reports focusing on retrospective clinical experience at a few centers of excellence. Despite these limitations, a systematic approach to diagnosis and treatment of this anomaly is warranted and expounded on herein. When plausible, clinical recommendations based on best available literature are made.

Chronic lower extremity wounds in a patient with Klippel Trenaunay syndrome

Klippel-Trenaunay syndrome is a rare disorder consisting of the triad of vascular and/or lymphatic malformations, capillary malformations, and soft tissue or bony hypertrophy. Symptom control is the mainstay of treatment for these patients, with many of the symptoms never fully being relieved. In this case report, we present the case of a 46-year-old man with chronic lower extremity ulcerations unresponsive to wound care therapy. Owing to the chronic nature of his wounds and associated pain, reconstruction of his iliac vein was performed using polytetrafluoroethylene graft and an arteriovenous fistula.