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Palavani LB, Mitre LP, Almeida MV, Neto LBA, Ferreira MY, Semione G, Farias CAG, Batista S, Soares LGB, Pereira FS, Filho LM, Bertani R, Lawton MT, Figueiredo EG. Presentation and management of cerebral proliferative angiopathy: a systematic review and meta-analysis on treatment outcomes. Neurosurg Rev 2024; 47:664. [PMID: 39312085 DOI: 10.1007/s10143-024-02878-z] [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: 07/28/2024] [Revised: 09/13/2024] [Accepted: 09/14/2024] [Indexed: 10/15/2024]
Abstract
Cerebral Proliferative Angiopathy (CPA) is a rare brain vascular malformation, similar to Arteriovenous Malformations (AVM) but lacking of early venous drainage. Presentation and treatment outcomes were investigated, examining for morbidity, mortality and complications. A meta-analysis was conducted according to PRISMA guidelines. PubMed, Embase and Web Of Science were searched with keywords such as "cerebral proliferative angiopathy" and "management". We pooled and meta-analyzed outcomes on documented CPA cases. 11,079 studies were pooled as a result of manual citation searching, 50 studies were included, adding up to 115 CPA cases. The majority of patients were females (1.38:1), with a mean age of presentation of 26.9 (19.4) years. Headache (46%) and seizures (34%) were the most common presenting symptoms. 37% of patients presented with focal neurologic deficit. Patients managed conservatively from the surgical standpoint (i.e. nonoperative management) did not undergo homogenous treatment strategies, and major complications were at 47% (95% CI: 17%, 76%), with a 1% mortality (95% CI: 0%, 6%). Surgical and embolization interventions presented the highest proportion of major complications, 66% (95% CI: 33%, 99%) and 73% (95% CI: 42%, 100%), respectively. The embolization subgroup led in mortality, with 3% (95% CI: 0%, 10%). No death was documented in patients undergoing surgery. CPA has a similar presentation to brain arteriovenous malformations, but its treatment outcomes are potentially worse. This difference is not attributable to heterogeneity in assigning patient treatment strategies. This highlights the need for more accurate diagnostic methods.
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Affiliation(s)
- Lucca B Palavani
- Faculty of Medicine, Max Planck University Center, Indaiatuba, São Paulo, Brazil
| | - Lucas Pari Mitre
- Faculty of Medicine, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil.
- Faculty of Medicine, Santa Casa de São Paulo School of Medical Sciences, Rua Dr Cesário Motta Júnior, N° 112, Santa Cecília, São Paulo, SP, Brazil.
| | - Miguel V Almeida
- Faculty of Medicine, State University of Ceará, Fortaleza, Ceará, Brazil
| | - Luis B A Neto
- Faculty of Medical Sciences, Universidade de Pernambuco, Recife, Brazil
| | | | - Gabriel Semione
- Department of Medicine, University of West of Santa Catarina, Joaçaba, SC, Brazil
| | | | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luís G B Soares
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Felipe S Pereira
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Raphael Bertani
- Department of Neurosurgery, São Paulo University, São Paulo, São Paulo, Brazil
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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Gautam D, Morrison DE, Bounajem MT, Shah LM, Grandhi R. The Treatment of Symptomatic Diffuse Proliferative Cerebral Angiopathy With Cilostazol: A Case Report. Cureus 2024; 16:e63387. [PMID: 39070371 PMCID: PMC11283842 DOI: 10.7759/cureus.63387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Diffuse proliferative cerebral angiopathy (DPCA) is a rare form of cerebral vascular malformation responsible for 3.4% of all cerebral arteriovenous malformations (AVMs). The relative risk of rupture for DPCA is lower than for classic AVMs, so they are often managed medically. Despite the somewhat lower rupture risk, the risk of rebleeding is paradoxically higher than in classical AVMs, and there is a potential for significant morbidity and mortality. The aim of this article is to describe a case of a patient with symptomatic DPCA who experienced symptomatic improvement after treatment with the vasodilating agent cilostazol. This is a case report of a patient who presented with aphasia and was found to have DPCA. CT perfusion with acetazolamide challenge confirmed that the patient's symptoms were due to steal phenomena. Subsequently, the patient was treated with 50 mg of cilostazol daily to mediate a vasodilatory response within the arterial tree. Within three days of treatment with cilostazol, the patient showed significant improvement in his aphasia. The patient returned to the clinic a month later and reported continued improvement in his aphasia with speech therapy. Patients who present with neurological deficits from steal phenomena caused by DPCA are difficult to treat surgically because DPCAs often involve normal parenchyma. We present an example of a noninterventional alternative, oral cilostazol paired with functional rehabilitation, for alleviating symptoms associated with DPCA.
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Affiliation(s)
- Diwas Gautam
- Neurosurgery, University of Utah, Salt Lake City, USA
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3
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Luo FR, Zhou Y, Wang Z, Liu QY. Cerebral proliferative angiopathy in pediatric age presenting as neurological disorders: A case report. World J Clin Cases 2023; 11:8071-8077. [DOI: 10.12998/wjcc.v11.i33.8071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare subtype of arteriovenous malformation. It is extremely rare in pediatric patients and has serious implications for developing children. However, reports of these disorders worldwide are limited, and no uniform reference for diagnosis and treatment options exists. We report the case of a 6-year-old with CPA having predominantly neurological dysfunction and review the literature on pediatric CPA.
CASE SUMMARY We report the case of a pediatric patient with CPA analyzed using digital subtraction angiography (DSA) who presented initially with a neurological disorder as the main manifestation. This case is the basis for further discussion of the clinical presentation, pathogenesis, diagnosis, and treatment of CPA in children. After the cerebral DSA, the patient was treated conservatively with sedation, fluid replacement, and blood anticoagulation. She could not cooperate with the follow-up magnetic resonance imaging examination because of her young age, and her family declined further treatment because of the surgery’s high risk. She was followed up for 3 months; her symptoms did not worsen.
CONCLUSION This report of rare pediatric CPA can inform and advance clinical research on congenital cerebrovascular diseases.
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Affiliation(s)
- Fu-Ren Luo
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Ying Zhou
- Department of Radiology, Mianyang Central Hospital, Mianyang 621000, Sichuan Province, China
| | - Zhong Wang
- Department of Radiology, Mianyang Central Hospital, Mianyang 621000, Sichuan Province, China
| | - Qi-Yu Liu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
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Gerstl JVE, Bernstock JD, Kappel AD, Torio EF, Du R. Recurrent Intraventricular Haemorrhage in Cerebral Proliferative Angiopathy - A Case Report and Review of the Literature. Neurohospitalist 2023; 13:345-350. [PMID: 37701260 PMCID: PMC10494813 DOI: 10.1177/19418744231180046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Cerebral proliferative angiopathy (CPA) is an entity distinct from that of classical arteriovenous malformations. As such, few reports have considered the long-term follow-up of patients with hemorrhage in CPA. Accordingly, herein the authors present a case of recurrent hemorrhage in CPA with 32 years of follow-up and in so doing summarize the literature of hemorrhagic cases in CPA. A 19-year-old presented with focal awareness seizures and diagnostic work-up revealed a left hemispheric vascular lesion. The patient presented again with intracranial hemorrhage at ages 28, 43 and 51. Angioarchitectural workup revealed intermingled brain parenchyma between vascular spaces, absence of dominant feeders and a clear nidus consistent with CPA. The size and diffuse nature of the lesion deemed it inoperable. Given our case and review of the literature it is apparent that CPA has a high risk of re-hemorrhage in the rare event that hemorrhage does occur.
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Affiliation(s)
- Jakob V. E. Gerstl
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ari D. Kappel
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Erickson F. Torio
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Shomura K, Kamide T, Misaki K, Tsutsui T, Nambu I, Uchiyama N, Nakada M. Multiple Endovascular Treatments for Hemorrhagic Cerebral Proliferative Angiopathy: A Case Report. Case Rep Neurol 2022; 14:433-440. [PMID: 36636273 PMCID: PMC9830309 DOI: 10.1159/000527559] [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: 08/05/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022] Open
Abstract
Cerebral proliferative angiopathy (CPA) is a rare vascular abnormality characterized by transdural supply, stenoses of feeding arteries, and intermingled normal brain parenchyma in abnormal vessels. CPA is often regarded as a separate entity from "classical" brain arteriovenous malformations in angioarchitecture, natural history, clinical presentation, and treatment. Bleeding from CPA is uncommon, but once bleeding occurs, the risk of rebleeding is high. Herein, we describe a case of cerebral hemorrhage caused by CPA. We performed two different endovascular treatments: partial embolization with glue for a ruptured aneurysm and coil embolization for an unruptured growing aneurysm. To our knowledge, this is the first report of serial endovascular treatments for hemorrhagic CPA that included a ruptured aneurysm and a growing unruptured aneurysm.
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Affiliation(s)
- Keijiro Shomura
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Tomoya Kamide
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan,*Tomoya Kamide,
| | - Kouichi Misaki
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Taishi Tsutsui
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Iku Nambu
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
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Chen YN, Lee CW, Xiao F, Chen YF, Hu TY, Kuo MF. A Proposed Algorithm for Managing Cerebral Proliferative Angiopathy. World Neurosurg 2022; 167:e360-e369. [PMID: 35961587 DOI: 10.1016/j.wneu.2022.08.009] [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: 04/19/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Cerebral proliferative angiopathy (CPA) is a rare disease, characterized by a large vascular nidus, diffuse angiogenesis, and intermingled normal brain tissue. Conservative treatment, endovascular intervention, indirect revascularization, and radiotherapy have been applied to treat this disease. However, some cases deteriorate even after non-conservative treatment, and there has been no standard of treatment for this disease so far. In order to build a better treatment strategy, we review literature, present our case and propose an algorithm for managing CPA. METHODS Following the PRISMA principle, we systemically reviewed literature discussing CPA. A case successfully managed with multi-modal treatment is also illustrated. RESULTS A total of 23 articles with 74 cases of CPA were found. Thirty-three patients received single-modal management. These 33 cases include 24 receiving endovascular intervention, 7 receiving indirect revascularization, and 2 receiving radiotherapy. Three of the 33 patients deteriorated clinically, and 1 expired. We present a 6-year-old boy with left hemispheric CPA receiving indirect revascularization, followed by 2 consecutive courses of stereotactic radiosurgery targeting arteriovenous shunts in the left basal ganglia and arteriovenous shunts around the olfactory groove. In the follow-up period of more than 4 years, good collateral formation, improved perilesional perfusion, CPA shrinkage, and symptom relief were all achieved. CONCLUSIONS Based on our literature review and case, we propose an algorithm for the management of CPA and emphasize that multi-modal treatment is necessary for most CPA cases.
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Affiliation(s)
- Yu-Ning Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Furen Xiao
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Tiffany Y Hu
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Meng-Fai Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan.
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7
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Hess RM, Zhang JF, Cappuzzo JM, Bregy A, Levy EI. Cerebral Proliferative Angiopathy Presenting as Subdural Hematoma: A Case Report and Systematic Literature Review. World Neurosurg 2022; 164:281-289. [PMID: 35636668 DOI: 10.1016/j.wneu.2022.05.096] [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: 04/03/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
Cerebral proliferative angiopathy (CPA) is a rare cerebrovascular pathology that presents with unique clinical features due to distinct histologic, angiographic, and pathophysiologic characteristics that separate it from classical arteriovenous malformation. The disorder is characterized by uncontrolled angiogenesis in which functional brain parenchyma is interspersed with abnormal vascular channels without a distinct nidus. Common presenting symptoms include headache, seizures, and stroke-like symptoms. Hemorrhagic presentations are rare in contrast to the typical presentations of classical arteriovenous malformation. Here, we report a young woman with a history of a suspected connective tissue disorder who presented to the emergency department with worsening headaches in a delayed fashion after experiencing minor head trauma and was found to have a left-sided subdural hematoma. Angiography confirmed a diagnosis of CPA after abnormal cortical vasculature was noted during the patient's craniotomy. A systematic review of CPA cases described in the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with the findings discussed.
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Affiliation(s)
- Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jeff F Zhang
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Amade Bregy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA.
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Hemorrhagic cerebral proliferative angiopathy in two pediatric patients: case reports. Childs Nerv Syst 2022; 38:789-794. [PMID: 33956211 DOI: 10.1007/s00381-021-05181-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Cerebral proliferative angiopathy (CPA) is an infrequent vascular malformation. It is composed of a nidus, arterial feeders, and venous drainage. Some special features differentiate it from the common arteriovenous malformations (AVM). The nidus has normal cerebral tissue intermingled and occupies a large portion of the brain. There is a frequent transdural arterial supply. Arterial feeders and draining veins are of small caliber concerning the nidus size. Ischemic strokes are the most common clinical event. Intracranial bleeding when occurs has a worse prognosis due to its high recurrence rate. We have presented two cases of CPA in pediatric patients who required surgical resolution of their acute episode.
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Xia Y, Yu XF, Ma ZJ, Sun ZW. Hemorrhagic transformation of ischemic cerebral proliferative angiopathy: A case report. World J Clin Cases 2021; 9:5730-5736. [PMID: 34307632 PMCID: PMC8281439 DOI: 10.12998/wjcc.v9.i20.5730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/06/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare vascular disease characterized by the presence of diffuse vascular proliferation, progressive vascular hyperflow and vasodilation of multiple vessels in the normal brain parenchyma. Unlike cerebral arteriovenous malformations, CPA has a mixed appearance between that of lesions with cell proliferation and endothelial proliferation. To date, the pathogenesis of CPA is unclear, in which changes induced by cortical ischemia in the elastic layer of the blood supply artery and smooth muscle cells may be involved.
CASE SUMMARY In this article, we retrospectively analyzed a case of hemorrhagic transformation of ischemic CPA diagnosed by digital subtraction angiography and reviewed the related literature for further exploration of its pathogenesis, diagnosis and treatment.
CONCLUSION The information in the present case report may facilitate further clinical research on this cerebrovascular disease.
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Affiliation(s)
- Yu Xia
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Xian-Feng Yu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Zhen-Juan Ma
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Zhong-Wu Sun
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
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10
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Martín-Noguerol T, Concepción-Aramendia L, Lim CT, Santos-Armentia E, Cabrera-Zubizarreta A, Luna A. Conventional and advanced MRI evaluation of brain vascular malformations. J Neuroimaging 2021; 31:428-445. [PMID: 33856735 DOI: 10.1111/jon.12853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/14/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
Vascular malformations (VMs) of the central nervous system (CNS) include a wide range of pathological conditions related to intra and extracranial vessel abnormalities. Although some VMs show typical neuroimaging features, other VMs share and overlap pathological and neuroimaging features that hinder an accurate differentiation between them. Hence, it is not uncommon to misclassify different types of VMs under the general heading of arteriovenous malformations. Thorough knowledge of the imaging findings of each type of VM is mandatory to avoid these inaccuracies. Conventional MRI sequences, including MR angiography, have allowed the evaluation of CNS VMs without using ionizing radiation. Newer MRI techniques, such as susceptibility-weighted imaging, black blood sequences, arterial spin labeling, and 4D flow imaging, have an added value of providing physiopathological data in real time regarding the hemodynamics of VMs. Beyond MR images, new insights using 3D printed models are being incorporated as part of the armamentarium for a noninvasive evaluation of VMs. In this paper, we briefly review the pathophysiology of CNS VMs, focusing on the MRI findings that may be helpful to differentiate them. We discuss the role of each conventional and advanced MRI sequence for VMs assessment and provide some insights about the value of structured reports of 3D printing to evaluate VMs.
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Affiliation(s)
| | | | - Cc Tchoyoson Lim
- Neuroradiology Department, National Neuroscience Institute and Duke-NUS Medical School, Singapore
| | | | | | - Antonio Luna
- MRI Unit, Radiology Department, HT Medica, Jaén, Spain
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11
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Guest W, Krings T. Brain Arteriovenous Malformations: The Role of Imaging in Treatment Planning and Monitoring Response. Neuroimaging Clin N Am 2021; 31:205-222. [PMID: 33902875 DOI: 10.1016/j.nic.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Brain arteriovenous malformations (AVMs) are characterized by shunting between pial arteries and cortical or deep veins, with the presence of an intervening nidus of tortuous blood vessels. These lesions present a therapeutic challenge, because their natural history entails a risk of intracranial hemorrhage, but treatment may cause significant morbidity. In this article, imaging features of AVMs on MR imaging and catheter angiography are reviewed to stratify the risk of hemorrhage and guide appropriate management. The angioarchitecture of AVMs may evolve over time, spontaneously or in response to treatment, necessitating ongoing imaging surveillance.
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Affiliation(s)
- Will Guest
- Department of Neuroradiology, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Timo Krings
- Department of Neuroradiology, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
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12
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The current clinical picture of cerebral proliferative angiopathy: systematic review. Acta Neurochir (Wien) 2020; 162:1727-1733. [PMID: 32206904 DOI: 10.1007/s00701-020-04289-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/11/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare subset of arteriovenous malformations (AVM). It has unique clinical presentation, angiographic characteristics, and pathophysiology which often brings challenges for the treatment. We aimed to define its epidemiology, pathophysiology are unknown, and best management strategies. METHODS A systematic review was conducted according to the PRISMA guidelines. MEDLINE was searched for articles regarding CPA. Extracted data included epidemiological, clinical, and angiographical characteristics, treatment, and outcomes. Treatment was classified as conservative, radiosurgery, endovascular, decompression, and indirect vascularization. A meta-analytical approach was employed for description of the data as study-size adjusted percentages or weighted means, as appropriate. RESULTS Thirty-three studies were analyzed, rendering a total 95 cases-half of which came from a single study. Patients were predominantly young (mean 23 years old) and female (60.0%) presenting with headaches (44.9%), seizures (37.1%), or transient ischemic attacks (33.7%). Hemorrhage was present in 18.0%, but rebleeding rates were as high as 67%. The majority of nidus were > 6 cm (52.5%) with hemispheric extension (73.0%). Capillary angioectatic appearance (85.7%), transdural supply (62.5%), and deep venous drainage (73.0%) were also frequent features. Most patients were treated conservatively (54.4%), followed by endovascular (34.2%). Indirect vascularization and radiosurgery were attempted in five and two patients, respectively. Mean follow-up was 110.8 patient-years. Neurological status improved in 50.7%, remained stable in 40.2%, and worsened in 9.0%. CONCLUSIONS Conservative and endovascular treatments seem adequate interventions, despite limited evidence. Complementary techniques can be used in patients throughout disease history, according to symptom-based, individualized approach. More studies are required for choosing interventions based on reliable long-term results.
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Voronovich ZA, Wolfe K, Foster K, Sorte D, Carlson AP. Restrictive cerebral cortical venopathy: A new clinicopathological entity. Interv Neuroradiol 2019; 25:322-329. [PMID: 31138039 DOI: 10.1177/1591019918821861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child's presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.
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Affiliation(s)
- Zoya A Voronovich
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Kathy Wolfe
- 2 Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Kimberly Foster
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Danielle Sorte
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA.,3 Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Andrew P Carlson
- 1 Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, USA
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Kimiwada T, Hayashi T, Takahashi M, Shirane R, Tominaga T. Progressive Cerebral Ischemia and Intracerebral Hemorrhage after Indirect Revascularization for a Patient with Cerebral Proliferative Angiopathy. J Stroke Cerebrovasc Dis 2019; 28:853-858. [PMID: 30737070 DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 11/01/2018] [Accepted: 11/16/2018] [Indexed: 12/31/2022] Open
Abstract
We previously reported a patient with cerebral proliferative angiopathy (CPA) who showed cerebral ischemia in resting and acetazolamide-stressed N-isopropyl-p-[123I] iodoamphetamine single-photon emission computed tomography (123I-IMP-SPECT). At onset, the patient was treated conservatively. However, during the 2 years following initial onset, his hemiparesis and aphasia had gradually aggravated and his IQ scores were markedly decreased. MRI revealed progressive vascular proliferation and brain atrophy. 123I-IMP-SPECT showed more severely impaired cerebral blood flow (CBF) and cerebrovascular reactivity over the affected hemisphere. We performed an indirect revascularization to augment CBF; however, his neurological deficits were not improved and new arteriovenous shunts via extracranial-intracranial bypass were developed, followed by an asymptomatic small intracerebral hemorrhage. There are no reports on CPA patients who have shown cerebral hemorrhage after indirect revascularization. Treatments for CPA are still challenging and controversial. Cases with severe stenosis of the proximal arteries may benefit from indirect revascularization. But indirect bypass should not be indicated for such patients without main arterial stenosis, even if they have persistent ischemia.
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Affiliation(s)
- Tomomi Kimiwada
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan.
| | | | - Misaki Takahashi
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Somji M, McEachern J, Silvaggio J. Cerebral revascularization in cerebral proliferative angiopathy: a systematic review. Neurosurg Focus 2019; 46:E11. [DOI: 10.3171/2018.11.focus18529] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/13/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVECerebral proliferative angiopathy (CPA) is considered a discrete vascular malformation of the brain separate from classical brain arteriovenous malformations (AVMs). It has unique angiographic characteristics and has been hypothesized to result from chronic cortical ischemia and perinidal oligemia. Treatment with cerebral revascularization has been proposed in an attempt to disrupt regional hypoperfusion and interrupt the angiogenesis that defines CPA. A systematic review of the literature pertaining to the role of cerebral revascularization may highlight a treatment paradigm for this rare disease.METHODSA systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. MEDLINE and Embase were searched from inception for papers relating to CPA. Included articles were categorized according to methodology (case series or imaging study) and treatment modality (conservative, radiation, endovascular, or revascularization). A synthesis was compiled summarizing the current evidence regarding cerebral revascularization in CPA.RESULTSThe initial search revealed 43 articles, of which 28 studies met the inclusion criteria. Nine studies were identified that described imaging findings, which suggested hemodynamic dysregulation and perinidal impairments in the cerebrovascular reserve could be identified compared to unaffected hemispheres and classical brain AVMs. Six studies including 7 patients undergoing indirect forms of cerebral revascularization were identified. Clinical and radiological outcomes following revascularization were favorable in all but one study.CONCLUSIONSA small body of radiological and clinical studies has emerged, suggesting that CPA is a response to perinidal oligemia. While the long-term clinical efficacy of revascularization remains unclear, early results suggest that this may be a novel treatment paradigm for patients with CPA.
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Affiliation(s)
| | - James McEachern
- 2Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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