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Zhang S, Wang J, Sun S, Zhang Q, Zhai Y, Wang X, Ge P, Shi Z, Zhang D. CT Angiography Radiomics Combining Traditional Risk Factors to Predict Brain Arteriovenous Malformation Rupture: a Machine Learning, Multicenter Study. Transl Stroke Res 2024; 15:784-794. [PMID: 37311939 DOI: 10.1007/s12975-023-01166-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/04/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
This study aimed to develop a machine learning model for predicting brain arteriovenous malformation (bAVM) rupture using a combination of traditional risk factors and radiomics features. This multicenter retrospective study enrolled 586 patients with unruptured bAVMs from 2010 to 2020. All patients were grouped into the hemorrhage (n = 368) and non-hemorrhage (n = 218) groups. The bAVM nidus were segmented on CT angiography images using Slicer software, and radiomic features were extracted using Pyradiomics. The dataset included a training set and an independent testing set. The machine learning model was developed on the training set and validated on the testing set by merging numerous base estimators and a final estimator based on the stacking method. The area under the receiver operating characteristic (ROC) curve, precision, and the f1 score were evaluated to determine the performance of the model. A total of 1790 radiomics features and 8 traditional risk factors were contained in the original dataset, and 241 features remained for model training after L1 regularization filtering. The base estimator of the ensemble model was Logistic Regression, whereas the final estimator was Random Forest. In the training set, the area under the ROC curve of the model was 0.982 (0.967-0.996) and 0.893 (0.826-0.960) in the testing set. This study indicated that radiomics features are a valuable addition to traditional risk factors for predicting bAVM rupture. In the meantime, ensemble learning can effectively improve the performance of a prediction model.
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Affiliation(s)
- Shaosen Zhang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Junjie Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengjun Sun
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanren Zhai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochen Wang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peicong Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhiyong Shi
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.
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Hayama M, Maeda Y, Obata S, Tsuda T, Takeda K, Nishida T, Inohara H. Understanding hereditary hemorrhagic telangiectasia: From genetic anomalies to systemic manifestations, quality of life, and epistaxis management-Exploring the otolaryngologist's integral role. Auris Nasus Larynx 2024; 51:305-312. [PMID: 38008660 DOI: 10.1016/j.anl.2023.11.002] [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: 09/11/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/28/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Rendu-Weber syndrome, is a rare autosomal dominant disorder characterized by vascular malformations. This comprehensive review aimed to provide an overview and summarize various aspects of HHT, including the genetic abnormalities, complications associated with visceral arteriovenous malformations (AVMs), prognosis of HHT, quality of life (QOL), and treatment of epistaxis. In addition, this review highlights the challenges in diagnosing HHT and emphasizes the critical role of otolaryngologists in the early detection of HHT. Otolaryngologists can refer patients with refractory epistaxis for AVM screening to expedite intervention. Mutation of the genes involved in the transforming growth factor-β signaling pathway leads to the incidence of HHT, resulting in the formation of abnormal blood vessel formation. These vascular malformations commonly manifest as telangiectasia on the skin and mucous membranes; however, epistaxis remains the hallmark symptom of HHT. The impact of HHT goes beyond the visible symptoms and often includes the formation of life-threatening visceral AVMs in the lungs, liver, and brain. The prognosis of patients with HHT is closely related to the development of these complications, necessitating timely diagnosis and intervention. Refractory epistaxis diminishes the QOL of patients with HHT. The management of epistaxis ranges from conservative measures to advanced interventions such as prevention, conservative treatments, ablation, surgical procedures, and the administration of anti-angiogenic agents. However, effective management requires a multidisciplinary approach. The diagnosis of HHT remains challenging due to its variable presentation and lack of awareness among physicians. This review highlights the importance of reducing the duration between symptom onset and diagnosis. Otolaryngologists who are experienced in the management of refractory epistaxis can aid in identifying potential cases of HHT. They can facilitate the initiation of screening for visceral AVMs via prompt recognition of the signs and symptoms of HHT, contributing to improved patient outcomes. Early detection and intervention through screening can extend the life expectancy of patients with HHT to levels comparable with that of the general population. In conclusion, this review provides insight into various aspects of HHT and emphasizes the importance of timely diagnosis and intervention in the mitigation of the potentially life-threatening complications associated with this disorder. Otolaryngologists play a critical role in this process, serving as gatekeepers to the identification of cases of HHT and implementation of appropriate screening and management pathways, thereby improving the life expectancy and QOL of patients.
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Affiliation(s)
- Masaki Hayama
- Department of Otorhinolaryngology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan.
| | - Yohei Maeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan; Department of Otorhinolaryngology, Japan Community Healthcare Organization Osaka Hospital, Osaka City, Osaka, Japan
| | - Sho Obata
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeshi Tsuda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Kazuya Takeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
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Sharma L, Almaghlouth F, Mckernan H, Springett J, Tighe HC, Shovlin CL. Iron deficiency responses and integrated compensations in patients according to hereditary hemorrhagic telangiectasia ACVRL1, ENG and SMAD4 genotypes. Haematologica 2024; 109:958-962. [PMID: 37731378 PMCID: PMC10905072 DOI: 10.3324/haematol.2022.282038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/12/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
- Lakshya Sharma
- National Heart and Lung Institute, Imperial College London, UK; NIHR Imperial Biomedical Research Centre
| | | | - Heidi Mckernan
- Specialist Medicine, Imperial College Healthcare NHS Trust
| | | | - Hannah C Tighe
- Specialist Medicine, Imperial College Healthcare NHS Trust
| | - Claire L Shovlin
- National Heart and Lung Institute, Imperial College London, UK; NIHR Imperial Biomedical Research Centre, London, UK; Specialist Medicine, Imperial College Healthcare NHS Trust.
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Grobost V, Hammi S, Pereira B, Guilhem A, Duffau P, Seguier J, Parrot A, Gautier G, Alric L, Kerjouan M, Le Guillou X, Simon D, Chaussavoine L, Rondeau-Lutz M, Leguy-Seguin V, Delagrange L, Lavigne C, Maillard H, Dupuis-Girod S. Antiplatelet and anticoagulant therapies in hereditary hemorrhagic telangiectasia: A large French cohort study (RETROPLACOTEL). Thromb Res 2023; 229:107-113. [PMID: 37437516 DOI: 10.1016/j.thromres.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND It is unclear whether hereditary hemorrhagic telangiectasia (HHT) patients can tolerate antithrombotic therapies (AT) including antiplatelet (AP) and/or anticoagulant (AC) agents. OBJECTIVES Primary endpoint was tolerance to AT in HHT. Secondary endpoints were to identify factors associated with major bleeding events (MBE) and premature discontinuation of AT. METHODS Retrospective multicenter study in French national HHT Registry patients exposed to AT. RESULTS We included 126 patients with 180 courses of AT. Median follow-up was 24 [11-52] months. Mean age was 65.6 ± 13.1 years. The first 3 months of AT exposure had an increased risk of hospitalization for hemorrhage (p < 0.001) and transfusions (p < 0.001). MBE (n = 63) occurred more frequently in the first 3 months of AT exposure (p < 0.001). Premature discontinuation of AT occurred in 61 cases. Rate of premature discontinuation was 29 % under both AP and AT therapy but significantly higher under dual AP therapy (n = 4/7, 57 % p = 0.008). Risk factors for MBE were: age ≥ 60 years (HR 2.34 [1.12;4.87], p = 0.023), prior hospitalization in the 3 months before starting AT for hemorrhage (HR 3.59 [1.93;6.66], p < 0.001) or transfusion (HR 3.15 [1.61;6.18], p = 0.001), previous history of gastro-intestinal bleeding (HR 2.71 [1.57;4.65], p < 0.001) or MBE (HR 4.62 [2.68;7.98], p < 0.001). Frequency of MBE did not differ between groups except for a higher risk in the dual AP group (HR 3.92 [1.37;11.22], p = 0.011). CONCLUSION Tolerance of AC or AP therapy was similar in HHT population but not dual AP therapy. We identified risk factors for MBE occurrence or premature discontinuation under AT.
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Affiliation(s)
- Vincent Grobost
- Service de Médecine Interne, Clermont-Ferrand University Hospital, CHU Estaing, 63000 Clermont-Ferrand, France.
| | - Sami Hammi
- Department of Internal Medicine, Angers University Hospital, 49100 Angers, France
| | - Bruno Pereira
- Biostatistics Unit, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France
| | - Alexandre Guilhem
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| | - Pierre Duffau
- Bordeaux University Hospital, Internal Medicine and Clinical Immunology Department, Université de Bordeaux, CNRS ImmunoConcEpT UMR 5164, 33000 Bordeaux, France
| | - Julie Seguier
- Département de Médecine Interne, Marseille University Hospital, 13000 Marseille, France
| | - Antoine Parrot
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie et Centre de Compétence de la Maladie de Rendu Osler, Hôpital Tenon, 75020 Paris, France
| | - Giovanni Gautier
- Nantes Université, Nantes University Hospital, Department of Internal and Vascular Medicine, 44000 Nantes, France
| | - Laurent Alric
- Internal Medicine-Digestive Medicine, CHU Rangueil Toulouse 3 University, 31000 Toulouse, France
| | - Mallorie Kerjouan
- Service de Pneumologie, Hôpital Pontchaillou, CHU Rennes, 35000 Rennes, France
| | - Xavier Le Guillou
- Medical Genetics Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Delphine Simon
- Service de Médecine Interne, CHU Charles Nicolle, 76000 Rouen, France
| | - Laurent Chaussavoine
- Centre Hospitalier Universitaire de Caen Normandie, Service de Médecine Vasculaire, 14000 Caen, France
| | - Murielle Rondeau-Lutz
- Service de Médecine Interne, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 67 091 Strasbourg cedex, France
| | | | - Laura Delagrange
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| | - Christian Lavigne
- Department of Internal Medicine, Angers University Hospital, 49100 Angers, France
| | - Hélène Maillard
- Department of Internal Medicine and Clinical Immunology, Referral Centre for rare systemic autoimmune diseases for North and North-West France (CeRAINO), CHU Lille, 59000, Lille, France
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
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Parrot A, Barral M, Amiot X, Bachmeyer C, Wagner I, Eyries M, Alamowitch S, Ederhy S, Epaud R, Dupuis-Girod S, Cadranel J. [Hereditary hemorrhagic telangiectasia]. Rev Mal Respir 2023; 40:391-405. [PMID: 37062633 DOI: 10.1016/j.rmr.2023.02.007] [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: 12/14/2022] [Accepted: 02/26/2023] [Indexed: 04/18/2023]
Abstract
Hereditary hemorrhagic telangiectasia, also known as Rendu-Osler - Weber disease, is a rare, autosomal dominant vascular disease, with prevalence of 1/5,000. The condition is characterized by muco-cutaneous telangiectasias, which are responsible for a hemorrhagic syndrome of variable severity, as well as arteriovenous malformations (AVMs) appearing in the lungs, the liver, and the nervous system. They can be the source of shunts, which may be associated with high morbidity (neurological ischemic stroke, brain abscess, high-output heart failure, biliary ischemia…). It is therefore crucial to establish a clinical diagnosis using the Curaçao criteria or molecular diagnosis based on genetic analysis of the ENG, ACVRL1, SMAD4 and GDF2 genes. In most cases, multidisciplinary management allows patients to have normal life expectancy. Advances in interventional radiology and better understanding of the pathophysiology of angiogenesis have resulted in improved therapeutic management. Anti-angiogenic treatments, such as bevacizumab (BVZ, an anti-VEGF antibody), have proven to be effective in cases involving bleeding complications and severe liver damage with cardiac repercussions. Other anti-angiogenic agents are currently being investigated, including tyrosine kinase inhibitors.
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Affiliation(s)
- A Parrot
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France.
| | - M Barral
- Service de radiologie, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
| | - X Amiot
- Service de gastroentérologie, hôpital Tenon, AP-HP, 75020 Paris, France
| | - C Bachmeyer
- Service de médecine interne, hôpital Tenon, AP-HP, 75020 Paris, France
| | - I Wagner
- Service d'ORL, hôpital Tenon, AP-HP, 75020 Paris, France
| | - M Eyries
- Service de génétique, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Alamowitch
- Service des urgences cérébrovasculaires, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Ederhy
- Service de cardiologie et GRC no 27, hôpital Saint-Antoine, AP-HP, 75020 Paris, France
| | - R Epaud
- Service de pédiatrie, centre intercommunaux de Créteil, Créteil, France
| | - S Dupuis-Girod
- Service de génétique, centre de référence pour la maladie de Rendu-Osler, hospices civils de Lyon, hôpital Mère-Enfant, 69500 Bron, France
| | - J Cadranel
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
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Zanetto A, Cossiga V, Shalaby S, Guarino M, Invernizzi F, Lapenna L, Becchetti C, Morisco F, Morelli MC, Merli M, Toniutto P, Burra P. Vascular liver diseases: A sex-oriented analysis of the literature. Dig Liver Dis 2023; 55:178-186. [PMID: 35906168 DOI: 10.1016/j.dld.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023]
Abstract
Vascular liver diseases are an heterogenous group of diseases that collectively represent an important health issue in the field of liver diseases. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF). We aimed to review the current knowledge regarding the potential role of biological sex in patients with vascular liver diseases such as splanchnic vein thrombosis, hepatic vein thrombosis, porto-sinusoidal vascular disorder, and hereditary hemorrhagic telangiectasia. As vascular liver diseases commonly affect young individuals, including women in childbearing age, we also included a specific section on the management of pregnancy in these challenging patients.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Valentina Cossiga
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Maria Guarino
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, University of Rome Sapienza, Rome, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | | | - Manuela Merli
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy.
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Xiang J, Xie W, Zhang C, Wang H. Right hemihepatectomy combined with ligation of the common hepatic artery and gastroduodenal artery for the treatment of intrahepatic HHT: A case report. Front Surg 2022; 9:900297. [PMID: 36017509 PMCID: PMC9395736 DOI: 10.3389/fsurg.2022.900297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a rare disease that lacks effective treatment. Here, the authors report the case of a 30-year-old woman presenting with abdominal pain accompanied by severe malnutrition. After a definite diagnosis of HHT involvement in the liver, liver transplantation was the first-choice treatment according to the guidelines of HHT. However, the patient firmly refused liver transplantation. Finally, a new type of surgery, right hemihepatectomy combined with ligation of the common hepatic artery and gastroduodenal artery, was performed based on careful study of the case and with the maximum benefit of the patient in mind. Although the patient developed transient liver dysfunction after surgery, she eventually recovered well and continued to be followed up. As far as we know, this is the first report of this kind of surgery for the treatment of intrahepatic HHT.
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Affiliation(s)
- Jifeng Xiang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Wei Xie
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Cuncheng Zhang
- Department of Ultrasonography, Chongqing General Hospital, Chongqing, China
| | - Huaizhi Wang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
- Correspondence: Huaizhi Wang
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Floria M, Năfureanu ED, Iov DE, Sîrbu O, Dranga M, Ouatu A, Tănase DM, Bărboi OB, Drug VL, Cobzeanu MD. Hereditary Hemorrhagic Telangiectasia and Arterio-Venous Malformations—From Diagnosis to Therapeutic Challenges. J Clin Med 2022; 11:jcm11092634. [PMID: 35566759 PMCID: PMC9105924 DOI: 10.3390/jcm11092634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia is a rare autosomal dominant vascular disease defined by the presence of mucosal and cutaneous telangiectasia and visceral arterio-venous malformations. The latter are abnormal capillary-free direct communications between the pulmonary and systemic circulations with the following consequences: arterial hypoxemia caused by right-to-left shunts; paradoxical embolism with transient ischemic attack or stroke and brain abscess caused by the absence of the normally filtering capillary bed; and hemoptysis or hemothorax due to the rupture of the thin-walled arterio-venous malformations (particularly during pregnancy). It is frequently underdiagnosed, commonly presenting as complications from shunting through arterio-venous malformations: dyspnea, chronic bleeding, or embolism. Arterio-venous malformations are present not only in the lungs, but can also be found in the liver, central nervous system (mainly in the brain), nasal mucosa, or the gastrointestinal tract. The first choice of therapy is embolization of the afferent arteries of the arterio-venous malformations, a minimally invasive procedure with a high efficacy, a low morbidity, and low mortality. Other therapeutic modalities are surgery (resection) or stereotactic radiosurgery (using radiation). Routine screening for arterio-venous malformations is indicated in patients diagnosed with this condition and can prevent severe complications such as acute hemorrhages, brain abscesses, or strokes. Clinicians should provide a long-term follow-up for patients with arterio-venous malformations, in an effort to detect their growth or reperfusion in case of previously treated malformations. In spite of two experts’ consensuses, it still possesses multiple therapeutic challenges for physicians, as several aspects regarding the screening and management of arterio-venous malformations still remain controversial. Multidisciplinary teams are especially useful in complex cases.
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Affiliation(s)
- Mariana Floria
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- “Dr. Iacob Czihac” Military Emergency Hospital, 700483 Iași, Romania
| | - Elena Diana Năfureanu
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- “Dr. Iacob Czihac” Military Emergency Hospital, 700483 Iași, Romania
| | - Diana-Elena Iov
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
- Correspondence: (D.-E.I.); (D.M.T.); Tel.: +40-232-301-600 (D.-E.I.)
| | - Oana Sîrbu
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
| | - Mihaela Dranga
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- “Dr. Iacob Czihac” Military Emergency Hospital, 700483 Iași, Romania
| | - Anca Ouatu
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
| | - Daniela Maria Tănase
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
- Correspondence: (D.-E.I.); (D.M.T.); Tel.: +40-232-301-600 (D.-E.I.)
| | - Oana Bogdana Bărboi
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
| | - Vasile Liviu Drug
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (E.D.N.); (O.S.); (M.D.); (A.O.); (O.B.B.); (V.L.D.)
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
| | - Mihail Dan Cobzeanu
- Sf. Spiridon Emergency Hospital, 700111 Iași, Romania;
- Surgical Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
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Thompson KP, Nelson J, Kim H, Weinsheimer SM, Marchuk DA, Lawton MT, Krings T, Faughnan ME. Utility of modified Rankin Scale for brain vascular malformations in hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:390. [PMID: 34538258 PMCID: PMC8451134 DOI: 10.1186/s13023-021-02012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Approximately 10% of hereditary hemorrhagic telangiectasia (HHT) patients harbour brain vascular malformations (VMs). Intracranial hemorrhage (ICH) from brain VMs can lead to death or morbidity, while treatment options for brain VMs also have associated morbidity. The modified Rankin Scale (mRS) may provide an approach to identifying HHT-brain VM patients with poor outcomes, and their predictors. We aimed to measure the relationship between mRS score and brain VM, brain VM number, as well as other aspects of HHT, at enrollment and during prospective follow-up. Methods 1637 HHT patients (342 with brain VMs) were recruited from 14 HHT centres of the Brain Vascular Malformation Consortium since 2010 and followed prospectively (mean = 3.4 years). We tested whether the presence of brain VM, other HHT organ involvement, and HHT mutation genotype were associated with worse mRS scores at baseline and during follow-up, using linear mixed models, adjusting for age, sex, and year of visit. Results Presence of brain VMs was not associated with worse mRS score at baseline and there was no significant worsening of mRS with prospective follow-up in these patients; 92% had baseline mRS of 0–2. HHT-related gastrointestinal (GI) bleeding was associated with worse mRS scores at baseline (0.37, 95% CI 0.26–0.47, p < 0.001), as were history of anemia (0.35, 95% CI 0.27–0.43, p < 0.001) and liver VMs (0.19, 95% CI 0.09–0.30, p < 0.001). Presence of pulmonary arteriovenous malformations (AVMs) was not associated with worse mRS scores at baseline. mRS score was not associated with either HHT genotype (Endoglin vs ACVRL1). Only GI bleeding was associated with a significantly worsening mRS during prospective follow-up (0.64, 95% CI 0.21–1.08, p = 0.004). Conclusion Most HHT-brain VM patients had good functional capacity (mRS scores 0–2) at baseline that did not change significantly over 3.4 mean years of follow-up, suggesting that mRS may not be useful for predicting or measuring outcomes in these patients. However, HHT patients with GI bleeding, anemia history or liver VMs had worse mRS scores, suggesting significant impact of these manifestations on functional capacity. Our study demonstrates the insensitivity of the mRS as an outcomes measure in HHT brain VM patients and reinforces the continued need to develop outcomes measures, and their predictors, in this group.
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Affiliation(s)
- K P Thompson
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - H Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - S M Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - T Krings
- Division of Neurosurgery, Department of Medical Imaging, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neuroradiology, Toronto Western Hospital, Univeristy Health Network, Toronto, Canada
| | - M E Faughnan
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada. .,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
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Wetzel-Strong SE, Weinsheimer S, Nelson J, Pawlikowska L, Clark D, Starr MD, Liu Y, Kim H, Faughnan ME, Nixon AB, Marchuk DA. Pilot investigation of circulating angiogenic and inflammatory biomarkers associated with vascular malformations. Orphanet J Rare Dis 2021; 16:372. [PMID: 34479577 PMCID: PMC8414780 DOI: 10.1186/s13023-021-02009-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/24/2021] [Indexed: 01/03/2023] Open
Abstract
Background Vascular malformations in the central nervous system are difficult to monitor and treat due to their inaccessible location. Angiogenic and inflammatory proteins are secreted into the bloodstream and may serve as useful biomarkers for identifying patients at risk for complications or with certain disease phenotypes.
Methods A validated multiplex protein array consisting of 26 angiogenic and inflammatory biomarkers (Angiome) was assessed in plasma isolated from healthy controls and patients with either sporadic brain arteriovenous malformation (BAVM), familial cerebral cavernous malformation (CCM), or hereditary hemorrhagic telangiectasia (HHT). These samples were obtained from archives of ongoing research studies at the University of California San Francisco and through prospective collection at the Toronto HHT Centre at St. Michael’s Hospital. Results We compared circulating biomarker levels from each patient group to healthy controls and analyzed each pairwise combination of patient groups for differences in biomarker levels. Additionally, we analyzed the HHT samples to determine the association between biomarker levels and the following HHT-specific phenotypes, BAVM, pulmonary arteriovenous malformation (PAVM), liver vascular malformation (LVM), and gastrointestinal (GI) bleeding. Compared to controls, levels of SDF1 were significantly elevated in HHT patients (Proportional Increase [PI] = 1.87, p < 0.001, q = 0.011). Levels of sENG were significantly reduced in HHT patients compared to controls (PI = 0.56, p < 0.001, q < 0.001), reflecting the prevalence of HHT1 patients in this cohort. Levels of IL6 (PI = 3.22, p < 0.001, q < 0.001) and sTGFβR3 (PI = 0.70, p = 0.001, q < 0.029) differed significantly in CCM patients compared to controls. Compared to controls, ten of the biomarkers were significantly different in sporadic BAVM patients (q-values < 0.05). Among the pairwise combinations of patient groups, a significant elevation was observed in TGFβ1 in CCM patients compared to sporadic BAVM patients (PI = 2.30, p < 0.001, q = 0.034). When examining the association of circulating biomarker levels with HHT-specific phenotypes, four markers were significantly lower in HHT patients with BAVM (q-values < 0.05), and four markers were significantly higher in patients with LVM (q-values < 0.05). Conclusions This pilot study suggests that the profile of circulating angiogenic and inflammatory biomarkers may be unique to each type of vascular malformation. Furthermore, this study indicates that circulating biomarkers may be useful for assessing phenotypic traits of vascular malformations. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02009-7.
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Affiliation(s)
- Sarah E Wetzel-Strong
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, 265 CARL Bldg., Box #3175 DUMC, Durham, NC, 27710, USA
| | - Shantel Weinsheimer
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Ludmila Pawlikowska
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Dewi Clark
- Toronto HHT Centre, St. Michael's Hospital and the Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Mark D Starr
- Department of Medicine, Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Yingmiao Liu
- Department of Medicine, Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Marie E Faughnan
- Toronto HHT Centre, St. Michael's Hospital and the Li Ka Shing Knowledge Institute, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Andrew B Nixon
- Department of Medicine, Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Douglas A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, 265 CARL Bldg., Box #3175 DUMC, Durham, NC, 27710, USA.
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Al-Samkari H. Giving hereditary haemorrhagic telangiectasia the attention it deserves. THE LANCET HAEMATOLOGY 2021; 8:e472-e474. [DOI: 10.1016/s2352-3026(21)00164-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/28/2021] [Indexed: 12/11/2022]
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