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Maruyama D, Iida H, Koshino K, Nakagawara J, Morita Y, Hashimura N, Mori H, Satow T, Takahashi JC, Fukuda T, Iihara K, Kataoka H. Comparative analysis of peri-nidal cerebral blood flow and metabolism using a novel quantitative 15O-PET method in patients with arteriovenous malformations. J Cereb Blood Flow Metab 2024:271678X241270416. [PMID: 39129183 DOI: 10.1177/0271678x241270416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
To effectively treat cerebral arteriovenous malformations (AVMs), peri-nidal flow regulation and metabolic status must be understood. In this study, we used 15O-oxygen positron emission tomography (PET) post-processing analysis to investigate vascular radioactivity in the nidal region of AVMs. Single-dynamic PET imaging was performed on seven unruptured AVM patients during the sequential inhalation of 15O2 and C15O2. A previously validated dual-tracer basis function method (DBFM) was employed to calculate parametric images. The results of our study were as follows. First, in remote and contralateral AVM regions, DBFM and a previous approach of dual-tracer autoradiography (DARG) showed strong positive correlations in cerebral blood flow (CBF), cerebral oxygen metabolism rate (CMRO2), and oxygen extraction fraction. Second, peri-nidal CBF and CMRO2 correlation was lower, and overestimation occurred with DARG compared to with DBFM. Third, on comparing DBFM to quantitative 123I-iodoamphetamine single-photon emission computed tomography (SPECT), CBF correlated significantly. In contrast, the correlation between DARG and quantitative 123I-iodoamphetamine-SPECT was weaker in the peri-nidal regions. Fourth, analysis of tissue time-activity curves demonstrated good reproducibility using the novel formulation in the control, peri-nidus, and core nidal regions, indicating the adequacy of this approach. Overall, the DBFM approach holds promise for assessing haemodynamic alterations in patients with AVMs.
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Affiliation(s)
- Daisuke Maruyama
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hidehiro Iida
- Turku PET Centre, University of Turku, Turku, Finland
- Department of Investigative Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuhiro Koshino
- Department of Investigative Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jyoji Nakagawara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naoki Hashimura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Wen Z, Zheng K, Guo S, Liu Y, Wang K, Liu Q, Wu J, Wang S. The difference of functional MR imaging in evaluating outcome of patients with diffuse and compact brain arteriovenous malformation. Neurosurg Rev 2024; 47:347. [PMID: 39043982 DOI: 10.1007/s10143-024-02593-9] [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: 05/21/2024] [Revised: 06/26/2024] [Accepted: 07/19/2024] [Indexed: 07/25/2024]
Abstract
Microsurgical resection is an effective method to treat brain arteriovenous malformations (BAVMs). Functional magnetic resonance imaging (fMRI) can evaluate the spatial relationship of nidus and eloquent. Diffuse BAVMs are related to poor outcomes postoperatively. The role of fMRI in evaluating outcomes in patients with different nidus types remains unclear. BAVM patients received microsurgical resection were included from a prospective, multicenter cohort study. All patients underwent fMRI evaluation preoperatively and were regularly followed up postoperatively. Diffuse BAVM is radiologically identified as nidus containing normal brain tissue interspersing between malformed vessels. Lesion-to-eloquent distance (LED) was calculated based on the relationship between nidus and eloquent. The primary outcome was 180-day unfavorable neurological status postoperatively. The risk of primary outcome was investigated within different BAVM nidus types. The LED's performance to predict poor outcome was evaluated using area under curve (AUC). 346 BAVM patients were included in this study. 93 (26.9%) patients were found to have a 180-day unfavorable outcome. Multivariate logistic analysis demonstrated LED (odd ratio [OR], 0.44; 0.34-0.57; P < 0.001) and mRS at admission (OR, 2.59; 1.90-3.54; P < 0.001) as factors of unfavorable outcome. Subgroup analysis showed LED and mRS at admission as factors of unfavorable outcome for patients with compact BAVMs (all P < 0.05), but not for patients with diffuse BAVMs. Subsequent analysis showed that LED performed poorly to predict the unfavorable outcome for patients with diffuse BAVMs, compared with patients with compact BAVMs (AUC as 0.69 vs. 0.86, P < 0.05). A larger cutoff value of LED to unfavorable outcome was found in patients with diffuse BAVMs (15 mm) compared with patients with compact BAVMs (4.7 mm). Usage of LED to evaluate postoperative outcome of patients with diffuse BAVMs differs from its use in patients with compact BAVMs. Specific assessment strategy considering BAVM nidus types could help improve patients' outcome. MITASREAVM cohort (unique identifier: NCT02868008, https://clinicaltrials.gov/study/NCT02868008?term=NCT02868008&rank=1 ).
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Affiliation(s)
- Zheng Wen
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kaige Zheng
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuaiwei Guo
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Devarajan A, Schupper AJ, Rossitto CP, Bonet JM, Sorscher M, Vasan V, Morgenstern PF, Ghatan S, Shigematsu T, Berenstein A, Fifi JT. Use of a mini balloon microcatheter to facilitate penetration of fine vascular networks and curative embolization in vein of Galen malformations. J Neurointerv Surg 2024; 16:698-705. [PMID: 38085160 DOI: 10.1136/jnis-2023-020577] [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: 05/11/2023] [Accepted: 07/07/2023] [Indexed: 06/19/2024]
Abstract
Background Patients with vein of Galen malformations (VOGMs) can develop fine angiogenic networks with fistulous connections to the precursor of the vein of Galen. In these cases, transarterial embolization (TAE) with liquid embolic agents (LEAs) is challenging due to reflux in the pedicle leading to the network, causing poor penetration. Transvenous approaches carry a risk of hemorrhage from pathologic vasculature. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA) improve distal pedicle access, preventing reflux. Objective Here, we report on the use of the Scepter Mini for TAE of angiogenic VOGM. Methods A single-institution retrospective chart review identified all VOGMs treated with Scepter Mini microcatheters. Clinical data, angioarchitecture, and technical parameters were reviewed. Results 17 Scepter Mini catheters were used in 12 embolization procedures of 7 patients with VOGM at a median age of 2.1 years. Patients presented with hydrocephalus (100%) and gross motor and speech delays (57.1%). Networks developed extra-axially into the subependymal zone fed by posterior choroidal, posterior cerebral, and thalamoperforator arteries. Posterior choroidal branches (n=7/17, 41.2%) were most frequently catheterized to achieve distal access to the network. Embolization with Onyx-18 and significant network penetration occurred in 17/17 uses. Near tip entrapment with LEA cast displacement occurred in 1/17 uses. Another patient experienced postprocedural intraventricular hemorrhage requiring a third ventriculostomy without permanent neurologic deficit. Conclusion The Scepter Mini provided excellent distal access with penetration to the fistula and extra-axial network reduction with few complications. The Scepter Mini provides a means for successful treatment of technically challenging angiogenic VOGM.
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Affiliation(s)
- Alex Devarajan
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Alexander J Schupper
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Christina P Rossitto
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jessica M Bonet
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Michelle Sorscher
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Vikram Vasan
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Peter F Morgenstern
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Saadi Ghatan
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Tomoyoshi Shigematsu
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Alejandro Berenstein
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Lauzier DC, Srienc AI, Vellimana AK, Dacey Jr RG, Zipfel GJ. Peripheral macrophages in the development and progression of structural cerebrovascular pathologies. J Cereb Blood Flow Metab 2024; 44:169-191. [PMID: 38000039 PMCID: PMC10993883 DOI: 10.1177/0271678x231217001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 11/26/2023]
Abstract
The human cerebrovascular system is responsible for maintaining neural function through oxygenation, nutrient supply, filtration of toxins, and additional specialized tasks. While the cerebrovascular system has resilience imparted by elaborate redundant collateral circulation from supportive tertiary structures, it is not infallible, and is susceptible to developing structural vascular abnormalities. The causes of this class of structural cerebrovascular diseases can be broadly categorized as 1) intrinsic developmental diseases resulting from genetic or other underlying aberrations (arteriovenous malformations and cavernous malformations) or 2) extrinsic acquired diseases that cause compensatory mechanisms to drive vascular remodeling (aneurysms and arteriovenous fistulae). Cerebrovascular diseases of both types pose significant risks to patients, in some cases leading to death or disability. The drivers of such diseases are extensive, yet inflammation is intimately tied to all of their progressions. Central to this inflammatory hypothesis is the role of peripheral macrophages; targeting this critical cell type may lead to diagnostic and therapeutic advancement in this area. Here, we comprehensively review the role that peripheral macrophages play in cerebrovascular pathogenesis, provide a schema through which macrophage behavior can be understood in cerebrovascular pathologies, and describe emerging diagnostic and therapeutic avenues in this area.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Anja I Srienc
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ralph G Dacey Jr
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
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5
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Lauzier DC, Chiang SN, Moran CJ. Etiologies of Brain Arteriovenous Malformation Recurrence: A Focus on Pediatric Disease. Pediatr Neurol 2023; 148:94-100. [PMID: 37690270 DOI: 10.1016/j.pediatrneurol.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/18/2023] [Accepted: 08/15/2023] [Indexed: 09/12/2023]
Abstract
Pediatric brain arteriovenous malformations are a major cause of morbidity and mortality, with the harmful effects of this disease compounded by the additional disability-years experienced by children with ruptured or other symptomatic arteriovenous malformations. In addition to the risks shared with their adult counterparts, pediatric patients frequently experience recurrence following radiographic cure, which presents an additional source of morbidity and mortality. Therefore, there is a need to synthesize potential mechanisms contributing to the elevated recurrence risk in the pediatric population and discuss how these translate to practical considerations for managing these patients.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.
| | - Sarah N Chiang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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6
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Lu C, Han H, Ma L, Li R, Li Z, Zhang H, Yuan K, Zhang Y, Li A, Wang K, Zhao Y, Jin W, Gao D, Jin H, Meng X, Yan D, Li R, Lin F, Hao Q, Wang H, Ye X, Kang S, Pu J, Shi Z, Chao X, Lin Z, Lu J, Li Y, Zhao Y, Sun S, Chen X, Chen W, Chen Y, Wang S. Comparison of Long-Term Outcomes in Ruptured Diffuse Brain Arteriovenous Malformations Between Interventional Therapy and Conservative Management. Transl Stroke Res 2023:10.1007/s12975-023-01197-7. [PMID: 37776489 DOI: 10.1007/s12975-023-01197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Abstract
Brain arteriovenous malformations (AVMs) with a diffuse nidus structure present a therapeutic challenge due to their complexity and elevated risk of hemorrhagic events. This study examines the long-term effectiveness of interventional therapy versus conservative management in reducing hemorrhagic stroke or death in patients with ruptured diffuse AVMs. The analysis was conducted based on a multi-institutional database in China. Patients were divided into two groups: conservative management and interventional therapy. Using propensity score matching, patients were compared for the primary outcome of hemorrhagic stroke or death and the secondary outcomes of disability and neurofunctional decline. Out of 4286 consecutive AVMs in the registry, 901 patients were eligible. After matching, 70 pairs of patients remained with a median follow-up of 4.0 years. The conservative management group showed a trend toward higher rates of the primary outcome compared to the interventional group (4.15 vs. 1.87 per 100 patient-years, P = 0.090). While not statistically significant, intervention reduced the risk of hemorrhagic stroke or death by 55% (HR, 0.45 [95% CI 0.18-1.14], P = 0.094). No significant differences were observed in secondary outcomes of disability (OR, 0.89 [95% CI 0.35-2.26], P = 0.813) and neurofunctional decline (OR, 0.65 [95% CI 0.26 -1.63], P = 0.355). Subgroup analysis revealed particular benefits in interventional therapy for AVMs with a supplemented S-M grade of II-VI (HR, 0.10 [95% CI 0.01-0.79], P = 0.029). This study suggests a trend toward lower long-term hemorrhagic risks with intervention when compared to conservative management in ruptured diffuse AVMs, especially within supplemented S-M grade II-VI subgroups. No evidence indicated that interventional approaches worsen neurofunctional outcomes.
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Affiliation(s)
- Changyu Lu
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun Pu
- First Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhiyong Shi
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated to Nanjing University, Nanjing, Jiangsu, China
| | - Xiaofeng Chao
- Department of Neurosurgery, The Second Affiliated Hospital of Xuzhou Medical University, Jiangsu, China
| | - Zhengfeng Lin
- Department of Neurosurgery, The First People's Hospital of Qinzhou, Guangxi, China
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Weiwei Chen
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
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7
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Sun Z, Lin PK, Yrigoin K, Kemp SS, Davis GE. Increased Matrix Metalloproteinase-1 Activation Enhances Disruption and Regression of k-RasV12-Expressing Arteriovenous Malformation-Like Vessels. THE AMERICAN JOURNAL OF PATHOLOGY 2023; 193:1319-1334. [PMID: 37328101 PMCID: PMC10477956 DOI: 10.1016/j.ajpath.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
This study sought to identify potential mechanisms by which k-RasV12-expressing endothelial cell (EC) tubes demonstrate an increased propensity to regress compared with controls. Activated k-Ras mutations play a role in a variety of pathological conditions, including arteriovenous malformations, which are prone to bleed, causing serious hemorrhagic complications. ECs expressing active k-RasV12 demonstrate markedly excessive lumen formation with widened and shortened tubes accompanied by reduced pericyte recruitment and basement membrane deposition, leading to deficient capillary network assembly. The current study showed that active k-Ras-expressing ECs secreted greater amounts of MMP-1 proenzyme compared with control ECs, and readily converted it to increased active MMP-1 levels through the action of plasmin or plasma kallikrein (generated from their added zymogens). Active MMP-1 degraded three-dimensional collagen matrices, leading to more rapid and extensive regression of the active k-Ras-expressing EC tubes, in conjunction with matrix contraction, compared with control ECs. Under conditions where pericytes protect control EC tubes from plasminogen- and MMP-1-dependent tube regression, this failed to occur with k-RasV12 ECs, due to reduced pericyte interactions. In summary, k-RasV12-expressing EC vessels showed an increased propensity to regress in response to serine proteinases through accentuated levels of active MMP-1, a novel pathogenic mechanism that may underlie hemorrhagic events associated with arteriovenous malformation lesions.
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Affiliation(s)
- Zheying Sun
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida School of Medicine, Tampa, Florida
| | - Prisca K Lin
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida School of Medicine, Tampa, Florida
| | - Ksenia Yrigoin
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida School of Medicine, Tampa, Florida
| | - Scott S Kemp
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida School of Medicine, Tampa, Florida
| | - George E Davis
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida School of Medicine, Tampa, Florida.
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Oulasvirta E, Koroknay-Pál P, Numminen J, Hafez A, Raj R, Jahromi BR, Niemelä M, Laakso A. Recurrence of brain arteriovenous malformations in pediatric patients: a long-term follow-up study. Acta Neurochir (Wien) 2023; 165:1565-1573. [PMID: 37140647 DOI: 10.1007/s00701-023-05612-8] [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: 03/03/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Previously thought to be congenital, AVMs have shown evidence of de-novo formation and continued growth, thus shifting thoughts on their pathophysiology. Pediatric AVM patients have been reported to be more prone to develop AVM recurrence after a seemingly complete cure. Therefore, we assessed the risk of AVM treated in childhood to recur in adulthood after a long-term follow-up in our own cohort. METHODS Control DS-angiography was arranged during 2021-2022 as part of a new protocol for all AVM patients who were under 21 years of age at the time of their treatment and in whom the treatment had occurred at least five years earlier. Angiography was offered only to patients under 50 years of age at the time of the new protocol. The complete eradication of AVM after the primary treatment had been originally confirmed with DSA in every patient. RESULTS A total of 42 patients participated in the late DSA control, and 41 of them were included in this analysis after excluding the patient diagnosed with HHT. The median age at the time of admission for AVM treatment was 14.6 (IQR 12-19, range 7-21 years) years. The median age at the time of the late follow-up DSA was 33.8 years (IQR 29.8-38.6, range 19.4-47.9 years). Two recurrent sporadic AVMs and one recurrent AVM in a patient with hereditary hemorrhagic telangiectasia (HHT) were detected. The recurrence rate was 4.9% for sporadic AVMs and 7.1% if HHT-AVM was included. All the recurrent AVMs had originally bled and been treated microsurgically. The patients with sporadic AVM recurrence had been smoking their whole adult lives. CONCLUSIONS Pediatric and adolescent patients are prone to develop recurrent AVMs, even after complete AVM obliteration verified by angiography. Therefore, imaging follow-up is recommended.
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Affiliation(s)
- Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jussi Numminen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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9
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Lin CJ, Chen KK, Hu YS, Yang HC, Lin CF, Chang FC. Quantified flow and angioarchitecture show similar associations with hemorrhagic presentation of brain arteriovenous malformations. J Neuroradiol 2023; 50:79-85. [PMID: 35120975 DOI: 10.1016/j.neurad.2022.01.061] [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: 10/30/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The purpose of our study was to elucidate the impact of brain arteriovenous malformation (BAVM) flow and wall shear stress (WSS) on angioarchitecture and to evaluate their association with hemorrhagic presentations. MATERIALS AND METHODS Forty-one patients with BAVMs were evaluated by phase-contrast MR angiography. Volume flow rate and WSS were quantified. Angioarchitectural features such as location, angiogenesis, venous stenosis, venous ectasia, venous phlebitis, venous rerouting, exclusive deep vein and venous sac were evaluated by two neuroradiologists. The correlation between BAVM flow and size was evaluated with Spearman correlation coefficients. Differences of size, flow, and WSS between the hemorrhagic and non-hemorrhagic groups, the seizure and non-seizure groups, and between the different groups based on angioarchitecture were evaluated with Mann-Whitney U tests. Accuracy in predicting hemorrhage was evaluated with receiver operating characteristic curves. RESULT BAVM flow was highly correlated with volume (ρ = 0.77). Higher flow was more commonly associated with angiogenesis, venous ectasia, venous rerouting, and venous phlebitis. Flow and angioarchitecture showed similar efficacy in differentiating hemorrhagic from non-hemorrhagic BAVMs. WSS did not demonstrate differences across any clinical groups. CONCLUSION Flow quantification and angioarchitecture analysis of BAVMs showed similar efficacy as evaluated by associations with hemorrhagic presentation. High flow affects both arterial and venous angioarchitecture, reflecting the nature of low vascular resistance in BAVMs.
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Affiliation(s)
- Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Ko-Kung Chen
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan
| | - Huai-Che Yang
- Department of Radiology, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- Department of Radiology, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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10
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Muacevic A, Adler JR. Management of Brain Arteriovenous Malformations: A Review. Cureus 2023; 15:e34053. [PMID: 36824547 PMCID: PMC9942537 DOI: 10.7759/cureus.34053] [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: 01/22/2023] [Indexed: 01/23/2023] Open
Abstract
Brain arteriovenous malformations (bAVM) are vascular malformations of the brain affecting all ages. The optimum management strategy is essentially devoid of high-quality evidence and is highly nuanced and embedded in local customs. This study summarizes the frequently employed management strategies, drawing conclusions on the utility of each method of treatment and delving into controversies surrounding them. A literature search on PubMed and Medline was done on January 3rd, 2022. 11,767 articles were found, and abstracts were reviewed. Full-text review of 153 articles led to chapters from three books and 71 articles incorporated into a summative discussion. Spetzler-Ponce (S-P) Class A patients may be offered surgery if they are good surgical candidates and have a good number of high-quality years of life left. The exception is diffuse Spetzler-Martin (S-M) grade 2 in a patient older than 40 years: radiosurgery for unruptured and embolization for ruptured. S-P Class B may be offered surgery if a compact nidus or if younger than 40 years. If diffuse or age greater than 40, radiosurgery may be preferred if the Pollock-Flickinger score is less than 2.5. For the remainder of S-P Class B, conservative management may be preferred. S-P Class C is generally not treated unless young or those patients with poorly controlled seizures affecting their quality of life are willing to risk permanent neurological deficits. While the quality of studies is generally high, the level of evidence is concerning with only one randomized controlled trial (RCT). Most research output hails from high-income countries, i.e., perhaps not universally applicable to all settings owing to possible genetic, environmental, and resource differences. More research is needed: large volume studies in the pregnant population, validation of scoring systems in pediatric age groups, clinical trials focused on combination multi-staged treatment modalities, and studies originating from the developing world.
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State of the Art in the Role of Endovascular Embolization in the Management of Brain Arteriovenous Malformations-A Systematic Review. J Clin Med 2022; 11:jcm11237208. [PMID: 36498782 PMCID: PMC9739246 DOI: 10.3390/jcm11237208] [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] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
As a significant cause of intracerebral hemorrhages, seizures, and neurological decline, brain arteriovenous malformations (bAVMs) are a rare group of complex vascular lesions with devastating implications for patients' quality of life. Although the concerted effort of the scientific community has improved our understanding of bAVM biology, the exact mechanism continues to be elucidated. Furthermore, to this day, due to the high heterogeneity of bAVMs as well as the lack of objective data brought by the lack of evaluative and comparative studies, there is no clear consensus on the treatment of this life-threatening and dynamic disease. As a consequence, patients often fall short of obtaining the optimal treatment. Endovascular embolization is an inherent part of multidisciplinary bAVM management that can be used in various clinical scenarios, each with different objectives. Well-trained neuro-interventional centers are proficient at curing bAVMs that are smaller than 3 cm; are located superficially in noneloquent areas; and have fewer, larger, and less tortuous feeding arteries. The transvenous approach is an emerging effective and safe technique that potentially offers a chance to cure previously untreatable bAVMs. This review provides the state of the art in all aspects of endovascular embolization in the management of bAVMs.
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Shigematsu T, Bazil MJ, Fifi JT, Berenstein A. Fine, Vascular Network Formation in Patients with Vein of Galen Aneurysmal Malformation. AJNR Am J Neuroradiol 2022; 43:1481-1487. [PMID: 36137661 PMCID: PMC9575532 DOI: 10.3174/ajnr.a7649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/27/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE A vein of Galen aneurysmal malformation is known to present with recruitment of dural feeders and, in our cohort, a fine, vascular network formation. The vessels we have observed differ from dural vascular recruitment in that they produce a hairlike, collateral network of vessels. We reviewed treatment courses of vein of Galen aneurysmal malformation treatments in a series of 36 cases that displayed a fine, vascular network formation. MATERIALS AND METHODS We retrospectively analyzed 36 cases of vein of Galen aneurysmal malformation, including tectal/thalamic AVMs, treated at our center from January 2004 to September 2021, and reviewed fine, vascular network formations in the subarachnoid space and subependymal zone alongside the vein of Galen aneurysmal malformation. RESULTS Patients at first endovascular treatment ranged from neonates to 157 months (median age, 4.3 months). Patients with preinterventional fine, vascular network formations were significantly older at the initial angiogram than patients with postinterventional fine, vascular network formations (P < .05). On average, for 20 control choroidal/mural vein of Galen aneurysmal malformations whose treatment course had been completed and in which no plexiform network was visualized, a mean of 2.63 (SD, 1.64) treatments were required to achieve a radiographic cure. For the 36 choroidal/mural vein of Galen aneurysmal malformations whose treatment course had been completed and in which a fine, vascular network formation was visualized, a mean of 5.94 (SD, 2.73) treatments were required to achieve a radiographic cure (P < .01). CONCLUSIONS Development of a fine, vascular network formation is an acquired and reversible phenomenon that differs from typical dural vessel recruitment, given the hairlike nature of the network and its rapid onset postinterventionally. It typically resolves after completion of treatment, and this resolution correlates with closure of the vein. We recommend that neurointerventionalists avoid delays in treatment wherever possible to reduce the likelihood of a fine, vascular network formation.
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Affiliation(s)
- T Shigematsu
- From the Departments of Neurosurgery (T.S., M.J.B., J.T.F., A.B.)
| | - M J Bazil
- From the Departments of Neurosurgery (T.S., M.J.B., J.T.F., A.B.)
| | - J T Fifi
- From the Departments of Neurosurgery (T.S., M.J.B., J.T.F., A.B.)
- Neurology (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - A Berenstein
- From the Departments of Neurosurgery (T.S., M.J.B., J.T.F., A.B.)
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13
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Chen X, Wang Y, Yu J. Intra- and post-operative acute hemorrhagic complications of Onyx embolization of brain arteriovenous malformations: A single-center experience. Front Neurol 2022; 13:974954. [PMID: 36212665 PMCID: PMC9538697 DOI: 10.3389/fneur.2022.974954] [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: 06/21/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background The intra- and post-operative acute (within 72 h) hemorrhagic complications of endovascular treatment (EVT) for a brain arteriovenous malformation (BAVM) are disastrous. Thus, further experiential summaries are required to fully understand them. Materials and methods This was a retrospective study of 25 patients with consecutive BAVM who were treated via EVT with Onyx embolization and suffered intra- and post-operative acute hemorrhage. The clinical and imaging data of the patients were recorded, analyzed, and discussed. Result Twenty-five patients were aged 11-70 years (mean, 37.2 ± 16.1 years), of whom 12 were female (48%, 12/25). Of the 25 hemorrhagic complications, 17 (68%, 17/25) were intraoperative, and 8 (32%, 8/25) were post-operative and occurred between 1 and 12 h after EVT. Of 17 intraoperative hemorrhages, 13 (76.5%, 13/17) were due to high-pressure Onyx casting. Of eight post-operative hemorrhages, six (75%, 6/8) were attributed to normal perfusion pressure breakthrough. The degree of nidus Onyx embolization was more than 2/3 or complete in seven (87.5%, 7/8) BAVMs. Draining vein occlusion was observed in eight (32%, 8/25) of 25 BAVMs. After hemorrhage, conservative treatment was administered in 12 (48%, 12/25) cases, and surgical management was performed in other cases. There were eight cases of mortality; the remaining 17 patients had follow-up data. Among them, 15 patients had good outcomes, with Glasgow Outcome Scale scores of 5 and 4, accounting for 60% (15/25). Conclusion In EVT for BAVMs, intra- and post-operative acute hemorrhagic complications are disastrous; only 60% of patients have a good outcome. Therefore, high-pressure Onyx casting or casting too much Onyx at one time to pursue a high degree of nidus embolization should be performed cautiously, and primary draining vein occlusion should be avoided. In short, EVT needs to be performed carefully.
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14
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Izumo T, Yoshida M, Okamura K, Takahira R, Sadakata E, Yamaguchi S, Baba S, Morofuji Y, Hiu T, Anda T, Matsuo T. Pseudo-residual nidus after arteriovenous malformation surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022. [PMCID: PMC9379732 DOI: 10.3171/case2248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraoperative indocyanine green video angiography (ICG-VA) is useful for determining the extent of lesion removal during cerebral arteriovenous malformation (AVM) surgery. The authors described a case of surgical removal of an AVM presenting with early venous filling mimicking a residual nidus on intraoperative ICG-VA. OBSERVATIONS A 7-year-old girl experienced a sudden disturbance of consciousness. Computed tomography revealed right frontal intracerebral hemorrhage. Digital subtraction angiography showed a Spetzler-Martin grade 1 AVM in the right frontal lobe. The patient received surgical removal of the AVM after endovascular embolization. After removal of the nidus, the first intraoperative ICG-VA revealed early venous filling of the cortex around the excision cavity. Additional resection of the cortex around this area was performed. Histopathological examination of the lesion revealed a dilated normal vascular structure without an AVM. LESSONS Early venous filling in the surrounding brain tissue after AVM removal does not necessarily indicate a residual nidus. The need for additional resection of the lesion depends on the eloquence of the area.
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Affiliation(s)
- Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Michiharu Yoshida
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuaki Okamura
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryotaro Takahira
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Eisaku Sadakata
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Yamaguchi
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shiro Baba
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Hiu
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takeo Anda
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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15
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Shortened cerebral circulation time correlates with seizures in brain arteriovenous malformation: a cross-sectional quantitative digital subtraction angiography study. Eur Radiol 2022; 32:5402-5412. [PMID: 35320410 DOI: 10.1007/s00330-022-08690-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/01/2022] [Accepted: 02/22/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Seizure is the most common clinical presentation in patients with nonhemorrhagic brain arteriovenous malformations (BAVMs) and it influences their quality of life. Angioarchitectural analysis of the seizure risk for BAVMs is subjective and does not consider hemodynamics. This study aimed to investigate the angioarchitectural and hemodynamic factors that may be associated with seizure in patients with BAVMs. METHODS From 2011 to 2019, 104 patients with supratentorial BAVMs without previous hemorrhage or treatment were included and grouped according to the initial presentation of seizure. Their angiograms and MRI results were analyzed for morphological characteristics and quantitative digital subtraction angiography (QDSA) parameters. Modified cerebral circulation time (mCCT) was defined as the difference between the bolus arrival time of the ipsilateral cavernous internal carotid artery and the parietal vein on lateral DSA. Logistic regression analysis was performed to estimate the odds ratio (OR) for BAVMs presenting with seizure. RESULTS The seizure group had shorter mCCT (1.98 s vs. 2.44 s, p = 0.005) and more BAVMs with temporal location (45% vs. 30.8%, p = 0.013), neoangiogenesis (55% vs. 33%, p = 0.03), and long draining veins (95% vs. 72%, p = 0.004) than did the nonseizure group. Shorter mCCT (OR: 3.4, p = 0.02), temporal location (OR: 13.4, p < 0.001), and neoangiogenesis (OR: 4.7, p = 0.013) were independently associated with higher risks of seizure, after adjustments for age, gender, BAVM volume, and long draining vein. CONCLUSIONS Shorter mCCT, temporal location, and neoangiogenesis were associated with epileptic BAVMs. QDSA can objectively evaluate hemodynamic changes in epileptic BAVMs. KEY POINTS • Quantitative digital subtraction angiography may be used to evaluate the hemodynamic differences between brain arteriovenous malformations presenting with and without seizure. • BAVMs with temporal location, neoangiogenesis, and shortened cerebral circulation time were more likely to present with seizure.
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16
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Germans MR, Sun W, Sebök M, Keller A, Regli L. Molecular Signature of Brain Arteriovenous Malformation Hemorrhage: A Systematic Review. World Neurosurg 2021; 157:143-151. [PMID: 34687935 DOI: 10.1016/j.wneu.2021.10.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND The mechanisms of brain arteriovenous malformation (bAVM) development, formation, and progress are still poorly understood. By gaining more knowledge about the molecular signature of bAVM in relation to hemorrhage, we might be able to find biomarkers associated with this serious complication, which can function as a goal for further research and can be a potential target for gene therapy. AIMS To provide a comprehensive overview of the molecular signature of bAVM-related hemorrhage We conducted a systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, of articles published in Embase, Medline, Cochrane central, Scopus, and Chinese databases (CNKI, Wanfang). SUMMARY OF REVIEW Our search identified 3944 articles, of which 3108 remained after removal of duplicates. After title, abstract, and full-text screening, 31 articles were included for analysis. The results show an overview of molecular characteristics. Several genetic polymorphisms are identified that increase the risk of bAVM rupture by increasing the expression of certain inflammatory cytokines (interleukin [IL]-6, IL-17A, IL-1β, and tumor necrosis factor-α), NOTCH pathways, matrix metalloproteinase-9, and vascular endothelial growth factor-α. CONCLUSIONS Several molecular factors are associated with the risk of bAVM-related hemorrhage. These factors are associated with increased inflammation on the cellular level and changes in the endothelium leading to instability of the vessel wall. Further investigation of these biomarkers regarding hemorrhage rates, together with their relationship with noninvasive diagnostic methods, should be a goal of future studies to improve the patient specific risk estimation and future treatment options.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Wenhua Sun
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Annika Keller
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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17
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Takeda Y, Kin T, Sekine T, Hasegawa H, Suzuki Y, Uchikawa H, Koike T, Kiyofuji S, Shinya Y, Kawashima M, Saito N. Hemodynamic Analysis of Cerebral AVMs with 3D Phase-Contrast MR Imaging. AJNR Am J Neuroradiol 2021; 42:2138-2145. [PMID: 34620595 DOI: 10.3174/ajnr.a7314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/28/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The hemodynamics associated with cerebral AVMs have a significant impact on their clinical presentation. This study aimed to evaluate the hemodynamic features of AVMs using 3D phase-contrast MR imaging with dual velocity-encodings. MATERIALS AND METHODS Thirty-two patients with supratentorial AVMs who had not received any previous treatment and had undergone 3D phase-contrast MR imaging were included in this study. The nidus diameter and volume were measured for classification of AVMs (small, medium, or large). Flow parameters measured included apparent AVM inflow, AVM inflow index, apparent AVM outflow, AVM outflow index, and the apparent AVM inflow-to-outflow ratio. Correlation coefficients between the nidus volume and each flow were calculated. The flow parameters between small and other AVMs as well as between nonhemorrhagic and hemorrhagic AVMs were compared. RESULTS Patients were divided into hemorrhagic (n = 8) and nonhemorrhagic (n = 24) groups. The correlation coefficient between the nidus volume and the apparent AVM inflow and outflow was .83. The apparent AVM inflow and outflow in small AVMs were significantly smaller than in medium AVMs (P < .001 for both groups). The apparent AVM inflow-to-outflow ratio was significantly larger in the hemorrhagic AVMs than in the nonhemorrhagic AVMs (P = .02). CONCLUSIONS The apparent AVM inflow-to-outflow ratio was the only significant parameter that differed between nonhemorrhagic and hemorrhagic AVMs, suggesting that a poor drainage system may increase AVM pressure, potentially causing cerebral hemorrhage.
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Affiliation(s)
- Y Takeda
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - T Kin
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - T Sekine
- Department of Radiology (T.S.), Nippon Medical School Musashi-kosugi Hospital, Kanagawa, Japan
| | - H Hasegawa
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - Y Suzuki
- Radiology (Y.Suzuki), The University of Tokyo, Tokyo, Japan
| | - H Uchikawa
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - T Koike
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - S Kiyofuji
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - Y Shinya
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - M Kawashima
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
| | - N Saito
- From the Department of Neurosurgery (Y.T., T.K., H.H., H.U., T.K., S.K., Y. Shinya, M.K., N.S.)
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Abstract
Brain arteriovenous malformation (bAVM) is the most common cause of intracranial hemorrhage (ICH), particularly in young patients. However, the exact cause of bAVM bleeding and rupture is not yet fully understood. In bAVMs, blood bypasses the entire capillary bed and directly flows from arteries to veins. The vessel walls in bAVMs have structural defects, which impair vascular integrity. Mural cells are essential structural and functional components of blood vessels and play a critical role in maintaining vascular integrity. Changes in mural cell number and coverage have been implicated in bAVMs. In this review, we discussed the roles of mural cells in bAVM pathogenesis. We focused on 1) the recent advances in human and animal studies of bAVMs; 2) the importance of mural cells in vascular integrity; 3) the regulatory signaling pathways that regulate mural cell function. More specifically, the platelet-derived growth factor-B (PDGF-B)/PDGF receptor-β (PDGFR-β), EphrinB2/EphB4, and angiopoietins/tie2 signaling pathways that regulate mural cell-recruitment during vascular remodeling were discussed in detail.
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Perioperative Dynamics of Intracranial B-waves of Blood Flow Velocity in the Basal Cerebral Arteries in Patients with Brain Arteriovenous Malformation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839820 DOI: 10.1007/978-3-030-59436-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Intracranial B-waves (8-30 mHz) of blood flow velocity (BFV) in the cerebral arteries are observed in various pathologies of the brain. Changes in B-waves of BFV in pathological arteriovenous shunting and "steal" syndrome remain poorly understood. The aim of this study was to evaluate the dynamics of the B-wave amplitude of BFV (BWA) in patients with an arteriovenous malformation (AVM) in the brain. In 38 such patients, cerebral autoregulation (CA) was assessed using a cuff test and transfer function analysis of the mean blood pressure (BP) and BFV in the basal cerebral arteries within the range of Mayer waves (80-120 mHz). BWA was calculated with spectral analysis. Reliable CA impairment was denoted on the AVM side as compared with the contralateral side prior to intervention. BWA was greater on the AVM side (4.5 ± 2.7 cm/s) than on the contralateral side (2.2 ± 1.4 cm/s, p < 0.05). After embolization, there was a reliable improvement (p < 0.05) in CA and a decrease in BWA on the AVM side (2.7 ± 1.8 cm/s). Thus, a considerable increase in BWA on the AVM side that is not induced by BP fluctuations may indicate additional compensation for blood flow under conditions of reduced perfusion pressure. This assumption is supported by a reduction in BWA after AVM embolization.
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Li M, Liu Q, Guo R, Yang S, Jiang P, Chen X, Wu J, Cao Y, Wang S. Perinidal Angiogenesis Is a Predictor for Neurovascular Uncoupling in the Periphery of Brain Arteriovenous Malformations: A Task-Based and Resting-State fMRI Study. J Magn Reson Imaging 2020; 54:186-196. [PMID: 33345355 DOI: 10.1002/jmri.27469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Potential neurovascular uncoupling (NVU) related to perinidal angiogenesis (PA) of brain arteriovenous malformations (AVMs) may cause inappropriate presurgical mapping using functional magnetic resonance imaging (fMRI), resulting in overconfident resection and postoperative morbidity. PURPOSE To evaluate the potential impact of PA upon fMRI blood oxygen level-dependent signal in the periphery of AVMs. STUDY TYPE Prospective. POPULATION Twenty-one patients with AVMs located in the primary sensorimotor cortex (SM1) undergoing task-based fMRI (hand motor), and 19 patients with supratentorial AVMs undergoing resting-state fMRI. FIELD STRENGTH/SEQUENCE 3.0T, echo-planar, time-of-flight, and magnetization-prepared rapid gradient-echo. ASSESSMENT The presence of PA was determined by three observers (Y.C., J.W., and X.C.) according to digital subtraction angiography and MR angiography. Interhemispheric asymmetry of fMRI activations contralateral to hand movements was evaluated with the interhemispheric ratio of the average t-value within ipsilesional SM1 to contralesional SM1. Regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuations (fALFF) were extracted from ring-shaped perinidal regions and contralateral homologous regions, and the corresponding interhemispheric ratios were calculated. The effect of PA on the interhemispheric asymmetry of motor activations, ReHo, and fALFF was estimated. STATISTICAL TESTS Pearson analysis, paired and independent t-test, multiple linear regression, Friedman test, and factorial analysis of variance were used. RESULTS Motor activations were significantly reduced in ipsilesional SM1 compared to contralesional SM1 (P < 0.05). The presence of PA was the independent predictor of activation loss in ipsilateral SM1(P < 0.05). Furthermore, perinidal regions exhibited reduced ReHo compared to the homologous regions (P < 0.05). PA was significantly associated with the decline of ReHo and fALFF in perinidal regions (P < 0.05, for both). DATA CONCLUSION The presence of PA can predict perinidal NVU that may confound the interpretation of both task-based and resting-state fMRI, highlighting the importance of alternative approaches of brain functional localization in improving treatment of AVMs. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
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21
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Hauer AJ, Kleinloog R, Giuliani F, Rinkel GJ, de Kort GA, Berkelbach van der Sprenkel JW, van der Zwan A, Gosselaar PH, van Rijen PC, de Boer-Bergsma JJ, Deelen P, Swertz MA, De Muynck L, Van Damme P, Veldink JH, Ruigrok YM, Klijn CJ. RNA-Sequencing Highlights Inflammation and Impaired Integrity of the Vascular Wall in Brain Arteriovenous Malformations. Stroke 2020; 51:268-274. [DOI: 10.1161/strokeaha.119.025657] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Interventional treatment of unruptured brain arteriovenous malformations (BAVMs) has become increasingly controversial. Because medical therapy is still lacking, we aimed to obtain insight into the disease mechanisms implicated in BAVMs and to identify potential targets for medical treatment to prevent rupture of a BAVM.
Methods—
We used next-generation RNA sequencing to identify differential expression on a transcriptome-wide level comparing tissue samples of 12 BAVMs to 16 intracranial control arteries. We identified differentially expressed genes by negative binominal generalized log-linear regression (false discovery rate corrected
P
<0.05). We selected 10 genes for validation using droplet digital polymerase chain reaction. We performed functional pathway analysis accounting for potential gene-length bias, to establish enhancement of biological pathways involved in BAVMs. We further assessed which Gene Ontology terms were enriched.
Results—
We found 736 upregulated genes in BAVMs including genes implicated in the cytoskeletal machinery and cell-migration and genes encoding for inflammatory cytokines and secretory products of neutrophils and macrophages. Furthermore, we found 498 genes downregulated including genes implicated in extracellular matrix composition, the binary angiopoietin-TIE system, and TGF (transforming growth factor)-β signaling. We confirmed the differential expression of top 10 ranked genes. Functional pathway analysis showed enrichment of the protein digestion and absorption pathway (false discovery rate-adjusted
P
=1.70×10
−2
). We identified 47 enriched Gene Ontology terms (false discovery rate-adjusted
P
<0.05) implicated in cytoskeleton network, cell-migration, endoplasmic reticulum, transmembrane transport, and extracellular matrix composition.
Conclusions—
Our genome-wide RNA-sequencing study points to involvement of inflammatory mediators, loss of cerebrovascular quiescence, and impaired integrity of the vascular wall in the pathophysiology of BAVMs. Our study may lend support to potential receptivity of BAVMs to medical therapeutics, including those promoting vessel maturation, and anti-inflammatory and immune-modifying drugs.
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Affiliation(s)
- Allard J. Hauer
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Rachel Kleinloog
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Fabrizio Giuliani
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Gabriël J.E. Rinkel
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Gerard A. de Kort
- Brain Center Rudolf Magnus and Department of Radiology (G.A.d.K.), University Medical Center Utrecht, the Netherlands
| | - Jan Willem Berkelbach van der Sprenkel
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Albert van der Zwan
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Peter H. Gosselaar
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Peter C. van Rijen
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Jelkje J. de Boer-Bergsma
- Department of Genetics (J.J.d.B.-B., P.D., M.A.S.), University Medical Center Groningen, the Netherlands
- Genomics Coordination Center (J.J.d.B.-B., P.D., M.A.S.), University Medical Center Groningen, the Netherlands
| | - Patrick Deelen
- Department of Genetics (J.J.d.B.-B., P.D., M.A.S.), University Medical Center Groningen, the Netherlands
- Genomics Coordination Center (J.J.d.B.-B., P.D., M.A.S.), University Medical Center Groningen, the Netherlands
| | - Morris A. Swertz
- Department of Genetics (J.J.d.B.-B., P.D., M.A.S.), University Medical Center Groningen, the Netherlands
- Genomics Coordination Center (J.J.d.B.-B., P.D., M.A.S.), University Medical Center Groningen, the Netherlands
| | - Louis De Muynck
- Department of Neurology, University Hospital Leuven and Laboratory of Neurobiology, Center for Brain & Disease Research, VIB and KU Leuven, Belgium (L.D.M., P.V.D.)
| | - Philip Van Damme
- Department of Neurology, University Hospital Leuven and Laboratory of Neurobiology, Center for Brain & Disease Research, VIB and KU Leuven, Belgium (L.D.M., P.V.D.)
| | - Jan H. Veldink
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Ynte M. Ruigrok
- From the Department of Neurology and Neurosurgery (A.J.H., R.K., F.G., G.J.E.R., J.W.B.v.d.S., A.v.d.Z., P.H.G., P.C.v.R., J.H.V., Y.M.R., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute of Brain Cognition & Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands (C.J.M.K.)
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22
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Winkler EA, Birk H, Burkhardt JK, Chen X, Yue JK, Guo D, Rutledge WC, Lasker GF, Partow C, Tihan T, Chang EF, Su H, Kim H, Walcott BP, Lawton MT. Reductions in brain pericytes are associated with arteriovenous malformation vascular instability. J Neurosurg 2018; 129:1464-1474. [PMID: 29303444 PMCID: PMC6033689 DOI: 10.3171/2017.6.jns17860] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEBrain arteriovenous malformations (bAVMs) are rupture-prone tangles of blood vessels with direct shunting of blood flow between arterial and venous circulations. The molecular and/or cellular mechanisms contributing to bAVM pathogenesis and/or destabilization in sporadic lesions have remained elusive. Initial insights into AVM formation have been gained through models of genetic AVM syndromes. And while many studies have focused on endothelial cells, the contributions of other vascular cell types have yet to be systematically studied. Pericytes are multifunctional mural cells that regulate brain angiogenesis, blood-brain barrier integrity, and vascular stability. Here, the authors analyze the abundance of brain pericytes and their association with vascular changes in sporadic human AVMs.METHODSTissues from bAVMs and from temporal lobe specimens from patients with medically intractable epilepsy (nonvascular lesion controls [NVLCs]) were resected. Immunofluorescent staining with confocal microscopy was performed to quantify pericytes (platelet-derived growth factor receptor-beta [PDGFRβ] and aminopeptidase N [CD13]) and extravascular hemoglobin. Iron-positive hemosiderin deposits were quantified with Prussian blue staining. Syngo iFlow post-image processing was used to measure nidal blood flow on preintervention angiograms.RESULTSQuantitative immunofluorescent analysis demonstrated a 68% reduction in the vascular pericyte number in bAVMs compared with the number in NVLCs (p < 0.01). Additional analysis demonstrated 52% and 50% reductions in the vascular surface area covered by CD13- and PDGFRβ-positive pericyte cell processes, respectively, in bAVMs (p < 0.01). Reductions in pericyte coverage were statistically significantly greater in bAVMs with prior rupture (p < 0.05). Unruptured bAVMs had increased microhemorrhage, as evidenced by a 15.5-fold increase in extravascular hemoglobin compared with levels in NVLCs (p < 0.01). Within unruptured bAVM specimens, extravascular hemoglobin correlated negatively with pericyte coverage (CD13: r = -0.93, p < 0.01; PDGFRβ: r = -0.87, p < 0.01). A similar negative correlation was observed with pericyte coverage and Prussian blue-positive hemosiderin deposits (CD13: r = -0.90, p < 0.01; PDGFRβ: r = -0.86, p < 0.01). Pericyte coverage positively correlated with the mean transit time of blood flow or the time that circulating blood spends within the bAVM nidus (CD13: r = 0.60, p < 0.05; PDGFRβ: r = 0.63, p < 0.05). A greater reduction in pericyte coverage is therefore associated with a reduced mean transit time or faster rate of blood flow through the bAVM nidus. No correlations were observed with time to peak flow within feeding arteries or draining veins.CONCLUSIONSBrain pericyte number and coverage are reduced in sporadic bAVMs and are lowest in cases with prior rupture. In unruptured bAVMs, pericyte reductions correlate with the severity of microhemorrhage. A loss of pericytes also correlates with a faster rate of blood flow through the bAVM nidus. This suggests that pericytes are associated with and may contribute to vascular fragility and hemodynamic changes in bAVMs. Future studies in animal models are needed to better characterize the role of pericytes in AVM pathogenesis.
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Affiliation(s)
- Ethan A. Winkler
- Department of Neurological Surgery, University of California, San Francisco
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Harjus Birk
- Department of Neurological Surgery, University of California, San Francisco
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California, San Francisco
| | - Xiaolin Chen
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
- Department of Neurological Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco
| | - Diana Guo
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - W. Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - George F. Lasker
- Department of Neurological Surgery, University of California, San Francisco
| | - Carlene Partow
- Department of Neurological Surgery, University of California, San Francisco
| | - Tarik Tihan
- Department of Pathology, University of California, San Francisco
| | - Edward F. Chang
- Department of Neurological Surgery, University of California, San Francisco
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Brian P. Walcott
- Department of Neurological Surgery, University of California, San Francisco
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
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23
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Thomas JM, Surendran S, Abraham M, Sasankan D, Bhaadri S, Rajavelu A, Kartha CC. Gene expression analysis of nidus of cerebral arteriovenous malformations reveals vascular structures with deficient differentiation and maturation. PLoS One 2018; 13:e0198617. [PMID: 29897969 PMCID: PMC5999265 DOI: 10.1371/journal.pone.0198617] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 05/22/2018] [Indexed: 12/19/2022] Open
Abstract
Objective Arteriovenous malformations (AVMs) are characterised by tangles of dysplastic blood vessels which shunt blood from arteries to veins with no intervening capillary bed. It is not known at what stage of development and differentiation, AVM vessels became aberrant. To address this, we have analysed the expression of vascular differentiation, vascular maturation and brain capillary specific genes in AVM nidus. Methodology We performed immunohistochemistry and western blot analysis of vascular differentiation (HEY2, DLL4, EFNB2, and COUP-TFII), vascular maturation (ENG and KLF2) and brain capillary specific genes (GGTP and GLUT1) on ten surgically excised human brain AVMs and ten normal human brain tissues. Results Immunohistochemical analysis revealed that AVM vessels co-express both artery and vein differentiation genes. H-score analysis revealed that there is statistically significant (P < 0.0001) increase in expression of these proteins in AVM vessels compared to control vessels. These findings were further confirmed by western blot analysis and found to be statistically significant (P < 0.0001 and P < 0.001) for all proteins except Hey2. Both immunostaining and western blot analysis revealed that AVM vessels express GGTP and GLUT1, markers specific to brain capillaries. Immunofluorescent staining demonstrated that expression of KLF2, a vascular maturation marker is significantly (P <0.001) decreased in AVM vessels and was further confirmed by western blot analysis (P < 0.001). Immunohistochemical and western blot analysis demonstrated that another vascular maturation protein Endoglin had high expression in AVM vessels compared to control vessels. The results were found to be statistically significant (P < 0.0001). Summary Our findings suggest that vascular structures of AVMs co-express markers specific for arteries, veins and capillaries. We conclude that AVM nidus constitutes of aberrant vessels which are not terminally differentiated and inadequately matured.
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Affiliation(s)
- Jaya Mary Thomas
- Cardio Vascular Diseases and Diabetes Biology Program, Rajiv Gandhi Centre for Biotechnology, Poojapura, Thycaud, Thiruvananthapuram, Kerala, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sumi Surendran
- Cardio Vascular Diseases and Diabetes Biology Program, Rajiv Gandhi Centre for Biotechnology, Poojapura, Thycaud, Thiruvananthapuram, Kerala, India
| | - Mathew Abraham
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Kerala, India
| | - Dhakshmi Sasankan
- Cardio Vascular Diseases and Diabetes Biology Program, Rajiv Gandhi Centre for Biotechnology, Poojapura, Thycaud, Thiruvananthapuram, Kerala, India
| | - Sridutt Bhaadri
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Kerala, India
| | - Arumugam Rajavelu
- Cardio Vascular Diseases and Diabetes Biology Program, Rajiv Gandhi Centre for Biotechnology, Poojapura, Thycaud, Thiruvananthapuram, Kerala, India
- Tropical Disease Biology Program, Rajiv Gandhi Centre for Biotechnology, Poojapura, Thycaud, Thiruvananthapuram, Kerala, India
- * E-mail: (AR); (CCK)
| | - Chandrasekharan C. Kartha
- Cardio Vascular Diseases and Diabetes Biology Program, Rajiv Gandhi Centre for Biotechnology, Poojapura, Thycaud, Thiruvananthapuram, Kerala, India
- * E-mail: (AR); (CCK)
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24
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Morgan MK, Wiedmann MKH, Assaad NNA, Parr MJA, Heller GZ. Deliberate employment of postoperative hypotension for brain arteriovenous malformation surgery and the incidence of delayed postoperative hemorrhage: a prospective cohort study. J Neurosurg 2017; 127:1025-1040. [DOI: 10.3171/2016.9.jns161333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to examine the impact of deliberate employment of postoperative hypotension on delayed postoperative hemorrhage (DPH) for all Spetzler-Ponce Class (SPC) C brain arteriovenous malformations (bAVMs) and SPC B bAVMs ≥ 3.5 cm in diameter (SPC B 3.5+).METHODSA protocol of deliberate employment of postoperative hypotension was introduced in June 1997 for all SPC C and SPC B 3.5+ bAVMs. The aim was to achieve a maximum mean arterial blood pressure (BP) ≤ 70 mm Hg (with cerebral perfusion pressure > 50 mm Hg) for a minimum of 7 days after resection of bAVMs (BP protocol). The authors compared patients who experienced DPH (defined as brain hemorrhage into the resection bed that resulted in a new neurological deficit or that resulted in reoperation during the hospitalization for microsurgical bAVM resection) between 2 periods (prior to adopting the BP protocol and after introduction of the BP protocol) and 4 bAVM categories (SPC A, SPC B 3.5− [that is, SPC B < 3.5 cm maximum diameter], SPC B 3.5+, and SPC C). Patients excluded from treatment by the BP protocol were managed in the intensive care unit to avoid moderate hypertensive episodes. The pooled cases of all bAVM treated by surgery were analyzed to identify characteristics associated with the risk of DPH. These identified characteristics were then examined by multiple logistic regression analysis in both SPC B 3.5+ and SPC C cases.RESULTSFrom a cohort of 641 bAVMs treated by microsurgery, 32 patients with DPH were identified. Of those, 66% (95% CI 48–80) had a permanent new neurological deficit with a modified Rankin Scale score of 2–6. This included a mortality rate of 13% (95% CI 4.4–29). The BP protocol was used to treat 162 patients with either SPC B 3.5+ or SPC C. For SPC B 3.5+, there was no significant reduction in DPH with the introduction of the BP protocol (p = 0.77). For SPC C, there was a significant (p = 0.035) reduction of DPH from 29% (95% CI 13%–53%) to 8.2% (95% CI 3.2%–18%) associated with the introduction of the BP protocol. Multiple logistic regression analysis found that the absence of the BP protocol (p = 0.011, odds ratio 7.5, 95% CI 1.6–36) remained significant for the development of DPH in patients with SPC C bAVMs.CONCLUSIONSTreating patients with SPC C bAVMs with a protocol that lowers BP immediately after resection seems to reduce the risk of DPH. For SPC A and SPC B 3.5− bAVMs, there is unlikely to be a need to do more than avoid postoperative hypertension. For SPC B 3.5+ bAVMs, a larger number of patients would be required to test the absence of benefit of the BP protocol.
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Affiliation(s)
| | | | | | - Michael J. A. Parr
- Departments of 1Clinical Medicine and
- 3Department of Intensive Care, Macquarie University Hospital, Ryde, New South Wales, Australia
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25
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Kozyrev DA, Thiarawat P, Jahromi BR, Intarakhao P, Choque-Velasquez J, Hijazy F, Teo MK, Hernesniemi J. "Dirty coagulation" technique as an alternative to microclips for control of bleeding from deep feeders during brain arteriovenous malformation surgery. Acta Neurochir (Wien) 2017; 159:855-859. [PMID: 28283870 DOI: 10.1007/s00701-017-3138-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/27/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Meticulous haemostasis is one of the most important factors during microneurosurgical resection of brain arteriovenous malformation (AVM). Controlling major arterial feeders and draining veins with clips and bipolar coagulation are well-established techniques, while managing with bleeding from deep tiny vessels still proves to be challenging. This technical note describes a technique used by the senior author in AVM surgery for last 20 years in dealing with the issue highlighted. METHOD "Dirty coagulation" is a technique of bipolar coagulation of small feeders carried out together with a thin layer of brain tissue that surrounds these fragile vessels. The senior author uses this technique for achieving permanent haemostasis predominantly in large and/or deep-seated AVMs. To illustrate the efficacy of this technique, we retrospectively reviewed the outcome of Spetzler-Martin (SM) grade III-V AVMs resected by the senior author over the last 5 years (2010-2015). RESULTS Thirty-five cases of AVM surgeries (14 SM grade III, 15 SM grade IV and 6 SM grade V) in this 5-year period were analysed. No postoperative intracranial haemorrhage was encountered as a result of bleeding from the deep feeders. Postoperative angiograms showed complete resection of all AVMs, except in two cases (SM grade V and grade III). CONCLUSIONS "Dirty coagulation" provides an effective way to secure haemostasis from deep tiny feeders. This cost-effective method could be successfully used for achieving permanent haemostasis and thereby decreasing postoperative haemorrhage in AVM surgery.
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Affiliation(s)
- Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland.
- Department of Paediatric Neurology and Neurosurgery, North-Western State Medical University, St. Petersburg, Russia.
| | - Peeraphong Thiarawat
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Patcharin Intarakhao
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Ferzat Hijazy
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mario K Teo
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, UK
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
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26
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Abstract
OBJECTIVE Brain arteriovenous malformation (AVM) rupture results in substantial morbidity and mortality. The goal of AVM treatment is eradication of the AVM, but the risk of treatment must be weighed against the risk of future hemorrhage. CONCLUSION Imaging plays a vital role by providing the information necessary for AVM management. Here, we discuss the background, natural history, clinical presentation, and imaging of AVMs. In addition, we explain advances in techniques for imaging AVMs.
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Alternatively Activated Macrophages Play an Important Role in Vascular Remodeling and Hemorrhaging in Patients with Brain Arteriovenous Malformation. J Stroke Cerebrovasc Dis 2016; 25:600-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/29/2015] [Accepted: 11/22/2015] [Indexed: 12/30/2022] Open
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Barbagallo GMV, Certo F, Caltabiano R, Chiaramonte I, Albanese V, Visocchi M. Role of intraoperative indocyanine green video-angiography to identify small, posterior fossa arteriovenous malformations mimicking cavernous angiomas. Technical report and review of the literature on common features of these cerebral vascular malformations. Clin Neurol Neurosurg 2015; 138:45-51. [PMID: 26276727 DOI: 10.1016/j.clineuro.2015.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/19/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To illustrate the usefulness of intraoperative indocyanine green videoangiography (ICG-VA) to identify the nidus and feeders of a small cerebellar AVM resembling a cavernous hemangioma. To review the unique features regarding the overlay between these two vascular malformations and to highlight the importance to identify with ICG-VA, and treat accordingly, the arterial and venous vessels of the AVM. METHODS A 36-year old man presented with bilateral cerebellar hemorrhage. MRI was equivocal in showing an underlying vascular malformation but angiography demonstrated a small, Spetzler-Martin grade I AVM. Surgical resection of the AVM with the aid of intraoperative ICG-VA was performed. After hematoma evacuation, pre-resection ICG-VA did not reveal tortuous arterial and venous vessels in keeping with a typical AVM but rather an unusual blackberry-like image resembling a cavernous hemangioma, with tiny surrounding vessels. Such intraoperative appearance, which could also be the consequence of a "leakage" of fluorescent dye from the nidal pathological vessels, with absent blood-brain barrier, into the surrounding parenchymal pathological capillary network, is important to be recognized as an unusual AVM appearance. RESULTS Post-resection ICG-VA confirmed the AVM removal, as also shown by postoperative and 3-month follow-up DSAs. CONCLUSIONS Despite technical limitations associated with ICG-VA in post-hemorrhage AVMs, this case together with the intraoperative video, demonstrates the useful role of ICG-VA in identifying small AVMs with peculiar features.
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Affiliation(s)
- Giuseppe M V Barbagallo
- Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy.
| | - Francesco Certo
- Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy
| | - Rosario Caltabiano
- Department G.F. Ingrassia, Section of Anatomic Pathology, University of Catania, via Santa Sofia 78, 95123 Catania, Italy
| | - Ignazio Chiaramonte
- Radiology Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123 Catania, Italy
| | - Vincenzo Albanese
- Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy
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Abstract
An arteriovenous malformation is a tangle of dysplastic vessels (nidus) fed by arteries and drained by veins without intervening capillaries, forming a high-flow, low-resistance shunt between the arterial and venous systems. Arteriovenous malformations in the brain have a low estimated prevalence but are an important cause of intracerebral haemorrhage in young adults. For previously unruptured malformations, bleeding rates are approximately 1% per year. Once ruptured, the subsequent risk increases fivefold, depending on associated aneurysms, deep locations, deep drainage and increasing age. Recent findings from novel animal models and genetic studies suggest that arteriovenous malformations, which were long considered congenital, arise from aberrant vasculogenesis, genetic mutations and/or angiogenesis after injury. The phenotypical characteristics of arteriovenous malformations differ among age groups, with fistulous lesions in children and nidal lesions in adults. Diagnosis mainly involves imaging techniques, including CT, MRI and angiography. Management includes observation, microsurgical resection, endovascular embolization and stereotactic radiosurgery, alone or in any combination. There is little consensus on how to manage patients with unruptured malformations; recent studies have shown that patients managed medically fared better than those with intervention at short-term follow-up. By contrast, interventional treatment is preferred following a ruptured malformation to prevent rehaemorrhage. Management continues to evolve as new mechanistic discoveries and reliable animal models raise the possibility of developing drugs that might prevent the formation of arteriovenous malformations, induce obliteration and/or stabilize vessels to reduce rupture risk. For an illustrated summary of this Primer, visit: http://go.nature.com/TMoAdn.
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Mouchtouris N, Jabbour PM, Starke RM, Hasan DM, Zanaty M, Theofanis T, Ding D, Tjoumakaris SI, Dumont AS, Ghobrial GM, Kung D, Rosenwasser RH, Chalouhi N. Biology of cerebral arteriovenous malformations with a focus on inflammation. J Cereb Blood Flow Metab 2015; 35:167-75. [PMID: 25407267 PMCID: PMC4426734 DOI: 10.1038/jcbfm.2014.179] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/05/2014] [Accepted: 09/22/2014] [Indexed: 01/01/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) entail a significant risk of intracerebral hemorrhage owing to the direct shunting of arterial blood into the venous vasculature without the dissipation of the arterial blood pressure. The mechanisms involved in the growth, progression and rupture of AVMs are not clearly understood, but a number of studies point to inflammation as a major contributor to their pathogenesis. The upregulation of proinflammatory cytokines induces the overexpression of cell adhesion molecules in AVM endothelial cells, resulting in enhanced recruitment of leukocytes. The increased leukocyte-derived release of metalloproteinase-9 is known to damage AVM walls and lead to rupture. Inflammation is also involved in altering the AVM angioarchitecture via the upregulation of angiogenic factors that affect endothelial cell proliferation, migration and apoptosis. The effects of inflammation on AVM pathogenesis are potentiated by certain single-nucleotide polymorphisms in the genes of proinflammatory cytokines, increasing their protein levels in the AVM tissue. Furthermore, studies on metalloproteinase-9 inhibitors and on the involvement of Notch signaling in AVMs provide promising data for a potential basis for pharmacological treatment of AVMs. Potential therapeutic targets and areas requiring further investigation are highlighted.
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Affiliation(s)
- Nikolaos Mouchtouris
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - David M Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Mario Zanaty
- 1] Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA [2] Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Thana Theofanis
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stavropoula I Tjoumakaris
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - George M Ghobrial
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - David Kung
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Atri D, Larrivée B, Eichmann A, Simons M. Endothelial signaling and the molecular basis of arteriovenous malformation. Cell Mol Life Sci 2013; 71:10.1007/s00018-013-1475-1. [PMID: 24077895 PMCID: PMC3969452 DOI: 10.1007/s00018-013-1475-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/08/2013] [Accepted: 09/10/2013] [Indexed: 12/21/2022]
Abstract
Arteriovenous malformations occur when abnormalities of vascular patterning result in the flow of blood from arteries to veins without an intervening capillary bed. Recent work has revealed the importance of the Notch and TGF-β signaling pathways in vascular patterning. Specifically, Notch signaling has an increasingly apparent role in arterial specification and suppression of branching, whereas TGF-β is implicated in vascular smooth muscle development and remodeling under angiogenic stimuli. These physiologic roles, consequently, have implicated both pathways in the pathogenesis of arteriovenous malformation. In this review, we summarize the studies of endothelial signaling that contribute to arteriovenous malformation and the roles of genes implicated in their pathogenesis. We further discuss how endothelial signaling may contribute to vascular smooth muscle development and how knowledge of signaling pathways may provide us targets for medical therapy in these vascular lesions.
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Affiliation(s)
- Deepak Atri
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, United States
| | - Bruno Larrivée
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, United States
- Department of Ophthalmology, Hôpital Maisonneuve-Rosemont Research Centre, University of Montreal, Montreal, Canada
| | - Anne Eichmann
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, United States
- Center for Interdisciplinary Research in Biology (CIRB), Collège de France, Paris, France
| | - Michael Simons
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, United States
- Department of Cell Biology, Yale University School of Medicine, New Haven, United States
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Taeshineetanakul P, Krings T, Geibprasert S, Menezes R, Agid R, Terbrugge KG, Schwartz ML. Angioarchitecture determines obliteration rate after radiosurgery in brain arteriovenous malformations. Neurosurgery 2013; 71:1071-8; discussion 1079. [PMID: 22922676 DOI: 10.1227/neu.0b013e31826f79ec] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Radiosurgery as a potential treatment modality for brain arteriovenous malformations (AVM) has 60% to 90% obliteration rates. OBJECTIVE To test whether AVM angioarchitecture determines obliteration rate after radiosurgery. METHODS This study was a retrospective analysis of 139 patients with AVM who underwent radiosurgery. Multiple angioarchitectural characteristics were reviewed on conventional angiogram on the day of radiosurgery: enlargement of feeding arteries, flow-related or intranidal aneurysms, perinidal angiogenesis, arteriovenous transit time, nidus type, venous ectasia, focal pouches, venous rerouting, and presence of a pseudophlebitic pattern. The radiation plan was reviewed for nidus volume and eloquence of AVM location. A chart review was performed to determine clinical presentation and previous treatment. Outcome was dichotomized into complete/incomplete obliteration, and various statistics were performed, examining whether outcome status was associated with the investigated factors. RESULTS Marginal dose ranged from 15 to 25 Gy (mean, 18.8 Gy), with lower doses prescribed in eloquent locations. Sizes of AVMs ranged from 0.08 to 21 cm (mean, 3.78 ± 4.19 cm). Complete AVM obliteration was achieved in 92 patients (66%) and was related to these independent factors: noneloquent location (odds ratio [OR], 3.20), size (OR, 0.88), low flow (OR, 3.47), no or mild arterial enlargement (OR, 3.32), and absence of perinidal angiogenesis (OR, 2.61). Concerning the 3 last angioarchitectural characteristics, if no or only a single factor was present in an individual patient (n = 92 patients), obliteration was observed in 74 (80%); if 2 or 3 factors were present (n = 47), obliteration was observed in 18 patients (38%; OR, 6.62). CONCLUSION Angioarchitectural factors that indicate high flow are associated with a lower rate of AVM obliteration after radiosurgery.
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Forkert ND, Illies T, Goebell E, Fiehler J, Säring D, Handels H. Computer-aided nidus segmentation and angiographic characterization of arteriovenous malformations. Int J Comput Assist Radiol Surg 2013; 8:775-86. [PMID: 23468323 DOI: 10.1007/s11548-013-0823-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 02/12/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Exact knowledge about the nidus of an arteriovenous malformation (AVM) and the connected vessels is often required for image-based research projects and optimal therapy planning. The aim of this work is to present and evaluate a computer-aided nidus segmentation technique and subsequent angiographic characterization of the connected vessels that can be visualized in 3D. METHODS The proposed method was developed and evaluated based on 15 datasets of patients with an AVM. Each dataset consists of a high-resolution 3D and a 4D magnetic resonance angiography (MRA) image sequence. After automatic cerebrovascular segmentation from the 3D MRA dataset, a voxel-wise support vector machine classification based on four extracted features is performed to generate a new parameter map. The nidus is represented by positive values in this parameter map and can be extracted using volume growing. Finally, the nidus segmentation is dilated and used for an automatic identification of feeding arteries and draining veins by integrating hemodynamic information from the 4D MRA datasets. RESULTS A quantitative comparison of the computer-aided AVM nidus segmentation results to manual gold-standard segmentations by two observers revealed a mean Dice coefficient of 0.835, which is comparable to the inter-observer agreement for which a mean Dice coefficient of 0.830 was determined. The angiographic characterization was visually rated feasible for all patients. CONCLUSION The presented computer-aided method enables a reproducible and fast extraction of the AVM nidus as well as an automatic angiographic characterization of the connected vessels, which can be used to support image-based research projects and therapy planning of AVMs.
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Affiliation(s)
- Nils Daniel Forkert
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Bldg. W36, Martinistraße 52, 20246 , Hamburg, Germany,
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Chen W, Guo Y, Walker EJ, Shen F, Jun K, Oh SP, Degos V, Lawton MT, Tihan T, Davalos D, Akassoglou K, Nelson J, Pile-Spellman J, Su H, Young WL. Reduced mural cell coverage and impaired vessel integrity after angiogenic stimulation in the Alk1-deficient brain. Arterioscler Thromb Vasc Biol 2012; 33:305-10. [PMID: 23241407 DOI: 10.1161/atvbaha.112.300485] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Vessels in brain arteriovenous malformations are prone to rupture. The underlying pathogenesis is not clear. Hereditary hemorrhagic telangiectasia type 2 patients with activin receptor-like kinase 1 (Alk1) mutation have a higher incidence of brain arteriovenous malformation than the general population. We tested the hypothesis that vascular endothelial growth factor impairs vascular integrity in the Alk1-deficient brain through reduction of mural cell coverage. METHODS AND RESULTS Adult Alk1(1f/2f) mice (loxP sites flanking exons 4-6) and wild-type mice were injected with 2×10(7) PFU adenovious-cre recombinase and 2×10(9) genome copies of adeno-associated virus-vascular endothelial growth factor to induce focal homozygous Alk1 deletion (in Alk1(1f/2f) mice) and angiogenesis. Brain vessels were analyzed 8 weeks later. Compared with wild-type mice, the Alk1-deficient brain had more fibrin (99±30×10(3) pixels/mm(2) versus 40±13×10(3); P=0.001), iron deposition (508±506 pixels/mm(2) versus 6±49; P=0.04), and Iba1(+) microglia/macrophage infiltration (888±420 Iba1(+) cells/mm(2) versus 240±104 Iba1(+); P=0.001) after vascular endothelial growth factor stimulation. In the angiogenic foci, the Alk1-deficient brain had more α-smooth muscle actin negative vessels (52±9% versus 12±7%, P<0.001), fewer vascular-associated pericytes (503±179/mm(2) versus 931±115, P<0.001), and reduced platelet-derived growth factor receptor-β expression. CONCLUSIONS Reduction of mural cell coverage in response to vascular endothelial growth factor stimulation is a potential mechanism for the impairment of vessel wall integrity in hereditary hemorrhagic telangiectasia type 2-associated brain arteriovenous malformation.
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MESH Headings
- Actins/metabolism
- Activin Receptors, Type I/deficiency
- Activin Receptors, Type I/genetics
- Activin Receptors, Type II
- Animals
- Becaplermin
- Blood Vessels/enzymology
- Blood Vessels/pathology
- Brain/blood supply
- Dependovirus/genetics
- Disease Models, Animal
- Fibrin/metabolism
- Gene Transfer Techniques
- Genetic Vectors
- Iron/metabolism
- Macrophages/metabolism
- Macrophages/pathology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Microglia/metabolism
- Microglia/pathology
- Neovascularization, Pathologic
- Pericytes/enzymology
- Pericytes/pathology
- Proto-Oncogene Proteins c-sis/metabolism
- Receptor, Platelet-Derived Growth Factor beta/metabolism
- Telangiectasia, Hereditary Hemorrhagic/enzymology
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Telangiectasia, Hereditary Hemorrhagic/pathology
- Vascular Endothelial Growth Factor A/genetics
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- Wanqiu Chen
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA 94110, USA
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Choi EJ, Walker EJ, Shen F, Oh SP, Arthur HM, Young WL, Su H. Minimal homozygous endothelial deletion of Eng with VEGF stimulation is sufficient to cause cerebrovascular dysplasia in the adult mouse. Cerebrovasc Dis 2012; 33:540-7. [PMID: 22571958 PMCID: PMC3569027 DOI: 10.1159/000337762] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 03/05/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) represent a high risk for hemorrhagic stroke, leading to significant neurological morbidity and mortality in young adults. The etiopathogenesis of bAVM remains unclear. Research progress has been hampered by the lack of animal models. Hereditary Hemorrhagic Telangiectasia (HHT) patients with haploinsufficiency of endoglin (ENG, HHT1) or activin receptor-like kinase 1 (ALK1, HHT2) have a higher incidence of bAVM than the general population. We previously induced cerebrovascular dysplasia in the adult mouse that resembles human bAVM through Alk1 deletion plus vascular endothelial growth factor (VEGF) stimulation. We hypothesized that Eng deletion plus VEGF stimulation would induce a similar degree of cerebrovascular dysplasia as the Alk1-deleted brain. METHODS Ad-Cre (an adenoviral vector expressing Cre recombinase) and AAV-VEGF (an adeno-associated viral vector expressing VEGF) were co-injected into the basal ganglia of 8- to 10-week-old Eng(2f/2f) (exons 5 and 6 flanked by loxP sequences), Alk1(2f/2f) (exons 4-6 flanked by loxP sequences) and wild-type (WT) mice. Vascular density, dysplasia index, and gene deletion efficiency were analyzed 8 weeks later. RESULTS AAV-VEGF induced a similar degree of angiogenesis in the brain with or without Alk1- or Eng-deletion. Abnormally patterned and dilated dysplastic vessels were found in the viral vector-injected region of Alk1(2f/2f) and Eng(2f/2f) brain sections, but not in WT. Alk1(2f/2f) mice had about 1.8-fold higher dysplasia index than Eng(2f/2f) mice (4.6 ± 1.9 vs. 2.5 ± 1.1, p < 0.05). However, after normalization of the dysplasia index with the gene deletion efficiency (Alk1(2f/2f): 16% and Eng(2f/2f): 1%), we found that about 8-fold higher dysplasia was induced per copy of Eng deletion (2.5) than that of Alk1 deletion (0.3). ENG-negative endothelial cells were detected in the Ad-Cre-treated brain of Eng(2f/2f) mice, suggesting homozygous deletion of Eng in the cells. VEGF induced more severe vascular dysplasia in the Ad-Cre-treated brain of Eng(2f/2f) mice than that of Eng(+/-) mice. CONCLUSIONS (1) Deletion of Eng induces more severe cerebrovascular dysplasia per copy than that of Alk1 upon VEGF stimulation. (2) Homozygous deletion of Eng with angiogenic stimulation may be a promising strategy for development of a bAVM mouse model. (3) The endothelial cells that have homozygous causal gene deletion in AVM could be crucial for lesion development.
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Affiliation(s)
- Eun-Jung Choi
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Espen J. Walker
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Fanxia Shen
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - S. Paul Oh
- Shands Cancer Center, Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL, USA
| | - Helen M. Arthur
- Institute of Human Genetics, International Centre for Life, Newcastle University, Newcastle, United Kingdom
| | - William L. Young
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
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Discussion: Extracranial Arteriovenous Malformations: Natural Progression and Recurrence after Treatment. Plast Reconstr Surg 2010; 125:1195-1196. [DOI: 10.1097/prs.0b013e3181d18262] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Su H, Kim H, Pawlikowska L, Kitamura H, Shen F, Cambier S, Markovics J, Lawton MT, Sidney S, Bollen AW, Kwok PY, Reichardt L, Young WL, Yang GY, Nishimura SL. Reduced expression of integrin alphavbeta8 is associated with brain arteriovenous malformation pathogenesis. THE AMERICAN JOURNAL OF PATHOLOGY 2009; 176:1018-27. [PMID: 20019187 DOI: 10.2353/ajpath.2010.090453] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Brain arteriovenous malformations (BAVMs) are a rare but potentially devastating hemorrhagic disease. Transforming growth factor-beta signaling is required for proper vessel development, and defective transforming growth factor-beta superfamily signaling has been implicated in BAVM pathogenesis. We hypothesized that expression of the transforming growth factor-beta activating integrin, alphavbeta8, is reduced in BAVMs and that decreased beta8 expression leads to defective neoangiogenesis. We determined that beta8 protein expression in perivascular astrocytes was reduced in human BAVM lesional tissue compared with controls and that the angiogenic response to focal vascular endothelial growth factor stimulation in adult mouse brains with local Cre-mediated deletion of itgb8 and smad4 led to vascular dysplasia in newly formed blood vessels. In addition, common genetic variants in ITGB8 were associated with BAVM susceptibility, and ITGB8 genotypes associated with increased risk of BAVMs correlated with decreased beta8 immunostaining in BAVM tissue. These three lines of evidence from human studies and a mouse model suggest that reduced expression of integrin beta8 may be involved in the pathogenesis of sporadic BAVMs.
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Affiliation(s)
- Hua Su
- Center of Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA 94110, USA
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Pavesi G, Rustemi O, Berlucchi S, Frigo AC, Gerunda V, Scienza R. Acute surgical removal of low-grade (Spetzler-Martin I-II) bleeding arteriovenous malformations. ACTA ACUST UNITED AC 2009; 72:662-7. [DOI: 10.1016/j.surneu.2009.03.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
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Leblanc GG, Golanov E, Awad IA, Young WL. Biology of vascular malformations of the brain. Stroke 2009; 40:e694-702. [PMID: 19834013 DOI: 10.1161/strokeaha.109.563692] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE This review discusses recent research on the genetic, molecular, cellular, and developmental mechanisms underlying the etiology of vascular malformations of the brain (VMBs), including cerebral cavernous malformation, sporadic brain arteriovenous malformation, and the arteriovenous malformations of hereditary hemorrhagic telangiectasia. Summary of Review- The identification of gene mutations and genetic risk factors associated with cerebral cavernous malformation, hereditary hemorrhagic telangiectasia, and sporadic arteriovenous malformation has enabled the development of animal models for these diseases and provided new insights into their etiology. All of the genes associated with VMBs to date have known or plausible roles in angiogenesis and vascular remodeling. Recent work suggests that the angiogenic process most severely disrupted by VMB gene mutation is that of vascular stabilization, the process whereby vascular endothelial cells form capillary tubes, strengthen their intercellular junctions, and recruit smooth muscle cells to the vessel wall. In addition, there is now good evidence that in some cases, cerebral cavernous malformation lesion formation involves a genetic 2-hit mechanism in which a germline mutation in one copy of a cerebral cavernous malformation gene is followed by a somatic mutation in the other copy. There is also increasing evidence that environmental second hits can produce lesions when there is a mutation to a single allele of a VMB gene. CONCLUSIONS Recent findings begin to explain how mutations in VMB genes render vessels vulnerable to rupture when challenged with other inauspicious genetic or environmental factors and have suggested candidate therapeutics. Understanding of the cellular mechanisms of VMB formation and progression in humans has lagged behind that in animal models. New knowledge of lesion biology will spur new translational work. Several well-established clinical and genetic database efforts are already in place, and further progress will be facilitated by collaborative expansion and standardization of these.
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Affiliation(s)
- Gabrielle G Leblanc
- National Institute of Neurological Disorders and Stroke, Bethesda, Md., USA.
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Chen Y, Hao Q, Kim H, Su H, Letarte M, Karumanchi SA, Lawton MT, Barbaro NM, Yang GY, Young WL. Soluble endoglin modulates aberrant cerebral vascular remodeling. Ann Neurol 2009; 66:19-27. [PMID: 19670444 DOI: 10.1002/ana.21710] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) are an important cause of neurological morbidity in young adults. The pathophysiology of these lesions is poorly understood. A soluble form of endoglin (sEng) has been shown to cause endothelial dysfunction and induce preeclampsia. We tested if sEng would be elevated in brain AVM tissues relative to epilepsy brain tissues, and also investigated whether sEng overexpression via gene transfer in the mouse brain would induce vascular dysplasia and associated changes in downstream signaling pathways. METHODS Expression levels of sEng in surgical specimens were determined by Western blot assay and enzyme-linked immunosorbent assay. Vascular dysplasia, levels of matrix metalloproteinase (MMP), and oxidative stress were determined by immunohistochemistry and gelatin zymography. RESULTS Brain AVMs (n = 33) had higher mean sEng levels (245 +/- 175 vs 100 +/- 60, % of control, p = 0.04) compared with controls (n = 8), as determined by Western blot. In contrast, membrane-bound Eng was not significantly different (108 +/- 79 vs 100 +/- 63, % of control, p = 0.95). sEng gene transduction in the mouse brain induced abnormal vascular structures. It also increased MMP activity by 490 +/- 30% (MMP-9) and 220 +/- 30% (MMP-2), and oxidants by 260 +/- 20% (4-hydroxy-2-nonenal) at 2 weeks after injection, suggesting that MMPs and oxidative radicals may mediate sEng-induced pathological vascular remodeling. INTERPRETATION The results suggest that elevated sEng may play a role in the generation of sporadic brain AVMs. Our findings may provide new targets for therapeutic intervention for patients with brain AVMs. Ann Neurol 2009;66:19-27.
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Affiliation(s)
- Yongmei Chen
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, CA, USA
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Achrol AS, Guzman R, Varga M, Adler JR, Steinberg GK, Chang SD. Pathogenesis and radiobiology of brain arteriovenous malformations: implications for risk stratification in natural history and posttreatment course. Neurosurg Focus 2009; 26:E9. [PMID: 19409010 DOI: 10.3171/2009.2.focus0926] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Brain arteriovenous malformations (BAVMs) are an important cause of intracerebral hemorrhage (ICH) in young adults. Biological predictors of future ICH risk are lacking, and controversy exists over previous studies of natural history risk among predominantly ruptured BAVM cohorts. Recent studies have suggested that the majority of BAVMs are now diagnosed as unruptured lesions, and that the risk according to natural history among these lesions may be less than previously assumed. In the first part of this review, the authors discuss available data on the natural history of BAVMs and highlight the need for future studies that aim to develop surrogate biomarkers of disease progression that accurately predict future risk of ICH in BAVMs. The etiology of BAVM remains unknown. Recent studies have suggested a role for genetic factors in the pathogenesis of sporadic BAVM, which is further supported by reports of familial occurrence of BAVM and association with known systemic genetic disorders (such as Osler-Weber-Rendu disease, Sturge-Weber disease, and Wyburn-Mason syndrome). Molecular characterization of BAVM tissue demonstrates a highly angiogenic milieu with evidence of increased endothelial cell turnover. Taken together with a number of reports of de novo BAVM formation, radiographic growth after initial BAVM diagnosis, and regrowth after successful treatment of BAVM, these findings challenge the long-held assumption that BAVMs are static lesions of congenital origin. In the second part of this review, the authors discuss available data on the origins of BAVM and offer insights into future investigations into genetics and endothelial progenitor cell involvement in the pathogenesis of BAVM. Current treatment options for BAVM focus on removal or obliteration of the lesion in an attempt to protect against future ICH risk, including microsurgical resection, endovascular embolization, and stereotactic radiosurgery (SRS). In the third part of this review, the authors discuss available data on SRS in BAVMs and highlight the need for future studies on the radiobiology of BAVMs, especially in regard to biomarker detection for tracking SRS response during the latency period. Insights from future investigations in BAVM may not only prove important for the development of novel therapies and relevant biomarkers for BAVM, but could also potentially benefit a variety of other disorders involving new vessel formation in the CNS, including stroke, tumors, moyamoya disease, and other cerebrovascular malformations.
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Affiliation(s)
- Achal S Achrol
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5487, USA
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Pathophysiology and treatment of brain AVMs. ACTA ACUST UNITED AC 2009; 19:82-90. [PMID: 19636681 DOI: 10.1007/s00062-009-8035-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 11/09/2008] [Indexed: 10/20/2022]
Abstract
Cerebral arteriovenous malformations (AVMs) are a major source of intracerebral hemorrhage in younger adults. First, some basic ideas about AVM anatomy, the influences of pressure, macrovascular flow, perfusion and the "steal effect", and some recent observations in the field of inflammatory markers and genetics are briefly discussed. Then, some clinical aspects in the presentation and the natural course of AVMs are highlighted, with special emphasis on the prediction of hemorrhage. Finally, some problems of the current treatment options are mentioned, and future directions in diagnostics and therapy considered.
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43
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Moftakhar P, Hauptman JS, Malkasian D, Martin NA. Cerebral arteriovenous malformations. Part 2: physiology. Neurosurg Focus 2009; 26:E11. [PMID: 19408989 DOI: 10.3171/2009.2.focus09317] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe scientific understanding of the nature of arteriovenous malformations (AVMs) in the brain is evolving. It is clear from current work that AVMs can undergo a variety of phenomena, including growth, remodeling, and/or regression—and the responsible processes are both molecular and physiological. A review of these complex processes is critical to directing future therapeutic approaches. The authors performed a comprehensive review of the literature to evaluate current information regarding the genetics, pathophysiology, and behavior of AVMs.MethodsA comprehensive literature review was conducted using PubMed to reveal the angioarchitecture and cerebral hemodynamics of AVMS as they relate to lesion development.ResultsFeeding artery pressures, brain AVM compartmentalization, venous drainage, flow phenomena, and vascular steal are discussed.ConclusionsThe dynamic nature of brain AVMs is at least in part attributable to hemodynamic and flow-related phenomena. These forces acting on an evolving structure are critical to understanding the challenges in endovascular and surgical therapy. As knowledge in this field continues to progress, the natural history and predicted behavior of these AVMs will become more clearly elucidated.
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Affiliation(s)
| | - Jason S. Hauptman
- 2Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Dennis Malkasian
- 2Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Neil A. Martin
- 2Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, California
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Fiehler J, Illies T, Piening M, Säring D, Forkert N, Regelsberger J, Grzyska U, Handels H, Byrne JV. Territorial and microvascular perfusion impairment in brain arteriovenous malformations. AJNR Am J Neuroradiol 2009; 30:356-61. [PMID: 19001537 DOI: 10.3174/ajnr.a1351] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Both the existence and clinical relevance of a steal phenomenon in brain arteriovenous malformations (AVMs) remains a matter of debate. This study aimed to assess perfusion in the brain adjacent to brain AVMs and to relate these to macrovascular blood flow in a single measurement. MATERIALS AND METHODS Twenty consecutive patients with AVMs with a median age of 37 years were evaluated by 3T MR imaging by using 3D time-resolved MR angiography to determine blood flow and perfusion patterns. Cerebral perfusion was estimated by using an arterial spin-labeling technique in vascular territories around the nidus and in symmetric regions of interest in the ipsilateral and contralateral hemispheres. Mapping of concentric shells around the nidus was used to define the immediate and adjacent brain and relative perfusion reductions >20% of baseline, termed perinidal dip (PND). RESULTS A significant reduction in perfusion ratios between ipsilateral and contralateral hemispheres remote to the AVMs was demonstrated in the middle and posterior cerebral artery territories. PND was detected in 5 patients, and 17 patients overall showed reduced perfusion in the perinidal region on visual inspection. There was a negative correlation of the hemispheric territorial perfusion with the affected/nonaffected inflow time ratio (R = -0.402, P = .015). CONCLUSIONS The perfusion impairment in vascular territories adjacent to brain AVMs that we identified as PND may reflect the existence of 2 levels of perfusion impairment: a territorial and a microvascular perfusion disturbance. Although the hemispheric asymmetry in territorial perfusion seems the result of arterioarterial redistribution, the PND was inhomogeneously distributed within a single vascular territory and thus might result from low perfusion pressure in small arteries and arterioles.
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Affiliation(s)
- J Fiehler
- Department of Neuroradiology, University Medical Center Hamburg, Hamburg, Germany.
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Hashimoto N, Nozaki K, Takagi Y, Kikuta KI, Mikuni N. Surgery of cerebral arteriovenous malformations. Neurosurgery 2008; 61:375-87; discussion 387-9. [PMID: 18813152 DOI: 10.1227/01.neu.0000255491.95944.eb] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite remarkable progress, the microsurgical extirpation of cerebral arteriovenous malformations (AVMs) even by experienced neurosurgeons is not always easy or safe. This article focuses on how to render AVM surgery safer, and offers strategies and tactics for avoiding perilous bleeding and preserving postoperative neurological function. Our treatment strategies and surgical techniques are offered from the operating surgeon's perspective. An understanding of pathophysiology of cerebral AVMs is important for their appropriate surgical treatment. Sophisticated neuroimaging techniques and scrupulous neurophysiological examinations alert to possible complications, and improved surgical approaches help to minimize the sequelae of unanticipated complications. At the early stage of cerebral AVM surgery, extensive dissection of the sulci, fissures, and subarachnoid cistern should be performed to expose feeders, nidus, and drainers. Problems with the surgery of large and/or deep-seated lesions are exacerbated when arterial bleeding from the nidus continues even after all major feeders are thought to have been occluded. We routinely place catheters for angiography at the surgery of complex AVMs to find missing feeding arteries or to identify the real-time hemodynamic status of the lesion. Temporary clip application on feeders and less coagulation of the nidus is necessary to control intranidal pressure and to avoid uncontrollable bleeding from the nidus and adjacent brain. Intraoperative navigation images superimposed on tractography images can provide us with valuable information to minimize neurological deficits. Deeper insight into AVM nature and into events that occur during AVM surgery as well as the inclusion of molecular biological approaches will open new horizons for the safe and effective treatment of AVMs.
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Affiliation(s)
- Nobuo Hashimoto
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan.
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Xie Q, Chen XC, Gong Y, Gu YX. Leptin plays a role in ruptured human brain arteriovenous malformations. ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 105:221-224. [PMID: 19066113 DOI: 10.1007/978-3-211-09469-3_42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is one of the most common clinical manifestations of human brain arteriovenous malformation (BAVM). However, the hemorrhagic mechanism of BAVM is still unclear. Leptin, first discovered in obesity research, has not been systematically studied in BAVM and ICH. We investigated expression and effect of leptin on human BAVM. METHODS Specimens were obtained from 6 BAVM patients, who had been divided into either hemorrhagic or non-hemorrhagic groups. Leptin, leptin receptor, and signal transducers and activators of transcription-3 (STAT3) were analyzed by different methods, such as gene chips, reverse transcription-polymerase chain reaction (RT-PCR), immunohistochemistry, and Western blot. Perinidal brain tissue around each BAVM served as control. RESULTS Gene chips and RT-PCR found transcriptional leptin raised at least 2 levels in hemorrhagic BAVM. Immunohistochemical slices also showed higher expression of leptin, leptin receptor, and STAT3 on nidus part of hemorrhagic BAVM than non-hemorrhagic ones. On Western blot analysis, hemorrhagic BAVMs had higher levels of leptin (p < 0.01). CONCLUSIONS The transcriptional and translational levels of leptin, leptin receptor, and STAT3 were higher in hemorrhagic BAVM, suggesting that leptin may play an important role in the hemorrhagic mechanism of BAVM.
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Affiliation(s)
- Q Xie
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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Du R, Keyoung HM, Dowd CF, Young WL, Lawton MT. The effects of diffuseness and deep perforating artery supply on outcomes after microsurgical resection of brain arteriovenous malformations. Neurosurgery 2007; 60:638-46; discussion 646-8. [PMID: 17415200 DOI: 10.1227/01.neu.0000255401.46151.8a] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Diffuse arteriovenous malformations (AVM) have non-compact niduses, irregular margins, and intervening brain parenchyma. Deep perforating arteries often contribute to the ragged border of these diffuse AVMs. We hypothesized that diffuseness and deep perforator supply increase the difficulties and risks associated with microsurgical AVM resection. METHODS Diffuseness was quantified using computer-generated outlines of AVMs on angiograms, contour plots with varying image intensities, and calculations of nidus area-intensity profiles. Diffuse AVMs had nonlinear area-intensity profiles with high transition intensities ([I*] greater than 0.5). A consecutive series of 304 patients who were treated with microsurgical AVM resection over a period of 7.8 years was analyzed, along with quantification of diffuseness in a subset of 103 consecutive patients. Neurological outcomes were assessed by using the Modified Rankin Scale, and logistic regression analysis was used to identify predictors of deterioration and poor outcome at late follow-up evaluation. RESULTS Diffuse niduses were observed in 25% of patients, and 18% of patients had deep perforating artery supply. Patients with compact AVMs were more likely to have good outcomes or overall improvement (88 and 87%, respectively) than patients with diffuse AVMs (65 and 54%, respectively) (P = 0.008 and P < 0.001, respectively). Similarly, absence of deep perforator supply was associated with good outcomes or improvement in 85 and 78% of patients, respectively, compared with 63 and 64% of patients, respectively, in patients with deep perforator supply (P < 0.001 and P = 0.028, respectively). By logistic regression analysis, diffuseness and deep perforator supply were both associated with significant increases in surgical risk. CONCLUSION Diffuseness and deep perforating artery supply are subtle features of an AVM that predict worse outcomes after microsurgical resection. Diffuseness makes surgical planes more difficult to determine and follow, whereas deep perforators are friable, poorly visualized, and located in eloquent white matter tracts. The Spetzler-Martin grading scale does not directly account for these two features; however, they should be considered carefully when making treatment recommendations to patients with AVMs.
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Affiliation(s)
- Rose Du
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0112, USA
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Tu J, Stoodley MA, Morgan MK, Storer KP. Ultrastructure of Perinidal Capillaries in Cerebral Arteriovenous Malformations. Neurosurgery 2006; 58:961-70; discussion 961-70. [PMID: 16639333 DOI: 10.1227/01.neu.0000210248.39504.b5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE The ultrastructure of perinidal capillaries in cerebral arteriovenous malformations (AVMs) was examined to clarify their pathomorphological features. METHODS Fifteen AVM specimens were dissected and divided into perinidal and intranidal groups and processed for ultrastructural study immediately after surgical removal. Eleven of the patients had presented with hemorrhage. Tissue from four normal controls was also studied. Electron microscopy was used to compare features of the blood-brain barrier and endothelial cells (ECs) of capillaries in perinidal, intranidal, and controls. RESULTS Perinidal capillaries demonstrated abnormal ultrastructure of the blood-brain barrier with no basement membranes and astrocytic foot processes. ECs had fenestrated luminal surfaces. Large gaps were observed at endothelial intercellular junctions. ECs contained numerous filopodia, large numbers of cytoplasmic processes, numerous micropinocytotic vesicles, and the cytoplasm contained more filaments than those observed in controls. Pericytes were rich in pinocytotic vesicles, vacuoles, and filaments. Their processes were in close contact with ECs. Weibel-Palade bodies were present in perinidal ECs. CONCLUSION The absence of blood-brain barrier components in perinidal capillaries may contribute to extravasation of red blood cells into the surrounding brain in the absence of major hemorrhage and explain the gliosis and hemosiderin occasionally seen around AVMs. Cellular differentiation and proliferation in perinidal capillaries should be included in a systematic study aimed at a better understanding of the mechanisms underlying the recurrence of surgically removed AVMs.
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Affiliation(s)
- Jian Tu
- Prince of Wales Medical Research Institute, University of New South Wales, New South Wales, Australia
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