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Hou X, Liang F, Li J, Yang Y, Wang C, Qi T, Sheng W. Mapping cell diversity in human sporadic cerebral cavernous malformations. Gene 2024; 924:148605. [PMID: 38788816 DOI: 10.1016/j.gene.2024.148605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/12/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Cerebral cavernous malformation (CCM) is a low-flow, bleeding-prone vascular disease that can cause cerebral hemorrhage, seizure and neurological deficits. Its inheritance mode includes sporadic or autosomal dominant inheritance with incomplete penetrance, namely sporadic CCM (SCCM) and familial CCM. SCCM is featured by single lesion and single affection in a family. Among CCM patients especially SCCM, the pathogenesis of the corresponding phenotypes and pathological features or candidate genes have not been fully elucidated yet. METHODS Here, we performed in-depth single-cell RNA sequencing (scRNA-Seq) and bulk assay for transposase-accessible chromatin sequencing (ATAC-Seq) in SCCM and control patients. Further validation was conducted for the gene of interest using qPCR and RNA in situ hybridization (RNA FISH) techniques to provide further atlas and evidence for SCCM generative process. RESULTS We identified six cell types in the SCCM and control vessels and found that the expression of NEK1, RNPC3, FBRSL1, IQGAP2, MCUB, AP3B1, ESCO1, MYO9B and PVT1 were up-regulated in SCCM tissues. Among the six cell types, we found that compared with control conditions, PVT1 showed a rising peak which followed the pseudo-time axis in endothelial cell clusters of SCCM samples, while showed an increasing trend in smooth muscle cell clusters of SCCM samples. Further experiments indicated that, compared with the control vessels, PVT1 exhibited significantly elevated expression in SCCM samples. CONCLUSION In SCCM conditions, We found that in the process of development from control to lesion conditions, PVT1 showed a rising peak in endothelial cells and showed an increasing trend in smooth muscle cells at the same time. Overall, there was a significantly elevated expression of NEK1, RNPC3, FBRSL1, IQGAP2, MCUB, AP3B1, ESCO1, MYO9B and PVT1 in SCCM specimens compared to control samples.
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Affiliation(s)
- Xiaocan Hou
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Feng Liang
- Department of Neurosurgery, The First Affiliated Hospital, Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Jiaoxing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Yibing Yang
- Department of Neurosurgery, The First Affiliated Hospital, Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Chuhuai Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, China.
| | - Tiewei Qi
- Department of Neurosurgery, The First Affiliated Hospital, Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, China.
| | - Wenli Sheng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China.
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Li C, Huang S, Li Q, Zhuo L, Kang Y, Liu P, Huang W, Ma K, Lin X, Zhuang W, Chen D, Wang H, Yan L, Wang D, Lin Y, Kang D, Lin F. Plasma biomarkers in patients with familial cavernous malformation and their first-degree relatives. RESEARCH SQUARE 2024:rs.3.rs-4545797. [PMID: 39011103 PMCID: PMC11247933 DOI: 10.21203/rs.3.rs-4545797/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Background We aimed to explore the differences in plasma biomarker levels between patients with familial cerebral cavernous malformations (FCCM) and their healthy first-degree relatives (FDRs) and between FCCM patients with and without severe chronic disease aggressiveness (CDA). Methods Magnetic resonance imaging (MRI) scanning and genetic testing was performed in patients with multiple CCMs and their FDRs. Sixty-seven plasma biomarkers were tested using a customised multiplex bead immunoassay kit. Univariate and multivariate unconditional logistic regression analyses were conducted to determine the associations between plasma factors and the risk of developing FCCM and severe CDA. Receiver operating characteristic (ROC) curves were generated for each independent risk factor. Results Plasma factors of 37 patients with FCCM and 37 FDRs were examined. Low CD31 (P < 0.001) and BDNF levels (P = 0.013) were independent risk factors for FCCM. The best model was achieved by combining the results of CD31 and BDNF (AUC = 0.845, sensitivity 0.838, specificity 0.784, cutoff score - 4.295) to distinguish patients with FCCM from healthy FDRs. Low serpin E1/PAI-1 (P = 0.011) and high ROBO4 levels (P = 0.013) were independent risk factors for severe CDA in patients with FCCM. The best model was achieved by combining the results of E1/PAI-1 and ROBO4 levels (AUC = 0.913, sensitivity 1.000, specificity 0.760, cutoff score - 0.525) to identify patients with FCCM and severe CDA. Conclusions The plasma concentrations of CD31 and BDNF seem to be lower in patients with FCCM than in their healthy FDRs. Low serpin E1/PAI-1 and high ROBO4 concentrations may be correlated with high lesion burden and risk of recurrent bleeding.
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Affiliation(s)
- Chunwang Li
- First Affiliated Hospital of Fujian Medical University
| | - Shuna Huang
- First Affiliated Hospital of Fujian Medical University
| | - Qixuan Li
- First Affiliated Hospital of Fujian Medical University
| | - Lingyun Zhuo
- First Affiliated Hospital of Fujian Medical University
| | - Yaqing Kang
- First Affiliated Hospital of Fujian Medical University
| | - Penghui Liu
- First Affiliated Hospital of Fujian Medical University
| | - Weilin Huang
- First Affiliated Hospital of Fujian Medical University
| | - Ke Ma
- First Affiliated Hospital of Fujian Medical University
| | - Xinru Lin
- First Affiliated Hospital of Fujian Medical University
| | | | - Darong Chen
- First Affiliated Hospital of Fujian Medical University
| | - Huimin Wang
- First Affiliated Hospital of Fujian Medical University
| | - Lingjun Yan
- First Affiliated Hospital of Fujian Medical University
| | | | - Yuanxiang Lin
- First Affiliated Hospital of Fujian Medical University
| | - Dezhi Kang
- First Affiliated Hospital of Fujian Medical University
| | - Fuxin Lin
- First Affiliated Hospital of Fujian Medical University
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Bosisio L, Cognolato E, Nobile G, Mancardi MM, Nobili L, Pacetti M, Piatelli G, Giacomini T, Calevo MG, Fragola M, Venanzi MS, Consales A. Surgical treatment of cavernous malformation-related epilepsy in children: case series, systematic review, and meta-analysis. Neurosurg Rev 2024; 47:251. [PMID: 38819574 DOI: 10.1007/s10143-024-02491-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCMs) are cerebral vascular lesions that occasionally occur with seizures. We present a retrospective case series from IRCCS Gaslini Children's Hospital, a systematic review, and meta-analysis of the literature with the goal of elucidating the post-surgery seizure outcome in children with CCMs. METHODS a retrospective review of children with cavernous malformation related epilepsy who underwent surgery at Gaslini Children's Hospital from 2005 to 2022 was conducted. We also conducted a comprehensive search on PubMed/MEDLINE and Scopus databases from January 1989 to August 2022. Inclusion criteria were: presence of CCMs-related epilepsy, in under 18 years old subjects with a clear lesion site. Presence of post-surgery seizure outcome and follow-up ≥ 12 months. RESULTS we identified 30 manuscripts and 223 patients with CCMs-related epilepsy, including 17 patients reported in our series. We identified 85.7% Engel class I subjects. The risk of expected neurological deficits was 3.7%; that of unexpected neurological deficits 2.8%. We found no statistically significant correlations between Engel class and the following factors: site of lesion, type of seizure, drug resistance, duration of disease, type of surgery, presence of multiple CCMs. However, we found some interesting trends: longer disease duration and drug resistance seem to be more frequent in subjects in Engel class II, III and IV; multiple cavernomas would not seem to influence seizure outcome. CONCLUSIONS epilepsy surgery in children with CCMs is a safe and successful treatment option. Further studies are necessary to define the impact of clinical features on seizure prognosis.
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Affiliation(s)
- Luca Bosisio
- Child Neuropsychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Department of Neuroscience (DINOGMI), IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy.
| | - Erica Cognolato
- Child Neuropsychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Department of Neuroscience (DINOGMI), IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Giulia Nobile
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Child Neuropsychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Department of Neuroscience (DINOGMI), IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mattia Pacetti
- Pediatric Neurosurgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gianluca Piatelli
- Pediatric Neurosurgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thea Giacomini
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Martina Fragola
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Phi JH, Kim SK. Clinical Features and Treatment of Pediatric Cerebral Cavernous Malformations. J Korean Neurosurg Soc 2024; 67:299-307. [PMID: 38547881 PMCID: PMC11079565 DOI: 10.3340/jkns.2024.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024] Open
Abstract
Cerebral cavernous malformation (CCM) is a vascular anomaly commonly found in children and young adults. Common clinical presentations of pediatric patients with CCMs include headache, focal neurological deficits, and seizures. Approximately 40% of pediatric patients are asymptomatic. Understanding the natural history of CCM is crucial and hemorrhagic rates are higher in patients with an initial hemorrhagic presentation, whereas it is low in asymptomatic patients. There is a phenomenon known as temporal clustering in which a higher frequency of symptomatic hemorrhages occurs within a few years following the initial hemorrhagic event. Surgical resection remains the mainstay of treatment for pediatric CCMs. Excision of a hemosiderin-laden rim is controversial regarding its impact on epilepsy outcomes. Stereotactic radiosurgery is an alternative treatment, especially for deepseated CCMs, but its true efficacy needs to be verified in a clinical trial.
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Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
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Lee J, Lee H, Shin M, Park S. Cerebral Cavernous Malformation (CCM)-like Vessel Lesion in the Aged ANKS1A-deficient Brain. Exp Neurobiol 2023; 32:441-452. [PMID: 38196138 PMCID: PMC10789174 DOI: 10.5607/en23032] [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: 09/29/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
In this study, we show that ANKS1A is specifically expressed in the brain endothelial cells of adult mice. ANKS1A deficiency in adult mice does not affect the differentiation, growth, or patterning of the cerebrovascular system; however, its absence significantly impacts the cerebrovascular system of the aged brain. In aged ANKS1A knock-out (KO) brains, vessel lesions exhibiting cerebral cavernous malformations (CCMs) are observed. In addition, CCM-like lesions show localized peripheral blood leakage into the brain. The CCM-like lesions reveal immune cells infiltrating the parenchyma. The CCM-like lesions also contain significantly fewer astrocyte endfeets and tight junctions, indicating that the integrity of the BBB has been partially compromised. CCM-like lesions display increased fibronectin expression in blood vessels, which is also confirmed in cultured endothelial cells deficient for ANKS1A. Therefore, we hypothesize that ANKS1A may play a role in maintaining or stabilizing healthy blood vessels in the brain during aging.
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Affiliation(s)
- Jiyeon Lee
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| | - Haeryung Lee
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| | - Miram Shin
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| | - Soochul Park
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
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Tasiou A, Brotis AG, Kalogeras A, Tzerefos C. Cavernous malformations of the central nervous system: An international consensus statement. BRAIN & SPINE 2023; 3:102707. [PMID: 38020995 PMCID: PMC10668094 DOI: 10.1016/j.bas.2023.102707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/19/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial. Research question A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs. Material and methods A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%. Results A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases. Discussion and conclusion Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros G. Brotis
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Adamantios Kalogeras
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Flemming KD, Lanzino G. Are there differences in clinical presentation, radiologic findings, and outcomes in female patients with cavernous malformation? Acta Neurochir (Wien) 2023:10.1007/s00701-023-05652-0. [PMID: 37306819 DOI: 10.1007/s00701-023-05652-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/29/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Little data exist regarding sex differences in cavernous malformations (CM) patients. METHODS From an ongoing, prospective registry of consenting adults with CM, we assessed the differences between male and female patients in regard to age at presentation, type of presentation, radiologic characteristics and prospective, symptomatic hemorrhage and or focal neurologic deficit (FND) risk and functional outcome. Cox proportional-hazard ratios and 95% confidence intervals with P values < 0.05 were considered significant in the outcome analysis. Familial form CM female patients were compared to sporadic form. RESULTS As of 1/1/2023, our cohort comprised 386 people (58.0% female) after excluding radiation-induced CM. There were no demographic or clinical presentation differences between male and female patients. Radiological features did not differ between sexes, except that female, sporadic patients were more likely to have an associated developmental venous anomaly (DVA) (43.2% male vs. 56.2% female; p = 0.03). Overall, there was no difference in prospective symptomatic hemorrhage or functional outcome between sexes. Female sex was a predictor of symptomatic hemorrhage or FND in sporadic patients with ruptured CM (39.6% males versus 65.7% females; p = 0.02). The latter was not due to presence or absence of DVA. Familial CM females were more likely to have a spinal cord CM (15.2% familial female vs. 3.9% sporadic female; p = 0.001) and had a longer time to recurrent hemorrhage than sporadic female (2.2 years sporadic vs. 8.2 years familial; p = 0.0006). CONCLUSION Minimal differences in clinical, radiologic, and outcomes were found in male versus female patients and familial versus sporadic females in the overall CM patient group. The finding that sporadic form female patients with history of prior hemorrhage had increased rates of prospective hemorrhage or FND compared to male patients raise the question whether to "lump" or "split" ruptured versus unruptured CM patients when analyzing risk factors for prospective hemorrhage in natural history studies.
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Fisher DG, Sharifi KA, Ulutas EZ, Kumar JS, Kalani MYS, Miller GW, Price RJ, Tvrdik P. Magnetic Resonance Imaging of Mouse Cerebral Cavernomas Reveal Differential Lesion Progression and Variable Permeability to Gadolinium. Arterioscler Thromb Vasc Biol 2023; 43:958-970. [PMID: 37078284 PMCID: PMC10257814 DOI: 10.1161/atvbaha.122.318938] [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: 12/23/2022] [Accepted: 04/04/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Cerebral cavernous malformations, also known as cavernous angiomas, are blood vessel abnormalities comprised of clusters of grossly enlarged and hemorrhage-prone capillaries. The prevalence in the general population, including asymptomatic cases, is estimated to be 0.5%. Some patients develop severe symptoms, including seizures and focal neurological deficits, whereas others remain asymptomatic. The causes of this remarkable presentation heterogeneity within a primarily monogenic disease remain poorly understood. METHODS We established a chronic mouse model of cerebral cavernous malformations, induced by postnatal ablation of Krit1 with Pdgfb-CreERT2, and examined lesion progression in these mice with T2-weighted 7T magnetic resonance imaging (MRI). We also established a modified protocol for dynamic contrast-enhanced MRI and produced quantitative maps of gadolinium tracer gadobenate dimeglumine. After terminal imaging, brain slices were stained with antibodies against microglia, astrocytes, and endothelial cells. RESULTS These mice develop cerebral cavernous malformations lesions gradually over 4 to 5 months of age throughout the brain. Precise volumetric analysis of individual lesions revealed nonmonotonous behavior, with some lesions temporarily growing smaller. However, the cumulative lesional volume invariably increased over time and after about 2 months followed a power trend. Using dynamic contrast-enhanced MRI, we produced quantitative maps of gadolinium in the lesions, indicating a high degree of heterogeneity in lesional permeability. MRI properties of the lesions were correlated with cellular markers for endothelial cells, astrocytes, and microglia. Multivariate comparisons of MRI properties of the lesions with cellular markers for endothelial and glial cells revealed that increased cell density surrounding lesions correlates with stability, whereas denser vasculature within and surrounding the lesions may correlate with high permeability. CONCLUSIONS Our results lay a foundation for better understanding individual lesion properties and provide a comprehensive preclinical platform for testing new drug and gene therapies for controlling cerebral cavernous malformations.
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Affiliation(s)
- Delaney G. Fisher
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Khadijeh A. Sharifi
- Department of Neuroscience, University of Virginia, Charlottesville, VA
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - E. Zeynep Ulutas
- Department of Neuroscience, Georgia Institute of Technology, Atlanta, GA
| | - Jeyan S. Kumar
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | | | - G. Wilson Miller
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA
| | - Richard J. Price
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Petr Tvrdik
- Department of Neuroscience, University of Virginia, Charlottesville, VA
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
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Qi C, Bujaroski RS, Baell J, Zheng X. Kinases in cerebral cavernous malformations: Pathogenesis and therapeutic targets. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2023; 1870:119488. [PMID: 37209718 DOI: 10.1016/j.bbamcr.2023.119488] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/03/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
Cerebral cavernous malformations (CCMs) are low-flow, hemorrhagic vascular lesions of the central nervous system of genetic origin, which can cause stroke-like symptoms and seizures. From the identification of CCM1, CCM2 and CCM3 as genes related to disease progression, molecular and cellular mechanisms for CCM pathogenesis have been established and the search for potential drugs to target CCM has begun. Broadly speaking, kinases are the major group signaling in CCM pathogenesis. These include the MEKK3/MEK5/ERK5 cascade, Rho/Rock signaling, CCM3/GCKIII signaling, PI3K/mTOR signaling, and others. Since the discovery of Rho/Rock in CCM pathogenesis, inhibitors for Rho signaling and subsequently other components in CCM signaling were discovered and applied in preclinical and clinical trials to ameliorate CCM progression. This review discusses the general aspects of CCM disease, kinase-mediated signaling in CCM pathogenesis and the current state of potential treatment options for CCM. It is suggested that kinase target drug development in the context of CCM might facilitate and meet the unmet requirement - a non-surgical option for CCM disease.
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Affiliation(s)
- Chunxiao Qi
- Department of Pharmacology and Tianjin Key Laboratory of Inflammation Biology, School of Basic Medical Sciences, Tianjin Medical University, 300070, China
| | - Richard Sean Bujaroski
- Medicinal Chemistry Theme, Monash Institute of Pharmaceutical Sciences, Australian Translational Medicinal Chemistry Facility (ATMCF), Monash University, Parkville, Victoria, Australia
| | - Jonathan Baell
- School of Pharmaceutical Sciences, Nanjing Tech University, No. 30 South Puzhu Road, Nanjing 211816, China
| | - Xiangjian Zheng
- Department of Pharmacology and Tianjin Key Laboratory of Inflammation Biology, School of Basic Medical Sciences, Tianjin Medical University, 300070, China.
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Huo R, Yang Y, Sun Y, Zhou Q, Zhao S, Mo Z, Xu H, Wang J, Weng J, Jiao Y, Zhang J, He Q, Wang S, Zhao J, Wang J, Cao Y. Endothelial hyperactivation of mutant MAP3K3 induces cerebral cavernous malformation enhanced by PIK3CA GOF mutation. Angiogenesis 2023; 26:295-312. [PMID: 36719480 DOI: 10.1007/s10456-023-09866-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/18/2023] [Indexed: 02/01/2023]
Abstract
Cerebral cavernous malformations (CCMs) refer to a common vascular abnormality that affects up to 0.5% of the population. A somatic gain-of-function mutation in MAP3K3 (p.I441M) was recently reported in sporadic CCMs, frequently accompanied by somatic activating PIK3CA mutations in diseased endothelium. However, the molecular mechanisms of these driver genes remain elusive. In this study, we performed whole-exome sequencing and droplet digital polymerase chain reaction to analyze CCM lesions and the matched blood from sporadic patients. 44 of 94 cases harbored mutations in KRIT1/CCM2 or MAP3K3, of which 75% were accompanied by PIK3CA mutations (P = 0.006). AAV-BR1-mediated brain endothelial-specific MAP3K3I441M overexpression induced CCM-like lesions throughout the brain and spinal cord in adolescent mice. Interestingly, over half of lesions disappeared at adulthood. Single-cell RNA sequencing found significant enrichment of the apoptosis pathway in a subset of brain endothelial cells in MAP3K3I441M mice compared to controls. We then demonstrated that MAP3K3I441M overexpression activated p38 signaling that is associated with the apoptosis of endothelial cells in vitro and in vivo. In contrast, the mice simultaneously overexpressing PIK3CA and MAP3K3 mutations had an increased number of CCM-like lesions and maintained these lesions for a longer time compared to those with only MAP3K3I441M. Further in vitro and in vivo experiments showed that activating PI3K signaling increased proliferation and alleviated apoptosis of endothelial cells. By using AAV-BR1, we found that MAP3K3I441M mutation can provoke CCM-like lesions in mice and the activation of PI3K signaling significantly enhances and maintains these lesions, providing a preclinical model for the further mechanistic and therapeutic study of CCMs.
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Affiliation(s)
- Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yingxi Yang
- Department of Chemical and Biological Engineering, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong SAR, China
| | - Yingfan Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qiuxia Zhou
- Division of Life Science and State Key Laboratory of Molecular Neuroscience, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong SAR, China
| | - Shaozhi Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zongchao Mo
- Division of Life Science and State Key Laboratory of Molecular Neuroscience, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong SAR, China
| | - Hongyuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiancong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junze Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiguang Wang
- Department of Chemical and Biological Engineering, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong SAR, China.
- Division of Life Science and State Key Laboratory of Molecular Neuroscience, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong SAR, China.
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong Science Park, Hong Kong SAR, China.
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119S Fourth Ring Rd W, Fengtai District, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
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11
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Narita M, Miyairi Y, Motobayashi M, Chiba A, Inaba Y. Incidence of Cerebral Cavernous Malformation-Related Epilepsy in Children: A Single Center Survey. Cureus 2023; 15:e38178. [PMID: 37252508 PMCID: PMC10220326 DOI: 10.7759/cureus.38178] [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: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION Cerebral cavernous malformations (CCMs) are rare developmental cerebrovascular malformations. The risk of epilepsy is high in patients with CCMs, but the incidence of epilepsy has not been reported in a pure pediatric population. We herein present 14 pediatric cases of CCMs, including five with CCM-related epilepsy, and examine the incidence of CCM-related epilepsy in this pediatric population. Methods: Pediatric patients with CCMs who visited our Hospital between November 1, 2001, to September 31, 2020, were retrospectively screened for inclusion, and 14 were enrolled. Results: Fourteen enrolled patients were divided into two groups based on the presence or absence of CCM-related epilepsy. The "CCM-related epilepsy group" (n = 5) consisted of five males with a median age of 4.2 (range: 0.3-8.5) years at the first visit. The "non-epilepsy group" (n = 9) consisted of seven males and two females with a median age of 3.5 (range: 1.3-11.5) years at the first visit. The prevalence of CCM-related epilepsy at the time of the present analysis was 35.7%. Follow-up periods in CCM-related epilepsy and non-epilepsy groups were 19.3 and 24.9 patient-years, respectively: the incidence was 11.3% per patient-years. The frequency of seizures due to intra-CCM hemorrhage as the primary symptom was significantly higher in the CCM-related epilepsy group than in the non-CCM-related epilepsy group (p = 0.01). Other clinical characteristics, i.e., primary symptoms including vomiting/nausea and spastic paralysis, magnetic resonance imaging findings, including the number or maximum diameter of CCMs, cortical involvement, intra-CCM hemorrhage, and infratentorial lesions, surgical resection, and non-epileptic sequelae, such as motor disability and intellectual disability, did not significantly differ between the groups. Discussion: The incidence of CCM-related epilepsy in the present study was 11.3% per patient year, higher than in adults. This discrepancy may be attributed to these studies including both adult and pediatric patients, whereas the present study examined a pure pediatric population. The presence of seizures due to intra-CCM hemorrhage as the initial symptom was a risk factor for CCM-related epilepsy in the present study. To elucidate the pathophysiology of CCM-related epilepsy or the reason for its higher incidence in children than in adults, further analyses of a large number of children with CCM-related epilepsy are warranted.
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Affiliation(s)
- Masahiro Narita
- Pediatric Neurology, Nagano Children's Hospital, Azumino, JPN
| | | | | | - Akihiro Chiba
- Neurosurgery, Nagano Children's Hospital, Azumino, JPN
| | - Yuji Inaba
- Pediatric Neurology, Nagano Children's Hospital, Azumino, JPN
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12
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Goyal A, Fernandes-Torres J, Flemming KD, Williams LN, Daniels DJ. Clinical presentation, natural history, and outcomes for infantile intracranial cavernous malformations: case series and systematic review of the literature. Childs Nerv Syst 2023; 39:1545-1554. [PMID: 36917267 DOI: 10.1007/s00381-023-05903-6] [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: 01/21/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Intracranial cavernous malformations (CMs) are rare vascular malformations of the central nervous system in children. Infantile patients, being a developmentally vulnerable age group, pose a special challenge for management of these lesions. We pooled data from infantile patients diagnosed at our institution and individual cases published in the literature to provide input towards therapeutic decision-making. METHODS A systematic search of PubMed, MEDLINE, Embase, and Scopus was performed in accordance with PRISMA guidelines to identify all reported cases of intracranial CMs in the literature for infantile patients aged ≤ 2 years. In addition, cases from our institution diagnosed between 2010 and 2020 were also included. Individual cases were pooled and analyzed for clinical presentation, natural history, and outcomes from conservative and surgical management. RESULTS A total of 36 cases were included, of which 32 were identified from the literature. Median age at presentation was 14 months (range: 2 days to 24 months) months; 53% (n = 19) were females. Most cavernomas (64%, 23/36) were supratentorial, while 30% (n = 11) were located in brainstem and 5.5% (n = 2) in the cerebellum. With the exception of one patient, all cases were reported to be symptomatic; seizures (n = 15/31, 48.3%) and motor deficits (n = 13/31, 42%) were the most common symptom modalities. A total of 13 patients were managed conservatively upon initial presentation. No symptomatic hemorrhages were observed during 26 total person-years of follow-up. A total of 77% (28/36) underwent surgery; either upfront (23/28, 82%) at initial presentation or following conservative management. Among 12 patients who had preoperative seizures, 11/12 (91.6%) achieved seizure freedom post-resection. Among 7 patients who presented with hemiparesis preoperatively, 5 (71%) demonstrated some improvement, while 1 remained unchanged, and another patient with a brainstem cavernous malformation had worsening of motor function postoperatively. Postoperative recurrence was noted in 3 cases (3/27, 11%). CONCLUSION Annual risk of repeat hemorrhage may be low for infantile patients with intracranial cavernous malformations; however, better follow-up rates and higher number of cases are needed to make a definitive assertion. Surgical resection may be associated with high rates of epilepsy cure and provide improvement in neurological function in a select number of cases.
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Affiliation(s)
- Anshit Goyal
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jenelys Fernandes-Torres
- City University of New York School of Medicine, New York, NY, USA.,Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - David J Daniels
- City University of New York School of Medicine, New York, NY, USA.
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13
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Genetics of brain arteriovenous malformations and cerebral cavernous malformations. J Hum Genet 2023; 68:157-167. [PMID: 35831630 DOI: 10.1038/s10038-022-01063-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/13/2022] [Accepted: 06/26/2022] [Indexed: 11/08/2022]
Abstract
Cerebrovascular malformations comprise abnormal development of cerebral vasculature. They can result in hemorrhagic stroke due to rupture of lesions as well as seizures and neurological defects. The most common forms of cerebrovascular malformations are brain arteriovenous malformations (bAVMs) and cerebral cavernous malformations (CCMs). They occur in both sporadic and inherited forms. Rapidly evolving molecular genetic methodologies have helped to identify causative or associated genes involved in genesis of bAVMs and CCMs. In this review, we highlight the current knowledge regarding the genetic basis of these malformations.
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14
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Santos AN, Rauschenbach L, Gull HH, Dinger TF, Chihi M, Li Y, Tippelt S, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional outcome after initial and multiple intracerebral hemorrhages in children with cerebral cavernous malformations. Eur J Neurol 2023; 30:1364-1370. [PMID: 36789485 DOI: 10.1111/ene.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to assess the course and predictors of functional outcome after single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs) and to conduct a risk assessment of a third bleed during the first follow-up year after second ICH. METHODS We included patients aged ≤18 years with complete baseline characteristics, a magnetic resonance imaging dataset, ≥1 CCM-related ICH and ≥1 follow-up examination, who were treated between 2003 and 2021. Neurological functional status was obtained using modified Rankin Scale scores at diagnosis, before and after each ICH, and at last follow-up. Kaplan-Meier analysis was performed to determine the cumulative 1-year risk of third ICH. RESULTS A total of 55 pediatric patients (median [interquartile range] age 12 [11] years) were analyzed. Univariate analysis identified brainstem cavernous malformation (BSCM; p = 0.019) as a statistically significant predictor for unfavorable outcome after second ICH. Outcome after second ICH was significantly worse in 12 patients (42.9%; p = 0.030) than after first ICH and in five patients (55.6%; p = 0.038) after a third ICH compared to a second ICH. Cumulative 12-month risk of rebleeding during the first year after a second ICH was 10.7% (95% confidence interval 2.8%-29.37%). CONCLUSIONS Pediatric patients with a BSCM have a higher risk of worse outcome after second ICH. Functional outcome improves over time after an ICH but worsens following each ICH compared to baseline or previous ICH. Second bleed was associated with neurological deterioration compared to initial ICH, and this deteriorated further after a third ICH.
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Affiliation(s)
- Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Hannah Hadice Gull
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Pediatrics, University Hospital of Essen, Essen, Germany
| | | | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
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15
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Rauschenbach L, Santos AN, Dinger TF, Darkwah Oppong M, Li Y, Tippelt S, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Functional outcome after pediatric cerebral cavernous malformation surgery. Sci Rep 2023; 13:2286. [PMID: 36759693 PMCID: PMC9911771 DOI: 10.1038/s41598-023-29472-5] [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: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
The purpose of this study was to investigate the functional outcome following surgical resection of cerebral cavernous malformations (CCM) in pediatric patients. We screened our institutional database of CCM patients treated between 2003 and 2021. Inclusion regarded individuals younger or equal than 18 years of age with complete clinical baseline characteristics, magnetic resonance imaging dataset, and postoperative follow-up time of at least three months. Functional outcome was quantified using the modified Rankin Scale (mRS) score and assessed at admission, discharge, and last follow-up examination. The primary endpoint was the postoperative functional outcome. As a secondary endpoint, predictors of postoperative functional deterioration were assessed. A total of 49 pediatric patients with a mean age of 11.3 ± 5.7 years were included for subsequent analyses. Twenty individuals (40.8%) were female. Complete resection of the lesion was achieved in 44 patients (89.8%), and two patients with incomplete resection were referred for successive remnant removal. The mean follow-up time after surgery was 44 months (IQR: 13 - 131). The mean mRS score was 1.6 on admission, 1.7 at discharge, and 0.9 at the latest follow-up. Logistic regression analysis adjusted to age and sex identified brainstem localization (aOR = 53.45 [95%CI = 2.26 - 1261.81], p = .014) as a predictor of postoperative deterioration. This study indicates that CCM removal in children can be regarded as safe and favorable for the majority of patients, depending on lesion localization. Brainstem localization implies a high risk of postoperative morbidity and indication for surgery should be balanced carefully. Minor evidence indicates that second-look surgery for CCM remnants might be safe and favorable.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany. .,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany.
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences, C-TNBS, University Duisburg Essen, Essen, Germany
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16
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Xu XY, Li D, Song LR, Liu PP, Wu ZY, Wang L, Zhang LW, Zhang JT, Wu Z. Nomogram for predicting an individual prospective hemorrhage risk in untreated brainstem cavernous malformations. J Neurosurg 2022; 138:910-921. [PMID: 36152323 DOI: 10.3171/2022.8.jns221228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
In this study, the authors aimed to create a nomogram for precisely predicting the 5-year prospective hemorrhage risk in brainstem cavernous malformations (BSCMs).
METHODS
Patients with confirmed BSCMs in a single-center prospective observational series from January 2012 to December 2016 were included in the present study for nomogram building and validation. The concordance index (C-index), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy, discriminative ability, and clinical usefulness of the nomogram. Then, a nomogram-based risk stratification model for untreated BSCMs was developed.
RESULTS
In total, 600 patients were included in the study; 417 patients who had been enrolled before July 2015 were divided into the training and validation cohorts, and 183 subsequently enrolled patients were used as the external validation cohort. By applying a backward stepwise procedure in the multivariable Cox model, variables, including prior hemorrhage (HR 1.69), hemorrhage on admission (HR 3.33), lesion size > 1.5 cm (HR 1.84), lesion depth (HR 2.35), crossing the axial midpoint (HR 1.94), and developmental venous anomaly (HR 2.62), were incorporated to develop a nomogram. The Harrell C-index values for a 5-year prospective hemorrhage were 0.752 (95% CI 0.687–0.816), 0.801 (95% CI 0.665–0.936), and 0.758 (95% CI 0.674–0.842) in the training, internal validation, and external validation cohorts, respectively. The nomogram performed well in terms of consistency between prediction and actual observation according to the calibration curve. The patients could be classified into three distinct (low, medium, and high) risk groups using the final score of this nomogram.
CONCLUSIONS
Independent predictors of the 5-year hemorrhage risk in untreated BSCMs were selected to create the first nomogram for predicting individual prospective hemorrhage. The nomogram was able to stratify patients into different risk groups and assist in clinical decision-making.
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Affiliation(s)
- Xiao-Ying Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Lai-Rong Song
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Pan-Pan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Ze-Yu Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
- China National Clinical Research Center for Neurological Diseases, Beijing; and
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17
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Huo R, Wang J, Sun YF, Weng JC, Li H, Jiao YM, Xu HY, Zhang JZ, Zhao SZ, He QH, Wang S, Zhao JZ, Cao Y. Simplex cerebral cavernous malformations with MAP3K3 mutation have distinct clinical characteristics. Front Neurol 2022; 13:946324. [PMID: 36090889 PMCID: PMC9458974 DOI: 10.3389/fneur.2022.946324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To investigate the clinical characteristics of cerebral cavernous malformations (CCMs) with MAP3K3 somatic mutation. Methods We performed a retrospective review of our CCMs database between May 2017 and December 2019. The patients with simplex CCMs identified to harbor a MAP3K3 or CCM gene somatic mutation were included. Clinical characteristics were recorded. Univariate and multivariate logistic analyses were used to assess the risk factors associated with hemorrhage events of CCMs. To explore the underlying mechanism, we transfected MEKK3-I441M-overexpressing and CCM2-knockdown lentiviruses into human umbilical vein endothelial cells (HUVECs) and investigated thrombomodulin (TM) and tight junctions (TJs) protein expression by western blotting and immunofluorescence. Finally, immunohistochemistry was used to validate TM and TJs protein expression in surgical samples. Results Fifty simplex CCMs patients were included, comprising 38 MAP3K3 mutations and 12 CCM gene mutations. Nine (23.7%) patients with MAP3K3 mutations and 11(91.7%) patients with CCM gene mutations exhibited overt hemorrhage, respectively. Multivariate logistic analyses revealed that MAP3K3 mutation was associated with a lower risk of hemorrhage events. In the vitro experiments, ZO-1 expression was not reduced in MEKK3-I441M-overexpressing HUVECs compared with wild type, whereas it was significantly decreased in CCM2-knockdown HUVECs compared with control. In the MEKK3-I441M-overexpressing HUVECs, TM expression was increased, and the NF-κB pathway was significantly activated. After treatment with an NF-κB signaling inhibitor, TM expression was further upregulated. Meanwhile, TM expression was increased, but the NF-κB pathway was not activated in CCM2-knockdown HUVECs. Accordingly, immunohistochemistry showed that ZO-1 expression in the MAP3K3-mutant samples was significantly higher than that in the CCM-mutant samples. TM expression in the MAP3K3-mutant lesions was significantly lower than that in the CCM-mutant samples. Conclusion Simplex CCMs with MAP3K3 mutation occasionally present with overt hemorrhage, which is associated with the biological function of MAP3K3 mutation.
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Affiliation(s)
- Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ying-Fan Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jian-Cong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu-Ming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hong-Yuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun-Ze Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shao-Zhi Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qi-Heng He
- 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
| | - Ji-Zong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological 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
- *Correspondence: Yong Cao
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18
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Fang Z, Sun X, Wang X, Ma J, Palaia T, Rana U, Miao B, Ragolia L, Hu W, Miao QR. NOGOB receptor deficiency increases cerebrovascular permeability and hemorrhage via impairing histone acetylation-mediated CCM1/2 expression. J Clin Invest 2022; 132:e151382. [PMID: 35316220 PMCID: PMC9057619 DOI: 10.1172/jci151382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/16/2022] [Indexed: 11/17/2022] Open
Abstract
The loss function of cerebral cavernous malformation (CCM) genes leads to most CCM lesions characterized by enlarged leaking vascular lesions in the brain. Although we previously showed that NOGOB receptor (NGBR) knockout in endothelial cells (ECs) results in cerebrovascular lesions in the mouse embryo, the molecular mechanism by which NGBR regulates CCM1/2 expression has not been elucidated. Here, we show that genetic depletion of Ngbr in ECs at both postnatal and adult stages results in CCM1/2 expression deficiency and cerebrovascular lesions such as enlarged vessels, blood-brain-barrier hyperpermeability, and cerebral hemorrhage. To reveal the molecular mechanism, we used RNA-sequencing analysis to examine changes in the transcriptome. Surprisingly, we found that the acetyltransferase HBO1 and histone acetylation were downregulated in NGBR-deficient ECs. The mechanistic studies elucidated that NGBR is required for maintaining the expression of CCM1/2 in ECs via HBO1-mediated histone acetylation. ChIP-qPCR data further demonstrated that loss of NGBR impairs the binding of HBO1 and acetylated histone H4K5 and H4K12 on the promotor of the CCM1 and CCM2 genes. Our findings on epigenetic regulation of CCM1 and CCM2 that is modulated by NGBR and HBO1-mediated histone H4 acetylation provide a perspective on the pathogenesis of sporadic CCMs.
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Affiliation(s)
- Zhi Fang
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Xiaoran Sun
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Xiang Wang
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ji Ma
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Thomas Palaia
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Ujala Rana
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Benjamin Miao
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Louis Ragolia
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Wenquan Hu
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Qing Robert Miao
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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19
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Samanci Y, Ardor GD, Peker S. Management of pediatric cerebral cavernous malformations with gamma knife radiosurgery: a report of 46 cases. Childs Nerv Syst 2022; 38:929-938. [PMID: 35275282 DOI: 10.1007/s00381-022-05485-9] [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: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pediatric cerebral cavernous malformations (CCMs) are commonly treated vascular anomalies with different clinical characteristics than their adult counterparts. Outcomes of Gamma Knife Radiosurgery (GKRS) for pediatric CCMs have not explicitly been reported. This paper reports our experience in managing pediatric CCMs with GKRS. METHODS We retrospectively reviewed the clinical features, GKRS parameters, and clinical and radiological outcomes of 46 children with 64 CCMs. RESULTS A total of 46 children, including 19 girls and 27 boys, with a median age of 16 years (3-17 years), were enrolled in the study. The median age at first CCM diagnosis was 13 years (range, 2-17 years). Twenty-two patients (47.8%) had more than one neurological symptom at the time of diagnosis, and the most common presenting symptom was seizure (28.3%). The most common location was supratentorial superficial (53.1%), and 17.4% of patients had multiple CCMs. A developmental venous anomaly was detected in 5 patients (10.9%). During a total of 52.4 retrospective patient-years in patients with > 1 hemorrhage episode, the calculated annual hemorrhage rate was 40.1%. The median post-GKRS follow-up was 79 months (range, 19-175 months), with an overall 306.2 prospective patient years. The annual hemorrhage rate (AHR) during the first 2 years after GKRS and after the initial 2 years was 1.11% and 0.46%, respectively. Regarding clinical factors and GKRS parameters, univariate analysis revealed a significant association with post-GKRS AHR and volume (p = 0.023) only. Patients with pre-GKRS seizures showed favorable seizure control (Engel class I and II) in 8 children (61.5%). There was no mortality in our series. CONCLUSION Low AHR following GKRS with no radiation-induced toxicity makes GKRS a therapeutic alternative for pediatric CCMs.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey.,Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey
| | - Gokce Deniz Ardor
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey. .,School of Medicine, Department of Neurosurgery, Koç University, Davutpasa Caddesi No: 4, 34010, Zeytinburnu, Istanbul, Turkey.
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20
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Maderna C, Pisati F, Tripodo C, Dejana E, Malinverno M. A murine model of cerebral cavernous malformations with acute hemorrhage. iScience 2022; 25:103943. [PMID: 35265815 PMCID: PMC8898922 DOI: 10.1016/j.isci.2022.103943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/06/2021] [Accepted: 02/14/2022] [Indexed: 12/24/2022] Open
Abstract
Cavernomas are multi-lumen and blood-filled vascular malformations which form in the brain and the spinal cord. They lead to hemorrhage, epileptic seizures, neurological deficits, and paresthesia. An effective medical treatment is still lacking, and the available murine models for cavernomas have several limitations for preclinical studies. These include disease phenotypes that differ from human diseases, such as restriction of the lesions to the cerebellum, and absence of acute hemorrhage. Additional limitations of current murine models include rapid development of lesions, which are lethal before the first month of age. Here, we have characterized a murine model that recapitulates features of the human disease: lesions develop after weaning throughout the entire CNS, including the spinal cord, and undergo acute hemorrhage. This provides a preclinical model to develop new drugs for treatment of acute hemorrhage in the brain and spinal cord, as an unmet medical emergency for patients with cavernomas. Ccm3 deletion in endothelial progenitors drives cavernoma formation in a mouse model Mice develop acute hemorrhage and inflammation in brain and spinal cord The spleen has increased vascular density and altered hemopoiesis This model represents a useful tool for mechanistic studies and drug screening
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Affiliation(s)
- Claudio Maderna
- Vascular Biology Unit, The FIRC Institute of Molecular Oncology Foundation, Milan 20139, Italy
| | - Federica Pisati
- Tumour and Microenvironment Histopathology Unit, FIRC Institute of Molecular Oncology (IFOM), Milan, Italy
| | - Claudio Tripodo
- Tumour and Microenvironment Histopathology Unit, FIRC Institute of Molecular Oncology (IFOM), Milan, Italy.,Tumour Immunology Unit, University of Palermo, Palermo, Italy
| | - Elisabetta Dejana
- Vascular Biology Unit, The FIRC Institute of Molecular Oncology Foundation, Milan 20139, Italy.,Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala 752 37, Sweden
| | - Matteo Malinverno
- Vascular Biology Unit, The FIRC Institute of Molecular Oncology Foundation, Milan 20139, Italy
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21
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Munakomi S, Torregrossa F, Grasso G. Natural Course, Clinical Profile, and Treatment Strategies for Cerebral Cavernous Malformations. World Neurosurg 2022; 159:373-380. [DOI: 10.1016/j.wneu.2021.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 10/18/2022]
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22
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Fontanella MM, Zanin L, Panciani P, Belotti F, Doglietto F, Cremonesi A, Migliorati K, Roca E, Maria LD, Franzin A, Vivaldi O, Griva F, Narducci A, Draghi R, Calbucci F, Borghesi I, Crobeddu E, Cossandi C, Fioravanti A, Arias JA, Scerrati A, Bonis PD, Locatelli D, Agosti E, Veiceschi P, Ceraudo M, Zona G, Gasparotti R, Terzi di Bergamo L, Rigamonti D. Preliminary validation of FoRCaSco: a new Grading System for Cerebral and Cerebellar Cavernomas. World Neurosurg 2022; 162:e597-e604. [DOI: 10.1016/j.wneu.2022.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
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23
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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24
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Patel M, Mahajan U, Pace J, Rothstein B. Presentation and management of nervous system cavernous malformations in children: A systematic review and case report. Brain Circ 2022; 8:121-126. [PMID: 36267435 PMCID: PMC9578313 DOI: 10.4103/bc.bc_26_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022] Open
Abstract
Cerebral cavernous malformations (CMs) are slow-flow vascular lesions that affect up to 0.5% of the pediatric population. These lesions are at risk for hemorrhage, causing seizures, and leading to neurological deficits. Here, we conduct a literature review and then present a report of a supratentorial CM in a 2-year-old patient with no significant past medical history who presented at our institution with 1 month of eye twitching. We performed a literature search of five databases of all articles published before 2020. Our inclusion criteria included cohort and case series of children with mean age under 12 years. Our search yielded 497 unique articles, of which 16 met our inclusion criteria. In our pooled literature analysis, a total of 558 children were included, 8.3% of which had a positive family history and 15.9% had multiple CMs. About 46.1% of the children had seizures, and 88.4% of those who underwent surgery had a total resection. About 85.1% of those with epilepsy were Engel Class 1 postsurgery. Over a mean follow-up of 4.1 years, 3.4% of patients had additional neurological deficits, including paresis and speech deficits. Our analysis of published literature shows surgical intervention should be considered first-line therapy for patients who are symptomatic from CM, present with seizure, and have surgically accessible lesions. Additional work is needed on outcomes and long-term effects of minimally invasive treatments, including radiosurgery and laser ablation, in pediatric populations.
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25
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Cheng D, Shang X, Gao W, Barkhof F, Liu Y. Fetal Familial Cerebral Cavernous Malformation With a Novel Heterozygous KRIT1 Variation. Neurology 2021; 97:986-988. [PMID: 34556564 DOI: 10.1212/wnl.0000000000012852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To identify fetal familial cerebral cavernous malformation (CCM) and a novel variation. METHODS A 37-year-old pregnant woman (G4P0) presented with right-handed numbness since 2 weeks at 31 weeks of gestation. Evaluation with brain MRI revealed multiple CCMs. As a result, fetal MRI, fetal whole exome sequencing, and maternal Sanger sequencing were performed. RESULTS The mother's brain MRI demonstrated numerous CCMs involving the brain stem, cerebral hemispheres, and cerebellum. Fetal MRI showed a CCM located in the left frontal lobe in susceptibility-weighted imaging (SWI). The neuroimaging characteristics of the mother and the fetus suggested that their CCMs may be familial. Genetic analysis revealed a novel variation in KRIT1 (c.1A>G, p.0?), also called CCM1, in the mother and the baby. The mother delivered a daughter at 32 weeks of gestation with an Apgar score of 10 by cesarean section. DISCUSSION This variation of the initial codon in the KRIT1 gene leads to a phenotype with an early-onset. To our knowledge, this is the first-ever reported case of fetal familial CCM and this novel variation. Brain MRI has excellent sensitivity and specificity, providing the best option for detecting CCMs, even in utero, primarily when SWI is used.
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Affiliation(s)
- Dan Cheng
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Xiang Shang
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Wanli Gao
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Frederik Barkhof
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Yaou Liu
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands.
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26
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Santos AN, Rauschenbach L, Saban D, Chen B, Herten A, Dinger TF, Li Y, Tippelt S, Della Marina A, Dohna-Schwake C, Schmidt B, Jabbarli R, Wrede KH, Sure U, Dammann P. Natural Course of Cerebral Cavernous Malformations in Children: A Five-Year Follow-Up Study. Stroke 2021; 53:817-824. [PMID: 34706565 DOI: 10.1161/strokeaha.121.035338] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the natural course of cerebral cavernous malformations (CCM) in the pediatric population, with special emphasis on the risk of first and recurrent bleeding over a 5-year period. METHODS Our institutional database was screened for patients with CCM treated between 2003 and 2020. Patients ≤18 years of age with complete magnetic resonance imaging data set, clinical baseline characteristics, and ≥1 follow-up examination were included. Surgically treated individuals were censored after CCM removal. We assessed the impact of various parameters on first or recurrent intracerebral hemorrhage (ICH) at diagnosis using univariate and multivariate logistic regression adjusted for age and sex. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for (re)hemorrhage. RESULTS One hundred twenty-nine pediatric patients with CCM were analyzed. Univariate logistic regression identified brain stem CCM (odds ratio, 3.15 [95% CI, 1.15-8.63], P=0.026) and familial history of CCM (odds ratio, 2.47 [95% CI, 1.04-5.86], P=0.041) as statistically significant predictors of ICH at diagnosis. Multivariate logistic regression confirmed this correlation (odds ratio, 3.62 [95% CI, 1.18-8.99], P=0.022 and odds ratio, 2.53 [95% CI, 1.07-5.98], P=0.035, respectively). Cox regression analysis identified ICH as mode of presentation (hazard ratio, 14.01 [95% CI, 1.80-110.39], P=0.012) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of (re)bleeding was 15.9% (95% CI, 10.2%-23.6%) for the entire cohort, 30.2% (20.2%-42.3%) for pediatric patients with ICH at diagnosis, and 29.5% (95% CI, 13.9%-51.1%) for children with brain stem CCM. CONCLUSIONS Pediatric patients with brain stem CCM and familial history of CCM have a higher risk of ICH as mode of presentation. During untreated 5-year follow-up, they revealed a similar risk of (re)hemorrhage compared to adult patients. The probability of (re)bleeding increases over time, especially in cases with ICH at presentation or brain stem localization.
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Affiliation(s)
- Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany. (Y.L.)
| | - Stephan Tippelt
- Department of Pediatrics, University Hospital Essen, Germany. (S.T., A.D.M., C.D.-S.)
| | - Adela Della Marina
- Department of Pediatrics, University Hospital Essen, Germany. (S.T., A.D.M., C.D.-S.)
| | | | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Germany. (B.S.)
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany. (A.N.S., L.R., D.S., B.C., A.H., T.F.D., R.J., K.H.W., U.S., P.D.)
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27
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Noureldine MHA, Rasras S, Safari H, Sabahi M, Jallo GI, Arjipour M. Spontaneous regression of multiple intracranial capillary hemangiomas in a newborn-long-term follow-up and literature review. Childs Nerv Syst 2021; 37:3225-3234. [PMID: 33481102 DOI: 10.1007/s00381-021-05053-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intracranial capillary hemangiomas (ICHs) have a natural history and behavior that is very different from intracranial cavernous malformations. The literature is not consistent as to the best management strategy for ICHs. CASE DESCRIPTION Our patient is a 40-day-old male infant who presented with progressive increase in head circumference and multiple cutaneous capillary and ICHs. Obstructive hydrocephalus necessitated urgent cerebrospinal fluid (CSF) diversion, but no other surgical intervention was pursued due to the high risk-to-benefit ratio. All intracranial lesions spontaneously regressed by 11 years of age, albeit at a slower speed than the cutaneous lesions, with no functional or cognitive sequelae. We conducted a comprehensive literature review and provided a summary of all reported ICH cases. CONCLUSION Asymptomatic patients with ICHs are best approached with close follow-up and serial imaging studies as the potential for spontaneous regression is relatively high. Patients with isolated lesions or unclear diagnoses may benefit from a stereotactic biopsy, and surgical resection should be reserved for symptomatic lesions only.
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Affiliation(s)
| | - Saleh Rasras
- Department of Neurosurgery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hosein Safari
- Department of Neurosurgery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammadmahdi Sabahi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran.,Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - George I Jallo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
| | - Mahdi Arjipour
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Neurosurgery, Hamadan University of Medical Sciences, Shahid Fahmide St., Building No. 4, Hamadan, Iran.
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28
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Valentino M, Dejana E, Malinverno M. The multifaceted PDCD10/CCM3 gene. Genes Dis 2021; 8:798-813. [PMID: 34522709 PMCID: PMC8427250 DOI: 10.1016/j.gendis.2020.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/10/2020] [Accepted: 12/22/2020] [Indexed: 02/06/2023] Open
Abstract
The programmed cell death 10 (PDCD10) gene was originally identified as an apoptosis-related gene, although it is now usually known as CCM3, as the third causative gene of cerebral cavernous malformation (CCM). CCM is a neurovascular disease that is characterized by vascular malformations and is associated with headaches, seizures, focal neurological deficits, and cerebral hemorrhage. The PDCD10/CCM3 protein has multiple subcellular localizations and interacts with several multi-protein complexes and signaling pathways. Thus PDCD10/CCM3 governs many cellular functions, which include cell-to-cell junctions and cytoskeleton organization, cell proliferation and apoptosis, and exocytosis and angiogenesis. Given its central role in the maintenance of homeostasis of the cell, dysregulation of PDCD10/CCM3 can result in a wide range of altered cell functions. This can lead to severe diseases, including CCM, cognitive disability, and several types of cancers. Here, we review the multifaceted roles of PDCD10/CCM3 in physiology and pathology, with a focus on its functions beyond CCM.
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Affiliation(s)
| | - Elisabetta Dejana
- The FIRC Institute of Molecular Oncology (IFOM), Milan, 16 20139, Italy.,Department of Oncology and Haemato-Oncology, University of Milan, Milan, 7 20122, Italy.,Vascular Biology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, SE-751 05, Sweden
| | - Matteo Malinverno
- The FIRC Institute of Molecular Oncology (IFOM), Milan, 16 20139, Italy
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29
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Maiuri F, Mariniello G, Corvino S, Somma T, Guadagno E, Teodonno G, Del Basso De Caro M, Cappabianca P. Cavernous Malformations to Be Investigated for Familiarity: The Role of Ki67 MIB1. World Neurosurg 2021; 155:e75-e82. [PMID: 34389524 DOI: 10.1016/j.wneu.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Familial forms of cavernous malformations (CMs) often occur as multiple lesions. Nevertheless, the presence of a single CM does not exclude the familiarity. The aim of this study is to establish which patients who undergo surgery for a single cerebral cavernous malformation (CCM), with no family history at initial diagnosis, should be investigated for familiarity through genetic testing and counseling. METHODS Eight families with 2 or more members affected by CCM have been studied. A control group of sporadic cases operated on, with no family history and followed up 10 years or more, was also included. Analyzed factors were patient age and sex, location, number and size of the lesions, associated developmental venous anomaly, presence of epileptic seizures, symptomatic hemorrhage, focal neurological deficits, and documented growth of the malformation and Ki67 MIB1 proliferation index. RESULTS The familial group of CCMs showed higher incidence of pediatric patients (P = 0.01), more frequent occurrence of multiple lesions (P = 0.0004), higher rate of large CCMs, and symptomatic hemorrhage; besides, all 3 cases with documented growth belonged to the familial group (14%). The expression of Ki67 MIB1 was positive in 79% of the familial cases versus 0% in the sporadic ones (P < 0.00001). CONCLUSIONS Patients with CCM and no known family history at the time of the initial diagnosis who present specific features should be studied by genetic screening. The Ki67 MIB1 is a useful biomarker in favor of familial occurrence and may be studied in all patients with CMs to define the indication to the genetic tests.
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Affiliation(s)
- Francesco Maiuri
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy.
| | - Giuseppe Mariniello
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Sergio Corvino
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Teresa Somma
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, University "Federico II" of Naples, Naples, Italy
| | - Giuseppe Teodonno
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, University "Federico II" of Naples, Naples, Italy
| | - Paolo Cappabianca
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
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30
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Patel BK, Gohil AJ, Nair P, H V E, A N D. Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report. Oper Neurosurg (Hagerstown) 2021; 21:E136-E142. [PMID: 33825886 DOI: 10.1093/ons/opab094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Cavernous malformations (CMs) are angiographically occult low-flow vascular malformations that infrequently involve the optic pathway and the hypothalamus (OPH). CLINICAL PRESENTATION A 23-yr-old male presented with bitemporal hemianopia due to chaismal apoplexy. Imaging revealed a CM involving the OPH. The CM was resected by an extended endonasal approach. The patient had improvement in his visual field defects, and postoperative magnetic resonance imaging (MRI) revealed a gross total resection of the CM. CONCLUSION This case demonstrates the surgical technique of endoscopic endonasal resection of a CM involving the optic pathway.
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Affiliation(s)
- Biren Khimji Patel
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - A Jaypalsinh Gohil
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Easwer H V
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Deepti A N
- Department of Neuropathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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Shoubash L, Baldauf J, Matthes M, Kirsch M, Rath M, Felbor U, Schroeder HWS. Long-term outcome and quality of life after CNS cavernoma resection: eloquent vs. non-eloquent areas. Neurosurg Rev 2021; 45:649-660. [PMID: 34164745 PMCID: PMC8827309 DOI: 10.1007/s10143-021-01572-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/18/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Abstract
The aim of this study is to analyze the long-term quality of life after surgery of cavernoma. A monocentric retrospective study was conducted on 69 patients with cavernoma treated microsurgically between 2000 and 2016. The eloquence was adopted from Spetzler-Martin definition. A most recent follow-up was elicited between 2017 and 2019, in which the quality of life (QoL) was evaluated with the Short Form-12 questionnaire (SF12). Forty-one lesions were in eloquent group (EG), 22 in non-eloquent group (NEG), 3 in orbit, and 3 in the spinal cord. Postoperative worsening of the modified Rankin scale (mRS) occurred in 19.5% of cases in EG versus 4.5% in NEG. After a mean follow-up of 6.5 years (SD 4.6), the neurological status was better or unchanged compared to baseline in 85.4% of EG and 100% of NEG. Regarding QoL assessment of 44 patients (EG n = 27, NEG n = 14) attended the last follow-up. Patients after eloquent cavernoma resection reported a non-inferior QoL in most SF12 domains (except for physical role) compared to NEG. However, they reported general health perception inferior to norms, which was affected by the limited physical and emotional roles. At a late follow-up, the surgical morbidity was transient in the NEG and mostly recovered in the EG. The QoL comparison between eloquent and non-eloquent cavernomas created interesting and new data after prolonged follow-up. These results add value for decision-making as well as patient counseling for future encountered cases. Preoperative evaluation of QoL is recommended for future studies to assess QoL dynamics.
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Affiliation(s)
- Loay Shoubash
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany.
| | - Jörg Baldauf
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany
| | - Marc Matthes
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany
| | - Michael Kirsch
- Department of Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Rath
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Ute Felbor
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany
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32
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Alwedaie SMJ, Abolmaali M. Spontaneous Intracranial Hemorrhage: A Sign of Cavernous Angioma Diagnosis in Pediatric Age Group. Cureus 2021; 13:e14917. [PMID: 34123616 PMCID: PMC8189271 DOI: 10.7759/cureus.14917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Cerebral cavernous malformation (CCM) is a developmental abnormality of blood vessels that supply the brain. It is composed of large, adjacent capillaries which contain little or no neural tissue. They mostly occur in the supratentorial region. However, the occurrence of these vascular lesions can be seen at different sites of the central nervous system (CNS). The prevalence of CCM is estimated to be 0.4% in the general population and among the affected patients, 18.7% have multiple lesions. However, about 30-50% of CCM cases are asymptomatic and are found incidentally. Here we report a case of an eight-year-old girl with a massive hemorrhagic presentation of a left parietooccipital CCM.
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Affiliation(s)
| | - Meysam Abolmaali
- Department of Neuroscience, Salmaniya Medical Complex, Manama, BHR
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33
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Weng J, Yang Y, Song D, Huo R, Li H, Chen Y, Nam Y, Zhou Q, Jiao Y, Fu W, Yan Z, Wang J, Xu H, Di L, Li J, Wang S, Zhao J, Wang J, Cao Y. Somatic MAP3K3 mutation defines a subclass of cerebral cavernous malformation. Am J Hum Genet 2021; 108:942-950. [PMID: 33891857 PMCID: PMC8206158 DOI: 10.1016/j.ajhg.2021.04.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/30/2021] [Indexed: 12/22/2022] Open
Abstract
Cerebral cavernous malformations (CCMs) are vascular disorders that affect up to 0.5% of the total population. About 20% of CCMs are inherited because of familial mutations in CCM genes, including CCM1/KRIT1, CCM2/MGC4607, and CCM3/PDCD10, whereas the etiology of a majority of simplex CCM-affected individuals remains unclear. Here, we report somatic mutations of MAP3K3, PIK3CA, MAP2K7, and CCM genes in CCM lesions. In particular, somatic hotspot mutations of PIK3CA are found in 11 of 38 individuals with CCMs, and a MAP3K3 somatic mutation (c.1323C>G [p.Ile441Met]) is detected in 37.0% (34 of 92) of the simplex CCM-affected individuals. Strikingly, the MAP3K3 c.1323C>G mutation presents in 95.7% (22 of 23) of the popcorn-like lesions but only 2.5% (1 of 40) of the subacute-bleeding or multifocal lesions that are predominantly attributed to mutations in the CCM1/2/3 signaling complex. Leveraging mini-bulk sequencing, we demonstrate the enrichment of MAP3K3 c.1323C>G mutation in CCM endothelium. Mechanistically, beyond the activation of CCM1/2/3-inhibited ERK5 signaling, MEKK3 p.Ile441Met (MAP3K3 encodes MEKK3) also activates ERK1/2, JNK, and p38 pathways because of mutation-induced MEKK3 kinase activity enhancement. Collectively, we identified several somatic activating mutations in CCM endothelium, and the MAP3K3 c.1323C>G mutation defines a primary CCM subtype with distinct characteristics in signaling activation and magnetic resonance imaging appearance.
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Li D, Zheng JJ, Weng JC, Liu PP, Wu ZY, Zhang LW, Zhang JT, Wang L, Wu Z. Neurological outcomes of untreated brainstem cavernous malformations in a prospective observational cohort and literature review. Stroke Vasc Neurol 2021; 6:501-510. [PMID: 33737399 PMCID: PMC8717781 DOI: 10.1136/svn-2020-000608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Haemorrhages of brainstem cavernous malformations (CMs) can lead to neurological deficits, the natural history of which is uncertain. The study aimed to evaluate the neurological outcomes of untreated brainstem CMs and to identify the adverse factors associated with worsened outcomes. Methods From 2009 to 2015, 698 patients (321 women) with brainstem CMs were entered into the prospective cohort after excluding patients lost to follow-up (n=43). All patients were registered, clinical data were collected and scheduled follow-up was performed. Results After a median follow-up of 60.9 months, prospective haemorrhages occurred in 167 patients (23.9%). The mean modified Rankin Scale scores at enrolment and at censoring time were 1.6 and 1.2. Neurological status was improved, unchanged and worsened in 334 (47.9%), 293 (42.0%) and 71 (10.2%) patients, respectively; 233 (33.4%) recovered to normal levels. Lesions crossing the axial midpoint (relative risk (RR) 2.325, p=0.003) and developmental venous anomaly (DVA) (RR 1.776, p=0.036) were independently significantly related to worsened outcomes. The percentage of worsened outcomes was 5.3% (18 of 337) in low-risk patients (neither DVA nor crossing the axial point) and increased to 26.0% (13 of 50) in high-risk patients (with both DVA and crossing the axial point). The percentage of worsened outcomes significantly increased as the number of prospective haemorrhages increased (from 1.5% (8 of 531, if 0 prospective ictus) to 37.5% (48 of 128, if 1 ictus) and 38.5% (15 of 39, if >1 ictus)). Conclusions The neurological outcomes of untreated brainstem CMs were improved/unchanged in majority of patients (89.8%) with a fatality rate of 1.7% in our cohort, which seemed to be favourable. Radiological features significantly predicted worsened outcomes. Our results provide evidence for clinical consultation and individualised treatment. The referral bias of our cohort was underlined.
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Affiliation(s)
- Da Li
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing-Jie Zheng
- Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jian-Cong Weng
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pan-Pan Liu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ze-Yu Wu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Wei Zhang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun-Ting Zhang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Wang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Wu
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Paddock M, Lanham S, Gill K, Sinha S, Connolly DJA. Pediatric Cerebral Cavernous Malformations. Pediatr Neurol 2021; 116:74-83. [PMID: 33494000 DOI: 10.1016/j.pediatrneurol.2020.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/30/2020] [Accepted: 11/07/2020] [Indexed: 11/28/2022]
Abstract
Cerebral cavernous malformations are the second most common vascular malformations in the central nervous system, and over one-third are found in children. Lesions may be solitary or multiple, be discovered incidentally, be sporadic, or be secondary to familial cavernomatosis or radiation therapy. Children may present with focal seizures, intracranial hemorrhage, or focal neurological deficits without radiological evidence of recent hemorrhage. We present several children with cerebral cavernous malformations and explore the challenges of their diagnosis in children, their key imaging features, the role of follow-up imaging, and their subsequent management including stereotactic radiosurgery and microsurgical resection. Individual patient risk stratification is advocated for all affected children and their families.
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Affiliation(s)
- Michael Paddock
- Medical Imaging Department, Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom; Academic Unit of Child Health, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom.
| | - Sarah Lanham
- Department of Neuroradiology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Kanwar Gill
- Medical Imaging Department, Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom
| | - Saurabh Sinha
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Department of Neurosurgery, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Daniel J A Connolly
- Department of Neuroradiology, Royal Hallamshire Hospital, Sheffield, United Kingdom; Department of Radiology, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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36
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Li D, Wu ZY, Liu PP, Ma JP, Huo XL, Wang L, Zhang LW, Wu Z, Zhang JT. Natural history of brainstem cavernous malformations: prospective hemorrhage rate and adverse factors in a consecutive prospective cohort. J Neurosurg 2021; 134:917-928. [DOI: 10.3171/2019.12.jns192856] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEGiven the paucity of data on the natural history of brainstem cavernous malformations (CMs), the authors aimed to evaluate the annual hemorrhage rate and hemorrhagic risk of brainstem CMs.METHODSNine hundred seventy-nine patients diagnosed with brainstem CMs were referred to Beijing Tiantan Hospital from 2006 to 2015; 224 patients were excluded according to exclusion criteria, and 47 patients were lost to follow-up. Thus, this prospective observational cohort included 708 cases (324 females). All patients were registered, clinical data were recorded, and follow-up was completed.RESULTSSix hundred ninety (97.5%) of the 708 patients had a prior hemorrhage, 514 (72.6%) had hemorrhagic presentation, and developmental venous anomaly (DVA) was observed in 241 cases (34.0%). Two hundred thirty-seven prospective hemorrhages occurred in 175 patients (24.7%) during 3400.2 total patient-years, yielding a prospective annual hemorrhage rate of 7.0% (95% CI 6.2%–7.9%), which decreased to 4.7% after the 1st year. Multivariate Cox regression analysis after adjusting for sex and age identified hemorrhagic presentation (HR 1.574, p = 0.022), DVA (HR 1.678, p = 0.001), mRS score ≥ 2 on admission (HR 1.379, p = 0.044), lesion size > 1.5 cm (HR 1.458, p = 0.026), crossing the axial midpoint (HR 1.446, p = 0.029), and superficially seated location (HR 1.307, p = 0.025) as independent adverse factors for prospective hemorrhage, but history of prior hemorrhage was not significant. The annual hemorrhage rates were 8.3% and 4.3% in patients with and without hemorrhagic presentation, respectively; the rate was 9.9%, 6.0%, and 1.0% in patients with ≥ 2, only 1, and 0 prior hemorrhages, respectively; and the rate was 9.2% in patients with both hemorrhagic presentation and focal neurological deficit on admission.CONCLUSIONSThe study reported an annual hemorrhage rate of 7.0% exclusively for brainstem CMs, which significantly increased if patients presented with both hemorrhagic presentation and focal neurological deficit (9.2%), or any other risk factor. Patients with a risk factor for hemorrhage needed close follow-up regardless of the number of prior hemorrhages. It should be noted that the referral bias in this study could have overestimated the annual hemorrhage rate. This study improved the understanding of the natural history of brainstem CMs, and the results are important for helping patients and physicians choose a suitable treatment option based on the risk factors and stratified annual rates.Clinical trial registration no.: ChiCTR-POC-17011575 (http://www.chictr.org.cn/).
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Affiliation(s)
- Da Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Ze-Yu Wu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Pan-Pan Liu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
- 2Department of Neurosurgery, The Municipal Hospital of Weihai, People’s Republic of China
| | - Jun-Peng Ma
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Xu-Lei Huo
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Liang Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Li-Wei Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Zhen Wu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
| | - Jun-Ting Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing; and
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Jagathesan T, OBrien M. Aeromedical Implications of Cerebral Cavernomas. Aerosp Med Hum Perform 2021; 92:120-123. [PMID: 33468293 DOI: 10.3357/amhp.5747.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND: Cavernomas, cavernous angiomas, or cerebral cavernous malformations are clusters of endothelium-lined blood vessels usually found in the brain. With the increasing use of radiological imaging, these are being detected incidentally in asymptomatic aircrew. The UK Civil Aviation Authority (CAA) experience of cavernomas is described and the aeromedical concerns, that is, the risk of epilepsy, hemorrhage, and the development of a neurological deficit, are considered.METHODS: A search of the CAA database between 1990 and 2020 was performed for the term cavernoma. The gender, age at diagnosis, class of certification held, clinical presentation, location, and size of the lesion were noted. A PubMed literature review for papers with complications of cavernoma was performed.RESULTS: Six cases of cavernoma have been declared to the CAA: five professional pilots and one private pilot. Five were men and one was a woman. The age range was between 38 and 60 yr, with a mean of 48 yr. Two cases presented with clinical symptoms and four were asymptomatic. Complication rates for seizure and hemorrhage were extracted from the published literature together with the significance of other factors such as cavernoma size, family history, multiplicity, and the development of new lesions.DISCUSSION: A policy for the medical certification of aircrew with cavernomas that have presented with clinical symptoms and those that are detected incidentally is proposed.Jagathesan T, OBrien M. Aeromedical implications of cerebral cavernomas. Aerosp Med Hum Perform. 2021; 92(2):120123.
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Hart BL, Mabray MC, Morrison L, Whitehead KJ, Kim H. Systemic and CNS manifestations of inherited cerebrovascular malformations. Clin Imaging 2021; 75:55-66. [PMID: 33493737 DOI: 10.1016/j.clinimag.2021.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 12/25/2022]
Abstract
Cerebrovascular malformations occur in both sporadic and inherited patterns. This paper reviews imaging and clinical features of cerebrovascular malformations with a genetic basis. Genetic diseases such as familial cerebral cavernous malformations and hereditary hemorrhagic telangiectasia often have manifestations in bone, skin, eyes, and visceral organs, which should be recognized. Genetic and molecular mechanisms underlying the inherited disorders are becoming better understood, and treatments are likely to follow. An interaction between the intestinal microbiome and formation of cerebral cavernous malformations has emerged, with possible treatment implications. Two-hit mechanisms are involved in these disorders, and additional triggering mechanisms are part of the development of malformations. Hereditary hemorrhagic telangiectasia encompasses a variety of vascular malformations, with widely varying risks, and a more recently recognized association with cortical malformations. Somatic mutations are implicated in the genesis of some sporadic malformations, which means that discoveries related to inherited disorders may aid treatment of sporadic cases. This paper summarizes the current state of knowledge of these conditions, salient features regarding mechanisms of development, and treatment prospects.
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Affiliation(s)
- Blaine L Hart
- Department of Radiology, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Marc C Mabray
- Department of Radiology, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Leslie Morrison
- Department of Neurology, MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
| | - Kevin J Whitehead
- Division of Cardiovascular Medicine and the Program in Molecular Medicine, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA; George E. Wahlen Salt Lake City VA Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148, USA.
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143, USA.
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Singh TD, Hajeb M, Rabinstein AA, Kunchok AC, Pittock SJ, Krecke KN, Bartleson JD, Black DF. SMART syndrome: retrospective review of a rare delayed complication of radiation. Eur J Neurol 2020; 28:1316-1323. [PMID: 33159349 DOI: 10.1111/ene.14632] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND SMART (stroke-like migraine attacks after radiation therapy) is a rare, delayed complication of brain radiation. In this study, we wanted to review the spectrum of symptoms, neuroradiological findings, autoimmune status, and outcomes in SMART syndrome patients. METHODS We conducted a retrospective cohort study of all consecutive adult patients (≥18 years) diagnosed with SMART syndrome at Mayo Clinic, Rochester between January 1995 and December 2018. RESULTS We identified 25 unique patients with SMART syndrome and a total of 31 episodes and 15 (60%) patients were male. The median age at onset was 46 (interquartile range [IQR] 43-55) years and the median latency of onset after the initial radiation was 21.6 (IQR 14.4-28.2) years. Magnetic resonance imaging (MRI) showed gyral edema and enhancement in all cases with the temporal (25, 80.6%) and parietal (23, 74.2%) lobes being the most commonly affected. The median follow-up of the patients in our cohort was 10 (IQR 6-32) weeks. On univariate analysis, factors associated with an increased risk of recurrent SMART episodes were female gender (odds ratio [OR] 8.1, 95% confidence interval [95% CI] 1.1-52.6, p = 0.019) and absence of electrographic seizure discharges during initial symptoms (OR 7.4, 95% CI 1.1-45.9, p = 0.032). We could not identify an autoimmune etiology. Longer duration of symptoms (>10 weeks) correlated with an older age (p = 0.049), temporal lobe involvement (p < 0.001), and diffusion restriction (p = 0.043). CONCLUSIONS SMART is a syndrome with characteristic imaging findings and clinical features. Incomplete recovery by 10 weeks occurred in one-third of individuals and was associated with older age, temporal lobe involvement, and restricted diffusion on MRI.
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Affiliation(s)
- Tarun D Singh
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mania Hajeb
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amy C Kunchok
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David F Black
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Cerebral cavernous malformations (CCMs) are neurovascular abnormalities characterized by thin, leaky blood vessels resulting in lesions that predispose to haemorrhages, stroke, epilepsy and focal neurological deficits. CCMs arise due to loss-of-function mutations in genes encoding one of three CCM complex proteins, KRIT1, CCM2 or CCM3. These widely expressed, multi-functional adaptor proteins can assemble into a CCM protein complex and (either alone or in complex) modulate signalling pathways that influence cell adhesion, cell contractility, cytoskeletal reorganization and gene expression. Recent advances, including analysis of the structures and interactions of CCM proteins, have allowed substantial progress towards understanding the molecular bases for CCM protein function and how their disruption leads to disease. Here, we review current knowledge of CCM protein signalling with a focus on three pathways which have generated the most interest—the RhoA–ROCK, MEKK3–MEK5–ERK5–KLF2/4 and cell junctional signalling pathways—but also consider ICAP1-β1 integrin and cdc42 signalling. We discuss emerging links between these pathways and the processes that drive disease pathology and highlight important open questions—key among them is the role of subcellular localization in the control of CCM protein activity.
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Affiliation(s)
- Valerie L Su
- Department of Pharmacology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA
| | - David A Calderwood
- Department of Pharmacology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA.,Department of Cell Biology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA
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Nogueira RM, Cardoso LS, Fonseca L, Correia M, Iraneta A, Roque P, Matos M, Mafra M. Hydrocephalus in children - A rare case of pineal cavernoma and literature review. Surg Neurol Int 2020; 11:294. [PMID: 33093971 PMCID: PMC7568112 DOI: 10.25259/sni_231_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/21/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Cavernous malformations prevalence ranges from 0.4 to 0.6% and accounts for 5–15% of all central nervous system vascular malformations. Pineal cavernomas constitute <1% of all locations published in the literature, with a total of 26 cases reported, only 5 regarding the pediatric population until 2020. Overall annual hemorrhage rate is 2.4%. Symptoms are often due to hydrocephalus and intracranial hypertension. Case Description: We report a case of a 5-year-old child with visual disturbances, headache, and progressive neurologic deterioration. MR showed a lesion in the pineal region and triventricular hydrocephalus. She was submitted to endoscopic third ventriculostomy and total excision of the lesion by the infratentorial supracerebellar approach a few days later. Histopathological examination confirmed a pineal cavernous malformation. The patient returned to her normal life without any neurologic deficit and a normal development. Conclusion: The ideal treatment is primary lesion removal; however, due to the infrequency and because it is a curable lesion, studies seeking to deepen the knowledge of this disease are considered relevant.
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Affiliation(s)
- Ricardo Malcata Nogueira
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Luis Santos Cardoso
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Lino Fonseca
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Miguel Correia
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Amets Iraneta
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Pedro Roque
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Mario Matos
- Department of Neurosurgery, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
| | - Manuela Mafra
- Department of Pathological Anatomy, Centro Hospitalar Universitario Lisboa Central, R. Jose Antonio Serrano, Lisbon, Lisbon, Portugal
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Katsevman GA, Razzaq B, Serrano CA. Hypothalamic Cavernomas: Pediatric Case Report with 8.5-Year Follow-up and Review of the Literature. World Neurosurg 2020; 146:6-13. [PMID: 33080404 DOI: 10.1016/j.wneu.2020.10.065] [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: 07/31/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cavernous malformations (cavernomas) are angiographically occult vascular lesions that can present symptomatically or be discovered incidentally. Rarely, they present in the hypothalamus or in children. CASE DESCRIPTION We describe the case of a 14-year-old male patient who presented with headaches and fever and was found to have a hypothalamic cavernoma that hemorrhaged. It was managed expectantly, with 1 rehemorrhage 21 months later, and the patient remains asymptomatic to this day aside from headaches. CONCLUSIONS This is to our knowledge the youngest case of a hypothalamic cavernoma to be reported and includes 8.5 years of follow-up and imaging. In addition, a literature review is performed that summarizes the 11 previously reported cases of hypothalamic cavernomas, including associated symptoms, management options, and outcomes.
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Affiliation(s)
- Gennadiy A Katsevman
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
| | - Bayan Razzaq
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Cesar A Serrano
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
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Zhang F, Xue Y, Zhang F, Wei X, Zhou Z, Ma Z, Wang X, Shen H, Li Y, Cui X, Liu L. Identification of a Novel CCM1 Frameshift Mutation in a Chinese Han Family With Multiple Cerebral Cavernous Malformations. Front Neurosci 2020; 14:525986. [PMID: 33071727 PMCID: PMC7538688 DOI: 10.3389/fnins.2020.525986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 08/14/2020] [Indexed: 11/13/2022] Open
Abstract
Cerebral cavernous malformations (CCMs) are vascular lesions that predominantly occur in the brain. CCMs can be sporadic or hereditary in an autosomal dominant manner. The genes harboring variants of familial CCMs (FCCMs) include CCM1/KRIT1, CCM2/MGC4607, and CCM3/PDCD10. In this study, we identified a novel CCM1/KRIT1 mutation in a Chinese family with FCCMs. This family consists of 20 members, and 6 of them had been diagnosed with CCMs. The proband patient is a 17-year-old female who has suffered from CCM-related intracranial hemorrhage four times. Magnetic resonance imaging (MRI) revealed four lesions in the different brain regions and one lesion has progressively enlarged. The pathological histology confirmed CCMs. Whole exome sequencing revealed a novel deletion mutation (c.1635delA) within exon 15 of CCM1/KRIT1 gene in the proband patient, her mother, and her uncle who had CCMs. This frameshift mutation led to a premature termination codon (PTC) at nucleotides 1652-1654. We also detected that the CCM1 mRNA levels in the blood lymphocytes of the family members with CCMs were reduced by 46.4% compared to that in healthy controls. Collectively, our results suggested that the CCM1 mutation could potentially be a causative factor for FCCMs in the Chinese family and the reduction of CCM1 mRNA expression in the blood lymphocytes of the patients might be a potential biomarker for the diagnosis and prognosis of CCMs. Our findings expanded the spectrum of CCM mutations and helped to guide genetic counseling and early genetic diagnosis for at-risk family members.
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Affiliation(s)
- Fan Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yiteng Xue
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoming Wei
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhisong Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhaoru Ma
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaosong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong Shen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yujun Li
- Department of Microbiology and Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Xiaoying Cui
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD, Australia
| | - Li Liu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Flemming KD, Lanzino G. Cerebral Cavernous Malformation: What a Practicing Clinician Should Know. Mayo Clin Proc 2020; 95:2005-2020. [PMID: 32605781 DOI: 10.1016/j.mayocp.2019.11.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/17/2019] [Accepted: 11/13/2019] [Indexed: 01/24/2023]
Abstract
Cavernous malformations (CMs) are angiographically occult, low-flow vascular malformations of the central nervous system. They are acquired lesions, with approximately 80% of patients having the sporadic form and 20% the familial form of the disease. The lesions may also develop years after radiotherapy. At the microscopic level, they consist of endothelium-lined cavities (or "caverns") containing blood of different ages. The endothelium proliferates abnormally, and tight junctions are absent or dysfunctional, resulting in leakiness of the endothelium and clinical manifestations in some patients. Cavernous malformations can be an incidental finding or can present with focal neurologic deficits, seizures, or headache, with or without associated hemorrhage. Management of the CM lesion requires knowledge of the natural history of the disease compared with the risk of surgical intervention. Surgery is often considered for symptomatic patients with lesions in a noneloquent location. Medical management is warranted for symptoms related to the CM. Research aimed at understanding the genes and signaling pathways related to CMs have provided potential drug targets, and clinical trials are underway to determine whether medications reduce the risk of future bleeding without surgery or modify the disease course. In addition, recent epidemiologic data have aided practitioners in determining how to treat comorbid conditions in patients with a potentially hemorrhagic lesion. This review provides an overview of the epidemiology, presentation, and clinical management of CMs.
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Ishii K, Tozaka N, Tsutsumi S, Muroi A, Tamaoka A. Familial cerebral cavernous malformation presenting with epilepsy caused by mutation in the CCM2 gene: A case report. Medicine (Baltimore) 2020; 99:e19800. [PMID: 32702807 PMCID: PMC7373609 DOI: 10.1097/md.0000000000019800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cerebral cavernous malformation (CCM) of the familial type is caused by abnormalities in the CCM1, CCM2, and CCM3 genes. These 3 proteins forming a complex associate with the maintenance of vascular endothelial cell-cell junctions. Dysfunction of these proteins results in the development of hemangiomas and abnormal intercellular junctions. PATIENT CONCERNS We report a 68-year-old man with familial cerebral cavernous malformation with initial presentation as convulsions at an advanced age. Brain magnetic resonance imaging revealed multiple cavernous hemangiomas in the right occipital lobe. The convulsions were considered to be induced by hemorrhage from cavernous hemangioma in the right occipital lobe. DIAGNOSES Genetic screening of the CCM1, CCM2, and CCM3 genes revealed a novel mutation in the CCM2 gene (exon4 c: 359 T>A, p: V120D). No abnormalities were found in CCM1 or CCM3. Therefore, we diagnosed the patient with familial CCM caused by a CCM2 mutation. INTERVENTIONS This patient was treated with the administration of levetiracetam at a dosage of 1000 mg/day. OUTCOMES No seizures have been observed since the antiepileptic drug was administered. We performed brain magnetic resonance imaging (MRI) regularly to follow-up on appearance of new cerebral hemorrhages and cavernous hemangiomas. LESSONS This report reviews cases of familial cerebral cavernous malformations caused by abnormalities in the CCM2 gene. This mutation site mediates interactions with CCM1 and CCM3. The mutation occurs in the phosphotyrosine binding (PTB) site, which is considered functionally important to CCM2.
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MESH Headings
- Aged
- Anticonvulsants/administration & dosage
- Anticonvulsants/therapeutic use
- Carrier Proteins/genetics
- Genetic Testing
- Hemangioma, Cavernous/complications
- Hemangioma, Cavernous/genetics
- Hemangioma, Cavernous/pathology
- Hemangioma, Cavernous, Central Nervous System/diagnostic imaging
- Hemangioma, Cavernous, Central Nervous System/drug therapy
- Hemangioma, Cavernous, Central Nervous System/genetics
- Hemangioma, Cavernous, Central Nervous System/pathology
- Hemorrhage/diagnostic imaging
- Hemorrhage/etiology
- Humans
- Levetiracetam/administration & dosage
- Levetiracetam/therapeutic use
- Magnetic Resonance Imaging/methods
- Male
- Mutation
- Seizures/diagnosis
- Seizures/etiology
- Treatment Outcome
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Affiliation(s)
- Kazuhiro Ishii
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575
| | - Naoki Tozaka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575
| | - Satoshi Tsutsumi
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021
| | - Ai Muroi
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akira Tamaoka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575
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Cerebral cavernous malformation presenting in childhood: a single-centered surgical experience of 29 cases. Clin Neurol Neurosurg 2020; 194:105830. [DOI: 10.1016/j.clineuro.2020.105830] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/21/2022]
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Zheng JJ, Liu PP, Wang L, Zhang LW, Zhang JT, Li D, Wu Z, Wu YM. Natural history of incidentally diagnosed brainstem cavernous malformations in a prospective observational cohort. Neurosurg Rev 2020; 44:1151-1164. [PMID: 32399728 DOI: 10.1007/s10143-020-01308-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/21/2020] [Accepted: 04/26/2020] [Indexed: 12/18/2022]
Abstract
There was a lack of natural history of incidental brainstem cavernous malformations (CMs), hemorrhage of which would lead to severe neuropathies. The study aimed to evaluate the prospective hemorrhage rate and neurological outcome of the disease. This prospective cohort included patients with incidental brainstem CMs referred to our institute from 2009 to 2015. The diagnosis was confirmed based on the patients' complain, physical examination, and radiographic evidence. Clinical data were collected, scheduled follow-up was performed, and the independent risk factors were identified by multivariate analysis. This cohort included 48 patients (22 female, 45.8%). The median follow-up duration was 60.7 months, and 13 prospective hemorrhages occurred within 244.0 patient-years yielding an annual hemorrhage rate of 5.3%. The hemorrhage-free survival at 1 and 5 years was 91.6% and 80.6%. Age ≥ 55 years (hazard ratio (HR) = 8.59, p = 0.003), lesion size (per 1-mm increase) (HR = 3.55, p = 0.041), developmental venous anomaly (HR = 10.28, p = 0.017), and perilesional edema (HR = 4.90, p = 0.043) were independent risk factors for hemorrhage. Seven patients (14.6%) received surgical resection, and the other 41 patients remained under observation. Neurological function was improved in 22 patients (45.8%), unchanged in 19 (39.6%), and worsened in 7 (14.6%). Prospective hemorrhage (odds ratio = 14.95, p = 0.037) was the only independent risk factor for worsened outcomes. The natural history of incidental brainstem CMs seemed to be acceptable with improved/unchanged outcomes in most patients (85.4%). These results improved our understanding of the disease, and the future study of a large cohort was required to verify our findings.
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Affiliation(s)
- Jing-Jie Zheng
- Department of Gynecologic Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Pan-Pan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
- Department of Neurosurgery, The Municipal Hospital of Weihai, No. 70 Heping Road, Huancui District, Weihai, People's Republic of China
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China.
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Nansihuan Xilu 119, Fengtai District, Beijing, People's Republic of China.
| | - Yu-Mei Wu
- Department of Gynecologic Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China.
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48
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Carrión-Penagos J, Zeineddine HA, Polster SP, Girard R, Lyne SB, Koskimäki J, Romanos S, Srinath A, Zhang D, Cao Y, Stadnik A, Piedad K, Shenkar R, Awad IA. Subclinical imaging changes in cerebral cavernous angiomas during prospective surveillance. J Neurosurg 2020; 134:1147-1154. [PMID: 32244216 DOI: 10.3171/2020.1.jns193479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to systematically assess asymptomatic changes (ACs), including subclinical hemorrhage, growth, or new lesion formation (NLF) during longitudinal follow-up of cerebral cavernous angiomas (CAs), and to correlate these with symptomatic hemorrhage (SH) during the same period and with clinical features of the disease. METHODS One hundred ninety-two patients were included in this study, among 327 consecutive patients with CA, prospectively identified between September 2009 and February 2019. Included patients had undergone clinical and MRI follow-up, in conjunction with institutional review board-approved biomarker studies, and harbored ≥ 1 CA with a maximum diameter of ≥ 5 mm on T2-weighted MRI. Rates of AC and SH per lesion-year and patient-year were assessed using prospectively articulated criteria. In multifocal/familial cases, rates of NLF were also assessed. RESULTS There were no differences in demographic or disease features among cases included or excluded in the study cohort, except for a higher proportion of included patients with CCM3 mutation. Follow-up was 411 patient-years (2503 lesion-years). The rate of AC was higher than the rate of SH (12.9% vs 7.5% per patient-year, and 2.1% vs 1.2% per lesion-year, both p = 0.02). Patients presenting with a prior history of SH had a higher rate of AC than those with other forms of presentation (19.7% and 8.2% per patient-year, respectively; p = 0.003). A higher rate of NLF on T2-weighted MRI (p = 0.03) was observed in patients with prior SH. Three of 6 solitary/sporadic and 2 of 28 multifocal/familial patients underwent resection of the lesion after AC. CONCLUSIONS Rates of AC are greater than SH during prospective follow-up of CAs, and greater in cases with prior SH. AC may be a more sensitive biomarker of lesional activity, and a more efficient surrogate outcome in clinical trials than SH. Patients experiencing an AC are more likely to undergo a surgical intervention when CAs are solitary/sporadic than when they are multifocal/familial.
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49
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Chohan MO, Marchiò S, Morrison LA, Sidman RL, Cavenee WK, Dejana E, Yonas H, Pasqualini R, Arap W. Emerging Pharmacologic Targets in Cerebral Cavernous Malformation and Potential Strategies to Alter the Natural History of a Difficult Disease: A Review. JAMA Neurol 2020; 76:492-500. [PMID: 30476961 DOI: 10.1001/jamaneurol.2018.3634] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Cerebral cavernous malformations (CCMs) are vascular lesions of the brain that may lead to hemorrhage, seizures, and neurologic deficits. Most are linked to loss-of-function mutations in 1 of 3 genes, namely CCM1 (originally called KRIT1), CCM2 (MGC4607), or CCM3 (PDCD10), that can either occur as sporadic events or are inherited in an autosomal dominant pattern with incomplete penetrance. Familial forms originate from germline mutations, often have multiple intracranial lesions that grow in size and number over time, and cause an earlier and more severe presentation. Despite active preclinical research on a few pharmacologic agents, clinical translation has been slow. Open surgery and, in some cases, stereotactic radiosurgery remain the only effective treatments, but these options are limited by lesion accessibility and are associated with nonnegligible rates of morbidity and mortality. Observations We discuss the limits of CCM management and introduce findings from in vitro and in vivo studies that provide insight into CCM pathogenesis and indicate molecular mechanisms as potential therapeutic targets. These studies report dysregulated cellular pathways shared between CCM, cardiovascular diseases, and cancer. They also suggest the potential effectiveness of proper drug repurposing in association with, or as an alternative to, targeted interventions. Conclusions and Relevance We propose methods to exploit specific molecular pathways to design patient-tailored therapeutic approaches in CCM, with the aim to alter its natural progression. In this scenario, the lack of effective pharmacologic options remains a critical barrier that poses an unfulfilled and urgent medical need.
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Affiliation(s)
- Muhammad O Chohan
- The University of New Mexico Comprehensive Cancer Center, Albuquerque.,Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Serena Marchiò
- The University of New Mexico Comprehensive Cancer Center, Albuquerque.,Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque.,Department of Oncology, University of Torino School of Medicine, Candiolo, Torino, Italy.,Candiolo Cancer Institute-Fondazione del Piemonte per l'Oncologia, Istituto di Ricovero e Cura a Carattere Scientifico, Candiolo, Torino, Italy
| | - Leslie A Morrison
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque
| | - Richard L Sidman
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Webster K Cavenee
- Ludwig Institute for Cancer Research, University of California, San Diego
| | - Elisabetta Dejana
- Fondazione Italiana per la Ricerca sul Cancro Institute of Molecular Oncology Fondazione, Milan, Italy.,Mario Negri Institute for Pharmacological Research, Milan, Italy.,Department of Biosciences, School of Sciences and Department of Oncology, School of Medicine, Milano University, Milan, Italy.,Department of Immunology, Genetics and Pathology, University of Uppsala, Uppsala, Sweden
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Renata Pasqualini
- Rutgers Cancer Institute of New Jersey at University Hospital, Newark.,Division of Cancer Biology, Department of Radiation Oncology, Rutgers New Jersey Medical School, Newark
| | - Wadih Arap
- Rutgers Cancer Institute of New Jersey at University Hospital, Newark.,Division of Hematology/Oncology, Department of Medicine, Rutgers New Jersey Medical School, Newark
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50
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Zafar A, Quadri SA, Farooqui M, Ikram A, Robinson M, Hart BL, Mabray MC, Vigil C, Tang AT, Kahn ML, Yonas H, Lawton MT, Kim H, Morrison L. Familial Cerebral Cavernous Malformations. Stroke 2020; 50:1294-1301. [PMID: 30909834 DOI: 10.1161/strokeaha.118.022314] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Atif Zafar
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Syed A Quadri
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.A.Q.)
| | - Mudassir Farooqui
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Asad Ikram
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Myranda Robinson
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Blaine L Hart
- Radiology (B.L.H., M.C.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Marc C Mabray
- Radiology (B.L.H., M.C.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | | | - Alan T Tang
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.T., M.L.K.)
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.T., M.L.K.)
| | - Howard Yonas
- Neurosurgery (H.Y.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
| | - Helen Kim
- Department of Anesthesia and Perioperative Care and Department of Epidemiology and Biostatistics, University of California San Francisco (H.K.)
| | - Leslie Morrison
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
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