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Alyafaie A, Han W, Li Y, Vydro SA, Vella M, Truong TL, Park L, Langston D, Kim H, Conrad MB, Hetts SW. Arterial Spin-Labeling MR Imaging in the Detection of Intracranial Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia. AJNR Am J Neuroradiol 2024; 45:1019-1024. [PMID: 38991769 DOI: 10.3174/ajnr.a8281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/07/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that causes vascular malformations in a variety of organs and tissues, including brain AVMs. Because brain AVMs have the potential to cause disabling or fatal intracranial hemorrhage, detection of these lesions before rupture is the goal of screening MR imaging/MRA examinations in patients with HHT. Prior studies have demonstrated superior sensitivity for HHT-related brain AVMs by using postcontrast MR imaging sequences as compared with MRA alone. We now present data regarding the incremental benefit of including arterial spin-labeling (ASL) perfusion sequences as part of MR imaging/MRA screening in patients with this condition. MATERIALS AND METHODS We retrospectively analyzed 831 patients at the UCSF Hereditary Hemorrhagic Telangiectasia Center of Excellence. Of these, 42 patients had complete MR imaging/MRA, ASL perfusion scans, and criterion-standard DSA data. Two neuroradiologists reviewed imaging studies and a third provided adjudication when needed. RESULTS Eight patients had no brain AVMs detected on DSA. The remaining 34 patients had 57 brain AVMs on DSA. Of the 57 identified AVMs, 51 (89.5%) were detected on ASL and 43 (75.4%) were detected on conventional MR imaging/MRA sequences (P = .049), with 8 lesions detected on ASL perfusion but not on conventional MR imaging. CONCLUSIONS ASL provides increased sensitivity for brain AVMs in patients with HHT. Inclusion of ASL should be considered as part of comprehensive MR imaging/MRA screening protocols for institutions taking care of patients with HHT.
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Affiliation(s)
- Adam Alyafaie
- From the School of Medicine (A.A., S.A.V.), University of California, San Francisco, San Francisco, California
| | - Woody Han
- Department of Radiology and Biomedical Imaging (W.H., Y.L., M.V.), University of California, San Francisco, San Francisco, California
| | - Yi Li
- Department of Radiology and Biomedical Imaging (W.H., Y.L., M.V.), University of California, San Francisco, San Francisco, California
| | - Samuel A Vydro
- From the School of Medicine (A.A., S.A.V.), University of California, San Francisco, San Francisco, California
| | - Maya Vella
- Department of Radiology and Biomedical Imaging (W.H., Y.L., M.V.), University of California, San Francisco, San Francisco, California
| | - Torianna L Truong
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Lindsay Park
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Daniel Langston
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Helen Kim
- Department of Anesthesia, and Perioperative Care (H.K.), University of California, San Francisco, San Francisco, California
| | - Miles B Conrad
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Steven W Hetts
- HHT Center of Excellence, Departments of Radiology, Biomedical Imaging, and Neurological Surgery (S.W.H.), University of California, San Francisco, San Francisco, California
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Beslow LA, Krings T, Kim H, Hetts SW, Lawton MT, Ratjen F, Whitehead KJ, Gossage JR, McCulloch CE, Clancy M, Bagheri N, Faughnan ME. De Novo Brain Vascular Malformations in Hereditary Hemorrhagic Telangiectasia. Pediatr Neurol 2024; 155:120-125. [PMID: 38631080 PMCID: PMC11102835 DOI: 10.1016/j.pediatrneurol.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/26/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Approximately 10% of people with hereditary hemorrhagic telangiectasia (HHT) have brain vascular malformations (VMs). Few reports describe de novo brain VM formation. International HHT Guidelines recommend initial brain VM screening upon HHT diagnosis in children but do not address rescreening. We aimed to confirm whether brain VMs can form de novo in patients with HHT. METHODS The Brain Vascular Malformation Consortium HHT project is a 17-center longitudinal study enrolling patients since 2010. We analyzed the database for de novo VMs defined as those detected (1) on follow-up neuroimaging in a patient without previous brain VMs or (2) in a location distinct from previously identified brain VMs and reported those in whom a de novo VM could be confirmed on central neuroimaging review. RESULTS Of 1909 patients enrolled, 409 (21%) had brain VMs. Seven patients were recorded as having de novo brain VMs, and imaging was available for central review in four. We confirmed that three (0.7% of individuals with brain VMs) had de novo brain VMs (two capillary malformations, one brain arteriovenous malformation) with intervals of six, nine, and 13 years from initial imaging. Two with de novo brain VMs were <18 years. The fourth patient, a child, did not have a de novo brain VM but had a radiologically confirmed increase in size of an existing brain arteriovenous malformation. CONCLUSIONS Brain VMs can, albeit rarely, form de novo in patients with HHT. Given the potential risk of hemorrhage from brain VMs, regular rescreening in patients with HHT may be warranted.
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Affiliation(s)
- Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Helen Kim
- Department of Anesthesia, University of California - San Francisco, San Francisco, California
| | - Steven W Hetts
- Division of Neurointerventional Radiology, University of California - San Francisco, San Francisco, California
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Felix Ratjen
- Department of Paediatrics, Division of Paediatric Respiratory Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Kevin J Whitehead
- Departments of Internal Medicine and Pediatrics, The University of Utah, Salt Lake City, Utah
| | - James R Gossage
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California - San Francisco, San Francisco, California
| | | | - Negar Bagheri
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
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Pollak M, Gatt D, Shaw M, Hewko SL, Lamanna A, Santos S, Ratjen F. Longitudinal Assessment of Curaçao Criteria in Children with Hereditary Hemorrhagic Telangiectasia. J Pediatr 2023; 263:113665. [PMID: 37572862 DOI: 10.1016/j.jpeds.2023.113665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To assess the utility of the Curaçao criteria by age over time in children with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN This was a single-center, retrospective analysis of patients attending the HHT clinic at the Hospital for Sick Children (Toronto, Canada) between 2000 and 2019. The evaluation of the Curaçao criteria was completed during initial and follow-up visits. Screening for pulmonary and brain arteriovenous malformations was completed at 5 yearly intervals. RESULTS A total of 116 patients with genetic confirmation of HHT were included in the analysis. At initial screening at a median (IQR) age of 8.4 (2.8, 12.9) years, 41% met criteria for a definite clinical diagnosis (≥3 criteria). In children <6 years at presentation, only 23% fulfilled at least 3 criteria initially. In longitudinal follow-up, 63% reached a definite clinical diagnosis, with a median (IQR) follow-up duration of 5.2 (3.2, 7.9) years (P = .005). Specifically, more patients met the epistaxis and telangiectasia criteria at last visit compared with initial (79% vs 60%; P = .006; 47% vs 30%; P = .02) but not for the arteriovenous malformation criterion (59% vs 57%; P = .65). CONCLUSIONS In the pediatric population, most patients do not meet definite clinical criteria of HHT at initial presentation. Although the number of diagnostic criteria met increased over time, mainly due to new onset of epistaxis and telangiectasia, accuracy remained low during follow-up visits. Relying solely on clinical criteria may lead to underdiagnosis of HHT in children.
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Affiliation(s)
- Mordechai Pollak
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Pediatric Pulmonology Institute, The Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel.
| | - Dvir Gatt
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sheryl L Hewko
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Anthony Lamanna
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sara Santos
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Felix Ratjen
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
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Han C, Nguyen CL, Scherschinski L, Schriber TD, Arthur HM, Lawton MT, Oh SP. VEGFR2 Expression Correlates with Postnatal Development of Brain Arteriovenous Malformations in a Mouse Model of Type I Hereditary Hemorrhagic Telangiectasia. Biomedicines 2023; 11:3153. [PMID: 38137374 PMCID: PMC10740421 DOI: 10.3390/biomedicines11123153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 12/24/2023] Open
Abstract
Brain arteriovenous malformations (BAVMs) are a critical concern in hereditary hemorrhagic telangiectasia (HHT) patients, carrying the risk of life-threatening intracranial hemorrhage. While traditionally seen as congenital, the debate continues due to documented de novo cases. Our primary goal was to identify the precise postnatal window in which deletion of the HHT gene Endoglin (Eng) triggers BAVM development. We employed SclCreER(+);Eng2f/2f mice, enabling timed Eng gene deletion in endothelial cells via tamoxifen. Tamoxifen was given during four postnatal periods: P1-3, P8-10, P15-17, and P22-24. BAVM development was assessed at 2-3 months using latex dye perfusion. We examined the angiogenic activity by assessing vascular endothelial growth factor receptor 2 (VEGFR2) expression via Western blotting and Flk1-LacZ reporter mice. Longitudinal magnetic resonance angiography (MRA) was conducted up to 9 months. BAVMs emerged in 88% (P1-3), 86% (P8-10), and 55% (P15-17) of cases, with varying localization. Notably, the P22-24 group did not develop BAVMs but exhibited skin AVMs. VEGFR2 expression peaked in the initial 2 postnatal weeks, coinciding with BAVM onset. These findings support the "second hit" theory, highlighting the role of early postnatal angiogenesis in initiating BAVM development in HHT type I mice.
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Affiliation(s)
- Chul Han
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
| | - Candice L. Nguyen
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
| | - Lea Scherschinski
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Tyler D. Schriber
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
| | - Helen M. Arthur
- Biosciences Institute, Newcastle University, Newcastle NE1 7RU, UK;
| | - Michael T. Lawton
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Suk Paul Oh
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
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Hereditary Hemorrhagic Telangiectasia in Pediatric Age: Focus on Genetics and Diagnosis. Pediatr Rep 2023; 15:129-142. [PMID: 36810341 PMCID: PMC9944132 DOI: 10.3390/pediatric15010011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) or Rendu-Osler-Weber Syndrome (ROW) is an autosomal dominant vascular disease, with an estimated prevalence of 1:5000. Genes associated with HHT are ACVRL1, ENG, SMAD4, and GDF2, all encoding for proteins involved in the TGFβ/BMPs signaling pathway. The clinical diagnosis of HHT is made according to the "Curaçao Criteria," based on the main features of the disease: recurrent and spontaneous epistaxis, muco-cutaneous telangiectases, arteriovenous malformations in the lungs, liver, and brain, and familiarity. Since the clinical signs of HHT can be misinterpreted, and the primary symptom of HHT, epistaxis, is common in the general population, the disease is underdiagnosed. Although HHT exhibits a complete penetrance after the age of 40, young subjects may also present symptoms of the disease and are at risk of severe complications. Here we review the literature reporting data from clinical, diagnostic, and molecular studies on the HHT pediatric population.
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Neurovascular Manifestations in Pediatric Patients With Hereditary Haemorrhagic Telangiectasia. Pediatr Neurol 2022; 129:24-30. [PMID: 35176532 DOI: 10.1016/j.pediatrneurol.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a multiorgan vascular dysplasia with limited data regarding its neurovascular manifestations and genotype-phenotype correlation in children. The objective of this study was to describe the neurovascular findings in a large cohort of children with HHT and correlate between phenotype and genotype. METHODS This retrospective study was conducted on 221 children (<18 years) with a definite or possible diagnosis of HHT based on Curacao criteria, or with positive genetics for the mutated genes of ENG, ACVRL-1, and SMAD-4, who also underwent brain MRI and/or conventional angiography. Demographic and clinical information, imaging findings, and follow up information were gathered. RESULTS Two hundred twenty-one children with HHT (70.6% genetically confirmed, and 99.5% positive family history) were included, with a median age of 7 years (interquartile range: 3 to 11 years) and 58.8% male predominance. Neurovascular lesions were found in 64 of 221 (28.9%), with 3.1% prevalence of intracranial hemorrhage. The most commonly observed vascular malformations were developmental venous anomalies (48.5%) and brain arteriovenous malformations (AVMs) (31.2%), followed by capillary malformations (14.1%). Multiple AVMs were seen in 10.0% of the cohort. We found no instances of de novo AVM (1281.8 patient-years).A significantly higher proportion of patients with ENG mutations (19.7%) had brain AVM than those with ACVRL-1 (4.9%) and SMAD-4 (0%) mutations (P < 0.01). There was no significant difference in the hemorrhagic risk of shunting lesions associated with ENG (35.3%) or ACVRL-1 (33.3%) positivity (P = 0.9). CONCLUSIONS We describe the neurovascular imaging and genetic findings from a large pediatric cohort of HHT, to enhance clinical awareness and guide management of patients with HHT.
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Park H, Koh EJ, Lee EJ, Cheon JE, Kim SK. An acquired cerebral arteriovenous malformation after brain abscess treatment: case report and a review of the literature. Childs Nerv Syst 2021; 37:2923-2926. [PMID: 33502542 DOI: 10.1007/s00381-021-05050-w] [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: 12/29/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
A cerebral arteriovenous malformation (AVM) is a congenital and static disease. However, there are increasing reports of acquired AVMs. The pathophysiology of an acquired AVM has not been fully elucidated but the suggested pathophysiology is a combination of genetic abnormalities and inflammatory cytokines caused by previous brain insults. We report a patient who developed an acquired AVM after the treatment for a brain abscess. She underwent Gamma Knife surgery to treat the acquired AVM. It is necessary to understand the characteristics of acquired AVMs and to further research acquired AVMs.
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Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eun Jung Koh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jung-Eun Cheon
- Division of Pediatric Radiology, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, South Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Republic of Korea.
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Current concepts and perspectives on brain arteriovenous malformations: A review of pathogenesis and multidisciplinary treatment. World Neurosurg 2021; 159:314-326. [PMID: 34339893 DOI: 10.1016/j.wneu.2021.07.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. The appropriate selection of patients with brain arteriovenous malformations for interventional treatment requires balancing the risk of treatment complications against the risk of hemorrhaging during the natural course of the pathology; however, no definitive guidelines have been established for the management of brain arteriovenous malformations. In this paper, we comprehensively review the current basic and clinical studies on bAVMs and discuss the contemporary status of multidisciplinary management of bAVMs.
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Hetts SW, Shieh JT, Ohliger MA, Conrad MB. Hereditary Hemorrhagic Telangiectasia: The Convergence of Genotype, Phenotype, and Imaging in Modern Diagnosis and Management of a Multisystem Disease. Radiology 2021; 300:17-30. [PMID: 33973836 DOI: 10.1148/radiol.2021203487] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that manifests as vascular malformations in the brain, lung, liver, gastrointestinal tract, nasal mucosa, and skin. Diagnosis and management of HHT is guided in large part by imaging studies, making it a condition with which the radiology community needs familiarity. Proper screening and care lead to improved morbidity and mortality in patients with HHT. International guidelines were recently updated and form the basis for a detailed discussion of the role of imaging and image-guided therapy in HHT. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Steven W Hetts
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Joseph T Shieh
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Michael A Ohliger
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Miles B Conrad
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
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Florian IA, Beni L, Moisoiu V, Timis TL, Florian IS, Balașa A, Berindan-Neagoe I. 'De Novo' Brain AVMs-Hypotheses for Development and a Systematic Review of Reported Cases. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:201. [PMID: 33652628 PMCID: PMC7996785 DOI: 10.3390/medicina57030201] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 12/11/2022]
Abstract
Background and Objectives: Brain arteriovenous malformations AVMs have been consistently regarded as congenital malformations of the cerebral vasculature. However, recent case reports describing "de novo AVMs" have sparked a growing debate on the nature of these lesions. Materials and Methods: We have performed a systematic review of the literature concerning de novo AVMs utilizing the PubMed and Google Academic databases. Termes used in the search were "AVM," "arteriovenous," "de novo," and "acquired," in all possible combinations. Results: 53 articles including a total of 58 patients harboring allegedly acquired AVMs were identified by researching the literature. Of these, 32 were male (55.17%), and 25 were female (43.10%). Mean age at de novo AVM diagnosis was 27.833 years (standard deviation (SD) of 21.215 years and a 95% confidence interval (CI) of 22.3 to 33.3). Most de novo AVMs were managed via microsurgical resection (20 out of 58, 34.48%), followed by radiosurgery and conservative treatment for 11 patients (18.97%) each, endovascular embolization combined with resection for five patients (8.62%), and embolization alone for three (5.17%), the remaining eight cases (13.79%) having an unspecified therapy. Conclusions: Increasing evidence suggests that some of the AVMs discovered develop some time after birth. We are still a long way from finally elucidating their true nature, though there is reason to believe that they can also appear after birth. Thus, we reason that the de novo AVMs are the result of a 'second hit' of a variable type, such as a previous intracranial hemorrhage or vascular pathology. The congenital or acquired characteristic of AVMs may have a tremendous impact on prognosis, risk of hemorrhage, and short and long-term management.
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Affiliation(s)
- Ioan Alexandru Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, 400012 Cluj-Napoca, Romania; (L.B.); (V.M.); (I.S.F.)
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Lehel Beni
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, 400012 Cluj-Napoca, Romania; (L.B.); (V.M.); (I.S.F.)
| | - Vlad Moisoiu
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, 400012 Cluj-Napoca, Romania; (L.B.); (V.M.); (I.S.F.)
| | - Teodora Larisa Timis
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania;
| | - Ioan Stefan Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, 400012 Cluj-Napoca, Romania; (L.B.); (V.M.); (I.S.F.)
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adrian Balașa
- Clinic of Neurosurgery, Tîrgu Mureș County Clinical Emergency Hospital, 540136 Tîrgu Mureș, Romania;
- Department of Neurosurgery, Tîrgu Mureș University of Medicine, Pharmacy, Science and Technology, 540139 Tîrgu Mureș, Romania
| | - Ioana Berindan-Neagoe
- Research Center for Functional Genomics, Biomedicine, and Translational Medicine, Institute of Doctoral Studies, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
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Abdalla RN, Shokuhfar T, Hurley MC, Ansari SA, Jahromi BS, Potts MB, Batjer HH, Shaibani A. Metachronous spinal pial arteriovenous fistulas: case report. J Neurosurg Spine 2021; 34:310-315. [PMID: 33157537 DOI: 10.3171/2020.6.spine20600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/17/2020] [Indexed: 11/06/2022]
Abstract
Spinal pial arteriovenous fistulas (spAVFs) are believed to be congenital lesions, and the development of a de novo spAVF has not been previously described. A 49-year-old female with a childhood history of vascular malformation-induced right lower-extremity hypertrophy presented in 2004 with progressive pain in her right posterior thigh and outer foot. Workup revealed 3 separate type IV spAVFs, which were treated by combined embolization and resection, with final conventional angiography showing no residual spinal vascular lesion in 2005. Ten years later, the patient returned with new right lower-extremity weakness, perineal pain, and left plantar foot numbness. Repeat spinal angiography demonstrated 2 de novo intertwined conus medullaris spAVFs.
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Affiliation(s)
- Ramez N Abdalla
- Departments of1Radiology
- 2Department of Radiology, Ain Shams University, Cairo, Egypt
| | - Tahaamin Shokuhfar
- Departments of1Radiology
- 3Department of Neurology, Loyola University, Chicago, Illinois; and
| | | | - Sameer A Ansari
- Departments of1Radiology
- 4Neurological Surgery, and
- 5Neurology, Northwestern University, Chicago, Illinois
| | | | | | - H Hunt Batjer
- 6Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas
| | - Ali Shaibani
- Departments of1Radiology
- 4Neurological Surgery, and
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12
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Krithika S, Sumi S. Neurovascular inflammation in the pathogenesis of brain arteriovenous malformations. J Cell Physiol 2020; 236:4841-4856. [PMID: 33345330 DOI: 10.1002/jcp.30226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/11/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022]
Abstract
Brain arteriovenous malformations (bAVM) arise as congenital or sporadic focal lesions with a significant risk for intracerebral hemorrhage (ICH). A wide range of interindividual differences is present in the onset, progression, and severity of bAVM. A growing body of gene expression and polymorphism-based research studies support the involvement of localized inflammation in bAVM disease progression and rupture. In this review article, we analyze the altered responses of neural, vascular, and immune cell types that contribute to the inflammatory process, which exacerbates the pathophysiological progression of vascular dysmorphogenesis in bAVM lesions. The cumulative effect of inflammation in bAVM development is orchestrated by various genetic moderators and inflammatory mediators. We also discuss the potential therapies for the treatment of brain AVM by targeting the inflammatory processes and mediators. Elucidating the precise role of inflammation in the bAVM growth and hemorrhage would open novel avenues for noninvasive and effectual causal therapy that may complement the current therapeutic strategies.
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Affiliation(s)
- S Krithika
- Cardiovascular Diseases and Diabetes Biology, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - S Sumi
- Cardiovascular Diseases and Diabetes Biology, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
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13
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Mueller O, Kasper E, Droege F, Goericke S, Stein KP, Sure U. Cerebral Arteriovenous Malformations in Pediatric Patients with Hereditary Hemorrhagic Telangiectasia: Re-evaluating Appearance, Bleeding Risk, and Treatment Necessity in a Selective Meta-analysis. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1715499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractPediatric patients suffering from cerebral nidal arteriovenous malformations are a unique population due to the rare occurrence of the disease. Diagnosis of hereditary hemorrhagic telangiectasia (HHT) in children is a rare event and mainly restricted to coincidental detection from screening of possibly afflicted family members. In patients with HHT, it is well known that the incidence of cerebral vascular malformations (CVMs) is higher than expected when compared with the nonafflicted population. Even though CVMs comprise a variety of different distinct anatomical and radiographic entities (e.g., capillary telangiectasia, nidal arteriovenous malformation [AVM], cavernous malformation, dural or pial as well as mixed fistula, and vein of Galen malformation), they are mostly summarized and analyzed all in one category due to the low number of individual cases identified in single centers. Nevertheless, the best treatment algorithm will likely vary significantly between different CVMs as does the clinical presentation and the natural course of the CVM. It is therefore the objective of this article to focus on nidal AVMs in pediatric patients suffering from HHT. To this end, we performed a systematic selective literature research to estimate incidence, clinical and radiological appearance, as well as classification according to established grading system, and to evaluate the necessity of treatment of these lesions in light of their respective outcomes. Our line of arguments explains why we recommend to follow these lesions expectantly and suggest to keep pediatric patients under surveillance with sequential scans until they reach adulthood.
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Affiliation(s)
- Oliver Mueller
- Department of Neurosurgery, University of Essen, Essen, Germany
- Department of Neurosurgery, Dortmund Hospital, Dortmund, Germany
| | - Ekkehard Kasper
- Division of Neurosurgery, Hamilton General Hospital, Hamilton, Canada
| | - Freya Droege
- Department of Oto-Rhino-Laryngology, University of Essen, Essen, Germany
| | - Sophia Goericke
- Institute of Radiology, Neuroradiology and Interventional Radiology, University of Essen, Essen, Germany
| | - Klaus-Peter Stein
- Department of Neurosurgery, University of Essen, Essen, Germany
- Department of Neurosurgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University of Essen, Essen, Germany
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14
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Nagai Y, Anan M, Fujiki M. Cerebral Arteriovenous Malformations as Acquired Lesions: Case Reports and Review of the Literature. J Stroke Cerebrovasc Dis 2020; 29:105157. [PMID: 32912502 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105157] [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: 06/17/2020] [Accepted: 07/12/2020] [Indexed: 12/18/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) are generally attributed to congenital lesions that arise from aberrant vasculogenesis between the fourth and eighth weeks of embryonic life. However, this dogma has been challenged by several recent observations, one of which is de novo formation of AVMs. Forty cases of de novo AVMs were published between 2000 and 2019, all of which involved a history of intracranial insult, such as vascular abnormalities or nonvascular conditions, prior to AVM diagnosis. We hereby present two unique operative cases of ruptured de novo AVMs in older adult patients. Case 1 is novel in the sense that the patient did not experience any kind of environmental trigger ("second hit") such as a previous intracranial insult, while Case 2 serves as the second report of a de novo AVM patient with a medical history of Bell's palsy. Although the exact mechanisms of AVM formation remain to be elucidated, it is likely to be a multifactorial process related to environmental and hemodynamic factors.
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Affiliation(s)
- Yasuyuki Nagai
- Department of Neurosurgery, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita 8740011, Japan.
| | - Mitsuhiro Anan
- Department of Neurosurgery, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita 8740011, Japan
| | - Minoru Fujiki
- Department of Neurosurgery, Oita University Faculty of Medicine, 1-1 Idaigaoka Hasama-machi, Yufu, Oita 8795593, Japan
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15
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Beslow LA, Breimann J, Licht DJ, Waldman J, Fallacaro S, Pyeritz RE, Goldmuntz E, Vossough A. Cerebrovascular Malformations in a Pediatric Hereditary Hemorrhagic Telangiectasia Cohort. Pediatr Neurol 2020; 110:49-54. [PMID: 32718529 DOI: 10.1016/j.pediatrneurol.2020.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND We determined the frequency of cerebrovascular malformations in a pediatric cohort with hereditary hemorrhagic telangiectasia. METHODS Retrospective cohort study of 54 children diagnosed with hereditary hemorrhagic telangiectasia at a tertiary care center. All neuroimaging was reviewed to assess for number and types of cerebrovascular malformations and for intracerebral hemorrhage and arterial ischemic stroke. Clinical charts were reviewed for clinical manifestations, genetic mutation, and clinically evident intracerebral hemorrhages and arterial ischemic strokes. RESULTS Among 54 children with hereditary hemorrhagic telangiectasia with a median age of 3.5 years (interquartile range 0.4 to 7.9 years) at diagnosis, neuroimaging was performed in 52 (96.3%) at a median age of 5.2 years (interquartile range 1.8 to 9 years). Fourteen of 52 imaged children (26.9%) had cerebrovascular malformations. Cerebrovascular malformations included arteriovenous malformations, arteriovenous fistulas, vein of Galen malformations, and developmental venous anomalies. Six of the 14 children with cerebrovascular malformations (42.9%) had multiple malformations. Three children developed new cerebral arteriovenous malformations over time. Six children (11.1%) had clinically evident intracerebral hemorrhage, arterial ischemic stroke, or transient ischemic attack. The three children with intracerebral hemorrhage presented at young ages (4.3 to 7.7 years). CONCLUSIONS More than a quarter of children with hereditary hemorrhagic telangiectasia who were imaged had cerebrovascular malformations, and overt stroke occurred in more than 10%. Intracerebral hemorrhages can occur in pediatric hereditary hemorrhagic telangiectasia patients at young ages, and new cerebral arteriovenous malformations may develop over time. Early screening with neuroimaging including neurovascular imaging as well as repeat neuroimaging may be warranted in children with hereditary hemorrhagic telangiectasia.
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Affiliation(s)
- Lauren A Beslow
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Jake Breimann
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jake Waldman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samantha Fallacaro
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Reed E Pyeritz
- Department of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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Ryu B, Sato S, Mochizuki T, Inoue T, Okada Y, Niimi Y. De novo intracranial arteriovenous malformation development after endovascular treatment for a pial arteriovenous fistula in capillary malformation-arteriovenous malformation syndrome. Interv Neuroradiol 2020; 27:25-30. [PMID: 32635776 DOI: 10.1177/1591019920940515] [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] [Indexed: 12/16/2022] Open
Abstract
Capillary malformation-arteriovenous malformation (CM-AVM) syndrome is a newly described entity characterized by autosomal dominantly inherited multifocal capillary malformations caused by RASA1 mutations (CM-AVM1) or EPHB4 mutations (CM-AVM2). Concurrent high-flow vascular anomalies in the brain are often present in the form of intracranial AVM or arteriovenous fistula (AVF). These high-flow lesions are often identified at or soon after birth because of the characteristic unique capillary malformations or a systemic disorder due to a high-flow shunt, such as respiratory distress or heart failure. However, de novo intracranial AVMs have not been reported in patients with CM-AVM syndrome. Herein, we report the case of a six-year-old boy with CM-AVM1 who had been treated for an intracranial pial arteriovenous fistula approximately five years previously, in whom a de novo intracranial AVM was identified on a follow-up angiographic study. To the best of our knowledge, this report is the first to document a de novo intracranial AVM in a patient with CM-AVM. We recommend careful neuroimaging follow-up even if initial neuroimaging screening is negative because of the risk of de novo AVM development.
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Affiliation(s)
- Bikei Ryu
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan
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17
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Tasiou A, Tzerefos C, Alleyne CH, Boccardi E, Karlsson B, Kitchen N, Spetzler RF, Tolias CM, Fountas KN. Arteriovenous Malformations: Congenital or Acquired Lesions? World Neurosurg 2019; 134:e799-e807. [PMID: 31715403 DOI: 10.1016/j.wneu.2019.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) were believed to be congenital. However, an increasing number of de novo AVM cases have questioned this doctrine. METHODS A consensus meeting of international experts attempted to establish a consensus on the nature of these relatively rare but challenging vascular lesions. In addition, an extensive search of the subject was performed using the PubMed medical database. RESULTS All participants agreed that genetic factors may play a role in the pathogenesis of AVMs. All but 1 participant believed that an underlying genetic predisposition may be detected later on in a patient's life, whereas genetic variations may contribute to sporadic AVM formation. The presence of genetic variations alone may not be enough for an AVM formation. A second hit is probably required. This consensus opinion is also supported by our literature search. CONCLUSIONS We discuss the literature on the genetics of AVMs and compare it with the consensus meeting outcomes. The congenital or noncongenital character of intracranial AVMs has an impact on the understanding their biological behavior, as well as their efficient short-term and long-term management.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece.
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | | | - Edoardo Boccardi
- Department of Diagnostic and Interventional Neuroradiology, Niguarda Hospital, Milan, Italy
| | - Bengt Karlsson
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore
| | - Neil Kitchen
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Christos M Tolias
- Department of Neurovascular Surgery, Kings College Hospital, London, United Kingdom
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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18
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Komiyama M. The time frame of the brain AVM formation. Interv Neuroradiol 2019; 25:588. [DOI: 10.1177/1591019919845538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Masaki Komiyama
- Editor-in-Chief, Interventional Neuroradiology, Department of Neuro-Intervention, Osaka City General Hospital, Osaka, Japan
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19
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Merves M, Parsons K, Alazraki A, Meisel J, Sauer C, Li H. Significant Hematochezia and Intracranial Bleeding in Neonatal Hereditary Hemorrhagic Telangiectasia. AJP Rep 2019; 9:e10-e14. [PMID: 30701124 PMCID: PMC6351274 DOI: 10.1055/s-0039-1677735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 10/21/2018] [Indexed: 11/02/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an underreported autosomal dominant vascular dysplasia. Neonatal presentations of HHT are rare, as this disorder typically presents in adolescence or beyond with epistaxis. We report a female neonate with hematochezia on the 1st day of life secondary to multiple gastrointestinal arteriovenous malformations (AVMs) along with intracranial hemorrhage. We describe her clinical course and management, as well as her novel family mutation in ENG . This is the first reported HHT case with significant gastrointestinal bleeding in the newborn. We review neonatal HHT and raise the consideration for more directed prenatal imaging and delivery options for fetuses at high risk of HHT.
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Affiliation(s)
- Matthew Merves
- Department of Pediatrics, Division of Neonatology, Emory University, Atlanta, Georgia
| | - Kimberly Parsons
- Department of Pediatrics, Division of Neonatology, Emory University, Atlanta, Georgia
| | - Adina Alazraki
- Department of Radiology, Emory University, Atlanta, Georgia
| | | | - Cary Sauer
- Gastroenterology Section, Emory University, Atlanta, Georgia
| | - Hong Li
- Department of Human Genetics, Emory University, Atlanta, Georgia
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20
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Terada A, Komiyama M, Ishiguro T, Niimi Y, Oishi H. Nationwide survey of pediatric intracranial arteriovenous shunts in Japan: Japanese Pediatric Arteriovenous Shunts Study (JPAS). J Neurosurg Pediatr 2018; 22:550-558. [PMID: 30052118 DOI: 10.3171/2018.5.peds18123] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/10/2018] [Indexed: 11/06/2022]
Abstract
The authors performed a nationwide study in Japan to evaluate the annual detected rate of pediatric intracranial arteriovenous (AV) shunts such as brain AV malformations (BAVMs), pial AV fistulas (PAVFs), vein of Galen aneurysmal malformations (VGAMs), and dural AV fistulas (DAVFs). These rates were revealed for the first time and showed that VGAM, DAVF, and PAVF were relatively common but that BAVMs were extremely rare in neonates and infants.
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Affiliation(s)
- Aiko Terada
- Departments of1Neurosurgery and
- 2Neurointervention, Osaka City General Hospital, Osaka
| | | | | | - Yasunari Niimi
- 3Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo; and
| | - Hidenori Oishi
- Departments of4Neuroendovascular Therapy and
- 5Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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21
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Dalton A, Dobson G, Prasad M, Mukerji N. De novo intracerebral arteriovenous malformations and a review of the theories of their formation. Br J Neurosurg 2018; 32:305-311. [DOI: 10.1080/02688697.2018.1478060] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- A. Dalton
- James Cook University Hospital, Middlesbrough, UK
| | - G. Dobson
- James Cook University Hospital, Middlesbrough, UK
| | - M. Prasad
- James Cook University Hospital, Middlesbrough, UK
| | - N. Mukerji
- James Cook University Hospital, Middlesbrough, UK
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22
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Lv X, Wang G. Review of de novo cerebral arteriovenous malformation: haemorrhage risk, treatment approaches and outcomes. Neuroradiol J 2018; 31:224-229. [PMID: 29469668 PMCID: PMC5958505 DOI: 10.1177/1971400918759811] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective A small number of patients has been reported to develop a completely new or de novo arteriovenous malformation (AVM) after brain surgery, haemorrhage, head trauma or ischaemic stroke. The natural history of these lesions is unknown. In this review, both ruptured and unruptured de novo AVMs and their treatments were reviewed. Methods Published literature in the PubMed database citing 'de novo cerebral arteriovenous malformation' was reviewed. Additional studies were identified through reference searches in each reviewed article. A review was performed using all published cases, the treatment approaches and outcomes. Results A total of 38 patients, including 37 de novo AVMs reported from 1988 to 17 November 2017 and our one patient, was collected. The age at AVM diagnosis was 5-73 years (mean ± SD, 27.6 ± 20.5 years). The duration time, from negative examination to AVM diagnosis, was 2 months to 25 years (mean ± SD, 6.6 ± 4.9 years). The presentation of de novo AVM was headaches in three (7.9%) patients, bleedings in 12 (31.6%), incidental in 14 (36.8%) and seizure in nine (23.7%). The estimated risk of haemorrhage was 4.8% per year. Seventeen (44.7%) patients were treated with surgical resection, 10 (26.3%) were conservatively observed, nine (23.7%) were treated with radiosurgery and two (5.3%) were endovascularly embolised. The morbidity and mortality were reported as 5.3% and 7.9%, respectively. Conclusion Post-natal de novo AVMs have been reported. Their annual haemorrhage risk is 4.8%. Most of them are treated by surgical resection and are associated with morbidity and mortality.
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Affiliation(s)
| | - Guihuai Wang
- Guihuai Wang, Neurosurgery Department, Beijing Tsinghua Changgung Hospital, Tsinghua University, Changping, Litanglu 168, Beijing 102218, China.
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23
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Santos R, Aguilar-Salinas P, Entwistle JJ, Aldana PR, Beier AD, Hanel RA. De Novo Arteriovenous Malformation in a Pediatric Patient: Case Report and Review of the Literature. World Neurosurg 2018; 111:341-345. [DOI: 10.1016/j.wneu.2017.12.145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022]
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24
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Shidoh S, Kobayashi M, Akaji K, Kano T, Tanizaki Y, Mihara B. De Novo Arteriovenous Malformation after Aneurysm Clipping. NMC Case Rep J 2017; 4:89-92. [PMID: 28840086 PMCID: PMC5566691 DOI: 10.2176/nmccrj.cr.2016-0272] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/24/2017] [Indexed: 11/20/2022] Open
Abstract
We report a 73-year-old woman with de novo arteriovenous malformations (AVMs) that developed in the ipsilateral parietal lobe after craniotomy and aneurysm clipping. While intracerebral AVMs are considered to be congenital lesions, there have been several reported cases of acquired AVM arising after ischemic or traumatic episodes. We summarize previously reported cases of such acquired 'de novo' AVMs with a discussion of some pathophysiological responses or factors suggested to promote their development.
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Affiliation(s)
- Satoka Shidoh
- Department of Neurosurgery, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Gunma, Japan
| | - Masahito Kobayashi
- Department of Neurosurgery, Saitama Medical University, Iruma-gun, Saitama, Japan
| | - Kazunori Akaji
- Department of Neurosurgery, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Gunma, Japan
| | - Tadashige Kano
- Department of Neurosurgery, Gunma University, Gunma, Japan
| | - Yoshio Tanizaki
- Department of Neurosurgery, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Gunma, Japan
| | - Ban Mihara
- Department of Neurology, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Gunma, Japan
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25
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Matsumaru Y, Ishikawa E, Yamamoto T, Matsumura A. Recent Trends in Neuro-endovascular Treatment for Acute Ischemic Stroke, Cerebral Aneurysms, Carotid Stenosis, and Brain Arteriovenous Malformations. Neurol Med Chir (Tokyo) 2017; 57:253-260. [PMID: 28458385 PMCID: PMC5495956 DOI: 10.2176/nmc.ra.2017-0027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The efficacy of mechanical thrombectomy with stent retrievers for emergent large vessel occlusion has been proved by randomized trials. Mechanical thrombectomy is increasingly being adopted in Japan since stent retrievers were first approved in 2014. An urgent clinical task is to offer structured systems of care to provide this treatment in a timely fashion to all patients with emergent large vessel occlusion. Treatment with flow-diverting stents is currently a preferred treatment option worldwide for large and giant unruptured aneurysms. Initial studies reported high rates of complete aneurysm occlusion, even in large and giant aneurysms, without delayed aneurysmal recanalization and/or growth. The Pipeline Embolic Device is a flow diverter recently approved in Japan for the treatment of large and giant wide-neck unruptured aneurysms in the internal carotid artery, from the petrous to superior hypophyseal segments. Carotid artery stenting is the preferred treatment approach for carotid stenosis in Japan, whereas it remains an alternative for carotid endarterectomy in Europe and the United States. Carotid artery stenting with embolic protection and plaque imaging is effective in achieving favorable outcomes. The design and conclusions of a randomized trial of unruptured brain arteriovenous malformations (ARUBA) trial, which compared medical management alone and medical management with interventional therapy in patients with an unruptured arteriovenous brain malformation, are controversial. However, the annual bleeding rate (2.2%) of the medical management group obtained from this study is worthy of consideration when deciding treatment strategy.
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Affiliation(s)
- Yuji Matsumaru
- Division for Stroke, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
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Pabaney AH, Rammo RA, Tahir RA, Seyfried D. Development of De Novo Arteriovenous Malformation Following Ischemic Stroke: Case Report and Review of Current Literature. World Neurosurg 2016; 96:608.e5-608.e12. [PMID: 27671884 DOI: 10.1016/j.wneu.2016.09.062] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/12/2016] [Accepted: 09/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are hypothesized to be static, congenital lesions developing as early as 4 weeks of fetal life. New literature has shown that AVMs may represent dynamic and reactive vascular lesions arising from cerebral infarction, inflammation, or trauma. A literature search reveals 17 previously reported cases of new AVM formation after previous negative imaging studies. This reactive development or "second hit" theory suggests that at a molecular level, growth factors may play a vital role in aberrant angiogenesis and maturation of an arteriovenous fistula into an AVM. CASE DESCRIPTION A 52-year-old female presented with a ruptured left frontal AVM demonstrated by computed tomography angiography and digital subtraction angiography. The patient had suffered an acute ischemic stroke in the similar cerebral vascular territory 8 years prior due to left internal carotid artery occlusion. Detailed neuroimaging at that time failed to reveal any vascular malformation, suggesting that the AVM might have developed in response to initial vascular insult. CONCLUSIONS We believe that there might exist a subset of AVMs that display dynamic characteristics and could potentially appear, grow, or resolve spontaneously without intervention, especially in the presence of local growth factors and molecular signaling cascades. When combined with a previous cerebral insult such as stroke, trauma, or inflammation, de novo AVM formation may represent a "second hit" with abnormal angiogenesis and vessel formation.
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Affiliation(s)
- Aqueel H Pabaney
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
| | - Richard A Rammo
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Rizwan A Tahir
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Donald Seyfried
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Abstract
Brain arteriovenous malformations (bAVMs) represent a high risk of intracranial hemorrhages, which are substantial causes of morbidity and mortality of bAVMs, especially in children and young adults. Although a variety of factors leading to hemorrhages of bAVMs are investigated extensively, their pathogenesis is still not well elucidated. The author has reviewed the updated data of genetic aspects of bAVMs, especially focusing on clinical and experimental knowledge from hereditary hemorrhagic telangiectasia, which is the representative genetic disease presenting with bAVMs caused by loss-of-function in one of the two genes: endoglin and activin receptor-like kinase 1. This knowledge may allow us to infer the pathogensis of sporadic bAVMs and in the development of new medical therapies for them.
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Affiliation(s)
- Masaki Komiyama
- Department of Neuro-Intervention, Osaka City General Hospital
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