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Beslow LA, White AJ, Krings T, Hammill AM, Lang SS, Baba A, Clancy MS, Olitsky SE, Hetts SW. Current Practice: Rationale for Screening Children with Hereditary Hemorrhagic Telangiectasia for Brain Vascular Malformations. AJNR Am J Neuroradiol 2024; 45:1177-1184. [PMID: 38816017 PMCID: PMC11392374 DOI: 10.3174/ajnr.a8195] [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: 11/21/2023] [Accepted: 01/08/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia is an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectasias, recurrent epistaxis, and organ vascular malformations including in the brain, which occur in about 10% of patients. These brain vascular malformations include high-flow AVMs and AVFs as well as low-flow capillary malformations. High-flow lesions can rupture, causing neurologic morbidity and mortality. STATE OF PRACTICE International guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia recommend screening children for brain vascular malformations with contrast enhanced MR imaging at hereditary hemorrhagic telangiectasia diagnosis. Screening has not been uniformly adopted by some practitioners who contend that screening is not justified. Arguments against screening include application of short-term data from the adult A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial of unruptured sporadic brain AVMs to children with hereditary hemorrhagic telangiectasia as well as concerns about administration of sedation or IV contrast and causing patients or families increased anxiety. ANALYSIS In this article, a multidisciplinary group of experts on hereditary hemorrhagic telangiectasia reviewed data that support screening guidelines and counter arguments against screening. Children with hereditary hemorrhagic telangiectasia have a preponderance of high-flow lesions including AVFs, which have the highest rupture risk. The rupture risk among children is estimated at about 0.7% per lesion per year and is additive across lesions and during a lifetime. ARUBA, an adult clinical trial of expectant medical management versus treatment of unruptured brain AVMs, favored medical management at 5 years but is not applicable to pediatric patients with hereditary hemorrhagic telangiectasia given the life expectancy of a child. Additionally, interventional, radiosurgical, and surgical techniques have improved with time. Experienced neurovascular experts can prospectively determine the best treatment for each child on the basis of local resources. The "watch and wait" approach to imaging means that children with brain vascular malformations will not be identified until a potentially life-threatening and deficit-producing intracerebral hemorrhage occurs. This expert group does not deem this to be an acceptable trade-off.
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Affiliation(s)
- Lauren A Beslow
- From the Division of Neurology (L.A.B.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Departments of Neurology and Pediatrics (L.A.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J White
- Department of Pediatrics (A.J.W.), St. Louis University School of Medicine, St. Louis, Missouri
| | - Timo Krings
- Division of Neuroradiology (T.K.), Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Adrienne M Hammill
- Cancer and Blood Diseases Institute (A.M.H.), Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pediatrics (A.M.H.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shih Shan Lang
- Division of Neurosurgery (S.S.L.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Neurosurgery (S.S.L.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Atsuko Baba
- Department of Anesthesia (A.B.), University of California San Francisco, San Francisco, California
| | | | | | - Steven W Hetts
- Departments of Radiology & Biomedical Imaging and Neurological Surgery and Division of Neuroendovascular Surgery (S.W.H.), University of California San Francisco, San Francisco, California
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Lauzier DC, Conway AP. Complications and risk factors after digital subtraction angiography: 1-year single-center study. J Cerebrovasc Endovasc Neurosurg 2023; 25:473-474. [PMID: 37423719 PMCID: PMC10774678 DOI: 10.7461/jcen.2023.e2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
- David C. Lauzier
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, USA
| | - Alexander P. Conway
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, USA
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Lauzier DC, Chiang SN, Moran CJ. Etiologies of Brain Arteriovenous Malformation Recurrence: A Focus on Pediatric Disease. Pediatr Neurol 2023; 148:94-100. [PMID: 37690270 DOI: 10.1016/j.pediatrneurol.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/18/2023] [Accepted: 08/15/2023] [Indexed: 09/12/2023]
Abstract
Pediatric brain arteriovenous malformations are a major cause of morbidity and mortality, with the harmful effects of this disease compounded by the additional disability-years experienced by children with ruptured or other symptomatic arteriovenous malformations. In addition to the risks shared with their adult counterparts, pediatric patients frequently experience recurrence following radiographic cure, which presents an additional source of morbidity and mortality. Therefore, there is a need to synthesize potential mechanisms contributing to the elevated recurrence risk in the pediatric population and discuss how these translate to practical considerations for managing these patients.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.
| | - Sarah N Chiang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Levitte S, Ganguly A, Frolik S, Guevara-Tique AA, Patel S, Tadas A, Klein O, Shyr D, Agarwal-Hashmi R, Beach L, Callard E, Weinacht K, Bertaina A, Thakor AS. Precision Delivery of Steroids as a Rescue Therapy for Gastrointestinal Graft-versus-Host Disease in Pediatric Stem Cell Transplant Recipients. J Clin Med 2023; 12:4229. [PMID: 37445274 DOI: 10.3390/jcm12134229] [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: 05/13/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Graft versus host disease (GVHD) is one of the most serious complications following stem cell transplant in children and is a major cause of morbidity and mortality. Corticosteroids remain the mainstay of treatment, and although a majority of children respond to systemic steroids, those refractory to or dependent upon corticosteroids suffer from complications secondary to long-term steroid administration. This problem has prompted consideration of steroid-sparing treatment strategies, although the time to clinical remission can be variable. Intraarterial corticosteroid delivery has been used in adults as a rescue therapy in steroid-resistant patients, but its use in children has been limited. We investigated the feasibility of intraarterial steroid administration into the bowel and/or liver in a cohort of six pediatric patients with acute GVHD. All patients successfully underwent treatment with no serious adverse effects. Five of five (100%) patients with gastrointestinal bleeding due to GVHD had rapid symptom improvement by 48 h, which was durable up to three weeks. Three of four (75%) patients with hepatic GVHD had improved cholestasis following intraarterial steroid administration. Our experience with this small cohort preliminarily demonstrated the feasibility and safety of intraarterial steroid administration in children with acute GVHD. This approach warrants consideration as a rescue therapy in steroid-refractory cases and as a "bridge" therapy for children with severe acute GVHD who are transitioning to steroid-sparing regimens.
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Affiliation(s)
- Steven Levitte
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Abantika Ganguly
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Sophie Frolik
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Alix A Guevara-Tique
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Shaini Patel
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Ann Tadas
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Orly Klein
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - David Shyr
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Rajni Agarwal-Hashmi
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Lynn Beach
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Elizabeth Callard
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Katja Weinacht
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Alice Bertaina
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Avnesh S Thakor
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
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Levitte S, Yarani R, Ganguly A, Martin L, Gubatan J, Nadel HR, Franc B, Gugig R, Syed A, Goyal A, Park KT, Thakor AS. Case Series of Precision Delivery of Methylprednisolone in Pediatric Inflammatory Bowel Disease: Feasibility, Clinical Outcomes, and Identification of a Vasculitic Transcriptional Program. J Clin Med 2023; 12:jcm12062386. [PMID: 36983386 PMCID: PMC10053508 DOI: 10.3390/jcm12062386] [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: 01/24/2023] [Revised: 03/05/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
Systemic steroid exposure, while useful for the treatment of acute flares in inflammatory bowel disease (IBD), is associated with an array of side effects that are particularly significant in children. Technical advancements have enabled locoregional intraarterial steroid delivery directly into specific segments of the gastrointestinal tract, thereby maximizing tissue concentration while limiting systemic exposure. We investigated the feasibility of intraarterial steroid administration into the bowel in a cohort of nine pediatric patients who had IBD. This treatment approach provided symptom relief in all patients, with sustained relief (>2 weeks) in seven out of nine; no serious adverse effects occurred in any patient. In addition, we identified patterns of vascular morphologic changes indicative of a vasculopathy within the mesenteric circulation of inflamed segments of the bowel in pediatric patients with Crohn's disease, which correlated with disease activity. An analysis of publicly available transcriptomic studies identified vasculitis-associated molecular pathways activated in the endothelial cells of patients with active Crohn's disease, suggesting a possible shared transcriptional program between vasculitis and IBD. Intraarterial corticosteroid treatment is safe and has the potential to be widely accepted as a locoregional approach for therapy delivery directly into the bowel; however, this approach still warrants further consideration as a short-term "bridge" between therapy transitions for symptomatic IBD patients with refractory disease, as part of a broader steroid-minimizing treatment strategy.
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Affiliation(s)
- Steven Levitte
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Reza Yarani
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Abantika Ganguly
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Lynne Martin
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA 94304, USA
| | - Helen R Nadel
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Benjamin Franc
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Ali Syed
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Alka Goyal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Avnesh S Thakor
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
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The use of the Safeguard pressure-assisted device for maintenance of hemostasis following angiography in children. J Vasc Interv Radiol 2022; 33:1084-1088. [DOI: 10.1016/j.jvir.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
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