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Kim JY, Choi HJ, Kim SH, Ju H. Improved differentiation of cavernous malformation and acute intraparenchymal hemorrhage on CT using an AI algorithm. Sci Rep 2024; 14:11818. [PMID: 38782974 PMCID: PMC11116413 DOI: 10.1038/s41598-024-61960-0] [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: 01/19/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
This study aimed to evaluate the utility of an artificial intelligence (AI) algorithm in differentiating between cerebral cavernous malformation (CCM) and acute intraparenchymal hemorrhage (AIH) on brain computed tomography (CT). A retrospective, multireader, randomized study was conducted to validate the performance of an AI algorithm in differentiating AIH from CCM on brain CT. CT images of CM and AIH (< 3 cm) were identified from the database. Six blinded reviewers, including two neuroradiologists, two radiology residents, and two emergency department physicians, evaluated CT images from 288 patients (CCM, n = 173; AIH, n = 115) with and without AI assistance, comparing diagnostic performance. Brain CT interpretation with AI assistance resulted in significantly higher diagnostic accuracy than without (86.92% vs. 79.86%, p < 0.001). Radiology residents and emergency department physicians showed significantly improved accuracy of CT interpretation with AI assistance than without (84.21% vs. 75.35%, 80.73% vs. 72.57%; respectively, p < 0.05). Neuroradiologists showed a trend of higher accuracy with AI assistance in the interpretation but lacked statistical significance (95.83% vs. 91.67%, p = 0.56). The use of an AI algorithm can enhance the differentiation of AIH from CCM in brain CT interpretation, particularly for nonexperts in neuroradiology.
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Affiliation(s)
- Jung Youn Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University, 59 Yatap-Ro, Bundang, Seongnam, Gyeonggi-Do, 13496, Republic of Korea
| | - Hye Jeong Choi
- Department of Radiology, CHA Bundang Medical Center, CHA University, 59 Yatap-Ro, Bundang, Seongnam, Gyeonggi-Do, 13496, Republic of Korea.
| | - Sang Heum Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University, 59 Yatap-Ro, Bundang, Seongnam, Gyeonggi-Do, 13496, Republic of Korea
| | - Hwangseon Ju
- Department of Radiology, CHA Bundang Medical Center, CHA University, 59 Yatap-Ro, Bundang, Seongnam, Gyeonggi-Do, 13496, Republic of Korea
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2
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Croft J, Grajeda B, Aguirre LA, Abou-Fadel JS, Ellis CC, Estevao I, Almeida IC, Zhang J. Circulating Blood Prognostic Biomarker Signatures for Hemorrhagic Cerebral Cavernous Malformations (CCMs). Int J Mol Sci 2024; 25:4740. [PMID: 38731959 PMCID: PMC11084792 DOI: 10.3390/ijms25094740] [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: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Cerebral cavernous malformations (CCMs) are a neurological disorder characterized by enlarged intracranial capillaries in the brain, increasing the susceptibility to hemorrhagic strokes, a major cause of death and disability worldwide. The limited treatment options for CCMs underscore the importance of prognostic biomarkers to predict the likelihood of hemorrhagic events, aiding in treatment decisions and identifying potential pharmacological targets. This study aimed to identify blood biomarkers capable of diagnosing and predicting the risk of hemorrhage in CCM1 patients, establishing an initial set of circulating biomarker signatures. By analyzing proteomic profiles from both human and mouse CCM models and conducting pathway enrichment analyses, we compared groups to identify potential blood biomarkers with statistical significance. Specific candidate biomarkers primarily associated with metabolism and blood clotting pathways were identified. These biomarkers show promise as prognostic indicators for CCM1 deficiency and the risk of hemorrhagic stroke, strongly correlating with the likelihood of hemorrhagic cerebral cavernous malformations (CCMs). This lays the groundwork for further investigation into blood biomarkers to assess the risk of hemorrhagic CCMs.
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Affiliation(s)
- Jacob Croft
- Department of Molecular and Translational Medicine, Texas Tech University Health Science Center El Paso (TTUHSCEP), El Paso, TX 79905, USA (J.S.A.-F.)
| | - Brian Grajeda
- Department of Biological Sciences, University of Texas at El Paso, El Paso, TX 79902, USA; (B.G.); (I.E.)
| | - Luis A. Aguirre
- Department of Biological Sciences, University of Texas at El Paso, El Paso, TX 79902, USA; (B.G.); (I.E.)
| | - Johnathan S. Abou-Fadel
- Department of Molecular and Translational Medicine, Texas Tech University Health Science Center El Paso (TTUHSCEP), El Paso, TX 79905, USA (J.S.A.-F.)
| | - Cameron C. Ellis
- Department of Biological Sciences, University of Texas at El Paso, El Paso, TX 79902, USA; (B.G.); (I.E.)
| | - Igor Estevao
- Department of Biological Sciences, University of Texas at El Paso, El Paso, TX 79902, USA; (B.G.); (I.E.)
| | - Igor C. Almeida
- Department of Biological Sciences, University of Texas at El Paso, El Paso, TX 79902, USA; (B.G.); (I.E.)
| | - Jun Zhang
- Department of Molecular and Translational Medicine, Texas Tech University Health Science Center El Paso (TTUHSCEP), El Paso, TX 79905, USA (J.S.A.-F.)
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3
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Bin Abdulqader S, Alzhrani G. Endoscopic Endonasal Resection of a Cavernous Malformation of the Third Ventricle: Case Report and Literature Review. J Neurol Surg A Cent Eur Neurosurg 2024; 85:221-226. [PMID: 35644135 DOI: 10.1055/s-0041-1741070] [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: 10/18/2022]
Abstract
BACKGROUND Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM. CASE DESCRIPTION A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively. CONCLUSION This report demonstrates safe resection of a third ventricle CM via the endonasal route.
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Affiliation(s)
- Sarah Bin Abdulqader
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Gmaan Alzhrani
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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Ismaiel N, Ibrahem H, Jabbour G, Joha M, Abdulrahman M, Alshehabi Z. Spinal intradural extramedullary cavernoma: A case report. Int J Surg Case Rep 2024; 115:109274. [PMID: 38219515 PMCID: PMC10826290 DOI: 10.1016/j.ijscr.2024.109274] [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: 11/18/2023] [Revised: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 01/16/2024] Open
Abstract
INTRODUCTION Cavernomas are rare vascular lesions that can occur anywhere along the neuraxis. However, they are most commonly found in the cerebral hemispheres. Spinal cavernomas are more uncommon and intradural extramedullary cavernomas are the most uncommon as they constitute only 3 % of spinal cavernomas. PRESENTATION A 36-year-old female presented to our neurosurgical clinic with a history of back pain radiating to the left side of the chest with left lower extremity paresthesia and ataxia without urinary disturbance. Neurological exam showed left-sided hypoesthesia below the T9 dermatome in addition to increased patellar and Achilles reflexes on the left side. MRI showed a homogeneous intradural extramedullary mass which was hyperintense on T1 and hypointense on T2 and it was surgically resected. Pathological examination confirmed the diagnosis of intradural extramedullary cavernoma. DISCUSSION Intradural extramedullary cavernomas are extremely rare lesions that arise within the area located between the inner surface of the dura and the pial surface of the spinal cord. Up until 2022 only 40 cases of intradural extramedullary cavernomas were reported in the literature. MRI is the preferred imaging modality and pathology is the golden standard for diagnosis. Surgical resection showed very promising results and it is considered the golden standard for treating this condition. However, surgery should be performed urgently to give an optimal outcome. CONCLUSION Clinicians should consider this condition in their differential diagnoses when faced with progressive spinal root compression symptoms, sudden onset myelopathy, or progressive subarachnoid hemorrhage.
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Affiliation(s)
- Nahar Ismaiel
- Cancer Research Center, Tishreen University, Latakia, Syria; Faculty of Medicine, Tishreen University, Latakia, Syria.
| | - Hayyan Ibrahem
- Department of Neurosurgery, Tishreen University Hospital, Latakia, Syria
| | - Georges Jabbour
- Department of Neurosurgery, Tishreen University Hospital, Latakia, Syria
| | - Mohamad Joha
- Department of Neurosurgery, Tishreen University Hospital, Latakia, Syria
| | | | - Zuheir Alshehabi
- Cancer Research Center, Tishreen University, Latakia, Syria; Department of Pathology, Tishreen University Hospital, Latakia, Syria
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Sharma R. The rare case of optic nerve cavernoma: A case report depicting the diagnostic challenge. Radiol Case Rep 2024; 19:190-199. [PMID: 38028314 PMCID: PMC10630766 DOI: 10.1016/j.radcr.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 12/01/2023] Open
Abstract
The manuscript describes a case of Cavernous Malformation in the optic pathway which is extremely rare, accounting for less than 1% of central nervous system cavernomas. This case report highlights a patient initially diagnosed with a glioma, but subsequent MRI changes and extensive analysis ruled in favor of a hemorrhagic optic neuropathy caused by an optic nerve cavernoma. The patient experienced temporary vision loss but fully regained her vision within a week. Based on clinical, biochemical, and radiological findings, it was confirmed as a rare case of optic nerve cavernoma, and the patient was managed expectantly due to her complete recovery of vision. Follow-up imaging after 1 year indicated a stable lesion with evolving characteristics consistent with a cavernoma. This study provides an informative review of the condition and highlights the key radiologic features of this disease.
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Oh H, Im K, Yang HR, Kim HJ, Koo YS, Lee SA. Seizure outcome in medically treated patients with adult-onset epilepsy and cerebral cavernous malformation. Clin Neurol Neurosurg 2023; 233:107951. [PMID: 37683297 DOI: 10.1016/j.clineuro.2023.107951] [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: 06/07/2023] [Revised: 08/02/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE We evaluated long-term seizure outcomes of antiseizure medications (ASMs) and risk factors for drug resistance in patients with adult-onset epilepsy associated with cerebral cavernous malformation (CCM). MATERIALS AND METHODS This retrospective observational study included patients newly diagnosed with adult-onset focal epilepsy associated with CCM. Patients received individualized treatments with ASMs. All patients were followed-up for at least 2 years. The main outcome measure was terminal 2 year seizure freedom (2-YSF). RESULTS Forty eight subjects (28 men and 20 women) were included. Thirty-one (64.6%) subjects achieved a terminal 2-YSF (range 2.0-17.0 years). After treatment with the first drug regimen, 31 (64.6%) subjects achieved 2-YSF, with 23 remaining seizure-free until final follow-up visit. Of the 23 subjects treated with the second drug regimen and the six treated with the third drug regimen, ten (43.5%) and one (16.7%), respectively, achieved a terminal 2-YSF. Stepwise logistic regression analyses showed that terminal 2-YSF was negatively associated with epileptiform discharge on EEG at the time of diagnosis (odds ratio = 0.214, p = 0.047) and tended to be associated with age ≥ 45 years at seizure onset (odds ratio = 4.260, p = 0.056). CONCLUSION The present study found that 64.6% of CCM patients with adult-onset epilepsy achieved terminal 2-YSF after ASM initiation. Interictal epileptiform discharge on EEG at the time of diagnosis was associated with poor prognosis. Failure to achieve sustained seizure freedom after two ASMs may indicate the need for surgical treatment.
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Affiliation(s)
- Hyunsun Oh
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kayeong Im
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha-Rin Yang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Jae Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Harrar DB, Sun LR, Segal JB, Lee S, Sansevere AJ. Neuromonitoring in Children with Cerebrovascular Disorders. Neurocrit Care 2023; 38:486-503. [PMID: 36828980 DOI: 10.1007/s12028-023-01689-2] [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: 04/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.
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Affiliation(s)
- Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
| | - Lisa R Sun
- Divisions of Pediatric Neurology and Vascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Bradley Segal
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
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Muacevic A, Adler JR, Wichmann W, Magagna-Poveda A, Fandino J. Lumbar Epidural Cavernous Hemangioma: A Case Report and Review of the Literature. Cureus 2023; 15:e33677. [PMID: 36788892 PMCID: PMC9918856 DOI: 10.7759/cureus.33677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Pure epidural cavernous hemangioma (ECH) of the spine are rare and account for only 4% of all epidural spinal lesions. We report a case of epidural cavernoma at L3/4 presenting with L4 radiculopathy. Radiological, intraoperative findings and histopathology are presented. We present the case of a 56-year-old man who was admitted with a right L4 radiculopathy including an M4 paresis of the right leg, hypoesthesia L4, and radicular pain. Magnetic resonance imaging (MRI) confirmed an extradural lesion L3/4 partially expanding into the right intervertebral foramen. The lesion had a heterogeneous signal, isointense on T1-weighted and hyperintense on proton density (PD) and T2-weighted images. At surgery, an epidural, ovoid, gray-red, soft mass, lightly adherent to the dura and extending to the right L4 foramen was observed. Findings in the histological examination indicated a cavernous hemangioma without signs of hemorrhage. Symptoms and paresis improved rapidly after surgery. The follow-up MRI showed complete resection of the lesion with no signs of radicular compression. Spinal ECH should be considered as a cause of chronic lumbar radiculopathy with atypical radiological findings. Early diagnosis and total removal of the spinal ECH might prevent hemorrhage and neurological deficits. Fewer than 50 cases of lumbar epidural spinal hemangioma have been reported until today, and our case report is adding valuable knowledge to the existing literature.
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Kawagishi J, Jokura H, Watanabe M, Fujimura M, Niizuma K, Endo H, Suzuki H, Tominaga T. Retiform endothelial hyperplasia mimicking cavernous malformation as a late complication of Gamma Knife radiosurgery. J Neurosurg 2022:1-11. [PMID: 36681954 DOI: 10.3171/2022.11.jns221535] [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: 06/29/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is a powerful tool for the management of arteriovenous malformations; however, newly formed mass lesions resembling cavernous malformations are a rare late complication of GKRS. In this retrospective study, the authors tried to clarify the unique histological features of these mass lesions. METHODS The authors retrospectively reviewed the clinical course of 889 patients who had undergone GKRS for arteriovenous malformations at their institute from 1991 to 2021. Among the 848 patients who had been followed up periodically with neuroradiological imaging, 37 developed a mass lesion mimicking a cavernous malformation and underwent surgical removal of the lesion. The median volume of the original nidus was 3.7 cm3 (range 0.07-30.5 cm3), and the median prescription dose was 21 Gy (range 12-25 Gy). The histological characteristics and radiological and clinical features of the 37 patients were investigated. RESULTS Histological examination showed an organized hematoma and a structure termed "retiform endothelial hyperplasia" (RFEH) consisting of endothelium forming multiple lumen-like vascular channels mimicking cavernous malformations but lacking the subendothelial connective tissue that forms the typical vascular wall structure found in cavernous angioma and capillary telangiectasia. RFEH was detected a median of 10.8 years (range 3.2-27.4 years) after GKRS. Neuroimaging showed hematoma surrounded by massive brain edema in all 37 patients. Symptoms caused by mass effect of the lesion and perifocal edema worsened relatively rapidly but completely disappeared after surgery. No recurrence or morbidity occurred after the surgery. CONCLUSIONS The delayed formation of RFEH that is mimicking a cavernous malformation neuroradiologically but is histologically distinct from a vascular malformation is a potential complication of GKRS. Its progressive clinical course suggests that surgical removal should be considered for symptomatic patients and/or patients with an apparent radiological mass sign.
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Affiliation(s)
- Jun Kawagishi
- 1Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki
| | - Hidefumi Jokura
- 1Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki
| | - Mika Watanabe
- 2Department of Pathology, Tohoku Kosai Hospital, Sendai
| | - Miki Fujimura
- 3Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo
| | - Kuniyasu Niizuma
- 4Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai.,5Department of Neurosurgical Engineering and Translational Neuroscience, Graduate School of Biomedical Engineering, Tohoku University, Sendai.,6Department of Neurosurgical Engineering and Translational Neuroscience, Tohoku University Graduate School of Medicine, Sendai
| | - Hidenori Endo
- 7Department of Neurosurgery, Kohnan Hospital, Sendai.,8Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai; and
| | | | - Teiji Tominaga
- 4Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
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Catapano JS, Benner D, Rhodenhiser EG, Rumalla K, Graffeo CS, Srinivasan VM, Winkler EA, Lawton MT. Safety of brainstem safe entry zones: comparison of microsurgical outcomes associated with superficial, exophytic, and deep brainstem cavernous malformations. J Neurosurg 2022:1-11. [PMID: 36681989 DOI: 10.3171/2022.9.jns222012] [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: 08/30/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Safe entry zones (SEZs) enable safe tissue transgression to lesions beneath the brainstem surface. However, evidence for the safety of SEZs is scarce and is based on anatomical studies, case reports, and small series. METHODS A cohort of 154 patients who underwent microsurgical brainstem cavernous malformation (BSCM) treatment during a 23-year period and who had preoperative MR images and intraoperative photographs or videos was retrospectively examined. This study assessed the safety of SEZs for access to deep BSCMs, preoperative MRI to predict BSCM surface proximity, and the relationships between BSCM subtype, surgical approach, and SEZs. Lesions were characterized as exophytic, superficial, or deep on the basis of preoperative MRI and intraoperative inspection. Outcomes were scored as good (modified Rankin Scale [mRS] score ≤ 2) or poor (mRS score > 2) and relative outcomes as stable/improved or worse relative to baseline (± 1 point). RESULTS Resections included 34 (22%) in the midbrain, 102 (66%) in the pons, and 18 (12%) in the medulla. Of those, 23 (15%) were exophytic, 57 (37%) were superficial, and 74 (48%) were deep. Established SEZs were used for 97% (n = 72) of deep lesions; the preferred SEZ associated with its subtype was used for 91% (n = 67). MR images accurately depicted exophytic BSCMs that did not require SEZ approaches (sensitivity, 96%) but overestimated the proximity of lesions superficial to brainstem surfaces (specificity, 67%), resulting in unanticipated SEZ use. Final neurological outcomes were good in 80% of patients with follow-up data (119/149), and relative outcomes were stable/improved in 93% (139/149). Outcomes for patients with brainstem transgression through an SEZ did not differ from outcomes for patients with superficial or exophytic lesions that did not require SEZ use (final mRS score ≤ 2 in 72% of all patients with deep lesions vs 82% of all patients with superficial or exophytic lesions [p = 0.10]). Among patients with follow-up, the rates of permanent new cranial nerve deficits in patients with deep BSCMs and superficial or exophytic BSCMs were 21% and 20%, respectively (p = 0.81), with no significant change in overall cranial nerve deficit (0 and -1, p = 0.65). CONCLUSIONS Neurological outcomes for patients with deep BSCMs were equivalent to those for superficial or exophytic BSCMs, validating the safety of SEZs for deep BSCMs. Preoperative T1-weighted MR images overestimated the lesion's surface proximity, necessitating detailed knowledge of SEZs and readiness to use them in cases of radiological-microsurgical discordance. Most patients achieved favorable outcomes despite the transgression of eloquent brainstem tissue in and around SEZs.
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Affiliation(s)
- Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Emmajane G. Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Christopher S. Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Visish M. Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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11
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Ibrahim AH, Mohamad N, Mohd Yusof Rasid TA, Abdullah MS. Cerebellar hemorrhage in a healthy young adult: a case report. J Med Case Rep 2022; 16:380. [PMID: 36258203 PMCID: PMC9580125 DOI: 10.1186/s13256-022-03584-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Cavernous venous malformation is an uncommon entity that occurs in around 0.5% of the general population. Cerebellar cavernous venous malformation accounts for 1.2–11.8% of intracranial cavernous venous malformation cases. Patients are commonly asymptomatic until a hemorrhage occurs. In approximately 20% of the cases, cavernous venous malformation and developmental venous anomalies occur together, called mixed vascular malformation. Our case report reveals the imaging features of the mixed vascular malformation and highlights the appropriate imaging modality and sequence to detect the abnormalities. Case presentation We report the case of a 15-year-old Malay male, a healthy young male who presented with dizziness, vomiting, and mild headache for 1 month. Computed tomography brain imaging at presentation revealed cerebellar hemorrhage with multiple cavernous venous malformation and coexisting developmental venous anomalies, which was then confirmed by magnetic resonance imaging. The patient was started on dexamethasone 4 mg four times a day, observed in the ward, and discharged well without neurological sequelae. Conclusion A cavernous malformation with concurrent developmental venous anomalies requires accurate diagnosis. Our case report contributes to the literature on the imaging diagnosis of this disease, which is beneficial for current and future reference.
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Affiliation(s)
- A H Ibrahim
- Department of Radiology, School of Medical Sciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia.,Department of Radiology, Hospital Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia
| | - N Mohamad
- Department of Radiology, School of Medical Sciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia. .,Department of Radiology, Hospital Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia.
| | - T A Mohd Yusof Rasid
- Department of Diagnostic Imaging, Hospital Raja Perempuan Zainab II, 15586, Kota Bharu, Kelantan, Malaysia
| | - M S Abdullah
- Department of Radiology, School of Medical Sciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia.,Department of Radiology, Hospital Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia
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12
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Tu T, Peng Z, Ren J, Zhang H. Cerebral Cavernous Malformation: Immune and Inflammatory Perspectives. Front Immunol 2022; 13:922281. [PMID: 35844490 PMCID: PMC9280619 DOI: 10.3389/fimmu.2022.922281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/18/2022] [Indexed: 12/03/2022] Open
Abstract
Cerebral cavernous malformation (CCM) is a type of vascular anomaly that arises due to the dyshomeostasis of brain capillary networks. In the past two decades, many advances have been made in this research field. Notably, as a more reasonable current view, the CCM lesions should be attributed to the results of a great number of additional events related to the homeostasis disorder of the endothelial cell. Indeed, one of the most fascinating concerns in the research field is the inflammatory perturbation in the immune microenvironment, which would affect the disease progression as well as the patients’ outcomes. In this work, we focused on this topic, and underlined the immune-related factors’ contribution to the CCM pathologic progression.
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Affiliation(s)
- Tianqi Tu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenghong Peng
- Health Management Department, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Hongqi Zhang,
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13
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Won YI, Choi Y, Yuh WT, Kwon SW, Kim CH, Yang SH, Chung CK. Validity of magnetic resonance imaging (MRI) in the primary spinal cord tumors in routine clinical setting. Sci Rep 2022; 12:10151. [PMID: 35710920 PMCID: PMC9203586 DOI: 10.1038/s41598-022-13881-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/30/2022] [Indexed: 12/02/2022] Open
Abstract
MRI is the primary diagnostic modality for spinal cord tumors. However, its validity has never been vigorously scrutinized in daily routine clinical practice, where MRI tissue diagnosis is usually not a single one but multiple ones with several differential diagnoses. Here, we aimed to assess the validity of MRI in terms of predicting the pathology and location of the tumor in routine clinical settings. We analyzed 820 patients with primary spinal cord tumors, who have a pathological diagnosis and location in the operation record which were confirmed. We modified traditional measures for validity based upon a set of diagnoses instead of a single diagnosis. Sensitivity and specificity and positive and negative predictabilities were evaluated for the tumor location and pathology. For tumor location, 456 were intradural extramedullary; 165 were intramedullary, and 156 were extradural. The overall sensitivity and specificity were over 90.0%. However, the sensitivity became lower when the tumor resided simultaneously in two spaces such as in the intradural-and-extradural or intramedullary-and-extramedullary space (54.6% and 30.0%, respectively). Most common pathology was schwannoma (n = 416), followed by meningioma (114) and ependymoma (87). Sensitivities were 93.3%, 90.4%, and 89.7%, respectively. Specificities were 70.8%, 82.9%, and 76.0%. In rare tumors such as neurofibromas, and diffuse midline gliomas, the sensitivity was much lower (less than 30%). For common locations and pathologies, the validity of MRI is generally acceptable. However, for rare locations and pathologies, MRI diagnosis still needs some improvement.
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Affiliation(s)
- Young Il Won
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woon Tak Yuh
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Shin Won Kwon
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea.
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Brain and Cognitive Sciences, Seoul National University, Seoul, Republic of Korea.
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14
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Phillips CM, Stamatovic SM, Keep RF, Andjelkovic AV. Cerebral Cavernous Malformation Pathogenesis: Investigating Lesion Formation and Progression with Animal Models. Int J Mol Sci 2022; 23:5000. [PMID: 35563390 PMCID: PMC9105545 DOI: 10.3390/ijms23095000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 02/01/2023] Open
Abstract
Cerebral cavernous malformation (CCM) is a cerebromicrovascular disease that affects up to 0.5% of the population. Vessel dilation, decreased endothelial cell-cell contact, and loss of junctional complexes lead to loss of brain endothelial barrier integrity and hemorrhagic lesion formation. Leakage of hemorrhagic lesions results in patient symptoms and complications, including seizures, epilepsy, focal headaches, and hemorrhagic stroke. CCMs are classified as sporadic (sCCM) or familial (fCCM), associated with loss-of-function mutations in KRIT1/CCM1, CCM2, and PDCD10/CCM3. Identifying the CCM proteins has thrust the field forward by (1) revealing cellular processes and signaling pathways underlying fCCM pathogenesis, and (2) facilitating the development of animal models to study CCM protein function. CCM animal models range from various murine models to zebrafish models, with each model providing unique insights into CCM lesion development and progression. Additionally, these animal models serve as preclinical models to study therapeutic options for CCM treatment. This review briefly summarizes CCM disease pathology and the molecular functions of the CCM proteins, followed by an in-depth discussion of animal models used to study CCM pathogenesis and developing therapeutics.
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Affiliation(s)
- Chelsea M. Phillips
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Svetlana M. Stamatovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Richard F. Keep
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Anuska V. Andjelkovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
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15
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Zuurbier SM, Hickman CR, Rinkel LA, Berg R, Sure U, Al-Shahi Salman R. Association Between Beta-Blocker or Statin Drug Use and the Risk of Hemorrhage From Cerebral Cavernous Malformations. Stroke 2022; 53:2521-2527. [PMID: 35410492 PMCID: PMC9311291 DOI: 10.1161/strokeaha.121.037009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to determine the association between beta-blocker or statin drug use and the future risk of symptomatic intracranial hemorrhage or persistent/progressive focal neurological deficit from cerebral cavernous malformations (CCM). METHODS The population-based Scottish Audit of Intracranial Vascular Malformations prospectively identified adults resident in Scotland first diagnosed with CCM during 1999 to 2003 or 2006 to 2010. We compared the association between beta-blocker or statin drug use after first presentation and the occurrence of new intracranial hemorrhage or persistent/progressive focal neurological deficit due to CCM for up to 15 years of prospective follow-up. We confirmed proportional hazards and used survival analysis with multivariable adjustment for age, intracranial hemorrhage at CCM presentation, and brain stem CCM location. RESULTS Sixty-three (21%) of 300 adults used beta-blockers (27/63 [43%] used propranolol), and 73 (24%) used statin drugs over 3634 person-years of follow-up. At baseline, the only statistically significant imbalances in prespecified potential confounders were age by statin use and intracranial hemorrhage at presentation by beta-blocker use. Beta-blocker use was associated with a lower risk of new intracranial hemorrhage or persistent/progressive focal neurological deficit (adjusted hazard ratio, 0.09 [95% CI, 0.01-0.66]; P=0.018). Statin use was associated with a nonsignificant lower risk of intracranial hemorrhage or persistent/progressive focal neurological deficit (adjusted hazard ratio, 0.37 [95% CI, 0.01-1.07]; P=0.067). CONCLUSIONS Beta-blocker, but not statin, use was associated with a lower risk of intracranial hemorrhage or persistent/progressive focal neurological deficit in patients with CCM.
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Affiliation(s)
- Susanna M Zuurbier
- Department of Neurology, Amsterdam University Medical Center, The Netherlands (S.M.Z., L.A.R.)
| | - Charlotte R Hickman
- Edinburgh Medical School, College of Medicine and Veterinary Medicine (C.R.H.)
| | - Leon A Rinkel
- Department of Neurology, Amsterdam University Medical Center, The Netherlands (S.M.Z., L.A.R.)
| | - Rebecca Berg
- University of Edinburgh, United Kingdom. Department of Neurosurgery, University of Duisburg-Essen, Germany (R.B., U.S.)
| | - Ulrich Sure
- University of Edinburgh, United Kingdom. Department of Neurosurgery, University of Duisburg-Essen, Germany (R.B., U.S.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Usher Institute of Population Health Sciences and Informatics (R.A.-S.S.)
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16
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Kostic M, Subramanian PS, Falcone SF, El-Swaify ST, Sur S, Spasic S, Miller NR, Morcos JJ, Lam BL. Cavernous Malformation of the Optic Nerve and Chiasm: Prompt Suspicion and Surgery Matter. J Neuroophthalmol 2022; 42:108-114. [PMID: 34001730 DOI: 10.1097/wno.0000000000001238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cavernous malformations (CMs) of the optic nerve and chiasm are extremely rare, accounting for less than 1% of all intracranial CMs. Acute, subacute, or progressive visual loss from CM may occur with or without hemorrhage. Prompt surgical excision of the CM offers the best hope to improve or stabilize vision. Given its rarity, optic nerve and chiasm CMs may not be readily suspected. We provide 3 cases of optic nerve and chiasm CM, highlighting key neuroimaging features and the importance of expedited intervention. METHODS Case records of the neuro-ophthalmology clinics of the Bascom Palmer Eye Institute and the University of Colorado, and literature review of reported cases of optic CM. RESULTS A 49-year-old woman reported acute progressive painless vision loss in the right eye. MRI showed a suprasellar mass with heterogeneity in signal involving the right prechiasmatic optic nerve. Surgical excision of the CM 5 days after onset of visual loss improved vision from 20/300 to 20/30. A 29-year-old woman with acute painless blurred vision in the right eye had anterior chiasmal junctional visual field defects corresponding to a heterogeneously minimally enhancing mass with blood products enlarging the optic chiasm and proximal right optic nerve. Surgical excision of the CM 8 weeks after onset of visual loss improved vision from 20/40 to 20/15 with improved visual fields. A 33-year-old woman with a history of familial multiple CMs, diagnosed at age 18, reported new-onset severe headache followed by blurred vision. MRI showed a hemorrhagic lesion of the optic chiasm and right optic tract. She was 20/20 in each eye with a reported left superior homonymous hemianopia. No intervention was recommended. Vision of the right eye worsened to 20/400 2 months later. The patient was followed over 13 years, and the MRI and visual function remained unchanged. Literature review yielded 87 optic CM cases occurring across gender and nearly all ages with visual loss and headache as the most common presenting symptoms. Optic chiasm is the most common site of involvement (79%). Nearly 95% of reported CM cases were treated with surgery with 81% with improved vision and 1% with worsened vision. CONCLUSION MRI features are critical to the diagnosis of optic nerve and chiasm CM and may mimic other lesions. A high index of suspicion by the neuro-ophthalmologist and neuroradiologist leads to early recognition and intervention. Given optic CM displaces and does not infiltrate neural tissue, expedited surgical resection by a neurosurgeon after consideration of other diagnostic possibilities improves visual function in most cases.
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Affiliation(s)
- Maja Kostic
- Bascom Palmer Eye Institute (MK, BLL), University of Miami, Miami, Florida; Sue Anschutz-Rodgers UCHealth Eye Center and Departments of Ophthalmology, Neurology, and Neurosurgery (PSS), University of Colorado, Denver, Colorado; Departments of Radiology (SFF) and Neurological Surgery (STE, S. Sur, JJM), Pathology (S. Spasic), University of Miami, Miami, Florida; and Wilmer Eye Institute (NRM), Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Ganz JC. Cavernous malformations. PROGRESS IN BRAIN RESEARCH 2022; 268:115-132. [PMID: 35074077 DOI: 10.1016/bs.pbr.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cavernous malformations are relatively common intracerebral malformations of which we only became properly aware after the introduction of MRI. They may be sporadic or familial. Familial CMs may be multiple and new lesions appear over time requiring intermittent MR control. Many sporadic CMs have no symptoms. The commonest location is in the supratentorial cerebral parenchyma presenting with epilepsy. The best treatment is microsurgery. A small proportion are in the brainstem and may rebleed and even be lethal. Treatment includes microsurgery and radiosurgery. Microsurgery cures the patient but has substantial problems with complications, deterioration and partial removal. Radiosurgery has taken time to demonstrate that it can over 2 years substantially reduce the risk of rebleeds without the risks of microsurgery. Both methods have a part to play in the treatment.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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18
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Ren J, Jiang N, Bian L, Dmytriw AA, Zeng G, He C, Sun L, Li X, Ma Y, Yu J, Li G, Ye M, Hu P, Li J, Yang F, Li Q, Ling F, Zhang H, Hong T. Natural History of Spinal Cord Cavernous Malformations: A Multicenter Cohort Study. Neurosurgery 2022; 90:390-398. [PMID: 35049523 DOI: 10.1227/neu.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The natural history of spinal cord cavernous malformations (SCCMs) remains relatively unclear. OBJECTIVE To investigate the natural history for hemorrhagic risks and neurological outcomes, as well as relevant predicting factors, of SCCMs. METHODS All patients between 2002 and 2019 with diagnosis of SCCMs were identified retrospectively. An observational study of patients with conservative management was performed to reveal the natural history of SCCMs. RESULTS We identified 305 patients in the full cohort, including 126 patients who were conservatively treated for at least 6 months (median observational period, 24.0 months). Forty-five hemorrhage events occurred during 527 person-years of follow-up, yielding an annual hemorrhage rate of 8.5% per person-year. The 1-, 2-, and 5-year cumulative risks of hemorrhage were 13.9%, 26.1%, and 35.1%, respectively. Prior hemorrhage (hazard ratio [HR] = 12.948, P = .012) and pediatric patients (HR = 2.841, P = .031) were independent predictors of hemorrhage in the long-term follow-up. Familial form (adjusted odds ratio [OR] = 30.695, P = .010) and subsequent hemorrhage events (adjusted OR = 16.333, P = .000) were independent risk factors for worsening of neurological function, and baseline neurological status (adjusted OR = 78.984, P = .000) and presence of subsequent hemorrhage (adjusted OR = 9.611, P = .001) were significantly associated with neurological outcomes. CONCLUSION The natural history of SCCMs varies. Baseline characteristics, such as pediatric patients, familial form, and baseline neurological status, as well as prior and subsequent hemorrhagic events, significantly affect the natural history of the SCCMs, which prompts a differentiated treatment strategy.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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Brotis A, Fotakopoulos G, Fountas K. Dilemmas in managing coexisting arteriovenous and cavernous malformations: Case report. Brain Circ 2022; 8:45-49. [PMID: 35372726 PMCID: PMC8973448 DOI: 10.4103/bc.bc_52_21] [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: 07/07/2021] [Revised: 09/26/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022] Open
Abstract
Coexisting arteriovenous malformations (AVMs) and cavernous malformations (CMs) are rare. Here, we present our dilemmas in managing a patient with a cerebral AVM and a pontine CM. A 47-year-old patient suffered from headaches, vomiting, and transient swallowing difficulties. The cerebral computed tomography showed a pontine hyperintense lesion, while the axial magnetic resonance imaging of the head disclosed a frontal interhemispheric AVM and a CM located in the rostral and ventral aspect of the pons. Despite a pontine hemorrhage, the patient underwent microsurgical excision of the frontal lesion in the first place, due to the increased bleeding risk, followed by stereotactic radiosurgery of the pontine CM. On the 6 months follow-up, the patient's clinical status was stable. A reasonable treatment strategy based on risk stratification is paramount in managing patients with coexisting AVMs and CMs. The optimal outcome frequently requires a staged multidisciplinary approach.
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20
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Yang Z, Yu G, Zhu W, Chen L, Song J, Mao Y. The benefit and outcome prediction of acute surgery for hemorrhagic brainstem cavernous malformation with impending respiratory failure. J Clin Neurosci 2021; 93:213-220. [PMID: 34656250 DOI: 10.1016/j.jocn.2021.09.020] [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: 02/21/2021] [Revised: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Impending respiratory failure is catastrophic neurological deterioration caused by repeated c of a brainstem cavernous malformation (BSCM). The benefit and outcome prediction of acute surgery for this fatal condition is rarely reported. In this study, the authors reported a case series of acute surgical treatment (≤3 weeks after the last hemorrhagic episode) for the BSCM with impending respiratory failure and reviewed literature over the past 20 years. MATERIALS AND METHODS Clinical and outcome data from 6 consecutive acute surgically-treated BSCM patients were analyzed. Intracerebral hemorrhage (ICH) scores, primary pontine hemorrhage (PPH) scores, and Lawton's BSCM grading were applied for surgical outcome prediction. Ten related articles were included for the literature review. RESULTS There were three men and three women, with a mean age of 32.2 ± 9.3 years (range 15-45 years). The BSCMs were located at the pons in 5 cases and the medulla in 1 case. The ICH score was 1-2 in all cases, while the PPH score was 0 in all pontine BSCMs. For Lawton's BSCM grading, 3 cases were grade 2, 2 cases were grade 3, and 1 case was grade 1. All patients achieved spontaneous respiratory dysfunction relief postoperatively and significantly improved at follow-up (mean 4.47 ± 0.24 years;range4.0-5.6 years). CONCLUSIONS Repeated hemorrhagic BSCM with impending respiratory failure can benefit from acute surgical treatment. The ICH score, PPH score, and Lawton's BSCM grading are promisingly useful tools for fast and efficient surgical outcome prediction.
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Affiliation(s)
- Zixiao Yang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; National Center for Neuological Disorders, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai 200040, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; National Center for Neuological Disorders, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai 200040, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; National Center for Neuological Disorders, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai 200040, China
| | - Liang Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; National Center for Neuological Disorders, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai 200040, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; National Center for Neuological Disorders, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai 200040, China; Department of Neurosurgery, Fudan University Huashan Hospital Fujian Campus, Fujian Medical University The First Affiliated Hospital Binhai Campus, National Regional Medical Center, Fuzhou, Fujian 350209, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; National Center for Neuological Disorders, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai 200040, China
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21
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Zattra CM, Restelli F, Broggi M. Commentary: Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report. Oper Neurosurg (Hagerstown) 2021; 21:E163-E164. [PMID: 34015827 DOI: 10.1093/ons/opab166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Costanza M Zattra
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Restelli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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22
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Dammann P, Herten A, Santos AN, Rauschenbach L, Chen B, Darkwah Oppong M, Schmidt B, Forsting M, Kleinschnitz C, Sure U. Multimodal outcome assessment after surgery for brainstem cavernous malformations. J Neurosurg 2021; 135:401-409. [PMID: 33065532 DOI: 10.3171/2020.6.jns201823] [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: 03/15/2020] [Accepted: 10/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to assess outcome after surgery for brainstem cavernous malformations (BSCMs) using functional, health-related quality of life (HRQOL), and psychological surveys to analyze the interrelation of these measurements, and to compare HRQOL and anxiety and depression scores with those in a healthy population. METHODS The authors performed a cross-sectional outcome study of all patients surgically treated for BSCM in their department between January 1, 2003, and December 31, 2019. They assessed functional outcome via the modified Rankin Scale (mRS), health-related quality of life (HRQOL) via the SF-36 and 9-item Life Satisfaction Questionnaire (LISAT-9), cranial nerve and brainstem function using a questionnaire, symptom-based psychological outcome via the Hospital Anxiety and Depression Scale (HADS), and timepoint of a return to previous employment. They analyzed the correlation between absolute (mRS score ≤ 2) and relative (postoperative deterioration in initial mRS score) outcome endpoints and the interrelation of the outcome measures and performed a comparison of HRQOL and HADS scores with findings in a healthy population. RESULTS Seventy-four patients were eligible for inclusion in the study. HRQOL was impaired after surgery for BSCM compared to that in a healthy population. This impairment was substantial in patients with an unfavorable functional outcome (mRS > 2) but was also present in those with a favorable outcome (mRS ≤ 2) in selected domains. Psychological impairment was negligible in patients with a favorable outcome and grave in those with an unfavorable outcome. LISAT-9 results revealed that brainstem and cranial nerve symptoms reduce satisfaction mainly in self-care abilities for both unfavorable and favorable outcome patients. Among the brainstem and cranial nerve symptoms, balance impairment showed the most significant impact on HRQOL. Absolute outcome endpoints were superior to relative outcome endpoints in reflecting impairment in HRQOL after surgery. CONCLUSIONS The study data can improve patient counseling and decision-making in BSCM treatment and may function as a benchmark. The authors report outcomes after BSCM surgery in high detail, emphasizing the specific impact of cranial nerve and brainstem symptoms on HRQOL. When reporting BSCM surgery outcome, absolute outcome endpoints should be applied.
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Affiliation(s)
| | - Annika Herten
- 1Department of Neurosurgery, University Hospital Essen
| | | | | | - Bixia Chen
- 1Department of Neurosurgery, University Hospital Essen
| | | | - Börge Schmidt
- 2Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen
| | - Michael Forsting
- 3Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen; and
| | - Christoph Kleinschnitz
- 4Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- 1Department of Neurosurgery, University Hospital Essen
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Fernando PM, Munasinghe BM, Jayamanne MDCJP, Jayasundara KA, Arambepola WSNWBMAG, Pranavan S, Ranathunge ND. Cerebral cavernous malformation in a child leading to a fatal subarachnoid hemorrhage - "silent but sinister:" A case report and literature review. Surg Neurol Int 2021; 12:253. [PMID: 34221584 PMCID: PMC8247693 DOI: 10.25259/sni_248_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/29/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Cerebral cavernous malformations (CCMs), otherwise known as cavernous hemangiomas/ cavernomas, are a type of vascular malformation. It is the third most common cerebral vascular malformation, histologically characterized by ectatic, fibrous, blood filled “caverns” with thin-walled vasculature without intervening normal brain parenchyma. Case Description: Herein, we present a case of an original, spontaneous hemorrhage from a sporadic form of CCM without associated gross developmental venous anomaly in an 11-year-old child, which is an extremely rare occurrence, with the special emphasis on the demographic data of the affected population, risk factors associated with hemorrhage, and correlation of histopathological and radiological findings with an in-depth literature review. Conclusion: The significant majority of the CCM are clinically occult. Hence, the development of risk assessment tools and guidelines for timely neurosurgical intervention poses a greater clinical challenge for medical experts rendering the management of the affected individuals with CCM in an anecdotal situation. Presentation of life-threatening rebleeds and neurological deficits in the diagnosed population albeit uncommon is possibly preventable outcomes.
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Affiliation(s)
- Pasindu M Fernando
- Department of Transfusion Medicine, District General Hospital, Mannar, Sri Lanka
| | - B M Munasinghe
- Department of Anaesthesia and Intensive Care, District General Hospital, Mannar, Sri Lanka
| | | | - K A Jayasundara
- Department of Paediatrics, District General Hospital, Mannar, Sri Lanka
| | | | - Selliah Pranavan
- Department of Forensic Pathology District General Hospital, Mannar, Sri Lanka
| | - N D Ranathunge
- Department of Pathology, District General Hospital, Mannar, Sri Lanka
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24
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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. [PMID: 32168479 DOI: 10.3171/2019.12.jns192856] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given 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. METHODS Nine 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. RESULTS Six 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. CONCLUSIONS The 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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25
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Culleton S, McKenna B, Dixon L, Taranath A, Oztekin O, Prasad C, Siddiqui A, Mankad K. Imaging pitfalls in paediatric posterior fossa neoplastic and non-neoplastic lesions. Clin Radiol 2021; 76:391.e19-391.e31. [PMID: 33648757 DOI: 10.1016/j.crad.2020.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/22/2020] [Indexed: 11/27/2022]
Abstract
Paediatric posterior fossa lesions can have much overlap in their clinical and radiological presentation. There are, however, a number of key imaging features that can help the reading radiologist to distinguish tumours from important tumour mimics which are often inflammatory or metabolic entities. This pictorial review provides a number of important cases that proved challenging on imaging and illustrates some common pitfalls when interpreting lesions in the posterior fossa in children. Not everything that is abnormal will be a tumour, but often other causes are overlooked and misinterpreted as tumours, leading to great morbidity for that child. This article highlights some lesions that were mistaken as tumours and will introduce the reader to less commonly seen pathologies which are important to consider on a differential list for this location.
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Affiliation(s)
- S Culleton
- Department of Paediatric Neuroradiology, Great Ormond Street Hospital, London, UK.
| | - B McKenna
- Department of Paediatric Neuroradiology, Great Ormond Street Hospital, London, UK
| | - L Dixon
- Department of Paediatric Neuroradiology, Great Ormond Street Hospital, London, UK
| | - A Taranath
- Department of Paediatric Neuroradiology, Women and Children's Hospital, Adelaide, Australia
| | - O Oztekin
- Department of Paediatric Neuroradiology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - C Prasad
- Department of Paediatric Neuroradiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - A Siddiqui
- Department of Paediatric Neuroradiology, Evelina London Children's Hospital, London, UK
| | - K Mankad
- Department of Paediatric Neuroradiology, Great Ormond Street Hospital, London, UK
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26
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Rafee S, Killeen RP, Tubridy N. 'Popcorn' in the Brain: A Cause for Confusion. Am J Med 2021; 134:216-217. [PMID: 33091393 DOI: 10.1016/j.amjmed.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Shameer Rafee
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland.
| | - Ronan P Killeen
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
| | - Niall Tubridy
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
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27
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Han G, Ma L, Qiao H, Han L, Wu Q, Li Q. A Novel CCM2 Missense Variant Caused Cerebral Cavernous Malformations in a Chinese Family. Front Neurosci 2021; 14:604350. [PMID: 33469417 PMCID: PMC7813800 DOI: 10.3389/fnins.2020.604350] [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: 09/09/2020] [Accepted: 11/12/2020] [Indexed: 11/13/2022] Open
Abstract
Cerebral cavernous malformations (CCMs) are common vascular malformations in the central nervous system. Familial CCMs (FCCMs) are autosomal dominant inherited disease with incomplete penetrance and variable symptoms. Mutations in the KRIT1, CCM2, and PDCD10 genes cause the development of FCCM. Approximately 476 mutations of three CCM-related genes have been reported, most of which were case reports, and lack of data in stable inheritance. In addition, only a small number of causative missense mutations had been identified in patients. Here, we reported that 8/20 members of a Chinese family were diagnosed with CCMs. By direct DNA sequencing, we found a novel variant c.331G > C (p.A111P) in exon 4 of the CCM2 gene, which was a heterozygous exonic variant, in 7/20 family members. We consider this variant to be causative of disease due to a weaken the protein-protein interaction between KRIT1 and CCM2. In addition, we also found the exon 13 deletion in KRIT1 coexisting with the CCM2 mutation in patient IV-2, and this was inherited from her father (patient III-1H). This study of a Chinese family with a large number of patients with CCMs and stable inheritance of a CCM2 mutation contributes to better understanding the spectrum of gene mutations in CCMs.
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Affiliation(s)
- Guoqing Han
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Li Ma
- Department of Preventive Dentistry, School of Stomatology, Tianjin Medical University, Tianjin, China
| | - Huanhuan Qiao
- Tianjin Key Laboratory of Brain Science and Neural Engineering, Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Lin Han
- Running Gene Inc., Beijing, China
| | - Qiaoli Wu
- Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China
| | - Qingguo Li
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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28
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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29
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Alhoobi MMM, Khan A, Abu-Qadous FF, Kockro R, Hammadi F, Jarir RA, Belkhair S, Ayyad A. Translamina Terminalis Approach to the Hypothalamus Using Supraorbital Craniotomy: Technical Note and Comparison with Other Surgical Corridors. Asian J Neurosurg 2020; 15:660-665. [PMID: 33145223 PMCID: PMC7591184 DOI: 10.4103/ajns.ajns_29_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/14/2020] [Accepted: 04/16/2020] [Indexed: 11/04/2022] Open
Abstract
Objectives Approaches to the hypothalamus and anterior third ventricle are variable. We present a technical note on access of the hypothalamus using the trans-lamina terminalis approach by supraorbital craniotomy in a patient who had a hypothalamic cavernoma and presented to us with recurrent hemorrhage. Patients and methods The trans-lamina terminalis approach, including anatomical landmarks and surgical steps through a supra-orbital craniotomy, is described and a comparison with other surgical corridors is discussed. Results The supraorbital trans lamina terminalis approach allowed an effective access to the hypothalamic lesions. This approach provided a safe and minimally invasive corridor for gross total resection of the lesion since trespass of viable brain tissue is avoided. One clinical case illustrates the feasibility of the approach allowing complete removal of a cavernoma without surgery related neurological of endocrinological deficits. Conclusions The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for hypothalamic lesions. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long and narrow surgical corridor requires some technical familiarization. The clinical outcomes are comparable to other surgical corridors.
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Affiliation(s)
| | - Adnan Khan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ralf Kockro
- Department of Neurosurgery, Hirslanden Klinik, Zurich, Switzerland
| | - Firas Hammadi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Raed Abu Jarir
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Sirajeddin Belkhair
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar.,Department of Surgery, Michigan State University, Lansing, US
| | - Ali Ayyad
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar.,Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
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30
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Park H, Kim S, Rhim JH, Park JH, Choi IS, Kim JS, Kim KH. The development of numerous radiation-induced cavernous malformations in a germ cell tumor patient: A case report. Curr Probl Cancer 2020; 45:100654. [PMID: 32958338 DOI: 10.1016/j.currproblcancer.2020.100654] [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: 06/24/2020] [Revised: 08/08/2020] [Accepted: 08/28/2020] [Indexed: 12/01/2022]
Abstract
Radiation-induced cavernous malformations (RICMs) are most commonly reported in young patients who have previously received radiotherapy. Here, we report a case of a patient with a germ cell tumor who was treated with whole brain radiotherapy (WBRT) and then incidentally found to have numerous RICMs. A 31-year-old male visited the hospital for a testicular mass. On examination, he was diagnosed with a mixed germ cell tumor with lung/brain metastases. The patient underwent a left orchiectomy and received 4 cycles of chemotherapy. He was then treated with WBRT for residual lesions in the brain and a wedge resection for the lung metastasis. Four years later, approximately 250-300 RICMs were incidentally observed in a follow-up brain image. Because the patient had not noticed any symptoms and the RICMs were small in size, he was not treated. To our knowledge, this is the first reported case of numerous (approximately 250-300) RICMs in a germ cell tumor patient after WBRT. Herein, we report details of this case and discuss the typical clinical features of RICM.
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Affiliation(s)
- Hyunkyung Park
- Department of Internal Medicine, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Suzy Kim
- Department of Radiation Oncology, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jung Hyo Rhim
- Department of Radiology, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jin Hyun Park
- Department of Internal Medicine, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - In Sil Choi
- Department of Internal Medicine, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jin-Soo Kim
- Department of Internal Medicine, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Ki Hwan Kim
- Department of Internal Medicine, SMG-Seoul National University Boramae Medical Center, Seoul, South Korea.
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31
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Palkopoulou M, Bakola E, Foliadi M, Stefanidis P, Acquaviva PT. Cerebral cavernous malformation in a patient with pontine hemorrhage: A case study. Clin Pract 2020; 10:1211. [PMID: 33042507 PMCID: PMC7520705 DOI: 10.4081/cp.2020.1211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 09/14/2020] [Indexed: 12/14/2022] Open
Abstract
The cerebral cavernous malformations are benign vascular hamartomas, with thin and dilated vascular walls and therefore constantly susceptible to hemorrhage. Clinically, they present with recurrent headaches, acute intracranial hemorrhage and focal neurological deficits. They are considered as angiographically occult vascular malformations and the imaging technique of choice for their diagnosis is magnetic resonance tomography. We present the case of a female patient with acute-onset symptomatology, congruent with a lesion in the basal pons. Her medical history included an intracranial hemorrhage due to a cavernoma, which was surgically removed. The magnetic resonance imaging of the brain revealed two new cavernomas, which were not identified in the imaging conducted in the past. In literature, the cases of de novo appearance of cavernomas are considered highly rare, especially in patients with no consistent family history or medical history of radiation therapy. Resultantly, they should be considered as dynamic lesions, regarding their number, size and behavior.
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Affiliation(s)
| | | | | | - Petros Stefanidis
- Department of Neurosurgery, General Hospital of Elefsina Thriasio, Greece
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32
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Neuroimaging of Pediatric Intracerebral Hemorrhage. J Clin Med 2020; 9:jcm9051518. [PMID: 32443470 PMCID: PMC7290500 DOI: 10.3390/jcm9051518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023] Open
Abstract
Hemorrhagic strokes account for half of all strokes seen in children, and the etiologies of these hemorrhagic strokes differ greatly from those seen in adult patients. This review gives an overview about incidence and etiologies as well as presentation of children with intracerebral hemorrhage and with differential diagnoses in the emergency department. Most importantly it describes how neuroimaging of children with intracerebral hemorrhage should be tailored to specific situations and clinical contexts and recommends specific imaging protocols for acute and repeat imaging. In this context it is important to keep in mind the high prevalence of underlying vascular lesions and adapt the imaging protocol accordingly, meaning that vascular imaging plays a key role regardless of modality. Magnetic resonance imaging (MRI), including advanced sequences, should be favored whenever possible at the acute phase.
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33
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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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Hemorrhage owing to cerebral cavernous malformation: imaging, clinical, and histopathological considerations. Jpn J Radiol 2020; 38:613-621. [PMID: 32221793 DOI: 10.1007/s11604-020-00949-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
Cavernous malformation (CM) is the second most common cerebral vascular malformation and is often found incidentally. Their natural history is usually benign, however, patients with CM who present with symptomatic hemorrhage may later follow a serious clinical course if left untreated. The risk of hemorrhage is associated with previous hemorrhage, lesion location (infratentorial and deep), and the presence of associated developmental venous anomaly (DVA). Histopathological specimens also indicate that coexistence of DVA and other vascular malformations may be associated with hemorrhage owing to CMs. Diagnosing CMs is difficult, even in patients who initially present with symptomatic hemorrhage. Computed tomography scans typically reveal a hemorrhagic CM as a nonspecific heterogenous mass of high density, which may not be misdiagnosed as a solitary hematoma, especially when located in the infratentorial region. Magnetic resonance imaging demonstrates internal loculation with mixed-signal intensities typical for CMs, although this may be partially or completely masked by acute hemorrhage. Susceptibility-weighted imaging (SWI) reveals a significant "blooming" effect of hemosiderin deposition. Three-dimensional postcontrast T1-weighted imaging is essential to identify associated DVAs, and this is important for both diagnosis and planning of surgical treatment. Contrast-enhanced MRI should be performed to diagnose hemorrhagic CMs and differentiate them from spontaneous solitary hematoma or hemorrhagic tumors.
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Kumar S, Brinjikji W, Lanzino G, Flemming KD. Distinguishing mimics from true hemorrhagic cavernous malformations. J Clin Neurosci 2020; 74:11-17. [PMID: 31982281 DOI: 10.1016/j.jocn.2020.01.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
Cavernous malformations (CM) are angiographically occult vascular malformations. CM appear as discrete, small lesions with mixed-signal characteristics on T2 reflecting the underlying pathology. However, the appearance is not pathognomonic. Distinguishing true CM from hemorrhagic tumors can be difficult. We report 5 cases of tumors mimicking CMs. We compared clinical, initial radiologic features, and MRI evolution between 5 tumor mimics and 51 true hemorrhagic, sporadic, brain CM. Compared to true CM, mimic patients were older (47.0 vs. 38.3 years; p = 0.076) and more likely to have a history of primary neoplasm (60% vs 12%; p = 0.0267). Radiologically, the CM mimics demonstrated a higher likelihood of lesion enhancement on the initial diagnostic MRI (60% vs. 16.7%%; p = 0.0609). On follow-up MRI (<1 year after baseline), CM mimics typically had persistent edema (100.0% vs. 6.25%, p = 0.0003) and demonstrated mixed density on ADC (100% vs. 32.1%; p = 0.0199) as well as increased likelihood of enhancement (100% vs 25.8, p = 0.0852). CM mimics were less likely to evolve to Type 2 or 3 lesions (25.0% vs. 84.4%, p = 0.0278). Clinical and radiologic factors may distinguish tumor metastases from true hemorrhagic CM. CM mimics should be suspected in older patients with a history of neoplasm and contrast enhancement on initial MRI. A repeat MRI within 90 days post-initial hemorrhage should be considered to confirm CM diagnosis. Persistent edema without rebleed, lesion enhancement, mixed signal on apparent diffusion co-efficient, and persistence of a Type 1 lesion should raise suspicion of a metastatic tumor.
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Affiliation(s)
- Shivram Kumar
- Departments of Neurology, Mayo Clinic, Rochester, MN, USA
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Bergametti F, Viot G, Verny C, Brechard MP, Denier C, Labauge P, Petit P, Nouet A, Viallet F, Chaussenot A, Hervé D, Tournier-Lasserve E, Riant F. Novel CCM2 missense variants abrogating the CCM1-CCM2 interaction cause cerebral cavernous malformations. J Med Genet 2020; 57:400-404. [PMID: 31937560 DOI: 10.1136/jmedgenet-2019-106401] [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: 06/27/2019] [Revised: 11/20/2019] [Accepted: 12/21/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) are vascular malformations mostly located within the central nervous system. Most deleterious variants are loss of function mutations in one of the three CCM genes. These genes code for proteins that form a ternary cytosolic complex with CCM2 as a hub. Very few CCM2 missense variants have been shown to be deleterious by modifying the ternary CCM complex stability. OBJECTIVES To investigate the causality of novel missense CCM2 variants detected in patients with CCM. METHODS The three CCM genes were screened in 984 patients referred for CCM molecular screening. Interaction between CCM1 and CCM2 proteins was tested using co-immunoprecipitation experiments for the CCM2 missense variants located in the phosphotyrosine binding (PTB) domain. RESULTS 11 distinct CCM2 rare missense variants were found. Six variants predicted to be damaging were located in the PTB domain, four of them were novel. When co-transfected with CCM1 in HEK293T cells, a loss of interaction between CCM1 and CCM2 was observed for all six variants. CONCLUSION We showed, using co-immunoprecipitation experiments, that CCM2 missense variants located in the PTB domain were actually damaging by preventing the normal interaction between CCM1 and CCM2. These data are important for diagnosis and genetic counselling, which are challenging in patients harbouring such variants.
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Affiliation(s)
| | - Geraldine Viot
- Unité de Génétique, Hopital Americain de Paris, Neuilly-sur-Seine, Île-de-France, France
| | - Christophe Verny
- Service de Neurologie, CHU Angers, Angers, Pays de la Loire, France
| | - Marie Pierre Brechard
- Service de Génétique Médicale, Hopital Saint Joseph, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Christian Denier
- Département de Neurologie, Hospital Bicetre, Le Kremlin-Bicetre, Île-de-France, France
| | - Pierre Labauge
- Service de Neurologie, CHRU de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Paul Petit
- Cabinet de Neurologie - Cabestan, Cabestan, France
| | - Aurélien Nouet
- Service de Neurochirurgie, Hopital Universitaire Pitie Salpetriere, Paris, Île-de-France, France
| | - François Viallet
- Service de Neurologie, CH intercommunal Aix-Pertuis, Aix en Provence, France
| | - Annabelle Chaussenot
- Service de Génétique Médicale, Hopital de l'Archet, Nice, Provence-Alpes-Côte d'Azur, France
| | - Dominique Hervé
- Service de Neurologie, GH Saint Louis - Lariboisiere - Fernand Widal, Paris, Île-de-France, France.,Centre de Référence pour les Maladies Rares des Vaisseaux du Cerveau et de l'Oeil (CERVCO), GH Saint Louis - Lariboisiere - Fernand Widal, Paris, Île-de-France, France
| | - Elisabeth Tournier-Lasserve
- UMR-S1141, INSERM, Paris, Île-de-France, France.,Centre de Référence pour les Maladies Rares des Vaisseaux du Cerveau et de l'Oeil (CERVCO), GH Saint Louis - Lariboisiere - Fernand Widal, Paris, Île-de-France, France.,Service de Génétique Moléculaire Neurovasculaire, GH Saint Louis - Lariboisière - Fernand Widal, Paris, Île-de-France, France
| | - Florence Riant
- UMR-S1141, INSERM, Paris, Île-de-France, France .,Centre de Référence pour les Maladies Rares des Vaisseaux du Cerveau et de l'Oeil (CERVCO), GH Saint Louis - Lariboisiere - Fernand Widal, Paris, Île-de-France, France.,Service de Génétique Moléculaire Neurovasculaire, GH Saint Louis - Lariboisière - Fernand Widal, Paris, Île-de-France, France
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Benedetti V, Pellegrino E, Brusco A, Piva R, Retta SF. Next Generation Sequencing (NGS) Strategies for Genetic Testing of Cerebral Cavernous Malformation (CCM) Disease. Methods Mol Biol 2020; 2152:59-75. [PMID: 32524544 DOI: 10.1007/978-1-0716-0640-7_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The application of next generation sequencing (NGS) technique has a great impact on complex disease studies. Indeed, genetic heterogeneity, phenotypic variability, and disease rarity are all factors that make the traditional diagnostic approach to genetic disorders, whereby a specific gene is selected for sequencing based on the clinical phenotype, very challenging and obsolete.Exome sequencing, which sequences the protein-coding region of the genome, has been rapidly applied to variant discovery in research settings. Recent coverage and accuracy improvements have accelerated the development of clinical exome sequencing (CES) platforms targeting disease-related genes and enabling variant identification in patients with suspected genetic diseases. Nowadays, CES is rapidly becoming the diagnostic test of choice in patients with suspected Mendelian diseases, especially for those with heterogeneous etiology and clinical presentation. Reporting large CES series can improve guidelines on best practices for test utilization, and a better variant interpretation through clinically oriented data sharing.Herein, we suggest a feasible CES procedure for the genetic testing of Cerebral Cavernous Malformation (CCM) disease, including proband identification, library preparation, data analysis, and variant interpretation.
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Affiliation(s)
- Valerio Benedetti
- Department of Clinical and Biological Sciences, University of Torino, Orbassano (Torino), Italy.
- CCM Italia Research Network, Torino, Italy.
| | - Elisa Pellegrino
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Alfredo Brusco
- Departmentof Medical Sciences, University of Torino, Torino, Italy
- Medical Genetics Unit, Città Della Salute e della Scienza University Hospital, Torino, Italy
| | - Roberto Piva
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
- Medical Genetics Unit, Città Della Salute e della Scienza University Hospital, Torino, Italy
| | - Saverio Francesco Retta
- CCM Italia Research Network, Torino, Italy.
- Department of Clinical and Biological Science, School of Medicine and Surgery, University of Torino, Orbassano (Torino), Italy.
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Splendiani A, Bruno F, Cerase A. Neuroradiology: Differential Diagnosis, Follow-Up, and Reporting. Methods Mol Biol 2020; 2152:97-107. [PMID: 32524547 DOI: 10.1007/978-1-0716-0640-7_8] [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] [Indexed: 06/11/2023]
Abstract
Cavernous cerebral malformations (CCMs) can show typical and characteristic findings at neuroradiology, above all at magnetic resonance imaging, but differential diagnosis with other lesions of similar appearance can be challenging and should be taken into consideration. Management of CCMs can be conservative in most cases, and thus appropriate follow-up timing and modality is required. Growing input from neurologists, neurosurgeons, neuroradiologists, and patients recommend to offer a standard neuroradiological report, to enhance interpretation and comparability in daily clinical practice. The purpose of this chapter is to present differential diagnosis, follow-up, and reporting of CCMs by neuroradiology.
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Affiliation(s)
- Alessandra Splendiani
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy.
| | - Federico Bruno
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Alfonso Cerase
- Unit of Neuroimaging (Diagnostic and Functional Neuroradiology), Department of Neurological and Motor Sciences, "Santa Maria alle Scotte" NHS & University Hospital, Siena, Italy
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Zuurbier SM, Hickman CR, Tolias CS, Rinkel LA, Leyrer R, Flemming KD, Bervini D, Lanzino G, Wityk RJ, Schneble HM, Sure U, Al-Shahi Salman R. Long-term antithrombotic therapy and risk of intracranial haemorrhage from cerebral cavernous malformations: a population-based cohort study, systematic review, and meta-analysis. Lancet Neurol 2019; 18:935-941. [PMID: 31401075 PMCID: PMC6744367 DOI: 10.1016/s1474-4422(19)30231-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antithrombotic (anticoagulant or antiplatelet) therapy is withheld from some patients with cerebral cavernous malformations, because of uncertainty around the safety of these drugs in such patients. We aimed to establish whether antithrombotic therapy is associated with an increased risk of intracranial haemorrhage in adults with cerebral cavernous malformations. METHODS In this population-based, cohort study, we used data from the Scottish Audit of Intracranial Vascular Malformations, which prospectively identified individuals aged 16 years and older living in Scotland who were first diagnosed with a cerebral cavernous malformation during 1999-2003 or 2006-10. We compared the association between use of antithrombotic therapy after first presentation and the occurrence of intracranial haemorrhage or persistent or progressive focal neurological deficit due to the cerebral cavernous malformations during up to 15 years of prospective follow-up with multivariable Cox proportional hazards regression assessed in all individuals identified in the database. We also did a systematic review and meta-analysis, in which we searched Ovid MEDLINE and Embase from database inception to Feb 1, 2019, to identify comparative studies to calculate the intracranial haemorrhage incidence rate ratio according to antithrombotic therapy use. We then generated a pooled estimate using the inverse variance method and a random effects model. FINDINGS We assessed 300 of 306 individuals with a cerebral cavernous malformation who were eligible for study. 61 used antithrombotic therapy (ten [16%] of 61 used anticoagulation) for a mean duration of 7·4 years (SD 5·4) during follow-up. Antithrombotic therapy use was associated with a lower risk of subsequent intracranial haemorrhage or focal neurological deficit (one [2%] of 61 vs 29 [12%] of 239, adjusted hazard ratio [HR] 0·12, 95% CI 0·02-0·88; p=0·037). In a meta-analysis of six cohort studies including 1342 patients, antithrombotic therapy use was associated with a lower risk of intracranial haemorrhage (eight [3%] of 253 vs 152 [14%] of 1089; incidence rate ratio 0·25, 95% CI 0·13-0·51; p<0·0001; I2=0%). INTERPRETATION Antithrombotic therapy use is associated with a lower risk of intracranial haemorrhage or focal neurological deficit from cerebral cavernous malformations than avoidance of antithrombotic therapy. These findings provide reassurance about safety for clinical practice and require further investigation in a randomised controlled trial. FUNDING UK Medical Research Council, Chief Scientist Office of the Scottish Government, The Stroke Association, Cavernoma Alliance UK, and the Remmert Adriaan Laan Foundation.
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Affiliation(s)
- Susanna M Zuurbier
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Charlotte R Hickman
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Christos S Tolias
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Leon A Rinkel
- University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Rebecca Leyrer
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | | | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Robert J Wityk
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Ulrich Sure
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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Abstract
BACKGROUND Brain arteriovenous malformations (AVMs) are the single most common cause of intracerebral haemorrhage in young adults. Brain AVMs also cause seizure(s) and focal neurological deficits (in the absence of haemorrhage, migraine or an epileptic seizure); approximately one-fifth are incidental discoveries. Various interventions are used in an attempt to eradicate brain AVMs: neurosurgical excision, stereotactic radiosurgery, endovascular embolization, and staged combinations of these interventions. This is an update of a Cochrane Review first published in 2006, and last updated in 2009. OBJECTIVES To determine the effectiveness and safety of the different interventions, alone or in combination, for treating brain AVMs in adults compared against either each other, or conservative management, in randomized controlled trials (RCTs). SEARCH METHODS The Cochrane Stroke Group Information Specialist searched the Cochrane Stroke Group Trials Register (last searched 7 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library, MEDLINE Ovid (1980 to 14 January 2019), and Embase OVID (1980 to 14 January 2019). We searched international registers of clinical trials, the contents pages of relevant journals, and bibliographies of relevant articles (November 2009). We also contacted manufacturers of interventional treatments for brain AVMs (March 2005). SELECTION CRITERIA We sought RCTs of any intervention for brain AVMs (used alone or in combination), compared against each other or against conservative management, with relevant clinical outcome measures. DATA COLLECTION AND ANALYSIS One author screened the results of the updated searches for potentially eligible RCTs for this updated review. Both authors independently read the potentially eligible RCTs in full and confirmed their inclusion according to the inclusion criteria. We resolved disagreement by discussion. We assessed the risk of bias in included studies and applied GRADE. MAIN RESULTS We included one trial with 226 participants: A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA), comparing intervention versus conservative management for unruptured brain AVMs (that had never bled). The quality of evidence was moderate because we found just one trial that was at low risk of bias other than a high risk of performance bias due to participants and treating physicians not being blinded to allocated treatment. Data on functional outcome and death at a follow-up of 12 months were provided for 218 (96%) of the participants in ARUBA. In this randomized controlled trial (RCT), intervention compared to conservative management increased death or dependency (modified Rankin Scale score ≥ 2, risk ratio (RR) 2.53, 95% confidence interval (CI) 1.28 to 4.98; 1 trial, 226 participants; moderate-quality evidence) and the proportion of participants with symptomatic intracranial haemorrhage (RR 6.75, 95% CI 2.07 to 21.96; 1 trial, 226 participants; moderate-quality evidence), but there was no difference in the frequency of epileptic seizures (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 226 participants; moderate-quality evidence). Three RCTs are ongoing. AUTHORS' CONCLUSIONS We found moderate-quality evidence from one RCT including adults with unruptured brain AVMs that conservative management was superior to intervention with respect to functional outcome and symptomatic intracranial haemorrhage over one year after randomization. More RCTs will help to confirm or refute these findings.
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Affiliation(s)
- Susanna M Zuurbier
- Amsterdam University Medical CentersDepartment of NeurologyAmsterdamNetherlands1105 AZ
| | - Rustam Al‐Shahi Salman
- University of EdinburghCentre for Clinical Brain SciencesFU303i, First floor, Chancellor's Building49 Little France CrescentEdinburghMidlothianUKEH16 4SB
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Awad IA, Polster SP. Cavernous angiomas: deconstructing a neurosurgical disease. J Neurosurg 2019; 131:1-13. [PMID: 31261134 PMCID: PMC6778695 DOI: 10.3171/2019.3.jns181724] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 01/08/2023]
Abstract
Cavernous angioma (CA) is also known as cavernoma, cavernous hemangioma, and cerebral cavernous malformation (CCM) (National Library of Medicine Medical Subject heading unique ID D006392). In its sporadic form, CA occurs as a solitary hemorrhagic vascular lesion or as clustered lesions associated with a developmental venous anomaly. In its autosomal dominant familial form (Online Mendelian Inheritance in Man #116860), CA is caused by a heterozygous germline loss-of-function mutation in one of three genes-CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10-causing multifocal lesions throughout the brain and spinal cord.In this paper, the authors review the cardinal features of CA's disease pathology and clinical radiological features. They summarize key aspects of CA's natural history and broad elements of evidence-based management guidelines, including surgery. The authors also discuss evidence of similar genetic defects in sporadic and familial lesions, consequences of CCM gene loss in different tissues at various stages of development, and implications regarding the pathobiology of CAs.The concept of CA with symptomatic hemorrhage (CASH) is presented as well as its relevance to clinical care and research in the field. Pathobiological mechanisms related to CA include inflammation and immune-mediated processes, angiogenesis and vascular permeability, microbiome driven factors, and lesional anticoagulant domains. These mechanisms have motivated the development of imaging and plasma biomarkers of relevant disease behavior and promising therapeutic targets.The spectrum of discoveries about CA and their implications endorse CA as a paradigm for deconstructing a neurosurgical disease.
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Bervini D, Jaeggi C, Mordasini P, Schucht P, Raabe A. Antithrombotic medication and bleeding risk in patients with cerebral cavernous malformations: a cohort study. J Neurosurg 2019; 130:1922-1930. [PMID: 29882707 DOI: 10.3171/2018.1.jns172547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCMs) are frequently diagnosed vascular abnormalities. The hemorrhagic risk associated with the use of long-term antithrombotic medication (ATM) in patients with CCMs is a matter of controversy. The aim of this study was to determine the hemorrhagic risk associated with ATM use in patients diagnosed with one or more CCMs. METHODS Demographic, clinical, treatment, and ATM-related information on patients diagnosed with one or more CCMs at a single institution over more than 34 years was retrospectively recorded. Univariate and multivariate descriptive and survival analyses were used to assess potential risk factors associated with CCM-related hemorrhage at presentation and during follow-up (first or subsequent hemorrhage). RESULTS A total of 408 patients were included in the analysis and 492 CCMs were followed up after diagnosis, for a total of 1616 lesion-years. Thirty-seven (7.5%) CCMs bled during follow-up, leading to an overall annual rate of CCM-related symptomatic hemorrhage of 2.3% (95% CI 1.7%-3.2%). Eighty-two patients harboring 91 CCMs (16.8%) were on ATM. When stratified for ATM, the annual rates of hemorrhage were 0.7% (95% CI < 0.01% to 4.2%) for the lesions in patients on ATM versus 2.5% (95% CI 1.8%-3.4%) for those not on ATM. ATM was not found to be associated with either an increased risk of CCM-related hemorrhage at presentation (p = 0.355) or an increased risk of CCM-related hemorrhage (first or subsequent hemorrhage) in multivariate descriptive (p = 0.912) and survival (p = 0.145) analyses. CONCLUSIONS The use of ATM does not seem to be associated with an increased risk of hemorrhage in patients diagnosed with CCMs.
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Affiliation(s)
- David Bervini
- 1Department of Neurosurgery, Inselspital, Bern University Hospital
| | | | - Pasquale Mordasini
- 3Department of Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Philippe Schucht
- 1Department of Neurosurgery, Inselspital, Bern University Hospital
| | - Andreas Raabe
- 1Department of Neurosurgery, Inselspital, Bern University Hospital
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Flemming KD, Kumar S, Lanzino G, Brinjikji W. Baseline and Evolutionary Radiologic Features in Sporadic, Hemorrhagic Brain Cavernous Malformations. AJNR Am J Neuroradiol 2019; 40:967-972. [PMID: 31097428 DOI: 10.3174/ajnr.a6076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/21/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Much has been written about the initial radiologic features of cavernous malformations, but less known are the radiologic natural history and evolution of the lesions, particularly when they initially present with hemorrhage. We aimed to describe the typical evolution of a sporadic, hemorrhagic brain cavernous malformation with time. MATERIALS AND METHODS From our institutional review board-approved cavernous malformation registry, we assessed initial clinical and radiologic features and the subsequent MR imaging evolution of 51 patients with sporadic, hemorrhagic brain cavernous malformations (with follow-up brain MRIs available for review). RESULTS The initial MR imaging demonstrated mostly Zabramski type I lesions (94.2%) with T1 hyperintensity (94.2%) and associated edema (76.5%). Eight patients (15.6%) rebled in the first year with lesions characterized by new T1 hyperintensity (100%), edema (61.5%), and growth (median, 4 mm). By 90 days, most lesions had changed from Zabramski type I to type II or III (65.2%). While 76.5% had edema associated with the acute hemorrhage, none had persistent edema beyond 90 days unless rebleeding occurred. Across time, the frequency of T1 hyperintensity decreased from 94.2% at baseline to 73.9%, 57.1%, and 50.0% at <90, 91-365, and >365 days. DWI intensity at baseline and <90, 91-365, and >365 days was hypointense at 53.1%, 56.5%, 70.1%, and 81.2%, respectively. CONCLUSIONS Hemorrhagic cavernous malformation demonstrates a characteristic pattern of evolution on follow-up imaging. Knowing this evolution helps to analyze the timing of imaging in relation to the clinical presentation and may help distinguish true cavernous malformation hemorrhagic evolution from mimics and guide appropriate timing of interval-imaging follow-up after symptomatic bleeds in untreated patients.
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Affiliation(s)
- K D Flemming
- From the Departments of Neurology (K.D.F., S.K.)
| | - S Kumar
- From the Departments of Neurology (K.D.F., S.K.)
| | | | - W Brinjikji
- Neuroradiology (W.B.), Mayo Clinic, Rochester, Minnesota
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Lawton MT, Lang MJ. The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms. J Neurosurg 2019; 130:1409-1425. [PMID: 31042667 DOI: 10.3171/2019.1.jns182156] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/18/2019] [Indexed: 11/06/2022]
Abstract
Despite the erosion of microsurgical case volume because of advances in endovascular and radiosurgical therapies, indications remain for open resection of pathology and highly technical vascular repairs. Treatment risk, efficacy, and durability make open microsurgery a preferred option for cerebral cavernous malformations, arteriovenous malformations (AVMs), and many aneurysms. In this paper, a 21-year experience with 7348 cases was reviewed to identify trends in microsurgical management. Brainstem cavernous malformations (227 cases), once considered inoperable and managed conservatively, are now resected in increasing numbers through elegant skull base approaches and newly defined safe entry zones, demonstrating that microsurgical techniques can be applied in ways that generate entirely new areas of practice. Despite excellent results with microsurgery for low-grade AVMs, brain AVM management (836 cases) is being challenged by endovascular embolization and radiosurgery, as well as by randomized trials that show superior results with medical management. Reviews of ARUBA-eligible AVM patients treated at high-volume centers have demonstrated that open microsurgery with AVM resection is still better than many new techniques and less invasive approaches that are occlusive or obliterative. Although the volume of open aneurysm surgery is declining (4479 cases), complex aneurysms still require open microsurgery, often with bypass techniques. Intracranial arterial reconstructions with reimplantations, reanastomoses, in situ bypasses, and intracranial interpositional bypasses (third-generation bypasses) augment conventional extracranial-intracranial techniques (first- and second-generation bypasses) and generate innovative bypasses in deep locations, such as for anterior inferior cerebellar artery aneurysms. When conventional combinations of anastomoses and suturing techniques are reshuffled, a fourth generation of bypasses results, with eight new types of bypasses. Type 4A bypasses use in situ suturing techniques within the conventional anastomosis, whereas type 4B bypasses maintain the basic construct of reimplantations or reanastomoses but use an unconventional anastomosis. Bypass surgery (605 cases) demonstrates that open microsurgery will continue to evolve. The best neurosurgeons will be needed to tackle the complex lesions that cannot be managed with other modalities. Becoming an open vascular neurosurgeon will be intensely competitive. The microvascular practice of the future will require subspecialization, collaborative team effort, an academic medical center, regional prominence, and a large catchment population, as well as a health system that funnels patients from hospital networks outside the region. Dexterity and meticulous application of microsurgical technique will remain the fundamental skills of the open vascular neurosurgeon.
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Mariniello G, De Liso M, Russo C, Del Vecchio W, De Divitiis O, Bruno F, Maggialetti N, Arrigoni F, Brunese L, Caranci F. Radiation-induced brain cavernomas in elderly: review of the literature and a rare case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:77-83. [PMID: 31085976 PMCID: PMC6625569 DOI: 10.23750/abm.v90i5-s.8328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 12/16/2022]
Abstract
Radiation-induced brain cavernomas have been mainly reported in children who underwent radiotherapy for medulloblastoma, leukemia, or low-grade glioma. Otherwise, the “de novo” appearance of a cavernoma in an elderly long-survivor patient after resection and radiotherapy of a glioblastoma is a rare event. We report the case of a 62-year-old female patient who underwent surgical resection of a right temporal glioblastoma, followed by radiation therapy of the operative field and surrounding brain and concomitant adjuvant temozolomide. Four years after the operation, a follow-up Magnetic Resonance revealed a good tumor control and a small round lesion at the superior surface of the right cerebellar hemisphere, close to the margins of the previous irradiation field. The radiological items were consistent with a cavernous angioma. Because of the small size of the malformation and the absence of related symptoms, no treatment was performed. The patient died for tumor progression 86 months after the initial operation, with unchanged cerebellar cavernoma. The occurrence of a cavernous angioma in an elderly patient after radiotherapy for brain glioblastoma is an exceptional event; the distribution of radiotherapy-induced cavernous malformations reported in current literature is presented and the mechanism of their formation is discussed. (www.actabiomedica.it)
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Affiliation(s)
- Giuseppe Mariniello
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, Neurosurgical Clinic, University of Naples Federico II, Naples, Italy.
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Ghobrial GM, Liounakos J, Starke RM, Levi AD. Surgical Treatment of Vascular Intramedullary Spinal Cord Lesions. Cureus 2018; 10:e3154. [PMID: 30345209 PMCID: PMC6191006 DOI: 10.7759/cureus.3154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Vascular lesions represent a rare subset of intramedullary spinal cord pathology and consist of cavernous malformations (CM), hemangioblastomas, and arteriovenous malformations (AVM). These lesions are each unique and the literature pertaining to their surgical management is largely limited to retrospective case series and case reports. Objectives To evaluate the surgical management of each of these lesions with special attention to postoperative functional status. Methods A single-institution case series of intramedullary vascular lesions treated with surgery was retrospectively evaluated. The primary variables of interest included preoperative and postoperative McCormick grades. Other variables of interest included frequency and indication for conventional spinal angiography, rates of preoperative embolization, postprocedural complications, operative time, intraoperative blood loss, and length of hospital stay. Results Thirty-six patients were identified over the 17-year study period, including 20 with hemangioblastomas, 13 with CMs, and three with AVMs. The median preoperative McCormick grades were 2, 2, and 3 for hemangioblastomas, CMs, and AVMs, respectively. The median postoperative McCormick grades were 2, 2, and 2 for hemangioblastomas, CMs, and AVMs, respectively at the most recent follow-up. Preoperative angiography was performed in all AVM cases and 29% of hemangioblastomas. Preoperative embolization was performed in 40% of hemangioblastoma cases undergoing preoperative angiography. Operative times were similar between the three lesion groups. In three cases of hemangioblastoma resection and one case of CM resection, McCormick grade improved by one point following surgery. At a mean follow-up of 30.9 months for hemangioblastomas, 7.95 months for CMs, and 24 months for AVMs, all patients were at least at their discharge baseline, with no new neurologic complaints. Conclusion Intramedullary vascular lesions are rare and represent a complex surgical patient population. Surgical resection with or without preoperative angiography and embolization appears to be safe and to halt neurologic decline.
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Affiliation(s)
| | | | | | - Allan D Levi
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
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Abstract
A unique case is presented of chronic occipital neuralgia (ON) caused by cavernous malformation (CM) in the intramedullary C2 spinal cord and subsequent pain relief and remodeling of allodynic pain following dorsal root rhizotomy. A 53-year-old male presented with a 30-year history of chronic allodynic, paroxysmal lancinating pain in the greater and lesser occipital nerves. Typically, the pain was aggravated with neck extension and head movement. Magnetic resonance imaging showed a CM in the right posterolateral side of the intramedullary C2 cord. Considering potential risks associated with removal of the lesion, intradural C1-3 dorsal root rhizotomy with dentate ligament resection was performed. The paroxysmal lancinating pain of ON was significantly alleviated, and the remodeling of the extent of allodynic pain was noted after C1-3 dorsal root rhizotomy. These changes gradually occurred during the second postoperative month, and this effect was maintained for 24 months postoperatively. Significant reduction in chronic allodynic pain of secondary ON caused by cervicomedullary CM involving central sensitization in the trigeminocervical complex was observed with reduction of irritating, afferent input with C1-C3 dorsal root rhizotomy.
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Affiliation(s)
- Sang-Woo Ha
- Department of Neurosurgery, Chosun University Hospital, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Jin-Gyu Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Byung-Chul Son
- Department of Neurosurgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea.,Catholic Neuroscience Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Neu MA, Tanyildizi Y, Wingerter A, Henninger N, El Malki K, Alt F, Doerr B, Schmidberger H, Stockinger M, Wagner W, Keweloh S, Brockmann MA, Russo A, Faber J. Susceptibility-weighted magnetic resonance imaging of cerebrovascular sequelae after radiotherapy for pediatric brain tumors. Radiother Oncol 2018; 127:280-286. [PMID: 29605477 DOI: 10.1016/j.radonc.2018.03.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 03/01/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND PURPOSE Due to sensitive neuroimaging techniques, cerebrovascular complications such as cerebral microbleeds (CMB) and cerebral cavernous malformations (CCM) are increasingly recognized as considerable late effects after treatment for pediatric brain tumor. The aim of this study was to analyze CMB in a cohort of patients after cranial irradiation therapy for medulloblastoma or other pediatric brain tumors using susceptibility-weighted magnetic resonance imaging (SWI). MATERIALS AND METHODS Forty former pediatric brain tumor patients were enrolled in this prospective cross-sectional study and examined by cranial MRI including SWI sequences. Cerebral microbleeds, clinical symptoms and disability were evaluated. RESULTS Thirty-six (90%) of the examined individuals (mean follow-up age 22.2 y; mean follow-up time 13.5 y) were affected by CMB. Longer follow-up time and higher craniospinal irradiation doses correlated with higher total lesion count (p < 0.01). Thirteen patients (32.5%) presented with clinical symptoms. Individuals with CMB were more severely disabled than patients without CMB (p < 0.05). CONCLUSIONS Cerebrovascular sequelae occur frequently after treatment for pediatric brain tumor. In this study, a remarkable part of pediatric brain tumor patients presents with CMB. As a sign of vascular damage, they can cause clinical symptoms and may correspond to neurocognitive decline. Further studies are needed to standardize MRI protocols and to improve quality of long-term follow-up.
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Affiliation(s)
- Marie A Neu
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | | | - Arthur Wingerter
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | - Nicole Henninger
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | - Khalifa El Malki
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | - Francesca Alt
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | - Barbara Doerr
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology and Radiation Therapy, University Medical Center Mainz, Germany
| | - Marcus Stockinger
- Department of Radiation Oncology and Radiation Therapy, University Medical Center Mainz, Germany
| | - Wolfgang Wagner
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Stefanie Keweloh
- Department of Neuroradiology, University Medical Center Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Germany
| | - Alexandra Russo
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany
| | - Joerg Faber
- Department of Pediatric Hematology/Oncology/Hemostaseology, University Medical Center Mainz, Germany.
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Al-Sharydah AM, Al-Suhibani SS, Al-Jubran SA, Al-Abdulwahhab AH, Al-Bar M, Al-Jehani HM, Al-Issawi WM. Endoscopic management of Atypical sellar cavernous hemangioma: A case report and review of the literature. Int J Surg Case Rep 2017; 42:161-164. [PMID: 29248833 PMCID: PMC5985255 DOI: 10.1016/j.ijscr.2017.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/29/2017] [Accepted: 12/02/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION supratentorial cavernous hemangiomas, particularly those found in the sellar region, are extremely rare. We present a case of sellar cavernous hemangioma with radiological characteristics that have never been reported. Due to the difficulty diagnosing these lesions, misdiagnosis might occur. Thus, briefing surgeons about the clinico-radiological features of such rare lesions is crucial for better understanding the enigmatic features of such rare lesions and to develop early management approaches that could result in better surgical excision with a lower tendency for complications. PRESENTATION OF CASE A 43-year-old male presented with headache, blurred vision, and impotence for the last 2 years. Brain magnetic resonance imaging showed an atypical sellar mass displaying signals of heterogeneous intensity on T1- and T2-weighted imaging. The mass exhibited heterogeneous enhancement after gadolinium injection. Endoscopic endonasal surgery was subsequently performed, during which an uneventful subtotal resection of the mass was achieved. Histopathological analysis confirmed the diagnosis of intrasellar cavernous hemangioma. DISCUSSION Many questions regarding how best to manage such lesions remain unanswered. Hence, we summarize the relevant surgical techniques and discuss misconceptions. CONCLUSION Seller cavernous hemangioma (SCH) is an extremely rare lesion that can be misdiagnosed. It is characterized by clinico-radiological features similar to those of other lesions such as pituitary macroadenoma and should be included in the differential diagnosis. The endoscopic endonasal transsphenoidal (EET) approach with subtotal/total resection appears to be a feasible option for debulking, with less surgical complications. Nonetheless, combining stereotactic radiosurgery will reduce postsurgical morbidities.
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Affiliation(s)
- A M Al-Sharydah
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia
| | - S S Al-Suhibani
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - S A Al-Jubran
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - A H Al-Abdulwahhab
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - M Al-Bar
- Otolaryngology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - H M Al-Jehani
- Neurosurgery Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - W M Al-Issawi
- Neurosurgery Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
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