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Otsuka E, Kitamura M, Sawase K, Nakamura M, Inoue H, Yamaguchi K, Funakoshi S, Takazono T, Mukae H, Nishino T. Hereditary Hemorrhagic Telangiectasia in a Patient Undergoing Hemodialysis with Anticoagulants and Antiplatelets. Intern Med 2024; 63:1609-1614. [PMID: 37866921 PMCID: PMC11189710 DOI: 10.2169/internalmedicine.2180-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that causes abnormal blood vessel formation and bleeding. We herein report a 61-year-old woman with aggravated HHT symptoms after hemodialysis initiation. She was diagnosed with HHT based on her recurrent bleeding, abnormal blood vessel formation, and family history. Despite bleeding complications, the patient required anticoagulants and antiplatelet agents to treat cardiovascular complications. Eventually, the patient died of extensive cerebral hemorrhaging. Our experience suggests that special attention should be paid to bleeding complications in high-risk patients.
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Affiliation(s)
- Emiko Otsuka
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Nagasaki Renal Center, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Nagasaki Renal Center, Japan
| | | | - Maiko Nakamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Nagasaki Renal Center, Japan
| | - Hiro Inoue
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kosei Yamaguchi
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | | | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
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Kilian A, Latino GA, White AJ, Ratjen F, McDonald J, Whitehead KJ, Gossage JR, Krings T, Lawton MT, Kim H, Faughnan ME. Comparing Characteristics and Treatment of Brain Vascular Malformations in Children and Adults with HHT. J Clin Med 2023; 12:2704. [PMID: 37048789 PMCID: PMC10094792 DOI: 10.3390/jcm12072704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterized by the development of vascular malformations (VMs) in organs such as the brain and lungs, as well as telangiectases on mucosal surfaces. Prophylactic treatment of organ VMs may prevent potential complications, such as hemorrhage. However, brain VM treatment-surgical resection, embolization, and/or radiosurgery-is not recommended for all patients due to the associated risks. Given the scarcity of data regarding HHT-related brain VM presentation and treatment trends in pediatric patients, we aim to describe the clinical presentations and the patterns of treatment of HHT-related brain VMs in a pediatric cohort, and compare pediatric trends to those of adults. Demographic and clinical data were analyzed in 114 pediatric patients with HHT-related brain VMs and compared with a cohort of 253 adult patients enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. Our data demonstrated that a higher proportion of pediatric patients with HHT-related brain VMs were symptomatic at presentation (p = 0.004). Moreover, a higher proportion of pediatric patients presented with intracranial hemorrhage (p < 0.001) and seizure (p = 0.002) compared to adult patients. Surgical resection was the most common brain VM treatment modality in both children and adults. We conclude that pediatric patients may be more likely to present with symptoms and complications from brain VMs, supporting the case for screening for brain VMs in children with HHT.
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Affiliation(s)
- Alexandra Kilian
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
| | - Giuseppe A. Latino
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, ON M2K 1E1, Canada
| | - Andrew J. White
- Department of Pediatrics, St Louis University, St. Louis, MO 63103, USA
| | - Felix Ratjen
- Division of Respiratory Medicine and Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, UT 84132, USA
| | - Kevin J. Whitehead
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT 84132, USA
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT 84132, USA
| | - James R. Gossage
- Department of Medicine, Augusta University, Augusta, GA 30912, USA
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94110, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Marie E. Faughnan
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
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Ogino A, Tonetti D, Flickinger JC, Lunsford LD, Kano H. Clinico-Radiologic Outcomes After Stereotactic Radiosurgery for Patients with Complex High-Risk Multiple Arteriovenous Malformations. World Neurosurg 2020; 144:e244-e252. [PMID: 32822953 DOI: 10.1016/j.wneu.2020.08.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The present study aims to define the outcome and risks of patients with multiple arteriovenous malformations (AVMs) treated by stereotactic radiosurgery (SRS). METHODS We retrospectively analyzed the records of 1232 patients with AVMs who underwent SRS at our center between 1987 and 2017. We identified 10 patients who had SRS for multiple AVMs (total of 25). Eight patients presented with intracranial hemorrhage before SRS. Four patients had hereditary hemorrhagic telangiectasia. A Spetzler-Martin grade I AVM was diagnosed in 11 AVMs, grade II in 7, grade III in 6, and grade IV in 1 AVM. The median maximum diameter was 12 mm, the median target volume was 1.1 cm3, and the median margin dose was 20 Gy. Twenty-four AVMs were treated with single-session SRS, and 1 AVM was treated with volume-staged SRS. RESULTS The angiographic complete obliteration rate of each AVM was 18.2%, 58.0%, and 66.4% at 3, 5, and 7 years, respectively. The angiographic complete obliteration rate of all treated AVMs in each patient was 11.1%, 51.4%, and 51.4% at 3, 5, and 7 years, respectively. In multivariate analysis, higher marginal dose (≥18 Gy, P = 0.031) was significantly associated with complete obliteration of AVMs. After obliteration of all their AVMs was confirmed no patient bled. CONCLUSIONS Patients with complex multiple AVMs often presented with a brain hemorrhage. Reduction in bleeding risk after SRS requires complete obliteration that is more likely if the initial AVM margin dose is ≥18 Gy for each AVM.
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Affiliation(s)
- Akiyoshi Ogino
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Daniel Tonetti
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Woodall MN, Nakaji P, Spetzler RF. Benefits of Treating Arteriovenous Malformations in Hereditary Hemorrhagic Telangiectasia: A Retrospective Analysis of 14 Patients. World Neurosurg X 2019; 3:100029. [PMID: 31225521 PMCID: PMC6584483 DOI: 10.1016/j.wnsx.2019.100029] [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: 11/14/2018] [Accepted: 02/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background Arteriovenous malformations (AVMs) are a cardinal feature of hereditary hemorrhagic telangiectasia (HHT). However, whether to treat brain AVMs in patients with HHT remains questionable because of the possible risks. Methods We performed a retrospective study of patients with HHT who had been treated for brain AVMs at our institution from January 1, 2003, to December 31, 2016. An institutional database was queried for the phrases “hereditary hemorrhagic telangiectasia” and “HHT,” and those patients who had been treated during the study period were identified. Data were extracted regarding presentation, AVM characteristics, treatment modality, and treatment outcomes. Results We identified 14 patients (10 males, 4 females) with HHT who had had AVMs (n = 27) from the institutional database. The mean age of the patients was 43 years (range, 2–64). Of the 27 brain AVMs, 13 were Spetzler-Martin grade I, 12 were grade II, and 2 were grade III; none were grade IV or V. Treatment was by microsurgery only (11 AVMs in 10 patients), embolization followed by microsurgery (2 AVMs in 2 patients), and radiosurgery only (12 AVMs in 2 patients). AVM obliteration was achieved in 100% of the patients. No new fixed neurologic deficits developed after treatment of unruptured HHT AVMs. Conclusions The risk of treatment of brain AVMs in patients with HHT is quite low for appropriately selected patients with treatment individualized to radiosurgery, microsurgery, or a combination of embolization and microsurgery.
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Meybodi AT, Kim H, Nelson J, Hetts SW, Krings T, terBrugge KG, Faughnan ME, Lawton MT. Surgical Treatment vs Nonsurgical Treatment for Brain Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia: A Retrospective Multicenter Consortium Study. Neurosurgery 2018; 82:35-47. [PMID: 28973426 DOI: 10.1093/neuros/nyx168] [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: 07/15/2016] [Accepted: 05/24/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebral arteriovenous malformations (AVMs) are common in patients with hereditary hemorrhagic telangiectasia (HHT). However, due to the rarity of HHT and little published evidence of outcomes from management of brain AVMs in this disease, current international HHT guidelines recommend an individualized approach. Specifically, the outcomes for surgical vs nonsurgical management of these lesions have not been reported to date. OBJECTIVE To report long-term outcomes of surgical resection of brain AVMs in HHT patients compared to outcomes in nonsurgically treated patients. METHODS From the database of the Brain Vascular Malformation Consortium HHT project, 19 patients with 20 resected AVMs (group 1) and 22 patients with 33 AVMs who received nonsurgical treatment (group 2) were studied. The groups were retrospectively reviewed for changes in functional status (modified Rankin Scale score) during the follow-up period. RESULTS During the follow-up period, 9% of patients in group 1 suffered from worsening of functional status, whereas this figure was 16% for group 2 (P > .05). Functional outcomes were not statistically different between the 2 groups at the latest follow-up (P > .05). CONCLUSION HHT patients treated surgically for brain AVMs appear to have long-term functional outcomes comparable to nonsurgical (including observational) therapy with fewer unfavorable outcomes. It is therefore reasonable to consider surgical resection as a management option in the multidisciplinary team's individualized treatment strategy for HHT patients with brain AVMs.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Steven W Hetts
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Timo Krings
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karel G terBrugge
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
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Ishii D, Takechi A, Seyama G, Sogabe T. Ruptured large basilar artery aneurysm associated with an arteriovenous malformation in hereditary hemorrhagic telangiectasia. Neurol Med Chir (Tokyo) 2013; 52:502-5. [PMID: 22850500 DOI: 10.2176/nmc.52.502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 53-year-old woman presented with intracranial hemorrhage caused by a ruptured cerebral aneurysm. Digital subtraction angiography revealed a large aneurysm arising from the top of the basilar artery and a Spetzler-Martin grade 3 arteriovenous malformation. Endovascular embolization of the aneurysm was completed with a slight neck remnant. Medical examination confirmed that she suffered from hereditary hemorrhagic telangiectasia (HHT). HHT is a rare autosomal dominant disorder characterized by multiple mucocutaneous telangiectasia and associated vascular malformations. This case suggests that the prognosis for HHT patients with treatable aneurysms should be as good as that of healthy individuals. Consequently, neurosurgeons should suspect underlying HHT in all patients with cerebral vascular malformations.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Matsuyama Red Cross Hospital, Ehime, Japan.
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