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Parodi C, Aluffi Valletti M, Tortora D, Buratti S, Mallamaci M, Tuo G, Pistorio A, Moscatelli A, Rossi A, Severino M. Vein of Galen aneurysmal malformation: does size affect outcome? Neuroradiology 2024; 66:1031-1042. [PMID: 38607438 PMCID: PMC11133167 DOI: 10.1007/s00234-024-03347-6] [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: 08/08/2023] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE To validate a semiautomated method for segmenting vein of Galen aneurysmal malformations (VGAM) and to assess the relationship between VGAM volume and other angioarchitectural features, cardiological findings, and outcomes. METHODS In this retrospective study, we selected all subjects with VGAM admitted to the Gaslini Children's Hospital between 2009 and 2022. Clinical data were retrieved from electronic charts. We compared 3D-Slicer segmented VGAM volumes obtained by two independent observers using phase-contrast MR venography to those obtained with manual measurements performed on T2-weighted images. The relationship between VGAM volumes and clinical and neuroimaging features was then explored. RESULTS Forty-three subjects with VGAM (22 males, mean age 6.56 days) were included in the study. Manual and semiautomated VGAM volumes were well correlated for both readers (r = 0.86 and 0.82, respectively). Regarding reproducibility, the inter-rater interclass correlation coefficients were 0.885 for the manual method and 0.992 for the semiautomated method (p < 0.001). The standard error for repeated measures was lower for the semiautomated method (0.04 versus 0.40 of manual method). Higher VGAM volume was associated with superior sagittal sinus narrowing, jugular bulb stenosis, and aqueductal stenosis (p < 0.05). A weak correlation was found between VGAM volume and straight sinus dilatation (r = 0.331) and superior sagittal sinus index (r = - 0.325). No significant associations were found with cardiac findings, post-embolization complications, and outcome (p > 0.05). CONCLUSIONS Semiautomated VGAM volumetry is feasible and reliable with improved reproducibility compared to the manual method. VGAM volume is not a prognostic factor for clinical outcome, but it is related to other venous findings with potential hemodynamic effects.
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Affiliation(s)
- Costanza Parodi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | | | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marisa Mallamaci
- Neonatal and Pediatric Intensive Care Unit and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giulia Tuo
- Pediatric Cardiology and Cardiac Surgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Angela Pistorio
- Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Mariasavina Severino
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
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Buratti S, Mallamaci M, Tuo G, Severino M, Tortora D, Parodi C, Rossi A, Pasetti F, Castellan L, Capra V, Romano F, De Marco P, Pavanello M, Piatelli G, Paladini D, Calevo MG, Moscatelli A. Vein of Galen aneurysmal malformation in newborns: a retrospective study to describe a paradigm of treatment and identify risk factors of adverse outcome in a referral center. Front Pediatr 2023; 11:1193738. [PMID: 37587977 PMCID: PMC10426803 DOI: 10.3389/fped.2023.1193738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/03/2023] [Indexed: 08/18/2023] Open
Abstract
Background Vein of Galen aneurysmal malformation (VGAM) is a rare cerebral vascular malformation associated with significant morbidity and mortality. Newborns with VGAM without adequate treatment may develop rapidly deteriorating high output heart failure (HOHF) and are at risk for severe neurological outcomes. Objective To describe the clinical course and management of newborns with VGAM, and identify which echocardiographic and neuroradiologic factors may be associated with severe heart failure at birth and adverse short term outcomes. Methods This is a single center retrospective cohort study including all consecutive newborns with VGAM admitted to Gaslini Children's Hospital between 2009 and 2022. We reviewed clinical data, intensive care support, fetal and neonatal cardiologic and neuroradiologic findings and we studied the association with severe HOHF, endovascular complications and death. Results Out of 40 newborns, 17 (42.5%) developed severe HOHF requiring early endovascular procedures. Medical treatment was focused on the main components of HOHF by providing inotropic support and peripheral vasodilation. Pulmonary vasodilators were avoided to reduce the negative effects of pulmonary overflow and prevent vascular remodeling. Reduction of the obligatory left to right shunt through the VGAM was possible only through endovascular treatment. Fetal cardiothoracic ratio was significantly associated with severe HOHF at birth and death. Cardiologic parameters of right ventricular overload, pulmonary hypertension and systemic steal were the leading findings associated with haemodynamic compromise at birth. The mediolateral diameter of the straight or falcine sinus at its shortest section (SS-MD), and arterial pseudofeeders were significantly associated with severe HOHF at birth in prenatal and postnatal assessments. None of the postnatal echocardiographic and MRI variables, nor a higher inotropic support were associated with major periprocedural complications or death. Mortality was due to palliation for congenital severe brain damage (4/40, 10%), or major periprocedural complications (3/40, 7.5%). None of the patients died due to HOHF and multiorgan failure. Overall survival at discharge was 82.5% (33/40). Conclusions The complexity of neonatal VGAM pathophysiology requires a multidisciplinary approach, specialized intensive care management, and early endovascular treatment to reduce mortality and optimize clinical outcomes. Cardiologic and neuroradiologic parameters are key to define risk stratification and treatment strategies.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Marisa Mallamaci
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giulia Tuo
- Pediatric Cardiology and Cardiac Surgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mariasavina Severino
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Costanza Parodi
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Pediatric Cardiology and Cardiac Surgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco Pasetti
- Pediatric Radiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Lucio Castellan
- Neuroradiology Unit, Diagnostic Imaging and Radiotherapy Department, San Martino Polyclinic Hospital, Genoa, Italy
| | - Valeria Capra
- Genomics and Clinical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Ferruccio Romano
- Genomics and Clinical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Patrizia De Marco
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Pavanello
- Neurosurgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gianluca Piatelli
- Neurosurgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Dario Paladini
- Fetal Medicine and Surgery Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maria Grazia Calevo
- Epidemiology, Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Schwarz S, Brevis Nuñez F, Dürr NR, Brassel F, Schlunz-Hendann M, Feldkamp A, Rosenbaum T, Felderhoff-Müser U, Schulz K, Dohna-Schwake C, Bruns N. Doppler Ultrasound Flow Reversal in the Superior Sagittal Sinus to Detect Cerebral Venous Congestion in Vein of Galen Malformation. AJNR Am J Neuroradiol 2023; 44:707-715. [PMID: 37230540 PMCID: PMC10249685 DOI: 10.3174/ajnr.a7891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND AND PURPOSE Vein of Galen malformation is a rare congenital cerebrovascular malformation. In affected patients, increased cerebral venous pressure constitutes an important etiologic factor for the development of brain parenchymal damage. The aim of this study was to investigate the potential of serial cerebral venous Doppler measurements to detect and monitor increased cerebral venous pressure. MATERIALS AND METHODS This was a retrospective monocentric analysis of ultrasound examinations within the first 9 months of life in patients with vein of Galen malformation admitted at <28 days of life. Categorization of perfusion waveforms in the superficial cerebral sinus and veins into 6 patterns was based on antero- and retrograde flow components. We performed an analysis of flow profiles across time and correlation with disease severity, clinical interventions, and congestion damage on cerebral MR imaging. RESULTS The study included 44 Doppler ultrasound examinations of the superior sagittal sinus and 36 examinations of the cortical veins from 7 patients. Doppler flow profiles before interventional therapy correlated with disease severity determined by the Bicêtre Neonatal Evaluation Score (Spearman ρ = -0.97, P = < .001). At this time, 4 of 7 patients (57.1%) showed a retrograde flow component in the superior sagittal sinus, whereas after embolization, none of the 6 treated patients presented with a retrograde flow component. Only patients with a high retrograde flow component (equal or more than one-third retrograde flow, n = 2) showed severe venous congestion damage on cerebral MR imaging. CONCLUSIONS Flow profiles in the superficial cerebral sinus and veins appear to be a useful tool to noninvasively detect and monitor cerebral venous congestion in vein of Galen malformation.
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Affiliation(s)
- S Schwarz
- From the Clinic for Pediatrics and Adolescent Medicine (S.S., F.B.N., A.F., T.R.)
| | - F Brevis Nuñez
- From the Clinic for Pediatrics and Adolescent Medicine (S.S., F.B.N., A.F., T.R.)
| | - N R Dürr
- Clinic for Radiology and Neuroradiology (N.R.D., F.B., M.S.-H., K.S.)
| | - F Brassel
- Clinic for Radiology and Neuroradiology (N.R.D., F.B., M.S.-H., K.S.)
- Center for Pediatric Interventional Radiology/Neuroradiology and Interventional Treatment of Vascular Malformations (F.B.), Sana Clinics Duisburg, Duisburg, Germany
| | - M Schlunz-Hendann
- Clinic for Radiology and Neuroradiology (N.R.D., F.B., M.S.-H., K.S.)
| | - A Feldkamp
- From the Clinic for Pediatrics and Adolescent Medicine (S.S., F.B.N., A.F., T.R.)
| | - T Rosenbaum
- From the Clinic for Pediatrics and Adolescent Medicine (S.S., F.B.N., A.F., T.R.)
| | - U Felderhoff-Müser
- Clinic for Pediatrics I (U.F.-M., C.D.-S., N.B.)
- Centre for Translational Neuro- and Behavioural Sciences (U.F.-M., C.D.-S., N.B.), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - K Schulz
- Clinic for Radiology and Neuroradiology (N.R.D., F.B., M.S.-H., K.S.)
| | - C Dohna-Schwake
- Clinic for Pediatrics I (U.F.-M., C.D.-S., N.B.)
- Centre for Translational Neuro- and Behavioural Sciences (U.F.-M., C.D.-S., N.B.), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - N Bruns
- Clinic for Pediatrics I (U.F.-M., C.D.-S., N.B.)
- Centre for Translational Neuro- and Behavioural Sciences (U.F.-M., C.D.-S., N.B.), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Smajda SJ, Söderman M, Dorfmüller G, Dorison N, Nghe MC, Rodesch GL. OUP accepted manuscript. Brain Commun 2022; 4:fcac043. [PMID: 35243346 PMCID: PMC8889109 DOI: 10.1093/braincomms/fcac043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/14/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Paediatric intracranial dural arteriovenous shunts have clinical presentations and evolutions, with angiographic characteristics that differ from those described in adults. We report our experience concerning their therapeutic management, emphasizing the relevance of early diagnosis and appropriate treatment for satisfactory neurocognitive development. Using a prospective database, we reviewed the clinical and radiological data of all children with dural arteriovenous shunts managed between 2002 and 2020. Dural shunts were categorized into three types: dural sinus malformations with arteriovenous shunts; infantile dural arteriovenous shunts; and adult-type dural arteriovenous shunts. Therapeutic strategies and outcomes were analysed depending on lesional subtypes. Modified Rankin Scale for the paediatric population was assessed pre-treatment and at last follow-up. Twenty-eight patients [16 girls (57.1%); 12 boys (42.9%)] were included: 17 dural sinus malformation [10 boys (58.8%); seven girls (41.2%)], three infantile shunts [three girls (100%)], eight adult-type shunts [four girls (50%)]; four boys (50%)], with a mean age of 19.2 ± 36.6 months at presentation. Twelve (42.9%) had a modified Rankin Scale score of 0–2, four (14.3%) had a score of 3, three (10.7%) had a score of 4 and eight (28.6%) had a score of 5. Embolization was performed in 22 children [78.6%; 12 girls (54.5%); 10 boys (45.5%)]. Fifteen patients could be cured (68.2%): 11 dural sinus malformations (73.3%), four adult-type lesions (100%) but no infantile shunt. Mean post-treatment follow-up was 39.5 months (max. 139 months): 14 patients (63.6%) presented a modified Rankin Scale score of 0–2 and eight (36.4%) had a score ≥3. In the dural sinus malformation group, the modified Rankin Scale score was improved in 11 patients (73.3%) and unchanged in three (20%). Only one patient with infantile subtype (33.3%) improved clinically. In the adult-subtype group, all children (100%) improved. Of six untreated patients [four girls (66.7%); two boys (33.3%)], four with adult-subtype shunts showed uneventful evolutions, one with dural sinus malformation died, and therapeutic abortion was conducted in an antenatally diagnosed dural sinus malformation. Paediatric dural fistulas comprise different subtypes with variable clinical courses. Proper diagnosis is mandatory for optimal therapeutic strategies within appropriate therapeutic windows.
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Affiliation(s)
- Stanislas J. Smajda
- Correspondence to: Stanislas Smajda, MD Department of Interventional Neuroradiology 29 Rue Manin, 75019 Paris, France E-mail:
| | - Michael Söderman
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Georg Dorfmüller
- Department of Pediatric Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Nathalie Dorison
- Department of Pediatric Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Marie-Claire Nghe
- Department of Anesthesiology and Intensive Care, Rothschild Foundation Hospital, Paris, France
| | - Georges L. Rodesch
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
- Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
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Primikiris P, Hadjigeorgiou G, Tsamopoulou M, Biondi A, Iosif C. Review on the current treatment status of vein of Galen malformations and future directions in research and treatment. Expert Rev Med Devices 2021; 18:933-954. [PMID: 34424109 DOI: 10.1080/17434440.2021.1970527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Vein of Galen malformations (VOGMs) represent a rare pathologic entity with often catastrophic natural history. The advances in endovascular treatment in recent years have allowed for a paradigm shift in the treatment and outcome of these high-flow shunts, even though their pathogenetic mechanisms and evolution remain in part obscure. AREAS COVERED The overall management of VOGMs requires a tailored case-to-case approach, starting with in utero detection and reserving endovascular treatment for indicated cases. Lately, the advances in translational research with whole-genome sequencing and the coupling with cellular-level hemodynamics attempt to shed more light in the pathogenesis and evolution of these lesions. At the same time the advances in endovascular techniques allow for more safety and tailored technical strategy planning. Furthermore, the advances in MRI techniques allow a better understanding of their vascular anatomy. In view of these recent advances and by performing a PUBMED literature review of the last 15 years, we attempt a review of the evolutions in the imaging, management, endovascular treatment and understanding of underlying mechanisms for VOGMs. EXPERT OPINION The progress in the fields detailed in this review appears very promising in better understanding VOGMs and expanding the available therapeutic arsenal.
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Affiliation(s)
- Panagiotis Primikiris
- Department of Interventional Neuroradiology, Jean Minjoz University Hospital, Besancon, France
| | | | - Maria Tsamopoulou
- School of Medicine, National Kapodistrian University of Athens, Greece
| | - Alessandra Biondi
- Department of Interventional Neuroradiology, Jean Minjoz University Hospital, Besancon, France
| | - Christina Iosif
- School of Medicine, European University of Cyprus, Nicosia, Cyprus.,Department of Interventional Neuroradiology, Henry Dunant Hospital, Athens, Greece
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Smajda S, Söderman M, Dorfmüller G, Dorison N, Nghe MC, Rodesch G. Endovascular management of torcular dural sinus malformations in children: the role of straight sinus occlusion. J Neurointerv Surg 2020; 13:278-283. [PMID: 33199540 DOI: 10.1136/neurintsurg-2020-016888] [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: 09/21/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Torcular dural sinus malformations (tDSMs) with arteriovenous shunts are rare congenital intracranial vascular malformations that carry a high rate of neurologic impairment and death in the neonatal, infant and young pediatric population. Their impact on brain venous drainage, especially the deep venous system, is one of the key factors in the clinical prognosis and natural history of the disease. We describe our therapeutic strategy for tDSMs, disconnecting the reflux into the deep venous system by performing an endovascular straight sinus occlusion. METHODS Among all children with dural sinus malformations seen between 2002 and 2020, we retrospectively reviewed those with tDSM in whom straight sinus occlusion had been performed. RESULTS Our databank included nine patients with tDSM that were embolized. Mean age at the clinical onset was 8.9±9.6 months (min-max=0-31). Five patients presented a significant reflux in the straight sinus on digital subtraction angiography. Those patients were initially clinically worse (mean modified Rankin Scale (mRS) 3.8) than those who did not present with reflux (mean mRS 2.25), this reflux being responsible for intraventricular hemorrhage in three patients. The reflux was suppressed by transarterial embolization in one patient and by transvenous straight sinus occlusion in four patients. Staged endovascular treatment resulted in a complete cure in six patients without complications, and clinical improvement in all patients. CONCLUSION Straight sinus occlusion is a feasible technique that needs to be considered in the treatment strategy for tDSM with deep venous reflux in order to avoid or minimize brain damage.
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Affiliation(s)
- Stanislas Smajda
- Interventional Neuroradiology, The Fondation Adolphe de Rothschild Hospital, Paris, France
| | - Michael Söderman
- Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden.,Karolinska Institutet Department of Clinical Neuroscience, Stockholm, Sweden
| | - Georg Dorfmüller
- Department of Pediatric Neurosurgery, The Fondation Adolphe de Rothschild Hospital, Paris, France
| | - Nathalie Dorison
- Department of Pediatric Neurosurgery, The Fondation Adolphe de Rothschild Hospital, Paris, France
| | - Marie-Claire Nghe
- Department of Anesthesiology and Intensive Care, The Fondation Adolphe de Rothschild Hospital, Paris, France
| | - Georges Rodesch
- Diagnostic and Interventional Neuroradiology Department, Hôpital Foch, Suresnes, France
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Venous pathologies in paediatric neuroradiology: from foetal to adolescent life. Neuroradiology 2019; 62:15-37. [PMID: 31707531 DOI: 10.1007/s00234-019-02294-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
The interpretation of cerebral venous pathologies in paediatric practice is challenging as there are several normal anatomical variants, and the pathologies are diverse, involving the venous system through direct and indirect mechanisms. This paper aims to provide a comprehensive review of these entities, as their awareness can avoid potential diagnostic pitfalls. We also propose a practical classification system of paediatric cerebral venous pathologies, which will enable more accurate reporting of the neuroimaging findings, as relevant to the underlying pathogenesis of these conditions. The proposed classification system comprises of the following main groups: arterio-venous shunting-related disorders, primary venous malformations and veno-occlusive disorders. A multimodal imaging approach has been included in the relevant subsections, with a brief overview of the modality-specific pitfalls that can also limit interpretation of the neuroimaging. The article also summarises the current literature and international practices in terms of management options and outcomes in specific disease entities.
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