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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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Kofoed MS, Tørring PM, Christensen AA, Lange B, Kjeldsen AD, Nielsen TH. High risk of ischaemic stroke amongst patients with hereditary haemorrhagic telangiectasia. Eur J Neurol 2024; 31:e16128. [PMID: 37955551 PMCID: PMC11235815 DOI: 10.1111/ene.16128] [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: 07/24/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND AND PURPOSE Hereditary haemorrhagic telangiectasia (HHT) is a genetic disease with fragile blood vessels and vascular malformations, potentially causing neurological manifestations, including stroke and cerebral abscesses. The study aimed to investigate neurological manifestations in the Danish HHT database, focusing on pulmonary arteriovenous malformations (PAVMs) as a risk factor for cerebral events. METHODS Retrospective analysis of the Danish HHT database was conducted, cross-referencing neurological outcomes with the Danish Apoplexy Register for accuracy. Patients were stratified by HHT type. Primary outcomes included ischaemic stroke, transient ischaemic attack and cerebral haemorrhage. Secondary outcomes comprised age, age at HHT diagnosis, age at cerebral ischaemic event, and PAVM and cerebral arteriovenous malformation status. RESULTS Six hundred and sixty-four HHT patients were included. PAVM was diagnosed in 54% of patients, with higher prevalence in HHT type 1 (70%) compared to HHT type 2 (34%) and juvenile polyposis HHT (66%). Ischaemic stroke or transient ischaemic attack occurred in 12.5%, with a higher risk associated with macroscopic PAVM. Logistic regression showed a nearly 10 times increased risk of ischaemic stroke with macroscopic PAVM. Cerebral abscesses occurred in 3.2% of patients, all with macroscopic PAVM. Incomplete PAVM closure increased cerebral abscess risk. CONCLUSION This study provides valuable insights into the prevalence of neurological manifestations and vascular events in HHT patients. The presence of PAVM was associated with an increased risk of ischaemic stroke, highlighting the importance of early screening and intervention. The findings emphasize the need for comprehensive management strategies targeting both vascular and neurological complications in HHT patients, especially regarding secondary stroke prevention.
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Affiliation(s)
- Mikkel Seremet Kofoed
- Department of Neurosurgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- BRIDGE (Brain Research—Inter Disciplinary Guided Excellence)University of Southern DenmarkOdenseDenmark
- Department of Ear, Nose and Throat Surgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- University of Southern Denmark (SDU)OdenseDenmark
- OPENRegion of Southern DenmarkOdenseDenmark
| | - Pernille M. Tørring
- Department of Clinical GeneticsOdense University HospitalOdenseDenmark
- VASCERN HHT Reference CenterOdense Universitetshospital, Syddansk UniversitetOdenseDenmark
| | - Alex Alban Christensen
- Department of Neurology, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
| | - Bibi Lange
- Department of Ear, Nose and Throat Surgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
| | - Anette Drøhse Kjeldsen
- Department of Ear, Nose and Throat Surgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- University of Southern Denmark (SDU)OdenseDenmark
- OPENRegion of Southern DenmarkOdenseDenmark
- VASCERN HHT Reference CenterOdense Universitetshospital, Syddansk UniversitetOdenseDenmark
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- BRIDGE (Brain Research—Inter Disciplinary Guided Excellence)University of Southern DenmarkOdenseDenmark
- University of Southern Denmark (SDU)OdenseDenmark
- OPENRegion of Southern DenmarkOdenseDenmark
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Cheng HC, Faughnan ME, terBrugge KG, Liu HM, Krings T. Prevalence and Characteristics of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia. AJNR Am J Neuroradiol 2023; 44:1367-1372. [PMID: 38050014 PMCID: PMC10714847 DOI: 10.3174/ajnr.a8058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND PURPOSE The association between hereditary hemorrhagic telangiectasia and intracranial aneurysms remains controversial. This study evaluated the prevalence and characteristics of intracranial aneurysms in patients with hereditary hemorrhagic telangiectasia with brain vascular malformations. MATERIALS AND METHODS Between 2007 and 2021, patients enrolled in the Brain Vascular Malformation Consortium with definite hereditary hemorrhagic telangiectasia, the presence of brain vascular malformations, and available angiographic studies of the brain were retrospectively reviewed. Angiographic features of intracranial aneurysms and their relationship to coexisting brain vascular malformations were analyzed. We also examined the association between baseline clinical features and the presence of intracranial aneurysms. RESULTS One hundred eighty patients were included. A total of 14 intracranial aneurysms were found in 9 (5%) patients, and 4 intracranial aneurysms were considered flow-related aneurysms. Patients with intracranial aneurysms were significantly older than patients without intracranial aneurysms (mean, 48.1 [SD, 18.2] years versus 33.5 [SD, 21.0] years; P = .042). If we excluded flow-related intracranial aneurysms, the prevalence of intracranial aneurysms was 3.3%. All intracranial aneurysms were in the anterior circulation, were unruptured, and had an average maximal diameter of 3.9 (SD, 1.5) mm. No intracranial aneurysms were found in pediatric patients with hereditary hemorrhagic telangiectasia. No statistically significant correlation was observed among other baseline demographics, hereditary hemorrhagic telangiectasia features, and the presence of intracranial aneurysms. CONCLUSIONS The prevalence of intracranial aneurysms in this large cohort study is comparable with that in the general population and might be increased slightly due to hemodynamic factors associated with shunting brain vascular malformations.
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Affiliation(s)
- How-Chung Cheng
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery (H.-C.C.), Department of Surgery, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Marie E Faughnan
- Toronto HHT Centre (M.E.F.), St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Division of Respirology (M.E.F.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karel G terBrugge
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hon-Man Liu
- Department of Medical Imaging (H.-M.L.), Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Timo Krings
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Han C, Nguyen CL, Scherschinski L, Schriber TD, Arthur HM, Lawton MT, Oh SP. VEGFR2 Expression Correlates with Postnatal Development of Brain Arteriovenous Malformations in a Mouse Model of Type I Hereditary Hemorrhagic Telangiectasia. Biomedicines 2023; 11:3153. [PMID: 38137374 PMCID: PMC10740421 DOI: 10.3390/biomedicines11123153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 12/24/2023] Open
Abstract
Brain arteriovenous malformations (BAVMs) are a critical concern in hereditary hemorrhagic telangiectasia (HHT) patients, carrying the risk of life-threatening intracranial hemorrhage. While traditionally seen as congenital, the debate continues due to documented de novo cases. Our primary goal was to identify the precise postnatal window in which deletion of the HHT gene Endoglin (Eng) triggers BAVM development. We employed SclCreER(+);Eng2f/2f mice, enabling timed Eng gene deletion in endothelial cells via tamoxifen. Tamoxifen was given during four postnatal periods: P1-3, P8-10, P15-17, and P22-24. BAVM development was assessed at 2-3 months using latex dye perfusion. We examined the angiogenic activity by assessing vascular endothelial growth factor receptor 2 (VEGFR2) expression via Western blotting and Flk1-LacZ reporter mice. Longitudinal magnetic resonance angiography (MRA) was conducted up to 9 months. BAVMs emerged in 88% (P1-3), 86% (P8-10), and 55% (P15-17) of cases, with varying localization. Notably, the P22-24 group did not develop BAVMs but exhibited skin AVMs. VEGFR2 expression peaked in the initial 2 postnatal weeks, coinciding with BAVM onset. These findings support the "second hit" theory, highlighting the role of early postnatal angiogenesis in initiating BAVM development in HHT type I mice.
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Affiliation(s)
- Chul Han
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
| | - Candice L. Nguyen
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
| | - Lea Scherschinski
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Tyler D. Schriber
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
| | - Helen M. Arthur
- Biosciences Institute, Newcastle University, Newcastle NE1 7RU, UK;
| | - Michael T. Lawton
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Suk Paul Oh
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (C.H.); (C.L.N.); (L.S.); (M.T.L.)
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Eker OF, Dupuis-Girod S, Shovlin CL, Boccardi E. Comment on Kilian et al. Comparing Characteristics and Treatment of Brain Vascular Malformations in Children and Adults with HHT. J. Clin. Med. 2023, 12, 2704. J Clin Med 2023; 12:7179. [PMID: 38002793 PMCID: PMC10672674 DOI: 10.3390/jcm12227179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
We read with interest the recent article by Killian et al. regarding the characteristics and treatment of brain vascular malformations (VMs) in children and adults with hereditary hemorrhagic telangiectasia (HHT) [...].
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Affiliation(s)
- Omer F. Eker
- Hospices Civils de Lyon, 69006 Lyon, France;
- CREATIS Laboratory, INSA-Lyon, 69621 Villeurbanne, France
| | | | - Claire L. Shovlin
- Imperial College London, London W12 0NN, UK;
- Imperial College Healthcare National Health Service Trust, London W12 0HS, UK
| | - Edoardo Boccardi
- Department of Neuroradiology, Grande Ospedale Maggiore Niguarda, 20162 Milan, Italy;
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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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Yamada H, Akiyama T, Kamamoto D, Yoshida K, Fukumura M, Toda M. Combined transarterial and transvenous embolization of multi-hole pial arteriovenous fistula with large varix. Neuroradiol J 2022; 35:640-646. [PMID: 35477369 PMCID: PMC9513922 DOI: 10.1177/19714009221096829] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pial arteriovenous fistula (AVF) is a vascular fistulous disease in which the cerebral pial artery and vein are directly connected without the intervening nidus within a sub-pial space. Multi-hole pial AVFs, wherein multiple feeders flow into one drainer, are usually formed with complex angioarchitecture and are difficult to treat. METHODS A rare case of an adult patient with hereditary hemorrhagic telangiectasia and multi-hole pial AVF was described. A 23-year-old woman was referred to our hospital. She was previously diagnosed with left cerebellar pial AVF with multiple feeders (bilateral superior cerebellar artery and common trunk of the left anterior inferior cerebellar artery and posterior inferior cerebellar) and large varix that had been untreated for 9 years. The enlargement of the large varix with the new second varix formation was revealed by angiography. Although asymptomatic, considered to be a risk for future hemorrhage was the continuous high hemodynamic stress. RESULTS Endovascular embolization was performed by securing safe transarterial n-butyl-2-cyanoacrylate injection by transarterial and transvenous coil placement to the shunt points and feeders, resulting in total occlusion of the fistula without any complications. Extensive transvenous coil placement inside the varix allowed safe embolization of the entire fistula with multiple high-flow feeders. Moreover, bidirectional (transarterial and transvenous) retrograde coil embolization enabled firm obliteration of the shunt points. CONCLUSIONS Performing combined transarterial and transvenous embolization in a well-balanced manner was considered to treat multi-hole pial AVF to provide a safe and effective embolization.
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Affiliation(s)
- Hiroki Yamada
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Takenori Akiyama
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Dai Kamamoto
- Department of Neurosurgery, Tokyo Dental College Ichikawa General
Hospital, Chiba, Japan
| | - Keisuke Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mariko Fukumura
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Perez Akly MS, Vazquez C, Besada CH, Rodriguez MJ, Conde MF, Cajal AR, Peuchot VA, Dardik D, Baccanelli MM, Serra MM. Prevalence of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia: Report from a Single Reference Center. AJNR Am J Neuroradiol 2022; 43:844-849. [PMID: 35589139 DOI: 10.3174/ajnr.a7505] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/17/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Neurologic manifestations in hereditary hemorrhagic telangiectasia include an increased incidence of brain abscesses and ischemic strokes due to paradoxic embolization in addition to a wide spectrum of symptoms and complications due to typical brain vascular malformations. Intracranial aneurysms are not part of this brain vascular malformation spectrum. The aim of this study was to determine their prevalence in patients with hereditary hemorrhagic telangiectasia. MATERIALS AND METHODS This was a single-center, retrospective study. Adult patients from the institutional Hereditary Hemorrhagic Telangiectasia registry with a definitive diagnosis of hereditary hemorrhagic telangiectasia and an available report or angiographic imaging study were included and reviewed to determine the intracranial aneurysm prevalence. In addition, the morphologic characteristics of intracranial aneurysms and possible associated risk factors were collected. RESULTS Two hundred twenty-eight patients were analyzed. Thirty-seven aneurysms in 33 patients (14.5%; 95% CI, 9.9%-19%) were found. The median diameter of intracranial aneurysms was 3.2 mm (interquartile range, 2.6-4.4 mm). No association between intracranial aneurysm and sex, age, or genetic background was noted. There were no subarachnoid hemorrhagic events due to intracranial aneurysm rupture. CONCLUSIONS Due to the high prevalence of intracranial aneurysms in adult patients with hereditary hemorrhagic telangiectasia, further studies regarding bleeding risks and monitoring should be addressed.
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Affiliation(s)
- M S Perez Akly
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
| | - C Vazquez
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Department of Internal Medicine (C.V., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
| | - C H Besada
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
| | - M J Rodriguez
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M F Conde
- From the Department of Radiology (M.S.P.A., C.H.B., M.J.R., C.M.F.), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A R Cajal
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
- Translational Medicine and Biomedical Engineering Institute (A.R.C.), Buenos Aires, Argentina
- University Institute (A.R.C., M.M.B., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
| | - V A Peuchot
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Internal Medicine Research Area (V.A.P.), Hospital Italiano, Buenos Aires, Argentina
| | - D Dardik
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- From the Department of Radiology (D.D.), Clínica Instituto de Diagnóstico Sociedad Anónima (INDISA), Santiago, Chile
| | - M M Baccanelli
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Department of Neurosurgery (M.M.B.), Hospital Italiano, Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
- University Institute (A.R.C., M.M.B., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
| | - M M Serra
- A.R.G. Argentine Rendu Study Group (M.S.P.A., C.V., C.H.B., A.R.C., VA.P., D.D., M.M.B., M.M.S.), Buenos Aires, Argentina
- Department of Internal Medicine (C.V., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
- Hereditary Hemorrhagic Telangiectasia Unit (M.S.P.A., C.H.B., A.R.C., M.M.B., M.M.S.) Hospital Italiano, Buenos Aires, Argentina
- University Institute (A.R.C., M.M.B., M.M.S.), Hospital Italiano, Buenos Aires, Argentina
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Gaetani E, Peppucci E, Agostini F, Di Martino L, Lucci Cordisco E, Sturiale CL, Puca A, Porfidia A, Alexandre A, Pedicelli A, Pola R. Distribution of Cerebrovascular Phenotypes According to Variants of the ENG and ACVRL1 Genes in Subjects with Hereditary Hemorrhagic Telangiectasia. J Clin Med 2022; 11:jcm11102685. [PMID: 35628811 PMCID: PMC9146077 DOI: 10.3390/jcm11102685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 12/14/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder caused, in more than 80% of cases, by mutations of either the endoglin (ENG) or the activin A receptor-like type 1 (ACVRL1) gene. Several hundred variants have been identified in these HHT-causing genes, including deletions, missense and nonsense mutations, splice defects, duplications, and insertions. In this study, we have analyzed retrospectively collected images of magnetic resonance angiographies (MRA) of the brain of HHT patients, followed at the HHT Center of our University Hospital, and looked for the distribution of cerebrovascular phenotypes according to specific gene variants. We found that cerebrovascular malformations were heterogeneous among HHT patients, with phenotypes that ranged from classical arteriovenous malformations (AVM) to intracranial aneurysms (IA), developmental venous anomalies (DVA), and cavernous angiomas (CA). There was also wide heterogeneity among the variants of the ENG and ACVRL1 genes, which included known pathogenic variants, variants of unknown significance, variants pending classification, and variants which had not been previously reported. The percentage of patients with cerebrovascular malformations was significantly higher among subjects with ENG variants than ACVRL1 variants (25.0% vs. 13.1%, p < 0.05). The prevalence of neurovascular anomalies was different among subjects with different gene variants, with an incidence that ranged from 3.3% among subjects with the c.1231C > T, c.200G > A, or c.1120C > T missense mutations of the ACVRL1 gene, to 75.0% among subjects with the c.1435C > T missense mutation of the ACVRL1 gene. Further studies and larger sample sizes are required to confirm these findings.
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Affiliation(s)
- Eleonora Gaetani
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence:
| | - Elisabetta Peppucci
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fabiana Agostini
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luigi Di Martino
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Emanuela Lucci Cordisco
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Genetics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carmelo L. Sturiale
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alfredo Puca
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Angelo Porfidia
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Alexandre
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Radiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alessandro Pedicelli
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Radiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Roberto Pola
- HHT Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (E.P.); (F.A.); (L.D.M.); (E.L.C.); (C.L.S.); (A.P.); (A.P.); (A.A.); (A.P.); (R.P.)
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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10
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Neurovascular Manifestations in Pediatric Patients With Hereditary Haemorrhagic Telangiectasia. Pediatr Neurol 2022; 129:24-30. [PMID: 35176532 DOI: 10.1016/j.pediatrneurol.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a multiorgan vascular dysplasia with limited data regarding its neurovascular manifestations and genotype-phenotype correlation in children. The objective of this study was to describe the neurovascular findings in a large cohort of children with HHT and correlate between phenotype and genotype. METHODS This retrospective study was conducted on 221 children (<18 years) with a definite or possible diagnosis of HHT based on Curacao criteria, or with positive genetics for the mutated genes of ENG, ACVRL-1, and SMAD-4, who also underwent brain MRI and/or conventional angiography. Demographic and clinical information, imaging findings, and follow up information were gathered. RESULTS Two hundred twenty-one children with HHT (70.6% genetically confirmed, and 99.5% positive family history) were included, with a median age of 7 years (interquartile range: 3 to 11 years) and 58.8% male predominance. Neurovascular lesions were found in 64 of 221 (28.9%), with 3.1% prevalence of intracranial hemorrhage. The most commonly observed vascular malformations were developmental venous anomalies (48.5%) and brain arteriovenous malformations (AVMs) (31.2%), followed by capillary malformations (14.1%). Multiple AVMs were seen in 10.0% of the cohort. We found no instances of de novo AVM (1281.8 patient-years).A significantly higher proportion of patients with ENG mutations (19.7%) had brain AVM than those with ACVRL-1 (4.9%) and SMAD-4 (0%) mutations (P < 0.01). There was no significant difference in the hemorrhagic risk of shunting lesions associated with ENG (35.3%) or ACVRL-1 (33.3%) positivity (P = 0.9). CONCLUSIONS We describe the neurovascular imaging and genetic findings from a large pediatric cohort of HHT, to enhance clinical awareness and guide management of patients with HHT.
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11
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Sobrepera S, Monroe E, Gemmete JJ, Hallam D, Pinchot JW, Kaufman C. Imaging to intervention: a review of what the Interventionalist needs to Know about Hereditary Hemorrhagic Telangiectasia. CVIR Endovasc 2021; 4:84. [PMID: 34882285 PMCID: PMC8660943 DOI: 10.1186/s42155-021-00270-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/19/2021] [Indexed: 12/17/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder that affects 1 in 5000-10,000 people worldwide and can result in devastating complications such as cerebral abscess, stroke, massive hemorrhage, and even death. HHT is an autosomal dominant disorder that leads to the formation of abnormal communication between the arteries and veins with a resultant spectrum of vascular anomalies. The disorder affects many organ systems and thus requires a dedicated multidisciplinary approach. Interventional radiologists are vital members of this team providing expertise not only in disease management, but in complex embolotherapy, helping to maintain the health of these patients. This article reviews clinical manifestations, screening guidelines, diagnostic criteria, and endovascular management of HHT.
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Affiliation(s)
- Stephanie Sobrepera
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Eric Monroe
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danial Hallam
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jason W Pinchot
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Claire Kaufman
- Department of Radiology & Imaging Sciences, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132-2140, USA.
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12
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Song X, Li Z. Co-existing of craniofacial fibrous dysplasia and cerebrovascular diseases: a series of 22 cases and review of the literature. Orphanet J Rare Dis 2021; 16:471. [PMID: 34736485 PMCID: PMC8567608 DOI: 10.1186/s13023-021-02102-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 10/24/2021] [Indexed: 01/11/2023] Open
Abstract
Background Craniofacial fibrous dysplasia is a fairly rare condition. Some literature have reported a few patients with craniofacial fibrous dysplasia suffering from vascular abnormalities. This study aimed to describe the possible coexistence of craniofacial fibrous dysplasia and cerebrovascular diseases for the first time. Method We retrospectively reviewed the 1175 patients with craniofacial fibrous dysplasia in Beijing Tiantan Hospital and the information of the 22 patients coexisted with cerebrovascular diseases were described. In addition, we performed a systematic review for cases of craniofacial fibrous dysplasia with vascular abnormalities. Result 22 out of 1175 patients (1.9%) were diagnosed with craniofacial fibrous dysplasia and cerebrovascular diseases including 9 intracranial aneurysms, 4 venous malformations, 2 arteriovenous malformations, 1 moyamoya disease, 2 intracranial venous stenosis and 4 cerebral ischemia with a mean age of 38.18 years old. Only 2 patients were managed surgically for craniofacial fibrous dysplasia and 6 patients were treated with neurosurgery for cerebrovascular diseases. 8 patients were closely followed and only 1 patient’s symptoms worsened. Conclusion Craniofacial fibrous dysplasia might cause constriction of the intracranial vessels and alteration of the overall hemodynamics of the intracranial vasculature resulting in various cerebrovascular diseases. Multimodal screening and examinations seems reasonable for patients with craniofacial fibrous dysplasia for throughout treatment and prognosis evaluations.
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Affiliation(s)
- Xiaowen Song
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No 119, Nansihuan xilu, Beijing, 100070, China.,China National Research Center for Neurological Disease, Beijing, China
| | - Zhi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No 119, Nansihuan xilu, Beijing, 100070, China. .,China National Research Center for Neurological Disease, Beijing, China.
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13
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Thompson KP, Nelson J, Kim H, Weinsheimer SM, Marchuk DA, Lawton MT, Krings T, Faughnan ME. Utility of modified Rankin Scale for brain vascular malformations in hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:390. [PMID: 34538258 PMCID: PMC8451134 DOI: 10.1186/s13023-021-02012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Approximately 10% of hereditary hemorrhagic telangiectasia (HHT) patients harbour brain vascular malformations (VMs). Intracranial hemorrhage (ICH) from brain VMs can lead to death or morbidity, while treatment options for brain VMs also have associated morbidity. The modified Rankin Scale (mRS) may provide an approach to identifying HHT-brain VM patients with poor outcomes, and their predictors. We aimed to measure the relationship between mRS score and brain VM, brain VM number, as well as other aspects of HHT, at enrollment and during prospective follow-up. Methods 1637 HHT patients (342 with brain VMs) were recruited from 14 HHT centres of the Brain Vascular Malformation Consortium since 2010 and followed prospectively (mean = 3.4 years). We tested whether the presence of brain VM, other HHT organ involvement, and HHT mutation genotype were associated with worse mRS scores at baseline and during follow-up, using linear mixed models, adjusting for age, sex, and year of visit. Results Presence of brain VMs was not associated with worse mRS score at baseline and there was no significant worsening of mRS with prospective follow-up in these patients; 92% had baseline mRS of 0–2. HHT-related gastrointestinal (GI) bleeding was associated with worse mRS scores at baseline (0.37, 95% CI 0.26–0.47, p < 0.001), as were history of anemia (0.35, 95% CI 0.27–0.43, p < 0.001) and liver VMs (0.19, 95% CI 0.09–0.30, p < 0.001). Presence of pulmonary arteriovenous malformations (AVMs) was not associated with worse mRS scores at baseline. mRS score was not associated with either HHT genotype (Endoglin vs ACVRL1). Only GI bleeding was associated with a significantly worsening mRS during prospective follow-up (0.64, 95% CI 0.21–1.08, p = 0.004). Conclusion Most HHT-brain VM patients had good functional capacity (mRS scores 0–2) at baseline that did not change significantly over 3.4 mean years of follow-up, suggesting that mRS may not be useful for predicting or measuring outcomes in these patients. However, HHT patients with GI bleeding, anemia history or liver VMs had worse mRS scores, suggesting significant impact of these manifestations on functional capacity. Our study demonstrates the insensitivity of the mRS as an outcomes measure in HHT brain VM patients and reinforces the continued need to develop outcomes measures, and their predictors, in this group.
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Affiliation(s)
- K P Thompson
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - H Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - S M Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - T Krings
- Division of Neurosurgery, Department of Medical Imaging, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neuroradiology, Toronto Western Hospital, Univeristy Health Network, Toronto, Canada
| | - M E Faughnan
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada. .,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
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14
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Millward CP, Van Tonder L, Williams D, Thornton O, Foster M, Griffiths M, Puthuran M, Chandran A, Israni A, Sinha A, Kneen R, Mallucci C. Screening for cerebrovascular disorder on the basis of family history in asymptomatic children. Br J Neurosurg 2021; 35:584-590. [PMID: 34169790 DOI: 10.1080/02688697.2021.1922607] [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: 10/21/2022]
Abstract
Background: Cerebrovascular disorders represent a group of uncommon, heterogeneous, and complex conditions in children. We reviewed the screening practice for the detection of cerebrovascular disorder in asymptomatic children referred to our neurovascular service on the basis of a positive family history and parental and/or treating physician concern.Methods: Retrospective case-note review of referrals to our neurovascular service (July 2008-April 2018). Patients were included if the referral was made for screening, on the basis of a positive family history of cerebrovascular disorder. Symptomatic children, those with previous cranial imaging, or children under the care of a clinical geneticist (i.e. due to the child or their relative having HHT or mutations in KRIT1) were not eligible for inclusion.Results: Forty-one children were reviewed, 22 males (Median age 10.7 years, range 0.6-15.6 years). This represented 22% of the total number of referrals over a 10-year period. Twenty-nine children had an MRI/MRA brain. Twenty-eight children were referred due to a family history of intracranial aneurysm and/or subarachnoid haemorrhage, but only two had two first-degree relatives affected. Ten children were referred due to a family history of arteriovenous malformation. Three children were referred due to a family history of stroke. No cerebrovascular disease was detected during the study period (n = 29).Conclusions: Parental and/or physician concern generated a substantial number of referrals but no pathology was detected after screening. Whilst general screening guidance exists for the detection of intracranial aneurysms, consensus guidelines for the screening of children with a positive family history do not, but are required both to guide clinical practice and to assuage parental and/or physician concerns.
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Affiliation(s)
- Christopher Paul Millward
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Libby Van Tonder
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Dawn Williams
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Owen Thornton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mitchell Foster
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Michael Griffiths
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Mani Puthuran
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Arun Chandran
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Anil Israni
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Ajay Sinha
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rachel Kneen
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Conor Mallucci
- Neurosurgery Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
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15
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Zhang X, Xu L, Mang J, Shi X, Xu Z. CT-Negative Subarachnoid Hemorrhage Caused by Telangiectasia: A Case Report. Curr Med Imaging 2021; 17:1262-1265. [PMID: 34102984 DOI: 10.2174/1573405617666210608163746] [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: 02/14/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION At present, the mechanism of telangiectasia is unknown, but some evidence suggests that it may be related to genetic abnormalities. Telangiectasia may lead to bleeding of multiple sites. CT-negative subarachnoid hemorrhage is rare, which is mostly related to hemorrhage with a little amount of bleeding. CT-negative subarachnoid hemorrhage due to telangiectasia has not been reported. CASE REPORT In this case report, the patient experienced severe headache with nausea, vomiting, and blurred vision for 12 days, and had a history of hypertension. Physical examination revealed a clear state of mind, normal speech, normal limb muscle strength, 2 transverse fingers of neck stiffness, and negative bilateral Babinski signs. Brain CT, MRI, MRA, and MRV showed no obvious abnormalities. SWI suggested the possibility of capillary dilation. The cerebrospinal fluid was pale yellow in appearance after lumbar puncture. DIAGNOSIS The patient was diagnosed with subarachnoid hemorrhage(SAH) and capillary dilatation. INTERVENTIONS Therapeutic management of blood pressure and brain edema was started. CONCLUSION Lumbar puncture should be performed when subarachnoid hemorrhage is clinically suspected and CT is negative. While searching for the cause of subarachnoid hemorrhage, the presence of telangiectasia should be ascertained.
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Affiliation(s)
- Xin Zhang
- Department of Neurology, China-Japan Union Hospital of Jilin University, China
| | - Lei Xu
- Department of Neurology, China-Japan Union Hospital of Jilin University, China
| | - Jing Mang
- Department of Neurology, China-Japan Union Hospital of Jilin University, China
| | - Xiaohua Shi
- Department of Neurology, China-Japan Union Hospital of Jilin University, China
| | - Zhongxin Xu
- Department of Neurology, China-Japan Union Hospital of Jilin University, China
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16
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Hart BL, Mabray MC, Morrison L, Whitehead KJ, Kim H. Systemic and CNS manifestations of inherited cerebrovascular malformations. Clin Imaging 2021; 75:55-66. [PMID: 33493737 DOI: 10.1016/j.clinimag.2021.01.020] [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: 10/30/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 12/25/2022]
Abstract
Cerebrovascular malformations occur in both sporadic and inherited patterns. This paper reviews imaging and clinical features of cerebrovascular malformations with a genetic basis. Genetic diseases such as familial cerebral cavernous malformations and hereditary hemorrhagic telangiectasia often have manifestations in bone, skin, eyes, and visceral organs, which should be recognized. Genetic and molecular mechanisms underlying the inherited disorders are becoming better understood, and treatments are likely to follow. An interaction between the intestinal microbiome and formation of cerebral cavernous malformations has emerged, with possible treatment implications. Two-hit mechanisms are involved in these disorders, and additional triggering mechanisms are part of the development of malformations. Hereditary hemorrhagic telangiectasia encompasses a variety of vascular malformations, with widely varying risks, and a more recently recognized association with cortical malformations. Somatic mutations are implicated in the genesis of some sporadic malformations, which means that discoveries related to inherited disorders may aid treatment of sporadic cases. This paper summarizes the current state of knowledge of these conditions, salient features regarding mechanisms of development, and treatment prospects.
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Affiliation(s)
- Blaine L Hart
- Department of Radiology, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Marc C Mabray
- Department of Radiology, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Leslie Morrison
- Department of Neurology, MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
| | - Kevin J Whitehead
- Division of Cardiovascular Medicine and the Program in Molecular Medicine, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA; George E. Wahlen Salt Lake City VA Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148, USA.
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143, USA.
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17
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Potential Second-Hits in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9113571. [PMID: 33167572 PMCID: PMC7694477 DOI: 10.3390/jcm9113571] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder that presents with telangiectases in skin and mucosae, and arteriovenous malformations (AVMs) in internal organs such as lungs, liver, and brain. Mutations in ENG (endoglin), ACVRL1 (ALK1), and MADH4 (Smad4) genes account for over 95% of HHT. Localized telangiectases and AVMs are present in different organs, with frequencies which differ among affected individuals. By itself, HHT gene heterozygosity does not account for the focal nature and varying presentation of the vascular lesions leading to the hypothesis of a “second-hit” that triggers the lesions. Accumulating research has identified a variety of triggers that may synergize with HHT gene heterozygosity to generate the vascular lesions. Among the postulated second-hits are: mechanical trauma, light, inflammation, vascular injury, angiogenic stimuli, shear stress, modifier genes, and somatic mutations in the wildtype HHT gene allele. The aim of this review is to summarize these triggers, as well as the functional mechanisms involved.
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Eker OF, Boccardi E, Sure U, Patel MC, Alicante S, Alsafi A, Coote N, Droege F, Dupuis O, Fialla AD, Jones B, Kariholu U, Kjeldsen AD, Lefroy D, Lenato GM, Mager HJ, Manfredi G, Nielsen TH, Pagella F, Post MC, Rennie C, Sabbà C, Suppressa P, Toerring PM, Ugolini S, Buscarini E, Dupuis-Girod S, Shovlin CL. European Reference Network for Rare Vascular Diseases (VASCERN) position statement on cerebral screening in adults and children with hereditary haemorrhagic telangiectasia (HHT). Orphanet J Rare Dis 2020; 15:165. [PMID: 32600364 PMCID: PMC7322871 DOI: 10.1186/s13023-020-01386-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/22/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia inherited as an autosomal dominant trait. Approximately 10 % of patients have cerebral vascular malformations, a proportion being cerebral arteriovenous malformations (AVMs) and fistulae that may lead to potentially devastating consequences in case of rupture. On the other hand, detection and treatment related-risks are not negligible, and immediate. While successful treatment can be undertaken in individual cases, current data do not support the treatment of unruptured AVMs, which also present a low risk of bleeding in HHT patients. Screening for these AVMs is therefore controversial. Structured discussions, distinctions of different cerebrovascular abnormalities commonly grouped into an “AVM” bracket, and clear guidance by neurosurgical and neurointerventional radiology colleagues enabled the European Reference Network for Rare Vascular Disorders (VASCERN-HHT) to develop the following agreed Position Statement on cerebral screening: 1) First, we emphasise that neurological symptoms suggestive of cerebral AVMs in HHT patients should be investigated as in general neurological and emergency care practice. Similarly, if an AVM is found accidentally, management approaches should rely on expert discussions on a case-by-case basis and individual risk-benefit evaluation of all therapeutic possibilities for a specific lesion. 2) The current evidence base does not favour the treatment of unruptured cerebral AVMs, and therefore cannot be used to support widespread screening of asymptomatic HHT patients. 3) Individual situations encompass a wide range of personal, cultural and clinical states. In order to enable informed patient choice, and avoid conflicting advice, particularly arising from non-neurovascular interpretations of the evidence base, we suggest that all HHT patients should have the opportunity to discuss knowingly brain screening issues with their healthcare provider. 4) Any screening discussions in asymptomatic individuals should be preceded by informed pre-test review of the latest evidence regarding preventative and therapeutic efficacies of any interventions. The possibility of harm due to detection of, or intervention on, a vascular malformation that would not have necessarily caused any consequence in later life should be stated explicitly. We consider this nuanced Position Statement provides a helpful, evidence-based framework for informed discussions between healthcare providers and patients in an emotionally charged area.
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Affiliation(s)
- Omer F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - Edoardo Boccardi
- Niguarda Hospital, Milan, Italy and VASCERN HHT Reference Centre, Crema, Italy
| | - Ulrich Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Maneesh C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Saverio Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Ali Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Nicola Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Freya Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Olivier Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France
| | - Annette Dam Fialla
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Bryony Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Ujwal Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Anette D Kjeldsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - David Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Gennaro M Lenato
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Hans Jurgen Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Troels H Nielsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Fabio Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Marco C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Catherine Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Carlo Sabbà
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy.
| | - Patrizia Suppressa
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Pernille M Toerring
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Sara Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | | | - Claire L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK and Imperial College London, London, UK.
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19
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Brinjikji W, Iyer V, Lanzino G. Micro-Arteriovenous Malformations of the Spine in Hereditary Hemorrhagic Telangiectasia. Clin Neuroradiol 2020; 30:395-398. [DOI: 10.1007/s00062-019-00828-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
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20
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Park R, Philp A, Nagji AS, Kasi A. Pathologically Complete Response after Triple Therapy in Locally Advanced Esophageal Cancer in a Hereditary Hemorrhagic Telangiectasia Patient. Case Rep Oncol 2020; 13:176-181. [PMID: 32231541 PMCID: PMC7098335 DOI: 10.1159/000505832] [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: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 11/19/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by vascular manifestations including mucocutaneous and visceral telangiectasias and arteriovenous malformations. Herein we present the case of a relatively young patient with HHT with an incidentally discovered locally advanced esophageal cancer on endoscopic screening and pathologically complete response after neoadjuvant chemoradiation. This case highlights an unusual tumor response to chemoradiation in locally advanced esophageal cancer, and the surveillance care of HHT patients.
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Affiliation(s)
- Robin Park
- Department of Medicine, MetroWest Medical Center, Framingham, Massachusetts, USA
| | - Alisdair Philp
- Department of Medicine, Division of Medical Oncology, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Alykhan S Nagji
- Department of Cardiovascular and Thoracic Surgery, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Anup Kasi
- Department of Medicine, Division of Medical Oncology, Kansas University Medical Center, Kansas City, Kansas, USA
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21
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Mora-Luján JM, Iriarte A, Alba E, Sánchez-Corral MA, Cerdà P, Cruellas F, Ordi Q, Corbella X, Ribas J, Castellote J, Riera-Mestre A. Gender differences in hereditary hemorrhagic telangiectasia severity. Orphanet J Rare Dis 2020; 15:63. [PMID: 32122373 PMCID: PMC7053104 DOI: 10.1186/s13023-020-1337-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
Background Gender differences in organ involvement and clinical severity have been poorly described in hereditary hemorrhagic telangiectasia (HHT). The aim of this study was to describe differences in the severity of HHT manifestations according to gender. Methods Severity was measured according to Epistaxis Severity Score (ESS), Simple Clinical Scoring Index for hepatic involvement, a general HHT-score, needing for invasive treatment (pulmonary or brain arteriovenous malformations -AVMs- embolization, liver transplantation or Young’s surgery) or the presence of adverse outcomes (severe anemia, emergency department -ED- or hospital admissions and mortality). Results One hundred forty-two (58.7%) women and 100 (41.3%) men were included with a mean age of 48.9 ± 16.6 and 49 ± 16.5 years, respectively. Women presented hepatic manifestations (7.1% vs 0%) and hepatic involvement (59.8% vs 47%), hepatic AVMs (28.2% vs 13%) and bile duct dilatation (4.9% vs 0%) at abdominal CT, and pulmonary AVMs at thoracic CT (35.2% vs 23%) more often than men. The Simple Clinical Scoring Index was higher in women (3.38 ± 1.2 vs 2.03 ± 1.2), and more men were considered at low risk of harboring clinically significant liver disease than women (61% vs 25.3%). These differences were mantained when considering HHT1 and HHT2 patients separetely. Duodenal telangiectasia were more frequent in men than women (21% vs 9.8%). Invasive treatments were more frequently needed in women (28.2% vs 16%) but men needed attention at the ED more often than women (48% vs 28.2%), with no differences in ESS, HHT-score, anemia hospital admissions or mortality. Conclusions HHT women showed more severe hepatic involvement than men, also among HHT1 and HHT2 patients. Women had higher prevalence of pulmonary AVMs and needed invasive procedures more frequently, while men needed attention at the ED more often. These data might help physicians to individualize HHT patients follow-up.
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Affiliation(s)
- J M Mora-Luján
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - A Iriarte
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - E Alba
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Radiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - M A Sánchez-Corral
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Cardiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - P Cerdà
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - F Cruellas
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Otorhinolaryngology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Q Ordi
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Radiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - X Corbella
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - J Ribas
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Pneumology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - J Castellote
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Liver Transplant Unit, Department of Digestive Diseases, Hospital Universitari Bellvitge, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - A Riera-Mestre
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain. .,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain. .,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain. .,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
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22
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Texakalidis P, Sweid A, Mouchtouris N, Peterson EC, Sioka C, Rangel-Castilla L, Reavey-Cantwell J, Jabbour P. Aneurysm Formation, Growth, and Rupture: The Biology and Physics of Cerebral Aneurysms. World Neurosurg 2019; 130:277-284. [DOI: 10.1016/j.wneu.2019.07.093] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
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23
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Samuel N, Radovanovic I. Genetic basis of intracranial aneurysm formation and rupture: clinical implications in the postgenomic era. Neurosurg Focus 2019; 47:E10. [DOI: 10.3171/2019.4.focus19204] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/24/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVEDespite the prevalence and impact of intracranial aneurysms (IAs), the molecular basis of their pathogenesis remains largely unknown. Moreover, there is a dearth of clinically validated biomarkers to efficiently screen patients with IAs and prognosticate risk for rupture. The aim of this study was to survey the literature to systematically identify the spectrum of genetic aberrations that have been identified in IA formation and risk of rupture.METHODSA literature search was performed using the Medical Subject Headings (MeSH) system of databases including PubMed, EMBASE, and Google Scholar. Relevant studies that reported on genetic analyses of IAs, rupture risk, and long-term outcomes were included in the qualitative analysis.RESULTSA total of 114 studies were reviewed and 65 were included in the qualitative synthesis. There are several well-established mendelian syndromes that confer risk to IAs, with variable frequency. Linkage analyses, genome-wide association studies, candidate gene studies, and exome sequencing identify several recurrent polymorphic variants at candidate loci, and genes associated with the risk of aneurysm formation and rupture, including ANRIL (CDKN2B-AS1, 9p21), ARGHEF17 (11q13), ELN (7q11), SERPINA3 (14q32), and SOX17 (8q11). In addition, polymorphisms in eNOS/NOS3 (7q36) may serve as predictive markers for outcomes following intracranial aneurysm rupture. Genetic aberrations identified to date converge on posited molecular mechanisms involved in vascular remodeling, with strong implications for an associated immune-mediated inflammatory response.CONCLUSIONSComprehensive studies of IA formation and rupture have identified candidate risk variants and loci; however, further genome-wide analyses are needed to identify high-confidence genetic aberrations. The literature supports a role for several risk loci in aneurysm formation and rupture with putative candidate genes. A thorough understanding of the genetic basis governing risk of IA development and the resultant aneurysmal subarachnoid hemorrhage may aid in screening, clinical management, and risk stratification of these patients, and it may also enable identification of putative mechanisms for future drug development.
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Affiliation(s)
- Nardin Samuel
- 1Division of Neurosurgery, Department of Surgery, University of Toronto; and
| | - Ivan Radovanovic
- 1Division of Neurosurgery, Department of Surgery, University of Toronto; and
- 2Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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24
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Alsafi A, Jackson JE, Fatania G, Patel MC, Glover A, Shovlin CL. Patients with in-situ metallic coils and Amplatzer vascular plugs used to treat pulmonary arteriovenous malformations since 1984 can safely undergo magnetic resonance imaging. Br J Radiol 2019; 92:20180752. [PMID: 30894022 PMCID: PMC6592077 DOI: 10.1259/bjr.20180752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective: To examine the MRI safety of metallic coils and Amplatzer vascular plugs. Currently, concern regarding MR safety of devices used to treat pulmonary arteriovenous malformations (PAVMs) causes delays in performing emergency MRI in patients presenting with acute neurological symptoms. Methods: A retrospective audit was performed on all patients who underwent PAVM embolization at Hammersmith Hospital, London UK between 1984 and 2017. Outcomes of all MRI studies performed at our institution were recorded. In addition, known outcomes of all known MRI studies performed on patients treated with the earliest steel coils (1984–1995) were recorded. Results: At our institution, 20 patients underwent 1.5 T MRI after the insertion of 100 steel coils (15.5 – 28.6, median 22 years later), 140 coils designated MR-conditional (0.42 – 12.7, median 9.3 years later), and 54 MRI-conditional Amplatzer vascular plugs (0.17 – 8.0, median 0.75 years later), many in combination. The majority of scans were for cerebral indications, but other body regions scanned included spinal, thoracic, and pelvic regions. No adverse events were reported. Similarly, there were no adverse events in any MR scan known to have been performed in other institutions in seven further patients treated with the earliest steel coils (1984–1995). Again, the majority of scans were for cerebral indications. Conclusion: The findings demonstrate MR safety at 1.5 T of all PAVM embolization devices inserted in a main UK centre since inception in 1984. Advances in knowledge: MRI of patients who have had PAVMs treated by embolization can be implemented without contacting specialist pulmonary arteriovenous malformation treatment centres for approval.
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Affiliation(s)
- Ali Alsafi
- 1 Department of Imaging, Imperial College Healthcare NHS Trust , London , UK
| | - James E Jackson
- 1 Department of Imaging, Imperial College Healthcare NHS Trust , London , UK
| | - Gavin Fatania
- 1 Department of Imaging, Imperial College Healthcare NHS Trust , London , UK
| | - Maneesh C Patel
- 1 Department of Imaging, Imperial College Healthcare NHS Trust , London , UK
| | - Alan Glover
- 1 Department of Imaging, Imperial College Healthcare NHS Trust , London , UK
| | - Claire L Shovlin
- 2 Respiratory Medicine, Imperial College Healthcare NHS Trust , London , UK.,3 NHLI Vascular Science, Imperial College London , UK
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25
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Happle R. The concept of type 2 segmental mosaicism, expanding from dermatology to general medicine. J Eur Acad Dermatol Venereol 2018; 32:1075-1088. [PMID: 29405433 DOI: 10.1111/jdv.14838] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/19/2017] [Indexed: 12/11/2022]
Abstract
In autosomal dominant skin disorders, the well-known type 1 segmental mosaicism reflects heterozygosity for a postzygotic new mutation. By contrast, type 2 segmental mosaicism originates in a heterozygous embryo from an early postzygotic mutational event giving rise to loss of the corresponding wild-type allele, which results in a pronounced segmental involvement being superimposed on the ordinary, non-segmental phenotype. Today, this concept has been proven by molecular analysis in many cutaneous traits. The purpose of this review was to seek publications of cases suggesting an extracutaneous manifestation of type 2 segmental mosaicism. Case reports documenting a pronounced extracutaneous segmental involvement were collected from the literature available in PubMed and from personal communications to the author. Pertinent cases are compared to the description of cutaneous segmental mosaicism of type 1 or type 2 as reported in a given trait. In total, reports suggesting extracutaneous type 2 segmental mosaicism were found in 14 different autosomal dominant skin disorders. In this way, clinical evidence is accumulated that extracutaneous type 2 segmental mosaicism does likewise occur in many autosomal dominant skin disorders. So far, however, molecular proof of this particular form of mosaicism is lacking. The present review may stimulate readers to inform colleagues of other specialties on this new concept, in order to initiate further research in this particular field of knowledge that has important implications for diagnosis, treatment and genetic counselling.
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Affiliation(s)
- R Happle
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
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26
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Gamboa NT, Joyce EJ, Eli I, Park MS, Taussky P, Schmidt RH, McDonald J, Whitehead KJ, Kalani MYS. Clinical presentation and treatment paradigms of brain arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia. J Clin Neurosci 2018; 51:22-28. [PMID: 29483005 DOI: 10.1016/j.jocn.2018.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 01/08/2018] [Indexed: 11/25/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectases, and multisystem arteriovenous malformations (AVMs). Brain AVMs typically present at birth and are identified in approximately 10-20% of patients with HHT. A retrospective review was undertaken of all HHT patients with known single or multiple brain AVMs treated at our institution. Thirty-nine patients with brain AVM(s) were diagnosed with HHT. Most patients presented with at least one Curaçao criterion. A total of 78 brain AVMs were identified in 39 patients. Two-thirds of patients had solitary brain AVMs, whereas 33% of patients harbored at least two lesions (range: 2-16). Brain AVMs of the supratentorial cerebral hemispheres comprised 83% of all lesions, whereas infratentorial lesions accounted for only 17%. Of the 55 brain AVMs assigned Spetzler-Martin grading, the majority of patients were Grade 1 (73%), and 23% and 4% were Grades 2 and 3, respectively. Patients were treated with surgery alone (51%), embolization alone (6%), embolization followed by surgery (9%), stereotactic radiosurgery (11%), stereotactic radiosurgery followed by surgery (3%), or observation (20%). Of patients who underwent genetic analysis, 62% possessed mutations in ENG (HHT type 1), whereas 38% had mutations in ACVRL1 (HHT type 2). This robust patient cohort of brain AVMs in 39 patients with HHT advances the collective understanding of this disease's varied presentation, diagnostic workup, genetic underpinnings, and available treatment options.
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Affiliation(s)
- Nicholas T Gamboa
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Evan J Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ilyas Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Richard H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States; University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States
| | - Jamie McDonald
- University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States
| | - Kevin J Whitehead
- University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States
| | - M Yashar S Kalani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States; University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States.
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27
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Shovlin CL, Condliffe R, Donaldson JW, Kiely DG, Wort SJ. British Thoracic Society Clinical Statement on Pulmonary Arteriovenous Malformations. Thorax 2017; 72:1154-1163. [DOI: 10.1136/thoraxjnl-2017-210764] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/01/2017] [Accepted: 09/04/2017] [Indexed: 01/02/2023]
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Rattani A, Dewan MC, Hannig V, Naftel RP, Wellons JC, Jordan LC. Cerebral hemorrhage in monozygotic twins with hereditary hemorrhagic telangiectasia: case report and hemorrhagic risk evaluation. J Neurosurg Pediatr 2017; 20:164-169. [PMID: 28524787 DOI: 10.3171/2017.3.peds16587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a case of monozygotic twins with hereditary hemorrhagic telangiectasia (HHT) who experienced cerebral arteriovenous malformation (AVM) hemorrhage at a very young age. The clinical variables influencing HHT-related AVM rupture are discussed, and questions surrounding the timing of screening and intervention are explored. This is only the second known case of monozygotic HHT twins published in the medical literature, and the youngest pair of first-degree relatives to experience AVM-related cerebral hemorrhage. Evidence guiding the screening and management of familial HHT is lacking, and cases such as this underscore the need for objective and validated protocols.
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Affiliation(s)
- Abbas Rattani
- School of Medicine, Meharry Medical College, Nashville
| | - Michael C Dewan
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, and
| | - Vickie Hannig
- Divisions of 3 Medical Genetics and Genomic Medicine and
| | - Robert P Naftel
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, and
| | - John C Wellons
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, and
| | - Lori C Jordan
- Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Malhotra A, Wu X, Seifert K. Regarding "Neurovascular Manifestations of Hereditary Hemorrhagic Telangiectasia: A Consecutive Series of 376 Patients during 15 Years". AJNR Am J Neuroradiol 2017; 38:E16. [PMID: 27765743 DOI: 10.3174/ajnr.a4986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- A Malhotra
- Department of Radiology and Biomedical Imaging Yale School of Medicine New Haven, Connecticut
| | - X Wu
- Department of Radiology and Biomedical Imaging Yale School of Medicine New Haven, Connecticut
| | - K Seifert
- Department of Radiology and Biomedical Imaging Yale School of Medicine New Haven, Connecticut
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30
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Brinjikji W, Yamaki V, Lanzino G. Reply. AJNR Am J Neuroradiol 2017; 38:E17. [PMID: 27765742 DOI: 10.3174/ajnr.a5006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- W Brinjikji
- Department of Neurosurgery and Radiology Mayo Clinic Rochester, Minnesota
| | - V Yamaki
- Department of Neurosurgery and Radiology Mayo Clinic Rochester, Minnesota
| | - G Lanzino
- Department of Neurosurgery and Radiology Mayo Clinic Rochester, Minnesota
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Brinjikji W, Iyer VN, Wood CP, Lanzino G. Prevalence and characteristics of brain arteriovenous malformations in hereditary hemorrhagic telangiectasia: a systematic review and meta-analysis. J Neurosurg 2016; 127:302-310. [PMID: 27767404 DOI: 10.3171/2016.7.jns16847] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Patients with hereditary hemorrhagic telangiectasia (HHT) are known to suffer from high rates of cerebral arteriovenous malformations (AVMs). The authors performed a systematic review and meta-analysis of the literature examining prevalence rates, characteristics, and clinical presentation of cerebral AVMs in the HHT population. METHODS To identify studies on AVM prevalence and characteristics in the HHT population, 4 databases (MEDLINE, EMBASE, Scopus and Web of Science) were searched by a reference librarian with over 30 years experience in systematic reviews and meta-analysis. The search period was January 1, 1990-March 2016. The following search terms were used: hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome, AVM, brain AVM, arteriovenous malformation, arteriovenous fistula, prevalence, and epidemiology. The authors identified studies that examined the prevalence rates, characteristics, and clinical presentation of cerebral AVMs in patients with HHT. They assessed overall AVM prevalence rates as well as prevalence rates by age, sex, HHT type, and country/region. They also systematically reviewed the characteristics of AVMs, including rupture status, location, clinical presentation, angioarchitecture, and Spetzler-Martin grade. Data were analyzed using a random-effects meta-analysis model. RESULTS Thirty-nine studies were included in this meta-analysis. Thirty studies examined brain AVM prevalence rates in various HHT patient populations, and 18 studies examined AVM clinical and angiographic characteristics (9 studies examined both prevalence rates and AVM characteristics). The prevalence of brain AVMs in HHT patients was 10.4% (95% CI 7.9%-13.0%) with no significant difference between males (8.5%, 95% CI 4.9%-12.0%) and females (11.0%, 95% CI 5.9%-16.1%). Patients with HHT Type 1 (HHT1) had a significantly higher brain AVM prevalence (13.4%, 95% CI 9.5%-17.4%) compared with those with HHT Type 2 (HHT2) (2.4%, 95% CI 1.0%-3.8%) (p < 0.0001). In 55.2% (95% CI 38.3%-72.1%) of cases, the AVMs were symptomatic. Spetzler-Martin grade was 2 or less in 86.9% (95% CI 67.5%-95.2%) of patients. CONCLUSIONS The prevalence of brain AVMs in the HHT population is about 10%. HHT1 patients are significantly more likely to have brain AVMs than HHT2 patients. Most AVMs in the HHT population are symptomatic. The Spetzler-Martin grade for these lesions is 2 or less in nearly 90% of patients.
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Blei F. Update September 2016. Lymphat Res Biol 2016. [DOI: 10.1089/lrb.2016.29012.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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