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Putra J, Kim GE. Diagnostic approach to hepatic vascular lesions: a paediatric perspective. Histopathology 2024. [PMID: 38924138 DOI: 10.1111/his.15250] [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: 02/07/2024] [Revised: 06/04/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
The pathological evaluation of hepatic vascular lesions in children requires special consideration. Inconsistent terminology, rarity of pathology specimens and overlapping pathological features between various lesions may pose a serious diagnostic challenge. In this review, we highlight the importance of using the International Society for the Study of Vascular Anomalies (ISSVA) classification scheme to characterise these lesions. Selected entities are discussed, including hepatic vascular tumours exclusively seen in the paediatric age group, hepatic infantile haemangioma and hepatic congenital haemangioma. Vascular malformations, with emphasis on their syndromic associations (venous malformation in blue rubber bleb naevus syndrome) and complications (hepatocellular nodules in Abernethy malformation) are also covered.
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Affiliation(s)
- Juan Putra
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
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Engel ER, Wusik K, Bright P, Vadivelu S, Taylor JM, Hammill A. Prevalence and Predictors of Hereditary Hemorrhagic Telangiectasia and Capillary-Malformation Arteriovenous Malformation Syndrome Among Children with Neurovascular Malformations. J Pediatr 2024; 264:113761. [PMID: 37797790 DOI: 10.1016/j.jpeds.2023.113761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To investigate the prevalence and predictors of hereditary hemorrhagic telangiectasia (HHT) and capillary-malformation arteriovenous malformation (CM-AVM) syndrome among children with no prior personal or family history of these diseases who presented with an arteriovenous shunt lesion. STUDY DESIGN A retrospective chart review was completed on patients aged 0 through 21 years with arteriovenous shunt lesions evaluated at our Cerebrovascular Center. Diagnosis of definite or suspected HHT or CM-AVM was based on clinical features and genetic testing. Associations between final diagnosis and type and number of lesions, epistaxis, telangiectasias, CM, and pulmonary AVMs were assessed. RESULTS Eighty-nine patients were included. Thirteen (14.6%) had definite HHT, 11 (12.4%) suspected HHT, and 4 (4.5%) definite CM-AVM. Having ≥2 episodes of epistaxis/year and ≥ 2 sites with telangiectasias were each associated with definite HHT (P < .001). Having ≥ 2 CM was associated with definite CM-AVM (P < .001). Pulmonary AVM was associated with increased odds of having definite HHT (OR = 6.3, 95% CI: 1.2-33.4). Multiple lesions (OR = 24.5, 95% CI: 4.5-134.8) and arteriovenous fistulas (OR = 6.2, 95% CI: 1.9-20.3) each increased the likelihood of having definite HHT or CM-AVM. Genetic testing was positive in 31% of patients tested. CONCLUSIONS We recommend that children with neurovascular shunt lesions be offered genetic testing and undergo further evaluation for HHT and CM-AVM. Awareness and early diagnosis of these conditions is a critical step toward improving long-term outcomes and preventing disease-associated complications.
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katie Wusik
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Philip Bright
- University of Kentucky College of Medicine, Northern Kentucky Campus, Highland Heights, KY
| | - Sudhakar Vadivelu
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - J Michael Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adrienne Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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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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Pollak M, Gatt D, Shaw M, Hewko SL, Lamanna A, Santos S, Ratjen F. Longitudinal Assessment of Curaçao Criteria in Children with Hereditary Hemorrhagic Telangiectasia. J Pediatr 2023; 263:113665. [PMID: 37572862 DOI: 10.1016/j.jpeds.2023.113665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To assess the utility of the Curaçao criteria by age over time in children with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN This was a single-center, retrospective analysis of patients attending the HHT clinic at the Hospital for Sick Children (Toronto, Canada) between 2000 and 2019. The evaluation of the Curaçao criteria was completed during initial and follow-up visits. Screening for pulmonary and brain arteriovenous malformations was completed at 5 yearly intervals. RESULTS A total of 116 patients with genetic confirmation of HHT were included in the analysis. At initial screening at a median (IQR) age of 8.4 (2.8, 12.9) years, 41% met criteria for a definite clinical diagnosis (≥3 criteria). In children <6 years at presentation, only 23% fulfilled at least 3 criteria initially. In longitudinal follow-up, 63% reached a definite clinical diagnosis, with a median (IQR) follow-up duration of 5.2 (3.2, 7.9) years (P = .005). Specifically, more patients met the epistaxis and telangiectasia criteria at last visit compared with initial (79% vs 60%; P = .006; 47% vs 30%; P = .02) but not for the arteriovenous malformation criterion (59% vs 57%; P = .65). CONCLUSIONS In the pediatric population, most patients do not meet definite clinical criteria of HHT at initial presentation. Although the number of diagnostic criteria met increased over time, mainly due to new onset of epistaxis and telangiectasia, accuracy remained low during follow-up visits. Relying solely on clinical criteria may lead to underdiagnosis of HHT in children.
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Affiliation(s)
- Mordechai Pollak
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Pediatric Pulmonology Institute, The Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel.
| | - Dvir Gatt
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sheryl L Hewko
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Anthony Lamanna
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sara Santos
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Felix Ratjen
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
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Yusuf H, Rasheed A, Kim H, Conrad MB, Hetts SW. Identifying racial disparities in hereditary hemorrhagic telangiectasia. J Neurointerv Surg 2023; 15:1050-1054. [PMID: 36137744 DOI: 10.1136/jnis-2022-019162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/26/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder characterized by recurrent epistaxis (nose bleeds), mucosal telangiectasias (spider veins), and arteriovenous malformations. Although HHT affects all racial groups, few studies have explored racial disparities among patients with HHT. METHODS We performed a retrospective chart review of HHT patients who were seen at a single academic center between July 1, 2014 and January 1, 2022. The primary outcomes of this study were the Epistaxis Severity Score (ESS) and the presence of pulmonary, cerebral, gastrointestinal, spinal, and hepatic arteriovenous malformations (AVMs). We analyzed racial differences using t-tests and analysis of variance (ANOVA) for continuous variables, and chi-squared tests for categorical variables. We then performed multivariable linear and logistic regressions on outcomes. RESULTS Our review identified 35 Asian, 6 Black or African American, 72 Hispanic or Latino, and 244 White or Caucasian patients who met the inclusion criteria. Through an analysis of variance model, race/ethnicity was not significantly associated with ESS. Two univariable logistic regression models between race and both pulmonary and brain AVMs showed that race was associated with the incidence of pulmonary AVMs (p<0.01), with Asian patients at a 2.3-fold increased risk of pulmonary AVMs compared with White patients (p=0.03). Race was also associated with the incidence of cerebral AVMs (p<0.01) with Hispanic or Latino patients at a 4.8-fold increased risk compared with White patients (p<0.01). CONCLUSION Patients who identified as Asian may have higher rates of pulmonary AVMs while patients identifying as Hispanic or Latino may have more cerebral AVMs. The correlations may be important for identifying risk factors in certain patient populations.
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Affiliation(s)
- Hamzah Yusuf
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Amna Rasheed
- Touro College of Medicine, Vallejo, California, USA
| | - Helen Kim
- Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | | | - Steven W Hetts
- Neurointerventional Radiology, UCSF, San Francisco, California, USA
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Zhou X, Pucel JC, Nomura-Kitabayashi A, Chandakkar P, Guidroz AP, Jhangiani NL, Bao D, Fan J, Arthur HM, Ullmer C, Klein C, Marambaud P, Meadows SM. ANG2 Blockade Diminishes Proangiogenic Cerebrovascular Defects Associated With Models of Hereditary Hemorrhagic Telangiectasia. Arterioscler Thromb Vasc Biol 2023; 43:1384-1403. [PMID: 37288572 PMCID: PMC10524982 DOI: 10.1161/atvbaha.123.319385] [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: 03/27/2022] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a vascular disorder characterized by arteriovenous malformations and blood vessel enlargements. However, there are no effective drug therapies to combat arteriovenous malformation formation in patients with HHT. Here, we aimed to address whether elevated levels of ANG2 (angiopoietin-2) in the endothelium is a conserved feature in mouse models of the 3 major forms of HHT that could be neutralized to treat brain arteriovenous malformations and associated vascular defects. In addition, we sought to identify the angiogenic molecular signature linked to HHT. METHODS Cerebrovascular defects, including arteriovenous malformations and increased vessel calibers, were characterized in mouse models of the 3 common forms of HHT using transcriptomic and dye injection labeling methods. RESULTS Comparative RNA sequencing analyses of isolated brain endothelial cells revealed a common, but unique proangiogenic transcriptional program associated with HHT. This included a consistent upregulation in cerebrovascular expression of ANG2 and downregulation of its receptor Tyr kinase with Ig and EGF homology domains (TIE2/TEK) in HHT mice compared with controls. Furthermore, in vitro experiments revealed TEK signaling activity was hampered in an HHT setting. Pharmacological blockade of ANG2 improved brain vascular pathologies in all HHT models, albeit to varying degrees. Transcriptomic profiling further indicated that ANG2 inhibition normalized the brain vasculature by impacting a subset of genes involved in angiogenesis and cell migration processes. CONCLUSIONS Elevation of ANG2 in the brain vasculature is a shared trait among the mouse models of the common forms of HHT. Inhibition of ANG2 activity can significantly limit or prevent brain arteriovenous malformation formation and blood vessel enlargement in HHT mice. Thus, ANG2-targeted therapies may represent a compelling approach to treat arteriovenous malformations and vascular pathologies related to all forms of HHT.
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Affiliation(s)
- Xingyan Zhou
- Cell and Molecular Biology Department, Tulane University, New Orleans, LA, USA
| | - Jenna C. Pucel
- Cell and Molecular Biology Department, Tulane University, New Orleans, LA, USA
| | - Aya Nomura-Kitabayashi
- Litwin-Zucker Alzheimer’s Research Center, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Pallavi Chandakkar
- Litwin-Zucker Alzheimer’s Research Center, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Adella P. Guidroz
- Cell and Molecular Biology Department, Tulane University, New Orleans, LA, USA
| | - Nikita L. Jhangiani
- Cell and Molecular Biology Department, Tulane University, New Orleans, LA, USA
| | - Duran Bao
- Biochemistry and Molecular Biology Department, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jia Fan
- Biochemistry and Molecular Biology Department, Tulane University School of Medicine, New Orleans, LA, USA
| | - Helen M. Arthur
- Biosciences Institute, Center for Life, Newcastle University, Newcastle NE1 3BZ, UK
| | | | | | - Philippe Marambaud
- Litwin-Zucker Alzheimer’s Research Center, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Stryder M. Meadows
- Cell and Molecular Biology Department, Tulane University, New Orleans, LA, USA
- Tulane Brain Institute, Tulane University, New Orleans, LA, USA
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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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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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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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10
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A Rare Case of Upper Gastrointestinal Bleeding: Osler-Weber-Rendu Syndrome. Medicina (B Aires) 2022; 58:medicina58030333. [PMID: 35334510 PMCID: PMC8951266 DOI: 10.3390/medicina58030333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Osler-Weber-Rendu disease, also known as hereditary hemorrhagic telangiectasia (HHT), is a rare, autosomal dominant condition that affects approximately 1 in 5000 patients causing abnormal blood vessel formation. HHT patients have mucocutaneous telangiectasias and arteriovenous malformations in various organs. The most prominent symptom of HHT is epistaxis, which, together with gastrointestinal bleeding, may cause iron deficiency anemia. This study is a case report of a 62-year-old patient who was admitted to the Department of Gastroenterology due to acute upper gastrointestinal bleeding and a history of recurrent epistaxis and melena for 4 days, which was confirmed in digital rectal examination. Urgent upper gastrointestinal endoscopy revealed active bleeding from multiple angioectatic spots with bright-looking salmon-colored patches in the antrum and the body suggestive of HHT. The bleeding from two angioectatic spots was stopped by argon plasma coagulation, and four clips were placed to provide good hemostasis. The patient was treated with a proton pomp inhibitor infusion and iron infusion. She was discharged with no signs of GI bleeding, normalized iron levels and a diagnosis of HHT. She was referred to further genetic testing, including evaluation of first-degree relatives. She also had performed unenhanced thin-cut computed tomography (CT) with angiography to exclude the presence of pulmonary arteriovenous malformations (PAVMs). Due to the fact that the patient did not manifest any other HHT-related symptoms and that the instrumental screening discloses no silent AVMs in other organs, the “watch-and-wait strategy” was applied. Although, Osler-Weber-Rendu syndrome is widely described in the medical literature, effective treatment of gastrointestinal telangiectasias is not always available and still lacks standardization to date, which makes the management of gastroenterological involvement still a challenging issue.
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11
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Yamamoto H, Itamoto C, Yamaguchi T, Koshyo T. Severe Hypoxemia Caused by High-Output Heart Failure and Pulmonary Arteriovenous Malformations in Hereditary Hemorrhagic Telangiectasia. JACC Case Rep 2021; 3:1863-1868. [PMID: 34917969 PMCID: PMC8642735 DOI: 10.1016/j.jaccas.2021.10.008] [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: 08/11/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
A man affected by hereditary hemorrhagic telangiectasia who had chronic severe hypoxemia is presented. This hypoxemia was synergistically caused by high-output heart failure due to severe hepatic shunts and multiple pulmonary arteriovenous shunts. The symptomatic combination is rare, and genetic testing showed a novel endoglin mutation. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Hiroaki Yamamoto
- Department of Cardiology, Nagano Chuo Hospital, Nagano, Japan
- Address for correspondence: Dr Hiroaki Yamamoto. Department of Cardiology, Nagano Chuo Hospital, Nishitsuruga 1570, Nagano City, Nagano Prefecture, Japan.
| | - Chieko Itamoto
- Department of Cardiology, Nagano Chuo Hospital, Nagano, Japan
| | - Tomomi Yamaguchi
- Department of Genetic Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Center for Medical Genetics; and
- Division of Clinical Sequencing, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoki Koshyo
- Department of Genetic Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Center for Medical Genetics; and
- Division of Clinical Sequencing, Shinshu University School of Medicine, Matsumoto, Japan
- Research Center for Supports to Advanced Science, Shinshu University, Matsumoto, Japan
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12
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Matti E, Lizzio R, Ugolini S, Maiorano E, Zaccari D, De Silvestri A, De Sando E, Marseglia GL, Benazzo M, Olivieri C, Pagella F, Spinozzi G. Nasal Endoscopy in the Clinical Diagnosis of Hereditary Hemorrhagic Telangiectasia. J Pediatr 2021; 238:74-79.e2. [PMID: 34265342 DOI: 10.1016/j.jpeds.2021.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the role of nasal endoscopy for early clinical diagnosis of hereditary hemorrhagic telangiectasia (HHT) in children and to investigate the characteristics of epistaxis and mucocutaneous telangiectases in our pediatric population. STUDY DESIGN From May 2016 to December 2019, a cross-sectional observational study was conducted, recruiting children aged 2-18 years with a parent affected by HHT. To identify the Curaçao criteria, all children underwent collection of clinical history, mucocutaneous examination, and nasal endoscopy. The clinical data were then compared with the genetic data acquired subsequently. RESULTS Seventy children (median age, 10.8 years) were included. All underwent nasal endoscopy without complications. Forty-six children were positive by genetic testing; of these, 26 % had skin and oral telangiectases and 91 % had nasal telangiectases. The diagnostic sensitivity of the Curaçao criteria increased from 28 % (95 % CI, 16%-43 %) to 85 % (95 % CI, 71%-94 %; P < .0001) when the nasal telangiectases were included. CONCLUSIONS The magnified and complete endoscopic view of the nasal cavities proved useful in increasing the diagnostic sensitivity of the Curaçao criteria. Such an examination turned out to be feasible and safe. For this reason, we believe that nasal endoscopy should be included in the diagnostic assessment of pediatric patients with suspected HHT.
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Affiliation(s)
- Elina Matti
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberta Lizzio
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Sara Ugolini
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Otorhinolaryngology, Università degli Studi di Pavia, Pavia, Italy
| | - Eugenia Maiorano
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Otorhinolaryngology, Università degli Studi di Pavia, Pavia, Italy
| | - Dario Zaccari
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Otorhinolaryngology, Università degli Studi di Pavia, Pavia, Italy
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elisabetta De Sando
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Pediatrics, Università degli Studi di Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Otorhinolaryngology, Università degli Studi di Pavia, Pavia, Italy
| | - Carla Olivieri
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Pavia, Italy
| | - Fabio Pagella
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Otorhinolaryngology, Università degli Studi di Pavia, Pavia, Italy
| | - Giuseppe Spinozzi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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13
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Barral CM, Nunes ICC, Nunes SS, Sanches SMD. The role of nuclear medicine in a case of Rendu-Osler-Weber disease with pulmonary involvement. World J Nucl Med 2021; 20:389-391. [PMID: 35018158 PMCID: PMC8686737 DOI: 10.4103/wjnm.wjnm_48_21] [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: 04/12/2021] [Revised: 05/26/2021] [Accepted: 06/02/2021] [Indexed: 11/04/2022] Open
Abstract
Rendu-Osler-Weber syndrome or hereditary hemorrhagic telangiectasia (HHT) is a rare systemic disease. Its primary pathogenic expression is multiple arteriovenous malformations (AVM) and severe hypoxia. A case of suspected pulmonary embolism in a 49-year-old male with intestinal, cardiac, and pulmonary HHT affection is reported. Pulmonary AVM could create an apparent mismatch perfusion defect evident upon ventilation and perfusion scan (V/Q scan), leading to misinterpretation. It reinforces the importance between clinics, anatomy, and functional evaluation. Care must be taken when interpreting V/Q scan and the reporting physician must be alert to the possible sources of errors.
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Affiliation(s)
- Carlyle Marques Barral
- Densitometry and Nuclear Medicine Physician, Head of the Nuclear Medicine Service of Hospital das Clínicas-Federal University of Minas Gerais Clinics (HC-UFMG), Belo Horizonte, Minas Gerais, Brazill
| | - Isabella Correa Chaves Nunes
- Resident doctor, Head of the Nuclear Medicine Service of Hospital das Clínicas-Federal University of Minas Gerais Clinics (HC-UFMG), Belo Horizonte, Minas Gerais, Brazill
| | - Shirleide Santos Nunes
- Radiopharmacist, Head of the Nuclear Medicine Service of Hospital das Clínicas-Federal University of Minas Gerais Clinics (HC-UFMG), Belo Horizonte, Minas Gerais, Brazill
| | - Sandra Monetti Dumont Sanches
- Head of the Nuclear Medicine Service of Hospital das Clínicas-Federal University of Minas Gerais Clinics (HC-UFMG), Minas Gerais, Brazill.,Assistant Professor at the Department of Anatomy and Image, Faculty of Medicine, UFMG. Belo Horizonte, Minas Gerais, Brazill
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14
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Blei F. Update October 2020. Lymphat Res Biol 2020. [DOI: 10.1089/lrb.2020.29092.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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