A review of cardiovascular effects and underlying mechanisms of legacy and emerging per- and polyfluoroalkyl substances (PFAS)

Cardiovascular disease (CVD) poses the leading threats to human health and life, and their occurrence and severity are associated with exposure to environmental pollutants. Per- and polyfluoroalkyl substances (PFAS), a group of widely used industrial chemicals, are characterized by persistence, long-distance migration, bioaccumulation, and toxicity. Some PFAS, particularly perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA) and perfluorohexanesulfonic acid (PFHxS), have been banned, leaving only legacy exposure to the environment and human body, while a number of novel PFAS alternatives have emerged and raised concerns, such as polyfluoroalkyl ether sulfonic and carboxylic acid (PFESA and PFECA) and sodium p-perfluorous nonenoxybenzene sulfonate (OBS). Overall, this review systematically elucidated the adverse cardiovascular (CV) effects of legacy and emerging PFAS, emphasized the dose/concentration-dependent, time-dependent, carbon chain length-dependent, sex-specific, and coexposure effects, and discussed the underlying mechanisms and possible prevention and treatment. Extensive epidemiological and laboratory evidence suggests that accumulated serum levels of legacy PFAS possibly contribute to an increased risk of CVD and its subclinical course, such as cardiac toxicity, vascular disorder, hypertension, and dyslipidemia. The underlying biological mechanisms may include oxidative stress, signaling pathway disturbance, lipid metabolism disturbance, and so on. Various emerging alternatives to PFAS also play increasingly prominent toxic roles in CV outcomes that are milder, similar to, or more severe than legacy PFAS. Future research is recommended to conduct more in-depth CV toxicity assessments of legacy and emerging PFAS and explore more effective surveillance, prevention, and treatment strategies, accordingly.

Mechanisms of Arsenic Exposure-Induced Hypertension and Atherosclerosis: an Updated Overview

Arsenic is an abundant element in the earth's crust. In the environment and within the human body, this toxic element can be found in both organic and inorganic forms. Chronic exposure to arsenic can predispose humans to cardiovascular diseases including hypertension, stroke, atherosclerosis, and blackfoot disease. Oxidative damage induced by reactive oxygen species is a major player in arsenic-induced toxicity, and it can affect genes expression, inflammatory responses, and/or nitric oxide homeostasis. Exposure to arsenic in drinking water can lead to vascular endothelial dysfunction which is reflected by an imbalance between vascular relaxation and contraction. Arsenic has been shown to inactivate endothelial nitric oxide synthase leading to a reduction of the generation and bioavailability of nitric oxide. Ultimately, these effects increase the risk of vascular diseases such as hypertension and atherosclerosis. The present article reviews how arsenic exposure contributes to hypertension and atherosclerosis development.

Cerebral Proliferative Angiopathy Presenting as Subdural Hematoma: A Case Report and Systematic Literature Review

Cerebral proliferative angiopathy (CPA) is a rare cerebrovascular pathology that presents with unique clinical features due to distinct histologic, angiographic, and pathophysiologic characteristics that separate it from classical arteriovenous malformation. The disorder is characterized by uncontrolled angiogenesis in which functional brain parenchyma is interspersed with abnormal vascular channels without a distinct nidus. Common presenting symptoms include headache, seizures, and stroke-like symptoms. Hemorrhagic presentations are rare in contrast to the typical presentations of classical arteriovenous malformation. Here, we report a young woman with a history of a suspected connective tissue disorder who presented to the emergency department with worsening headaches in a delayed fashion after experiencing minor head trauma and was found to have a left-sided subdural hematoma. Angiography confirmed a diagnosis of CPA after abnormal cortical vasculature was noted during the patient's craniotomy. A systematic review of CPA cases described in the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with the findings discussed.

Predictors of preoperative cognitive dysfunction in adults with Moyamoya disease: a preliminary research

OBJECTIVE

To explore potential risk factors of preoperative cognitive dysfunction in adult patients with moyamoya disease (MMD) and discuss significance of moyamoya vessels.

METHODS

The author reviewed adult MMD patients harboring no parenchymal infarction or hemorrhage underwent a standardized neuropsychological assessment test battery from December 2018 to May 2019. The authors defined patients with cognitive dysfunction as cognitive impairment shown on 3 or more neuropsychological tests. According to the presence of cerebral angiography, arterial stenosis, moyamoya vessels, and compensatory arteries were conducted. Univariate and multivariate analyses were performed to identify predictors for cognitive dysfunction before surgery. Subgroup analyses by onset type and Suzuki stage were carried out to identify specific predictors for preoperative cognitive dysfunction.

RESULTS

In total, 29 of 92 (31.52%) patients had cognitive dysfunction. Multivariate analysis showed that moyamoya vessels generating from left hemisphere was recognized as independent predictor for cognitive dysfunction (P = 0.025, OR [95%CI], 0.085 [0.012-0.874]). For patients in left ICA-moyamoya subgroup, 19 of 45 (42.22%) cases with sparse moyamoya vessels had cognitive dysfunction (P = 0.031), while 22 (91.67%) of patients with dense moyamoya vessels had normal cognition (P = 0.004). Moyamoya vessels arising from ophthalmic artery had no significant association with cognitive dysfunction (P = 0.111). Multivariate analysis found that moyamoya vessels originating from left ICA was recognized as independent predictors for preoperative cognitive dysfunction (P = 0.048, OR [95%CI], 0.394 [0.132-0.926]).

CONCLUSIONS

Moyamoya vessels arising from left hemisphere was a risk factor for the preoperative cognitive dysfunction in adult patients with MMD, with the denser moyamoya vessels, the less cognitive dysfunction. The current study offers a new perspective of moyamoya vessels and supporting data for choosing MMD candidates on cerebral revascularization.

Progressive Pure Arterial Malformations of the Anterior Cerebral Artery

BACKGROUND

Pure arterial malformations (PAMs) are rare intracranial vascular anomalies. As recently reported, PAMs have a benign natural history and can be treated conservatively. However, their etiology, natural history, and treatment have not yet been fully elucidated.

METHODS

We present a rare case of the progression of a PAM involving the anterior cerebral artery. Magnetic resonance imaging showed a mass located in the suprasellar region associated with obstructive hydrocephalus. Digital subtraction angiography showed evolution of the arterial anomaly with progression compared with the studies 3 years earlier. Surgical trapping of the parent artery with electrophysiological monitoring was performed. Combined with previous data, the clinical features and therapeutic strategies for this unusual entity are discussed.

RESULTS

The patient recovered uneventfully after surgery. Postoperative digital subtraction angiography confirmed complete obliteration of the lesion. Axial computed tomography also showed shrinkage of the aneurysm, with improvement of the hydrocephalus. Our review of the reported data showed only 4 patients with a definite or probable PAM who had undergone surgery. To the best of our knowledge, the present case represents the first report of changes in the vascular architecture of a PAM during the follow-up period.

CONCLUSION

Whether the aneurysmal component of PAMs merits invasive treatment has remained controversial. The findings from our case raises the possibility of evolution for some patients with PAMs and stresses the importance of scheduled follow-up noninvasive imaging studies to rule out progression of these nosological entities, especially PAMs with an "aneurysm-like" component.

[Arterial sinus pericranii. First case report]

INTRODUCTION

Sinus pericranii (SP) is a rare vascular anomaly consisting in an abnormal intradiploic communication between intra and extra cranial venous systems. It usually presents as a congenital soft mass in the cranial midline with progressive growth, which enlarges significantly with Valsalva maneuver. A similar congenital vascular anomaly involving intra and extra cranial arterial systems has not been previously described in the medical literature.

CLINICAL CASE

A 6-year-old boy with suspected midline capillary malformation of the frontal bone was referred to our Vascular Anomalies Unit for progressive increase in size. A conclusive ultrasound of high flow malformation was performed. Angio-TAC confirmed the arterial nature of the lesion and its communication with the middle meningeal artery. Embolization of the distal portion of the middle meningeal artery was performed prior to surgery. Previous to exeresis of the malformation, skin expanders were placed to cover the subsequent defect. The histopathological result was an arteriovenous malformation. Currently the patient is 10 years old and is asymptomatic, with no recurrence of the lesion.

CONCLUSIONS

Since its first description, SP has been classified and described in the literature as a venous malformation. Although morphologically may resemble a SP, histologically and immunohistochemically it corresponds to an arteriovenous malformation with intracranial arterial connection. It is especially important to know how to diagnose this type of cranial malformations because their long-term evolution will depend on correct management and initial follow-up.

Internal Carotid Artery Dissection in Brazilian Jiu-Jitsu

Carotid artery dissection is a significant cause of stroke in young patients. It may be asymptomatic and go undiagnosed, or minimal transient manifestations may follow, commanding a higher index of suspicion than ordinarily exists to avoid misdiagnosis. Reported herein is a 27-year-old man who suffered extracranial internal carotid artery dissection while practicing a Brazilian Jiu-Jitsu submission maneuver. The patient's condition suddenly deteriorated one week later due to distal embolization and stroke. Despite endovascular treatment, with stenting of the cervical carotid artery, neurologic deficits remained. Of note, the objective in martial arts, which is to kill or incapacitate, has yet to be fully tempered in transitioning to sport. Brazilian Jiu-jitsu, a relatively new and fast-growing form of martial art, places emphasis on submission maneuvers. Related injuries are not common knowledge and are poorly described in the literature. This account is intended to shed light on the risk of this discipline. Through education and improved supervision, vascular injuries of this nature and the potentially lethal or disabling consequences may thus be prevented in young athletes.

The M2 macrophages induce autophagic vascular disorder and promote mouse sensitivity to urethane-related lung carcinogenesis

Tumor vessels are known to be abnormal, with typically aberrant, leaky and disordered vessels. Here, we investigated whether polarized macrophage phenotypes are involved in tumor abnormal angiogenesis and what is its mechanism. We found that there was no difference in chemotaxis of polarized M1 and M2 macrophages to lewis lung carcinoma (LLC) cells and that either M1 or M2 macrophage-conditioned media had no effect on LLC cell proliferation. Unexpectedly, the M2 but not M1 macrophage-conditioned media promoted the proliferation of human umbilical vein endothelial cells (HUVECs) and simultaneously increased endothelial cell permeability in vitro and angiogenic index in the chick embryo chorioallantoic membrane (CAM). The treatment with M2 but not M1 macrophage-conditioned media increased autophagosomes as well as microtubule-associated protein light chain 3B (LC3-B) expression (a robust marker of autophagosomes) but decreased p62 protein expression (a selective autophagy substrate) in HUVECs, the treatment with chloroquine that blocked autophagy abrogated the abnormal angiogenic efficacy of M2 macrophage-conditioned media. These results were confirmed in urethane-induced lung carcinogenic progression. Urethane-induced lung carcinogenesis led to more M2 macrophage phenotype and increased abnormal angiogenesis concomitant with the upregulation of LC3-B and the downregulation of p62. Clodronate liposome-induced macrophage depletion, chloroquine-induced autophagic prevention or salvianolic acid B-induced vascular protection decreased abnormal angiogenesis and lung carcinogenesis. In addition, we found that the tendency of age-related M2 macrophage polarization also promoted vascular permeability and carcinogenesis in urethane carcinogenic progression. These findings indicate that the M2 macrophages induce autophagic vascular disorder to promote lung cancer progression, and the autophagy improvement represents an efficacious strategy for abnormal angiogenesis and cancer prevention.

Effect of thymosin beta 4 in the presence of up-regulation of the insulin-like growth factor-1 signaling pathway on high-glucose-exposed vascular endothelial cells

Thymosin beta 4 (Tβ4), which regulates vascular cell growth, can ameliorate some of the problems associated with diabetes. However, the precise signaling mechanisms by which Tβ4 protects against hyperglycemia-induced damage to endothelial cells have not been investigated in detail. Thus, the aim of this study was to elucidate the role of Tβ4 in diabetes and the possible involvement of insulin-like growth factor-1 (IGF-1), which affects cellular survival, metabolism, and glucose homeostasis in high-glucose (HG)-injured human umbilical vein endothelial cells (HUVECs). Immunoblotting assays revealed that under HG blockade conditions, Tβ4 did not alter the insulin-signaling pathway, but induced overexpression of IGF-1 protein, leading to activation of factors in alternative signaling pathway. Small interfering RNA of Tβ4 and IGF-1 were studied to clarify relationship between Tβ4 and IGF-1. These findings suggest that IGF-1 induction by Tβ4 ameliorates the damage in HG-injured HUVECs which manifest as diabetic vascular disorder.

A Long-Term Follow-Up of Angiolymphoid Hyperplasia with Eosinophilia Treated by Corticosteroids: When a Traditional Therapy is Still Up-to-Date

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare and idiopathic vascular disorder. It is characterized by red to brown papules or nodules dislocated in the dermis or subcutaneous tissue. These lesions are typically localized on the head and neck, particularly around the ear as singular or multiple nodules. Although ALHE is a benign disease, lesions are often persistent and difficult to eradicate. ALHE can occur in all races, but it is reported more frequently in Asians. Young to middle-aged women are more commonly affected. The histological examination corresponds to a florid vascular proliferation with atypical endothelial cells surrounded by a lymphocytic and eosinophilic infiltrate. We describe the case of a 67-year-old Caucasian man with a nodular lesion in the right postauricular region for 3 years. The histological examination was consistent with ALHE. Monthly intralesional corticosteroid injections were performed for 6 months, and complete remission was achieved. After 10 years of follow-up, the patient is free of recurrence.