A prospective study of PHACE syndrome in infantile hemangiomas: demographic features, clinical findings, and complications

[Vascular lesions of the orbit in children]

Vascular lesions of the orbit in children are most often hemangiomas and lymphangiomas. Hemangioma is a tumor that tends toward spontaneous regression. Lymphangioma is a malformation that tends to increase in size with growth spurts that can occur until adulthood. The treatment is decided according to the functional impact.

[Infantile hemangioma]

Infantile hemangioma is the most common tumor in children, but its pathophysiology is still not well understood. Infantile hemangioma develops during the first weeks of life, usually builds up over 3 to 6 months, and then regresses very slowly over a period of 3 to 7 years. Three quarters of these hemangiomas are lobular and are not associated with malformations. On the other hand, the hemangiomas referred to as segmental may be associated with developmental abnormalities (PHACES and PELVIS/SACRAL syndromes). Because of their spontaneous involution, most infantile hemangiomas do not require therapeutic intervention. In 10 to 15 % of cases, treatment is necessary because of complications when life or physiological functioning is threatened, or there are local complications or the long-term esthetic risk is too high. Until now, the standard first-line treatment has been general corticosteroid therapy. The usual choice for second-line treatment is interferon or vincristine. The efficacy of propranolol, a non-cardioselective beta-blocker, was recently reported.

[Classification of superficial vascular anomalies]

All superficial vascular abnormalities are not angiomas even though this term continues - incorrectly - to be used. Because the suffix "oma" implies a tumor, it is necessary to differentiate true vascular tumors, such as infantile hemangioma, from vascular malformations. From a hemodynamic perspective, there are two types of vascular malformations: slow- and fast-flow. In addition to the functioning of the impaired or severely damaged vessels, we discuss slow-flow capillary, venous, or lymphatic malformations and rapid flow arterial and arteriovenous malformations. All combinations are possible. There are several types of childhood vascular tumors with different courses and different prognoses. Infantile hemangioma is by far the most frequent (8 to 10 children/100). The diverse other vascular tumors in children are sufficiently rare that they are described as orphan diseases. Since the end of the last century, a simple endothelial marker, GLUT-1, is available. This immunophenotype is present in all cases of infantile hemangioma at every stage and is negative in other tumors. Kasabach-Merritt syndrome and its accompanying severe thrombocytopenia never complicate childhood hemangioma, contrary to what has been said for nearly 60 years. When it is present, the tumor is either a tufted angioma or kaposiform hemangioendothelioma, and the GLUT1 marker can distinguish them from infantile hemangioma if the histologic diagnosis is uncertain (GLUT 1 is negative in both the latter cases). There are a wide variety of rare vascular tumors; many of them are benign, isolated, or limited; some are locally aggressive and recur after excision. A small number are low-grade malignant lesions with a risk of multivessel expansion, metastasis, and sometimes a fatal outcome. Major progress has been made in the imaging of these vascular abnormalities. Magnetic resonance imaging (MRI) in particular has revolutionized the non-invasive and especially the non-irradiating exploration of many of them. It provides information about the extent of the lesion and allows an etiological approach in many cases. Moreover, neuroradiologic evaluation of vascular cerebromeningeal lesions benefits not only from the now-standard diagnostic neurologic imaging methods of CT and MRI, but also from various advances in the techniques of functional imaging. Accordingly, for Sturge-Weber syndrome, functional imaging provides hope for an early prognosis, in particular cognitive, when these techniques are more widely used (SPECT, PET, especially the new advanced sequences of perfusion in MRI-DTI). Chronic - indeed lifelong - coagulation abnormalities, with phases of aggravation, occur in approximately half of the patients with venous malformations of the trunk and limbs, and more rarely in neck and face sites. This is not without consequences, but also not without therapeutic solutions: screening for it is therefore essential (measurement of dimer and fibrinogen levels). The discovery of gene mutations at the origin of some familial vascular malformations provides complementary data for the current classification of vascular abnormalities. It suggests that targeted therapy may be possible but probably not for quite a bit longer.

Need for comprehensive vascular assessment before surgical repair of aortic coarctation in PHACES syndrome

Children with PHACES syndrome commonly present with aortic coarctation and abnormalities of the supra-aortic and intracranial arteries. We describe a case of complex aortic coarctation in the context of PHACES syndrome, where preoperative detection of abnormalities in supra-aortic and intracranial arteries led to modification of the surgical technique adopted, in order to avoid potential neurological damage.

Consensus Statement on Diagnostic Criteria for PHACE Syndrome

OBJECTIVES

A subgroup of patients with infantile hemangiomas have associated structural anomalies of the brain, cerebral vasculature, eyes, sternum, and/or aorta in the neurocutaneous disorder known as PHACE syndrome. The diagnosis has been broadly inclusive by using a case definition of a facial hemangioma plus >or=1 extracutaneous features, leading to numerous reports of potential associated disease features, many of uncertain significance. This consensus statement was thus developed to establish diagnostic criteria for PHACE syndrome.

METHODS

A multidisciplinary group of specialists with expertise in PHACE syndrome drafted initial diagnostic criteria on the basis of review of published, peer-reviewed medical literature and clinical experience. The group then convened in both executive and general sessions during the PHACE Syndrome Research Conference held in November 2008 for discussion and used a consensus method. All conflicting recommendations were subsequently reconciled via electronic communication and teleconferencing.

RESULTS

These criteria were stratified into 2 categories: (1) PHACE syndrome or (2) possible PHACE syndrome. Major and minor criteria were determined for the following organ systems: cerebrovascular, structural brain, cardiovascular, ocular, and ventral/midline. Definite PHACE requires the presence of a characteristic segmental hemangioma or hemangioma >5 cm on the face or scalp plus 1 major criterion or 2 minor criteria. Possible PHACE requires the presence of a hemangioma >5 cm on the face or scalp plus 1 minor criterion. The group recognized that it may be possible to have PHACE syndrome with a hemangioma affecting the neck, chest, or arm only or no cutaneous hemangioma at all. In such cases, fulfillment of additional required criteria would also lead to a possible PHACE diagnosis.

CONCLUSIONS

These criteria represent current knowledge and are expected to enhance future assessments of PHACE syndrome. It is understood that modifications are to be expected over time to incorporate new research findings.

PHACES syndrome--report of two cases and their evolution over time

We describe two cases of PHACES syndrome that illustrate the importance of recognizing this rare syndrome. As children with this syndrome can present to general pediatricians, dermatologists, pediatric cardiologists, ophthalmologists, and neurologists, it is important that all are aware of the spectrum of associated abnormalities.

Etiology of chest wall deformities--a genetic review for the treating physician

Chest wall deformities such as pectus excavatum, pectus carinatum, and cleft sternum can be isolated malformations or dysmorphic features of genetic associations, monogenic disorders, and various numeric and structural chromosomal aberrations. In contrast to the most important syndromes such as Marfan syndrome or Noonan syndrome that can be associated with a chest wall deformity and for which the causative genes are known, etiology of isolated chest wall deformities is still a matter of research. Therefore, an interdisciplinary approach, particularly in patients with additional symptoms is strongly recommended to choose the best therapeutic approach for each patient and its family.

Progenitor cells in infantile hemangioma

Infantile hemangioma is a vascular tumor that occurs in 5% to 10% of infants of European descent. A hallmark of infantile hemangioma is its life cycle, which is divided into 3 stages. The proliferating phase spans in the first year of postnatal life and is characterized by cellular masses without a defined vascular architecture and nascent blood vessels with red blood cells evident within the lumenal space. The involuting phase begins at 1 year of age and continues for 3 to 5 years. Proliferation slows or stops in this phase, and histologic examination shows that the blood vessel architecture becomes more obvious and vessel size is enlarged. The involuted phase reaches 5 to 8 years of age, at which point blood vessels are replaced with a fibrofatty residuum and capillary-sized channels. The growth and involution life cycle of infantile hemangioma are very different from other vascular tumors and vascular malformations, which do not regress and can occur at any time during childhood or adult life. Many laboratories have reported on the endothelial characteristics of the cellular masses that are prominent in the proliferating phase of infantile hemangioma, as well as their immature appearance. These studies, along with isolation and characterization of hemangioma-derived cell populations with progenitor cell properties, have lead to an emerging hypothesis that hemangioma is caused by an abnormal or delayed differentiation of mesodermal progenitor cells into the disorganized mass of blood vessels. In this paper, we discuss the literature that supports this emerging hypothesis.

PHACE syndrome: current knowledge, future directions

On November 7-8, 2008, physicians gathered in Houston Texas for the first-ever workshop on PHACE syndrome, an important and recently described neurocutaneous syndrome. This article represents a summary of the discussions held at that workshop, which was attended by a broad range of medical specialists.

Vasculogenesis in infantile hemangioma

Infantile hemangioma is a vascular tumor that occurs in 5-10% of infants of European descent. A defining feature of infantile hemangioma is the dramatic growth and development into a disorganized mass of blood vessels. Subsequently, a slow spontaneous involution begins around 1 year of age and continues for 4-6 years. The growth and involution of infantile hemangioma is very different from other vascular tumors and vascular malformations, which do not regress and can occur at any time during childhood or adult life. Much has been learned from careful study of the tissue morphology and gene expression patterns during the life-cycle of hemangioma. Tissue explants and tumor-derived cell populations have provided further insight to unravel the cellular and molecular basis of infantile hemangioma. A multipotent progenitor cell capable of de novo blood vessel formation has been isolated from infantile hemangioma, which suggests that this common tumor of infancy, long considered to be a model for pathologic angiogenesis, may also represent pathologic vasculogenesis. Whether viewed as angiogenesis or vasculogenesis, infantile hemangioma represents a vascular perturbation during a critical period of post-natal growth, and as such provides a unique opportunity to decipher mechanisms of human vascular development.

Posterior fossa neoplasm and PHACES syndrome: a case report

A 4-year-old girl with PHACES syndrome (posterior fossa brain malformations, hemangiomas, arterial anomalies, cardiac anomalies/coarctation of the aorta, eye abnormalities, and sternal clefting/supraumbilical raphe) developed a cerebellar pilocytic astrocytoma 18 months after resolution of her neck, ear, and thoracic hemangiomas. Because cutaneous hemangiomas may have involuted by the time a patient is diagnosed with a central nervous system neoplasm, it seems possible that in other such patients the association may have gone unrecognized. Cerebellar pilocytic astrocytoma may be a rare manifestation of the posterior fossa malformations of PHACES.

Infantile hemangiomas involving the neuraxis: clinical and imaging findings

BACKGROUND AND PURPOSE

The neuroradiology and neurosurgery literature is replete with references to "hemangioma" involving the central nervous system (CNS). However, the number of cases of true infantile hemangiomas in the CNS reported to date is 15. Our purpose was to delineate the definition of infantile hemangiomas, determine their prevalence in the neuraxis, and describe their imaging characteristics and associations in this location.

MATERIALS AND METHODS

We reviewed our Vascular Anomalies Center data base from 1999 through May 2008 to assess the prevalence of intracranial or intraspinal involvement within the total cohort of infantile hemangiomas. Fifteen patients were identified with infantile hemangiomas that involved the neuraxis. Two board-certified neuroradiologists reviewed the available imaging of these 15 patients, and a board-certified pathologist reviewed the available histopathology. Clinical records of all 15 patients were reviewed to identify the type of treatment and the treatment response.

RESULTS

Of the 1454 patients listed with infantile hemangioma, 15 (approximately 1.0%) had involvement of the CNS. Eight patients had intracranial infantile hemangioma, 6 had intraspinal hemangioma, and 1 had both. In most instances, there was continuous extension into the neuraxis from an extracranial or extraspinal lesion. There were no cases of a CNS hemangioma without an accompanying extra-CNS tumor. Two patients had findings consistent with posterior fossa anomalies, cervicofacial hemangioma, arterial anomalies, cardiac defects, ocular abnormalities, and associated sternal or ventral defect. Of note, there were no brain or spinal parenchymal signal-intensity abnormalities, and there was no evidence of parenchymal invasion.

CONCLUSIONS

CNS involvement by infantile hemangiomas is an unusual occurrence, which, when recognized, can help optimize patient management.

PHACES syndrome: otolaryngic considerations in recognition and management

OBJECTIVES

To describe the otolaryngic manifestations of PHACES and evaluate current diagnostic and management principles for these patients.

METHODS

A retrospective review was performed within a tertiary children's hospital. Children with segmental facial hemangiomas of infancy and one extracutaneous manifestation comprising PHACES (posterior fossa malformation, arteriovenous malformations, cardiac/aortic defects, eye anomalies, and sternal defect) were identified. Otolaryngic problems were evaluated with physical examination, audiogram, swallow evaluation, polysomnography, and laryngoscopy. Extracutaneous manifestations were diagnosed using radiology, echocardiogram, and EEG. Treatment for cutaneous and airway hemangiomas included oral and intralesional steroids, CO(2) or pulse-dye laser, tracheotomy, and surgical excision. Management of extracutaneous problems was system-dependent.

RESULTS

Of 246 children with segmental facial hemangiomas of infancy evaluated since January 2000, 5 girls (2.0%) met diagnostic criteria for PHACES. Mean age at last follow-up was 2.6 years (range 0.4-5.8). Each child had one extracutaneous manifestation of aortic anomaly (2/5), sternal clefting (2/5), and brain malformation (1/5). Otolaryngic abnormalities included middle ear atelectasis (1/5), tympanic membrane hemangiomas with conductive hearing loss (3/5), skin and cartilage ulceration (2/5), dysphagia (4/5), and airway hemangiomas with stridor (3/5). Three children received oral steroids and required pulse-dye laser for cutaneous hemangiomas of infancy. One child underwent tracheotomy. Additional interventions included tympanostomy tubes and resection of nasal hemangioma.

CONCLUSIONS

Diagnosis of PHACES requires awareness of the association of facial hemangiomas of infancy with systemic and airway problems. Otolaryngology-related manifestations of PHACES are not commonly described, and management should be tailored to the individual patient.

PHACES syndrome: a review

Large, segmental, cervicofacial hemangiomas are often associated with anomalies of intracranial, cardiovascular, and ophthalmic systems as well as ventral development.

Arteriovenous shunting as a new feature of PHACES. Case report

Patients with the congenital neurocutaneous disorder PHACES are at a markedly increased risk of ischemic infarction during childhood. Although intracranial arterial anomalies have been well described, venous abnormalities have not been documented. The authors report on a unique case of a 3-month-old girl with PHACES and a skull base osteodural arteriovenous fistula. A separate arteriovenous shunt at T-5 may also have been present. Imaging findings and treatment strategies are discussed.

Four new cases of PHACES syndrome: variable phenotypic expression and endocrine features

AIM

PHACES syndrome is a neurocutaneous condition characterized by the coexistence of large facial haemangiomas and at least one feature among posterior fossa malformations, cardiac and arterial anomalies, eye defects and sternal clefting. We review and discuss the phenotypes and the endocrine aspects of PHACES syndrome, hypothesizing that endocrine anomalies, although rare, could be considered as feature of the disease.

METHODS

We described four new cases representative of the wide variable phenotype of this syndrome, commenting on the possible phenotypic expression.

RESULTS

Two children displayed endocrine anomalies, sporadically described among PHACES subjects. One of them developed a transient hyperthyreotropinemia induced by interferon alpha-2alpha treatment for a giant facial haemangioma, while the second presented with congenital hypothyroidism with an in situ thyroid gland, a trait previously unreported in the syndrome.

CONCLUSION

PHACES syndrome has a wide variable phenotypic expression and endocrine anomalies, especially hypothyroidism, may represent a trait of the syndrome and should be always investigated.

Haemangiomas and associated congenital malformations in a large population-based sample of infants

Haemangiomas are common, benign, vascular tumours, observed in 4-12% of infants during the first year of life. Most cases progress without complication, yet a small proportion experience life-threatening complications. Concomitant congenital malformations have been reported in a small but significant proportion of haemangioma patients. This study aimed to describe haemangioma cases and to identify patterns of congenital malformations associated with these diagnoses in a large population. Diagnoses of haemangiomas and 21 congenital malformations were extracted from electronic medical records of 467 295 singleton infants born to US military families from 1998 to 2003. Cluster analysis was used to group cases according to these diagnoses. Multivariable logistic regression was used to further explore the associations of the 21 congenital malformations with the diagnosis of haemangioma and to assess the adjusted relationships between a number of characteristics of interest and diagnosis of haemangioma. Clusters found to be associated with haemangioma were characterised by anomalies of the cervix, vagina, and external female genitalia, anophthalmia or microphthalmia, hydrocephalus without spina bifida, and reduction deformities of the brain. Logistic regression identified three congenital malformations significantly associated with haemangioma diagnosis: spina bifida without anencephalus, hydrocephalus without spina bifida, and anomalies of the cervix, vagina and external female genitalia. Characteristics significantly associated with haemangioma included female gender, preterm birth, white non-Hispanic race/ethnicity and increasing maternal age. This exploratory study identified a number of important associations between haemangiomas and congenital malformations that may provide insight into the pathogenesis of these disorders and have possible implications for clinical care.

Update on the morning glory disc anomaly

The morning glory disc anomaly has distinctive clinical characteristics and is important to diagnose correctly so that associated central nervous system and vascular abnormalities are promptly identified and treated. This review covers the ophthalmic findings, clinical features, and histopathologic findings in patients with this rare developmental abnormality. The most common systemic associations are described and reviewed.

The role of the hematologist/oncologist in the care of patients with vascular anomalies

Pediatric hematologist/oncologists have a critical role in the diagnosis and management of patients who have complex vascular anomalies. They provide the clinical and medical skills needed to diagnose, treat, and manage these patients. Hematologist/oncologists also provide support for clinical trials and drug development to further treatment options for these patients.

PHACES association: a neuroradiologic review of 17 patients

BACKGROUND AND PURPOSE

We present neuroradiologic findings in 17 patients with posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities, and sternal or ventral defects (PHACES) association and identify those at highest risk of central nervous system (CNS) structural, cerebrovascular, and neurodevelopmental abnormalities.

MATERIALS AND METHODS

Patients with PHACES association were identified in the Vascular Anomalies Program at New York University Medical Center from 1998 to 2007. Many patients were followed in conjunction with other specialists at the Birthmark Institute at Roosevelt Hospital. Clinical records and imaging studies were reviewed retrospectively. Criteria for diagnosis of PHACES were based on previously published indicators. Imaging studies were independently re-reviewed by a neuroradiologist. Segmental mapping of cutaneous hemangioma distribution by photograph review and presence or absence of other PHACES-associated findings were correlated with radiologic findings.

RESULTS

Patients with large facial cutaneous (S1-S4) hemangiomas were especially at risk of CNS structural and cerebrovascular anomalies; S1 with ocular anomalies; and S3 with airway, ventral, and cardiac anomalies. All patients with CNS structural malformations had a cerebrovascular abnormality, and this cohort was at risk for developmental and/or other neurologic sequelae. Four patients had supratentorial CNS anomalies, including cortical dysgenesis and migration abnormalities. Some patients with CNS arteriopathy progressed to aneurysms.

CONCLUSION

Our data support and expand the work of others, identifying risk factors for segmental hemangiomas. In addition to posterior fossa CNS anomalies, supratentorial anomalies may be present in patients with PHACES, and this may correlate with significant clinical sequelae. The long-term prognosis of these patients remains unknown.

Cutaneous and paravertebral infantile hemangioma: report of two cases

We report on two cases of segmental cutaneous infantile hemangioma associated with mediastinal hemangioma and paravertebral extension. Mediastinal involvement is rare in hemangioma and paravertebral and intraspinal extension of hemangioma have seldom reported and may have been overlooked in the past.

The cerebral vasculopathy of PHACES syndrome

BACKGROUND AND PURPOSE

PHACES syndrome is a neurocutaneous disorder of unknown etiology. We studied the spectrum of associated congenital and progressive cerebral vascular anomalies.

METHODS

The medical records of 7 patients with PHACES syndrome were reviewed and combined with an additional 108 PHACES cases identified from the literature. We reviewed the clinical characteristics, calculated the relative frequencies of each type of vascular anomaly, and assessed site of vessel involvement relative to hemangioma location.

RESULTS

Among a total of 115 PHACES cases, 89 (77.4%) had congenital and/or progressive cerebral vascular anomalies. The most commonly detected congenital arterial anomalies included dysplasia, aberrant origin or course, hypoplasia, and absence or agenesis. Arterial occlusions and stenoses were detected in 24 (20.9%) and 21 (18.3%) cases, respectively. Twenty (17.4%) had persistent embryonic arteries; 15 (13%) had saccular aneurysms. There appears to be a close relation between the regional distributions of cervicofacial hemangiomas and the locations of intracranial and extracranial vascular (and cardiac) anomalies.

CONCLUSIONS

The vasculopathy of PHACES chiefly comprises a spectrum of congenital and progressive large artery lesions. Based on known embryology and the relative frequencies of specific congenital vascular anomalies, we can predict that the initial cerebral vascular changes occur early in embryogenesis, by the fifth gestational week or earlier. There appears to be both a temporal and a regional link between the arterial anomalies of PHACES and the cutaneous infantile hemangioma.

PHACES syndrome with small, late-onset hemangiomas

Although hemangiomas are the hallmark of the PHACES syndrome, they may be nonexistent at birth and may not develop until later in early infancy. We report an infant who presented initially with cardiac defect, sternal nonunion, supraumbilical raphé, and congenital hypothyroidism without any hemangioma, and who subsequently developed facial hemangiomas at 2 months of age. We noted that there is a possibility that hemangiomas may subsequently develop later in early infancy and congenital hypothyroidism may be associated with the PHACES syndrome.

Pathogenesis of infantile haemangioma: new molecular and cellular insights

Infantile haemangioma is the most common tumour of infancy, yet the origin of these lesions remains controversial and the predictable life cycle is poorly understood. Much new information on infantile haemangiomas has emerged over the past decade, but experts continue to debate fundamental features, including cell of origin, nonrandom distribution, and mechanisms regulating the sometimes explosive growth and slow involution. The development of useful laboratory models has been difficult, in turn restricting the development of treatment options available to the clinician. Despite this, new research and creative thinking has spawned several hypotheses on the origin of these tumours and their interesting clinical behaviour, including suggestions of an intrinsic defect in local endothelial cells, a contribution of circulating endothelial progenitors or haemangioblasts, embolisation of shed placental cells and developmental field defects. While no single hypothesis seems to describe all features of infantile haemangioma, continued research seeks to integrate these ideas, create a better understanding of these important tumours and bring new treatments to the clinic.

Non-random maternal X-chromosome inactivation associated with PHACES

The acronym PHACES is used to describe the association of posterior fossa malformations, hemangiomas, arterial anomalies (cardiovascular or cerebrovascular), coarctation of the aorta and cardiac defects, eye abnormalities, and sternal or ventral defects. We report a female patient with an uncommon variant of this neurocutaneous disorder who manifested a sternal cleft; supraumbilical raphe; hemangiomas of the face, chest, and extremities; micrognathia and cerebrovascular anomalies. A literature review of PHACES patients with both sternal cleft and supraumbilical raphe showed a marked female predilection. Taken together with cases of sternal cleft, supraumbilical raphe and facial hemangiomas tabulated by Gorlin et al. (1994), 91% (40/44) of patients are female. One affected male died shortly after birth. We hypothesized that the gender bias in PHACES results from mutation in an X-linked dominant gene often lethal in males, and performed X-inactivation analysis of the polymorphic androgen receptor locus in this family. We documented consistently skewed X-inactivation (80%/20% in two independent analyses) in the unaffected mother and consistently random X-inactivation (47:53 and 61:39 in independent analyses) in the proband. These findings are consistent with favorably skewed X-inactivation producing a normal maternal phenotype, a phenomenon documented in X-linked dominant Rett syndrome.

PHACE syndrome with intracerebral hemangiomas, heterotopia, and endocrine dysfunction

PHACE is an acronym to describe the association of posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta, cardiac defects, and eye abnormalities. More than 200 cases have been reported. The present report presents the cases of two female infants with PHACE syndrome, both of whom had additional congenital defects of subependymal gray matter heterotopia, craniofacial arterial anomalies, and pituitary dysfunction. One had an extensive segmental facial hemangioma with ipsilateral intracranial hemangiomas. The other had multiple cutaneous hemangiomas, but no segmental facial hemangioma. These two cases suggest a further expansion of the spectrum of PHACE to include other forms of disordered cerebral development and endocrine dysfunction.

The neurologic aspects of PHACE: case report and review of the literature

PHACE syndrome is a neurocutaneous disorder characterized by large cervicofacial infantile hemangiomas and associated anomalies of the brain, cerebrovasculature, aorta, heart, and eyes. Two categories of neurologic disease are observed among PHACE patients: congenital malformations of the cerebellum, cerebrum, and cerebral vasculature and progressive stenoses and occlusions of principal cerebral arteries. A subgroup of patients develops a moyamoya-like vasculopathy and consequent ischemic strokes. This report details the clinical course and management of a young female with PHACE and reviews the various neurologic aspects of this neurocutaneous disorder. This patient presented with high-grade stenoses of the internal carotid arteries bilaterally, formation of extensive vascular collaterals, and multiple ischemic strokes. She underwent bilateral pial-synangiosis procedures and has not had stroke recurrence in 2 years of follow-up. The presence of a characteristic infantile hemangioma necessitates further evaluation for the extracutaneous features of PHACE. In cases of steno-occlusive vasculopathy, we recommend early consideration of encephaloduroarteriosynangiosis or a commensurate revascularization procedure.

Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment

OBJECTIVES

Infantile hemangiomas are the most common tumor of infancy. Risk factors for complications and need for treatment have not been studied previously in a large prospective study. This study aims to identify clinical characteristics associated with complications and the need for therapeutic intervention.

PATIENTS AND METHODS

We conducted a prospective cohort study at 7 US pediatric dermatology clinics with a consecutive sample of 1058 children, aged < or = 12 years, with infantile hemangiomas enrolled between September 2002 and October 2003. A standardized questionnaire was used to collect data on each patient and each hemangioma, including clinical characteristics, complications, and treatment.

RESULTS

Twenty-four percent of patients experienced complications related to their hemangioma(s), and 38% of our patients received some form of treatment during the study period. Hemangiomas that had complications and required treatment were larger and more likely to be located on the face. Segmental hemangiomas were 11 times more likely to experience complications and 8 times more likely to receive treatment than localized hemangiomas, even when controlled for size.

CONCLUSIONS

Large size, facial location, and/or segmental morphology are the most important predictors of poor short-term outcomes as measured by complication and treatment rates.