1
|
Deng H, Eichmann A, Schwartz MA. Fluid Shear Stress-Regulated Vascular Remodeling: Past, Present, and Future. Arterioscler Thromb Vasc Biol 2025; 45:882-900. [PMID: 40207366 DOI: 10.1161/atvbaha.125.322557] [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] [Indexed: 04/11/2025]
Abstract
The vascular system remodels throughout life to ensure adequate perfusion of tissues as they grow, regress, or change metabolic activity. Angiogenesis, the sprouting of new blood vessels to expand the capillary network, versus regression, in which endothelial cells die or migrate away to remove unneeded capillaries, controls capillary density. In addition, upstream arteries adjust their diameters to optimize blood flow to downstream vascular beds, which is controlled primarily by vascular endothelial cells sensing fluid shear stress (FSS) from blood flow. Changes in capillary density and small artery tone lead to changes in the resistance of the vascular bed, which leads to changes in flow through the arteries that feed these small vessels. The resultant decreases or increases in FSS through these vessels then stimulate their inward or outward remodeling, respectively. This review summarizes our knowledge of endothelial FSS-dependent vascular remodeling, offering insights into potential therapeutic interventions. We first provide a historical overview, then discuss the concept of set point and mechanisms of low-FSS-mediated and high-FSS-mediated inward and outward remodeling. We then cover in vivo animal models, molecular mechanisms, and clinical implications. Understanding the mechanisms underlying physiological endothelial FSS-mediated vascular remodeling and their failure due to mutations or chronic inflammatory and metabolic stresses may lead to new therapeutic strategies to prevent or treat vascular diseases.
Collapse
Affiliation(s)
- Hanqiang Deng
- Yale Cardiovascular Research Center CT (H.D., A.E., M.A.S.), Yale University School of Medicine, New Haven, CT
- Section of Cardiovascular Medicine, Department of Internal Medicine (H.D., A.E., M.A.S.), Yale University School of Medicine, New Haven, CT
| | - Anne Eichmann
- Yale Cardiovascular Research Center CT (H.D., A.E., M.A.S.), Yale University School of Medicine, New Haven, CT
- Section of Cardiovascular Medicine, Department of Internal Medicine (H.D., A.E., M.A.S.), Yale University School of Medicine, New Haven, CT
| | - Martin A Schwartz
- Yale Cardiovascular Research Center CT (H.D., A.E., M.A.S.), Yale University School of Medicine, New Haven, CT
- Section of Cardiovascular Medicine, Department of Internal Medicine (H.D., A.E., M.A.S.), Yale University School of Medicine, New Haven, CT
- Department of Cell Biology, Yale School of Medicine, New Haven, CT (M.A.S.)
- Department of Biomedical Engineering, Yale School of Engineering, New Haven, CT (M.A.S.)
| |
Collapse
|
2
|
Akers AL, Albanese J, Alcazar-Felix RJ, Al-Shahi Salman R, Awad IA, Connolly ES, Danehy A, Flemming KD, Gordon E, Hage S, Kim H, Lanzino G, Lee CH, McCormick PC, Mabray MC, Marchuk DA, Smith E, Smith KM, Srivastava S, Taylor JM, Vadivelu S. Guidelines for the Diagnosis and Clinical Management of Cavernous Malformations of the Brain and Spinal Cord: Consensus Recommendations Based on a Systematic Literature Review by the Alliance to Cure Cavernous Malformation Clinical Advisory Board Experts Panel. Neurosurgery 2025:00006123-990000000-01651. [PMID: 40396744 DOI: 10.1227/neu.0000000000003459] [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: 11/21/2024] [Accepted: 01/07/2025] [Indexed: 05/22/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Despite many publications about cavernous malformations (CMs), controversy remains regarding diagnostic and management strategies. To update evidence-based guidelines for the clinical management of brain and spinal cord CMs. METHODS The Alliance to Cure CMs, the patient support group in the United States advocating on behalf of patients and research in CM, convened a multidisciplinary writing group comprising expert CM clinicians to help summarize the existing literature related to the clinical care of CM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and imaging standards, (4) neurosurgical considerations, and (5) neurological considerations. Building on prior evidence-based recommendations reflecting literature review through October 2014, the group conducted a systematic review of the more recent literature, identified references for mandatory citation, rated evidence, developed recommendations, and established consensus according to a prespecified protocol. Finally, the writing group outlined remaining knowledge gaps and controversies to guide future research. RESULTS From 2672 publications published between October 1, 2014, and March 15, 2023, and meeting key word criteria, 234 were selected based on prearticulated criteria for mandatory consideration in evidence-based recommendations. Topic authors used these and other supporting references to summarize current knowledge and arrive at 53 management recommendations, with unanimous consensus based on a Delphi process. These were rated by class (strength of recommendation) and level (quality of evidence) per the American Heart Association/American Stroke Association criteria. Eighteen recommendations were class 1 (34%), class 2 in 31 (58%), and class 3 in 4 (8%). Three were level A (6%), 19 (36%) were level B, and 31 (58%) were level C. CONCLUSION Current evidence supports prior and new recommendations for the management of CMs, but many reflect moderate classes and low levels, mandating further research to better inform clinical practice.
Collapse
Affiliation(s)
- Amy L Akers
- Alliance to Cure Cavernous Malformation, Charlottesville, Virginia, USA
| | - John Albanese
- Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Issam A Awad
- Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Amy Danehy
- Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Errol Gordon
- Internal Medicine, The University of Oklahoma Health Sciences Center, Tulsa, Oklahoma, USA
| | - Stephanie Hage
- Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | - Helen Kim
- Anesthesis, University of California San Francisco, San Francisco, California, USA
| | | | - Cornelia H Lee
- Alliance to Cure Cavernous Malformation, Charlottesville, Virginia, USA
| | | | - Marc C Mabray
- Neuroradiology, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Douglas A Marchuk
- Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Edward Smith
- Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - J Michael Taylor
- Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sudhakar Vadivelu
- Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
3
|
Zou Q, Zhang Y, Hu R, Xu J, Yang J, Tang H, Yang Y, Li X, Su W. Predictors of postoperative epileptic seizures after microsurgical treatment in supratentorial single cerebral cavernous malformations: a retrospective study. Langenbecks Arch Surg 2025; 410:164. [PMID: 40392358 PMCID: PMC12092539 DOI: 10.1007/s00423-025-03741-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2025] [Accepted: 05/13/2025] [Indexed: 05/22/2025]
Abstract
PURPOSE Seizures are the most common symptom of supratentorial cerebral cavernous malformations (CCMs). This study aimed to investigate the predictors of seizure freedom in patients with single supratentorial CCMs after microsurgical treatment. METHODS Clinical data were retrospectively obtained from 164 patients with CCM (including 98 patients with preoperative seizures, and 66 patients without preoperative seizures) who underwent microsurgical treatment between January 2016 and December 2023 at the First Affiliated Hospital of Sun Yat-sen University. RESULTS After microsurgical treatment, early postoperative seizures (≤ 1 week) occurred in 2 of 98 (2.04%) and 2 of 66 (3.03%) CCM patients with and without preoperative seizures, respectively. The mean length of follow-up for all the patients was 44.70 ± 2.04 months (range: 1-98 months). Sixty-four of the 66 (96.97%) patients without preoperative seizures were seizure free during the follow-up period. Among the patients with preoperative seizures, 77 of 98 (78.57%) patients achieved followed-up seizure remission, including 18 of 28 (64.29%) patients with drug-resistant epilepsy and 59 of 70 (84.29%) patients with drug-controlled epilepsy. Univariate analysis indicated that preoperative seizure duration, drug-resistant epilepsy, tailored resection and the application of intraoperative electrocorticography (ECoG) were important risk factors that affected followed-up seizure remission among patients with preoperative seizures. However, according to multivariate regression, only the use of intraoperative ECoG was an independent predictor related to the followed-up seizure remission. CONCLUSION For CCM patients with preoperative seizures, intraoperative ECoG was an independent predictor of followed-up seizure remission. The application of intraoperative ECoG is beneficial for improving seizure outcome among CCM patients after microsurgical treatment, especially among patients with preoperative drug-resistant epilepsy.
Collapse
Affiliation(s)
- Qihang Zou
- Clinical Neuroscience Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yaqian Zhang
- Clinical Neuroscience Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Runfang Hu
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiakun Xu
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jia Yang
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongxing Tang
- Neurosurgery Unit, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yibing Yang
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xixi Li
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Weijie Su
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
4
|
Hou W, Hou Y, Ren X, Liu J. Hereditary Haemorrhagic Cerebrovascular Disease: Implications for Clinical Management. Ann Neurosci 2025:09727531241308346. [PMID: 40115281 PMCID: PMC11920984 DOI: 10.1177/09727531241308346] [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: 07/11/2023] [Revised: 10/26/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2025] Open
Abstract
Background At present, treatment of hereditary haemorrhagic cerebrovascular disease remains in the symptomatic stage. It is more important to provide strategies for developing rational treatment methods, expanding our understanding with regard to the pathophysiology in the context of familial diseases. Summary In this article, the combined data from the literature on diseases, including familial cerebral cavernous haemangiomas, hereditary cerebral haemorrhage with amyloidosis, familial intracranial aneurysms, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, were reviewed to manage the haemorrhagic diseases discussed through genetic counselling and early prevention and treatment of these patients and their families, the genetics, pathogenesis, clinical manifestations and treatment. Key Messages It is important to understand and treat hereditary haemorrhagic cerebrovascular disease through genetic treatment options.
Collapse
Affiliation(s)
- Wanting Hou
- Department of Pathology, Medical College of Yanbian University, Gongyuan, Yanji, China
| | - Yanbo Hou
- Department of Pathology, Medical College of Yanbian University, Gongyuan, Yanji, China
| | - Xiangshan Ren
- Department of Pathology, Medical College of Yanbian University, Gongyuan, Yanji, China
| | - Jingyao Liu
- Department of Neurology, The First Hospital, Jilin University, Jilin, Changchun, China
| |
Collapse
|
5
|
Hamilton-Jenkins M, Green J, Sivashankar H, Aygun B. Giant cavernous malformation: a rare paediatric presentation. BMJ Case Rep 2025; 18:e264147. [PMID: 40086850 DOI: 10.1136/bcr-2024-264147] [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] [Indexed: 03/16/2025] Open
Abstract
A boy in middle childhood with a history of early morning headaches presented to secondary care after being found to have bilateral papilloedema by his community optometrist. CT head showed a large right-sided heterogeneous calcific and haemorrhagic mass causing marked mass effect and midline shift. Preoperatively, the lesion was characterised on MRI as a haemorrhagic mass with a 'popcorn' appearance suggestive of a giant cavernous malformation measuring 6.6 × 3.7 × 5.7 cm3The patient made a successful recovery following stereotactic resection, and histopathological examination confirmed the radiological diagnosis of giant intracranial cavernous malformation.
Collapse
MESH Headings
- Humans
- Male
- Hemangioma, Cavernous, Central Nervous System/surgery
- Hemangioma, Cavernous, Central Nervous System/diagnostic imaging
- Hemangioma, Cavernous, Central Nervous System/pathology
- Hemangioma, Cavernous, Central Nervous System/complications
- Hemangioma, Cavernous, Central Nervous System/diagnosis
- Magnetic Resonance Imaging
- Tomography, X-Ray Computed
- Headache/etiology
- Child
- Papilledema/etiology
- Treatment Outcome
Collapse
Affiliation(s)
| | | | | | - Berna Aygun
- Radiology, King's College London, London, UK
| |
Collapse
|
6
|
Zhang Z, Deng J, Sun W, Wang Z. Cerebral Cavernous Malformation: From Genetics to Pharmacotherapy. Brain Behav 2025; 15:e70223. [PMID: 39740786 DOI: 10.1002/brb3.70223] [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] [Indexed: 01/02/2025] Open
Abstract
INTRODUCTION Cerebral cavernous malformation (CCM) is a type of cerebrovascular abnormality in the central nervous system linked to both germline and somatic genetic mutations. Recent preclinical and clinical studies have shown that various drugs can effectively reduce the burden of CCM lesions. Despite significant progress, the mechanisms driving CCM remain incompletely understood, and to date, no drugs have been developed that can cure or prevent CCM. This review aims to explore the genetic mutations, molecular mechanisms, and pharmacological interventions related to CCM. METHODS Literatures on the genetic mechanisms and pharmacological treatments of CCM can be searched in PubMed and Web of Science. RESULTS Germline and somatic mutations mediate the onset and development of CCM through several molecular pathways. Medications such as statins, fasudil, rapamycin, and propranolol can alleviate CCM symptoms or hinder its progression by specifically modulating the corresponding targets. CONCLUSIONS Understanding the molecular mechanisms underlying CCM offers potential for targeted therapies. Further research into novel mutations and treatment strategies is essential for improving patient outcomes.
Collapse
Affiliation(s)
- Zhuangzhuang Zhang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Jianwen Deng
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Weiping Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
| |
Collapse
|
7
|
Das K, Sen J, Borode AS. Cavernous Malformations of the Central Nervous System: A Comprehensive Review of Pathophysiology, Diagnosis, and Management. Cureus 2024; 16:e67591. [PMID: 39310452 PMCID: PMC11416750 DOI: 10.7759/cureus.67591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 08/23/2024] [Indexed: 09/25/2024] Open
Abstract
Cavernous malformations (CMs) of the central nervous system (CNS) are vascular anomalies characterized by clusters of dilated, thin-walled blood vessels prone to leakage and hemorrhage. These malformations can occur throughout the CNS, including the brain and spinal cord, and present with a wide range of clinical manifestations, from asymptomatic cases to severe neurological deficits. Advances in neuroimaging, particularly magnetic resonance imaging (MRI), have greatly improved the diagnosis and understanding of CMs, enabling more precise differentiation from other vascular lesions. The management of CMs has evolved alongside advancements in surgical and radiosurgical techniques, offering various therapeutic options depending on the lesion's characteristics and patient symptoms. While conservative management is often appropriate for asymptomatic or minimally symptomatic lesions, surgical resection or stereotactic radiosurgery may be indicated in cases with recurrent hemorrhage or significant neurological impairment. This comprehensive review explores the pathophysiology, clinical presentation, diagnosis, and management of CMs, highlighting current evidence-based practices and emerging therapeutic approaches. The review also addresses the genetic and molecular underpinnings of CMs, particularly in hereditary cases, and discusses potential future directions in research and treatment. By synthesizing the latest knowledge in the field, this review aims to enhance clinical decision-making and promote further investigation into the optimal management of CMs in the CNS.
Collapse
Affiliation(s)
- Kaustuv Das
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Jayshree Sen
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aishwarya S Borode
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
8
|
Dao L, You Z, Lu L, Xu T, Sarkar AK, Zhu H, Liu M, Calandrelli R, Yoshida G, Lin P, Miao Y, Mierke S, Kalva S, Zhu H, Gu M, Vadivelu S, Zhong S, Huang LF, Guo Z. Modeling blood-brain barrier formation and cerebral cavernous malformations in human PSC-derived organoids. Cell Stem Cell 2024; 31:818-833.e11. [PMID: 38754427 PMCID: PMC11162335 DOI: 10.1016/j.stem.2024.04.019] [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: 06/30/2023] [Revised: 02/24/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
The human blood-brain barrier (hBBB) is a highly specialized structure that regulates passage across blood and central nervous system (CNS) compartments. Despite its critical physiological role, there are no reliable in vitro models that can mimic hBBB development and function. Here, we constructed hBBB assembloids from brain and blood vessel organoids derived from human pluripotent stem cells. We validated the acquisition of blood-brain barrier (BBB)-specific molecular, cellular, transcriptomic, and functional characteristics and uncovered an extensive neuro-vascular crosstalk with a spatial pattern within hBBB assembloids. When we used patient-derived hBBB assembloids to model cerebral cavernous malformations (CCMs), we found that these assembloids recapitulated the cavernoma anatomy and BBB breakdown observed in patients. Upon comparison of phenotypes and transcriptome between patient-derived hBBB assembloids and primary human cavernoma tissues, we uncovered CCM-related molecular and cellular alterations. Taken together, we report hBBB assembloids that mimic the core properties of the hBBB and identify a potentially underlying cause of CCMs.
Collapse
Affiliation(s)
- Lan Dao
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Zhen You
- Department of Pediatric and Adolescent Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
| | - Lu Lu
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Tianyang Xu
- Shu Chien-Gene Lay Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Avijite Kumer Sarkar
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Hui Zhu
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Miao Liu
- Department of Pediatric and Adolescent Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
| | - Riccardo Calandrelli
- Shu Chien-Gene Lay Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - George Yoshida
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Pei Lin
- Shu Chien-Gene Lay Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Yifei Miao
- Center for Stem Cell and Organoid Medicine, Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Sarah Mierke
- Divisions of Pediatric Neurosurgery and Interventional Neuroradiology, Cincinnati Children's Hospital, Cincinnati, OH 45229, USA
| | - Srijan Kalva
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Haining Zhu
- Department of Pharmacology and Toxicology, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
| | - Mingxia Gu
- Center for Stem Cell and Organoid Medicine, Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Sudhakar Vadivelu
- Divisions of Pediatric Neurosurgery and Interventional Neuroradiology, Cincinnati Children's Hospital, Cincinnati, OH 45229, USA
| | - Sheng Zhong
- Shu Chien-Gene Lay Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA.
| | - L Frank Huang
- Department of Pediatric and Adolescent Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA.
| | - Ziyuan Guo
- Center for Stem Cell and Organoid Medicine, Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
| |
Collapse
|
9
|
Rubino F, Eichberg DG, Shah AH, Luther EM, Lu VM, Saad AG, Komotar RJ, Ivan ME. Is endoscopic resection a useful technique for a cavernous sinus sellar cavernoma? A case report and literature review. Br J Neurosurg 2024; 38:781-788. [PMID: 34406095 DOI: 10.1080/02688697.2021.1958154] [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: 03/01/2021] [Revised: 05/16/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cavernous sinus cavernous malformations (CSCMs) is a vascular malformation of the cavernous sinus. Nowadays, there is an increasing preference to withhold using the terms cavernoma or cavernous hemangioma in order to stop considering these lesions as vascular neoplasms. These lesions are highly vascularized making surgical resection a challenge, mainly in endoscopic approaches. We present a case of this tumor treated in our institution with an endoscopic endonasal approach and incomplete resection. Because of the strenuous resection through this approach, we systematically reviewed the reported endoscopic cases of CSCMs to determine their intraoperative complications, results and tumor features. METHODS Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, one database (PubMed) and crossed references were queried for CSCMs from 1948 to 2020. Data regarding demographic features, clinical presentation, MRI features, surgical results and overall pathology features extracted. RESULTS Eighteen patients were selected (including our case). The mean age was 50.4 ± 14 years. Pituitary dysfunction and cavernous sinus nerve compression were the most reported symptoms. Only five cases (27%) reported a gross total resection (GTR) through endoscopic endonasal approach. Intraoperative bleeding was the most frequent intraoperative complication. CONCLUSION We present a comprehensive analysis of every reported CSCM treated through endoscopic approach. Partial or subtotal resection are the most used techniques because of the intraoperative bleeding and the adherence to surrounding structures. Radiotherapy is a very good option for patients with incomplete resections.
Collapse
Affiliation(s)
- Franco Rubino
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ashish H Shah
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Evan M Luther
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Victor M Lu
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ali G Saad
- Department of Pathology, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Michael E Ivan
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| |
Collapse
|
10
|
Alfa R, Considine T, Virani S, Pfeiffer M, Donato A, Dickerson D, Shuster D, Ellis J, Rushton K, Wei H, Gibson C. Clinical pharmacology and tolerability of REC-994, a redox-cycling nitroxide compound, in randomized phase 1 dose-finding studies. Pharmacol Res Perspect 2024; 12:e1200. [PMID: 38655895 PMCID: PMC11040693 DOI: 10.1002/prp2.1200] [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: 02/21/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
Cerebral cavernous malformation (CCM) has variable clinical symptoms, including potentially fatal hemorrhagic stroke. Treatment options are very limited, presenting a large unmet need. REC-994 (also known as tempol), identified as a potential treatment through an unbiased drug discovery platform, is hypothesized to treat CCMs through a reduction in superoxide, a reactive oxygen species. We investigated the safety, tolerability, and pharmacokinetic profile of REC-994 in healthy volunteers. Single- and multiple-ascending dose (SAD and MAD, respectively) studies were conducted in adult volunteers (ages 18-55). SAD study participants received an oral dose of REC-994 or placebo. MAD study participants were randomized 3:1 to oral doses of REC-994 or matching placebo, once daily for 10 days. Thirty-two healthy volunteers participated in the SAD study and 52 in the MAD study. Systemic exposure increased in proportion to REC-994 dose after single doses of 50-800 mg and after 10 days of dosing over the 16-fold dose range of 50-800 mg. Median Tmax and mean t1/2 were independent of dose in both studies, and the solution formulation was more rapidly absorbed. REC-994 was well tolerated. Treatment-emergent adverse effects across both studies were mild and transient and resolved by the end of the study. REC-994 has a favorable safety profile and was well tolerated in single and multiple doses up to 800 mg with no dose-limiting adverse effects identified. Data support conducting a phase 2 clinical trial in patients with symptomatic CCM.
Collapse
Affiliation(s)
- Ron Alfa
- Recursion Pharmaceuticals, Inc.Salt Lake CityUtahUSA
- Present address:
NoetikSan FranciscoCaliforniaUSA
| | - Timothy Considine
- Recursion Pharmaceuticals, Inc.Salt Lake CityUtahUSA
- Present address:
Considine Comprehensive ConsultingSan DiegoCaliforniaUSA
| | | | - Matt Pfeiffer
- Recursion Pharmaceuticals, Inc.Salt Lake CityUtahUSA
| | - Anthony Donato
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | | | - Diana Shuster
- Recursion Pharmaceuticals, Inc.Salt Lake CityUtahUSA
- Present address:
CenExelSalt Lake CityUtahUSA
| | - Joel Ellis
- Recursion Pharmaceuticals, Inc.Salt Lake CityUtahUSA
- Present address:
Mariner BioPharmaSan JoseCaliforniaUSA
| | | | - Helen Wei
- Recursion Pharmaceuticals, Inc.Salt Lake CityUtahUSA
| | | |
Collapse
|
11
|
Salem R, Almutairi OT, Albrahim M, Alomar N. Cerebral Cavernous Malformation Bleeding Following Cerebrospinal Fluid Diversion Surgery: A Case Report and Literature Review. Cureus 2024; 16:e58689. [PMID: 38774181 PMCID: PMC11108089 DOI: 10.7759/cureus.58689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2024] [Indexed: 05/24/2024] Open
Abstract
Cavernous malformations (CM) are rare intracerebral vascular lesions occurring in the brain, or less commonly in the spine, with an annual bleeding risk of up to 1.1%. These lesions can be occult or present to signs and symptoms based on location or, more frequently, are a result of hemorrhagic events. The most challenging aspect of managing these cases is weighing the risks and benefits of surgical treatment and intervening before the onset of a devastating hemorrhagic event. Here, we present the second case of CM haemorrhage following the cerebrospinal fluid (CSF) diversion procedure with a literature review of theories explaining this phenomenon. We present a 37-year-old female who has a known case of brainstem cavernoma and underwent left sub-temporal resection with stable residual since 2011, then was managed conservatively due to patient preference till she had a deterioration in December 2021 manifested as confusion, diplopia, dysarthria, and significant left sided weakness leaving her wheelchair bound. CT showed supratentorial hydrocephalus with extensive periventricular transependymal edema and no clear haemorrhage. A ventriculoperitoneal (VP) shunt was inserted, with no intraoperative complications. A few hours post-VP shunt insertion, she experienced a worsening in her mental status, hemiparesis, and dysarthria. Subsequent imaging found evidence of acute haemorrhage in the location of the previously noted residual. She was managed by supportive care. Causative factors of CM haemorrhage are poorly understood, and current data only suggest that prior haemorrhage and CM location could increase bleeding risk. Only one case of CM bleeding post-shunt insertion was reported; however, studies on other types of intracranial vascular lesions suggest that alterations in transmural pressure (including cerebrospinal fluid diversion procedures) can increase the risk of haemorrhage by changing the hemodynamic flow in these abnormally formed and weak vascular structures.
Collapse
Affiliation(s)
- Raghad Salem
- Department of Neurological Surgery, King Saud Medical City, Riyadh, SAU
| | | | - Mohammed Albrahim
- Department of Surgery, Maternity and Children Hospital, Ad-Dammam, SAU
| | | |
Collapse
|
12
|
Lee J, Lee H, Shin M, Park S. Cerebral Cavernous Malformation (CCM)-like Vessel Lesion in the Aged ANKS1A-deficient Brain. Exp Neurobiol 2023; 32:441-452. [PMID: 38196138 PMCID: PMC10789174 DOI: 10.5607/en23032] [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: 09/29/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
In this study, we show that ANKS1A is specifically expressed in the brain endothelial cells of adult mice. ANKS1A deficiency in adult mice does not affect the differentiation, growth, or patterning of the cerebrovascular system; however, its absence significantly impacts the cerebrovascular system of the aged brain. In aged ANKS1A knock-out (KO) brains, vessel lesions exhibiting cerebral cavernous malformations (CCMs) are observed. In addition, CCM-like lesions show localized peripheral blood leakage into the brain. The CCM-like lesions reveal immune cells infiltrating the parenchyma. The CCM-like lesions also contain significantly fewer astrocyte endfeets and tight junctions, indicating that the integrity of the BBB has been partially compromised. CCM-like lesions display increased fibronectin expression in blood vessels, which is also confirmed in cultured endothelial cells deficient for ANKS1A. Therefore, we hypothesize that ANKS1A may play a role in maintaining or stabilizing healthy blood vessels in the brain during aging.
Collapse
Affiliation(s)
- Jiyeon Lee
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| | - Haeryung Lee
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| | - Miram Shin
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| | - Soochul Park
- Department of Biological Sciences, Sookmyung Women’s University, Seoul 04310, Korea
| |
Collapse
|
13
|
Sesen J, Ghalali A, Driscoll J, Martinez T, Lupieri A, Zurakowski D, Alexandrescu S, Smith ER, Fehnel KP. Discovery and Characterization of Ephrin B2 and EphB4 Dysregulation and Novel Mutations in Cerebral Cavernous Malformations: In Vitro and Patient-Derived Evidence of Ephrin-Mediated Endothelial Cell Pathophysiology. Cell Mol Neurobiol 2023; 44:12. [PMID: 38150042 PMCID: PMC11407144 DOI: 10.1007/s10571-023-01447-0] [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: 03/06/2023] [Accepted: 12/15/2023] [Indexed: 12/28/2023]
Abstract
Intracranial vascular malformations manifest on a continuum ranging from predominantly arterial to predominantly venous in pathology. Cerebral cavernous malformations (CCMs) are capillary malformations that exist at the midpoint of this continuum. The axon guidance factor Ephrin B2 and its receptor EphB4 are critical regulators of vasculogenesis in the developing central nervous system. Ephrin B2/EphB4 dysregulation has been implicated in the pathogenesis of arterial-derived arteriovenous malformations and vein-based vein of Galen malformations. Increasing evidence supports the hypothesis that aberrant Ephrin B2/EphB4 signaling may contribute to developing vascular malformations, but their role in CCMs remains largely uncharacterized. Evidence of Ephrin dysregulation in CCMs would be important to establish a common link in the pathogenic spectrum of EphrinB2/Ephb4 dysregulation. By studying patient-derived primary CCM endothelial cells (CCMECs), we established that CCMECs are functionally distinct from healthy endothelial cell controls; CCMECs demonstrated altered patterns of migration, motility, and impaired tube formation. In addition to the altered phenotype, the CCMECs also displayed an increased ratio of EphrinB2/EphB4 compared to the healthy endothelial control cells. Furthermore, whole exome sequencing identified mutations in both EphrinB2 and EphB4 in the CCMECs. These findings identify functional alterations in the EphrinB2/EphB4 ratio as a feature linking pathophysiology across the spectrum of arterial, capillary, and venous structural malformations in the central nervous system while revealing a putative therapeutic target.
Collapse
Affiliation(s)
- Julie Sesen
- Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Aram Ghalali
- Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Jessica Driscoll
- Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Tyra Martinez
- Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Adrien Lupieri
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | | | | | - Edward R Smith
- Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Katie P Fehnel
- Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
| |
Collapse
|
14
|
Genetics of brain arteriovenous malformations and cerebral cavernous malformations. J Hum Genet 2023; 68:157-167. [PMID: 35831630 DOI: 10.1038/s10038-022-01063-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/13/2022] [Accepted: 06/26/2022] [Indexed: 11/08/2022]
Abstract
Cerebrovascular malformations comprise abnormal development of cerebral vasculature. They can result in hemorrhagic stroke due to rupture of lesions as well as seizures and neurological defects. The most common forms of cerebrovascular malformations are brain arteriovenous malformations (bAVMs) and cerebral cavernous malformations (CCMs). They occur in both sporadic and inherited forms. Rapidly evolving molecular genetic methodologies have helped to identify causative or associated genes involved in genesis of bAVMs and CCMs. In this review, we highlight the current knowledge regarding the genetic basis of these malformations.
Collapse
|
15
|
Pilz RA, Skowronek D, Mellinger L, Bekeschus S, Felbor U, Rath M. Endothelial Differentiation of CCM1 Knockout iPSCs Triggers the Establishment of a Specific Gene Expression Signature. Int J Mol Sci 2023; 24:ijms24043993. [PMID: 36835400 PMCID: PMC9963194 DOI: 10.3390/ijms24043993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Cerebral cavernous malformation (CCM) is a neurovascular disease that can lead to seizures and stroke-like symptoms. The familial form is caused by a heterozygous germline mutation in either the CCM1, CCM2, or CCM3 gene. While the importance of a second-hit mechanism in CCM development is well established, it is still unclear whether it immediately triggers CCM development or whether additional external factors are required. We here used RNA sequencing to study differential gene expression in CCM1 knockout induced pluripotent stem cells (CCM1-/- iPSCs), early mesoderm progenitor cells (eMPCs), and endothelial-like cells (ECs). Notably, CRISPR/Cas9-mediated inactivation of CCM1 led to hardly any gene expression differences in iPSCs and eMPCs. However, after differentiation into ECs, we found the significant deregulation of signaling pathways well known to be involved in CCM pathogenesis. These data suggest that a microenvironment of proangiogenic cytokines and growth factors can trigger the establishment of a characteristic gene expression signature upon CCM1 inactivation. Consequently, CCM1-/- precursor cells may exist that remain silent until entering the endothelial lineage. Collectively, not only downstream consequences of CCM1 ablation but also supporting factors must be addressed in CCM therapy development.
Collapse
Affiliation(s)
- Robin A. Pilz
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17475 Greifswald, Germany
| | - Dariush Skowronek
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17475 Greifswald, Germany
| | - Lara Mellinger
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17475 Greifswald, Germany
| | - Sander Bekeschus
- ZIK Plasmatis, Leibniz Institute for Plasma Science and Technology (INP), 17489 Greifswald, Germany
| | - Ute Felbor
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17475 Greifswald, Germany
| | - Matthias Rath
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17475 Greifswald, Germany
- Department of Human Medicine and Institute for Molecular Medicine, MSH Medical School Hamburg, 20457 Hamburg, Germany
- Correspondence: ; Tel.: +49-3834-865396
| |
Collapse
|
16
|
Cerebral cavernous malformation: Management, outcomes, and surveillance strategies - A single centre retrospective cohort study. Clin Neurol Neurosurg 2023; 225:107576. [PMID: 36608471 DOI: 10.1016/j.clineuro.2022.107576] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may undergo a period of clinical and/or radiographical surveillance that precedes or follows definitive treatment. There are no international guidelines on the optimal surveillance strategy. This study describes the surveillance strategies at our centre and explore the related clinical outcomes. METHODS We performed a retrospective study of adult patients with CCMs referred to a neurovascular service over an 8-year period, to determine the frequency and type of surveillance, intervention, and explore the associated outcomes. We report our findings adhering to STROBE guidelines. RESULTS 133 patients (Male:Female 73:60; men age 42 years; range 12-82) were included. CCMs were identified in patients first presenting with symptomatic intracerebral haemorrhage (42.11%); headache, focal neurological deficit, or seizure without haemorrhage (41.35%); or, as an incidental finding (16.54%). The most common CCM location was supratentorial (59.40%), followed by brain stem (21.80%), cerebellum (10.53%) and basal ganglia (6.02%). Of the 133 patients, 77 patients (57.89%) were managed conservatively, 49 patients (36.84%) were managed by surgical resection alone, and seven patients (5.26%) were managed with stereotactic radiosurgery (SRS). Patients follow-up had a mean duration of 65.94 months, and varied widely (SD = 52.59; range 0-265), for a total of 730.83 person-years of follow up. During surveillance, 16 patients suffered an ICH equating to a bleeding rate of 2.19 per 100 patient years. CCMs that increased in size had a higher bleeding rate (p = 8.58 ×10-4). There were 8 (6.02%) cases where routine clinic review or MRI resulted in a change in management. CONCLUSIONS Our single centre retrospective study supports existing literature relating to presentation and sequalae of CCM, with an increase in CCM size being associated with higher rates of detected bleeding. There remains heterogeneity, even within a single centre, on the frequency and modality of surveillance. Further, there are no international guidelines or high-quality data that recommends the optimal duration and frequency of surveillance, and its effect on clinical outcomes. This is a future research direction.
Collapse
|
17
|
Liao D, Wang R, Shan B, Chen H. Surgical outcomes of spinal cavernous malformations: A retrospective study of 98 patients. Front Surg 2023; 9:1075276. [PMID: 36713668 PMCID: PMC9877401 DOI: 10.3389/fsurg.2022.1075276] [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: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
Objective Spinal cord cavernous malformation (SCCM) is a rare vascular lesion, and the treatment strategy remains controversial at present. The goal of this retrospective study was to analyze the surgical outcomes of the SCCM and to find more appropriate treatment strategies for a better prognosis. Method A retrospective review of 98 patients with SCCM from 2009 to 2018 was conducted at the neurosurgical center of our hospital. Neurological function was assessed using the American Spinal Injury Association (ASIA) impairment scale. Clinical features were analyzed using the multivariable logistic regression. Results Ninety-eight patients with SCCM were included, of whom 36% were female and 64% male. The mean age was 41.6 years; and family history was reported in 8% of patients. Definite hemorrhage was found in 6%. Before surgery, the neurological status was Grade A in 2%, Grade B in 2%, Grade C in 12%, Grade D in 54%, and Grade E in 30% of the patients. 83% (81/98) patients had long-term follow-up, of whom, 42% had improved, 51% were stable and 7% had deteriorated. Patients with dorsal or superficial lesions showed better improvement than those with ventral or lateral deep lesions. Those with symptoms lasting less than three months had higher rates of improvement than those with symptoms lasting more than three months. However, there was no significant difference in prognosis between hemilaminectomy and laminectomy. Conclusion These results suggest that surgical strategies should be preferred for severe symptomatic SCCMs if total resection can be achieved, thereby avoiding the risk of severe complications with subsequent lesion hemorrhage. Earlier (usually within 3 months of symptom duration) surgical resection generally may lead to a better prognosis. For ventral or lateral deep SCCMs, the surgical strategy should be considered more carefully.
Collapse
|
18
|
Flomin Y, Hetman T, Guliaieva M, Havryliv I, Tsurkalenko O. Determining the etiology of cerebral stroke: from the most prevalent to rare causes. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2022-2(40)-14-40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cerebral stroke remains the leading cause of death and disability worldwide as well as in Ukraine. After a cerebral stroke, there is an increased risk of a new cerebral stroke (9‒15 % within 1 year), and about a quarter of all cerebral stroke are recurrent. Up to 80 % of recurrent cerebral stroke can be avoided through lifestyle modifications (healthy diet, sufficient amount of physical activity, normalization of body weight, cessation of smoking and alcohol abuse) and control of chronic diseases such as hypertension, diabetes, hyperlipidemia and atrial fibrillation. The key to effective secondary prevention is determining the etiology of cerebral stroke, which requires a primary examination in all cases and a number of additional tests as needed. The most common causes of ischemic cerebral stroke are cardiogenic embolism, atherosclerosis of the large cerebral arteries (macroangiopathy), and brain small vessels disease (microangiopathy), but approximately 1/3 of cerebral stroke have other, rear, determined cause or the cause remains unknown despite the appropriate workup (cryptogenic cerebral stroke). In the review, we discuss modern approaches to ischemic cerebral stroke classification and determination of their etiology, from the most prevalent to the rarest causes. A careful search for the cause of cerebral stroke is particularly important in young patients (aged 18 to 50 years) with a high life expectancy. We have reviewed in detail the possibilities of screening for subclinical atrial fibrillation by long-term cardiac monitoring with implantable devices and the diagnosis of monogenetic causes of cerebral stroke, with a particular focus on Fabry disease, for which there is an effective treatment.
Collapse
|
19
|
Gorick CM, Breza VR, Nowak KM, Cheng VWT, Fisher DG, Debski AC, Hoch MR, Demir ZEF, Tran NM, Schwartz MR, Sheybani ND, Price RJ. Applications of focused ultrasound-mediated blood-brain barrier opening. Adv Drug Deliv Rev 2022; 191:114583. [PMID: 36272635 PMCID: PMC9712235 DOI: 10.1016/j.addr.2022.114583] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 01/25/2023]
Abstract
The blood brain barrier (BBB) plays a critically important role in the regulation of central nervous system (CNS) homeostasis, but also represents a major limitation to treatments of brain pathologies. In recent years, focused ultrasound (FUS) in conjunction with gas-filled microbubble contrast agents has emerged as a powerful tool for transiently and non-invasively disrupting the BBB in a targeted and image-guided manner, allowing for localized delivery of drugs, genes, or other therapeutic agents. Beyond the delivery of known therapeutics, FUS-mediated BBB opening also demonstrates the potential for use in neuromodulation and the stimulation of a range of cell- and tissue-level physiological responses that may prove beneficial in disease contexts. Clinical trials investigating the safety and efficacy of FUS-mediated BBB opening are well underway, and offer promising non-surgical approaches to treatment of devastating pathologies. This article reviews a range of pre-clinical and clinical studies demonstrating the tremendous potential of FUS to fundamentally change the paradigm of treatment for CNS diseases.
Collapse
Affiliation(s)
- Catherine M Gorick
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Victoria R Breza
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Katherine M Nowak
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, VA 22908, USA
| | - Vinton W T Cheng
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA; Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Delaney G Fisher
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Anna C Debski
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Matthew R Hoch
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Zehra E F Demir
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Nghi M Tran
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Mark R Schwartz
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Natasha D Sheybani
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Richard J Price
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA.
| |
Collapse
|
20
|
Litts C, Jasper P, Wessell JE, Eskandari R. 3-Dimensional Exoscope for Far Lateral Approach to Pontomedullary Cavernous Malformation. World Neurosurg 2022; 166:88. [PMID: 35953042 DOI: 10.1016/j.wneu.2022.07.098] [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: 03/19/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 12/15/2022]
Abstract
Brainstem cavernous malformations account for 15%-18% of all central nervous system cavernomas and are histologically characterized by thin-walled, low-pressure capillaries, classically without intervening brain tissue.1,2 Cavernomas may be sporadic, typically characterized by a single lesion, or inherited. The inherited form is most often autosomal dominant with incomplete penetrance and variable expression. Multiple cavernomas are associated with the familial form; although this is not always the case, genetic workup should be pursued.3,4 Clinical presentation typically includes focal neurologic deficit related to hemorrhage location, seizures, and rarely obstructive hydrocephalus.1,2 Indications for surgical management include severe or progressive neurologic dysfunction, lesion size ≥2 cm, recurring hemorrhages, and/or significant mass effect.5 Microsurgical resection of a cavernoma is associated with an overall 28% complication rate and perioperative neurologic morbidity upwards of 45% according to some series. Long-term surgical outcomes at 12 months are more reassuring: 84% reported their condition to have improved or remained the same, and the long-term morbidity rate is 14%.1,6 The location of the lesion dictates the approaches available-cavernomas in the pons or medulla are commonly approached via a retrosigmoid or retrolabyrinthine approach, while more ventral pathologies in this region necessitate a far lateral approach.1,5,7,8 In Videos 1 and 2, we describe our experience with an exoscope-assisted far lateral approach to a pontomedullary cavernoma in a 10-year-old male presenting with numerous cavernomas and confirmed gene mutation. We demonstrate the exoscope's unparalleled visualization of the anterolateral brainstem, with nominal condylar drilling. The patient and his parents consented to the procedure and publication.
Collapse
Affiliation(s)
- Christopher Litts
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Polly Jasper
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jeffrey E Wessell
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
21
|
Santos AN, Rauschenbach L, Saban D, Chen B, Lenkeit A, Gull HH, Rieß C, Deuschl C, Schmidt B, Jabbarli R, Wrede KH, Zhu Y, Frank B, Sure U, Dammann P. Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations. J Neurosurg 2022; 137:1088-1094. [PMID: 35213840 DOI: 10.3171/2022.1.jns212724] [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: 11/28/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to analyze the impact of medication intake on hemorrhage risk in patients with familial cerebral cavernous malformation (FCCM). METHODS The authors' institutional database was screened for patients with FCCM who had been admitted to their department between 2003 and 2020. Patients with a complete magnetic resonance imaging (MRI) data set, evidence of multiple CCMs, clinical baseline characteristics, and follow-up (FU) examination were included in the study. The authors assessed the influence of medication intake on first or recurrent intracerebral hemorrhage (ICH) using univariate and multivariate logistic regression adjusted for age and sex. The longitudinal cumulative 5-year risk of hemorrhage was calculated by applying Kaplan-Meier and Cox regression analyses adjusted for age and sex. RESULTS Two hundred five patients with FCCMs were included in the study. Multivariate Cox regression analysis revealed ICH as a predictor for recurrent hemorrhage during the 5-year FU. The authors also noted a tendency toward a decreased association with ICH during FU in patients on statin medication (HR 0.22, 95% CI 0.03-1.68, p = 0.143), although the relationship was not statistically significant. No bleeding events were observed in patients on antithrombotic therapy. Kaplan-Meier analysis and log-rank test showed a tendency toward a low risk of ICH during FU in patients on antithrombotic therapy (p = 0.085), as well as those on statin therapy (p = 0.193). The cumulative 5-year risk of bleeding was 22.82% (95% CI 17.33%-29.38%) for the entire cohort, 31.41% (95% CI 23.26%-40.83%) for patients with a history of ICH, 26.54% (95% CI 11.13%-49.7%) for individuals on beta-blocker medication, 6.25% (95% CI 0.33%-32.29%) for patients on statin medication, and 0% (95% CI 0%-30.13%) for patients on antithrombotic medication. CONCLUSIONS ICH at diagnosis was identified as a risk factor for recurrent hemorrhage. Although the relationships were not statistically significant, statin and antithrombotic medication tended to be associated with decreased bleeding events.
Collapse
Affiliation(s)
- Alejandro N Santos
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | | | - Dino Saban
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Bixia Chen
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Annika Lenkeit
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Hanah Hadice Gull
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Christoph Rieß
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Cornelius Deuschl
- 2Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen
| | - Börge Schmidt
- 3Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen; and
| | - Ramazan Jabbarli
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Karsten H Wrede
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Yuan Zhu
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Benedikt Frank
- 4Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Germany
| | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Philipp Dammann
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| |
Collapse
|
22
|
Identification of a novel LATS1 variant associated with familial cerebral cavernous malformations in a Chinese family. Neurol Sci 2022; 43:6389-6397. [DOI: 10.1007/s10072-022-06323-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
|
23
|
Moloney PB, Dugan P, Widdess-Walsh P, Devinsky O, Delanty N. Genomics in the Presurgical Epilepsy Evaluation. Epilepsy Res 2022; 184:106951. [DOI: 10.1016/j.eplepsyres.2022.106951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/23/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
|
24
|
Patterson TT, McGinity M, Crownover R, Grandhi R. Remote Development of Symptomatic Intracranial Cavernous Malformation After Stereotactic Radiosurgery. Cureus 2022; 14:e21635. [PMID: 35233313 PMCID: PMC8881241 DOI: 10.7759/cureus.21635] [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: 09/06/2019] [Accepted: 01/26/2022] [Indexed: 11/17/2022] Open
Abstract
Cavernous hemangiomas, or cavernomas, are vascular malformations that affect about 0.1-0.5% of the population and usually result from sporadic or familial mutations of genes involved with endothelial cell junctions. They are histologically described as dilated vascular clusters, and they may occur in various areas of the body. Cavernomas of the central nervous system can generate localizing symptoms, including focal neurological defects, headaches, seizures, and hemorrhage. Radiation-induced cavernomas (RICs) have been described in the literature since 1994 and have been more frequently described in children. Although there has been speculation about the pathophysiology of RICs, no consensus exists in the literature, and pathological evaluation of RICs remains sparsely reported. We present the case of a 63-year-old patient who underwent stereotactic radiosurgery for treatment of an intracranial arteriovenous malformation (AVM) and subsequently developed a symptomatic RIC seven years later that required microresection. Clinicians should exercise diligence when monitoring patients with a history of intracranial radiation because of growing evidence supporting cavernomas as potential late-stage sequelae.
Collapse
|
25
|
Santos AN, Rauschenbach L, Saban D, Chen B, Darkwah Oppong M, Herten A, Hadice Gull H, Rieß C, Deuschl C, Schmidt B, Jabbarli R, Wrede KH, Zhu Y, Frank B, Sure U, Dammann P. Multiple Cerebral Cavernous Malformations – Clinical Course of Confirmed, Assumed and Non‐Familial Disease. Eur J Neurol 2022; 29:1427-1434. [DOI: 10.1111/ene.15253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Alejandro N. Santos
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Dino Saban
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Bixia Chen
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Hanah Hadice Gull
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Christoph Rieß
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology University Hospital of Essen Essen Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Karsten H. Wrede
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Yuan Zhu
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Benedikt Frank
- Department of Neurology University Hospital Essen Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery University Hospital Essen Essen Germany
| |
Collapse
|
26
|
Surgical Management of Cavernous Malformations and Venous Anomalies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
27
|
A series of 14 representative presentations of cerebral cavernous malformations. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
28
|
Chojdak-Łukasiewicz J, Dziadkowiak E, Budrewicz S. Monogenic Causes of Strokes. Genes (Basel) 2021; 12:1855. [PMID: 34946804 PMCID: PMC8700771 DOI: 10.3390/genes12121855] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
Strokes are the main cause of death and long-term disability worldwide. A stroke is a heterogeneous multi-factorial condition, caused by a combination of environmental and genetic factors. Monogenic disorders account for about 1% to 5% of all stroke cases. The most common single-gene diseases connected with strokes are cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) Fabry disease, mitochondrial myopathy, encephalopathy, lactacidosis, and stroke (MELAS) and a lot of single-gene diseases associated particularly with cerebral small-vessel disease, such as COL4A1 syndrome, cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), and Hereditary endotheliopathy with retinopathy, nephropathy, and stroke (HERNS). In this article the clinical phenotype for the most important single-gene disorders associated with strokes are presented. The monogenic causes of a stroke are rare, but early diagnosis is important in order to provide appropriate therapy when available.
Collapse
|
29
|
Maiuri F, Mariniello G, Corvino S, Somma T, Guadagno E, Teodonno G, Del Basso De Caro M, Cappabianca P. Cavernous Malformations to Be Investigated for Familiarity: The Role of Ki67 MIB1. World Neurosurg 2021; 155:e75-e82. [PMID: 34389524 DOI: 10.1016/j.wneu.2021.08.008] [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: 05/19/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Familial forms of cavernous malformations (CMs) often occur as multiple lesions. Nevertheless, the presence of a single CM does not exclude the familiarity. The aim of this study is to establish which patients who undergo surgery for a single cerebral cavernous malformation (CCM), with no family history at initial diagnosis, should be investigated for familiarity through genetic testing and counseling. METHODS Eight families with 2 or more members affected by CCM have been studied. A control group of sporadic cases operated on, with no family history and followed up 10 years or more, was also included. Analyzed factors were patient age and sex, location, number and size of the lesions, associated developmental venous anomaly, presence of epileptic seizures, symptomatic hemorrhage, focal neurological deficits, and documented growth of the malformation and Ki67 MIB1 proliferation index. RESULTS The familial group of CCMs showed higher incidence of pediatric patients (P = 0.01), more frequent occurrence of multiple lesions (P = 0.0004), higher rate of large CCMs, and symptomatic hemorrhage; besides, all 3 cases with documented growth belonged to the familial group (14%). The expression of Ki67 MIB1 was positive in 79% of the familial cases versus 0% in the sporadic ones (P < 0.00001). CONCLUSIONS Patients with CCM and no known family history at the time of the initial diagnosis who present specific features should be studied by genetic screening. The Ki67 MIB1 is a useful biomarker in favor of familial occurrence and may be studied in all patients with CMs to define the indication to the genetic tests.
Collapse
Affiliation(s)
- Francesco Maiuri
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy.
| | - Giuseppe Mariniello
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Sergio Corvino
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Teresa Somma
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, University "Federico II" of Naples, Naples, Italy
| | - Giuseppe Teodonno
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, University "Federico II" of Naples, Naples, Italy
| | - Paolo Cappabianca
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, Naples, Italy
| |
Collapse
|
30
|
López Pérez V, Jaro M, Arcas JJ, Del Olmo M, Tebar MY. The dilemma of choosing obstetrics and anesthesia techniques in a patient with cerebral cavernomatosis: a case report. Braz J Anesthesiol 2021; 72:516-518. [PMID: 33984346 PMCID: PMC9373679 DOI: 10.1016/j.bjane.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 11/25/2022] Open
Abstract
This report describes the case of a pregnant woman who arrived for preanesthetic assessment of External Cephalic Version (ECV) for fetus in breech presentation and cesarean section in case of ECV failure. Although the technique seems simple, attempts to rotate the fetus can result in elevated intracranial pressure, which might cause malformation bleeding. The most appropriate anesthetic technique in cases of arteriovenous malformations during C-sections has not been determined. Neuroaxial anesthesia is safe only in stable brain cavernomas, but the presence of spinal malformations contraindicates it. Anesthetic goals include stabilizing the blood pressure and reducing the risk of rupture.
Collapse
Affiliation(s)
| | | | - Jose J Arcas
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | |
Collapse
|
31
|
Riolo G, Ricci C, Battistini S. Molecular Genetic Features of Cerebral Cavernous Malformations (CCM) Patients: An Overall View from Genes to Endothelial Cells. Cells 2021; 10:704. [PMID: 33810005 PMCID: PMC8005105 DOI: 10.3390/cells10030704] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023] Open
Abstract
Cerebral cavernous malformations (CCMs) are vascular lesions that affect predominantly microvasculature in the brain and spinal cord. CCM can occur either in sporadic or familial form, characterized by autosomal dominant inheritance and development of multiple lesions throughout the patient's life. Three genes associated with CCM are known: CCM1/KRIT1 (krev interaction trapped 1), CCM2/MGC4607 (encoding a protein named malcavernin), and CCM3/PDCD10 (programmed cell death 10). All the mutations identified in these genes cause a loss of function and compromise the protein functions needed for maintaining the vascular barrier integrity. Loss of function of CCM proteins causes molecular disorganization and dysfunction of endothelial adherens junctions. In this review, we provide an overall vision of the CCM pathology, starting with the genetic bases of the disease, describing the role of the proteins, until we reach the cellular level. Thus, we summarize the genetics of CCM, providing a description of CCM genes and mutation features, provided an updated knowledge of the CCM protein structure and function, and discuss the molecular mechanisms through which CCM proteins may act within endothelial cells, particularly in endothelial barrier maintenance/regulation and in cellular signaling.
Collapse
Affiliation(s)
| | | | - Stefania Battistini
- Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (G.R.); (C.R.)
| |
Collapse
|
32
|
Sabayan B, Lineback C, Viswanathan A, Leslie‐Mazwi TM, Shaibani A. Central nervous system vascular malformations: A clinical review. Ann Clin Transl Neurol 2021; 8:504-522. [PMID: 33434339 PMCID: PMC7886037 DOI: 10.1002/acn3.51277] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/11/2020] [Accepted: 11/27/2020] [Indexed: 11/27/2022] Open
Abstract
CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.
Collapse
Affiliation(s)
- Behnam Sabayan
- Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Christina Lineback
- Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Anand Viswanathan
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Thabele M. Leslie‐Mazwi
- Departments of Neurosurgery and NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Ali Shaibani
- Department of RadiologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| |
Collapse
|
33
|
Vázquez-Osorio I, García-González N, Viejo-Díaz M, Gonzalvo-Rodríguez P, Rodríguez-Díaz E. Cerebral Cavernous Malformations: The Importance of Cutaneous Manifestations. Indian J Dermatol 2021; 66:93-95. [PMID: 33911302 PMCID: PMC8061482 DOI: 10.4103/ijd.ijd_594_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Igor Vázquez-Osorio
- Servicio de Dermatología, Hospital Clínico Universitario de Santiago de Compostela, Spain
| | | | - Mónica Viejo-Díaz
- Unidad de Genética, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Eloy Rodríguez-Díaz
- Servicio de Dermatología, Hospital Universitario de Cabueñes, Gijón. E-mail:
| |
Collapse
|
34
|
Abstract
Cerebral cavernous malformations (CCMs) are neurovascular abnormalities characterized by thin, leaky blood vessels resulting in lesions that predispose to haemorrhages, stroke, epilepsy and focal neurological deficits. CCMs arise due to loss-of-function mutations in genes encoding one of three CCM complex proteins, KRIT1, CCM2 or CCM3. These widely expressed, multi-functional adaptor proteins can assemble into a CCM protein complex and (either alone or in complex) modulate signalling pathways that influence cell adhesion, cell contractility, cytoskeletal reorganization and gene expression. Recent advances, including analysis of the structures and interactions of CCM proteins, have allowed substantial progress towards understanding the molecular bases for CCM protein function and how their disruption leads to disease. Here, we review current knowledge of CCM protein signalling with a focus on three pathways which have generated the most interest—the RhoA–ROCK, MEKK3–MEK5–ERK5–KLF2/4 and cell junctional signalling pathways—but also consider ICAP1-β1 integrin and cdc42 signalling. We discuss emerging links between these pathways and the processes that drive disease pathology and highlight important open questions—key among them is the role of subcellular localization in the control of CCM protein activity.
Collapse
Affiliation(s)
- Valerie L Su
- Department of Pharmacology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA
| | - David A Calderwood
- Department of Pharmacology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA.,Department of Cell Biology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA
| |
Collapse
|
35
|
Sun Y, Zhao Z, Zhang H, Li J, Chen J, Luan X, Min W, He Y. The interaction of lead exposure and CCM3 defect plays an important role in regulating angiogenesis through eNOS/NO pathway. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2020; 79:103407. [PMID: 32512318 DOI: 10.1016/j.etap.2020.103407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/14/2020] [Accepted: 05/03/2020] [Indexed: 06/11/2023]
Abstract
In this study, we aimed to explore the role of nitric oxide (NO) in regulating angiogenesis in cerebral cavernous malformations 3 gene (CCM3)-deficient mice exposed to lead during vascular development; further, we aimed to identify and study the potential mechanism involved as well. Angiogenesis was detected by whole mount immunofluorescent staining of retinal vessels in WT and CCM3+/- mice. Brain microvascular endothelial cells (BMECs) isolated from WT and CCM3+/- mice, primary HUVECs, and immortalized HUVECs (imHUVECs) (CCM3+/+ and CCM3-/-) were used and treated with lead acetate (PbAc). RT-PCR and Western blotting were used to detect the mRNA and protein expression of iNOS, eNOS, and VEGF genes. The results showed that both lead exposure and CCM3 gene deficiency adversely affected endothelial cell function, causing abnormal angiogenesis and vascular remodeling. The mRNA expression of eNOS and iNOS was significantly different in WT and CCM3+/- BMECs (0.04 ± 0.001 vs. 0.016 ± 0.002; 0.26 ± 0.002 vs. 0.306 ± 0.002, respectively), and the expression of eNOS and iNOS in imHUVECs (CCM3+/+ and CCM3-/-) also increased after PbAc exposure. In conclusion, CCM3 gene-deficient mice were more susceptible to abnormal vascular development after low-level lead exposure, probably due to the release of NO.
Collapse
Affiliation(s)
- Yi Sun
- Department of Health Toxicology, Sun Yat-sen University School of Public Health, Guangzhou, Guangdong, 510080, China; Department of Environmental Health and Occupational Medicine, Guilin Medical University School of Public Health, Guilin, Guangxi, 541004, China
| | - Zhiqiang Zhao
- Department of Health Toxicology, Sun Yat-sen University School of Public Health, Guangzhou, Guangdong, 510080, China
| | - Haifeng Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, CT, 06510, USA
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jingli Chen
- Department of Health Toxicology, Sun Yat-sen University School of Public Health, Guangzhou, Guangdong, 510080, China
| | - Xiaoyi Luan
- Department of Environmental Health and Occupational Medicine, Guilin Medical University School of Public Health, Guilin, Guangxi, 541004, China
| | - Wang Min
- Department of Pathology, Yale University School of Medicine, New Haven, CT, 06510, USA
| | - Yun He
- Department of Health Toxicology, Sun Yat-sen University School of Public Health, Guangzhou, Guangdong, 510080, China.
| |
Collapse
|
36
|
Gaviria Carrillo M, López J, Rodríguez Q. JH, Gaona I, Ortiz-Guerrero G, Nava-Mesa MO. Apparent False Lateralization of Seizure Onset by Scalp EEG in Temporal Lobe Epilepsy Associated with Cerebral Cavernous Malformation: A Case Report and Overview. Brain Sci 2020; 10:brainsci10090584. [PMID: 32846994 PMCID: PMC7565586 DOI: 10.3390/brainsci10090584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022] Open
Abstract
False lateralization of ictal onset by scalp electroencephalogram (EEG) is an infrequent entity that has been reported in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis (HS). In these cases, a tendency for rapid seizures that spread through the frontal-limbic system and hippocampal commissural pathways to the contralateral hemisphere has been proposed. Cerebral cavernous malformations (CCMs), which constitute a collection of abnormally configured small blood vessels with irregular structures, is a well-defined epilepsy-associated pathology. Their primary association with seizures might be explained either as a result of physiological changes affecting the cerebral cortex immediately surrounding the CCM (an epileptogenic mechanism that is relevant for both, temporal and extratemporal lesions) or as a result of promoting epileptogenicity in remote but anatomo-functionally connected brain regions, a mechanism that is particularly relevant for temporal lobe lesions. To date, there have been only two publications on falsely lateralizing ictal onsets by EEG in temporal cavernoma, but not in other regions. Here, we report a rare case of apparent false lateralization of ictal onset by scalp EEG in a patient with a left medial frontal gyrus cavernoma (supplementary motor area), and discuss some relevant pathophysiological mechanisms of false lateralization.
Collapse
Affiliation(s)
- Mariana Gaviria Carrillo
- Department of Neurology, Fundación Cardioinfantil (FCI), Bogotá 110131, Colombia; (M.G.C.); (J.H.R.Q.); (I.G.)
- Escuela de Medicina y Ciencias de la Salud, GI en Neurociencias-NeURos, Universidad del Rosario, Bogotá 111221, Colombia
| | - Jonathan López
- Department of Neurology, Universidad del Sinú, Cartagena 130001, Colombia;
| | - Jesús H. Rodríguez Q.
- Department of Neurology, Fundación Cardioinfantil (FCI), Bogotá 110131, Colombia; (M.G.C.); (J.H.R.Q.); (I.G.)
- Escuela de Medicina y Ciencias de la Salud, GI en Neurociencias-NeURos, Universidad del Rosario, Bogotá 111221, Colombia
- Department of Neurology, Hospital Universitario Mayor—Mederi, Bogotá 111411, Colombia
| | - Ivan Gaona
- Department of Neurology, Fundación Cardioinfantil (FCI), Bogotá 110131, Colombia; (M.G.C.); (J.H.R.Q.); (I.G.)
| | - Gloria Ortiz-Guerrero
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS 66160, USA;
| | - Mauricio O. Nava-Mesa
- Escuela de Medicina y Ciencias de la Salud, GI en Neurociencias-NeURos, Universidad del Rosario, Bogotá 111221, Colombia
- Correspondence: or ; Tel.: +571-2970200 (ext. 3354)
| |
Collapse
|
37
|
Ishii K, Tozaka N, Tsutsumi S, Muroi A, Tamaoka A. Familial cerebral cavernous malformation presenting with epilepsy caused by mutation in the CCM2 gene: A case report. Medicine (Baltimore) 2020; 99:e19800. [PMID: 32702807 PMCID: PMC7373609 DOI: 10.1097/md.0000000000019800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cerebral cavernous malformation (CCM) of the familial type is caused by abnormalities in the CCM1, CCM2, and CCM3 genes. These 3 proteins forming a complex associate with the maintenance of vascular endothelial cell-cell junctions. Dysfunction of these proteins results in the development of hemangiomas and abnormal intercellular junctions. PATIENT CONCERNS We report a 68-year-old man with familial cerebral cavernous malformation with initial presentation as convulsions at an advanced age. Brain magnetic resonance imaging revealed multiple cavernous hemangiomas in the right occipital lobe. The convulsions were considered to be induced by hemorrhage from cavernous hemangioma in the right occipital lobe. DIAGNOSES Genetic screening of the CCM1, CCM2, and CCM3 genes revealed a novel mutation in the CCM2 gene (exon4 c: 359 T>A, p: V120D). No abnormalities were found in CCM1 or CCM3. Therefore, we diagnosed the patient with familial CCM caused by a CCM2 mutation. INTERVENTIONS This patient was treated with the administration of levetiracetam at a dosage of 1000 mg/day. OUTCOMES No seizures have been observed since the antiepileptic drug was administered. We performed brain magnetic resonance imaging (MRI) regularly to follow-up on appearance of new cerebral hemorrhages and cavernous hemangiomas. LESSONS This report reviews cases of familial cerebral cavernous malformations caused by abnormalities in the CCM2 gene. This mutation site mediates interactions with CCM1 and CCM3. The mutation occurs in the phosphotyrosine binding (PTB) site, which is considered functionally important to CCM2.
Collapse
MESH Headings
- Aged
- Anticonvulsants/administration & dosage
- Anticonvulsants/therapeutic use
- Carrier Proteins/genetics
- Genetic Testing
- Hemangioma, Cavernous/complications
- Hemangioma, Cavernous/genetics
- Hemangioma, Cavernous/pathology
- Hemangioma, Cavernous, Central Nervous System/diagnostic imaging
- Hemangioma, Cavernous, Central Nervous System/drug therapy
- Hemangioma, Cavernous, Central Nervous System/genetics
- Hemangioma, Cavernous, Central Nervous System/pathology
- Hemorrhage/diagnostic imaging
- Hemorrhage/etiology
- Humans
- Levetiracetam/administration & dosage
- Levetiracetam/therapeutic use
- Magnetic Resonance Imaging/methods
- Male
- Mutation
- Seizures/diagnosis
- Seizures/etiology
- Treatment Outcome
Collapse
Affiliation(s)
- Kazuhiro Ishii
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575
| | - Naoki Tozaka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575
| | - Satoshi Tsutsumi
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021
| | - Ai Muroi
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akira Tamaoka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki, 305-8575
| |
Collapse
|
38
|
Role of aspirin and statin therapy in patients with cerebral cavernous malformations. J Clin Neurosci 2020; 78:246-251. [PMID: 32340842 DOI: 10.1016/j.jocn.2020.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/14/2020] [Accepted: 04/05/2020] [Indexed: 12/23/2022]
Abstract
Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.
Collapse
|
39
|
Benzaquen M, Fareau J, Riccardi F, Philip‐Sarles N, Bertrand F, Berbis P, Delaporte E. Multiple venous malformations revealing a familial cerebral cavernomatosis. Clin Exp Dermatol 2020; 45:263-264. [DOI: 10.1111/ced.14051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 11/26/2022]
Affiliation(s)
- M. Benzaquen
- Department of Dermatology Aix Marseille University, APHM, Hôpital Nord Marseille France
| | - J. Fareau
- Department of Dermatology Aix Marseille University, APHM, Hôpital Nord Marseille France
| | - F. Riccardi
- Department of Genetics and Molecular Biology Aix Marseille University, APHM, Hôpital Timone Enfants Marseille France
| | - N. Philip‐Sarles
- Department of Genetics and Molecular Biology Aix Marseille University, APHM, Hôpital Timone Enfants Marseille France
| | - F. Bertrand
- Dermatological Center Aix‐en‐Provence France
| | - P. Berbis
- Department of Dermatology Aix Marseille University, APHM, Hôpital Nord Marseille France
| | - E. Delaporte
- Department of Dermatology Aix Marseille University, APHM, Hôpital Nord Marseille France
| |
Collapse
|
40
|
Chohan MO, Marchiò S, Morrison LA, Sidman RL, Cavenee WK, Dejana E, Yonas H, Pasqualini R, Arap W. Emerging Pharmacologic Targets in Cerebral Cavernous Malformation and Potential Strategies to Alter the Natural History of a Difficult Disease: A Review. JAMA Neurol 2020; 76:492-500. [PMID: 30476961 DOI: 10.1001/jamaneurol.2018.3634] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Cerebral cavernous malformations (CCMs) are vascular lesions of the brain that may lead to hemorrhage, seizures, and neurologic deficits. Most are linked to loss-of-function mutations in 1 of 3 genes, namely CCM1 (originally called KRIT1), CCM2 (MGC4607), or CCM3 (PDCD10), that can either occur as sporadic events or are inherited in an autosomal dominant pattern with incomplete penetrance. Familial forms originate from germline mutations, often have multiple intracranial lesions that grow in size and number over time, and cause an earlier and more severe presentation. Despite active preclinical research on a few pharmacologic agents, clinical translation has been slow. Open surgery and, in some cases, stereotactic radiosurgery remain the only effective treatments, but these options are limited by lesion accessibility and are associated with nonnegligible rates of morbidity and mortality. Observations We discuss the limits of CCM management and introduce findings from in vitro and in vivo studies that provide insight into CCM pathogenesis and indicate molecular mechanisms as potential therapeutic targets. These studies report dysregulated cellular pathways shared between CCM, cardiovascular diseases, and cancer. They also suggest the potential effectiveness of proper drug repurposing in association with, or as an alternative to, targeted interventions. Conclusions and Relevance We propose methods to exploit specific molecular pathways to design patient-tailored therapeutic approaches in CCM, with the aim to alter its natural progression. In this scenario, the lack of effective pharmacologic options remains a critical barrier that poses an unfulfilled and urgent medical need.
Collapse
Affiliation(s)
- Muhammad O Chohan
- The University of New Mexico Comprehensive Cancer Center, Albuquerque.,Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Serena Marchiò
- The University of New Mexico Comprehensive Cancer Center, Albuquerque.,Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque.,Department of Oncology, University of Torino School of Medicine, Candiolo, Torino, Italy.,Candiolo Cancer Institute-Fondazione del Piemonte per l'Oncologia, Istituto di Ricovero e Cura a Carattere Scientifico, Candiolo, Torino, Italy
| | - Leslie A Morrison
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque
| | - Richard L Sidman
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Webster K Cavenee
- Ludwig Institute for Cancer Research, University of California, San Diego
| | - Elisabetta Dejana
- Fondazione Italiana per la Ricerca sul Cancro Institute of Molecular Oncology Fondazione, Milan, Italy.,Mario Negri Institute for Pharmacological Research, Milan, Italy.,Department of Biosciences, School of Sciences and Department of Oncology, School of Medicine, Milano University, Milan, Italy.,Department of Immunology, Genetics and Pathology, University of Uppsala, Uppsala, Sweden
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Renata Pasqualini
- Rutgers Cancer Institute of New Jersey at University Hospital, Newark.,Division of Cancer Biology, Department of Radiation Oncology, Rutgers New Jersey Medical School, Newark
| | - Wadih Arap
- Rutgers Cancer Institute of New Jersey at University Hospital, Newark.,Division of Hematology/Oncology, Department of Medicine, Rutgers New Jersey Medical School, Newark
| |
Collapse
|
41
|
Yang L, Wu J, Zhang J. A Novel CCM2 Gene Mutation Associated With Cerebral Cavernous Malformation. Front Neurol 2020; 11:70. [PMID: 32117029 PMCID: PMC7020567 DOI: 10.3389/fneur.2020.00070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 01/20/2020] [Indexed: 01/01/2023] Open
Abstract
Cerebral cavernous malformations (CCMs) are the second most prevalent type of vascular malformation within the central nervous system. CCMs occur in two forms—sporadic and familial—the latter of which has an autosomal dominant mode of inheritance with incomplete penetrance and variable clinical expressivity. There are three genes considered to be associated with CCMs,—CCM1, which codes for KRIT1 protein; CCM2, which codes for MGC4607 protein; and CCM3, which codes for PDCD10 protein. To date, more than 74 gene mutations of CCM2 have been reported, and ~45% are deletion mutations. In this article, we disclose a novel CCM2 genetic variant (c.755delC, p.S252fs*40X) identified in a Chinese family to enrich the database of CCM2 genotypes.
Collapse
Affiliation(s)
- Lipeng Yang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jing Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| |
Collapse
|
42
|
Castro M, Laviña B, Ando K, Álvarez-Aznar A, Abu Taha A, Brakebusch C, Dejana E, Betsholtz C, Gaengel K. CDC42 Deletion Elicits Cerebral Vascular Malformations via Increased MEKK3-Dependent KLF4 Expression. Circ Res 2020; 124:1240-1252. [PMID: 30732528 DOI: 10.1161/circresaha.118.314300] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
RATIONALE Aberrant formation of blood vessels precedes a broad spectrum of vascular complications; however, the cellular and molecular events governing vascular malformations are not yet fully understood. OBJECTIVE Here, we investigated the role of CDC42 (cell division cycle 42) during vascular morphogenesis and its relative importance for the development of cerebrovascular malformations. METHODS AND RESULTS To avoid secondary systemic effects often associated with embryonic gene deletion, we generated an endothelial-specific and inducible knockout approach to study postnatal vascularization of the mouse brain. Postnatal endothelial-specific deletion of Cdc42 elicits cerebrovascular malformations reminiscent of cerebral cavernous malformations (CCMs). At the cellular level, loss of CDC42 function in brain endothelial cells (ECs) impairs their sprouting, branching morphogenesis, axial polarity, and normal dispersion within the brain tissue. Disruption of CDC42 does not alter EC proliferation, but malformations occur where EC proliferation is the most pronounced during brain development-the postnatal cerebellum-indicating that a high, naturally occurring EC proliferation provides a permissive state for the appearance of these malformations. Mechanistically, CDC42 depletion in ECs elicited increased MEKK3 (mitogen-activated protein kinase kinase kinase 3)-MEK5 (mitogen-activated protein kinase kinase 5)-ERK5 (extracellular signal-regulated kinase 5) signaling and consequent detrimental overexpression of KLF (Kruppel-like factor) 2 and KLF4, recapitulating the hallmark mechanism for CCM pathogenesis. Through genetic approaches, we demonstrate that the coinactivation of Klf4 reduces the severity of vascular malformations in Cdc42 mutant mice. Moreover, we show that CDC42 interacts with CCMs and that CCM3 promotes CDC42 activity in ECs. CONCLUSIONS We show that endothelial-specific deletion of Cdc42 elicits CCM-like cerebrovascular malformations and that CDC42 is engaged in the CCM signaling network to restrain the MEKK3-MEK5-ERK5-KLF2/4 pathway.
Collapse
Affiliation(s)
- Marco Castro
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| | - Bàrbara Laviña
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| | - Koji Ando
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| | - Alberto Álvarez-Aznar
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| | - Abdallah Abu Taha
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| | - Cord Brakebusch
- Biotech Research and Innovation Center, University of Copenhagen, Denmark (C. Brakebusch).,ICMC (Integrated Cardio Metabolic Centre), Karolinska Institutet/AstraZeneca/Integrated Cardio Metabolic Centre, Huddinge, Stockholm, Sweden (C. Betsholtz)
| | - Elisabetta Dejana
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.).,FIRC (Italian Foundation for Cancer Research) Institute of Molecular Oncology Foundation, Milan, Italy (E.D.)
| | - Christer Betsholtz
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| | - Konstantin Gaengel
- From the Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Sweden (M.C., B.L., K.A., A.Á.-A., A.A.T., E.D., C. Betsholtz, K.G.)
| |
Collapse
|
43
|
Zafar A, Quadri SA, Farooqui M, Ikram A, Robinson M, Hart BL, Mabray MC, Vigil C, Tang AT, Kahn ML, Yonas H, Lawton MT, Kim H, Morrison L. Familial Cerebral Cavernous Malformations. Stroke 2020; 50:1294-1301. [PMID: 30909834 DOI: 10.1161/strokeaha.118.022314] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Atif Zafar
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Syed A Quadri
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.A.Q.)
| | - Mudassir Farooqui
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Asad Ikram
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Myranda Robinson
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Blaine L Hart
- Radiology (B.L.H., M.C.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Marc C Mabray
- Radiology (B.L.H., M.C.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | | | - Alan T Tang
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.T., M.L.K.)
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.T., M.L.K.)
| | - Howard Yonas
- Neurosurgery (H.Y.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
| | - Helen Kim
- Department of Anesthesia and Perioperative Care and Department of Epidemiology and Biostatistics, University of California San Francisco (H.K.)
| | - Leslie Morrison
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| |
Collapse
|
44
|
Enhanced recovery after surgery in intramedullary and extramedullary spinal cord lesions: perioperative considerations and recommendations. Spinal Cord 2019; 57:729-738. [PMID: 31358909 DOI: 10.1038/s41393-019-0335-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 01/16/2023]
Abstract
Enhanced recovery after surgery (ERAS) is an evidence-based approach developed to ameliorate the patient recovery process following surgical procedures. Employing a multimodal, multidisciplinary approach, ERAS implements strategies and treatment paradigms that have been shown to improve patient outcomes, reduce hospital length of stay, and ultimately reduce healthcare costs. With a substantial body of the literature supporting the implementation of ERAS in other surgical specialties, ERAS has only recently made its foray into spine surgery. Despite this, current studies are limited to spinal deformity and degenerative disease, with limited data regarding spinal cord surgery. This is due in part to the complex nature and rarity of spinal cord lesions, making the establishment of a formal ERAS protocol difficult. In developing an ERAS protocol, there must be a consensus on what factors are important to consider and implement. To address this, we reviewed the most recent advances in intramedullary and extramedullary spinal cord surgery in order to identify elements that influence patient outcomes. Using this information, the authors provide evidence-based recommendations with the intent of introducing a framework for future ERAS protocols with respect to treating spinal cord lesions.
Collapse
|
45
|
Scimone C, Donato L, Marino S, Alafaci C, D’Angelo R, Sidoti A. Vis-à-vis: a focus on genetic features of cerebral cavernous malformations and brain arteriovenous malformations pathogenesis. Neurol Sci 2018; 40:243-251. [DOI: 10.1007/s10072-018-3674-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/01/2018] [Indexed: 01/07/2023]
|
46
|
Scimone C, Donato L, Katsarou Z, Bostantjopoulou S, D'Angelo R, Sidoti A. Two Novel KRIT1 and CCM2 Mutations in Patients Affected by Cerebral Cavernous Malformations: New Information on CCM2 Penetrance. Front Neurol 2018; 9:953. [PMID: 30487773 PMCID: PMC6246743 DOI: 10.3389/fneur.2018.00953] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/24/2018] [Indexed: 11/18/2022] Open
Abstract
Wide comprehension of genetic features of cerebral cavernous malformations (CCM) represents the starting point to better manage patients and risk rating in relatives. The causative mutations spectrum is constantly growing. KRIT1, CCM2, and PDCD10 are the three loci to date linked to familial CCM development, although germline mutations have also been detected in patients affected by sporadic forms. In this context, the main challenge is to draw up criteria to formulate genotype-phenotype correlations. Clearly, genetic factors determining incomplete penetrance of CCM need to be identified. Here, we report two novel intronic variants probably affecting splicing. Molecular screening of CCM genes was performed on DNA purified by peripheral blood. Coding exons and intron-exon boundaries were sequenced by the Sanger method. The first was detected in a sporadic patient and involves KRIT1. The second affects CCM2 and it is harbored by a woman with familial CCM. Interestingly, molecular analysis extended to both healthy and ill relatives allowed to estimate, for the first time, a penetrance for CCM2 lower than 100%, as to date reported. Moreover, heterogeneity of clinical manifestations among those affected carrying the same genotype further confirms involvement of modifier factors in CCM development.
Collapse
Affiliation(s)
- Concetta Scimone
- Department of Biomedical and Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy.,Department of Vanguard Medicine and Therapies, Biomolecular Strategies and Neuroscience, I.E.ME.S.T., Palermo, Italy
| | - Luigi Donato
- Department of Biomedical and Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy.,Department of Vanguard Medicine and Therapies, Biomolecular Strategies and Neuroscience, I.E.ME.S.T., Palermo, Italy.,Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Zoe Katsarou
- Department of Neurology, Hippokration General Hospital, Thessaloniki, Greece
| | | | - Rosalia D'Angelo
- Department of Biomedical and Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonina Sidoti
- Department of Biomedical and Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy.,Department of Vanguard Medicine and Therapies, Biomolecular Strategies and Neuroscience, I.E.ME.S.T., Palermo, Italy
| |
Collapse
|
47
|
Soares-Souza G, Borda V, Kehdy F, Tarazona-Santos E. Admixture, Genetics and Complex Diseases in Latin Americans and US Hispanics. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0151-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
48
|
Nardella G, Visci G, Guarnieri V, Castellana S, Biagini T, Bisceglia L, Palumbo O, Trivisano M, Vaira C, Scerrati M, Debrasi D, D'Angelo V, Carella M, Merla G, Mazza T, Castori M, D'Agruma L, Fusco C. A single-center study on 140 patients with cerebral cavernous malformations: 28 new pathogenic variants and functional characterization of a PDCD10 large deletion. Hum Mutat 2018; 39:1885-1900. [PMID: 30161288 DOI: 10.1002/humu.23629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/12/2018] [Accepted: 07/22/2018] [Indexed: 12/12/2022]
Abstract
Cerebral cavernous malformation (CCM) is a capillary malformation arising in the central nervous system. CCM may occur sporadically or cluster in families with autosomal dominant transmission, incomplete penetrance, and variable expressivity. Three genes are associated with CCM KRIT1, CCM2, and PDCD10. This work is a retrospective single-center molecular study on samples from multiple Italian clinical providers. From a pool of 317 CCM index patients, we found germline variants in either of the three genes in 80 (25.2%) probands, for a total of 55 different variants. In available families, extended molecular analysis found segregation in 60 additional subjects, for a total of 140 mutated individuals. From the 55 variants, 39 occurred in KRIT1 (20 novel), 8 in CCM2 (4 novel), and 8 in PDCD10 (4 novel). Effects of the three novel KRIT1 missense variants were characterized in silico. We also investigated a novel PDCD10 deletion spanning exon 4-10, on patient's fibroblasts, which showed significant reduction of interactions between KRIT1 and CCM2 encoded proteins and impaired autophagy process. This is the largest study in Italian CCM patients and expands the known mutational spectrum of KRIT1, CCM2, and PDCD10. Our approach highlights the relevance of seeking supporting information to pathogenicity of new variants for the improvement of management of CCM.
Collapse
Affiliation(s)
- Grazia Nardella
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.,Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Grazia Visci
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Vito Guarnieri
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Stefano Castellana
- Bioinformatics Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Tommaso Biagini
- Bioinformatics Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Luigi Bisceglia
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Orazio Palumbo
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Marina Trivisano
- Department of Neuroscience, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Carmela Vaira
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Debrasi
- Department of Pediatrics, Università Federico II, Naples, Italy
| | | | - Massimo Carella
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Giuseppe Merla
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Tommaso Mazza
- Bioinformatics Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Marco Castori
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Leonardo D'Agruma
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Carmela Fusco
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| |
Collapse
|
49
|
Abstract
Cerebral cavernous malformations (CCM) are manifested by microvascular lesions characterized by leaky endothelial cells with minimal intervening parenchyma predominantly in the central nervous system predisposed to hemorrhagic stroke, resulting in focal neurological defects. Till date, three proteins are implicated in this condition: CCM1 (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10). These multi-domain proteins form a protein complex via CCM2 that function as a docking site for the CCM signaling complex, which modulates many signaling pathways. Defects in the formation of this signaling complex have been shown to affect a wide range of cellular processes including cell-cell contact stability, vascular angiogenesis, oxidative damage protection and multiple biogenic events. In this review we provide an update on recent advances in structure and function of these CCM proteins, especially focusing on the signaling cascades involved in CCM pathogenesis and the resultant CCM cellular phenotypes in the past decade.
Collapse
Affiliation(s)
- Akhil Padarti
- Department of Biomedical Sciences, Texas Tech University Health Science Center El Paso, El Paso, TX 79905, USA
| | - Jun Zhang
- Department of Biomedical Sciences, Texas Tech University Health Science Center El Paso, El Paso, TX 79905, USA
| |
Collapse
|
50
|
Detection of cavernous malformations after whole-brain radiotherapy in primitive neuroectodermal tumor patients—comparing susceptibility-weighted imaging and T2 gradient-echo sequences. Neuroradiology 2018; 60:913-919. [DOI: 10.1007/s00234-018-2055-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
|