Congenital cutaneous hemangioma causing cardiac failure: a case report and review of the literature

Pediatric Vascular Anomalies: A Clinical and Radiological Perspective

According to the International Society for the Study of Vascular Anomalies (ISSVA) classification, vascular anomalies include a diverse range of pathologies, classified as either vascular tumors or vascular malformations. This classification, last revised in 2018, aims to explain the biological basis of vascular lesions and help clinicians to manage the anomalies. In vascular tumors, there are proliferative changes of endothelial cells, while vascular malformations primarily consist of structural vascular abnormalities. Infantile hemangioma is the most common soft-tissue vascular tumor. Vascular malformations are an extensive group of malformations of the arterial, venous, and lymphatic systems, either in isolation or in combination. Radiological evaluation plays a key part in the management of pediatric patients with these entities. The understanding of sonography and magnetic resonance imaging findings entails its correlation with clinical findings at the time of scanning.

Multidisciplinary Treatment of a Giant Maxillofacial Congenital Hemangioma With Multiple Severe Complications

Giant congenital hemangiomas are rare, especially when combined with multiple complications. This article presents a case of a giant congenital hemangioma of the maxillofacial region in a neonate with combined thrombocytopenia, coagulation dysfunction, and heart failure, which was eventually treated surgically after a multidisciplinary consultation and achieved a good outcome.

A Case Series of 18 Congenital Haemangiomas: Clinical, Histological and Ultrasound Features, and their Relationship with Complications and Atypical Behaviour

Recent studies have advanced our understanding of the clinical, histological and imaging characteristics of congenital haemangiomas (CHs), and have reported possible complications and atypical behaviour. The aim of this study is to describe the clinical, histological and ultrasound features of a series of CHs and to analyse their association with complications and atypical behaviour, with a view to providing diagnostic and management recommendations. The medical records, histology results and ultrasound images of all patients with CH diagnosed in the Dermatology Department of Alicante University General Hospital between 2006 and 2021 were retrospectively reviewed. A total of 18 patients were included, of whom 4 (22.2%) had complications. The most severe was 1 case with heart failure. There was a significant association between large CH size (> 5 cm) and the occurrence of complications (p = 0.019). The study identified 3 different lobule patterns, but found no relationship with CH subtype or other findings. The associations of venous ectasia, venous lakes and arteriovenous microshunts with occurrence of complications was borderline significant (p = 0.055). Study limitations were the small sample and the retrospective analysis. To conclude, haematological and cardiological assessment is indicated in large CHs and should be considered in CHs with ultrasound findings of venous ectasia, venous lakes or arteriovenous microshunts, as these cases present a greater risk of complications.

Rapidly involuting congenital haemangioma: diagnostic and therapeutic approach regarding two case reports

Two unrelated neonates were born with a large purplish congenital mass of the thigh and forearm. Both showed signs of heart dysfunction, and one of them had anaemia and thrombocytopenia. The imaging assessment of the lesions showed well-defined subcutaneous solid masses with an exuberant vascular component. Both were kept under surveillance and maintenance therapy. A progressive dimensional reduction of the lesions supported the diagnosis of rapidly involuting congenital haemangioma (RICH). RICH is a rare vascular tumour that presents as a congenital purplish bulky mass. The diagnosis depends on the clinical evaluation of the lesion and the imaging characterisation of its solid components and vascular network. RICH may be complicated by high-output heart failure, anaemia and thrombocytopenia. Despite its exuberant presentation, it undergoes involution in the first year of life; therefore, early invasive therapies should be avoided. It is essential to detect any dimensional increase, suggesting more aggressive diagnoses, such as kaposiform haemangioendothelioma.

Catastrophic congenital hemangioma with severe coagulopathy leading to fatal cardiac failure: Case report and review

We present a complex case of a neonate, delivered urgently for hydrops fetalis, with a large vascular mass of the extremity, diagnosed postnatally as a congenital hemangioma. The patient suffered immediate cardiac compromise and severe coagulopathy atypical for the diagnosis and subsequently died from these complications. Treatment was imperative but challenging due to a lack of a standardized treatment approach and few historical reports of equally critically ill patients. In this report, we review potential medical and surgical interventions and discuss treatment considerations in similar, life-threatening cases of congenital hemangiomas.

Preoperative trans-arterial embolization of a giant scalp congenital hemangioma associated with cardiac failure in a premature newborn

Scalp congenital hemangiomas are a rare, but well-known, vascular malformation in infants. These hemangiomas are usually benign, but occasionally these are associated with cardiac complications and disfigurement. Giant hemangiomas that are associated with high-output heart failure require intervention because they have a high mortality rate and do not respond to medical therapy. We report here a case of a premature newborn who was diagnosed with a giant scalp hemangioma associated with cardiac failure. The newborn underwent successful arterial feeder embolization of the superficial temporal artery. He then underwent surgical excision 14 days after embolization. We believe that preoperative embolization of a giant scalp hemangioma in newborns is a safe measure for alleviating underlying cardiac failure and minimizing the risk of intraoperative bleeding.

Congenital haemangiomas: a single-centre retrospective review

OBJECTIVE

Congenital haemangiomas (CHs) are rare, benign vascular tumours that are fully developed at birth. Three subtypes of CHs have been described based on clinical behaviour: rapidly involuting CHs (RICHs), non-involuting CHs (NICHs) and partially involuting CHs (PICHs). We explore in our study clinical, evolutionary and paraclinical characteristics of the three CH subtypes.

DESIGN

Children with CH attending our department of paediatric dermatology at Bordeaux University Hospital over a 13-year period were retrospectively included. Epidemiological, clinical and evolutionary data, photographs and imaging results were reviewed. All available tissue samples were histologically examined.

RESULTS

We included 57 patients: 22 with RICH, 22 with NICH and 13 with PICH. Males predominated (ratio 1.7); the most common CH location was on the limbs. RICH, NICH and PICH exhibited overlapping characteristics; all were single telangiectatic lesions with pale peripheral halos. At birth, NICHs were flat but RICHs and PICHs bulky. The median age at complete RICH involution was 12 months. One-third of CHs that appeared RICH-like at birth underwent incomplete involution to become PICHs. Heart failure and thrombocytopenia were rare complications. PICHs were frequently ulcerated. Pain was common for NICH and PICH. The imaging and histological data of the three CH subtypes were rather similar.

CONCLUSIONS

We describe the characteristics and evolution of the three CH subtypes using a case series. Certain overlapping features were apparent, reinforcing the hypothesis that RICH, NICH and PICH lie on the same pathological spectrum.

Atypical presentations of congenital hemangiomas: Extending the clinical phenotype

BACKGROUND/OBJECTIVES

Congenital hemangiomas (CH) are a group of benign vascular tumors that are present at birth and exhibit variable involution during infancy. Congenital hemangiomas that do not involute are typically solitary patch or plaque-type tumors that grow proportionally with somatic growth. We report a case series of 9 patients with persistent CH, which exhibited uncommon features including segmental involvement, recurrent or severe pain, or growth via volumetric increase in size or apparent increased extent of anatomic involvement over time.

METHODS

Via retrospective chart review, we included patients with persistent CH and atypical presentations. Available data regarding clinical characteristics, natural history, histopathology, imaging, and genetic tests were collected.

RESULTS

Data on 9 patients were collected, including 7 noninvoluting CH and 2 partially involuting CH. Three of the 9 cases had segmental distribution, 6 had apparent growth or clinical evolution, and 4 were symptomatic with pain. One also had marked localized intravascular coagulopathy.

CONCLUSIONS

Ongoing or recurrent pain and large extent of anatomic involvement can be features of CH, albeit uncommon ones, and can pose both diagnostic and management challenges. Tissue genomic studies can offer a novel tool for CH diagnosis.

Management of a Large Congenital Hemangioma Obstructing Visual Axis: A Case Report and Review of Literature

Congenital hemangiomas comprise a subset of vascular tumors with clinicopathologic features that are distinct from the more common infantile hemangioma. The authors present a patient with a large congenital hemangioma involving the forehead and brow which obstructed the visual axis and created significant risk for deprivational amblyopia. Management of the congenital hemangioma involved customized headgear to clear the visual axis and early vascular embolization of feeder vessels with the subsequent successful surgical resection at 23 days of life.A large amblyogenic congenital hemangioma required a multidisciplinary approach involving early vascular embolization of feeder vessels and subsequent surgical resection at 23 days of life.

Abnormal hemostasis in children with vascular anomalies, part I: Thrombocytopenias among different vascular anomalies

Long before the classification of vascular anomalies from the International Society for the Study of Vascular Anomalies (ISSVA) provided a framework to differentiate vascular anomalies, otherwise known as vascular birthmarks, it was recognized that patients with such lesions can present with acute life-threatening hemostatic and/or thrombotic complications, as well as chronic long-standing bleeding or thrombotic issues. Scenarios such as a rapidly growing vascular lesion with severe acute thrombocytopenia, a visceral hemorrhagic lesion, a lesion associated with repetitive and painful superficial thrombosis, and cases of unprovoked or post-procedural fatal pulmonary embolism highlight the wide spectrum of manifestations of abnormal coagulation in patients with vascular anomalies. The separation of vascular anomalies into two distinct groups, vascular tumors and vascular malformations, was followed by the characterization that their respective coagulopathies were due to either a derangement of platelets or to a disequilibrium of the patient's coagulation/fibrinolytic process. This configuration of coagulopathies will be the foundation for this two-chapter review series. In the initial review, coagulopathies where thrombocytopenia is the main feature will be characterized, whereas the second review will focus on vascular malformations that have a coagulation disorder secondary to some degree of coagulation consumption and/or fibrinolytic pathway derangement.

Prenatal diagnosis of rapidly involuting congenital hemangioma: a case report and review of the literature

Congenital hemangiomata are rare benign vascular tumors, presenting as fully mature lesions at birth. Three types have been described; the “rapidly involuting congenital hemangioma” (RICH), the “non-involuting congenital hemangioma” (NICH)and the “partially involuting congenital hemangioma” (PICH). We herein report on a RICH type congenital hemangioma, identified during a fetal morphology ultrasound performed at 19 weeks’ gestation. Early diagnosis allowed close surveillance of the fetus and neonate and observation of the natural course of this lesion. Although being a potentially life-threatening condition, no intervention was required. It presented as a 4 cm vascular tumor on the forehead at time of the cesarean section and diminished rapidly over the first 4 neonatal months, resulting in some skin excess and discoloration which is expected to entirely resolve by 14 months of age.

Advances in the Medical Management of Vascular Anomalies

Vascular anomalies comprise a spectrum of diseases that are broadly classified as tumors and malformations. Diagnosis is often challenging, given a wide range of clinical presentations with overlapping signs and symptoms. Accurate diagnosis is critical to determine prognosis and to generate a management plan, which frequently involves multiple subspecialists during different phases of treatment. An updated classification system provides structure and clear, consistent terminology, allowing for improved diagnosis, provider communication, and collaboration. Historically, treatment of vascular anomalies was primarily surgical and medical therapies were limited or ineffective. Recent discoveries of pharmacologic agents effective in treating vascular anomalies have broadened our medical therapeutic options, limiting the need for unnecessary or high-risk procedures and improving patients' quality of life.

Scalp congenital hemangioma with associated high-output cardiac failure in a premature infant: Case report and review of literature

Introduction Scalp congenital hemangiomas (CHs) are rare vascular malformations among infants; they can be associated with an array of complications, including cardiac and cosmetic issues. Here, we report the endovascular treatment of a premature infant with a suspected large right parietal scalp hemangioma and associated high-output cardiac failure. Case description A two-day-old female premature infant (29 weeks gestational age; 1330 g birth weight) was referred by the neonatologists to our department for consultation and potential treatment of a large right parietal CH causing abrupt hypotension and high-output cardiac failure. Doppler ultrasound imaging at bedside revealed areas of arterial-venous shunting from the scalp and the presence of a superior sagittal sinus waveform, consistent with intracranial venous drainage. To alleviate cardiac dysfunction secondary to this lesion, trans-arterial embolization via n-butyl cyanoacrylate (nBCA) glue and deployment of detachable coils was performed via umbilical artery to occlude the right superficial temporal and occipital artery branches supplying the CH. Following treatment, the infant continued to require ventilator management, vasopressor support, and correction of coagulopathy, but by post-operative day two, her condition improved remarkably and the mass size began decreasing. The patient was discharged after a relatively uncomplicated subsequent 2½-month course in the neonatal intensive care unit. Conclusion Endovascular therapy proved effective and safe in treating cardiac failure associated with scalp CH, despite potential complications associated with neuro-interventional surgery in premature infants. Appropriate consideration in this patient population should be given to factors including blood loss, contrast use, radiation exposure, operative time, and possible intra-/post-operative complications.

Multiple Successful Angioembolizations for Refractory Cardiac Failure in a Preterm with Rapidly Involuting Congenital Hemangioma

Rapidly involuting congenital hemangiomas (RICH) are the commonest variety of congenital hemangioma, often diagnosed antenatally as high-flow arteriovenous shunts causing hemodynamic compromise to the fetus. The postnatal management of such patients is often challenging. We present the case of an infant boy who was delivered prematurely at 29 weeks of gestation due to fetal compromise by a RICH, with features of high-output cardiac failure and major systemic hemodynamic steal from peripheral organs. Two early angioembolizations were required to manage his high-output cardiac failure. To our knowledge, this infant is the smallest and earliest newborn case of successful angioembolization for a complex, life-threatening vascular anomaly. We discuss the interventional dilemmas regarding the optimal timing of delivery and early embolization.

[Congenital hemangiomas: Report on ten patients]

INTRODUCTION

Congenital hemangiomas (CHs) are rare congenital vascular tumors seldom mentioned in the literature.

MATERIALS AND METHODS

We carried out a retrospective study of all the cases of CH diagnosed and treated at Besançon Hospital from 2008 to 2014. The clinical, radiological, and histological data of each case were collected. All the children were seen again in 2014.

RESULTS

Ten CHs (seven rapidly involuting CHs, RICH and three non-involuting CH, NICH), predominantly full-term eutrophic male infants, were enrolled. RICHs were located on the head (n=2), trunk (n=2), and lower limbs (n=3), and NICHs were found on the hands. Diagnosis was clinical for all ten infants. All CHs resembled "tumor" congenital lesions: single, oval-shaped, nonpulsatile, and well delimited, and their size did not increase after birth. Two RICHs were warm, one had phlebolites, and two had draining veins at the first visit. The mean age of the RICH involution onset was 1.7 months and the mean time to complete involution was 10.4 months. One CH was classified as a PICH (partially involuting CH) due to partial regression, two RICHs were still in the involution process at the age of 10 and 15 months, and one regressed very quickly within 7 days. No complications were observed in the NICH. Two RICHs presented benign complications (ulcerations and bleeding). Two RICHs regressed entirely, and five regressed with sequelae: lipoatrophy (n=3), cutaneous excess (n=2), dysplastic veins (n=3), a pigmented area (n=1), and an anemic halo (n=2).

DISCUSSION

The small number of patients in our cohort, in spite of the length of the study, confirms the rarity of CH. The sex-ratio in favor of male infants and the location of NICH on the hands have not been reported. The most discriminating element remained the follow-up over 1 year. The initial clinical aspect of the NICH and the progression of one RICH into a NICH suggested possible overlapping forms between RICH and NICH. Some CHs, including one PICH, presented clinical and radiological criteria similar to those of vascular malformations (warm lesion, dysplastic veins, and echo-Doppler results in favor of vascular malformation). RICH regressed with sequelae in most cases.

CONCLUSION

This study reveals a polymorphous clinical presentation of CH and provides a thorough description of their progression. It underlines the existence of overlapping phenomena between RICH and NICH, and between CH and vascular malformations, thus suggesting a possible link between proliferation and malformation phenomena at the origin of these lesions.

Propranolol responsiveness in vascular tumors is not determined by qualitative differences in adrenergic receptors

Propranolol, a beta 1 (ADBR1) and beta 2 (ADBR2) adrenergic receptor blocker, accelerates regression of proliferating infantile hemangiomas (IH-P) while not affecting non-involuting congenital hemangiomas (NICH) and nonproliferating IH (IH-NP). To determine the expression of ADBRs in vascular tumors, immunofluorescent staining and confocal microscopy were employed to determine the in situ cellular distribution of ADBRs in formalin-fixed paraffin-embedded tissue sections of IH-P, IH-NP, and NICH. In situ cellular proliferation, indexed by Ki-67 expression, distinguished IH-P (n = 3) from both IH-NP (n = 3) and NICH (n = 2). In IH-P, IH-NP, and NICH tumor sections, both ADBR1 and ADBR2 were co-localized in both endothelial cells (ECs; GLUT1(+) in IH; CD31+ in NICH) and pericytes (smooth muscle actin). We tentatively conclude that either EC and/or pericytes in IH-P could be target(s) of propranolol. Cell proliferation, but not absence of either class of ADBR, distinguished the propranolol responsive IH-P from the nonresponsive IH-NP and NICH.