Association between trauma and acute hemorrhage of cavernous malformations in children: report of 3 cases

Clinical presentation, natural history, and outcomes for infantile intracranial cavernous malformations: case series and systematic review of the literature

INTRODUCTION

Intracranial cavernous malformations (CMs) are rare vascular malformations of the central nervous system in children. Infantile patients, being a developmentally vulnerable age group, pose a special challenge for management of these lesions. We pooled data from infantile patients diagnosed at our institution and individual cases published in the literature to provide input towards therapeutic decision-making.

METHODS

A systematic search of PubMed, MEDLINE, Embase, and Scopus was performed in accordance with PRISMA guidelines to identify all reported cases of intracranial CMs in the literature for infantile patients aged ≤ 2 years. In addition, cases from our institution diagnosed between 2010 and 2020 were also included. Individual cases were pooled and analyzed for clinical presentation, natural history, and outcomes from conservative and surgical management.

RESULTS

A total of 36 cases were included, of which 32 were identified from the literature. Median age at presentation was 14 months (range: 2 days to 24 months) months; 53% (n = 19) were females. Most cavernomas (64%, 23/36) were supratentorial, while 30% (n = 11) were located in brainstem and 5.5% (n = 2) in the cerebellum. With the exception of one patient, all cases were reported to be symptomatic; seizures (n = 15/31, 48.3%) and motor deficits (n = 13/31, 42%) were the most common symptom modalities. A total of 13 patients were managed conservatively upon initial presentation. No symptomatic hemorrhages were observed during 26 total person-years of follow-up. A total of 77% (28/36) underwent surgery; either upfront (23/28, 82%) at initial presentation or following conservative management. Among 12 patients who had preoperative seizures, 11/12 (91.6%) achieved seizure freedom post-resection. Among 7 patients who presented with hemiparesis preoperatively, 5 (71%) demonstrated some improvement, while 1 remained unchanged, and another patient with a brainstem cavernous malformation had worsening of motor function postoperatively. Postoperative recurrence was noted in 3 cases (3/27, 11%).

CONCLUSION

Annual risk of repeat hemorrhage may be low for infantile patients with intracranial cavernous malformations; however, better follow-up rates and higher number of cases are needed to make a definitive assertion. Surgical resection may be associated with high rates of epilepsy cure and provide improvement in neurological function in a select number of cases.

Cerebral cavernous malformation in a child leading to a fatal subarachnoid hemorrhage - "silent but sinister:" A case report and literature review

Background:

Cerebral cavernous malformations (CCMs), otherwise known as cavernous hemangiomas/ cavernomas, are a type of vascular malformation. It is the third most common cerebral vascular malformation, histologically characterized by ectatic, fibrous, blood filled “caverns” with thin-walled vasculature without intervening normal brain parenchyma.

Case Description:

Herein, we present a case of an original, spontaneous hemorrhage from a sporadic form of CCM without associated gross developmental venous anomaly in an 11-year-old child, which is an extremely rare occurrence, with the special emphasis on the demographic data of the affected population, risk factors associated with hemorrhage, and correlation of histopathological and radiological findings with an in-depth literature review.

Conclusion:

The significant majority of the CCM are clinically occult. Hence, the development of risk assessment tools and guidelines for timely neurosurgical intervention poses a greater clinical challenge for medical experts rendering the management of the affected individuals with CCM in an anecdotal situation. Presentation of life-threatening rebleeds and neurological deficits in the diagnosed population albeit uncommon is possibly preventable outcomes.

Spontaneous Intracranial Hemorrhage: A Sign of Cavernous Angioma Diagnosis in Pediatric Age Group

Cerebral cavernous malformation (CCM) is a developmental abnormality of blood vessels that supply the brain. It is composed of large, adjacent capillaries which contain little or no neural tissue. They mostly occur in the supratentorial region. However, the occurrence of these vascular lesions can be seen at different sites of the central nervous system (CNS). The prevalence of CCM is estimated to be 0.4% in the general population and among the affected patients, 18.7% have multiple lesions. However, about 30-50% of CCM cases are asymptomatic and are found incidentally. Here we report a case of an eight-year-old girl with a massive hemorrhagic presentation of a left parietooccipital CCM.

Developmental venous anomaly associated ischemic stroke caused by minor head trauma: A case report

RATIONALE

A developmental venous anomaly (DVA) is the most common intracranial congenital anomaly and is mostly asymptomatic. Thrombosis rarely develops in a DVA due to hypercoagulation. We report a case of ischemic stroke in the area of a DVA after minor head trauma in a patient with DVA and without a predisposition thrombosis.

PATIENT CONCERNS

A healthy 17-year-old male was admitted to the emergency room due to left hemiparesis, which was caused by a ball hitting the right side of his head during a soccer game.

DIAGNOSIS

Brain magnetic resonance (MR) susceptibility-weighted image showed several small veins draining to the central vein in the area from the right posterior putamen to the periventricular white matter.

INTERVENTIONS

We diagnosed the patient with an ischemic stroke associated with a DVA and administered antiplatelet agents. The patient's autoantibodies (including antiphospholipid antibody) and factors of blood coagulation were normal.

OUTCOMES

The left hemiparesis of the patient worsened by the second day of admission. Moreover, high signal intensity was observed in the DVA region of the diffusion weighted image of brain MR. The patient's symptoms gradually improved afterward, and left hemiparesis recovered fully 3 weeks after the onset.

LESSONS

DVAs may predispose to ischemic stroke due to thrombosis and hypercoagulation, although it is rare. It is necessary to consider the possibility of ischemic stroke due to minor head trauma, even without factors causing hypercoagulation.

Head trauma and cavernoma haemorrhage - the importance of causality

Cavernomas are common, benign vascular lesions that affect the brain. Five-year bleeding risk is approximately 3.8% for asymptomatic lesions. Non-spontaneous, traumatic cavernoma haemorrhage has been seldom reported. We present the case of a 49-year-old male with multiple traumatic brain injuries who was managed conservatively. Initial imaging was suggested, and reported as, a traumatic brainstem haemorrhage. However, after resuscitation and a follow-up MRI scan, the diagnosis of a cavernoma bleed was confirmed in keeping with his mild neurological syndrome. This case illustrates the old dictum to treat the patient and not the scan. It serves as one of the few reported cases of post-traumatic cavernoma bleed, and showcases the difficulty in ascribing haemorrhage to spontaneous or traumatic aetiology. We recommend having a low threshold to investigate further in these unusual situations.

The Influence of Physical Activity on Cavernous Malformation Hemorrhage

BACKGROUND AND AIM

Cavernous malformations are low-flow vascular malformations of the central nervous system. Brainstem location and prior hemorrhage increase future hemorrhage risk. We sought to determine the influence of physical activity on hemorrhage risk.

METHODS

Consecutive patients with radiologically confirmed cavernous malformations participated in a prospective registry with structured, baseline interviews, surveys, and examinations. Patients were asked about unusual events prior to initial clinical presentation. Medical records and MRIs were reviewed. Patients were surveyed about their physical activity after receiving their diagnosis. Annual follow-up surveys to patients ascertained new hemorrhages. Follow-up terminated at last follow-up, hemorrhage, surgery, or death. Univariate analysis assessed the risk of physical activities on prospective hemorrhage.

RESULTS

Of 195 patients, 117 (60%) were female. Median diagnosis age was 41 years. After diagnosis, 103 (52.8%) patients returned the physical activity survey (cerebral n = 100; spine n = 3). Over 539.4 patient years, 23 had a prospective hemorrhage. Five patients were removed from analysis because they had less than 6 weeks of physical-activity exposure before censor. The remaining 98 had no difference in prospective hemorrhage risk than those patients participating greater than or equal to 3 times monthly in walking, running, greater than 20-pound or less than 20-pound weight lifting, or noncontact sports. Few (n = 5) reported contact-sport participation, scuba diving (n = 2), or high-altitude climbing (n = 1) greater than 3 times monthly.

CONCLUSIONS

Aerobic activity and noncontact sports do not increase hemorrhage risk in cerebral cavernous malformation; patients should not be restricted. Less is known about contact sports, high-altitude climbing, scuba diving, and those with spinal-cord cavernous malformation.

Hormonal receptors in cutaneous vascular malformations: 51 cases

Vascular malformations (VMs) are rare congenital anomalies that develop during embryogenesis in different types of vessels. Several triggering factors of cutaneous VMs include trauma, infections, or hormonal changes. We investigated the expression of hormonal receptors (androgen, estrogen, progesterone) in tissue samples of well-characterized VMs. A secondary objective was to identify self-reported triggering factors for these VMs, including hormonal changes, in the cohort of patients. We included patients with VM samples obtained in the tertiary center for vascular anomalies of the University Hospital Center of Tours, France, from January 1, 2007, to August 1, 2018. Immunohistochemistry was used to detect the expression of hormonal receptors (estrogen, progesterone, androgens). We obtained 51 samples from 51 patients: 13 cystic lymphatic malformations (CLMs), 16 venous malformations (VeMs), 11 arteriovenous malformations (AVMs), 4 combined VMs, 4 PIK3CA-related overgrowth spectrum, 1 Parkes-Weber syndrome, 1 Gorham syndrome, and 1 multiple lymphangioendotheliomatosis with thrombopenia. In total, 38 (74.5%) samples were positive for androgen receptor: 11 (84.6%) CLMs, 12 (75.0%) VeMs, 8 (72.2%) AVMs, and 7/11 (63.5%) other samples. All samples were negative for estrogen and progesterone receptors. Triggering factors were self-reported in 7 cases and were most frequently hormonal changes (n = 6, 18.2%). Hormonal triggers were frequent in AVMs (n = 4). Among patients with identified hormonal triggers, VM samples were positive for androgen receptor in 3 and negative in 3. Three-quarters of our VM samples expressed androgen receptor, and most CLM, VeM, and AVM samples were positive. Hormonal triggers were identified in 6/33 patients, mostly with AVMs.

Developmental venous anomalies and brainstem cavernous malformations: a proposed physiological mechanism for haemorrhage

The incidental diagnosis of both developmental venous anomalies (DVAs) and cavernous malformations (CMs) in the central nervous system is increasing with improved imaging techniques. While classically silent diseases, these cerebrovascular pathologies can follow an aggressive course, particularly when present in the brainstem. In the last decade, substantial research has focussed on KRIT1-mediated tight junction gene expression and their role in CM development. However, our understanding of the physiologic conditions precipitating symptomatic CM development or CM haemorrhage with and without concomitant DVAs, remains lacking. The only established risk factor for CM haemorrhage is a previous history of haemorrhage, and literature currently reports trauma as the only precipitant for symptomatic events. While plausible, this occurs in a minority, with many patients experiencing occult events. This manuscript presents a hypothesis for symptomatic CM events by first discussing the anatomical pathways for intracranial venous outflow via the internal jugular veins (IJV) and vertebral venous plexus (VVP), then exploring the role of venous flow diversion away from the IJVs under physiologic stress during dynamic postural shift. The resultant increase in intracranial venous pressure can exacerbate normal and pre-existing structural DVA pathologies, with repeated exposure causing symptomatic or CM-inducing events. This pathophysiological model is considered in the context of the role of the autonomic nervous system (ANS) in postural intracranial venous outflow diversion, and how this may increase the risk of DVA or CM events. It is hoped that this hypothesis invokes further investigation into precipitants for DVA or CM events and their sequela and, also, furthers the current knowledge on pathophysiological development of DVAs and CMs.