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Weinsheimer S, Bendjilali N, Nelson J, Guo DE, Zaroff JG, Sidney S, McCulloch CE, Al-Shahi Salman R, Berg JN, Koeleman BPC, Simon M, Bostroem A, Fontanella M, Sturiale CL, Pola R, Puca A, Lawton MT, Young WL, Pawlikowska L, Klijn CJM, Kim H. Genome-wide association study of sporadic brain arteriovenous malformations. J Neurol Neurosurg Psychiatry 2016; 87:916-23. [PMID: 26818729 PMCID: PMC4963303 DOI: 10.1136/jnnp-2015-312272] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/28/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND The pathogenesis of sporadic brain arteriovenous malformations (BAVMs) remains unknown, but studies suggest a genetic component. We estimated the heritability of sporadic BAVM and performed a genome-wide association study (GWAS) to investigate association of common single nucleotide polymorphisms (SNPs) with risk of sporadic BAVM in the international, multicentre Genetics of Arteriovenous Malformation (GEN-AVM) consortium. METHODS The Caucasian discovery cohort included 515 BAVM cases and 1191 controls genotyped using Affymetrix genome-wide SNP arrays. Genotype data were imputed to 1000 Genomes Project data, and well-imputed SNPs (>0.01 minor allele frequency) were analysed for association with BAVM. 57 top BAVM-associated SNPs (51 SNPs with p<10(-05) or p<10(-04) in candidate pathway genes, and 6 candidate BAVM SNPs) were tested in a replication cohort including 608 BAVM cases and 744 controls. RESULTS The estimated heritability of BAVM was 17.6% (SE 8.9%, age and sex-adjusted p=0.015). None of the SNPs were significantly associated with BAVM in the replication cohort after correction for multiple testing. 6 SNPs had a nominal p<0.1 in the replication cohort and map to introns in EGFEM1P, SP4 and CDKAL1 or near JAG1 and BNC2. Of the 6 candidate SNPs, 2 in ACVRL1 and MMP3 had a nominal p<0.05 in the replication cohort. CONCLUSIONS We performed the first GWAS of sporadic BAVM in the largest BAVM cohort assembled to date. No GWAS SNPs were replicated, suggesting that common SNPs do not contribute strongly to BAVM susceptibility. However, heritability estimates suggest a modest but significant genetic contribution.
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Affiliation(s)
- Shantel Weinsheimer
- Mental Health Center, Sct. Hans MHS-Capital Region of Denmark, Institute of Biological Psychiatry, Roskilde, Denmark
| | | | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA
| | - Diana E Guo
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA
| | - Jonathan G Zaroff
- Division of Research, Kaiser Permanente of Northern California, Oakland, California, USA
| | - Stephen Sidney
- Division of Research, Kaiser Permanente of Northern California, Oakland, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | | | - Jonathan N Berg
- Department of Clinical Genetics, University of Dundee, Dundee, UK
| | - Bobby P C Koeleman
- Department of Medical Genetics, University Medical Center, Utrecht, The Netherlands
| | - Matthias Simon
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany
| | - Azize Bostroem
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany
| | - Marco Fontanella
- Division of Neurosurgery, University of Torino, University of Brescia, Brescia, Italy
| | | | - Roberto Pola
- Institute of Medicine, Catholic University of Rome, Rome, Italy
| | - Alfredo Puca
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - William L Young
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA
| | - Ludmila Pawlikowska
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA Institute for Human Genetics, University of California, San Francisco, California, USA
| | - Catharina J M Klijn
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA Institute for Human Genetics, University of California, San Francisco, California, USA
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Han Z, Shen F, He Y, Degos V, Camus M, Maze M, Young WL, Su H. Correction: Activation of α-7 Nicotinic Acetylcholine Receptor Reduces Ischemic Stroke Injury through Reduction of Pro-Inflammatory Macrophages and Oxidative Stress. PLoS One 2016; 11:e0152218. [PMID: 26986202 PMCID: PMC4795596 DOI: 10.1371/journal.pone.0152218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Adams HP, El Ahmadieh TY, Albers GW, Alexandrov AV, Anrather J, Arai K, Aronowski J(J, Auer RN, Awad IA, Ay H, Baltan S, Batjer HH, Benavente OR, Bendok BR, Bershad EM, Bonati LH, Bookland MJ, Bousser MG, Braca JA, Broderick JP, Brown MM, Brown WE, Brust JC, Bushnell C, Bösel J, Canhão P, Caplan LR, Castellanos M, Chamorro A, Chandler JP, Chen J, Chopp M, Chrissobolis S, Chabriat H, Cramer SC, Cucchiara BL, Dannenbaum MJ, Davis PH, Dawson TM, Dawson VL, Day AL, del Zoppo GJ, Diener HC, Di Tullio MR, Dobkin BH, Dzialowski I, Economos A, Eddleman CS, Elkind MS, Feigin VL, Ferro JM, Findlay JM, Furie KL, Fusco MR, Field TS, Geibprasert S, Gensic AP, Gobin YP, Goldberg MP, Goldstein LB, Gonzales NR, Gounis MJ, Greenberg SM, Gregson BA, Grotta JC, Gutierrez J, Hacke W, Hallenbeck JM, Haršány M, Heiferman DM, Homma S, Howard G, Howard VJ, Hwang JY, Iadecola C, Jahan R, Joutel A, Jüttler E, Kase CS, Kasner SE, Katan M, Khader Eliyas J, Khan M, Kim H, Kidwell CS, Kim JS, Krings T, Krishnamurthi R, Kurth T, Lamy C, Lansberg MG, Levy EI, Liebeskind DS, Lo EH, Loftus CM, Lyden PD, Mas JL, Massari F, Meckler JM, Mendelow AD, Meschia JF, Messé SR, Mitchel P, Morgenstern LB, Mokin M, Moskowitz MA, Mullen MT, Nedergaard M, Neugebauer H, Newell DW, Norrving B, O'Donnell M, Ofengeim D, Ogata J, Ogilvy CS, Pancioli AM, Parsha K, Parsons MW, Pawlikowska L, Pérez A, Perez-Pinzon MA, Powers WJ, Puetz V, Puri AS, Ransom BR, Roine RO, Rundek T, Russin JJ, Sacco RL, Spetzler RF, Sattenberg RJ, Saver JL, Savitz SI, Schönenberger S, Seshadri S, Sharma VK, Shi Y, Shoamanesh A, Silverboard G, Singhal AB, Sobey CG, Stapf C, Su H, Suarez JI, Sykora M, Tatlisumak T, El Tecle N, terBrugge KG, Thompson JW, Tilley BC, Tournier-Lasserve E, Tsivgoulis G, Vilela MD, von Kummer R, Wakhloo AK, Wagner KR, Warach S, Weksler BB, Werring D, Willey JZ, Wintermark M, Wolf PA, Wong LK, Woo D, Wright C, Xi G, Yamaguchi T, Yasaka M, Young WL, Zammar SG, Zahuranec DB, Zhang F, Zhang H, Zhang JH, Zhang ZG, Zukin RS, Zweifler RM. List of Contributors. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00090-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abla AA, Nelson J, Rutledge WC, Young WL, Kim H, Lawton MT. The natural history of AVM hemorrhage in the posterior fossa: comparison of hematoma volumes and neurological outcomes in patients with ruptured infra- and supratentorial AVMs. Neurosurg Focus 2015; 37:E6. [PMID: 25175444 DOI: 10.3171/2014.7.focus14211] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with posterior fossa arteriovenous malformations (AVMs) are more likely to present with hemorrhage than those with supratentorial AVMs. Observed patients subject to the AVM natural history should be informed of the individualized effects of AVM characteristics on the clinical course following a new, first-time hemorrhage. The authors hypothesize that the debilitating effects of first-time bleeding from an AVM in a previously intact patient with an unruptured AVM are more pronounced when AVMs are located in the posterior fossa. METHODS The University of California, San Francisco prospective registry of brain AVMs was searched for patients with a ruptured AVM who had a pre-hemorrhage modified Rankin Scale (mRS) score of 0 and a post-hemorrhage mRS score obtained within 2 days of the hemorrhagic event. A total of 154 patients met the inclusion criteria for this study. Immediate post-hemorrhage presentation mRS scores were dichotomized into nonsevere outcome (mRS ≤ 3) and severe outcome (mRS > 3). There were 77 patients in each group. Univariate and multivariate logistic regression analyses using severe outcome as the binary response were run. The authors also performed a logistic regression analysis to measure the effects of hematoma volume and AVM location on severe outcome. RESULTS Posterior fossa location was a significant predictor of severe outcome (OR 2.60, 95% CI 1.20-5.67, p = 0.016) and the results were strengthened in a multivariate model (OR 4.96, 95% CI 1.73-14.17, p = 0.003). Eloquent location (OR 3.47, 95% CI 1.37-8.80, p = 0.009) and associated arterial aneurysms (OR 2.58, 95% CI 1.09, 6.10; p = 0.031) were also significant predictors of poor outcome. Hematoma volume for patients with a posterior fossa AVM was 10.1 ± 10.1 cm(3) compared with 25.6 ±28.0 cm(3) in supratentorial locations (p = 0.003). A logistic analysis (based on imputed hemorrhage volume values) found that posterior fossa location was a significant predictor of severe outcome (OR 8.03, 95% CI 1.20-53.77, p = 0.033) and logarithmic hematoma volume showed a positive, but not statistically significant, association in the model (p = 0.079). CONCLUSIONS Patients with posterior fossa AVMs are more likely to have severe outcomes than those with supratentorial AVMs based on this natural history study. Age, sex, and ethnicity were not associated with an increased risk of severe outcome after AVM rupture, but posterior fossa location, associated aneurysms, and eloquent location were associated with poor post-hemorrhage mRS scores. Posterior fossa hematomas are poorly tolerated, with severe outcomes observed even with smaller hematoma volumes. These findings support an aggressive surgical posture with respect to posterior fossa AVMs, both before and after rupture.
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Affiliation(s)
- Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
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Kim H, Nelson J, Krings T, terBrugge KG, McCulloch CE, Lawton MT, Young WL, Faughnan ME. Hemorrhage rates from brain arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia. Stroke 2015; 46:1362-4. [PMID: 25858236 DOI: 10.1161/strokeaha.114.007367] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 03/12/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia (HHT) is a systemic disease characterized by mucocutaneous telangiectasias, epistaxis, and arteriovenous malformations (AVMs). Intracranial hemorrhage (ICH) rates in this population are not well described. We report ICH rates and characteristics in HHT patients with brain AVMs (HHT-BAVMs). METHODS We studied the first 153 HHT-BAVM patients with follow-up data enrolled in the Brain Vascular Malformation Consortium HHT Project. We estimated ICH rates after BAVM diagnosis. RESULTS The majority of patients were women (58%) and white (98%). The mean age at BAVM diagnosis was 31±19 years (range, 0-70), with 61% of cases diagnosed on asymptomatic screening. Overall, 14% presented with ICH; among symptomatic cases, 37% presented ruptured. During 493 patient-years of follow-up, 5 ICH events occurred yielding a rate of 1.02% per year (95% confidence interval, 0.42-2.44%). ICH-free survival differed significantly by ICH presentation (P=0.003); ruptured cases had a higher ICH rate (10.07%; 95% confidence interval, 3.25-31.21%) than unruptured cases (0.43%; 95% confidence interval, 0.11-1.73%). CONCLUSIONS Patients with HHT-BAVM who present with hemorrhage are at a higher risk for rehemorrhage compared with patients with BAVM detected presymptomatically.
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Affiliation(s)
- Helen Kim
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.).
| | - Jeffrey Nelson
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Timo Krings
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Karel G terBrugge
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Charles E McCulloch
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Michael T Lawton
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - William L Young
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Marie E Faughnan
- From the Departments of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Epidemiology and Biostatistics (H.K., C.E.M.), and Neurological Surgery (M.T.L., W.L.Y.), University of California, San Francisco; Division of Neuroradiology, Department of Medical Imaging (T.K., K.G.T.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; and Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
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Pawlikowska L, Nelson J, Guo DE, McCulloch CE, Lawton MT, Young WL, Kim H, Faughnan ME. The ACVRL1 c.314-35A>G polymorphism is associated with organ vascular malformations in hereditary hemorrhagic telangiectasia patients with ENG mutations, but not in patients with ACVRL1 mutations. Am J Med Genet A 2015; 167:1262-7. [PMID: 25847705 DOI: 10.1002/ajmg.a.36936] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/14/2014] [Indexed: 02/03/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is characterized by vascular malformations (VMs) and caused by mutations in TGFβ/BMP9 pathway genes, most commonly ENG or ACVRL1. Patients with HHT have diverse manifestations related to skin and mucosal telangiectases and organ VMs, including arteriovenous malformations (AVM). The clinical heterogeneity of HHT suggests a role for genetic modifiers. We hypothesized that the ACVRL1 c.314-35A>G and ENG c.207G>A polymorphisms, previously associated with sporadic brain AVM, are associated with organ VM in HHT. We genotyped these variants in 716 patients with HHT and evaluated association of genotype with presence of any organ VM, and specifically with brain VM, liver VM and pulmonary AVM, by multivariate logistic regression analyses stratified by HHT mutation. Among all patients with HHT, neither polymorphism was significantly associated with presence of any organ VM; ACVRL1 c.314-35A>G showed a trend toward association with pulmonary AVM (OR = 1.48, P = 0.062). ACVRL1 c.314-35A>G was significantly associated with any VM among patients with HHT with ENG (OR = 2.66, P = 0.022), but not ACVRL1 (OR = 0.79, P = 0.52) mutations. ACVRL1 c.314-35A>G was also associated with pulmonary AVM and liver VM among ENG mutation heterozygotes. There were no significant associations between ENG c.207G>A and any VM phenotype. These results suggest that common polymorphisms in HHT genes other than the mutated gene modulate phenotype severity of HHT disease, specifically presence of organ VM.
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Affiliation(s)
- Ludmila Pawlikowska
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California.,Institute for Human Genetics, University of California, San Francisco, California
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Diana E Guo
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, California
| | - William L Young
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, California.,Department of Neurology, University of California, San Francisco, California
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California.,Institute for Human Genetics, University of California, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Marie E Faughnan
- Division of Respirology, Department of Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
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Abstract
OBJECT Resection is an appealing therapy for brain arteriovenous malformations (AVMs) because of its high cure rate, low complication rate, and immediacy, and has become the first-line therapy for many AVMs. To clarify safety, efficacy, and outcomes associated with AVM resection in the aftermath of A Randomized Trial of Unruptured Brain AVMs (ARUBA), the authors reviewed their experience with low-grade AVMs-the most favorable AVMs for surgery and the ones most likely to have been selected for treatment outside of ARUBA's randomization process. METHODS A prospective AVM registry was searched to identify patients with Spetzler-Martin Grade I and II AVMs treated using resection during a 16-year period. RESULTS Of the 232 surgical patients included, 120 (52%) presented with hemorrhage, 33% had Spetzler-Martin Grade I, and 67% had Grade II AVMs. Overall, 99 patients (43%) underwent preoperative embolization, with unruptured AVMs embolized more often than ruptured AVMs. AVM resection was accomplished in all patients and confirmed angiographically in 218 patients (94%). There were no deaths among patients with unruptured AVMs. Good outcomes (modified Rankin Scale [mRS] score 0-1) were found in 78% of patients, with 97% improved or unchanged from their preoperative mRS scores. Patients with unruptured AVMs had better functional outcomes (91% good outcome vs 65% in the ruptured group, p = 0.0008), while relative outcomes were equivalent (98% improved/unchanged in patients with ruptured AVMs vs 96% in patients with unruptured AVMs). CONCLUSIONS Surgery should be regarded as the "gold standard" therapy for the majority of low-grade AVMs, utilizing conservative embolization as a preoperative adjunct. High surgical cure rates and excellent functional outcomes in patients with both ruptured and unruptured AVMs support a dominant surgical posture for low-grade AVMS, with radiosurgery reserved for risky AVMs in deep, inaccessible, and highly eloquent locations. Despite the technological advances in endovascular and radiosurgical therapy, surgery still offers the best cure rate, lowest risk profile, and greatest protection against hemorrhage for low-grade AVMs. ARUBA results are influenced by a low randomization rate, bias toward nonsurgical therapies, a shortage of surgical expertise, a lower rate of complete AVM obliteration, a higher rate of delayed hemorrhage, and short study duration. Another randomized trial is needed to reestablish the role of surgery in unruptured AVM management.
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Yang ST, Rodriguez-Hernandez A, Walker EJ, Young WL, Su H, Lawton MT. Adult mouse venous hypertension model: common carotid artery to external jugular vein anastomosis. J Vis Exp 2015:50472. [PMID: 25650793 DOI: 10.3791/50472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The understanding of the pathophysiology of brain arteriovenous malformations and arteriovenous fistulas has improved thanks to animal models. A rat model creating an artificial fistula between the common carotid artery (CCA) and the external jugular vein (EJV) has been widely described and proved technically feasible. This construct provokes a consistent cerebral venous hypertension (CVH), and therefore has helped studying the contribution of venous hypertension to formation, clinical symptoms, and prognosis of brain AVMs and dural AVFs. Equivalent mice models have been only scarcely described and have shown trouble with stenosis of the fistula. An established murine model would allow the study of not only pathophysiology but also potential genetic therapies for these cerebrovascular diseases. We present a model of arteriovenous fistula that produces a durable intracranial venous hypertension in the mouse. Microsurgical anastomosis of the murine CCA and EJV can be difficult due to diminutive anatomy and frequently result in a non-patent fistula. In this step-by-step protocol we address all the important challenges encountered during this procedure. Avoiding excessive retraction of the vein during the exposure, using 11-0 sutures instead of 10-0, and making a carefully planned end-to-side anastomosis are some of the critical steps. Although this method requires advanced microsurgical skills and a longer learning curve that the equivalent in the rat, it can be consistently developed. This novel model has been designed to integrate transgenic mouse techniques with a previously well-established experimental system that has proved useful to study brain AVMs and dural AVFs. By opening the possibility of using transgenic mice, a broader spectrum of valid models can be achieved and genetic treatments can also be tested. The experimental construct could also be further adapted to the study of other cerebrovascular diseases related with venous hypertension such as migraine, transient global amnesia, transient monocular blindness, etc.
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Affiliation(s)
- Shun-Tai Yang
- Department of Anesthesia and Perioperative Care and Center for Cerebrovascular Research, University of California, San Francisco
| | | | - Espen J Walker
- Department of Anesthesia and Perioperative Care and Center for Cerebrovascular Research, University of California, San Francisco
| | - William L Young
- Department of Anesthesia and Perioperative Care and Center for Cerebrovascular Research, University of California, San Francisco; Department of Neurological Surgery, University of California, San Francisco; Department of Neurology, University of California, San Francisco
| | - Hua Su
- Department of Anesthesia and Perioperative Care and Center for Cerebrovascular Research, University of California, San Francisco
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco;
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Krings T, Kim H, Power S, Nelson J, Faughnan ME, Young WL, terBrugge KG. Neurovascular manifestations in hereditary hemorrhagic telangiectasia: imaging features and genotype-phenotype correlations. AJNR Am J Neuroradiol 2015; 36:863-70. [PMID: 25572952 DOI: 10.3174/ajnr.a4210] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/08/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia is an autosomal dominant disease that presents in 10%-20% of patients with various brain vascular malformations. We aimed to report the radiologic features (phenotype) and the genotype-phenotype correlations of brain vascular malformations in hereditary hemorrhagic telangiectasia. MATERIALS AND METHODS Demographic, clinical, genotypic, and imaging information of 75 patients with hereditary hemorrhagic telangiectasia with brain arteriovenous malformations enrolled in the Brain Vascular Malformation Consortium from 2010 to 2012 were reviewed. RESULTS Nonshunting, small, superficially located conglomerates of enhancing vessels without enlarged feeding arteries or draining veins called "capillary vascular malformations" were the most commonly observed lesion (46 of 75 patients; 61%), followed by shunting "nidus-type" brain AVMs that were typically located superficially with a low Spetzler-Martin Grade and a small size (32 of 75 patients; 43%). Direct high-flow fistulous arteriovenous shunts were present in 9 patients (12%). Other types of vascular malformations (dural AVF and developmental venous anomalies) were present in 1 patient each. Multiplicity of vascular malformations was seen in 33 cases (44%). No statistically significant correlation was observed between hereditary hemorrhagic telangiectasia gene mutation and lesion type or lesion multiplicity. CONCLUSIONS Depending on their imaging features, brain vascular malformations in hereditary hemorrhagic telangiectasia can be subdivided into brain AVF, nidus-type AVM, and capillary vascular malformations, with the latter being the most common phenotype in hereditary hemorrhagic telangiectasia. No genotype-phenotype correlation was observed among patients with this condition.
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Affiliation(s)
- T Krings
- From the Division of Neuroradiology (T.K., S.P., K.G.t.B.), Department of Medical Imaging Division of Neurosurgery (T.K.), Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - H Kim
- Department of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Center for Cerebrovascular Research Department of Epidemiology and Biostatistics (H.K.), University of California San Francisco, San Francisco, California
| | - S Power
- From the Division of Neuroradiology (T.K., S.P., K.G.t.B.), Department of Medical Imaging
| | - J Nelson
- Department of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Center for Cerebrovascular Research
| | - M E Faughnan
- Division of Respirology (M.E.F.), Department of Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada Division of Respirology (M.E.F.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - W L Young
- Department of Anesthesia and Perioperative Care (H.K., J.N., W.L.Y.), Center for Cerebrovascular Research
| | - K G terBrugge
- From the Division of Neuroradiology (T.K., S.P., K.G.t.B.), Department of Medical Imaging
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Bendjilali N, Nelson J, Weinsheimer S, Sidney S, Zaroff JG, Hetts SW, Segal M, Pawlikowska L, McCulloch CE, Young WL, Kim H. Common variants on 9p21.3 are associated with brain arteriovenous malformations with accompanying arterial aneurysms. J Neurol Neurosurg Psychiatry 2014; 85:1280-3. [PMID: 24777168 PMCID: PMC4201968 DOI: 10.1136/jnnp-2013-306461] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate whether previously reported 9p21.3 single nucleotide polymorphisms (SNPs) are associated with risk of brain arteriovenous malformations (BAVM), which often have accompanying arterial aneurysms. Common variants in the 9p21.3 locus have been reported to be associated with multiple cardiovascular phenotypes, including coronary artery disease and intracranial aneurysms (rs10757278 and rs1333040). METHODS We used data from 338 BAVM cases participating in the University of California, San Francisco (UCSF)-Kaiser Brain AVM Study Project and 504 healthy controls to evaluate genotypes for seven common SNPs (minor allele frequency>0.05) that were imputed using 1000 Genomes Phase 1 European data (R(2)>0.87). Association with BAVM was tested using logistic regression adjusting for age, sex and the top three principal components of ancestry. Subgroup analysis included 205 BAVM cases with aneurysm data: 74 BAVM with aneurysm versus 504 controls and 131 BAVM without aneurysm versus 504 controls. RESULTS We observed suggestive association with BAVM and rs10757278-G (OR=1.23, 95% CI 0.99 to 1.53, p=0.064) and rs1333040-T (OR=1.27, 95% CI 1.01 to 1.58, p=0.04). For rs10757278-G, the association was stronger in BAVM cases with aneurysm (OR=1.52, 95% CI 1.03 to 2.22, p=0.032) than in BAVM without aneurysm (OR=0.98, 95% CI 0.72 to 1.34, p=0.91). Similar patterns of effects were observed for rs1333040 and for other SNPs in linkage disequilibrium (r(2)>0.8) with rs10757278. CONCLUSIONS Common 9p21.3 variants showed similar effect sizes for association with BAVM as previously reported for aneurysmal disease. The association with BAVM appears to be explained by known associations with aneurysms, suggesting that BAVM-associated aneurysms share similar vascular pathology mechanisms with other aneurysm types.
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Affiliation(s)
- Nasrine Bendjilali
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA Kaiser Permanente of Northern California, Division of Research, Oakland, California, USA
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA
| | - Shantel Weinsheimer
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA
| | - Stephen Sidney
- Kaiser Northern California Division of Research, San Francisco, California, USA
| | - Jonathan G Zaroff
- Kaiser Permanente of Northern California, Division of Research, Oakland, California, USA
| | - Steven W Hetts
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Mark Segal
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Ludmila Pawlikowska
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA Institute for Human Genetics, University of California, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - William L Young
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA Department of Neurological Surgery, University of California, San Francisco, California, USA Department of Neurology, University of California, San Francisco, California, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA Institute for Human Genetics, University of California, San Francisco, California, USA
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Han Z, Shen F, He Y, Degos V, Camus M, Maze M, Young WL, Su H. Activation of α-7 nicotinic acetylcholine receptor reduces ischemic stroke injury through reduction of pro-inflammatory macrophages and oxidative stress. PLoS One 2014; 9:e105711. [PMID: 25157794 PMCID: PMC4144901 DOI: 10.1371/journal.pone.0105711] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/23/2014] [Indexed: 12/17/2022] Open
Abstract
Activation of α-7 nicotinic acetylcholine receptor (α-7 nAchR) has a neuro-protective effect on ischemic and hemorrhagic stroke. However, the underlying mechanism is not completely understood. We hypothesized that α-7 nAchR agonist protects brain injury after ischemic stroke through reduction of pro-inflammatory macrophages (M1) and oxidative stress. C57BL/6 mice were treated with PHA568487 (PHA, α-7 nAchR agonist), methyllycaconitine (MLA, nAchR antagonist), or saline immediately and 24 hours after permanent occlusion of the distal middle cerebral artery (pMCAO). Behavior test, lesion volume, CD68+, M1 (CD11b+/Iba1+) and M2 (CD206/Iba1+) microglia/macrophages, and phosphorylated p65 component of NF-kB in microglia/macrophages were quantified using histological stained sections. The expression of M1 and M2 marker genes, anti-oxidant genes and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase were quantified using real-time RT-PCR. Compared to the saline-treated mice, PHA mice had fewer behavior deficits 3 and 7 days after pMCAO, and smaller lesion volume, fewer CD68+ and M1 macrophages, and more M2 macrophages 3 and 14 days after pMCAO, whereas MLA's effects were mostly the opposite in several analyses. PHA increased anti-oxidant genes and NADPH oxidase expression associated with decreased phosphorylation of NF-kB p65 in microglia/macrophages. Thus, reduction of inflammatory response and oxidative stress play roles in α-7 nAchR neuro-protective effect.
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Affiliation(s)
- Zhenying Han
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Tianjin Medical University General Hospital, Tianjin, China
| | - Fanxia Shen
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Yue He
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Vincent Degos
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Hôpital Pitié Salpetrière, Assistance Publique-Hopitaux de Paris (APHP), Université Pierre et Marie Curie-Paris VI and UMR INSERM 1141, Paris, France
| | - Marine Camus
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Mervyn Maze
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - William L. Young
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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Kim H, Al-Shahi Salman R, McCulloch CE, Stapf C, Young WL. Untreated brain arteriovenous malformation: patient-level meta-analysis of hemorrhage predictors. Neurology 2014; 83:590-7. [PMID: 25015366 DOI: 10.1212/wnl.0000000000000688] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify risk factors for intracranial hemorrhage in the natural history course of brain arteriovenous malformations (AVMs) using individual patient data meta-analysis of 4 existing cohorts. METHODS We harmonized data from Kaiser Permanente of Northern California (n = 856), University of California San Francisco (n = 787), Columbia University (n = 672), and the Scottish Intracranial Vascular Malformation Study (n = 210). We censored patients at first treatment, death, last visit, or 10-year follow-up, and performed stratified Cox regression analysis of time-to-hemorrhage after evaluating hemorrhagic presentation, sex, age at diagnosis, deep venous drainage, and AVM size as predictors. Multiple imputation was performed to assess impact of missing data. RESULTS A total of 141 hemorrhage events occurred during 6,074 patient-years of follow-up (annual rate of 2.3%, 95% confidence interval [CI] 2.0%-2.7%), higher for ruptured (4.8%, 3.9%-5.9%) than unruptured (1.3%, 1.0%-1.7%) AVMs at presentation. Hemorrhagic presentation (hazard ratio 3.86, 95% CI 2.42-6.14) and increasing age (1.34 per decade, 1.17-1.53) independently predicted hemorrhage and remained significant predictors in the imputed dataset. Female sex (1.49, 95% CI 0.96-2.30) and exclusively deep venous drainage (1.60, 0.95-2.68, p = 0.02 in imputed dataset) may be additional predictors. AVM size was not associated with intracerebral hemorrhage in multivariable models (p > 0.5). CONCLUSION This large, individual patient data meta-analysis identified hemorrhagic presentation and increasing age as independent predictors of hemorrhage during follow-up. Additional AVM cohort data may further improve precision of estimates, identify new risk factors, and allow validation of prediction models.
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Affiliation(s)
- Helen Kim
- From the Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (H.K., W.L.Y.), and Departments of Epidemiology and Biostatistics (H.K., C.E.M.), Neurological Surgery (W.L.Y.), and Neurology (W.L.Y.), University of California, San Francisco; Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, University of Edinburgh, UK; and Neurovasc-Paris Sorbonne (C.S.), Univ Paris Diderot-Sorbonne Paris Cité, and Department of Neurology, APHP-Hôpital Lariboisière, Paris, France.
| | - Rustam Al-Shahi Salman
- From the Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (H.K., W.L.Y.), and Departments of Epidemiology and Biostatistics (H.K., C.E.M.), Neurological Surgery (W.L.Y.), and Neurology (W.L.Y.), University of California, San Francisco; Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, University of Edinburgh, UK; and Neurovasc-Paris Sorbonne (C.S.), Univ Paris Diderot-Sorbonne Paris Cité, and Department of Neurology, APHP-Hôpital Lariboisière, Paris, France
| | - Charles E McCulloch
- From the Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (H.K., W.L.Y.), and Departments of Epidemiology and Biostatistics (H.K., C.E.M.), Neurological Surgery (W.L.Y.), and Neurology (W.L.Y.), University of California, San Francisco; Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, University of Edinburgh, UK; and Neurovasc-Paris Sorbonne (C.S.), Univ Paris Diderot-Sorbonne Paris Cité, and Department of Neurology, APHP-Hôpital Lariboisière, Paris, France
| | - Christian Stapf
- From the Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (H.K., W.L.Y.), and Departments of Epidemiology and Biostatistics (H.K., C.E.M.), Neurological Surgery (W.L.Y.), and Neurology (W.L.Y.), University of California, San Francisco; Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, University of Edinburgh, UK; and Neurovasc-Paris Sorbonne (C.S.), Univ Paris Diderot-Sorbonne Paris Cité, and Department of Neurology, APHP-Hôpital Lariboisière, Paris, France
| | - William L Young
- From the Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (H.K., W.L.Y.), and Departments of Epidemiology and Biostatistics (H.K., C.E.M.), Neurological Surgery (W.L.Y.), and Neurology (W.L.Y.), University of California, San Francisco; Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, University of Edinburgh, UK; and Neurovasc-Paris Sorbonne (C.S.), Univ Paris Diderot-Sorbonne Paris Cité, and Department of Neurology, APHP-Hôpital Lariboisière, Paris, France
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Potts MB, Sheth SA, Louie J, Smyth MD, Sneed PK, McDermott MW, Lawton MT, Young WL, Hetts SW, Fullerton HJ, Gupta N. Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes. J Neurosurg Pediatr 2014; 14:1-11. [PMID: 24766309 DOI: 10.3171/2014.3.peds13381] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
UNLABELLED OBJECT.: Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. METHODS The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. RESULTS A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm(3) (range 0.09-62.3 cm(3)), and median prescription marginal dose used was 17.5 Gy (range 12-20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18-20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%-37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0-2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. CONCLUSIONS A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.
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15
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Shen F, Degos V, Chu PL, Han Z, Westbroek EM, Choi EJ, Marchuk D, Kim H, Lawton MT, Maze M, Young WL, Su H. Endoglin deficiency impairs stroke recovery. Stroke 2014; 45:2101-6. [PMID: 24876084 DOI: 10.1161/strokeaha.114.005115] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Endoglin deficiency causes hereditary hemorrhagic telangiectasia-1 and impairs myocardial repair. Pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia-1 are associated with a high incidence of paradoxical embolism in the cerebral circulation and ischemic brain injury. We hypothesized that endoglin deficiency impairs stroke recovery. METHODS Eng heterozygous (Eng+/-) and wild-type mice underwent permanent distal middle cerebral artery occlusion (pMCAO). Pial collateral vessels were quantified before pMCAO. Infarct/atrophic volume, vascular density, and macrophages were quantified in various days after pMCAO, and behavioral function was assessed using corner and adhesive removal tests on days 3, 15, 30, and 60 after pMCAO. The association between ENG 207G>A polymorphism and brain arteriovenous malformation rupture and surgery outcome was analyzed using logistic regression analysis in 256 ruptured and 157 unruptured patients. RESULTS After pMCAO, Eng+/- mice showed larger infarct/atrophic volumes at all time points (P<0.05) and showed worse behavior performance (P<0.05) at 15, 30, and 60 days when compared with wild-type mice. Eng+/- mice had fewer macrophages on day 3 (P=0.009) and more macrophages on day 60 (P=0.02) in the peri-infarct region. Although Eng+/- and wild-type mice had similar numbers of pial collateral vessels before pMCAO, Eng+/- mice had lower vascular density in the peri-infarct region (P=0.05) on day 60 after pMCAO. In humans, ENG 207A allele has been associated with worse outcomes after arteriovenous malformation rupture or surgery of patients with unruptured arteriovenous malformation. CONCLUSIONS Endoglin deficiency impairs brain injury recovery. Reduced angiogenesis, impaired macrophage homing, and delayed inflammation resolution could be the underlying mechanism.
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MESH Headings
- Alleles
- Animals
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Behavior, Animal/physiology
- Disease Models, Animal
- Endoglin
- Humans
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/metabolism
- Intracellular Signaling Peptides and Proteins/deficiency
- Intracellular Signaling Peptides and Proteins/genetics
- Intracellular Signaling Peptides and Proteins/metabolism
- Intracranial Arteriovenous Malformations/genetics
- Intracranial Arteriovenous Malformations/metabolism
- Intracranial Arteriovenous Malformations/surgery
- Mice
- Mice, Knockout
- Polymorphism, Genetic/genetics
- Receptors, Cell Surface/deficiency
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/metabolism
- Recovery of Function/genetics
- Recovery of Function/physiology
- Time Factors
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Affiliation(s)
- Fanxia Shen
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Vincent Degos
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Pei-Lun Chu
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Zhenying Han
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Erick M Westbroek
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Eun-Jung Choi
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Douglas Marchuk
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Helen Kim
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Michael T Lawton
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Mervyn Maze
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - William L Young
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.)
| | - Hua Su
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (F.S., V.D., Z.H., E.M.W., E.-J.C., H.K., M.M., W.L.Y., H.S.) and Departments of Neurological Surgery (M.T.L., W.L.Y.) and Neurology (W.L.Y.), University of California, San Francisco; Department of Neurology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (F.S.); Department of Anesthesia and Intensive Care, INSERM, U676, Hôpital Robert Debré, Paris, France (V.D.); and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC (P.-L.C., D.M.).
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Potts MB, Young WL, Lawton MT. Deep arteriovenous malformations in the Basal Ganglia, thalamus, and insula: microsurgical management, techniques, and results. Neurosurgery 2014; 73:417-29. [PMID: 23728451 DOI: 10.1227/neu.0000000000000004] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) in the basal ganglia, thalamus, and insula are considered inoperable given their depth, eloquence, and limited surgical exposure. Although many neurosurgeons opt for radiosurgery or observation, others have challenged the belief that deep AVMs are inoperable. Further discussion of patient selection, technique, and multimodality management is needed. OBJECTIVE To describe and discuss the technical considerations of microsurgical resection for deep-seated AVMs. METHODS Patients with deep AVMs who underwent surgery during a 14-year period were reviewed through the use of a prospective AVM registry. RESULTS Microsurgery was performed in 48 patients with AVMs in the basal ganglia (n=10), thalamus (n=13), or insula (n=25). The most common Spetzler-Martin grade was III- (68%). Surgical approaches included transsylvian (67%), transcallosal (19%), and transcortical (15%). Complete resection was achieved in 34 patients (71%), and patients with incomplete resection were treated with radiosurgery. Forty-five patients (94%) were improved or unchanged (mean follow-up, 1.6 years). CONCLUSION This experience advances the notion that select deep AVMs may be operable lesions. Patients were highly selected for small size, hemorrhagic presentation, young age, and compactness-factors embodied in the Spetzler-Martin and Supplementary grading systems. Overall, 10 different approaches were used, exploiting direct, transcortical corridors created by hemorrhage or maximizing anatomic corridors through subarachnoid spaces and ventricles that minimize brain transgression. The same cautious attitude exercised in selecting patients for surgery was also exercised in deciding extent of resection, opting for incomplete resection and radiosurgery more than with other AVMs to prioritize neurological outcomes.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, CA 94143-0112, USA
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17
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Potts MB, Jahangiri A, Jen M, Sneed PK, McDermott MW, Gupta N, Hetts SW, Young WL, Lawton MT. Deep arteriovenous malformations in the basal ganglia, thalamus, and insula: multimodality management, patient selection, and results. World Neurosurg 2014; 82:386-94. [PMID: 24657255 DOI: 10.1016/j.wneu.2014.03.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 10/21/2013] [Accepted: 03/14/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to describe a single institution's experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fashion. METHODS We conducted a retrospective review of all deep AVMs treated at our institution between 1997 and 2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes. RESULTS A total of 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage with 29% located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, whereas Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Posttreatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients). CONCLUSIONS Modern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared with SRS, and is associated with satisfactory results in carefully selected patients.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Arman Jahangiri
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Maxwell Jen
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology, University of California, San Francisco, San Francisco, California, USA
| | - William L Young
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA; Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California, USA.
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18
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Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJM, Harkness K, Libman R, Barreau X, Moskowitz AJ. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383:614-21. [PMID: 24268105 PMCID: PMC4119885 DOI: 10.1016/s0140-6736(13)62302-8] [Citation(s) in RCA: 723] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The clinical benefit of preventive eradication of unruptured brain arteriovenous malformations remains uncertain. A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA) aims to compare the risk of death and symptomatic stroke in patients with an unruptured brain arteriovenous malformation who are allocated to either medical management alone or medical management with interventional therapy. METHODS Adult patients (≥18 years) with an unruptured brain arteriovenous malformation were enrolled into this trial at 39 clinical sites in nine countries. Patients were randomised (by web-based system, in a 1:1 ratio, with random permuted block design [block size 2, 4, or 6], stratified by clinical site) to medical management with interventional therapy (ie, neurosurgery, embolisation, or stereotactic radiotherapy, alone or in combination) or medical management alone (ie, pharmacological therapy for neurological symptoms as needed). Patients, clinicians, and investigators are aware of treatment assignment. The primary outcome is time to the composite endpoint of death or symptomatic stroke; the primary analysis is by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00389181. FINDINGS Randomisation was started on April 4, 2007, and was stopped on April 15, 2013, when a data and safety monitoring board appointed by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health recommended halting randomisation because of superiority of the medical management group (log-rank Z statistic of 4·10, exceeding the prespecified stopping boundary value of 2·87). At this point, outcome data were available for 223 patients (mean follow-up 33·3 months [SD 19·7]), 114 assigned to interventional therapy and 109 to medical management. The primary endpoint had been reached by 11 (10·1%) patients in the medical management group compared with 35 (30·7%) in the interventional therapy group. The risk of death or stroke was significantly lower in the medical management group than in the interventional therapy group (hazard ratio 0·27, 95% CI 0·14-0·54). No harms were identified, other than a higher number of strokes (45 vs 12, p<0·0001) and neurological deficits unrelated to stroke (14 vs 1, p=0·0008) in patients allocated to interventional therapy compared with medical management. INTERPRETATION The ARUBA trial showed that medical management alone is superior to medical management with interventional therapy for the prevention of death or stroke in patients with unruptured brain arteriovenous malformations followed up for 33 months. The trial is continuing its observational phase to establish whether the disparities will persist over an additional 5 years of follow-up. FUNDING National Institutes of Health, National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- J P Mohr
- The Neurological Institute, Columbia University Medical Center, New York, NY, USA
| | - Michael K Parides
- International Center for Health Outcomes and Innovation Research, Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christian Stapf
- The Neurological Institute, Columbia University Medical Center, New York, NY, USA; Department of Neurology, APHP-Hôpital Lariboisière, Univ Paris Diderot-Sorbonne Paris Cité, Paris, France; DHU NeuroVasc, APHP-Hôpital Lariboisière, Univ Paris Diderot-Sorbonne Paris Cité, Paris, France.
| | - Ellen Moquete
- International Center for Health Outcomes and Innovation Research, Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claudia S Moy
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Jessica R Overbey
- International Center for Health Outcomes and Innovation Research, Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Eric Vicaut
- Unité de Recherche Clinique, APHP-Hôpital Lariboisière, Univ Paris Diderot-Sorbonne Paris Cité, Paris, France
| | - William L Young
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Emmanuel Houdart
- Department of Neuroradiology, APHP-Hôpital Lariboisière, Univ Paris Diderot-Sorbonne Paris Cité, Paris, France
| | - Charlotte Cordonnier
- Department of Neurology, CHRU Lille, Université Lille Nord de France, Lille, France
| | - Marco A Stefani
- Department of Neurology and Neurosurgery, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Andreas Hartmann
- Charité-Universitätsmedizin Berlin Berlin, Germany; Department of Neurology, Klinikum Frankfurt/Oder, Frankfurt/Oder Oder, Germany
| | - Rüdiger von Kummer
- Department of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Therapy, Jean Minjoz Hospital, University of Franche Comté, Besançon, France
| | - Joachim Berkefeld
- Department of Neuroradiology, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, Netherlands
| | - Kirsty Harkness
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | - Richard Libman
- Department of Neurology, North Shore Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Xavier Barreau
- Department of Diagnostic and Interventional Neuroimaging, CHU Pellegrin, Bordeaux, France
| | - Alan J Moskowitz
- International Center for Health Outcomes and Innovation Research, Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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19
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Choi EJ, Chen W, Jun K, Arthur HM, Young WL, Su H. Novel brain arteriovenous malformation mouse models for type 1 hereditary hemorrhagic telangiectasia. PLoS One 2014; 9:e88511. [PMID: 24520391 PMCID: PMC3919779 DOI: 10.1371/journal.pone.0088511] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 01/08/2014] [Indexed: 12/24/2022] Open
Abstract
Endoglin (ENG) is a causative gene of type 1 hereditary hemorrhagic telangiectasia (HHT1). HHT1 patients have a higher prevalence of brain arteriovenous malformation (AVM) than the general population and patients with other HHT subtypes. The pathogenesis of brain AVM in HHT1 patients is currently unknown and no specific medical therapy is available to treat patients. Proper animal models are crucial for identifying the underlying mechanisms for brain AVM development and for testing new therapies. However, creating HHT1 brain AVM models has been quite challenging because of difficulties related to deleting Eng-floxed sequence in Eng2fl/2fl mice. To create an HHT1 brain AVM mouse model, we used several Cre transgenic mouse lines to delete Eng in different cell-types in Eng2fl/2fl mice: R26CreER (all cell types after tamoxifen treatment), SM22α-Cre (smooth muscle and endothelial cell) and LysM-Cre (lysozyme M-positive macrophage). An adeno-associated viral vector expressing vascular endothelial growth factor (AAV-VEGF) was injected into the brain to induce focal angiogenesis. We found that SM22α-Cre-mediated Eng deletion in the embryo caused AVMs in the postnatal brain, spinal cord, and intestines. Induction of Eng deletion in adult mice using R26CreER plus local VEGF stimulation induced the brain AVM phenotype. In both models, Eng-null endothelial cells were detected in the brain AVM lesions, and formed mosaicism with wildtype endothelial cells. However, LysM-Cre-mediated Eng deletion in the embryo did not cause AVM in the postnatal brain even after VEGF stimulation. In this study, we report two novel HHT1 brain AVM models that mimic many phenotypes of human brain AVM and can thus be used for studying brain AVM pathogenesis and testing new therapies. Further, our data indicate that macrophage Eng deletion is insufficient and that endothelial Eng homozygous deletion is required for HHT1 brain AVM development.
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Affiliation(s)
- Eun-Jung Choi
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Wanqiu Chen
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Kristine Jun
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Helen M. Arthur
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle, United Kingdom
| | - William L. Young
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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20
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Sheth SA, Potts MB, Sneed PK, Young WL, Cooke DL, Gupta N, Hetts SW. Angiographic features help predict outcome after stereotactic radiosurgery for the treatment of pediatric arteriovenous malformations. Childs Nerv Syst 2014; 30:241-7. [PMID: 23892391 DOI: 10.1007/s00381-013-2231-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Arteriovenous malformations (AVMs) are a frequent cause of hemorrhagic stroke in children. Stereotactic radiosurgery (SRS) is an established treatment for these lesions, particularly those that are surgically inaccessible. Because only complete AVM obliteration is believed to protect against the future risk of hemorrhage, identifying lesion characteristics that predict response to therapy is an important objective. The goal of this study is to evaluate the influence of angiographic features of AVMs on the rate of obliteration following treatment with SRS. METHODS This is a retrospective cohort study of pediatric patients (age ≤18 years) treated with Gamma Knife SRS for cerebral AVMs between 2000 and 2012. Detailed angiographic data at the time of initial angiographic evaluation were prospectively recorded by experienced neurointerventional radiologists. The primary outcome was the rate of obliteration on a 3-year follow-up angiogram. RESULTS We identified 42 pediatric patients treated with SRS for cerebral AVMs. Twenty-seven patients completed 3-year angiographic follow-ups. Complete obliteration was seen in 30%, partial response in 67%, and no response in 4%. Higher SRS dose was associated with complete obliteration. Larger AVM diameter, presence of multiple draining veins, and presence of multiple draining veins reaching a sinus were associated with partial response. In this small cohort, diffuse AVM borders, presence of aneurysm, and pre-SRS embolization were not associated with obliteration. CONCLUSIONS Our study identifies AVMs in the pediatric population with a nidus diameter of <2.5 cm and a solitary draining vein as the most likely to undergo complete obliteration after SRS treatment.
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Affiliation(s)
- Sunil A Sheth
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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21
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Kim H, Nelson J, Krings T, ter Brugge K, Young WL, Faughnan ME. Abstract W MP120: Hemorrhage Rates from Brain Arteriovenous Malformations in HHT Patients. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wmp120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disease caused by mutations in transforming growth factor-beta signaling genes (ENG, ALK1, or SMAD4), and is characterized by mucocutaneous telangiectasia and arteriovenous malformations (AVM) primarily in brain, lung and liver. In contrast to sporadic brain AVM, HHT brain AVMs are often multiple though small series to date have suggested that they may have a lower risk of intracranial hemorrhage (ICH). We sought to describe ICH rates and characteristics in HHT patients with brain arteriovenous malformations (HHT-BAVM).
Methods:
We collected data from the first 134 HHT-BAVM patients with follow-up enrolled in the BVMC HHT Project, including age, sex, race, HHT gene mutation, and ICH at diagnosis. We performed Kaplan-Meier survival analysis to estimate ICH rates after diagnosis censoring at date of first treatment, death or last follow-up, out to 15 years.
Results:
The majority of patients were female (57%) and Caucasian (93%). HHT gene mutation status was known in 57%, of which 74% had ENG mutations, 23% ALK1, and 3% SMAD4. The mean age at BAVM diagnosis was 30±19 years (range: 0-70), with over half of cases diagnosed based on asymptomatic screening (54%). Among symptomatic cases, 32% presented initially with ICH. During 482 person-years of follow-up, there were 5 ICH events corresponding to a rate of 1.04% per year (95% CI: 0.43 - 2.49%). ICH-free survival differed significantly by ICH presentation (P=0.003); ruptured cases had a higher rate (5.23%, 95% CI: 1.31 - 20.89%) than unruptured cases (0.51%, 95% CI: 0.13 - 2.04%). ICH-free survival did not differ by gender (P=0.285).
Conclusions:
HHT-BAVM patients who present with hemorrhage are at a higher risk for rehemorrhage compared to BAVMs detected presymptomatically in HHT patients. Correlation with unruptured sporadic BAVM cases will however need a larger sample and number of events in the HHT BAVM cohort. Ongoing recruitment of HHT-BAVM patients into the BVMC study will increase precision of ICH estimates and ability to examine additional risk factors such as angiographic features that may differ from sporadic BAVM.
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Affiliation(s)
| | | | - Timo Krings
- Divison of Neuroradiology, Univ of Toronto, Toronto, Canada
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22
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Han Z, Shen F, He Y, Degos V, Camus M, Wankhede M, Maze M, Young WL, Su H. Abstract W P98: Activation of α7 Nicotinic Acetylcholine Receptor Reduces Pro-Inflammatory Macrophage and Improves Ischemic Stroke Recovery. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Inflammation influences stroke recovery. Activation of α7 nicotinic acetylcholine receptor (α7 nAchR) attenuates inflammation. We hypothesize that α7 nAchR agonist treatment reduces pro-inflammatory macrophages (M1) and improves ischemic stroke recovery.
Methods:
C57BL/6 mice underwent permanent distal middle cerebral artery occlusion (pMCAO). They were randomly assigned to 7 groups: injected intraperitoneally with 0.4 or 0.8 mg/Kg PHA568487 (PHA, α7 nAchR agonist), 4 or 6 mg/Kg methyllycaconitine (MLA, α7 nAchR antagonist), or saline immediately after pMCAO, or with 0.8 mg/Kg PHA or 6 mg/kg MLA immediately and 24 hours after pMCAO. Behavior was assessed by corner and adhesive removal tests at 3, 7, and 14 days after pMCAO (n=12). Atrophic volume (n=7) and the percentage of total (CD68
+
) and M1 (CD11b
+
/Iba1
+
) macrophages (n=6) among total cells in the peri-infarct region were quantified 14 days after pMCAO. The expression of M1 (CD11b and iNOS) and M2 marker (CD206) were quantified using real-time RT-PCR (n=4).
Results:
Compared to the saline-treated mice, those treated with two doses of 0.8 mg/kg PHA performed better in both behavioral tests at 3 (adhesive: p=0.01, corner: p=0.02) and 7 (adhesive: p=0.005, corner: p=0.03) days, and in the adhesive removal test at 14 days (p=0.004) after pMCAO. They had smaller atrophic volume (16±7 mm
3
vs
26±5 mm
3
, p=0.008), and fewer total (9±2.5% vs 15.8±1.7%, p<0.001) and M1 (14±2.3% vs 20.6±4.2%, p=0.005) macrophages. Mice treated with two doses of 6 mg/kg MLA performed worse in the behavioral tests at all times (p<0.05), had larger atrophic volume (48±20 mm
3
, p=0.03), and more total (25±4.2%, p=0.0003) and M1 macrophages (28±4.5%, p=0.01). The expression of CD11b and iNOS decreased (p<0.05) in the PHA group, and increased (p=0.01) in the MLA group. CD206 expression increased (p=0.04) in the PHA group and did not change in the MLA group. One-dose treatment had no effect.
Conclusions:
Activation of α7 nAchR reduces pro-inflammatory macrophages in the peri-infarct region, which is associated with reduction of atrophic volume and improvement of behavioral recovery.
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Affiliation(s)
- Zhenying Han
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Fanxia Shen
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Yue He
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Vincent Degos
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Marine Camus
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Mamta Wankhede
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Mervyn Maze
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - William L. Young
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
| | - Hua Su
- Dept of Anesthesia and Perioperative Care, Univ of California, San Francisco, San Francisco, CA
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Chen W, Sun Z, Han Z, Jun K, Camus M, Wankhede M, Mao L, Arnold T, Young WL, Su H. De novo cerebrovascular malformation in the adult mouse after endothelial Alk1 deletion and angiogenic stimulation. Stroke 2014; 45:900-2. [PMID: 24457293 DOI: 10.1161/strokeaha.113.003655] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In humans, activin receptor-like kinase 1 (Alk1) deficiency causes arteriovenous malformations (AVMs) in multiple organs, including the brain. Focal Alk1 pan-cellular deletion plus vascular endothelial growth factor stimulation induces brain AVMs in the adult mouse. We hypothesized that deletion of Alk1 in endothelial cell (EC) alone plus focal vascular endothelial growth factor stimulation is sufficient to induce brain AVM in the adult mouse. METHODS Focal angiogenesis was induced in the brain of 8-week-old Pdgfb-iCreER;Alk1(2f/2f) mice by injection of adeno-associated viral vectors expressing vascular endothelial growth factor. Two weeks later, EC-Alk1 deletion was induced by tamoxifen treatment. Vascular morphology was analyzed, and EC proliferation and dysplasia index (number of vessels with diameter>15 μm per 200 vessels) were quantified 10 days after tamoxifen administration. RESULTS Tangles of enlarged vessels resembling AVMs were present in the brain angiogenic region of tamoxifen-treated Pdgfb-iCreER;Alk1(2f/2f) mice. Induced brain AVMs were marked by increased dysplasia index (P<0.001) and EC proliferation clustered within the dysplastic vessels. AVMs were also detected around the ear tag-wound and in other organs. CONCLUSIONS Deletion of Alk1 in EC in adult mice leads to an increased local EC proliferation during brain angiogenesis and de novo brain AVM.
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Affiliation(s)
- Wanqiu Chen
- From the Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (W.C., Z.H., K.J., M.C., M.W., L.M., W.L.Y., H.S.), Departments of Radiology (Z.S.), Pediatrics (T.A.), Neurological Surgery (W.L.Y.), and Neurology (W.L.Y.), University of California, San Francisco
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24
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Abstract
Brain arteriovenous malformations (bAVM) are tangles of abnormal, dilated vessels that directly shunt blood between the arteries and veins. The pathogenesis of bAVM is currently unknown. Patients with hereditary hemorrhagic telangiectasia (HHT) have a higher prevalence of bAVM than the general population. Animal models are important tools for dissecting the disease etiopathogenesis and for testing new therapies. Here, we introduce a method that induces the bAVM phenotype through regional deletion of activin-like kinase 1 (Alk1, the causal gene for HHT2) and vascular endothelial growth factor (VEGF) stimulation.
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Affiliation(s)
- Wanqiu Chen
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, CA, USA
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25
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Guo Y, Tihan T, Kim H, Hess C, Lawton MT, Young WL, Zhao Y, Su H. Distinctive distribution of lymphocytes in unruptured and previously untreated brain arteriovenous malformation. ACTA ACUST UNITED AC 2014; 1:147-152. [PMID: 25568888 DOI: 10.4103/2347-8659.143674] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To test the hypothesis that lymphocyte infiltration in brain arteriovenous malformation (bAVM) is not associated with iron deposition (indicator of microhemorrhage). METHODS Sections of unruptured, previously untreated bAVM specimens (n=19) were stained immunohistochemically for T-lymphocytes (CD3+), B-lymphocytes (CD20+), plasma cells (CD138+) and macrophages (CD68+). Iron deposition was assessed by hematoxylin and eosin and Prussian blue stains. Superficial temporal arteries (STA) were used as control. RESULTS Both T lymphocytes and macrophages were present in unruptured, previously untreated bAVM specimens, whereas few B cells and plasma cells were detected. Iron deposition was detected in 8 specimens (42%; 95% confidence interval =20-67%). The samples with iron deposition tended to have more macrophages than those without (666±313 vs 478±174 cells/mm2; P=0.11). T-cells were clustered on the luminal side of the endothelial surface, on the vessel-wall, and in the perivascular regions. There was no correlation between T lymphocyte load and iron deposition (P=0.88). No macrophages and lymphocytes were detected in STA controls. CONCLUSIONS T-lymphocytes were present in bAVM specimens. Unlike macrophages, the load and location of T-lymphocytes were not associated with iron deposition, suggesting the possibility of an independent cell-mediated immunological mechanism in bAVM pathogenesis.
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Affiliation(s)
- Yi Guo
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA 94110, USA ; Department of Neurosurgery, Affiliated Hospital of Hebei University, Baoding 071000 China
| | - Tarik Tihan
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Christopher Hess
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94110, USA
| | - William L Young
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA 94110, USA ; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94110, USA ; Department of Neurology, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 410011, China
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA 94110, USA
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Cooke DL, Su H, Sun Z, Guo Y, Guo D, Saeed MM, Hetts SW, Higashida RT, Dowd CF, Young WL, Halbach VV. Endovascular biopsy: evaluating the feasibility of harvesting endothelial cells using detachable coils. Interv Neuroradiol 2013; 19:399-408. [PMID: 24355142 DOI: 10.1177/159101991301900401] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 05/20/2013] [Indexed: 11/16/2022] Open
Abstract
The absence of safe and reliable methods to harvest vascular tissue in situ limits the discovery of the underlying genetic and pathophysiological mechanisms of many vascular disorders such as aneurysms. We investigated the feasibility and comparable efficacy of endothelial cell collection using a spectrum of endovascular coils. Nine detachable coils ranging in k coefficient (0.15-0.24), diameter (4.0 mm-16.0 mm), and length (8.0 cm-47.0 cm) were tested in pigs. All coils were deployed and retrieved within the iliac artery of pigs (three coils/pig). Collected coils were evaluated under light microscopy. The total and endothelial cells collected by each coil were quantified. The nucleated cells were identified by Wright-Giemsa and DAPI stains. Endothelial and smooth muscle cells were identified by CD31 and α-smooth muscle actin antibody staining. Coils were deployed and retrieved without technical difficulty. Light microscopy demonstrated sheets of cellular material concentrated within the coil winds. All coils collected cellular material while five of nine (55.6%) coils retrieved endothelial cells. Coils collected mean endothelial cell counts of 89.0±101.6. Regression analysis demonstrated a positive correlation between increasing coil diameter and endothelial cell counts (R(2)=0.52, p = 0.029). Conventional detachable coils can be used to harvest endothelial cells. The number of endothelial cells collected by a coil positively correlated with its diameter. Given the widespread use of coils and their well-described safety profile their potential as an endovascular biopsy device would expand the availability of tissue for cellular and molecular analysis.
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Affiliation(s)
- Daniel L Cooke
- Department of Radiology and Biomedical Imaging; University of California; San Francisco, CA, USA -
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Weinsheimer SM, Xu H, Achrol AS, Stamova B, McCulloch CE, Pawlikowska L, Tian Y, Ko NU, Lawton MT, Steinberg GK, Chang SD, Jickling G, Ander BP, Kim H, Sharp FR, Young WL. Gene expression profiling of blood in brain arteriovenous malformation patients. Transl Stroke Res 2013; 2:575-87. [PMID: 22184505 DOI: 10.1007/s12975-011-0103-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Brain arteriovenous malformations (BAVMs) are an important cause of intracranial hemorrhage (ICH) in young adults. Gene expression profiling of blood has led to the identification of stroke biomarkers, and may help identify BAVM biomarkers and illuminate BAVM pathogenesis. It is unknown whether blood gene expression profiles differ between 1) BAVM patients and healthy controls, or 2) unruptured and ruptured BAVM patients at presentation. We characterized blood transcriptional profiles in 60 subjects (20 unruptured BAVM, 20 ruptured BAVM, and 20 healthy controls) using Affymetrix whole genome expression arrays. Expression differences between groups were tested by ANOVA, adjusting for potential confounders. Genes with absolute fold change ≥ 1.2 (false discovery rate corrected p ≤ 0.1) were selected as differentially expressed and evaluated for over-representation in KEGG biological pathways (p ≤ 0.05). Twenty-nine genes were differentially expressed between unruptured BAVM patients and controls, including 13 which may be predictive of BAVM. Patients with ruptured BAVM compared to unruptured BAVM differed in expression of 1490 genes, with over-representation of genes in 8 pathways including MAPK, VEGF, Wnt signaling and several inflammatory pathways. These results suggest clues to the pathogenesis of BAVM and/or BAVM rupture and point to potential biomarkers or new treatment targets.
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Affiliation(s)
- Shantel M Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA
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28
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Hasan DM, Amans M, Tihan T, Hess C, Guo Y, Cha S, Su H, Martin AJ, Lawton MT, Neuwelt EA, Saloner DA, Young WL. Ferumoxytol-enhanced MRI to Image Inflammation within Human Brain Arteriovenous Malformations: A Pilot Investigation. Transl Stroke Res 2013; 3:166-73. [PMID: 23002401 DOI: 10.1007/s12975-012-0172-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Inflammation cell infiltration and cytokine expression are seen in the vascular walls and intervening stroma of resected brain arteriovenous malformation (bAVM) specimens, even in unruptured and previously untreated lesions. Macrophages may play a critical role in bAVM progression to rupture, and could serve as a marker for rupture risk. We assessed feasibility of imaging macrophages within the bAVM nidus using ferumoxytol-enhanced MRI in four patients with already diagnosed bAVMs using iron-sensitive imaging (ISI; T2*-GE-MRI sequence). Patients were imaged at baseline and at either 1 day (n=2) or 5 days (n=2) after infusion of 5mg/kg of ferumoxytol. Residual intravascular ferumoxytol obscured evaluation for uptake in bAVM vascular walls and stroma at the 1-day time point. The two cases imaged at 5 days showed less intravascular tracer but had signal loss in the nidal region consistent with ferumoxytol localization. One case underwent surgical resection; there was prominent vascular wall CD68 staining. Ferumoxytol-enhanced-MRI for assessing bAVM inflammatory cell burden appears feasible and has the potential to be developed as a biomarker to study lesional inflammatory events.
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Affiliation(s)
- David M Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA
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Bendjilali N, Kim H, Weinsheimer S, Guo DE, Kwok PY, Zaroff JG, Sidney S, Lawton MT, McCulloch CE, Koeleman BPC, Klijn CJM, Young WL, Pawlikowska L. A genome-wide investigation of copy number variation in patients with sporadic brain arteriovenous malformation. PLoS One 2013; 8:e71434. [PMID: 24098321 PMCID: PMC3789669 DOI: 10.1371/journal.pone.0071434] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 06/30/2013] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Brain arteriovenous malformations (BAVM) are clusters of abnormal blood vessels, with shunting of blood from the arterial to venous circulation and a high risk of rupture and intracranial hemorrhage. Most BAVMs are sporadic, but also occur in patients with Hereditary Hemorrhagic Telangiectasia, a Mendelian disorder caused by mutations in genes in the transforming growth factor beta (TGFβ) signaling pathway. METHODS To investigate whether copy number variations (CNVs) contribute to risk of sporadic BAVM, we performed a genome-wide association study in 371 sporadic BAVM cases and 563 healthy controls, all Caucasian. Cases and controls were genotyped using the Affymetrix 6.0 array. CNVs were called using the PennCNV and Birdsuite algorithms and analyzed via segment-based and gene-based approaches. Common and rare CNVs were evaluated for association with BAVM. RESULTS A CNV region on 1p36.13, containing the neuroblastoma breakpoint family, member 1 gene (NBPF1), was significantly enriched with duplications in BAVM cases compared to controls (P = 2.2×10(-9)); NBPF1 was also significantly associated with BAVM in gene-based analysis using both PennCNV and Birdsuite. We experimentally validated the 1p36.13 duplication; however, the association did not replicate in an independent cohort of 184 sporadic BAVM cases and 182 controls (OR = 0.81, P = 0.8). Rare CNV analysis did not identify genes significantly associated with BAVM. CONCLUSION We did not identify common CNVs associated with sporadic BAVM that replicated in an independent cohort. Replication in larger cohorts is required to elucidate the possible role of common or rare CNVs in BAVM pathogenesis.
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Affiliation(s)
- Nasrine Bendjilali
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Shantel Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Diana E. Guo
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Pui-Yan Kwok
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, United States of America
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California, United States of America
| | - Jonathan G. Zaroff
- Kaiser Northern California Division of Research, San Francisco, California, United States of America
| | - Stephen Sidney
- Kaiser Northern California Division of Research, San Francisco, California, United States of America
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Bobby P. C. Koeleman
- Department of Medical Genetics, University Medical Center, Utrecht, The Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht, The Netherlands
| | - William L. Young
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
| | - Ludmila Pawlikowska
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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Gabarrós Canals A, Rodríguez-Hernández A, Young WL, Lawton MT. Temporal lobe arteriovenous malformations: anatomical subtypes, surgical strategy, and outcomes. J Neurosurg 2013; 119:616-28. [PMID: 23848823 DOI: 10.3171/2013.6.jns122333] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Descriptions of temporal lobe arteriovenous malformations (AVMs) are inconsistent. To standardize reporting, the authors blended existing descriptions in the literature into an intuitive classification with 5 anatomical subtypes: lateral, medial, basal, sylvian, and ventricular. The authors' surgical experience with temporal lobe AVMs was reviewed according to these subtypes. METHODS Eighty-eight patients with temporal lobe AVMs were treated surgically. RESULTS Lateral temporal lobe AVMs were the most common (58 AVMs, 66%). Thirteen AVMs (15%) were medial, 9 (10%) were basal, and 5 (6%) were sylvian. Ventricular AVMs were least common (3 AVMs, 3%). A temporal craniotomy based over the ear was used in 64%. Complete AVM resection was achieved in 82 patients (93%). Four patients (5%) died in the perioperative period (6 in all were lost to follow-up); 71 (87%) of the remaining 82 patients had good outcomes (modified Rankin Scale scores 0-2); and 68 (83%) were unchanged or improved after surgery. CONCLUSIONS Categorization of temporal AVMs into subtypes can assist with surgical planning and also standardize reporting. Lateral AVMs are the easiest to expose surgically, with circumferential access to feeding arteries and draining veins at the AVM margins. Basal AVMs require a subtemporal approach, often with some transcortical dissection through the inferior temporal gyrus. Medial AVMs are exposed tangentially with an orbitozygomatic craniotomy and transsylvian dissection of anterior choroidal artery and posterior cerebral artery feeders in the medial cisterns. Medial AVMs posterior to the cerebral peduncle require transcortical approaches through the temporo-occipital gyrus. Sylvian AVMs require a wide sylvian fissure split and differentiation of normal arteries, terminal feeding arteries, and transit arteries. Ventricular AVMs require a transcortical approach through the inferior temporal gyrus that avoids the Meyer loop. Surgical results with temporal lobe AVMs are generally good, and classifying them does not offer any prediction of surgical risk.
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Affiliation(s)
- Andreu Gabarrós Canals
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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Rodríguez-Hernández A, Kim H, Pourmohamad T, Young WL, Lawton MT. Cerebellar arteriovenous malformations: anatomic subtypes, surgical results, and increased predictive accuracy of the supplementary grading system. Neurosurgery 2013; 71:1111-24. [PMID: 22986595 DOI: 10.1227/neu.0b013e318271c081] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anatomic diversity among cerebellar arteriovenous malformations (AVMs) calls for a classification that is intuitive and surgically informative. Selection tools like the Spetzler-Martin grading system are designed to work best with cerebral AVMs but have shortcomings with cerebellar AVMs. OBJECTIVE To define subtypes of cerebellar AVMs that clarify anatomy and surgical management, to determine results according to subtypes, and to compare predictive accuracies of the Spetzler-Martin and supplementary systems. METHODS From a consecutive surgical series of 500 patients, 60 had cerebellar AVMs, 39 had brainstem AVMs and were excluded, and 401 had cerebral AVMs. RESULTS Cerebellar AVM subtypes were as follows: 18 vermian, 13 suboccipital, 12 tentorial, 12 petrosal, and 5 tonsillar. Patients with tonsillar and tentorial AVMs fared best. Cerebellar AVMs presented with hemorrhage more than cerebral AVMs (P < .001). Cerebellar AVMs were more likely to drain deep (P = .04) and less likely to be eloquent (P < .001). The predictive accuracy of the supplementary grade was better than that of the Spetzler-Martin grade with cerebellar AVMs (areas under the receiver-operating characteristic curve, 0.74 and 0.59, respectively). The predictive accuracy of the supplementary system was consistent for cerebral and cerebellar AVMs, whereas that of the Spetzler-Martin system was greater with cerebral AVMs. CONCLUSION Patients with cerebellar AVMs present with hemorrhage more often than patients with cerebral AVMs, justifying an aggressive treatment posture. The supplementary system is better than the Spetzler-Martin system at predicting outcomes after cerebellar AVM resection. Key components of the Spetzler-Martin system such as venous drainage and eloquence are distorted by cerebellar anatomy in ways that components of the supplementary system are not.
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Affiliation(s)
- Ana Rodríguez-Hernández
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0112, USA
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Zaroff JG, Leong J, Kim H, Young WL, Cullen SP, Rao VA, Sorel M, Quesenberry CP, Sidney S. Cardiovascular predictors of long-term outcomes after non-traumatic subarachnoid hemorrhage. Neurocrit Care 2013; 17:374-81. [PMID: 21769457 DOI: 10.1007/s12028-011-9592-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac injury is common after subarachnoid hemorrhage (SAH) and is associated with adverse early outcomes, but long-term effects are unknown. The first aim of this study was to compare the long-term rates of death, stroke, and cardiac events in SAH survivors versus a matched population without SAH. The second aim was to quantify the effects of cardiac injury on the outcome rates. METHODS This was a retrospective cohort study of patients with and without non-traumatic SAH. For aim #1, the predictor variable was SAH and the outcome variables were all-cause and cerebrovascular mortality, stroke, cardiac mortality, acute coronary syndrome (ACS), and heart failure (HF) admission. A multivariable Cox proportional hazards analysis was performed. For aim #2, the predictor variables were cardiac injury (elevated serum cardiac enzymes or a diagnosis code for ACS) and dysfunction (pulmonary edema on X-Ray or a diagnosis code for HF). RESULTS Compared with 4,695 members without SAH, the 910 SAH patients had higher rates of all-cause mortality (hazard ratio [HR 2.6], 95% confidence intervals [CI] 2.0-3.4), cerebrovascular mortality (HR 30.6, CI 13.5-69.4), and stroke (HR 10.2, CI 7.5-13.8). Compared with the non-SAH group, the SAH patients with cardiac injury had increased rates of all-cause mortality (HR 5.3, CI 3.0-9.3), cardiac mortality (HR 7.3, CI 1.7-31.6), and heart failure (HR 4.3, CI 1.53-11.88). CONCLUSIONS SAH survivors have increased long-term mortality and stroke rates compared with a matched non-SAH population. SAH-induced cardiac injury is associated with an increased risk of death and heart failure hospitalization.
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Affiliation(s)
- Jonathan G Zaroff
- Kaiser Northern California Division of Research, San Francisco, CA, USA.
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Degos V, Gourraud PA, Tursis VT, Whelan R, Colonne C, Korinek AM, Clarençon F, Boch AL, Nouet A, Young WL, Apfel CC, Puybasset L. Elderly age as a prognostic marker of 1-year poor outcome for subarachnoid hemorrhage patients through its interaction with admission hydrocephalus. Anesthesiology 2013; 117:1289-99. [PMID: 22854979 DOI: 10.1097/aln.0b013e318267395b] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An increasing number of elderly patients are treated for aneurysmal subarachnoid hemorrhage. Given that elderly age is associated with both poor outcome and an increased risk of hydrocephalus, we sought to investigate the interaction between age and hydrocephalus in outcome prediction. METHODS We enrolled 933 consecutive patients treated for subarachnoid hemorrhage between 2002 and 2010 and followed them for 1 yr after intensive care unit discharge. We first performed stepwise analyses to determine the relationship among neurologic events, elderly age (60 or more yr old), and 1-yr poor outcome (defined as Rankin 4-6). Within the most parsimonious model, we then tested for interaction between admission hydrocephalus and elderly age. Finally, we tested the association between age as a stratified variable and 1-yr poor outcome for each subgroup of patients with neurologic events. RESULTS 24.1% (n=225) of subarachnoid hemorrhage patients were 60 yr old or more and 19.3% (n=180) had 1-yr poor outcomes. In the most parsimonious model (area under the receiver operating characteristic curve, 0.84; 95% CI: 0.82 to 0.88; P<0.001), elderly age and admission hydrocephalus were two independent predictors for 1-yr outcome (P<0.001 and P=0.004, respectively). Including the significant interaction between age and hydrocephalus (P=0.04) improved the model's outcome prediction (P=0.03), but elderly age was no longer a significant predictor. Finally, stratified age was associated with 1-yr poor outcome for hydrocephalus patients (P=0.007), but not for patients without hydrocephalus (P=0.87). CONCLUSION In this observational study, elderly age and admission hydrocephalus predicted poor outcome, but elderly age without hydrocephalus did not. An external validation, however, will be needed to generalize this finding.
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Affiliation(s)
- Vincent Degos
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
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Akers AL, Ball KL, Clancy M, Comi AM, Faughnan ME, Gopal-Srivastava R, Jacobs TP, Kim H, Krischer J, Marchuk DA, McCulloch CE, Morrison L, Moses M, Moy CS, Pawlikowska L, Young WL. Brain Vascular Malformation Consortium: Overview, Progress and Future Directions. J Rare Disord 2013; 1:5. [PMID: 25221778 PMCID: PMC4160161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Brain vascular malformations are resource-intensive to manage effectively, are associated with serious neurological morbidity, lack specific medical therapies, and have no validated biomarkers for disease severity and progression. Investigators have tended to work in "research silos" with suboptimal cross-communication. We present here a paradigm for interdisciplinary collaboration to facilitate rare disease research. The Brain Vascular Malformation Consortium (BVMC) is a multidisciplinary, inter-institutional group of investigators, one of 17 consortia in the Office of Rare Disease Research Rare Disease Clinical Research Network (RDCRN). The diseases under study are: familial Cerebral Cavernous Malformations type 1, common Hispanic mutation (CCM1-CHM); Sturge-Weber Syndrome (SWS); and brain arteriovenous malformation in hereditary hemorrhagic telangiectasia (HHT). Each project is developing biomarkers for disease progression and severity, and has established scalable, relational databases for observational and longitudinal studies that are stored centrally by the RDCRN Data Management and Coordinating Center. Patient Support Organizations (PSOs) are a key RDCRN component in the recruitment and support of participants. The BVMC PSOs include Angioma Alliance, Sturge Weber Foundation, and HHT Foundation International. Our networks of clinical centers of excellence in SWS and HHT, as well as our PSOs, have enhanced BVMC patient recruitment. The BVMC provides unique and valuable resources to the clinical neurovascular community, and recently reported findings are reviewed. Future planned studies will apply successful approaches and insights across the three projects to leverage the combined resources of the BVMC and RDCRN in advancing new biomarkers and treatment strategies for patients with vascular malformations.
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Affiliation(s)
| | | | | | - Anne M Comi
- Hugo Moser Kennedy Krieger Research Institute; Departments of Neurology and Pediatrics at the Johns Hopkins School of Medicine, Baltimore, MD
| | - Marie E Faughnan
- Toronto HHT Centre, Division of Respirology, Department of Medicine, St Michael's Hospital, University of Toronto and Keenan Research Centre and the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | | | | | - Helen Kim
- Center for Cerebrovascular Research, Departments of Anesthesia and Perioperative Care, Neurological Surgery, Neurology, and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | | | | | - Charles E McCulloch
- Center for Cerebrovascular Research, Departments of Anesthesia and Perioperative Care, Neurological Surgery, Neurology, and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Leslie Morrison
- Department of Neurology, University of New Mexico, Albuquerque, NM
| | | | | | - Ludmilla Pawlikowska
- Center for Cerebrovascular Research, Departments of Anesthesia and Perioperative Care, Neurological Surgery, Neurology, and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - William L Young
- Center for Cerebrovascular Research, Departments of Anesthesia and Perioperative Care, Neurological Surgery, Neurology, and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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Pavlakis SG, Young WL. Isak Prohovnik (1950 to 2012). J Neurosurg Anesthesiol 2013. [DOI: 10.1097/ana.0b013e3182840fd2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hasan DM, Chalouhi N, Jabbour P, Dumont AS, Kung DK, Magnotta VA, Young WL, Hashimoto T, Richard Winn H, Heistad D. Evidence that acetylsalicylic acid attenuates inflammation in the walls of human cerebral aneurysms: preliminary results. J Am Heart Assoc 2013; 2:e000019. [PMID: 23525414 PMCID: PMC3603234 DOI: 10.1161/jaha.112.000019] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Inflammatory cells and molecules may play a critical role in formation and rupture of cerebral aneurysms. Recently, an epidemiologic study reported that acetylsalicylic acid (ASA) decreases the risk of aneurysm rupture. The goal of this study was to determine the effects of ASA on inflammatory cells and molecules in the walls of human cerebral aneurysms, using radiographic and histological techniques. Methods and Results Eleven prospectively enrolled patients harboring unruptured intracranial aneurysms were randomized into an ASA‐treated (81 mg daily) group (n=6) and an untreated (control) group (n=5). Aneurysms were imaged at baseline using ferumoxytol‐enhanced MRI to estimate uptake by macrophages. After 3 months, patients were reimaged before undergoing microsurgical clipping. Aneurysm tissues were collected for immunostaining with monoclonal antibodies for cyclooxygenase‐1 (COX‐1), cyclooxygenase‐2 (COX‐2), microsomal prostaglandin E2 synthase‐1 (mPGES‐1), and macrophages. A decrease in signal intensity on ferumoxytol‐enhanced MRI was observed after 3 months of ASA treatment. Expression of COX‐2 (but not COX‐1), mPGES‐1, and macrophages was lower in the ASA group than in the control group. Conclusions This study provides preliminary radiographical and histological evidence that ASA may attenuate the inflammatory process in the walls of human cerebral aneurysms. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01710072.
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Affiliation(s)
- David M Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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37
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Hasan DM, Chalouhi N, Jabbour P, Magnotta VA, Kung DK, Young WL. Imaging aspirin effect on macrophages in the wall of human cerebral aneurysms using ferumoxytol-enhanced MRI: preliminary results. J Neuroradiol 2013; 40:187-91. [PMID: 23428244 DOI: 10.1016/j.neurad.2012.09.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/17/2012] [Accepted: 09/30/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Daily intake of aspirin was shown to decrease human cerebral aneurysm rupture by 60%. The feasibility of imaging macrophages in human cerebral aneurysm walls using ferumoxytol-enhanced MRI has been demonstrated. The goal of the present study is to image aspirin effect on macrophages in the wall of human cerebral aneurysm using ferumoxytol-enhanced MRI. MATERIAL AND METHODS Five patients with known intracranial aneurysms underwent baseline imaging using T2(*) gradient-echo and T1 MRI sequences using ferumoxytol-enhanced MRI 72-hour post-ferumoxytol infusion. Patients then received 81 mg aspirin per os daily. After 3 months, imaging studies were repeated and analyzed by co-registration using a histogram and subtraction of follow-up images from baseline. RESULTS In all five patients, after 3 months of treatment with aspirin, the signal intensity corresponding to the uptake of ferumoxytol by macrophages in the aneurysm wall was less intense than in the baseline images. This was confirmed by co-registration of images using histogram and subtraction of follow-up images from baseline. CONCLUSION These preliminary results suggest the feasibility of imaging aspirin effect on macrophages localized in the wall of human cerebral aneurysm using ferumoxytol-enhanced MRI. The findings provide radiographic evidence of decreased inflammation in human cerebral aneurysms with daily intake of aspirin using macrophages as a surrogate marker for inflammation.
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Affiliation(s)
- David M Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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38
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Abstract
Background and Objective:
Endoglin (Eng) deficiency causes hereditary hemorrhagic telangiectasia (HHT) and impairs myocardial repair. Pulmonary arteriovenous malformations in HHT patients are associated with a high incidence of paradoxical embolism in the cerebral circulation and ischemic brain injury. We hypothesized that Eng deficiency exacerbates ischemic brain injury.
Methods:
Eng heterozygous (
Eng
+/-
) mice and wild type (WT) mice underwent permanent distal middle cerebral artery occlusion (pMCAO). Infarct volume and CD68
+
cells were quantified 3 days and vascular density was determined 60 days after pMCAO. Behavior was assessed by corner test and adhesive removal test at 3, 15, 30 and 60 days after pMCAO. Matrix metalloproteinase 9
(Mmp9)
and
Notch1
expression in bone marrow (BM)-derived macrophages from
Eng
+/-
and WT were analyzed using real-time RT-PCR.
Results:
Eng
+/-
mice had a larger Infarct volume than WT mice (22±6% of the affected hemisphere vs. 16±6%, p=0.04).
Eng
+/-
mice had longer adhesive-removal time (p<0.05) and more frequent turning to the lesion side than WT mice at 15, 30 and 60 days (p<0.05) after pMCAO. Both groups had similar numbers of CD68
+
cells in the peri-infarct area at 3 days after pMCAO (370±80 vs 338±44 cells/mm
2
, p=0.37), but
Eng
+/-
mice had lower peri-infarct vessel density (417±69 vs 490±52 vessels/mm
2
, p=0.05) at 60 days after pMCAO. Up-regulation of
Mmp9
and
Notch1
expression in response to VEGF was attenuated in
Eng
+/-
BM-derived macrophages.
Conclusions:
Endoglin deficiency exacerbated brain injury and behavior dysfunction in mice after pMCAO and was associated with reduced angiogenesis. Although macrophage homing was not affected, reduced expression of two angiogenic-related genes,
Mmp9
and
Notch1
, by
Eng
+/-
BM-derived macrophages suggests a potential role of these cells in recovery from an ischemic injury.
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Affiliation(s)
- Fanxia Shen
- Univ of California, San Francisco, San Francisco, CA
| | - Vincent Degos
- Univ of California, San Francisco, San Francisco, CA
| | - Zhenying Han
- Univ of California, San Francisco, San Francisco, CA
| | - Eun-Jung Choi
- Univ of California, San Francisco, San Francisco, CA
| | | | - Hua Su
- Univ of California, San Francisco, San Francisco, CA
| |
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39
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Bendjilali N, Nelson J, Weinsheimer S, Sidney S, Zaroff JG, Segal M, Pawlikowska L, McCulloch CE, Young WL, Kim H. Abstract TMP30: Genetic Variants on 9p21.3 are Associated with Brain Arteriovenous Malformations with Associated Arterial Aneurysms. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atmp30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The 9p21.3 locus is associated with risk of coronary artery disease and intracranial and abdominal aortic aneurysms (rs10757278). We investigated whether previously reported 9p21.3 SNPs are associated with risk of brain arteriovenous malformations (BAVM), which often have accompanying flow-related arterial aneurysms.
Methods:
Genotypes for 6 SNPs, including rs10757278, were imputed using 1000 Genomes Phase 1 CEU data (R2>0.9). We tested for association using logistic regression of imputed dosages adjusting for age, sex and top 3 components of ancestry in 338 BAVM cases vs. 504 controls. Of these, 205 cases had aneurysm data available for subgroup analysis: (a) 74 BAVM+(with) aneurysm cases vs. 504 controls, and (b) 131 BAVM-(without) aneurysm cases vs. 504 controls.
Results:
rs10757278-G was marginally associated with increased risk of BAVM (OR=1.23, 95% CI=0.99-1.53, P=0.064). Compared to controls, the association was stronger in BAVM+aneurysm (OR=1.52, 95% CI=1.03-2.22, P=0.032) than in BAVM-aneurysm cases (OR=0.98, 95% CI=0.72-1.34, P=0.91). Similar effects were observed for other SNPs in linkage disequilibrium (r2>0.8) with rs10757278 (Table).
Conclusion:
Common 9p21.3 variants showed similar effect sizes as previously reported for aneurysmal disease. The SNP association with BAVM appears to be explained by known association with aneurysms, suggesting that BAVM associated aneurysms share similar vascular pathology mechanisms.
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Affiliation(s)
| | | | | | - Stephen Sidney
- Div of Rsch, Kaiser Permanente Med Care Program of Northern California (KPNC), Oakland, CA
| | - Jonathan G Zaroff
- Div of Rsch, Kaiser Permanente Med Care Program of Northern California (KPNC), Oakland, CA
| | - Mark Segal
- Univ of California, San Francisco, San Francisco, CA
| | | | | | | | - Helen Kim
- Univ of California, San Francisco, San Francisco, CA
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40
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Abstract
Background and Purpose:
VEGF stimulation induced dysplasia vessel formation in the
Alk1
-deficient brain. The dysplastic vessels had less mural cell coverage associated with increased extravasation of blood contents. Platelet-derived growth factor B (PDGFB) signaling is important in mural cell recruitment during angiogenesis. Notch signaling is upstream of PDGFB. We hypothesized that
Alk1
deletion impairs pericyte recruitment through downregulation of DLL4/PDGFB signaling. Thalidomide can increase PDGFB expression and was used to test our hypothesis in vivo.
Methods:
Human brain microvascular endothelial cells (HBMECs) were infected with a lentiviral vector carrying
ALK1
shRNA. Cells with 80% reduction of
ALK1
gene expression were treated with vascular endothelial growth factor (VEGF; 0, 10, 50, and 100 ng/ml) for 18 hours.
DLL4
and
PDGFB
mRNA were measured using real-time PCR. Pericyte-recruitment was evaluated by co-culturing pericytes with HBMECs. Cerebrovascular dysplasia was induced by co-injection of an adenoviral vector expressing cre-recombinase and an adeno-associated viral vector expressing VEGF into the basal ganglia of
Alk1
-floxed mice. Two weeks later, thalidomide (75 mg/kg, i.p.) or DMSO was administered twice per week for six weeks.
Results:
Knockdown of
ALK1
attenuated the increase of DLL4 and PDGFB in HBMECs following VEGF stimulation.
DLL4
and
PDGFB
expression was highly correlated (R
2
= 0.93).
ALK1
knockdown reduced the ability of HBMEC to recruit pericytes (P = 0.014). In vivo, thalidomide treatment significantly reduced vascular dysplasia (dysplastic vessels: thalidomide vs. DMSO, 3.4±1.2/200 vessels vs. 1.0±0.5, P = 0.003), without affecting vessel density (P = 0.11). Smooth muscle-negative dysplastic vessels decreased in thalidomide-treated mice, compared to DMSO-treated mice (21%±6 vs 47±9, P = 0.0002). Prussian blue-positive area was reduced in the thalidomide group, compared to the DMSO group (P = 0.0011).
Conclusions:
Our findings suggest that
Alk1
regulates pericyte recruitment through DLL4/PDGFB signaling during brain angiogenesis.
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Affiliation(s)
- Wanqiu Chen
- Univ of California, San Francisco, San Francisco, CA
| | - Yi Guo
- Univ of California, San Francisco, San Francisco, CA
| | - Kristine Jun
- Univ of California, San Francisco, San Francisco, CA
| | | | - Hua Su
- Univ of California, San Francisco, San Francisco, CA
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41
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Mao L, Shen F, Chen W, Akinpelu B, Lawton MT, Young WL, Su H. Abstract TMP116: AAV-sFLT: A Potential Therapeutic Agent for the Treatment of Brain Angiogenic Diseases. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atmp116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
The soluble vascular endothelial growth factor (VEGF) receptor 1 (sFLT) has been tested in both animals and humans for anti-angiogenic therapy, e.g., age-related macular degeneration. We hypothesized that adeno-associated viral vector (AAV)-mediated sFLT expression could be used to treat brain angiogenic diseases, such as brain arteriovenous malformation (bAVM). We tested the anti-angiogenic effect of sFLT and the feasibility of using AAV serotype 9 to deliver AAV-sFLT by intravenous injection (IV) to brain angiogenic lesions.
Methods:
AAV vectors were packaged in AAV serotypes 1 and 2 (stereotactic injection) and 9 (IV-injection). Angiogenic model was induced in adult wildtype (WT) mice through stereotactic injection of AAV1-VEGF (2×10
9
genome copies (gcs)). Brain AVM model was induced in adult mice with floxed Alk1 (a causative gene for hereditary hemorrhagic telangiectasia that causes AVMs in multiple organs) through co-injection of AAV1-VEGF and Ad-Cre. AAV2-sFLT (2×10
9
gcs) was co-injected with AAV1-VEGF to inhibit brain angiogenesis. Gene expression in the brain by IV-delivered AAV9 was tested using intra-jugular vein injection of AAV9-LacZ or AAV9-GFP (1×10
11
gcs). We then compared gene expression mediated by stereotactic injection of AAV1 and by 2 packaged AAV-LacZ vectors.
Results:
Co-injection of AAV2-sFLT with AAV1-VEGF completely abolished VEGF-angiogenic effect (320±30/mm
2
vs 434±86 p=0.01). The vessel density around the injection sites was similar to AAV1-LacZ-injected control mice (p=0.84). AAV2-EV (empty virus) had no effect. Intravenous injection of AAV9-LacZ or AAV9-GFP resulted in a higher level of gene expression in the angiogenic foci or bAVM than in normal brain tissues. Gene expression mediated by AAV1 was about 5 times higher than AAV2.
Conclusion:
AAV mediated sFLT expression inhibited VEGF-induced brain angiogenesis. The sFLT anti-angiogenic effect can be achieved at about 1 to 5 molar ratio of sFLT vs. VEGF. Intravenously injected AAV9 can mediate effective transgene expression in brain angiogenic lesions.
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Affiliation(s)
- Lei Mao
- Univ of California, San Francisco, San Francisco, CA
| | - Fanxia Shen
- Univ of California, San Francisco, San Francisco, CA
| | - Wanqiu Chen
- Univ of California, San Francisco, San Francisco, CA
| | | | | | | | - Hua Su
- Univ of California, San Francisco, San Francisco, CA
| |
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Choi EJ, Walker EJ, Degos V, Jun K, Kuo R, Pile-Spellman J, Su H, Young WL. Endoglin deficiency in bone marrow is sufficient to cause cerebrovascular dysplasia in the adult mouse after vascular endothelial growth factor stimulation. Stroke 2013; 44:795-8. [PMID: 23306322 DOI: 10.1161/strokeaha.112.671974] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Bone marrow-derived cells (BMDCs) home to vascular endothelial growth factor (VEGF)-induced brain angiogenic foci, and VEGF induces cerebrovascular dysplasia in adult endoglin heterozygous (Eng(+/-)) mice. We hypothesized that Eng(+/-) BMDCs cause cerebrovascular dysplasia in the adult mouse after VEGF stimulation. METHODS BM transplantation was performed using adult wild-type (WT) and Eng(+/-) mice as donors/recipients. An adeno-associated viral vector expressing VEGF was injected into the basal ganglia 4 weeks after transplantation. Vascular density, dysplasia index (vessels >15 µm/100 vessels), and BMDCs in the angiogenic foci were analyzed. RESULTS The dysplasia index of WT/Eng(+/-) BM mice was higher than WT/WT BM mice (P<0.001) and was similar to Eng(+/-)/Eng(+/-) BM mice (P=0.2). Dysplasia in Eng(+/-) mice was partially rescued by WT BM (P<0.001). WT/WT BM and WT/Eng(+/-) BM mice had similar numbers of BMDCs in the angiogenic foci (P=0.4), most of which were CD68(+). Eng(+/-) monocytes/macrophages expressed less matrix metalloproteinase-9 and Notch1. CONCLUSIONS Endoglin-deficient BMDCs are sufficient for VEGF to induce vascular dysplasia in the adult mouse brain. Our data support a previously unrecognized role of BM in the development of cerebrovascular malformations.
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Affiliation(s)
- Eun-Jung Choi
- UCSF, Department of Anesthesia and Perioperative Care, San Francisco, CA 94110, USA
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43
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Shen F, Kuo R, Milon-Camus M, Han Z, Jiang L, Young WL, Su H. Intravenous delivery of adeno-associated viral vector serotype 9 mediates effective gene expression in ischemic stroke lesion and brain angiogenic foci. Stroke 2012; 44:252-4. [PMID: 23250995 DOI: 10.1161/strokeaha.112.662965] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Adeno-associated viral vector (AAV) is a powerful tool for delivering genes to treat brain diseases. Intravenous delivery of a self-complementary but not single-stranded AAV9 (ssAAV9) mediates robust gene expression in the adult brain. We tested if ssAAV9 effectively mediates gene expression in the ischemic stroke lesion and angiogenic foci. METHODS Focal ischemic stroke was induced by permanent occlusion of the left middle cerebral artery (MCAO) and focal angiogenesis was induced by injecting an AAV expressing vascular endothelial growth factor (AAV-VEGF) into the basal ganglia. ssAAV vectors that have cytomegalovirus (CMV) promoter driving (AAV-CMVLacZ) or hypoxia response elements controlling (AAV-H9LacZ) LacZ expression were packaged in AAV9 or AAV1 capsid and injected into mice through the jugular vein 1 hour after MCAO or 4 weeks after the induction of angiogenesis. LacZ gene expression was analyzed in the brain and other organs 5 days after LacZ vector injection. RESULTS LacZ expression was detected in the peri-infarct region of AAV9-CMVLacZ and AAV9-H9LacZ-injected MCAO mice and the brain angiogenic foci of AAV9-CMVLacZ-injected mice. Minimum LacZ expression was detected in the brain of AAV1-CMVLacZ-injected mice. Robust LacZ expression was found in the liver and heart of AAV-CMVLacZ-injected mice, but not in AAV9-H9LacZ-injected mice. CONCLUSIONS ssAAV9 could be a useful tool to deliver therapeutic genes to the ischemic stroke lesion or brain angiogenic foci.
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Affiliation(s)
- Fanxia Shen
- University of California, San Francisco, Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, San Francisco, CA 94110, USA
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44
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Chen W, Guo Y, Walker EJ, Shen F, Jun K, Oh SP, Degos V, Lawton MT, Tihan T, Davalos D, Akassoglou K, Nelson J, Pile-Spellman J, Su H, Young WL. Reduced mural cell coverage and impaired vessel integrity after angiogenic stimulation in the Alk1-deficient brain. Arterioscler Thromb Vasc Biol 2012; 33:305-10. [PMID: 23241407 DOI: 10.1161/atvbaha.112.300485] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Vessels in brain arteriovenous malformations are prone to rupture. The underlying pathogenesis is not clear. Hereditary hemorrhagic telangiectasia type 2 patients with activin receptor-like kinase 1 (Alk1) mutation have a higher incidence of brain arteriovenous malformation than the general population. We tested the hypothesis that vascular endothelial growth factor impairs vascular integrity in the Alk1-deficient brain through reduction of mural cell coverage. METHODS AND RESULTS Adult Alk1(1f/2f) mice (loxP sites flanking exons 4-6) and wild-type mice were injected with 2×10(7) PFU adenovious-cre recombinase and 2×10(9) genome copies of adeno-associated virus-vascular endothelial growth factor to induce focal homozygous Alk1 deletion (in Alk1(1f/2f) mice) and angiogenesis. Brain vessels were analyzed 8 weeks later. Compared with wild-type mice, the Alk1-deficient brain had more fibrin (99±30×10(3) pixels/mm(2) versus 40±13×10(3); P=0.001), iron deposition (508±506 pixels/mm(2) versus 6±49; P=0.04), and Iba1(+) microglia/macrophage infiltration (888±420 Iba1(+) cells/mm(2) versus 240±104 Iba1(+); P=0.001) after vascular endothelial growth factor stimulation. In the angiogenic foci, the Alk1-deficient brain had more α-smooth muscle actin negative vessels (52±9% versus 12±7%, P<0.001), fewer vascular-associated pericytes (503±179/mm(2) versus 931±115, P<0.001), and reduced platelet-derived growth factor receptor-β expression. CONCLUSIONS Reduction of mural cell coverage in response to vascular endothelial growth factor stimulation is a potential mechanism for the impairment of vessel wall integrity in hereditary hemorrhagic telangiectasia type 2-associated brain arteriovenous malformation.
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MESH Headings
- Actins/metabolism
- Activin Receptors, Type I/deficiency
- Activin Receptors, Type I/genetics
- Activin Receptors, Type II
- Animals
- Becaplermin
- Blood Vessels/enzymology
- Blood Vessels/pathology
- Brain/blood supply
- Dependovirus/genetics
- Disease Models, Animal
- Fibrin/metabolism
- Gene Transfer Techniques
- Genetic Vectors
- Iron/metabolism
- Macrophages/metabolism
- Macrophages/pathology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Microglia/metabolism
- Microglia/pathology
- Neovascularization, Pathologic
- Pericytes/enzymology
- Pericytes/pathology
- Proto-Oncogene Proteins c-sis/metabolism
- Receptor, Platelet-Derived Growth Factor beta/metabolism
- Telangiectasia, Hereditary Hemorrhagic/enzymology
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Telangiectasia, Hereditary Hemorrhagic/pathology
- Vascular Endothelial Growth Factor A/genetics
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- Wanqiu Chen
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA 94110, USA
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45
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Potts MB, Chang EF, Young WL, Lawton MT. Transsylvian-transinsular approaches to the insula and basal ganglia: operative techniques and results with vascular lesions. Neurosurgery 2012; 70:824-34; discussion 834. [PMID: 21937930 DOI: 10.1227/neu.0b013e318236760d] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lesions in the insula and basal ganglia can be risky to resect because of their depth and proximity to critical structures, particularly in the dominant hemisphere. Transsylvian approaches shorten the surgical distance to these lesions, preserve perisylvian temporal and frontal cortex, and minimize brain transgression. OBJECTIVE To report our experience with transsylvian-transinsular approaches to vascular lesions. METHODS The anterior approach opened the sphenoidal and insular portions of the sylvian fissure and exposed the limen insulae and short gyri, whereas the posterior approach opened the insular and opercular portions of the sylvian fissure and exposed the circular sulcus and long gyri. RESULTS Forty-one patients with vascular lesions (24 arteriovenous malformations [AVMs] and 17 cavernous malformations) were treated surgically with a transsylvian-transinsular approach. Complete resection was obtained in 87.5% of AVMs and 95% of cavernous malformations. Permanent neurological morbidity related to surgery was observed in 2 AVM patients (5%), with the remaining 39 patients (95%) improved or unchanged postoperatively (modified Rankin Scale scores 0-2 in 83%). There were no new language deficits in patients with dominant hemisphere lesions. CONCLUSION Transsylvian-transinsular approaches safely expose vascular pathology in or deep to the insula while preserving overlying eloquent cortex in the frontal and temporal lobes. The anterior transsylvian-transinsular approach can be differentiated from the posterior approach based on technical differences in splitting the sylvian fissure and anatomic differences in final exposure. Discriminating patient selection and careful microsurgical technique are essential.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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46
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Hasan D, Chalouhi N, Jabbour P, Dumont AS, Kung DK, Magnotta VA, Young WL, Hashimoto T, Winn HR, Heistad D. Early change in ferumoxytol-enhanced magnetic resonance imaging signal suggests unstable human cerebral aneurysm: a pilot study. Stroke 2012; 43:3258-65. [PMID: 23138441 DOI: 10.1161/strokeaha.112.673400] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The clinical significance of early (ie, within the first 24 hours) uptake of ferumoxytol by macrophages in the wall of human cerebral aneurysms is not clear. The purpose of this study was to determine whether early uptake of ferumoxytol suggests unstable cerebral aneurysm. METHODS Thirty unruptured aneurysms in 22 patients were imaged with magnetic resonance imaging 24 hours after infusion of ferumoxytol. Eighteen aneurysms were also imaged 72 hours after infusion of ferumoxytol. Aneurysm dome tissue was collected from 4 patients with early magnetic resonance imaging signal changes, 5 patients with late signal changes, and 5 other patients with ruptured aneurysms. The tissue was immunostained for expression of cyclooxygenase-1, cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages. RESULTS In 23% (7/30) of aneurysms, there was pronounced early uptake of ferumoxytol. Four aneurysms were clipped. The remaining 3 aneurysms were managed conservatively; all 3 ruptured within 6 months. In 53% (16 of 30) of aneurysms, there was pronounced uptake of ferumoxytol at 72 hours. Eight aneurysms were surgically clipped, and 8 were managed conservatively; none ruptured or increased in size after 6 months. Expression of cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages was similar in unruptured aneurysms with early uptake of ferumoxytol and ruptured aneurysms. Expression of these inflammatory molecules was significantly higher in aneurysms with early uptake of ferumoxytol versus aneurysms with late uptake. CONCLUSIONS Uptake of ferumoxytol in aneurysm walls within the first 24 hours strongly suggests aneurysm instability and probability of rupture within 6 months, and may warrant urgent intervention.
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Affiliation(s)
- David Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JCP 1616, Iowa City, IA 52242, USA.
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47
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Nishida T, Faughnan ME, Krings T, Chakinala M, Gossage JR, Young WL, Kim H, Pourmohamad T, Henderson KJ, Schrum SD, James M, Quinnine N, Bharatha A, Terbrugge KG, White RI. Brain arteriovenous malformations associated with hereditary hemorrhagic telangiectasia: gene-phenotype correlations. Am J Med Genet A 2012; 158A:2829-34. [PMID: 22991266 DOI: 10.1002/ajmg.a.35622] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 07/26/2012] [Indexed: 11/06/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disease with a wide spectrum of vascular malformations (VMs) involving multiple organs. Nine to 16% of patients with HHT harbor brain arteriovenous malformations (AVMs), which can cause intracranial hemorrhage (ICH). Our objective was to study clinical manifestations of brain AVMs in patients with HHT and correlate these with the specific gene mutated. We reviewed records of 171 patients with HHT and brain AVMs. A history of ICH was found in 27% (41/152) patients, with a mean age of 26 ± 18 range, (0-68) years. All of patients with ICH were neurologically asymptomatic prior to ICH. Multiple brain AVMs were found in 23% (170/39) of patients on initial examination. Genetic test results were available in 109 (64%) patients. Mutations in ENG, ACVRL1, and SMAD4 were present in 75 (69%), 18 (17%), and 2 (2%), respectively. A history of ICH was reported in 24% of patients with an ENG mutation and 27% of patients with an ACVRL1 mutation, with a mean age of 26 ± 16 (range, 2-50) and 18 ± 21 (0-48) years, respectively. No statistically significant differences in age at first brain AVM diagnosis, prevalence of ICH history, age at ICH, or other manifestations of brain AVMs were observed among gene groups. In conclusion, no evidence for differences in brain AVM characteristics was observed among HHT gene groups, although we cannot exclude clinically important differences. Larger studies are needed to further guide brain AVM screening decisions in patients with HHT.
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Affiliation(s)
- Takeo Nishida
- Yale HHT Center, Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
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Hoffmann A, Bredno J, Wendland MF, Derugin N, Hom J, Schuster T, Zimmer C, Su H, Ohara PT, Young WL, Wintermark M. MRI blood-brain barrier permeability measurements to predict hemorrhagic transformation in a rat model of ischemic stroke. Transl Stroke Res 2012; 3:508-16. [PMID: 24323835 DOI: 10.1007/s12975-012-0212-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 09/03/2012] [Indexed: 10/27/2022]
Abstract
Permeability imaging might add valuable information in the risk assessment of hemorrhagic transformation. This study evaluates the predictive value of blood-brain barrier permeability (BBBP) measurements extracted from dynamic contrast-enhanced MRI for hemorrhagic transformation in ischemic stroke. Spontaneously hypertensive and Wistar rats with 2 h filament occlusion of the right MCA underwent MRI during occlusion, at 4 and 24 h post reperfusion. BBBP was imaged by DCE imaging and quantified by Patlak analysis. Cresyl-violet staining was used to characterize hemorrhage in sacrificed rats at 24 h, immediately following the last imaging study. BBBP changes were evaluated at baseline, 4 and 24 h after reperfusion. Receiver-operating characteristic (ROC) analysis was performed to determine the most accurate BBBP threshold to predict hemorrhagic transformation. In animals showing macroscopic hemorrhage at 24 h, 95th BBBP percentile values ipsilateral were 0.323 [0.260, 0.387], 0.685 [0.385, 0.985], and 0.412 [0.210, 0.613] ml/min·100 g (marginal mean [95%CI]) during occlusion, at 4 and 24 h post reperfusion, respectively. The BBBP values on the infarcted and contralateral side were significantly different at 4 (p = 0.034) and 24 h post reperfusion (p = 0.031). The predictive value of BBBP in terms of macroscopic hemorrhage was highest 4 h after reperfusion (ROC area under the curve = 84 %) with a high negative predictive value (98.3 %) and limited positive predictive value (14.9 %) for a threshold of 0.35 ml/min·100g. Altered BBBP is a necessary but not sufficient condition to cause hemorrhagic transformation in rats with an infarct. Further research is needed to identify those additional risk factors that are required for hemorrhagic transformation to develop in the setting of ischemic stroke.
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Affiliation(s)
- Angelika Hoffmann
- Department of Radiology, Neuroradiology Division, University of Virginia, Box 800170, Charlottesville, VA, 22908, USA
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Englot DJ, Young WL, Han SJ, McCulloch CE, Chang EF, Lawton MT. Seizure predictors and control after microsurgical resection of supratentorial arteriovenous malformations in 440 patients. Neurosurgery 2012; 71:572-80; discussion 580. [PMID: 22592327 PMCID: PMC5815296 DOI: 10.1227/neu.0b013e31825ea3ba] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Seizures are a common symptom of supratentorial arteriovenous malformations (AVMs), and uncontrolled epilepsy can considerably reduce patient quality of life. Potential risk factors for epilepsy in patients with AVMs are poorly understood, and the importance of achieving freedom from seizures in their surgical treatment remains underappreciated. OBJECTIVE To characterize risks factors for preoperative seizures and factors associated with postoperative freedom from seizures in patients with surgically resected supratentorial AVMs. METHODS We analyzed prospectively collected patient data for 440 patients who underwent microsurgical resection of supratentorial AVMs at our institution. RESULTS Among 440 patients with supratentorial AVMs, 130 (30%) experienced preoperative seizures, and 23 (18%) with seizures progressed to medically refractory epilepsy. Seizures were associated with a history of AVM hemorrhage (relative risk, 6.65; 95% confidence interval [CI], 3.81-11.6), male sex (relative risk, 2.07; 95% CI, 1.26-3.39), and frontotemporal lesion location (relative risk, 1.75; 95% CI, 1.05-2.93). After resection, 96% of patients had a modified Engel class I outcome, characterized by freedom from seizures (80%) or only 1 postoperative seizure (16%; mean follow-up, 20.7 ± 2.3 months). Comparable rates of postoperative seizures were seen in patients with (7%) or without (3%) preoperative seizures. AVMs with deep artery perforators were significantly associated with postoperative seizures (hazard ratio, 4.35; 95% CI, 1.61-11.7). CONCLUSION In the microsurgical treatment of supratentorial AVMs, hemorrhage, male sex, and frontotemporal location are associated with higher rates of preoperative seizures, whereas deep artery perforators are associated with postoperative seizures. Achieving freedom from seizure is an important goal that can be achieved in the surgical treatment of AVMs because epilepsy can significantly diminish patient quality of life.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA.
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Davies J, Yanamadala V, Young WL, Lawton MT. 124 In-Hospital Morbidity and Mortality After Treatment of Arteriovenous Malformations in the United States, 2000-2009. Neurosurgery 2012. [DOI: 10.1227/01.neu.0000417714.57720.9f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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