Capillary malformations

Capillary malformation (CM), or port wine birthmark, is a cutaneous congenital vascular anomaly that occurs in 0.1%-2% of newborns. Patients with a CM localized on the forehead have an increased risk of developing a neurocutaneous disorder called encephalotrigeminal angiomatosis or Sturge-Weber syndrome (SWS), with complications including seizure, developmental delay, glaucoma, and vision loss. In 2013, a groundbreaking study revealed causative activating somatic mutations in the gene (GNAQ) encoding guanine nucleotide-binding protein Q subunit α (Gαq) in CM and SWS patient tissues. In this Review, we discuss the disease phenotype, the causative GNAQ mutations, and their cellular origin. We also present the endothelial Gαq-related signaling pathways, the current animal models to study CM and its complications, and future options for therapeutic treatment. Further work remains to fully elucidate the cellular and molecular mechanisms underlying the formation and maintenance of the abnormal vessels.

Safety and efficacy of combined dilation/stenting of venous abnormalities, including complete obstructions, during lead extractions in patients with congenital heart disease

INTRODUCTION

Management of transvenous leads in patients with congenital heart disease (CHD) can be complicated by venous obstructions and residual shunts. We present our experience performing concurrent lead extraction and dilation/stenting of venous pathways, including patients with complete venous obstruction.

METHODS

All cases of concurrent lead extraction and recanalization of vena cavae/baffles between 2017 and 2021 at Boston Children's Hospital were retrospectively included and reviewed for safety and efficacy.

RESULTS

Eight patients, 4 female, median 38.5 years of age (range 16.7-49 years) and 81.6 kg weight (range 41.3-97.8 kg) at time of procedure were included. All patients had CHD, a majority (n = 7) having transposition of the great arteries palliated via atrial switch. All leads were removed in their entirety, with most patients having two leads extracted (n = 7). Median lead dwell time was 13.8 years (range 3.6-35.3 years). Three patients had complete obstructions, three required stenting of their innominate veins and three required recanalization of their femoral vessels. Median procedure time was 9.8 h (range 5.4-12.8 h). Complications included blood transfusion (n = 2), arrhythmia (n = 3), pleural effusion (n = 1), and pressure ulcer (n = 1). There were no cardiac perforations, venous tears, or deaths.

CONCLUSION

Lead extraction along with dilation and stenting of venous anomalies, though long in duration, proved effective with minimal complications. This combined procedure can safely and effectively resolve complete obstructions secondary to transvenous leads.

Arteriovenous malformations as a presenting sign of PTEN hamartoma tumor syndrome: A case series

High-flow vascular malformations have been associated with multiple syndromes including capillary malformation-arteriovenous malformation (CM-AVM) syndrome, hereditary hemorrhagic telangiectasia syndrome, and less commonly, phosphatase and tensin homolog hamartoma tumor syndrome (PHTS). We present a series of three patients with clinically challenging complex AVMs who were found to have underlying PHTS. In all patients, diagnosis was delayed, and the presence of the AVM prompted sampling and genetic testing for PHTS in the absence of other clinical features of the condition. This series highlights the importance of screening for PHTS in the setting of high-flow vascular malformations.

Arterial tortuosity in pediatric Loeys-Dietz syndrome patients

Loeys-Dietz syndrome (LDS) is an autosomal connective tissue disorder commonly presenting with hypertelorism, bifid uvula, aortic aneurysms, and arterial tortuosity. The aim of the present study was to investigate differences in tortuosity index (TI) between genotypes of LDS, possible progression over time and its use as an adjunctive prognostic tool alongside aortic dimensions to aid timely surgical planning in pediatric patients. A retrospective observational study of pediatric LDS patients referred to our center (November 2012-February 2021) was conducted. Using magnetic resonance angiography (MRA) with 3D maximum intensity projection volume-rendered angiogram, arterial TI was measured. Twenty three patients had genetically confirmed LDS with at least one head and neck MRA and 19 had no less than one follow-up MRA available. All patients presented arterial tortuosity. Patients with TGFBR2 variants had greater values of TI compared to patients with TGFB2 variants (p = 0.041). For patients who did not undergo surgery (n = 18), z-scores at the level of the sinus of Valsalva showed a significant correlation with vertebral TI (rs  = 0.547). There was one death during follow-up. This study demonstrates that patients with LDS and TGFBR2 variants have greater values of TI than patients with TGFB2 variants and that greatest values of TI are associated with increased aortic root z-scores. Furthermore, as TI decreases over time, less frequent neuroimaging follow-up can be considered. Nevertheless, additional studies are needed to better define more accurate risk stratification and long-term surveillance in these patients.

Life-threatening pulmonary haemorrhage treated with coil embolisation followed by lobectomy in a patient with KCNT1 mutation

KCNT1 mutations are associated with childhood epilepsy, developmental delay, and vascular malformations. We report a child with a likely pathogenic KCNT1 mutation (c.1885A>C, p.Lys629Glu) with recurrent pulmonary haemorrhage due to aortopulmonary collaterals successfully managed with coil embolisation followed by right upper lobectomy.

Cervical anterior spinal artery infarction associated with anomalous vertebral artery: a case report

We report a unique case of cervical anterior spinal artery (ASA) infarction in a 49-year-old male with hypercholesterolemia and sleep apnea. The patient experienced sudden cervical pain, quadriparesis, areflexia, and urinary incontinence after swallowing a large food bolus. Imaging revealed an infarction at the C3-C5 levels and an anomalous right vertebral artery (VA) originating from the thoracic aorta, tightly enclosed between the aorta and a vertebral column with an anterior osteophyte. This aberrant VA was the primary vascular supply to the ASA, with no contribution from the left VA or supreme intercostal arteries. We propose that transient injury to the right VA, induced by compression between the aortic arch, the food bolus, and the osteophyte, led to temporary hypoperfusion of the ASA, causing a watershed ischemic injury in the mid cervical cord's anterior gray matter. The article also provides an in-depth discussion of the developmental and clinical characteristics associated with this rare vascular anomaly.

Intraosseous hemangioma with aneurysmal bone cyst-like changes of the hyoid bone: Case report and literature review

RATIONALE

Intraosseous hemangioma is a rare benign vascular tumor of the bone that can affect any body part; however, the most common site is the vertebra, followed by calvarial bones.

PATIENT CONCERNS

We present a case of intraosseous hemangioma in a 23-year-old male who presented a feeling of fullness in the throat for 3 months. The hyoid bone level had a hard mass of about 5 cm. Fine needle aspiration showed 5 mL dark bloody aspirates. Magnetic resonance image showed a 5.3 cm mixed signal intensity lesion in the hyoid body.

DIAGNOSIS

Histopathologic examination showed intraosseous hemangioma with aneurysmal bone cyst (ABC)-like changes in the hyoid bone.

INTERVENTIONS

The mass was completely removed without significant problems.

OUTCOMES

Complete mass excision and symptomatic improvements were achieved, and no subsequent relapses were observed.

LESSONS

The authors experienced a case of intraosseous hemangioma with ABC-like changes. There has been no case report of intraosseous hemangioma in the hyoid bone. This case showed a spectral pattern of the ABC-like changes developing from the underlying bone tumor as a secondary change. ABC-like changes in bone tumors can mislead the diagnosis. Careful examination of the tumor is essential for the correct diagnosis of ABC or ABC-like changes.

Rapidly Growing and Ruptured Great Saphenous Vein Aneurysm in a Liver Transplant Patient

Venous aneurysms are rare vascular malformations that can lead to significant clinical complications, including thrombosis, pulmonary embolism, rupture, and even fatal outcomes when not promptly and adequately managed. This case report presents a liver transplant patient under immunosuppressive therapy who developed a rapidly progressing great saphenous vein aneurysm, ultimately requiring urgent surgical intervention due to acute bleeding from the ruptured aneurysm. Immunosuppression emerges as a potential key factor in the formation and rapid growth of the aneurysm, with the pathophysiological mechanism potentially involving increased expression of specific matrix metalloproteinases. Further research is warranted to gain a better understanding of the role of immunosuppression in the development of venous aneurysms.

Factors affecting the ability of patients with complex vascular anomalies to navigate the healthcare system

BACKGROUND

Vascular anomalies (VAs) are rare congenital disorders that can cause pain, disfigurement, coagulopathy, asymmetric growth, and disability. Patients with complex VAs experience multiple barriers to accessing expert care. It is imperative to understand which factors support these patients' ability to navigate the healthcare system.

RESULTS

We surveyed adult patients with VAs using previously validated measures, recruiting participants from five patient advocacy groups and multidisciplinary VA clinics. The primary outcome was self-reported ability to access needed medical care, using the "Navigating the Healthcare System" subscale of the Health Literacy Questionnaire. We evaluated factors associated with the ability to navigate the healthcare system using multivariate linear regression (n = 136). We also performed an exploratory model that included the primary care doctor's knowledge of VAs for the subset of participants with a primary care doctor (n = 114). Participants were predominantly women (n = 90, 66%), White and non-Hispanic (n = 109, 73%), and college-educated (n = 101, 73%). Most participants had PIK3CA-Related Overgrowth Spectrum (n = 107, 78%). Most participants reported that navigating the healthcare system was "sometimes" or "usually difficult" (mean score 16.4/30, standard deviation 5.6). In multivariate linear regression, ability to navigate the healthcare system was associated positively with quality of information exchange (β = 0.38, 95% Confidence Interval (CI) 0.22 to 0.55, p <.001) and whether patients had VA specialists (β = 2.31, 95% CI 0.35 to 4.28, p =.021), but not associated with patient self-advocacy, anxiety, education, age, race and ethnicity, gender, or having a primary care doctor. In exploratory analysis of participants with primary care doctors, ability to navigate the healthcare system was positively associated with quality of information exchange (β = 0.27, 95% CI 0.09 to 0.45, p =.004), having a VA specialist (β = 2.31, 95% CI 0.22 to 4.39, p =.031), and primary care doctors' VA knowledge (β = 0.27, 95% CI 0.04 to 0.50, p =.023).

CONCLUSION

Patients with VAs struggle to navigate the healthcare system. High-quality information from clinicians and more knowledgeable primary care doctors might help patients to access needed care. Relying on patient self-advocacy is insufficient. Future efforts should focus on patient-directed and clinician-directed educational interventions. Additionally, future work should assess the structural barriers that impede healthcare access for these patients.

Giant Congenital Hemangioma of the Skull: Prenatal Diagnosis and Multimodal Endovascular and Surgical Management

Introduction: calvarial capillary hemangiomas are vascular tumors rarely seen in newborns. Differential diagnosis may be not straightforward on imaging studies and the management depends on patient and lesion characteristics. Case report: we present the case of a large congenital intracranial extra-axial lesion detected by routine prenatal US screening, a giant calvarial congenital hemangioma, treated with a multimodal strategy. Neonatal MR showed a hemorrhagic solid lesion, causing compression of brain tissue. Conservative treatment was attempted, but a one-month follow-up MR showed growth of the lesion with increased mass effect. Pre-operative endovascular embolization and surgical resection were performed. The pathology was consistent with intraosseous capillary hemangioma. The post-operative course was uneventful. At the 8-month follow-up, the patient had no clinical deficits and MR showed complete resection of the lesion. At the 13-month follow-up, the patient was asymptomatic, showing normal neurological examination and psychophysical development. Conclusions: although wait-and-see policy is feasible for small and asymptomatic lesions, radical resection is indicated when the mass is large, thus causing severe mass effect on the brain. Hypervascularization of the tumor may be responsible for hemorrhagic complications and severe anemia. On these grounds, endovascular treatment is feasible and effective to reduce hemorrhagic complications.

Delayed ulceration following combination pulse dye laser and topical sirolimus treatment for port wine birthmarks: A case series

Port wine birthmarks (PWB) are capillary vascular malformations within the papillary and reticular dermis, most commonly occurring on the head and neck and may darken and thicken with age. Pulsed dye laser (PDL) is the gold standard of treatment for PWB as it selectively targets involved vessels. Sirolimus is a macrolide antibiotic that selectively inhibits mammalian target of rapamycin, thereby suppressing the angiogenesis pathways that can be activated by PDL. Sirolimus and PDL may be used together to treat PWB. We present a case series describing three cases of delayed ulceration and systemic sirolimus absorption following combination therapy, highlighting a potential complication and patient safety concern.

Para-aortic lymphadenectomy in endometrial cancer patients with left-sided inferior vena cava: A case report and literature review

OBJECTIVE

The incidence of left-sided inferior vena cava (IVC) is extremely low. However, without a preoperative diagnosis of left-sided IVC, the risk of intraoperative vascular injury during para-aortic lymph node (PAN) lymphadenectomy is high.

CASE REPORT

Herein, we present two cases in which left-sided IVCs were diagnosed using preoperative imaging. PAN lymphadenectomies were safely performed in these patients with endometrial cancer. In the first case, the left-sided IVC crossed the abdominal aorta after the left renal and gonadal veins had drained into it and joined the right renal vein. In the second case, the left-sided IVC crossed the abdominal aorta after the left renal and gonadal veins flowed into it and the ascending lumbar vein flowed into the right side.

CONCLUSION

These cases demonstrate that even in the presence of vascular malformations, PAN lymphadenectomy can be performed safely by employing preoperative anatomical imaging analysis and judicious intraoperative surgical maneuvers to avoid vascular injury.

[Intraosseous cavernous hemangioma of the middle turbinate. Clinical cases]

Intraosseous vascular pathology of the turbinates is extremely rare in the practice of an otorhinolaryngologist and can be presented in various histopathological variants. The article presents two clinical cases in which an intraosseous cavernous hemangioma was hidden under the mask of a hypertrophied middle turbinate. The final diagnosis was established by the results of histological examination. The analysis of these clinical cases indicates that, despite the low prevalence, atypical clinical and CT picture, intraosseous formations of the nasal cavity can be of a vascular nature and certainly require a comprehensive examination, including CT, CT with contrast and/or MRI of the nose and paranasal sinuses. These clinical observations indicate that preliminary embolization of feeding vessels before surgical treatment is not required.

Giant Internal Carotid Artery Aneurysm of the Cavernous Segment

A 70-year-old woman with a history of hypertension developed acute onset of severe tightness headache accompanied by vomiting. Patient reported having right diplopia and occasional and temporary right peripheral facial paralysis for two weeks. Neurological examination revealed only a right squint. Cerebral multi-detector computed tomographic angiography (MD-CTA) and Magnetic Resonance Imaging (MRI) revealed a giant right internal carotid aneurysm (2.7 cm) at the cavenous segment (Figure 1A, 1B). No abnormalities were noted in subarachnoid spaces and white - grey matter. A selective digital subtraction angiography (DSA) of the right internal carotid artery confirmed the giant aneurysm at the cavenous segment (Figure 2A, 2B). Subsequently endovascular flow-diverting stent was deployed at the cavernous segment of the right internal carotid artery to treat over time the giant aneurysm. Her clinical course has no neurological symptoms and she was discharged after two days with established over time clinical and imaging follow-up. Giant intracranial aneurysms and vascular anomalies of the internal carotid are rare, and are defined "giant" those greater than 2.5 cm in diameter (1-4). Conservative treatment of giant intracranial aneurysms have a mortality rates of 65-100% in 2-5 years (4). Clinical presentation of internal carotid aneurysms at the petrous segment can manifest from no-symptom to headache, cranial nerve disturbs and epistaxis (1- 4). MD-CTA and MRI are the two gold standard methods for diagnosis in patients with suspected internal carotid artery and intracranial artery aneurysm (1,5). Internal carotid aneurysms at the cavenous segment are located in a surgically difficult accessible area, therefore endovascular percutaneous techniques are considered the first lines treatments (6).

Multiple vascular anomalies and refractory pericardial effusion in a young patient with Cantu syndrome: a case report and review of the literature

BACKGROUND

Cantu syndrome is a rare and complex multisystem disorder characterized by hypertrichosis, facial dysmorphism, osteochondroplasia and cardiac abnormalities. With only 150 cases reported worldwide, Cantu syndrome is now gaining wider recognition due to molecular testing and a growing body of literature that further characterizes the syndrome and some of its most important features. Cardiovascular pathology previously described in the literature include cardiomegaly, pericardial effusion, vascular dilation and tortuosity, and other congenital heart defects. However, cardiovascular involvement is highly variable amongst individuals with Cantu syndrome. In some instances, it can be extensive and severe requiring surgical management and long term follow up.

CASE PRESENTATION

Herein we report a case of a fourteen-year-old female who presented with worsening pericardial effusion of unknown etiology, and echocardiographic findings of concentric left ventricular hypertrophy, a mildly dilated aortic root and ascending aorta. Her medical history was notable for hemoptysis and an episode of pulmonary hemorrhage secondary to multiple aortopulmonary collaterals that were subsequently embolized in early childhood. She was initially managed with Ibuprofen and Colchicine but continued to worsen, and ultimately required a pericardial window for the management of refractory pericardial effusion. Imaging studies obtained on subsequent visits revealed multiple dilated and tortuous blood vessels in the head, neck, chest, and pelvis. A cardiomyopathy molecular studies panel was sent, and a pathogenic variant was identified in the ABCC9 gene, confirming the molecular diagnosis of autosomal dominant Cantu syndrome.

CONCLUSIONS

Vascular anomalies and significant cardiac involvement are often present in Cantu syndrome, however there are currently no established screening recommendations or surveillance protocols in place. The triad of hypertrichosis, facial dysmorphism, and unexplained cardiovascular involvement in any patient should raise suspicion for Cantu syndrome and warrant further investigation. Initial cardiac evaluation and follow up should be indicated in any patient with a clinical and/or molecular diagnosis of Cantu syndrome. Furthermore, whole body imaging should be utilized to evaluate the extent of vascular involvement and dictate long term monitoring and care.

Clinical applications of arterial spin labeling of the intracranial compartment in vascular anomalies-A case-based review

Arterial spin labeling (ASL) is a magnetic resonance perfusion technique that allows for quantification of cerebral blood flow (CBF) without the use of contrast or radiation. Several applications of ASL have been described in diagnosis of strokes and stroke mimics, intracranial tumors, and other conditions. Various vascular anomalies exhibit specific CBF patterns that correlate with different signal intensities on ASL. In this case-based review, we demonstrate the utility of ASL in diagnosis and surveillance of vascular anomalies in the intracranial compartment.

Overcoming roadblocks in clinical innovation via high fidelity simulation: use of a phantom simulator to achieve FDA and IRB approval of a clinical trial of fetal embolization of vein of Galen malformations

BACKGROUND

Vein of Galen malformation (VOGM) is a rare, life-threatening vascular malformation in neonates and is treated with embolization. However, even at the most experienced centers, patients face high mortality and morbidity. In utero treatment options have been limited by lack of animal models or simulations.

OBJECTIVE

To create a novel ultrasound phantom simulator for a preclinical feasibility study of in utero fetal intervention for VOGM.

METHODS

Novel phantoms were designed and built in two configurations of spherical and windsock shape from cryogel material to mimic the salient vasculature of the fetal VOGM, based on real-patient fetal MR imaging dimensions. Critical anatomy was realistically mimicked within this model and transtorcular ultrasound-guided coil deployment was simulated. Each phantom model was assessed before and after treatment to evaluate coil mass deposition within the target.

RESULTS

The two phantoms underwent pretreatment T2-weighted MR imaging assessment, ultrasound-guided embolization, post-treatment MR and fluoroscopic imaging, and visual inspection of the sliced phantoms for target embolization verification. Postoperative MR scans confirmed realistic compact deposition of the coil masses within the central cavity. Phantom embolization results were submitted as part of the institutional review board and US Food and Drug Administration investigative device exemption approval for a first-in-humans clinical trial of fetal intervention for VOGM.

CONCLUSIONS

A phantom simulator for fetal intervention of VOGM produces lifelike results during trial interventions, removing obstacles to feasibility and safety evaluations, typically precluded by non-availability of appropriate animal models. The study provides a proof of concept for potentially wider applications of medical simulation to enable novel procedural advancements in neurointerventions.

Monogenic Causes of Cerebrovascular Disease in Childhood: A Case Series

BACKGROUND

Despite an increase in the number of genes associated with pediatric stroke, imaging phenotypes in children have not been well reported. Guidelines are needed to facilitate the identification and treatment of patients with monogenic causes of cerebrovascular disorders.

METHODS

We performed a retrospective review of imaging and medical records of patients aged zero to 21 years with monogenic causes of vascular malformations, small or large vessel disease, transient ischemic attacks, and/or ischemic or hemorrhagic stroke. We classified patients according to their imaging phenotype and reviewed neurological and systemic features and management strategies. We reviewed the literature to identify genes associated with cerebrovascular disorders presenting in childhood.

RESULTS

We identified 18 patients with monogenic causes of cerebrovascular disorders and classified each patient as belonging to one or more of three cerebrovascular phenotypes according to predominant imaging characteristics: small vessel disease, large vessel disease, and/or vascular malformations. Preventative treatments included aspirin, N-acetylcysteine, tocilizumab, therapeutic low-molecular-weight heparin, and resection of vascular malformations.

CONCLUSIONS

Classifying pediatric patients with cerebrovascular disorders by imaging phenotype can aid in determining the next steps in genetic testing and treatment.

Clinical and auxological characteristics and quality of life of 50 children and adolescents with segmental overgrowth syndromes at a single center

Introduction. Segmental overgrowth syndromes are a group of rare diseases characterized by overgrowth in one or more parts of the body, mostly related to mosaic mutations in the AKT/PI3K/mTOR and RAS- MAPK signaling pathway. Our objective was to analyze the clinical and auxological characteristics and health-related quality of life (HRQoL) in this group of patients at a tertiary care hospital. Population and methods. Cross-sectional study of a follow-up cohort. Age, sex, sociodemographic data, anthropometric measurements of the affected and contralateral segments, complications, treatment, quality of life (PedsQL 4.0), and pain were analyzed. Central and dispersion measures were estimated. A univariate analysis between the quality of life and study variables was done. Results. A total of 50 patients were included; 29 were males. Median age: 9.95 (r: 1.44-17.81) years. The most common diagnosis was PIK3CA-related overgrowth spectrum (PROS) (37/50). The median number of affected segments was 2 (r: 1-7) per patient. Vascular malformations were observed in 40, and capillary malformations, in 20 patients. Pain was the most common complication (24/50). An asymmetry of the lower extremities of < 5 cm was observed in 31 patients. In most children, height was between the 50th and 97th percentiles. A lower HRQoL was observed among girls, patients with complex vascular malformations, and those with unmet basic needs (UBNs). Conclusions. PROS was the most common diagnosis. Pain was the most common complication. HRQoL was lower among girls, patients with combined vascular malformations, and those with UBNs.

Percutaneous sclerotherapy for head and neck lymphatic malformations in neonates and infants ≤12 months of age

BACKGROUND

Percutaneous sclerotherapy is an effective treatment for lymphatic malformations (LM) of the head and neck in adults. The purpose of this study was to examine the indications and efficacy of sclerotherapy for head/neck LM in the neonate and infant population.

METHODS

We retrospectively reviewed patients treated with percutaneous sclerotherapy for LM of the head/neck at age ≤12 months at a single vascular anomalies clinic. The clinical, anatomic, and technical aspects of each treatment, complications, and post-treatment clinical and imaging outcomes were analyzed.

RESULTS

22 patients underwent 36 treatments during the first year of life. Median age at first treatment was 6.2 months (range 2-320 days). Severe airway compromise was the most frequent indication for treatment (31.8%). Sclerosants included doxycycline (80.5%), sodium tetradecyl sulfate (55.5%), bleomycin (11.1%) and ethanol (2.8%). There were no immediate procedure-related complications; sclerosant-related laboratory complications included transient metabolic acidosis (8.3%) and hemolytic anemia (5.5%). Median follow-up was 3.7 years (IQR 0.6-4.8). 47.6% of patients showed >75% lesion size reduction and 19.0% showed minimal response (<25% improvement). At last follow-up, 71.4% of children were developmentally normal and asymptomatic, 23.8% had recurring symptoms, and 4.8% required permanent tracheostomy. Patients with ongoing symptoms or limited response to percutaneous sclerotherapy (33.3%) were treated with long-term sirolimus.

CONCLUSIONS

Percutaneous sclerotherapy is a safe and effective treatment for symptomatic LM of the head and neck in neonates and infants. Treatment strategy and management of recurrent symptoms requires consensus from an experienced, multidisciplinary team.

Endothelial cells differentiated from patient dermal fibroblast-derived induced pluripotent stem cells resemble vascular malformations of port-wine birthmark

Lesional induced pluripotent stem cell-derived endothelial cells can resemble pathological vascular phenotypes of port-wine birthmark (PWB). Our data demonstrate that multiple pathways, including Hippo and Wnt, NFκB, TNF, MAPK and cholesterol metabolism, are dysregulated. These data suggest new therapeutics can be developed to target such dysregulated pathways in the treatment of PWB.

When Carotid Artery Stenosis Cause Posterior Fossa Infarct. An Unusual Case of Persistent Hypoglossal Artery

BACKGROUND

The primitive anastomosis between the carotid artery and the vertebrobasilar arteries usually regress, in rare cases they persist beyond fetal development and form vascular anomalies such as primitive persistent hypoglossal artery(PPHA), with prevalence of 0.02-0.1% in the general population.

CASE REPORT

A 77-year-old female presented with aphasia, weakness of both legs and arms. Computed Tomography Angiography (CTA) revealed subacute infarct in right pones, severe stenosis of the right internal carotid artery(RICA) and ipsilateral PPHA. We performed Right carotid artery stenting (CAS) using a distal filter into the PPHA to protect the posterior circulation, with good result.

DISCUSSION

The posterior circulation was utterly dependent on the RICA, therefore, despite the general notion that carotid stenosis is usually associated with anterior circulation infarcts, in cases having vascular anomalies it may cause a posterior stroke. Carotid artery stenting offer a safe and simple solution, however the use of EPD requires special considerations regarding decision on the suitable protection technique and placement.

CONCLUSION

Neurological symptoms in the presence of carotid artery stenosis and PPHA can manifest as ischemia of the anterior and/or the posterior circulation. In our opinion, CAS gives a simple and safe treatment solution.

A Rare Cause of Red Tympanic Membrane: Jugular Bulb Diverticulum

SIGNIFICANCE STATEMENT

Pulsatile tinnitus with erythematous tympanic membrane mass suggests vascular pathologies such as dural arteriovenous fistula, glomus tympanicum, or aberrant carotid artery. Jugular bulb aneurysmatic diverticulum is rare but should be suspected in a case with the presence of aneurysm in other organs. An imaging study is mandatory to confirm the diagnosis. Patient must avoid digging ear as it can cause profuse bleeding. Treatment option can be open surgery or endovascular treatment.

ACR Appropriateness Criteria® Tinnitus: 2023 Update

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Radiologic and Clinical Features of Infantile Hemangioma: Potential Pitfalls and Differential Diagnosis

Infantile hemangioma (IH) is the most common neoplasm in children, but it may mimic other types of vascular anomalies or nonvascular benign and malignant tumors. In most cases, the clinical appearance, time of onset, and pattern of involution facilitate its diagnosis. Imaging evaluation is not always needed since the IH features at clinical presentation are usually characteristic, but when needed, US and frequently MRI are the imaging modalities of choice. Clinical photography or photographic documentation plays a central role in monitoring these lesions over their clinical course. Photographic documentation can also add confidence and alert the radiologist when interpreting imaging studies. Some vascular anomalies, especially vascular malformations, are a frequent source of confusion, as these may resemble IHs clinically and at imaging. The lack of uniform terminology also hinders an accurate diagnosis. To unify the terminology and minimize confusion, the International Society for the Study of Vascular Anomalies created a helpful classification in 1994. In addition, radiologists need to be aware of and become familiar with other neoplasms in children that may resemble IH to avoid misdiagnosis and unnecessary procedures. Fibrous and lipomatous tumors are examples of benign tumors that can mimic IHs clinically and at imaging, whereas rhabdomyosarcoma, infantile fibrosarcoma, neuroblastoma, and lymphoproliferative disorders are examples of malignant neoplasms. The authors review the features of IH at clinical presentation and imaging evaluation, highlighting its different phases of evolution and stressing the importance of photographic documentation. The authors also review pitfalls of IH with helpful pearls for differentiation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Khanna and Briones in this issue.

Differences in Efficacy and Safety of Sirolimus and Sildenafil in Pediatric Lymphatic Malformations

OBJECTIVES

To explore the differences in the efficacy and safety of oral sirolimus and sildenafil in the treatment of pediatric intractable lymphatic malformations (LMs).

METHODS

From January 2014 to May 2022, we retrospectively enrolled children with intractable LMs treated with oral drugs (sirolimus or sildenafil) and divided the patients into sirolimus and sildenafil groups from Beijing Children's Hospital (BCH). Clinical features, treatment, and follow-up data were collected and analyzed. The indicators were the ratio of reduction in lesion volume pre and posttreatment, the number of patients with improved clinical symptoms, and adverse reactions to the two drugs.

RESULTS

Twenty-four children in the sildenafil group and 31 children in the sirolimus group were included in the present study. The effective rate in the sildenafil group was 54.2% (13/24), with a median lesion volume reduction ratio of 0.32 (-0.23, 0.89) and clinical symptoms improved in 19 patients (79.2%). On the contrary, the effective rate in the sirolimus group was 93.5% (29/31), with a median lesion volume reduction ratio of 0.68 (0.34, 0.96), and clinical symptoms improved in 30 patients (96.8%). There were significant differences (p < 0.05) between the two groups. Regarding safety, four patients in the sildenafil group and 23 patients in the sirolimus group with mild adverse reactions were reported.

CONCLUSION

Both sildenafil and sirolimus can reduce the volume of LMs and improve clinical symptoms in partial patients with intractable LMs. Sirolimus is more effective than sildenafil and the adverse reactions associated with both drugs are mild and controllable.

LEVEL OF EVIDENCE

III Laryngoscope, 133:3192-3199, 2023.

Importance of Determining Vascular Endothelial Growth Factor Serum Levels in Children with Infantile Hemangioma

Background and Objectives: A potential role of vascular endothelial growth factor (VEGF) in the pathophysiology of infantile hemangiomas (IH) is thought to be plausible. The primary objective of this study was to investigate the importance of determining VEGF serum levels at various stages of IH growth in children. Materials and Methods: A nested case-control study was conducted. For the purposes of the researched target group, samples of fifty (N = 50) children with IH without associated diseases at different stages of hemangioma growth (proliferative and involutional stages) were used. The control group consisted of one hundred (N = 100) healthy children comparable in terms of age and sex, in whom the existence of IH and vascular malformations was ruled out via clinical examination. An immunoassay (ELISA) was used to determine VEGF serum levels in hemangioma growth's proliferation and involution phases. Results: A comparison of serum levels of VEGF in the phases of proliferation and involution in the group of patients with IH did not show a statistically significant difference (p = 0.171). The control group had significantly higher serum VEGF levels than the patient group in both the proliferation phase (p = 0.009) and the involution phase (p = 0.019). In the proliferation phase, a multivariate regression model explained 15% of the variance in the dependent variable, without significant predictor variables, while in the involution phase, it explained 21% of the variance in the dependent variable, and the history of invasive prenatal procedures stood out as a significant predictor variable positively associated with serum VEGF levels (beta coefficient = 0.33; p = 0.043). Conclusions: Although IH is thought to be the result of the dysregulation of angiogenesis and vasculogenesis under the influence of angiogenic factors, especially VEGF, this study did not demonstrate that VEGF serum levels in the proliferation phase of hemangioma growth were higher than those in the involution phase, or in relation to the control group.

Relative expression of hormone receptors by endothelial and smooth muscle cells in proliferative and non-proliferative areas of congenital arteriovenous malformations

BACKGROUND

Episodic growth due to microvascular proliferations (MVP) has been reported in congenital arteriovenous malformations (AVM), which are normally quiescent lesions composed of mature malformed vessels. Since AVM also may worsen under conditions of hormonal dysregulation, we hypothesized that hormonal influences may stimulate this process of vasoproliferative growth through potential interactions with hormone receptors (HR).

METHODS

13 Cases of AVM tissue with histologically documented vasoproliferative growth were analyzed quantitatively for the presence and tissue localization of estrogen receptor (ER), progesterone receptor (PGR), growth hormone receptor (GHR) and follicle-stimulating hormone receptor (FSHR) in relation to resident cells of interest (endothelial cells (EC), smooth muscle cells (SMC) and mast cells (MC)) by applying multiplex immunohistochemistry (IHC) staining. Expression patterns in lesions with MVP and mature vessels were quantified and compared. Available fresh frozen tissues of 3 AVM samples were used to confirm the presence of HR using Reverse-Transcriptase quantitative Polymerase Chain Reaction (RT-qPCR).

RESULTS

All four HR studied were expressed in all cases within EC and SMC in areas of MVP and mature vessels, but not in normal skin tissue. ER, GHR, and FSHR showed more expression in EC of MVP and in SMC of mature vessels. RT-qPCR confirmed presence of all 4 HR in both areas.

CONCLUSION

Expression of ER, PGR, GHR, and FSHR in vasoproliferative areas of congenital AVM could explain onset of sudden symptomatic growth, as has observed in a subpopulation of patients. These findings may have implications for eventual anti-hormonal targeted therapy in the lesions involved.

Left anterior cerebral artery arising from a right internal carotid artery: a rare case of carotid-anterior cerebral artery anastomosis

Carotid-anterior cerebral artery anastomosis (carotid-ACA anastomosis) is described as infrequent vascular connections between the pre-ophthalmic segment of the internal carotid artery (ICA) and the A1 segment of the anterior cerebral artery (ACA). The embryological origin of these variant is still unclear and they are often associated to other vascular anomalies of the circle of Willis, as well as to the presence of aneurysms. Carotid-ACA anastomosis is often right-sided although left and bilateral cases have also been described. We report a rare case by MR angiography of a carotid-ACA anastomosis in which the abnormal vessel arises from the right ICA and takes an infraoptic course to join the A2 segment of the contralateral ACA, making this vascular anomaly function as a 'left ACA with an origin at the right ICA'. The A1 segment of the left ACA is absent and both A2 segments of the ACAs present fenestration. To our knowledge, no similar cases have been reported in English literature so far.

Clinical features of tumours and tumour-like pathologies involving the buccal fat pad

This study aimed to investigate the clinical, radiological, and pathological characteristics of pathologies involving the buccal fat pad (BFP) and to explore the treatment protocols. The cases of 109 patients with primary pathologies involving the BFP (pBFP) diagnosed between January 2013 and September 2021 were assessed. The patients' clinical presentations and radiological and histopathological findings were analysed retrospectively, and their treatment outcomes were evaluated. The 109 pBFP were categorized as benign tumours (n = 17), malignant tumours (n = 29), vascular malformations (n = 38), and inflammatory masses (n = 25). Of the 17 benign tumours, seven were lipomas, five were pleomorphic adenomas, three were solitary fibrous tumours, and two were other tumours. The 29 malignant tumours included five adenoid cystic carcinomas, six mucoepidermoid carcinomas, three synovial sarcomas, and 15 other tumours. Of the 38 vascular malformations, 37 were venous and one was arteriovenous. Regarding the inflammatory masses, the lesions appeared after cosmetic facial botulinum toxin injection in 13 cases and after other cosmetic facial procedures in five. The upper body of the BFP was the most frequently involved site (79/109), while other frequently involved sites were the lower body (67/109) and the masseteric (41/109), temporal (32/109), and pterygopalatine (30/109) extensions.

Difficulty in the Diagnosis of Biliary Atresia Splenic Malformation Syndrome In Utero

The fetus of a 30-year-old pregnant Japanese woman was diagnosed with absence of inferior vena cava (IVC) and azygos continuation of interrupted IVC without cardiac anomalies at 34 weeks of gestation, and a healthy male neonate weighing 2,910 g was delivered at 37 weeks of gestation. On day 42 after birth, direct bilirubin predominant hyperbilirubinemia and high serum gamma-GTP levels were detected. Computed tomography revealed the presence of a lobulated and accessory spleen, and laparotomy demonstrated type III biliary atresia (BA), confirming the final diagnosis of BA splenic malformation (BASM) syndrome. In retrospect, non-visualization of the gallbladder was missed in utero. The combination of the absence of IVC and BA without cardiac anomalies is far less likely to occur in left isomerism. Although BA remains difficult to detect in utero, special attention should be paid to cases of BA associated with findings of left isomerism, including the absence of IVC, to enable early diagnosis and treatment of BASM.

Incidence and Risk Factors for Poor Postoperative Visual Outcome After Excision of Orbital Cavernous Venous Malformations

AIMS

To determine the incidence and risk factors for poor postoperative visual outcome (PPVO) after removal of orbital cavernous venous malformations (OCVMs).

METHODS

Retrospective case-note and imaging review for patients undergoing excision of OCVMs, with estimation of odds-ratios (ORs) and relative risks (RRs) for visual loss in relation to the position of the mass, surgical approach, and patient factors.

RESULTS

The 290 patients (179 female; 62%) presented at a mean age of 46.4 years: 243/287 (85%) OCVMs were intraconal, with 213/243 (88%) located freely in the posterior two-thirds of the orbit, and 30/243 (12%) wedged tightly in the apex. PPVO was observed in 6.9% (20/290) patients, solely after removal of intraconal lesions, Univariate analysis showed increased risk with preoperative relative afferent pupillary defect (RAPD) (14/107 [13%]; RR 2.9; P = 0.011), apical lesions (9/30 [30%]; RR 5.8; P < 0.001), situated below optic nerve (15/115 [13%]; RR 3.3; P = 0.007), fibrous masses (14/78 [18%]; RR 6.7; P = 0.005), or intraoperative diastolic blood pressure below 50mmHg (10/64 [16%]; RR 2.8; P = 0.007). Multivariate analysis found apical extension (OR 4.9; P = 0.036) and fibrous lesions (OR 10.0; P = 0.035) as strongest predictors for PPVO. The incidence of complete visual loss (no light perception) was 4.1% (12/290); half of these patients had preoperative acuity of counting fingers or worse, 8 (67%) had RAPD, 7 (58%) wedged apical lesions, and 8 (67%) were below the optic nerve.

CONCLUSION

PPVO after excision of OCVMs can occur in up to 5% of "free" retrobulbar intraconal lesions and in approximately one-third of apical lesions.

Dual-agent percutaneous sclerotherapy technique for macrocystic lymphatic malformations

Percutaneous sclerotherapy is an effective technique for treating lymphatic malformations of the head and neck, with clinical success rates exceeding 84%.1 Sodium tetradecyl, which damages lipid membranes and stimulates free radical-induced local damage, and doxycycline, which inhibits angiogenesis, have emerged as the safest and most effective of several available sclerosants.2-4 Although severe periprocedural morbidity is rare, temporary local complications are reported in 14% and skin necrosis or scarring in up to 0.8-5.8% of sclerotherapy procedures.5 As these lesions are frequently located in the face and/or neck, even minor complications can be disfiguring and must be avoided. This technical video describes a 'dual-agent' approach for percutaneous sclerotherapy of macrocystic lymphatic malformations using sodium tetradecyl as a 'primer' followed by doxycycline as a definitive sclerosant (video 1). This technique emphasizes meticulous backtable preparation and effective use of ultrasound and fluoroscopy to minimize complications. neurintsurg;15/9/931/V1F1V1Video 1 .

Renal arteriovenous malformation causing hematuria: Case report and review of the literature

RATIONALE

Renal arteriovenous malformations are rare vascular morphological anomalies that can be classified as congenital, idiopathic and acquired, of which congenital renal arteriovenous malformations are the most common. This disease is a rare cause of hematuria. In this case report, we report the diagnosis and treatment of a patient with renal arteriovenous malformation. We also review the symptoms, diagnosis and treatment of renal arteriovenous malformations in the published literature.

PATIENT CONCERNS

A 35-year-old female patient presented to a local hospital with right-sided lumbar abdominal pain with hematuria for 2 days. Physical examination showed percussion pain in the right renal area. Laboratory tests such as routine blood and blood biochemistry did not show any significant abnormalities when the patient entered the hospital. Considering the patient's medical history, a urological computed tomography scan showed blood accumulation in the right renal pelvis, upper middle ureter and bladder. Subsequently, routine blood tests showed that the patient's red blood cells and hemoglobin continued to decrease. An emergency renal arteriogram was performed, which showed a tortuous right upper renal pole branch artery and multiple thickened veins communicating with it.

DIAGNOSIS

This patient was diagnosed with cirsoid renal arteriovenous malformation.

INTERVENTIONS

Renal artery embolization was performed immediately after the renal arteriogram was performed on the patient.

OUTCOMES

On review of the angiogram, the tortuous right upper renal pole branch artery was found to be obstructed, and the thickened vein disappeared, and the renal vein was normally visualized in due course. On the third postoperative day, the patient was free of hematuria. Physical examination showed no percussion pain in the renal area. The patient healed and was discharged. A 1-year follow-up was performed and the patient gave feedback that she no longer had symptoms such as back pain and hematuria in her daily life.

LESSONS

This case illustrates that early use of vascular interventions is an important method for the diagnosis and treatment of cirsoid renal arteriovenous malformations.

DDX24 Mutation Alters NPM1 Phase Behavior and Disrupts Nucleolar Homeostasis in Vascular Malformations

Point mutations in the DEAD-box helicase DDX24 are associated with vascular malformations such as multi-organ venous and lymphatic defect (MOVLD) syndrome and Budd-Chiari syndrome, with the pathogenesis largely uncharacterized. DDX24 is mainly located in the nucleolus, where nucleophosmin (NPM1) regulates nucleolar homeostasis via liquid-liquid phase separation (LLPS). However, the connection between DDX24 and NPM1 in vascular malformation remains elusive. Here we demonstrated that DDX24 formed biomolecular condensates in vitro and the mutated DDX24 protein, DDX24E271K, partitioned less into the nucleoli in tissues from patients with MOVLD syndrome and cultured endothelial cells (ECs), altering nucleolar morphology. Furthermore, DDX24 was directly associated with NPM1 to regulate its phase behavior as a client in the nucleolar granular component (GC). Functionally, we showed that DDX24 was essential in maintaining nucleolar homeostasis of ECs and that either mutation or knockdown of DDX24 led to the dysfunction of ribosome biogenesis and the elevated capability of cell migration and tube formation. Our findings illustrate how DDX24 mutation affects nucleolar structure and function by regulating the phase behavior of NPM1 in the setting of vascular malformation.