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Oushy S, Orbach DB. Infantile dural arteriovenous fistula: a reconsideration. J Neurointerv Surg 2024:jnis-2023-021355. [PMID: 38453460 DOI: 10.1136/jnis-2023-021355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/12/2023] [Accepted: 02/18/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Infantile-type dural arteriovenous shunts (IDAVS) are rare and heterogeneous vascular lesions, complicating their classification and management. The current tripartite classification of pediatric dural arteriovenous shunts (DAVS) into dural sinus malformation, infantile-type, and adult-type, does not stand up to scrutiny, given the variable presentations of the latter two types in children. We estimate the prevalence of IDAVS and evaluate the long term outcomes after endovascular treatment (EVT). METHODS A retrospective review of a pediatric cerebrovascular database between 2006 and 2023 was conducted. Clinical and radiographic data were analyzed to evaluate the presentation and long term outcomes of IDAVS. RESULTS IDAVS were identified in 8 (0.5%) of 1463 patients, with mean age at diagnosis of 34.7 months; male infants comprised 62.5%. The most common clinical presentations included macrocephaly (37.5%), seizures (25%), and dilated scalp veins (25%). EVT was performed in 87.5% of cases, averaging 5.8 procedures per patient. Radiographic obliteration was observed in 28.6%. Good clinical outcomes (modified Rankin Scale score of ≤2) were achieved in 85.7%. Our findings showcased discrepancies and limitations in the current classification of pediatric DAVS, prompting a re-evaluation. CONCLUSION IDAVS accounted for a small proportion of pediatric cerebrovascular pathologies, with markedly heterogeneous presentations. Stepwise selective embolization was associated with favorable outcomes, and is recommended over an aggressive approach with the goal of complete angiographic obliteration. Our proposed revised classification system bifurcates pediatric DAVS into dural sinus malformations and all other DAVS that are manifest in children, thereby enhancing diagnostic clarity and therapeutic approaches.
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Affiliation(s)
- Soliman Oushy
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Darren B Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Montaser A, Kappel AD, Driscoll J, Day E, Karsten M, See AP, Orbach DB, Smith ER. Posterior cerebral territory ischemia in pediatric moyamoya: Surgical techniques and long-term clinical and radiographic outcomes. Childs Nerv Syst 2024; 40:791-800. [PMID: 37955716 DOI: 10.1007/s00381-023-06219-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To describe a surgical technique for posterior cerebral revascularization in pediatric patients with moyamoya arteriopathy. Here, we describe the clinical characteristics, surgical indications, operative techniques, and clinical and radiographic outcomes in a series of pediatric patients with moyamoya disease affecting the posterior cerebral artery (PCA) territory. METHODS A retrospective single-center series of all pediatric patients with moyamoya disease who presented to our institute between July 2009 through August 2019 were reviewed. The clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic outcomes of pediatric moyamoya patients with PCA territory ischemia were collected and analyzed. RESULTS A total of 10 PCA revascularization procedures were performed in 9 patients, 5 female, ages 1 to 11.1 years (average 5.2 years). Complications included 1 stroke, with no infections, hemorrhages, seizures, or deaths. One patient had less than 1 year of radiographic and clinical follow-up. In 8 of 9 patients with at least 1 year of radiographic follow-up, there was engraftment of surgical vessels present in all cases. No new strokes were identified on long-term follow-up despite the radiographic progression of the disease. In the 8 cases available for analysis, the average follow-up was 50.8 months with a range of 12 to 117 months. CONCLUSIONS PCA territory ischemia in patients with progressive moyamoya disease can be surgically treated with indirect revascularization. Here, we describe our experience with PCA revascularization procedures for moyamoya disease, including pial pericranial dural (PiPeD) revascularization and pial synangiosis utilizing the occipital artery. These surgical options may be useful for decreasing the risk of stroke in pediatric moyamoya patients with severe posterior circulation disease.
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Affiliation(s)
- Alaa Montaser
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Ari D Kappel
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
- Department of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Driscoll
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
| | - Emily Day
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
| | - Madeline Karsten
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
| | - Alfred P See
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
- Department of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren B Orbach
- Department of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Smith
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA.
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3
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Naggara O, Stirnemann J, Boulouis G, Orbach DB, Grévent D, James S, Boddaert N, Kossorotoff M, Blauwblomme T, Ville Y. Prenatal treatment of a vein of Galen malformation by embolization and 1-year follow-up. Am J Obstet Gynecol 2024; 230:372-374. [PMID: 38043773 DOI: 10.1016/j.ajog.2023.11.1248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Olivier Naggara
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris-Cité, Paris, France; Department of Pediatric Radiology, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Cité, Paris, France
| | - Julien Stirnemann
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades University Hospital, Université Paris-Cité, Paris, France
| | - Gregoire Boulouis
- Department of Pediatric Radiology, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Cité, Paris, France
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - David Grévent
- Department of Pediatric Radiology, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Cité, Paris, France
| | - Syril James
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Cité, Institut Imagine, INSERM UMR 1163, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Cité, Paris, France
| | - Manoëlle Kossorotoff
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades University Hospital, Université Paris-Cité, Paris, France; Department of Pediatric Neurology, French Centre for Pediatric Stroke, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Cité, Institut Imagine, INSERM UMR 1163, Paris, France
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades University Hospital, Université Paris-Cité, Paris, France.
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4
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Slingerland AL, Papadakis JE, Staffa SJ, Scott RM, See AP, Orbach DB, Fehnel KP. Management of Choroid Plexus Tumors and the Benefit of Preoperative Embolization in Pediatric Patients: Report of 46 Cases from a Single Institution. World Neurosurg 2024; 181:e1071-e1087. [PMID: 37977483 DOI: 10.1016/j.wneu.2023.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Optimal choroid plexus tumor (CPT) treatment involves gross total resection; however, intraoperative hemorrhage risk remains significant given tumor vascularity. This study describes pediatric CPT management and identifies patients most likely to benefit from preoperative embolization. METHODS CPTs resected from 1997 to 2021 were included. The characteristics of embolized patients were compared to nonembolized patients; nonembolized patients were further stratified based on open vascular control-pedicle feeder ligation versus no pedicle ligation prior to tumor debulking. Statistical analyses identified factors associated with estimated blood loss (EBL), transfusion, length of stay, and complications. RESULTS Among the 46 CPT cases identified, 98% achieved gross total resection, and 15% received embolization. Embolized patients were younger, smaller, and had larger tumors compared to nonembolized patients (median: 0.8 vs. 2.1 years; 9.3 vs. 14.4 kg; 91.08 vs. 5.5 cm3). Transfused patients were similarly younger and smaller (P < 0.05) than nontransfused patients. Among nonembolized patients, open vascular control was achieved in smaller tumors (<13 cm3) with significantly lower EBL (P = 0.002). Higher EBL was observed in patients with larger tumors, hydrocephalus, transependymal edema, vomiting, lethargy, and developmental regression (all P < 0.05). Patients with lethargy had longer hospital stays and a higher likelihood of postoperative complications (P < 0.05). There were no significant differences in complication rates between the embolization and nonembolization groups. CONCLUSIONS Despite higher surgical risk profiles, embolized patients had similar complication rates and postoperative hydrocephalus management as nonembolized patients. Embolization was particularly beneficial in patients at high risk for surgical morbidity, such as those <2 years, weighing <10 kg, and with a tumor volume >15 cm3.
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Affiliation(s)
- Anna L Slingerland
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joanna E Papadakis
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - R Michael Scott
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfred P See
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katie P Fehnel
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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5
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Orbach DB, Wilkins-Haug LE, Benson CB, Rangwala SD, Pak C, Saffarzadeh M, Weinstock P. 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. J Neurointerv Surg 2023; 15:1218-1223. [PMID: 36690441 DOI: 10.1136/jnis-2022-019658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Darren B Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Louise E Wilkins-Haug
- Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shivani D Rangwala
- Department of Neurological Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Christopher Pak
- Boston Children's Hospital Simulator Program (SIMPeds), Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mona Saffarzadeh
- Boston Children's Hospital Simulator Program (SIMPeds), Boston Children's Hospital, Boston, Massachusetts, USA
| | - Peter Weinstock
- Department of Anesthesia, BCH Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA
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6
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Rangwala SD, Johnson K, See AP, Smith ER, Orbach DB. Direct Transverse Sinus Puncture for Transvenous Coil Embolization of Vein of Galen Malformations: Innovating Existing Techniques. Oper Neurosurg (Hagerstown) 2023; 25:e352-e358. [PMID: 37819101 DOI: 10.1227/ons.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Vein of Galen malformations (VOGMs) are complex arteriovenous malformations in neonates and young children. Recent advances in endovascular interventions have drastically improved treatment and clinical outcomes in what was previously high-morbidity, high-mortality disease. The high-flow shunt pathophysiology in VOGMs can lead to dynamic changes in the malformation angioarchitecture, and over time patients can develop jugular bulb stenosis. In the setting of inaccessible transvenous access to the malformation for endovascular embolization in cases where transarterial embolization is inadequate, a combined surgical and endovascular technique must be used. We present the first successful modern-day application of direct puncture through transverse sinus for transvenous embolization of a VOGM. CLINICAL PRESENTATION We present 2 unique cases of complex VOGM malformations in patients who had previously undergone staged endovascular embolization for reduction of flow within the malformation. On follow-up, in both cases, there was development of severe sigmoid sinus and jugular bulb stenosis, increasing intracranial venous congestion and causing marked clinical deterioration. The stenosis prevented traditional transvenous access and treatment. We describe a direct puncture transverse sinus access using a burr hole approach for endovascular transvenous embolization in both cases with successful clinical outcomes. CONCLUSION Direct access using burr hole craniotomy to the transverse sinus for transvenous endovascular embolization is a safe approach in the setting of severe jugular bulb stenosis for treatment of VOGMs. This technique can be done efficiently to achieve complete flow elimination in the malformation, in cases where that is called for, without significant risks or complications related to the approach.
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Affiliation(s)
- Shivani D Rangwala
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Kristin Johnson
- Vascular Biology Program, Boston Children's Hospital, Boston , Massachusetts , USA
| | - Alfred P See
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston , Massachusetts , USA
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston , Massachusetts , USA
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7
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Zhao S, Mekbib KY, van der Ent MA, Allington G, Prendergast A, Chau JE, Smith H, Shohfi J, Ocken J, Duran D, Furey CG, Hao LT, Duy PQ, Reeves BC, Zhang J, Nelson-Williams C, Chen D, Li B, Nottoli T, Bai S, Rolle M, Zeng X, Dong W, Fu PY, Wang YC, Mane S, Piwowarczyk P, Fehnel KP, See AP, Iskandar BJ, Aagaard-Kienitz B, Moyer QJ, Dennis E, Kiziltug E, Kundishora AJ, DeSpenza T, Greenberg ABW, Kidanemariam SM, Hale AT, Johnston JM, Jackson EM, Storm PB, Lang SS, Butler WE, Carter BS, Chapman P, Stapleton CJ, Patel AB, Rodesch G, Smajda S, Berenstein A, Barak T, Erson-Omay EZ, Zhao H, Moreno-De-Luca A, Proctor MR, Smith ER, Orbach DB, Alper SL, Nicoli S, Boggon TJ, Lifton RP, Gunel M, King PD, Jin SC, Kahle KT. Mutation of key signaling regulators of cerebrovascular development in vein of Galen malformations. Nat Commun 2023; 14:7452. [PMID: 37978175 PMCID: PMC10656524 DOI: 10.1038/s41467-023-43062-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 11/07/2022] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and most severe of congenital brain arteriovenous malformations, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP (RASA1) harbored a genome-wide significant burden of loss-of-function de novo variants (2042.5-fold, p = 4.79 x 10-7). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 (EPHB4) (17.5-fold, p = 1.22 x 10-5), which cooperates with p120 RasGAP to regulate vascular development. Additional probands had damaging variants in ACVRL1, NOTCH1, ITGB1, and PTPN11. ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomic analysis defined developing endothelial cells as a likely spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant (Phe867Leu) exhibited disrupted developmental angiogenesis and impaired hierarchical development of arterial-capillary-venous networks, but only in the presence of a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have implications for patients and their families.
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Affiliation(s)
- Shujuan Zhao
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kedous Y Mekbib
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Martijn A van der Ent
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Garrett Allington
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Andrew Prendergast
- Yale Zebrafish Research Core, Yale School of Medicine, New Haven, CT, USA
| | - Jocelyn E Chau
- Department of Molecular Biophysics and Biochemistry, Yale School of Medicine, New Haven, CT, USA
| | - Hannah Smith
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - John Shohfi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Jack Ocken
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel Duran
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charuta G Furey
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
- Ivy Brain Tumor Center, Department of Translational Neuroscience, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Le Thi Hao
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Phan Q Duy
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Junhui Zhang
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | | | - Di Chen
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Boyang Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Timothy Nottoli
- Yale Genome Editing Center, Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Suxia Bai
- Yale Genome Editing Center, Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Myron Rolle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xue Zeng
- Department of Molecular Biophysics and Biochemistry, Yale School of Medicine, New Haven, CT, USA
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Weilai Dong
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Po-Ying Fu
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Yung-Chun Wang
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Shrikant Mane
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Paulina Piwowarczyk
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katie Pricola Fehnel
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alfred Pokmeng See
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Quentin J Moyer
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evan Dennis
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emre Kiziltug
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Ana B W Greenberg
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrew T Hale
- Department of Neurosurgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip B Storm
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shih-Shan Lang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul Chapman
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Georges Rodesch
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
| | - Stanislas Smajda
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tanyeri Barak
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Hongyu Zhao
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Andres Moreno-De-Luca
- Department of Radiology, Autism & Developmental Medicine Institute, Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Stefania Nicoli
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Department of Pharmacology, Yale School of Medicine, New Haven, CT, USA
- Yale Cardiovascular Research Center, Department of Internal Medicine, Section of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | - Titus J Boggon
- Department of Molecular Biophysics and Biochemistry, Yale School of Medicine, New Haven, CT, USA
- Department of Pharmacology, Yale School of Medicine, New Haven, CT, USA
| | - Richard P Lifton
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Murat Gunel
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Philip D King
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Sheng Chih Jin
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, US.
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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8
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Buratti S, Orbach DB, Muthusami P, Robertson F. Editorial: Vein of galen malformation: a scientific and clinical journey targeting the best outcome. Front Pediatr 2023; 11:1323889. [PMID: 38027306 PMCID: PMC10656608 DOI: 10.3389/fped.2023.1323889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Darren B. Orbach
- Neurointerventional Radiology, Boston Children’s Hospital, Boston, MA, United States
| | - Prakash Muthusami
- Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Fergus Robertson
- Department of Radiology, Great Ormond Street Hospital, London, United Kingdom
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9
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Khurana J, Orbach DB, Gauvreau K, Collins SL, Tella JB, Agrawal PB, Christou HA, Mullen MP. Pulmonary Hypertension in Infants and Children with Vein of Galen Malformation and Association with Clinical Outcomes. J Pediatr 2023; 258:113404. [PMID: 37023946 DOI: 10.1016/j.jpeds.2023.113404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 03/09/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To assess the extent and resolution of pulmonary hypertension (PH), cardiovascular factors, and echocardiographic findings associated with mortality in infants and children with vein of Galen malformation (VOGM). STUDY DESIGN We performed a retrospective review of 49 consecutive children with VOGM admitted to Boston Children's Hospital from 2007 to 2020. Patient characteristics, echocardiographic data, and hospital course were analyzed for 2 cohorts based on age at presentation to Boston Children's Hospital: group 1 (age ≤60 days) or group 2 (age >60 days). RESULTS Overall hospital survival was 35 of 49 (71.4%); 13 of 26 (50%) in group 1 and 22 of 23 (96%) in group 2 (P < .001). High-output PH (P = .01), cardiomegaly (P = .011), intubation (P = .019), and dopamine use (P = .01) were significantly more common in group 1 than group 2. Among patients in group 1, congestive heart failure (P = .015), intubation (P < .001), use of inhaled nitric oxide (P = .015) or prostaglandin E1 (P = .030), suprasystemic PH (P = .003), and right-sided dilation were significantly associated with mortality; in contrast, left ventricular volume and function, structural congenital heart disease, and supraventricular tachycardia were not associated. Inhaled nitric oxide achieved no clinical benefit in 9 of 11 treated patients. Resolution of PH was associated with overall survival (P < .001). CONCLUSIONS VOGM remains associated with substantial mortality among infants presenting at ≤60 days of life owing to factors associated with high output PH. Resolution of PH is an indicator associated with survival and a surrogate end point for benchmarking outcomes.
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Affiliation(s)
- Jai Khurana
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA; Neurointerventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Shane L Collins
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Joseph B Tella
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Pankaj B Agrawal
- Harvard Medical School, Boston, MA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Helen A Christou
- Harvard Medical School, Boston, MA; Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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10
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Lu VM, Abou-Al-Shaar H, Rangwala SD, Kappel AD, Lehman LL, Orbach DB, See AP. Neurosurgical outcomes of pediatric cerebral venous sinus thrombosis following acute mastoiditis: a systematic review and meta-analysis. J Neurosurg Pediatr 2023; 32:60-68. [PMID: 37060317 DOI: 10.3171/2023.2.peds2319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/27/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE Neurosurgical outcomes are not well defined in the management of pediatric patients with cerebral venous sinus thrombosis (CVST) following acute mastoiditis. Specific notable sequelae are otogenic (otitic) hydrocephalus and CVST management. Correspondingly, the aim of this study was to integrate the currently published metadata to summarize these outcomes. METHODS Electronic searches were performed using the Ovid Embase, PubMed, Scopus, and Cochrane databases from inception to November 2022 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Cohort-level data were then abstracted for analysis for appropriate pediatric patients. Outcomes were pooled by random-effects meta-analyses of proportions where possible. RESULTS Twenty-three study cohorts describing 312 pediatric patients with otogenic CVST were included. At a cohort level, the median patient age was 6 years among 181 boys (58%) and 131 girls (42%). Modeling indicated papilledema at presentation in 46% of cases (95% CI 30%-62%). Regarding management, antibiotics were applied universally in all cases, mastoidectomy or other otologic surgery was performed in 91% (95% CI 82%-98%), and prophylactic anticoagulation was administered in 86% (95% CI 75%-95%). There was only 1 case (0.3%) of postprocedural intracranial hemorrhage, and there were no deaths reported among all studies. Although diagnostic lumbar puncture was performed in 14% (95% CI 3%-28%) at presentation, clinical otogenic hydrocephalus was ultimately suspected in 31% (95% CI 14%-49%), and acetazolamide was given in 65% (95% CI 35%-91%) overall. There were 10 cases (3%) that proceeded to permanent CSF diversion in the form of ventricular shunting. At a median follow-up of 8 months among all studies, the venous sinus was completely recanalized in 67% (95% CI 53%-79%). CONCLUSIONS Most CVSTs following acute mastoiditis will recanalize with the standard use of antibiotics, otologic surgery, and anticoagulation, with minimal symptomatic hemorrhage risk. However, an appreciable proportion of these patients will develop symptomatic otogenic hydrocephalus, and it is imperative that the appropriate surveillance and workup is performed to fully optimize patient outcomes long-term. The possible need for permanent CSF diversion should be recognized.
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Affiliation(s)
- Victor M Lu
- Departments of1Neurosurgery and
- 2Department of Neurological Surgery, University of Miami, Florida
| | - Hussam Abou-Al-Shaar
- 3Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | | | - Laura L Lehman
- 4Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Darren B Orbach
- Departments of1Neurosurgery and
- 5Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Alfred P See
- Departments of1Neurosurgery and
- 5Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
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11
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Northam WT, Slingerland AL, Orbach DB, Smith ER. Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis. Neurosurgery 2023; 92:1243-1248. [PMID: 36744923 DOI: 10.1227/neu.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/08/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Digital subtraction angiography (DSA) assesses revascularization in pediatric moyamoya patients after surgery, but MRI and angiography (MRI/A) may provide comparable data. OBJECTIVE To evaluate DSA and MRI/A with respect to clinical utility in postoperative follow-up, complication profile, and relative cost at 1 year. METHODS All pediatric moyamoya patients who received bilateral indirect revascularization between 2011 and 2020 were retrospectively reviewed at 1 institution. Patients who underwent MRI/A-only, DSA-only, or both after 1 year were compared. RESULTS Eighty-two patients were included. At 1 year, patients who underwent either MRI/A (n = 29) or DSA (n = 40) had no significant differences in detection rate of new at-risk hypovascular territories (6.9% vs 2.5%, P = .568) or need for subsequent revascularization beyond the mean 40 ± 24-month follow-up period (3.4% vs 5.0%, P > .9). Among patients who underwent both MRI/A and DSA (n = 13), both studies identified the same at-risk territories. No patients experienced MRI/A-related complications, compared with 3 minor DSA-related complications. The use of MRI/A yielded a 6.5-fold reduction in cost per study vs DSA at 1 year. CONCLUSION Using DSA to follow moyamoya patients after indirect revascularization is generally safe but associated with a low rate of minor complications and a 6.5-fold greater financial cost relative to MRI/A. These data support changing practice to eliminate the use of DSA when following routine bilateral moyamoya cases in the absence of clinical symptoms or specific concerns. Using MRI/A as the primary postoperative follow-up modality in this select population provides noninferior care and greater patient access, while reducing cost and potentially decreasing risk.
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Affiliation(s)
- Weston T Northam
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anna L Slingerland
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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12
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Liddle D, Ibrahim B, Isibor C, Judge J, Orbach DB, Saleeb SF. Heart Failure Following Sinus Venosus Defect Closure in a Patient With Vein of Galen Malformation. JACC Case Rep 2023; 14:101831. [PMID: 37077875 PMCID: PMC10106996 DOI: 10.1016/j.jaccas.2023.101831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/15/2022] [Revised: 03/11/2023] [Accepted: 03/20/2023] [Indexed: 04/21/2023]
Abstract
This case concerns an 18-month-old with masked congestive heart failure (CHF) from an unrepaired vein of Galen malformation and superior sinus venosus defect who progressed to severe, refractory CHF following superior sinus venosus defect repair. Partial transvenous coil embolization of a very-high-risk vein of Galen malformation resolved CHF symptoms. (Level of Difficulty: Advanced.).
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Affiliation(s)
- David Liddle
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Bishoy Ibrahim
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Christopher Isibor
- Department of Neurosurgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Jennifer Judge
- Department of Neurosurgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Darren B. Orbach
- Department of Neurosurgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Neurointerventional Radiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Susan F. Saleeb
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Address for correspondence: Dr Susan Saleeb, Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts 02115, USA.
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13
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Hadad S, Rangwala SD, Stout JN, Mut F, Orbach DB, Cebral JR, See AP. Understanding development of jugular bulb stenosis in vein of galen malformations: identifying metrics of complex flow dynamics in the cerebral venous vasculature of infants. Front Physiol 2023; 14:1113034. [PMID: 37275225 PMCID: PMC10236198 DOI: 10.3389/fphys.2023.1113034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/24/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction: Computational fluid dynamics (CFD) assess biological systems based on specific boundary conditions. We propose modeling more advanced hemodynamic metrics, such as core line length (CL) and critical points which characterize complexity of flow in the context of cerebral vasculature, and specifically cerebral veins during the physiologically evolving early neonatal state of vein of Galen malformations (VOGM). CFD has not been applied to the study of arteriovenous shunting in Vein of Galen Malformations but could help illustrate the pathophysiology of this malformation. Methods: Three neonatal patients with VOGM at Boston Children's Hospital met inclusion criteria for this study. Structural MRI data was segmented to generate a mesh of the VOGM and venous outflow. Boundary condition flow velocity was derived from PC-MR sequences with arterial and venous dual velocity encoding. The mesh and boundary conditions were applied to model the cerebral venous flow. We computed flow variables including mean wall shear stress (WSSmean), mean OSI, CL, and the mean number of critical points (nCrPointsmean) for each patient specific model. A critical point is defined as the location where the shear stress vector field is zero (stationary point) and can be used to describe complexity of flow. Results: The division of flow into the left and right venous outflow was comparable between PC-MR and CFD modeling. A high complexity recirculating flow pattern observed on PC-MR was also identified on CFD modeling. Regions of similar WSSmean and OSImean (<1.3 fold) in the left and right venous outflow channels of a single patient have several-fold magnitude difference in higher order hemodynamic metrics (> 3.3 fold CL, > 1.7 fold nCrPointsmean). Specifically, the side which developed JBS in each model had greater nCrPointsmean compared to the jugular bulb with no stenosis (VOGM1: 4.49 vs. 2.53, VOGM2: 1.94 vs. 0, VOGM3: 1 vs. 0). Biologically, these regions had subsequently divergent development, with increased complexity of flow associating with venous stenosis. Discussion: Advanced metrics of flow complexity identified in computational models may reflect observed flow phenomena not fully characterized by primary or secondary hemodynamic parameters. These advanced metrics may indicate physiological states that impact development of jugular bulb stenosis in VOGM.
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Affiliation(s)
- Sara Hadad
- Department of Bioengineering, George Mason University, Fairfax, VA, United States
| | - Shivani D. Rangwala
- Cerebrovascular Surgery and Interventions Center, Department of Neurosurgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Neurosurgery, University of Southern California LAC+USC, Los Angeles, CA, United States
| | - Jeffrey N. Stout
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, United States
| | - Fernando Mut
- Department of Bioengineering, George Mason University, Fairfax, VA, United States
| | - Darren B. Orbach
- Cerebrovascular Surgery and Interventions Center, Department of Neurosurgery, Boston Children’s Hospital, Boston, MA, United States
- Neurointerventional Radiology, Boston Children’s Hospital, Boston, MA, United States
| | - Juan R. Cebral
- Department of Bioengineering, George Mason University, Fairfax, VA, United States
| | - Alfred P. See
- Cerebrovascular Surgery and Interventions Center, Department of Neurosurgery, Boston Children’s Hospital, Boston, MA, United States
- Neurointerventional Radiology, Boston Children’s Hospital, Boston, MA, United States
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14
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Orbach DB, Wilkins-Haug LE, Benson CB, Tworetzky W, Rangwala SD, Guseh SH, Gately NK, Stout JN, Mizrahi-Arnaud A, See AP. Transuterine Ultrasound-Guided Fetal Embolization of Vein of Galen Malformation, Eliminating Postnatal Pathophysiology. Stroke 2023; 54:e231-e232. [PMID: 37139817 DOI: 10.1161/strokeaha.123.043421] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Darren B Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital, MA. (D.B.O.)
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, MA. (D.B.O., A.P.S., J.N.S)
| | - Louise E Wilkins-Haug
- Departments of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA. (L.E.W.-H., S.H.G.)
| | - Carol B Benson
- Radiology, Brigham and Women's Hospital, Boston, MA. (C.B.B.)
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, MA. (W.T.)
| | - Shivani D Rangwala
- Department of Neurosurgery, Boston Children's Hospital, MA. (A.P.S., S.D.R.)
| | - Stephanie H Guseh
- Departments of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA. (L.E.W.-H., S.H.G.)
| | - Nicole K Gately
- Maternal Fetal Care Center, Boston Children's Hospital, MA. (N.K.G.)
| | - Jeffrey N Stout
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, MA. (D.B.O., A.P.S., J.N.S)
| | | | - Alfred P See
- Department of Neurosurgery, Boston Children's Hospital, MA. (A.P.S., S.D.R.)
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, MA. (D.B.O., A.P.S., J.N.S)
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15
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Chen M, Fargen KM, Mocco J, Siddiqui AH, Miyachi S, Mahadevan J, Ayudya SSN, Churojana A, Chryssidis S, De Villiers L, Rahman M, Dey SK, Zhang H, Wang D, Petrocelli S, Garbugino S, Kulcsar Z, Januel A, Kocer N, Manfre L, Tanaka M, Matsumaru Y, Suh SH, Yoon W, de Freitas C, Mont'Alverne F, Desal H, Caroff J, Lee W, Anil G, Harrichandparsad R, LeFeuvre D, Agid R, Orbach DB, Taylor A. World federation of interventional and therapeutic neuroradiology (WFITN) federation assembly neurointerventional surgery safety checklist. Interv Neuroradiol 2023:15910199231174550. [PMID: 37143331 DOI: 10.1177/15910199231174550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Over the last 10 years, there has been a rise in neurointerventional case complexity, device variety and physician distractions. Even among experienced physicians, this trend challenges our memory and concentration, making it more difficult to remember safety principles and their implications. Checklists are regarded by some as a redundant exercise that wastes time, or as an attack on physician autonomy. However, given the increasing case and disease complexity along with the number of distractions, it is even more important now to have a compelling reminder of safety principles that preserve habits that are susceptible to being overlooked because they seem mundane. Most hospitals have mandated a pre-procedure neurointerventional time-out checklist, but often it ends up being done in a cursory fashion for the primary purpose of 'checking off boxes'. There may be value in iterating the checklist to further emphasize safety and communication. The Federation Assembly of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel.
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Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Shigeru Miyachi
- Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
| | | | | | | | - Steve Chryssidis
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Laetitia De Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Mohibur Rahman
- National Institute of Neurosciences & Hospital, Sher-E-Bangla Nagar, Bangladesh
| | | | - Hongqi Zhang
- Neurosurgery, Xuanwu Hospital, Beijing, Beijing, China
| | - Donghai Wang
- Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Sergio Petrocelli
- Interventional Neuroradiology, Sanatorio Parque, Rosario- Santa Fe, Argentina
| | - Silvia Garbugino
- Neurosurgery, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina
| | - Zsolt Kulcsar
- Neuroradiology, Zurich University Hospital, Zurich, Switzerland
| | - Anne Januel
- University Hospital Centre Toulouse, Toulouse, Occitanie, France
| | - Naci Kocer
- Department of Radiology, Cerrahpasa Medical School, Istanbul, Turkey
| | - Luigi Manfre
- Department of Radiology, IOM Mediterranean Oncology Institute, Viagrande, Italy
| | | | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Sang Hyun Suh
- Radiology, Gangnam Severance Hospital Yonsei University, Seoul, Korea
| | - Woong Yoon
- Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Carlos de Freitas
- Sao Paulo State University Julio de Mesquita Filho - Rosana Campus, Rosana, Brazil
| | | | - Hubert Desal
- Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Wickly Lee
- National Neuroscience Institute, Singapore
| | - Gopinathan Anil
- Department of Diagnostic Imaging, National University Health System, National University Hospital, Singapore
- Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rohen Harrichandparsad
- Neurosurgery, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
| | | | - Ronit Agid
- Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Allan Taylor
- Neurosurgery, University of Cape Town, Cape Town, South Africa
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16
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Chen M, Fargen KM, Mocco J, Siddiqui AH, Miyachi S, Mahadevan J, Na Ayudya SS, Churojana A, Chryssidis S, De Villiers L, Rahman M, Dey SK, Zhang H, Wang D, Petrocelli S, Garbugino S, Kulcsar Z, Januel A, Kocer N, Manfre L, Tanaka M, Matsumaru Y, Suh SH, Yoon W, de Freitas C, Mont'Alverne F, Desal H, Caroff J, Lee W, Anil G, Harrichandparsad R, LeFeuvre D, Agid R, Orbach DB, Taylor A. World Federation of Interventional and Therapeutic Neuroradiology (WFITN) Federation Assembly neurointerventional surgery safety checklist. J Neurointerv Surg 2023:jnis-2023-020309. [PMID: 37147004 DOI: 10.1136/jnis-2023-020309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Shigeru Miyachi
- Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
| | | | | | | | - Steve Chryssidis
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Laetitia De Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Mohibur Rahman
- National Institute of Neurosciences & Hospital, Sher-E-Bangla Nagar, Bangladesh
| | | | - Hongqi Zhang
- Neurosurgery, Xuanwu Hospital, Beijing, Beijing, China
| | - Donghai Wang
- Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Sergio Petrocelli
- Interventional Neuroradiology, Sanatorio Parque, Rosario- Santa Fe, Argentina
| | - Silvia Garbugino
- Neurosurgery, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina
| | - Zsolt Kulcsar
- Neuroradiology, Zurich University Hospital, Zurich, Switzerland
| | - Anne Januel
- University Hospital Centre Toulouse, Toulouse, Occitanie, France
| | - Naci Kocer
- Department of Radiology, Cerrahpasa Medical School, Istanbul, Turkey
| | - Luigi Manfre
- Department of Radiology, IOM Mediterranean Oncology Institute, Viagrande, Italy
| | | | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Sang Hyun Suh
- Radiology, Gangnam Severance Hospital Yonsei University, Seoul, Korea (the Republic of)
| | - Woong Yoon
- Radiology, Chonnam National University Hospital, Gwangju, Korea (the Republic of)
| | - Carlos de Freitas
- Sao Paulo State University Julio de Mesquita Filho - Rosana Campus, Rosana, Brazil
| | | | - Hubert Desal
- Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Wickly Lee
- National Neuroscience Institute, Singapore
| | - Gopinathan Anil
- Department of Diagnostic Imaging, National University Health System, National University Hospital, Singapore
- Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rohen Harrichandparsad
- Neurosurgery, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
| | | | - Ronit Agid
- Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Allan Taylor
- Neurosurgery, University of Cape Town, Cape Town, South Africa
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17
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Kappel AD, Orbach DB. Standard umbilical artery catheters used as diagnostic and neurointerventional guide catheters in the treatment of neonatal cerebrovascular malformations. J Neurointerv Surg 2023; 15:375-379. [PMID: 35577562 DOI: 10.1136/neurintsurg-2022-018764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/01/2022] [Accepted: 04/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Vascular access in neonates is limited by the small size of the femoral artery and the risk of complications, including thrombosis and limb ischemia. Although umbilical artery access has been described, previous reports detail exchange of the umbilical artery catheter (UAC) for a conventional arterial sheath, which can be difficult and cumbersome. We aim to describe direct use of the UAC as the sheath and guide catheter in neonatal patients requiring endovascular treatment for life-threatening intracranial arteriovenous shunts. METHODS We reviewed all cases between 2016 and 2021 of neonatal intervention using a direct UAC approach. We describe our technique of utilizing UACs for cerebral angiography and neurointerventions in newborns without catheter exchange, allowing for repeated, straightforward endovascular access in neonates across multiple interventions. RESULTS Seven consecutive neonates underwent endovascular neurointerventional procedures for the treatment of life-threatening, high-flow arteriovenous shunts using a direct UAC access technique without procedural morbidity. Five of seven patients underwent more than one procedure in the neonatal period, between day 1 and day 10 of life. CONCLUSIONS Use of the UAC itself as a diagnostic catheter for cerebral angiography or as a guide catheter for neurointerventions greatly facilitates endovascular interventions in newborns and is ideal for patients requiring multiple interventions in the neonatal period. This technique helps to mitigate the risk of neonatal femoral artery access and its complications, including thrombosis, dissection, spasm, stenosis, and limb ischemia.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA.,Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA .,Radiology, Harvard Medical School, Boston, Massachusetts, USA
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18
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Zhao S, Mekbib KY, van der Ent MA, Allington G, Prendergast A, Chau JE, Smith H, Shohfi J, Ocken J, Duran D, Furey CG, Le HT, Duy PQ, Reeves BC, Zhang J, Nelson-Williams C, Chen D, Li B, Nottoli T, Bai S, Rolle M, Zeng X, Dong W, Fu PY, Wang YC, Mane S, Piwowarczyk P, Fehnel KP, See AP, Iskandar BJ, Aagaard-Kienitz B, Kundishora AJ, DeSpenza T, Greenberg ABW, Kidanemariam SM, Hale AT, Johnston JM, Jackson EM, Storm PB, Lang SS, Butler WE, Carter BS, Chapman P, Stapleton CJ, Patel AB, Rodesch G, Smajda S, Berenstein A, Barak T, Erson-Omay EZ, Zhao H, Moreno-De-Luca A, Proctor MR, Smith ER, Orbach DB, Alper SL, Nicoli S, Boggon TJ, Lifton RP, Gunel M, King PD, Jin SC, Kahle KT. Genetic dysregulation of an endothelial Ras signaling network in vein of Galen malformations. bioRxiv 2023:2023.03.18.532837. [PMID: 36993588 PMCID: PMC10055230 DOI: 10.1101/2023.03.18.532837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and severe congenital brain arteriovenous malformation, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP ( RASA1 ) harbored a genome-wide significant burden of loss-of-function de novo variants (p=4.79×10 -7 ). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 ( EPHB4 ) (p=1.22×10 -5 ), which cooperates with p120 RasGAP to limit Ras activation. Other probands had pathogenic variants in ACVRL1 , NOTCH1 , ITGB1 , and PTPN11 . ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomics defined developing endothelial cells as a key spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant exhibited constitutive endothelial Ras/ERK/MAPK activation and impaired hierarchical development of angiogenesis-regulated arterial-capillary-venous networks, but only when carrying a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have clinical implications.
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19
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Alomari MH, Shahin MM, Fishman SJ, Kerr CL, Smith ER, Eng W, Ruiz-Gutierrez M, Adams DM, Orbach DB, Chaudry G, Shaikh R, Chewning R, Alomari AI. Cerebrospinal fluid leak in epidural venous malformations and blue rubber bleb nevus syndrome. J Neurosurg Spine 2022; 37:439-445. [PMID: 35364593 DOI: 10.3171/2022.1.spine2138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical manifestations of blue rubber bleb nevus syndrome (BRBNS) and multifocal venous malformation (MVM) vary depending on the location of the lesions. The aim of this study was to assess the risk of developing CSF leaks in patients with epidural venous malformations (VMs). METHODS The authors retrospectively investigated the relationship between the development of a CSF leak and the presence of epidural VMs. RESULTS Nine patients (5 females) had epidural VMs and presentation that was confirmatory or suggestive of a CSF leak: 4 had BRBNS, 4 had MVMs, and 1 had a solitary VM. Of 66 patients with BRBNS, clinical and imaging features of CSF leak were noted in 3 (4.5%) with epidural VMs at the age of 11-44 years. A fourth patient had suggestive symptoms without imaging confirmation. An epidural blood patch was ineffective in 2 patients, both with more than one source of leakage, requiring surgical repair or decompression. Symptomatic downward displacement of the cerebellar tonsils was noted in 3 patients with MVM and 1 with a solitary VM; 3 required surgical decompression. CONCLUSIONS These findings suggest an increased risk of CSF leak in patients with epidural VM, including BRBNS, MVMs, and solitary VMs. Awareness of the association between epidural VM and CSF leakage may facilitate earlier diagnosis and therapeutic intervention.
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Affiliation(s)
| | | | | | - Cindy L Kerr
- 1Division of Vascular and Interventional Radiology
| | | | - Whitney Eng
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melisa Ruiz-Gutierrez
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Denise M Adams
- 4Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Raja Shaikh
- 1Division of Vascular and Interventional Radiology
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20
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Jaimes C, Machado-Rivas F, Chen K, Bedoya MA, Yang E, Orbach DB. Brain Injury in Fetuses with Vein of Galen Malformation and Nongalenic Arteriovenous Fistulas: Static Snapshot or a Portent of More? AJNR Am J Neuroradiol 2022; 43:1036-1041. [PMID: 35654491 DOI: 10.3174/ajnr.a7533] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/18/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Brain injury in fetuses with vein of Galen malformations and nongalenic AVFs is a rare complication whose appearance, course, and prognosis are poorly studied. We sought to characterize the MR imaging features and examine associations with postnatal outcome. MATERIALS AND METHODS This was a retrospective analysis of fetal MRIs of subjects with vein of Galen malformation and nongalenic arteriovenous fistulas. Two pediatric neuroradiologists independently reviewed examinations to determine the presence of abnormalities on structural imaging (T1 volumetric interpolated breath-hold examination and T2-HASTE), DWI, and T2*-weighted images; discrepancies were adjudicated by a third reviewer. Radiologic progression of injury was determined by additional fetal or neonatal MRIs. A simple composite score evaluating poor neonatal clinical outcome as either intubation or death by postnatal day 2 was also queried. A body fetal imager evaluated the presence of systemic findings of right heart strain. RESULTS Forty-nine fetal MR imaging examinations corresponding to 31 subjects (27 vein of Galen malformations and 4 nongalenic AVF cases) were analyzed. Injury was observed in 8 subjects (26%) with 14 fetal examinations; the mean gestational age at identification of injury was 32.2 (SD 4.9) weeks. Structural abnormalities were present in all subjects with injury; restricted diffusion, in 5/7 subjects with available data; and T2* abnormalities, in all subjects with available data (n = 7). Radiologic progression was documented in all cases with follow-up imaging (n = 7). All subjects with fetal brain injury had a poor neonatal clinical outcome. CONCLUSIONS Brain injury in fetuses with vein of Galen malformation and nongalenic AVFs shows a combination of structural abnormalities, restricted diffusion, and blooming on T2* images. Injury appears to portend a poor prognosis, with relentless progression and a likely association with adverse neonatal outcomes.
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Affiliation(s)
- C Jaimes
- From the Department of Radiology (C.J., F.M.-R., M.A.B., E.Y., D.B.O.), Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - F Machado-Rivas
- From the Department of Radiology (C.J., F.M.-R., M.A.B., E.Y., D.B.O.), Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - K Chen
- Department of Radiology (K.C.), Texas Children's Hospital, Houston, Texas
| | - M A Bedoya
- From the Department of Radiology (C.J., F.M.-R., M.A.B., E.Y., D.B.O.), Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - E Yang
- From the Department of Radiology (C.J., F.M.-R., M.A.B., E.Y., D.B.O.), Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - D B Orbach
- From the Department of Radiology (C.J., F.M.-R., M.A.B., E.Y., D.B.O.), Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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21
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Kirton A, Jordan LC, Orbach DB, Fullerton HJ. The case against endovascular thrombectomy in neonates with arterial ischemic stroke. Clin Neuroradiol 2022; 32:581-582. [PMID: 35648152 DOI: 10.1007/s00062-022-01153-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Adam Kirton
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lori C Jordan
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
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22
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See AP, Wilkins-Haug LE, Benson CB, Tworetzky W, Orbach DB. Percutaneous transuterine fetal cerebral embolisation to treat vein of Galen malformations at risk of urgent neonatal decompensation: study protocol for a clinical trial of safety and feasibility. BMJ Open 2022; 12:e058147. [PMID: 35613814 PMCID: PMC9174825 DOI: 10.1136/bmjopen-2021-058147] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Although endovascular techniques have improved outcomes in vein of Galen malformations (VOGM), there is still a high rate of morbidity and mortality, particularly among cases with decompensation in the neonatal period. The dimension of the draining venous sinus on fetal imaging correlates with the risk of neonatal decompensation. In fetuses within this high-risk group who do not have end-organ injury, there is a theoretical therapeutic opportunity to reduce the arteriovenous shunt before the normal physiological changes of birth precipitate decompensation. This study investigates the safety and potential benefit of treating a VOGM in utero, which has not been previously studied. METHODS AND ANALYSIS This study aims to enroll 20 subjects: pregnant women with a fetus harbouring a high-risk VOGM (defined on MRI by a narrowest medial-lateral width greater than 8 mm in the draining venous sinus). Unfortunately, the subset of fetuses with in utero end-organ injury is ineligible, because the late stage of pathology is not amenable to recovery from a cerebrovascular intervention, likely not even in utero. This study aims to alter the physiology before such developments accrue.At or after 23 weeks of gestation, a transuterine transposterior fontanelle needle puncture to the torcular allows ultrasound-guided deployment of coils to embolise the draining venous malformation.This study has 97.5% power to detect major safety events at 30% or greater, and 80% power to detect a reduction in the rate of neonatal intervention from 80% to 30%. In the staged study design, an interval evaluation after 11 patients invokes study termination if safety events occur above the allowed threshold. ETHICS AND DISSEMINATION The institutional review boards at Mass General Brigham and Boston Children's Hospital (BCH) reviewed and approved this protocol. The BCH Department of Radiology and a patient family philanthropic donation fund this study. The trial results will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER NCT04434729.
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Affiliation(s)
- Alfred Pokmeng See
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Louise E Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Radiology (Neurointerventional), Boston Children's Hospital, Boston, Massachusetts, USA
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23
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Montaser AS, Lalgudi Srinivasan H, Staffa SJ, Zurakowski D, Slingerland AL, Orbach DB, Hausman-Kedem M, Roth J, Smith ER. Ivy sign: a diagnostic and prognostic biomarker for pediatric moyamoya. J Neurosurg Pediatr 2022; 29:458-466. [PMID: 34972077 DOI: 10.3171/2021.11.peds21384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 07/25/2021] [Accepted: 11/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ivy sign is a radiographic finding on FLAIR MRI sequences and is associated with slow cortical blood flow in moyamoya. Limited data exist on the utility of the ivy sign as a diagnostic and prognostic tool in pediatric patients, particularly outside of Asian populations. The authors aimed to investigate a modified grading scale with which to characterize the prevalence and extent of the ivy sign in children with moyamoya and evaluate its efficacy as a biomarker in predicting postoperative outcomes, including stroke risk. METHODS Pre- and postoperative clinical and radiographic data of all pediatric patients (21 years of age or younger) who underwent surgery for moyamoya disease or moyamoya syndrome at two major tertiary referral centers in the US and Israel, between July 2009 and August 2019, were retrospectively reviewed. Ivy sign scores were correlated to Suzuki stage, Matsushima grade, and postoperative stroke rate to quantify the diagnostic and prognostic utility of ivy sign. RESULTS A total of 171 hemispheres in 107 patients were included. The median age at the time of surgery was 9 years (range 3 months-21 years). The ivy sign was most frequently encountered in association with Suzuki stage III or IV disease in all vascular territories, including the anterior cerebral artery (53.7%), middle cerebral artery (56.3%), and posterior cerebral artery (47.5%) territories. Following surgical revascularization, 85% of hemispheres with Matsushima grade A demonstrated a concomitant, statistically significant reduction in ivy sign scores (OR 5.3, 95% CI 1.4-20.0; p = 0.013). Postoperatively, revascularized hemispheres that exhibited ivy sign score decreases had significantly lower rates of postoperative stroke (3.4%) compared with hemispheres that demonstrated no reversal of the ivy sign (16.1%) (OR 5.5, 95% CI 1.5-21.0; p = 0.008). CONCLUSIONS This is the largest study to date that focuses on the role of the ivy sign in pediatric moyamoya. These data demonstrate that the ivy sign was present in approximately half the pediatric patients with moyamoya with Suzuki stage III or IV disease, when blood flow was most unstable. The authors found that reversal of the ivy sign provided both radiographic and clinical utility as a prognostic biomarker postoperatively, given the statistically significant association with both better Matsushima grades and a fivefold reduction in postoperative stroke rates. These findings can help inform clinical decision-making, and they have particular value in the pediatric population, as the ability to minimize additional radiographic evaluations and tailor radiographic surveillance is requisite.
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Affiliation(s)
- Alaa S Montaser
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | | | - Steven J Staffa
- 4Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- 4Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna L Slingerland
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Darren B Orbach
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,5Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Moran Hausman-Kedem
- 6Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; and.,7Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- 3Department of Neurosurgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,7Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward R Smith
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Filippidis A, Lidov H, Al-Ibraheemi A, See AP, Srivastava S, Orbach DB, Fehnel KP. Intracranial venous malformation masquerading as a meningioma in PI3KCA-related overgrowth spectrum disorder. Am J Med Genet A 2021; 188:907-910. [PMID: 34854542 DOI: 10.1002/ajmg.a.62570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/14/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/08/2022]
Abstract
Gain of function PIK3CA pathogenic variants have been identified in overgrowth syndromes collectively termed "PIK3CA-related overgrowth spectrum" (PROS). There are no previously reported cases of cerebrovascular venous malformations in PROS syndromes, though somatic activating PIK3CA variants have been identified in extracranial venous malformation. This study was approved by the Institutional Review Boar at Boston Children's Hospital. A 14-year-old female mosaic for the de novo p.R108H pathogenic variant in the PIK3CA gene was found to have a large tumor involving the superior sagittal sinus with mass effect on the motor cortex most consistent with a parafalcine meningioma. She underwent surgical resection with pathology demonstrating a venous malformation. PIK3CA pathogenic variants have been identified in nonsyndromic extracranial venous and lymphatic malformations as well in brain tumors, including glioma and meningioma. However, PIK3CA variants have not previously been identified in purely intracranial venous malformations. This distinction is relevant to treatment decisions, given that mTOR inhibitors may provide an alternative option for noninvasive therapy in cases of suspected venous malformation.
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Affiliation(s)
- Aristotelis Filippidis
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts, USA
| | - Hart Lidov
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alyaa Al-Ibraheemi
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alfred P See
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katie Pricola Fehnel
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Chen K, Dawkins D, Orbach DB, Aagaard-Kienitz B. Low profile sheaths in pediatric neurointervention: a multicenter experience. J Neurointerv Surg 2021; 14:1135-1138. [PMID: 34625510 DOI: 10.1136/neurintsurg-2021-017936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/28/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population. METHODS All pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author's institution were introduced. RESULTS From January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children's Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05). CONCLUSION The 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist's armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.
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Affiliation(s)
- Karen Chen
- Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Demi Dawkins
- Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beverly Aagaard-Kienitz
- Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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26
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Kundishora AJ, Peters ST, Pinard A, Duran D, Panchagnula S, Barak T, Miyagishima DF, Dong W, Smith H, Ocken J, Dunbar A, Nelson-Williams C, Haider S, Walker RL, Li B, Zhao H, Thumkeo D, Marlier A, Duy PQ, Diab NS, Reeves BC, Robert SM, Sujijantarat N, Stratman AN, Chen YH, Zhao S, Roszko I, Lu Q, Zhang B, Mane S, Castaldi C, López-Giráldez F, Knight JR, Bamshad MJ, Nickerson DA, Geschwind DH, Chen SSL, Storm PB, Diluna ML, Matouk CC, Orbach DB, Alper SL, Smith ER, Lifton RP, Gunel M, Milewicz DM, Jin SC, Kahle KT. DIAPH1 Variants in Non-East Asian Patients With Sporadic Moyamoya Disease. JAMA Neurol 2021; 78:993-1003. [PMID: 34125151 PMCID: PMC8204259 DOI: 10.1001/jamaneurol.2021.1681] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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] [Received: 12/23/2020] [Accepted: 03/31/2021] [Indexed: 12/18/2022]
Abstract
Importance Moyamoya disease (MMD), a progressive vasculopathy leading to narrowing and ultimate occlusion of the intracranial internal carotid arteries, is a cause of childhood stroke. The cause of MMD is poorly understood, but genetic factors play a role. Several familial forms of MMD have been identified, but the cause of most cases remains elusive, especially among non-East Asian individuals. Objective To assess whether ultrarare de novo and rare, damaging transmitted variants with large effect sizes are associated with MMD risk. Design, Setting, and Participants A genetic association study was conducted using whole-exome sequencing case-parent MMD trios in a small discovery cohort collected over 3.5 years (2016-2019); data were analyzed in 2020. Medical records from US hospitals spanning a range of 1 month to 1.5 years were reviewed for phenotyping. Exomes from a larger validation cohort were analyzed to identify additional rare, large-effect variants in the top candidate gene. Participants included patients with MMD and, when available, their parents. All participants who met criteria and were presented with the option to join the study agreed to do so; none were excluded. Twenty-four probands (22 trios and 2 singletons) composed the discovery cohort, and 84 probands (29 trios and 55 singletons) composed the validation cohort. Main Outcomes and Measures Gene variants were identified and filtered using stringent criteria. Enrichment and case-control tests assessed gene-level variant burden. In silico modeling estimated the probability of variant association with protein structure. Integrative genomics assessed expression patterns of MMD risk genes derived from single-cell RNA sequencing data of human and mouse brain tissue. Results Of the 24 patients in the discovery cohort, 14 (58.3%) were men and 18 (75.0%) were of European ancestry. Three of 24 discovery cohort probands contained 2 do novo (1-tailed Poisson P = 1.1 × 10-6) and 1 rare, transmitted damaging variant (12.5% of cases) in DIAPH1 (mammalian diaphanous-1), a key regulator of actin remodeling in vascular cells and platelets. Four additional ultrarare damaging heterozygous DIAPH1 variants (3 unphased) were identified in 3 other patients in an 84-proband validation cohort (73.8% female, 77.4% European). All 6 patients were non-East Asian. Compound heterozygous variants were identified in ena/vasodilator-stimulated phosphoproteinlike protein EVL, a mammalian diaphanous-1 interactor that regulates actin polymerization. DIAPH1 and EVL mutant probands had severe, bilateral MMD associated with transfusion-dependent thrombocytopenia. DIAPH1 and other MMD risk genes are enriched in mural cells of midgestational human brain. The DIAPH1 coexpression network converges in vascular cell actin cytoskeleton regulatory pathways. Conclusions and Relevance These findings provide the largest collection to date of non-East Asian individuals with sporadic MMD harboring pathogenic variants in the same gene. The results suggest that DIAPH1 is a novel MMD risk gene and impaired vascular cell actin remodeling in MMD pathogenesis, with diagnostic and therapeutic ramifications.
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Affiliation(s)
- Adam J. Kundishora
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Samuel T. Peters
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson
| | - Amélie Pinard
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Daniel Duran
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson
| | | | - Tanyeri Barak
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
- Department of Neuroscience, Yale School of Medicine, New Haven, Connecticut
- Yale Program on Neurogenetics, Yale School of Medicine, New Haven, Connecticut
| | - Danielle F. Miyagishima
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
- Department of Neuroscience, Yale School of Medicine, New Haven, Connecticut
- Yale Program on Neurogenetics, Yale School of Medicine, New Haven, Connecticut
| | - Weilai Dong
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, New York
| | - Hannah Smith
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Jack Ocken
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Ashley Dunbar
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Shozeb Haider
- Department of Pharmaceutical and Biological Chemistry, University College London School of Pharmacy, London, United Kingdom
| | - Rebecca L. Walker
- Department of Neurology, Center for Autism Research and Treatment, Semel Institute, David Geffen School of Medicine, University of California, Los Angeles
| | - Boyang Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Hongyu Zhao
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Dean Thumkeo
- Department of Drug Discovery Medicine, Kyoto University, Graduate School of Medicine, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, Japan
| | - Arnaud Marlier
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Phan Q. Duy
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Nicholas S. Diab
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin C. Reeves
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | | | | | - Amber N. Stratman
- Department of Cell Biology and Physiology, Washington University School of Medicine, St Louis, Missouri
| | - Yi-Hsien Chen
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Shujuan Zhao
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Isabelle Roszko
- Department of Developmental Biology, Center of Regenerative Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Qiongshi Lu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison
| | - Bo Zhang
- Department of Developmental Biology, Center of Regenerative Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Shrikant Mane
- Yale Center for Genome Analysis, West Haven, Connecticut
| | | | | | | | | | | | - Daniel H. Geschwind
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles
| | - Shih-Shan Lang Chen
- Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Phillip B. Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michael L. Diluna
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Charles C. Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Darren B. Orbach
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seth L. Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Edward R. Smith
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard P. Lifton
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, New York
| | - Murat Gunel
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
| | - Dianna M. Milewicz
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Sheng Chih Jin
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Kristopher T. Kahle
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Cellular & Molecular Physiology, Yale School of Medicine, New Haven, Connecticut
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27
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Montaser A, Driscoll J, Smith H, Karsten MB, Day E, Mounlavongsy T, Orbach DB, Smith ER. Long-term clinical and radiographic outcomes after pial pericranial dural revascularization: a hybrid surgical technique for treatment of anterior cerebral territory ischemia in pediatric moyamoya disease. J Neurosurg Pediatr 2021; 28:351-359. [PMID: 34214976 DOI: 10.3171/2021.2.peds20743] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 08/31/2020] [Accepted: 02/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated anterior cerebral artery (ACA) territory ischemia in pediatric moyamoya disease (MMD) is rare but has been increasingly recognized, particularly in children manifesting progression of disease in a delayed fashion after middle cerebral artery revascularization surgery. Surgical treatment is complicated by limited graft choices, with the small number of case series largely focused on complex, higher-risk operations (omental flap transfers, large interhemispheric rotational grafts); direct bypass (often untenable in children due to vessel size); or, alternatively, the technically simpler method of multiple burr holes (of limited efficacy outside of infants). Faced with the problem of a growing cohort of pediatric patients with MMD that could benefit from anterior cerebral revascularization, the authors sought to develop a solution that was specifically designed for children and that would be lower risk than the more complex approaches adapted from adult populations but more effective than simple burr holes. In this study, the authors aimed to describe the long-term clinical and radiographic outcomes of a novel approach of pial pericranial dural (PiPeD) revascularization, building on the principles of pial synangiosis but unique in using the pericranium and the dura mater as the primary vascular supply, and employing a larger craniotomy with arachnoid dissection to provide robust full-territory revascularization in all ages with reduced risk relative to more complex procedures. METHODS The medical records of all pediatric patients with MMD who presented at a single center between July 2009 and August 2019 were retrospectively reviewed to identify patients with MMD with anterior cerebral territory ischemia. Clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic follow-up data were collected and analyzed. RESULTS A total of 25 operations (5.6% of total procedures) were performed in 21 patients (mean age 9.4 years [range 1-16.5 years]; 12 female and 9 male). Almost one-third of the patients had syndromic associations, with no familial cases. Complications included 1 patient (4.7%) with a superficial infection, with no postoperative strokes, hemorrhage, seizures, or deaths. Long-term follow-up was available in 18 of 21 patients (mean 24.9 months [range 4-60 months]). Radiographic engraftment was present in 90.9% (20/22 hemispheres), and no new strokes were evident on MRI on long-term follow-up, despite radiographic progression of the disease. CONCLUSIONS The use of the pericranium and the dura mater for indirect revascularization provided robust vascularized graft with great flexibility in location and high potential for engraftment, which may obviate more complex and higher-risk operations for ACA territory ischemia. Long-term follow-up demonstrated that PiPeD revascularization conferred durable, long-term radiographic and clinical protection from stroke in pediatric patients with MMD. Based on the results of the current study, the PiPeD technique can be considered an additional tool to the armamentarium of indirect revascularization procedures in select pediatric patients with MMD.
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Affiliation(s)
- Alaa Montaser
- Departments of1Neurosurgery and
- 2Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | | | | | | | | | | | - Darren B Orbach
- Departments of1Neurosurgery and
- 2Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
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28
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Affiliation(s)
- Hunter R Greer
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Torunn I Yock
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Adam L Green
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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29
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Chaudhary N, Elijovich L, Martinez M, Fifi JT, Ortega-Gutierrez S, Shaibani A, Pandey AS, Suzuki S, Field RR, Gemmete JJ, Cooke DL, Narayanan S, Hetts SW, Orbach DB, Pearl MS. Pediatric diagnostic cerebral angiography: practice recommendations from the SNIS Pediatric Committee. J Neurointerv Surg 2021; 13:762-766. [PMID: 33875551 DOI: 10.1136/neurintsurg-2021-017389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Neeraj Chaudhary
- Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Lucas Elijovich
- Departments of Neurology and Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Mesha Martinez
- Neurointerventional Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa, Iowa City, Iowa, USA
| | - Ali Shaibani
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Radiology, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Aditya S Pandey
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shuichi Suzuki
- Neurosurgery, University of California Irvine, Orange, California, USA
| | - R Ryan Field
- Anesthesia, Neurosurgery, University of California Irvine, Orange, California, USA
| | - Joseph J Gemmete
- Radiology and Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Sandra Narayanan
- Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA .,Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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30
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Sesen J, Driscoll J, Moses-Gardner A, Orbach DB, Zurakowski D, Smith ER. Non-invasive Urinary Biomarkers in Moyamoya Disease. Front Neurol 2021; 12:661952. [PMID: 33868159 PMCID: PMC8047329 DOI: 10.3389/fneur.2021.661952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: A major difficulty in treating moyamoya disease is the lack of effective methods to detect novel or progressive disease prior to the onset of disabling stroke. More importantly, a tool to better stratify operative candidates and quantify response to therapy could substantively complement existing methods. Here, we present proof-of-principle data supporting the use of urinary biomarkers as diagnostic adjuncts in pediatric moyamoya patients. Methods: Urine and cerebrospinal fluid specimens were collected from pediatric patients with moyamoya disease and a cohort of age and sex-matched control patients. Clinical and radiographic data were paired with measurements of a previously validated panel of angiogenic proteins quantified by ELISA. Results were compared to age and sex-matched controls and subjected to statistical analyses. Results: Evaluation of a specific panel of urinary and cerebrospinal fluid biomarkers by ELISA demonstrated significant elevations of angiogenic proteins in samples from moyamoya patients compared to matched controls. ROC curves for individual urinary biomarkers, including MMP-2, MMP-9, MMP-9/NGAL, and VEGF, showed excellent discrimination. The optimal urinary biomarker was MMP-2, providing a sensitivity of 88%, specificity of 100%, and overall accuracy of 91%. Biomarker levels changed in response to therapy and correlated with radiographic evidence of revascularization. Conclusions: We report, for the first time, identification of a panel of urinary biomarkers that predicts the presence of moyamoya disease. These biomarkers correlate with presence of disease and can be tracked from the central nervous system to urine. These data support the hypothesis that urinary proteins are useful predictors of the presence of moyamoya disease and may provide a basis for a novel, non-invasive method to identify new disease and monitor known patients following treatment.
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Affiliation(s)
- Julie Sesen
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jessica Driscoll
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alexander Moses-Gardner
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Departments of Surgery and Anesthesiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Edward R Smith
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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31
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Gallant SC, Chewning RH, Orbach DB, Trenor CC, Cunningham MJ. Contemporary Management of Vascular Anomalies of the Head and Neck-Part 1: Vascular Malformations: A Review. JAMA Otolaryngol Head Neck Surg 2021; 147:197-206. [PMID: 33237296 DOI: 10.1001/jamaoto.2020.4353] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Vascular anomalies of the head and neck are relatively rare lesions. Management is challenging because of the high likelihood of involvement of functionally critical structures. Multiple modalities of treatment exist for vascular anomalies of the head and neck, including medical therapies, sclerotherapy and embolization procedures, and surgery. This review focuses on the accurate diagnosis and the relative roles of the various therapeutic options. Observations Vascular anomalies are classified by the International Society for the Study of Vascular Anomalies into 2 major groups: vascular tumors and vascular malformations. Vascular tumors encompass proliferative lesions ranging from infantile and congenital hemangiomas to kaposiform hemangioendothelioma. Alternatively, vascular malformations are embryologic errors in vasculogenesis. This article focuses on the management of vascular malformations. The 3 primary vascular malformation subclassifications are lymphatic, venous, and arteriovenous. The burden of disease, diagnosis, and current management options are discussed in detail for each subtype. Conclusions and Relevance Most vascular malformations of the head and neck require a multidisciplinary approach. Available medical, interventional radiologic, and surgical interventions are constantly evolving. Optimization of function and cosmesis must be balanced with minimization of treatment-associated morbidity. Otolaryngologists-head and neck surgeons must remain up to date regarding options for diagnosis and management of these lesions.
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Affiliation(s)
- Sara C Gallant
- Department of Otolaryngology and Communication Sciences, Boston Children's Hospital, Boston, Massachusetts.,Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
| | - Rush H Chewning
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Darren B Orbach
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cameron C Trenor
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Michael J Cunningham
- Department of Otolaryngology and Communication Sciences, Boston Children's Hospital, Boston, Massachusetts.,Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
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32
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Alomari MH, Kozakewich HPW, Kerr CL, Uller W, Davis SL, Chaudry G, Liang MG, Orbach DB, Mulliken JB, Greene AK, Afshar S, Fishman SJ, Taghinia AH, Al-Ibraheemi A, Alomari AI. Congenital Disseminated Pyogenic Granuloma: Characterization of an Aggressive Multisystemic Disorder. J Pediatr 2020; 226:157-166. [PMID: 32622671 DOI: 10.1016/j.jpeds.2020.06.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 03/24/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the clinical, radiologic, and histopathologic features of "congenital disseminated pyogenic granuloma" involving various organs with high morbidity related to cerebral hemorrhagic involvement. STUDY DESIGN We searched the database of the Vascular Anomalies Center at Boston Children's Hospital from 1999 to 2019 for patients diagnosed as having multiple vascular lesions, visceral vascular tumors, congenital hemangiomatosis, multiple pyogenic granulomas, or multiple vascular lesions without a definite diagnosis. A retrospective review of the medical records, photographs, histopathologic, and imaging studies was performed. Only patients with imaging studies and histopathologic diagnosis of pyogenic granuloma were included. RESULTS Eight children (5 male, 3 female) had congenital multifocal cutaneous vascular tumors. Lesions also were found in the brain (n = 7), liver (n = 4), spleen (n = 3), muscles (n = 4), bone (n = 3), retroperitoneum (n = 3), and intestine/mesentery (n = 2). Less commonly affected were the spinal cord, lungs, kidneys, pancreas, and adrenal gland (n = 1 each). The mean follow-up period was 21.8 months. The cerebral and visceral lesions were hemorrhagic with severe neurologic sequelae. The histopathologic diagnosis was pyogenic granuloma with prominent areas of hemorrhage and necrosis. The endothelial cells had enlarged nuclei, pale cytoplasm and were immunopositive for CD31 and negative for D2-40 and glucose transporter 1. CONCLUSIONS Congenital disseminated pyogenic granuloma is a distinct multisystemic aggressive disorder that primarily affects the skin, brain, visceral organs, and musculoskeletal system. Differentiation of this entity from other multiple cutaneous vascular lesions is critical because of possible cerebral hemorrhagic involvement.
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Affiliation(s)
- Mohammed H Alomari
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Harry P W Kozakewich
- Harvard Medical School, Boston, MA; Department of Pathology, Boston Children's Hospital, Boston, MA
| | - Cindy L Kerr
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Wibke Uller
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Scott L Davis
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Gulraiz Chaudry
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Marilyn G Liang
- Harvard Medical School, Boston, MA; Division of Dermatology, Boston Children's Hospital, Boston, MA
| | - Darren B Orbach
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - John B Mulliken
- Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Arin K Greene
- Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Salim Afshar
- Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Steven J Fishman
- Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Amir H Taghinia
- Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Alya Al-Ibraheemi
- Harvard Medical School, Boston, MA; Department of Pathology, Boston Children's Hospital, Boston, MA
| | - Ahmad I Alomari
- Division of Vascular and Interventional Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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33
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Affiliation(s)
- Erika G Cordova
- Department of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Philip Levy
- Department of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Darren B Orbach
- Division of Neurointerventional Radiology, Maternal Fetal Medicine Center, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Carol Barnewolt
- Department of Radiology, Maternal Fetal Medicine Center, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Judy A Estroff
- Department of Radiology, Maternal Fetal Medicine Center, Boston Children's Hospital and Harvard Medical School, Boston, MA
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34
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Lehman LL, Bruccoleri R, Danehy A, Swanson J, Mrakotsky C, Smith E, Orbach DB, Burstein R. Adverse effects of erenumab on cerebral proliferative angiopathy: A case report. Cephalalgia 2020; 41:122-126. [PMID: 32814432 DOI: 10.1177/0333102420950484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 12/21/2022]
Abstract
BACKGROUND Cerebral proliferative angiopathy is a vascular malformation associated with compromised blood-brain barrier and with migraine-like headache. Treating blood-brain barrier-compromised patients with erenumab, an anti-calcitonin gene-related peptide receptor monoclonal antibody, may be risky. CASE We describe a case of a 22-year-old chronic migraine patient with cerebral proliferative angiopathy who presented to our hospital in status epilepticus 2 d after his first dose of erenumab. Serial magnetic resonance imaging (MRI) studies demonstrated progressive areas of diffusion restriction including the brain tissue adjacent to the cerebral proliferative angiopathy, bilateral white matter and hippocampi. His 6-month post-presentation magnetic resonance imaging was notable for white matter injury, encephalomalacia surrounding cerebral proliferative angiopathy and bilateral hippocampal sclerosis. He remains clinically affected with residual symptoms, including refractory epilepsy and cognitive deficits. CONCLUSION The evidence presented in this case supports further investigation into potential deleterious side effects of erenumab in patients with compromised blood-brain barrier, such as individuals with intracranial vascular malformations.
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Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rebecca Bruccoleri
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Amy Danehy
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Julie Swanson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Christine Mrakotsky
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA
| | - Edward Smith
- Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - Darren B Orbach
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Rami Burstein
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Hospital, Boston, MA, USA
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35
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Chen KS, Montaser A, Ashour R, Orbach DB. Intracranial venous malformations: Incidence and characterization in a large pediatric cohort. Interv Neuroradiol 2020; 27:6-15. [PMID: 32689840 DOI: 10.1177/1591019920943752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/15/2022] Open
Abstract
BACKGROUND Significant advances have been reported recently in the genetic and mechanistic characterization of extracranial venous malformations. However, intracranial purely venous malformations (icVM) analogous to those outside the CNS have not been systematically described. PURPOSE We sought to ascertain whether such an entity as icVM could in fact be identified, distinct from previously described CNS venous anomalies and analogous to extracranial venous malformations. METHODS Our prospectively collected pediatric cerebrovascular database was reviewed to identify patients with icVM; 1458 consecutive angiograms and/or angiographic interventions performed on 706 children at our institution from October, 2006 through May, 2019 were evaluated, in addition to outside imaging studies on 192 additional patients sent to our Vascular Anomalies Center for cerebrovascular review during the same time period. Thus, the cohort consisted of 898 children. RESULTS Nineteen of 898 patients (2.1%) were found to harbor icVM, including 9 (47.3%) with sinus pericranii, 15 (78.9%) with associated large, complex extracranial venous malformations, and 3 (15.7%) with neurocognitive delay. There was no intracranial hemorrhage or venous hypertension seen in the cohort. Asymptomatic venous thrombosis in the superior sagittal sinus was seen in three patients. CONCLUSION Venous malformations, both extracranial and icVM, share many characteristics that are distinct from developmental venous anomalies. icVM were not associated with venous hypertension. The underlying genetic mutations involved in the development of icVM, germ-line or somatic, remain to be elucidated, but may very well involve shared mechanisms and pathways with extracranial venous malformations.
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Affiliation(s)
- Karen S Chen
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alaa Montaser
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Neurological Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramsey Ashour
- Department of Neurosurgery, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Neurological Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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36
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Fiehler J, Brouwer P, Díaz C, Hirsch JA, Kulcsar Z, Liebeskind D, Linfante I, Lylyk P, Mack WJ, Milburn J, Nogueira R, Orbach DB, Pumar JMM, Tanaka M, Taylor A. COVID-19 and neurointerventional service worldwide: a survey of the European Society of Minimally Invasive Neurological Therapy (ESMINT), the Society of NeuroInterventional Surgery (SNIS), the Sociedad Iberolatinoamericana de Neuroradiologia Diagnostica y Terapeutica (SILAN), the Society of Vascular and Interventional Neurology (SVIN), and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN). J Neurointerv Surg 2020; 12:726-730. [PMID: 32546635 PMCID: PMC7316120 DOI: 10.1136/neurintsurg-2020-016349] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND This survey was focused on the provision of neurointerventional services, the current practices of managing patients under COVID-19 conditions, and the expectations for the future. METHODS Invitations for this survey were sent out as a collaborative effort of the European Society of Minimally Invasive Neurological Therapy (ESMINT), the Society of NeuroInterventional Surgery (SNIS), the Sociedad Iberolatinoamericana de Neuroradiologia Diagnostica y Terapeutica (SILAN), the Society of Vascular and Interventional Neurology (SVIN), and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN). RESULTS Overall, 475 participants from 61 countries responded (six from Africa (1%), 81 from Asia (17%), 156 from Europe (33%), 53 from Latin America (11%), and 172 from North America (11%)). The majority of participants (96%) reported being able to provide emergency services, though 26% of these reported limited resources. A decrease in emergency procedures was reported by 69% of participants (52% in ischemic and hemorrhagic stroke, 11% ischemic, and 6% hemorrhagic stroke alone). Only 4% reported an increase in emergency cases. The emerging need for social distancing and the rapid adoption of remote communication was reflected in the interest in establishing case discussion forums (43%), general online forums (37%), and access to angio video streaming for live mentoring and support (33%). CONCLUSION Neurointerventional emergency services are available in almost all centers, while the number of emergency patients is markedly decreased. Half of the participants have abandoned neurointerventions in non-emergent situations. There are considerable variations in the management of neurointerventions and in the expectations for the future.
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Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Patrick Brouwer
- Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Stockholmslän, Sweden
| | - Carlos Díaz
- Radiology, Universidad de Antioquia, Medellin, Antioquia, Colombia
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Italo Linfante
- Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | - Pedro Lylyk
- Interventional Neuroradiology, Clinical Institute ENERI, Buenos Aires, Argentina
| | - William J Mack
- Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - James Milburn
- Radiology, Ochsner Medical System, New Orleans, Louisiana, USA
| | - Raul Nogueira
- Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Darren B Orbach
- Neurointerventional Rdiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Allan Taylor
- Neurosurgery, University of Cape Town, Cape Town, W Cape, South Africa
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Arko L, Lambrych M, Montaser A, Zurakowski D, Orbach DB. Fetal and Neonatal MRI Predictors of Aggressive Early Clinical Course in Vein of Galen Malformation. AJNR Am J Neuroradiol 2020; 41:1105-1111. [PMID: 32467186 DOI: 10.3174/ajnr.a6585] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/03/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neonates with vein of Galen malformations are split into 2 cohorts: one needing urgent neonatal embolization, with relatively high mortality and morbidity even with expert care, and a cohort in which embolization can be deferred until infancy, with far better prognosis. We aimed to identify brain MR imaging characteristics obtained from fetal and early neonatal scans that can predict the clinical presentation. MATERIALS AND METHODS Patients with vein of Galen malformations were stratified into a neonatal at-risk cohort if the patient needed urgent neonatal intervention or if neonatal death occurred; or an infantile treatment cohort if they were stable enough not to require treatment until >1 month of age. Twelve vascular MR imaging parameters, measured by 2 independent observers, were systematically correlated with the need for early neonatal intervention and/or neonatal mortality. RESULTS A total of 32 neonatal patients (21 patients in the neonatal at-risk cohort, 11 in the infantile treatment cohort) were identified. Maximal mediolateral diameter (area under the curve = 0.866, P < .001) and cross-sectional area (area under the curve = 0.836, P = .002) at the narrowest point of the straight or falcine sinus were most predictive of clinical evolution into the neonatal at-risk cohort. There were 15 patients who had fetal MRIs (10 in the neonatal at-risk cohort and 5 in the infantile treatment cohort). Here too, maximal mediolateral diameter (area under the curve = 0.980, P = .003) and cross-sectional area (area under the curve = 0.941, P = .007) at the narrowest point of the straight or falcine sinus were highly predictive of the neonatal at-risk cohort. CONCLUSIONS Early neonatal and fetal MR imaging can be readily used for accurate early risk stratification, assisting in directing resources, timing treatment decisions, and identifying appropriate cohorts for novel interventions.
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Affiliation(s)
- L Arko
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.)
| | - M Lambrych
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.)
| | - A Montaser
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.)
| | | | - D B Orbach
- From the Departments of Neurosurgery (L.A., M.L., A.M., D.B.O.) .,Neurointerventional Radiology (D.B.O.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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38
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Wilson JL, Amlie-Lefond C, Abruzzo T, Orbach DB, Rivkin MJ, deVeber GA, Pergami P. Survey of practice patterns and preparedness for endovascular therapy in acute pediatric stroke. Childs Nerv Syst 2019; 35:2371-2378. [PMID: 31482313 DOI: 10.1007/s00381-019-04358-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Endovascular therapy benefits selected adults with acute stroke while data are lacking for children. The purpose of this study was to assess physician practice and institutional preparedness for endovascular therapy in pediatric stroke. METHODS A link to an anonymous online survey was sent to members of the International Pediatric Stroke Study (IPSS) group about physician experience with endovascular therapy, likelihood of treatment for provided clinical vignettes, and institutional readiness for the delivery of endovascular therapy to children. RESULTS Thirty-one pediatric physicians with a mean of 11 years (SD 7.1) of experience responded. All but two would consider endovascular therapy in a child, and 20 (64.5%) had recommended endovascular therapy for a child in the preceding year. Most (n = 19, 67.9%) did not commit to an age minimum for endovascular therapy. Sixteen (57.1%) would consider treatment up to 24 h after symptom onset with 19 (67.9%) respondents reporting that their practice changed after the 2018 American Heart Association guidelines extended the time window for endovascular therapy in adults. Seventeen (60.7%) preferred imaging that included perfusion in children presenting beyond 6 h. Nineteen (70.4%) had institutional endovascular therapy criteria. Physicians in larger pediatric groups had more "likely to treat" responses on the clinical vignettes than physicians working in smaller groups (11.7 vs. 6.1, p < 0.05). CONCLUSION Pediatric stroke physicians are largely willing to consider endovascular therapy with most changing their practice according to adult guidelines, though experience and selection criteria varied. These findings may help to inform consensus guidelines and clinical trial development.
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Affiliation(s)
- Jenny L Wilson
- Division of Pediatric Neurology, Oregon Health & Science University, 707 SW Gaines St, Portland, OR, 97239, USA.
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Todd Abruzzo
- Department of Radiology, Phoenix Children's Hospital, Mayo Clinic College of Medicine and University of Arizona, Tucson, AZ, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Rivkin
- Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, Boston, MA, USA
| | | | - Paola Pergami
- Pediatric Neurology, MedStar Georgetown University Hospital and Department of Neurology, Children's National Medical Center, Washington, DC, USA
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See AP, Fehnel KP, Orbach DB, Smith ER. Microsurgical Ligation of Residual Fistulous Arteriovenous Shunt From a Radicular Artery to a Thoracic Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 17:E206-E207. [PMID: 30873520 DOI: 10.1093/ons/opz017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/29/2018] [Accepted: 03/02/2019] [Indexed: 11/13/2022] Open
Abstract
The literature has long attempted distinct classifications of arteriovenous fistulae and arteriovenous malformations of the spine.1-3 It is worth noting that lesions can become more complex during recurrence and may not adhere to traditional definitions. In these cases, recognizing the principles of pathology and pathophysiology can guide management and treatment. We present the case of a spinal arteriovenous malformation with recurrence after prior treatment that is managed in the setting of a second opinion with a multidisciplinary approach. This case demonstrates (1) an evolution of recurrent arteriovenous shunting pathology observed both in the endovascular suite, and under direct microscopic visualization and (2) considerations in multimodal treatment with endovascular devices during microsurgical dissection and extirpation. This manuscript was prepared with informed assent provided by the patient (a minor) and with informed consent by the parent of the patient, who is their legal representative and health-care proxy.
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Affiliation(s)
- Alfred Pokmeng See
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Darren B Orbach
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts.,Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts.,Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts
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Bolar DS, Gagoski B, Orbach DB, Smith E, Adalsteinsson E, Rosen BR, Grant PE, Robertson RL. Comparison of CBF Measured with Combined Velocity-Selective Arterial Spin-Labeling and Pulsed Arterial Spin-Labeling to Blood Flow Patterns Assessed by Conventional Angiography in Pediatric Moyamoya. AJNR Am J Neuroradiol 2019; 40:1842-1849. [PMID: 31694821 PMCID: PMC6975103 DOI: 10.3174/ajnr.a6262] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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] [Received: 04/24/2019] [Accepted: 08/21/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Imaging CBF is important for managing pediatric moyamoya. Traditional arterial spin-labeling MR imaging detects delayed transit thorough diseased arteries but is inaccurate for measuring perfusion because of these delays. Velocity-selective arterial spin-labeling is insensitive to transit delay and well-suited for imaging Moyamoya perfusion. This study assesses the accuracy of a combined velocity-selective arterial spin-labeling and traditional pulsed arterial spin-labeling CBF approach in pediatric moyamoya, with comparison to blood flow patterns on conventional angiography. MATERIALS AND METHODS Twenty-two neurologically stable pediatric patients with moyamoya and 5 asymptomatic siblings without frank moyamoya were imaged with velocity-selective arterial spin-labeling, pulsed arterial spin-labeling, and DSA (patients). Qualitative comparison was performed, followed by a systematic comparison using ASPECTS-based scoring. Quantitative pulsed arterial spin-labeling CBF and velocity-selective arterial spin-labeling CBF for the middle cerebral artery, anterior cerebral artery, and posterior cerebral artery territories were also compared. RESULTS Qualitatively, velocity-selective arterial spin-labeling perfusion maps reflect the DSA parenchymal phase, regardless of postinjection timing. Conversely, pulsed arterial spin-labeling maps reflect the DSA appearance at postinjection times closer to the arterial spin-labeling postlabeling delay, regardless of vascular phase. ASPECTS comparison showed excellent agreement (88%, κ = 0.77, P < .001) between arterial spin-labeling and DSA, suggesting velocity-selective arterial spin-labeling and pulsed arterial spin-labeling capture key perfusion and transit delay information, respectively. CBF coefficient of variation, a marker of perfusion variability, was similar for velocity-selective arterial spin-labeling in patient regions of delayed-but-preserved perfusion compared to healthy asymptomatic sibling regions (coefficient of variation = 0.30 versus 0.26, respectively, Δcoefficient of variation = 0.04), but it was significantly different for pulsed arterial spin-labeling (coefficient of variation = 0.64 versus 0.34, Δcoefficient of variation = 0.30, P < .001). CONCLUSIONS Velocity-selective arterial spin-labeling offers a powerful approach to image perfusion in pediatric moyamoya due to transit delay insensitivity. Coupled with pulsed arterial spin-labeling for transit delay information, a volumetric MR imaging approach capturing key DSA information is introduced.
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Affiliation(s)
- D S Bolar
- From the Department of Radiology (D.S.B.)
- Center for Functional Magnetic Resonance Imaging (D.S.B.), UC San Diego, La Jolla, California
| | - B Gagoski
- Fetal Neonatal Neuroimaging and Developmental Science Center (B.G., P.E.G.)
- Department of Radiology (B.G., D.B.O., P.E.G., R.L.R.)
| | - D B Orbach
- Department of Radiology (B.G., D.B.O., P.E.G., R.L.R.)
- Division of Neurointerventional Radiology (D.B.O.)
| | - E Smith
- Department of Neurosurgery (E.S.)
| | - E Adalsteinsson
- Department of Electrical Engineering & Computer Science (E.A.), Massachusetts Institute of Technology, Cambridge, Massachusetts
- MGH/HST Athinoula A. Martinos Center for Biomedical Imaging (E.A., B.R.R.), Charlestown, Massachusetts
| | - B R Rosen
- MGH/HST Athinoula A. Martinos Center for Biomedical Imaging (E.A., B.R.R.), Charlestown, Massachusetts
| | - P E Grant
- Fetal Neonatal Neuroimaging and Developmental Science Center (B.G., P.E.G.)
- Department of Radiology (B.G., D.B.O., P.E.G., R.L.R.)
- Division of Newborn Medicine (P.E.G.), Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - R L Robertson
- Department of Radiology (B.G., D.B.O., P.E.G., R.L.R.)
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Rosi A, Riordan CP, Smith ER, Scott RM, Orbach DB. Clinical status and evolution in moyamoya: which angiographic findings correlate? Brain Commun 2019; 1:fcz029. [PMID: 32954269 PMCID: PMC7425301 DOI: 10.1093/braincomms/fcz029] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/20/2019] [Accepted: 08/12/2019] [Indexed: 11/23/2022] Open
Abstract
Moyamoya is a progressive steno-occlusive cerebrovascular pathology of unknown aetiology that usually involves the terminal portions of the internal carotid arteries and/or the proximal portions of the anterior and middle cerebral arteries bilaterally. The pre-operative Suzuki staging system and post-operative Matsushima grade are nearly universally used markers of natural history and surgical revascularization results, respectively, but their correlation with clinical and radiographic manifestations of moyamoya has not been systematically evaluated in a large cohort. This study evaluated the strength of correlations between pre- and post-operative angiographic parameters and clinical status among paediatric patients with moyamoya. The participants included 58 patients of mean age 11 years at the time of surgery who underwent bilateral indirect revascularization in the same procedure at Boston Children’s Hospital, between January 2010 and December 2015. All included patients had available pre-operative and 1-year post-operative digital subtraction angiography. Clinical data included presenting symptoms, degree of functional incapacity, and peri-operative and long-term complications. Radiographic data included pre-operative Suzuki stage, degree of arterial stenosis, a novel collateral score, the presence of hypovascular territories on digital subtraction angiography, and post-operative Matsushima grade and evolution of stenosis. Chi-squared test and Pearson coefficient were used for correlation studies for categorical variables and Spearman’s rho was used for correlation studies for continuous variables. Results showed that Suzuki stage, collateral score and degree of stenosis were insufficient to predict clinical presentation, pre-operative incapacity and radiographic presentation, whereas the presence of hypovascular territories was correlated with all of these. At 1-year follow-up, Matsushima grade was insufficient for predicting peri-operative or long-term complications, nor did it correlate with post-operative incapacity. The presence of hypovascular territories at 1-year follow-up was correlated with the incidence of post-operative ischaemic symptoms.
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Affiliation(s)
- Andrea Rosi
- Department of Experimental and Clinical Sciences, Careggi University Hospital, University of Florence, 3 Largo Giovanni Alessandro Brambilla, 50134 Florence, Italy
| | - Coleman P Riordan
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - R Michael Scott
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.,Neurointerventional Radiology Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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42
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Desai SB, O'Brien C, Shaikh R, Hedequist D, Proctor M, Orbach DB, Padua H. Multidisciplinary management of spinal aneurysmal bone cysts: A single-center experience. Interv Neuroradiol 2019; 25:564-569. [PMID: 31088242 DOI: 10.1177/1591019919848130] [Citation(s) in RCA: 7] [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] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The management of spinal aneurysmal bone cysts (ABCs) is complex and often requires multimodality therapy, including surgical intervention to stabilize the axial skeleton, and avoid neurologic injury or death. With en bloc resection, ABCs have a recurrence rate of 12%, which increases to >50% with subtotal resection. The use of doxycycline sclerotherapy has been reported to reduce the recurrence rate of non-spinal ABCs to 5% at >24 month follow-up. We retrospectively reviewed our institutional results for sodium tetradecyl sulfate (STS)/doxycycline sclerotherapy and surgical intervention for spinal ABCs, to assess our treatment paradigm for these tumors and inform our future approach to these lesions. METHODS Three cervical, two thoracic and two lumbar spine ABCs were treated in seven patients with spine-exclusive disease at our institution from 2011 to the present. The most common presenting complaint was pain. Each patient was retrospectively reviewed for clinical symptomology, number of treatments, technique and clinical follow-up. Qualitative assessment of improvement was based on the most recent clinical evaluation. RESULTS The cohort underwent a mean of three treatment sessions (range 2-15). All were treated with STS and/or doxycycline. Five patients underwent surgical intervention at some point, either before or following sclerotherapy. After the last sclerotherapy session, four patients reported stable or improved pain symptoms, while two reported progressive pain that required surgical intervention for that indication. One patient, who underwent both multiple rounds of sclerotherapy and surgical resection, died due to acute on chronic cervical spine collapse with cord compression and inability to control disease. CONCLUSION We report our experience in the treatment of spinal column ABCs. Stabilization or improvement in pain was seen in four patients, while the remainder had progressive disease. Our multidisciplinary approach allows patients to receive the most appropriate treatment at presentation and thereafter, for symptom amelioration or spinal stability. Important future goals are to quantitatively assess changes in symptoms over time and to incorporate a reproducible radiographic endpoint for the assessment of treatment efficacy.
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Affiliation(s)
- Sudhen B Desai
- Department of Radiology, Texas Children's Hospital, Houston, USA
| | - Cormac O'Brien
- Department of Radiology, Boston Children's Hospital, Boston, USA
| | - Raja Shaikh
- Department of Radiology, Boston Children's Hospital, Boston, USA
| | - Daniel Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, USA
| | - Mark Proctor
- Department of Neurosurgery, Boston Children's Hospital, Boston, USA
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital, Boston, USA
| | - Horacio Padua
- Department of Radiology, Boston Children's Hospital, Boston, USA
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Duran D, Zeng X, Jin SC, Choi J, Nelson-Williams C, Yatsula B, Gaillard J, Furey CG, Lu Q, Timberlake AT, Dong W, Sorscher MA, Loring E, Klein J, Allocco A, Hunt A, Conine S, Karimy JK, Youngblood MW, Zhang J, DiLuna ML, Matouk CC, Mane S, Tikhonova IR, Castaldi C, López-Giráldez F, Knight J, Haider S, Soban M, Alper SL, Komiyama M, Ducruet AF, Zabramski JM, Dardik A, Walcott BP, Stapleton CJ, Aagaard-Kienitz B, Rodesch G, Jackson E, Smith ER, Orbach DB, Berenstein A, Bilguvar K, Vikkula M, Gunel M, Lifton RP, Kahle KT. Mutations in Chromatin Modifier and Ephrin Signaling Genes in Vein of Galen Malformation. Neuron 2019; 101:429-443.e4. [PMID: 30578106 DOI: 10.1016/j.neuron.2018.11.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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] [Received: 06/14/2018] [Revised: 10/12/2018] [Accepted: 11/20/2018] [Indexed: 02/05/2023]
Abstract
Normal vascular development includes the formation and specification of arteries, veins, and intervening capillaries. Vein of Galen malformations (VOGMs) are among the most common and severe neonatal brain arterio-venous malformations, shunting arterial blood into the brain's deep venous system through aberrant direct connections. Exome sequencing of 55 VOGM probands, including 52 parent-offspring trios, revealed enrichment of rare damaging de novo mutations in chromatin modifier genes that play essential roles in brain and vascular development. Other VOGM probands harbored rare inherited damaging mutations in Ephrin signaling genes, including a genome-wide significant mutation burden in EPHB4. Inherited mutations showed incomplete penetrance and variable expressivity, with mutation carriers often exhibiting cutaneous vascular abnormalities, suggesting a two-hit mechanism. The identified mutations collectively account for ∼30% of studied VOGM cases. These findings provide insight into disease biology and may have clinical implications for risk assessment.
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Affiliation(s)
- Daniel Duran
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Xue Zeng
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Sheng Chih Jin
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA; Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Jungmin Choi
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA; Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | | | - Bogdan Yatsula
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan Gaillard
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Qiongshi Lu
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Weilai Dong
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Michelle A Sorscher
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erin Loring
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Jennifer Klein
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - August Allocco
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Ava Hunt
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Sierra Conine
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Jason K Karimy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Mark W Youngblood
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA; Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Jinwei Zhang
- Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Hatherly Laboratory, Exeter, UK
| | - Michael L DiLuna
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Shrikant Mane
- Yale Center for Genome Analysis, West Haven, CT, USA
| | | | | | | | - James Knight
- Yale Center for Genome Analysis, West Haven, CT, USA
| | - Shozeb Haider
- University College London, School of Pharmacy, London, UK
| | - Mariya Soban
- University College London, School of Pharmacy, London, UK; Department of Biochemistry, Aligarh Muslim University, Aligarh, India
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Masaki Komiyama
- Department of Neurointervention, Osaka City General Hospital, Osaka, Japan
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Brian P Walcott
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Georges Rodesch
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
| | - Eric Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward R Smith
- Department of Neurointerventional Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA; Department of Neurointerventional Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kaya Bilguvar
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA; Yale Center for Genome Analysis, West Haven, CT, USA
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Murat Gunel
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA; Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Richard P Lifton
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA; Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA; Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA; Department of Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA.
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Jernigan S, Storey A, Hammer C, Riordan C, Orbach DB, Scott RM, Smith E. Moyamoya syndrome and PHACE syndrome: clinical and radiographic characterization of the intracranial arteriopathy and response to surgical revascularization. J Neurosurg Pediatr 2019; 23:493-497. [PMID: 30717056 DOI: 10.3171/2018.10.peds18582] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE PHACE syndrome (PHACES) has been linked to cervical and cerebral vascular anomalies, including persistent embryonic anastomoses and progressive steno-occlusive disease. However, no prior studies have documented the long-term response of PHACES patients with moyamoya disease to surgical revascularization with pial or myosynangiosis. The authors present their experience with 8 consecutive patients with PHACES and moyamoya disease. METHODS Retrospective review of patients who underwent pial synangiosis revascularization for moyamoya disease with concurrent diagnosis of PHACES. RESULTS A total of 8 patients out of 456 surgically treated moyamoya patients had a diagnosis of PHACES. All patients were female, and their average age at the time of surgical treatment was 9.3 years (range 1.8-25.8 years). Five patients had associated basilar artery anomalies or stenosis. All patients had symptomatic narrowing of the petrous segment of the internal carotid artery with tortuous collateralization. Three patients underwent unilateral pial or myo-synangiosis and 5 underwent bilateral procedures. The average hospital length of stay was 5.0 days (range 3-7 days). There were no postoperative complications. Follow-up ranged from 8 to 160 months (average 56 months). Seven of 8 patients have had follow-up angiograms and all had Matsushima grade A or B collateralization without progression of stenosis in other locations. All patients had reduced cortical FLAIR signal on 6-month follow-up MRI and no evidence of new radiographic or clinical strokes. CONCLUSIONS Patients with moyamoya disease and PHACES had an intracranial arteriopathy characterized by ectactic anterior vasculature with concomitant basilar artery stenosis, and were all female. The patients had both radiographic and clinical responses to pial synangiosis. The surgical treatment of these patients can be challenging given facial hemangiomas located near the surgical field. Patients with unilateral disease did not have evidence of progression in other cerebral circulation during the given follow-up period.
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Affiliation(s)
| | | | | | | | - Darren B Orbach
- Departments of1Neurosurgery and
- 2Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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45
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Pricola Fehnel K, Klein J, Warf BC, Smith ER, Orbach DB. Reversible intracranial hypertension following treatment of an extracranial vascular malformation: case report. J Neurosurg Pediatr 2019; 23:369-373. [PMID: 30611152 DOI: 10.3171/2018.10.peds18235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 05/14/2018] [Accepted: 10/11/2018] [Indexed: 11/06/2022]
Abstract
Pediatric hydrocephalus is a well-studied and still incompletely understood entity. One of the physiological means by which hydrocephalus and intracranial hypertension evolve is through perturbations to normal vascular dynamics. Here the authors report a unique case of an extracranial vascular anomaly resulting in persistently elevated intracranial pressures (ICPs) independent of CSF diversion in a patient with a Joubert syndrome-related disorder. The patient developed worsening intracranial hypertension after successful CSF diversion of Dandy-Walker malformation-associated hydrocephalus via endoscopic third ventriculostomy-choroid plexus cauterization (ETV/CPC). Vascular workup and imaging revealed an extracranial arteriovenous fistula of the superficial temporal artery at the site of a prior scalp intravenous catheter. Following microsurgical obliteration of the lesion, ICP normalized from > 30 cm H2O preoperatively to 11 cm H2O postoperatively. A repeat lumbar puncture at 4 months postoperatively again demonstrated normal pressure, and the patient remained asymptomatic for 9 months. Recurrent symptoms at 9 months were attributed to inadequate CSF diversion, and the patient underwent ventriculoperitoneal shunt placement. This is the first report of an extracranial-to-extracranial vascular anastomosis resulting in intracranial hypertension. This case report demonstrates the need to consider extracranial vascular anomalies as potential sources of persistently elevated ICP in the syndromic pediatric population.
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Affiliation(s)
| | | | | | - Edward R Smith
- 1Vascular Biology Program.,2Department of Neurosurgery, and
| | - Darren B Orbach
- 3Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts
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Riordan CP, Orbach DB, Smith ER, Scott RM. Acute fatal hemorrhage from previously undiagnosed cerebral arteriovenous malformations in children: a single-center experience. J Neurosurg Pediatr 2018; 22:244-250. [PMID: 29856294 DOI: 10.3171/2018.3.peds1825] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 11/06/2022]
Abstract
OBJECTIVE The most significant adverse outcome of intracranial hemorrhage from an arteriovenous malformation (AVM) is death. This study reviews a single-center experience with pediatric AVMs to quantify the incidence and characterize clinical and radiographic factors associated with sudden death from the hemorrhage of previously undiagnosed AVMs in children. METHODS A single-center database review of the period from 2006 to 2017 identified all patients with a first-time intracranial hemorrhage from a previously undiagnosed AVM. Clinical and radiographic data were collected and compared between patients who survived to hospital discharge and those who died at presentation. RESULTS A total of 57 patients (average age 10.8 years, range 0.1-19 years) presented with first-time intracranial hemorrhage from a previously undiagnosed AVM during the study period. Of this group, 7/57 (12%) patients (average age 11.5 years, range 6-16 years) suffered hemorrhages that led directly to their deaths. Compared to the cohort of patients who survived their hemorrhage, patients who died were 4 times more likely to have an AVM in the posterior fossa. No clear pattern of antecedent triggering activity (sports, trauma, etc.) was identified, and 3/7 (43%) experienced cardiac arrest in the prehospital setting. Surviving patients were ultimately treated with resection of the AVM in 42/50 (84%) of cases. CONCLUSIONS Children who present with hemorrhage from a previously undiagnosed intracranial AVM had a 12% chance of sudden death in our single-institution series of pediatric cerebrovascular cases. Clinical triggers of hemorrhage are unpredictable, but subsequent radiographic evidence of a posterior fossa AVM was present in 57% of fatal cases, and all fatal cases were in locations with high risk of potential herniation. These data support a proactive, aggressive approach toward definitive treatment of AVMs in children.
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Affiliation(s)
| | - Darren B Orbach
- Departments of1Neurosurgery and.,2Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts
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Duran D, Karschnia P, Gaillard JR, Karimy JK, Youngblood MW, DiLuna ML, Matouk CC, Aagaard-Kienitz B, Smith ER, Orbach DB, Rodesch G, Berenstein A, Gunel M, Kahle KT. Human genetics and molecular mechanisms of vein of Galen malformation. J Neurosurg Pediatr 2018; 21:367-374. [PMID: 29350590 DOI: 10.3171/2017.9.peds17365] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 11/06/2022]
Abstract
Vein of Galen malformations (VOGMs) are rare developmental cerebrovascular lesions characterized by fistulas between the choroidal circulation and the median prosencephalic vein. Although the treatment of VOGMs has greatly benefited from advances in endovascular therapy, including technical innovation in interventional neuroradiology, many patients are recalcitrant to procedural intervention or lack accessibility to specialized care centers, highlighting the need for improved screening, diagnostics, and therapeutics. A fundamental obstacle to identifying novel targets is the limited understanding of VOGM molecular pathophysiology, including its human genetics, and the lack of an adequate VOGM animal model. Herein, the known human mutations associated with VOGMs are reviewed to provide a framework for future gene discovery. Gene mutations have been identified in 2 Mendelian syndromes of which VOGM is an infrequent but associated phenotype: capillary malformation-arteriovenous malformation syndrome ( RASA1) and hereditary hemorrhagic telangiectasia ( ENG and ACVRL1). However, these mutations probably represent only a small fraction of all VOGM cases. Traditional genetic approaches have been limited in their ability to identify additional causative genes for VOGM because kindreds are rare, limited in patient number, and/or seem to have sporadic inheritance patterns, attributable in part to incomplete penetrance and phenotypic variability. The authors hypothesize that the apparent sporadic occurrence of VOGM may frequently be attributable to de novo mutation or incomplete penetrance of rare transmitted variants. Collaboration among treating physicians, patients' families, and investigators using next-generation sequencing could lead to the discovery of novel genes for VOGM. This could improve the understanding of normal vascular biology, elucidate the pathogenesis of VOGM and possibly other more common arteriovenous malformation subtypes, and pave the way for advances in the diagnosis and treatment of patients with VOGM.
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Affiliation(s)
| | | | | | | | | | | | | | - Beverly Aagaard-Kienitz
- 2Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin; Departments of
| | | | - Darren B Orbach
- 4Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Georges Rodesch
- 5Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France; and
| | - Alejandro Berenstein
- 6Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Murat Gunel
- 1Department of Neurosurgery.,7Department of Genetics.,8Centers for Mendelian Genomics and Yale Program on Neurogenetics, and
| | - Kristopher T Kahle
- 1Department of Neurosurgery.,8Centers for Mendelian Genomics and Yale Program on Neurogenetics, and.,9Department of Pediatrics and Cellular & Molecular Physiology, Yale School of Medicine, New Haven, Connecticut
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Penn DL, Lanpher AB, Klein JM, Kozakewich HPW, Kahle KT, Smith ER, Orbach DB. Multimodal treatment approach in a patient with multiple intracranial myxomatous aneurysms. J Neurosurg Pediatr 2018; 21:315-321. [PMID: 29303459 DOI: 10.3171/2017.9.peds17288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 11/06/2022]
Abstract
The most common primary cardiac tumor is myxoma, typically originating in the left atrium. Emboli to the central nervous system can cause cerebral infarction or, rarely, seed tumor growth within vessel walls, causing myxomatous aneurysms. Fewer than 60 myxomatous aneurysms have been reported, including 2 cases in children. Here, the authors describe 2 different growing myxomatous aneurysms in a child successfully managed using a combined multidisciplinary approach. A 12-year-old boy developed a sudden headache, diplopia, gait instability, and speech difficulty. Magnetic resonance imaging revealed a left parietal hemorrhage and multifocal cerebral infarction, suspicious for an embolic etiology. A cardiac myxoma was identified in the left atrium and resected. Follow-up cranial vasculature imaging demonstrated multiple intracranial myxomatous aneurysms. These lesions were followed up, and serial imaging identified marked growth of 2 of them (right occipital and left parietal), prompting invasive intervention. The deep occipital lesion was better suited to endovascular treatment, while the superficial parietal lesion was amenable to resection. The patient underwent embolization of an enlarging fusiform aneurysm of the distal right posterior cerebral artery, followed by a left parietal craniotomy for a lesion of the distal left middle cerebral artery. Both procedures were performed without complications and achieved successful obliteration of the lesions, as confirmed by catheter angiography at the 30-month follow-up. To the authors' knowledge, this report illustrates the first combined endovascular and open surgical treatment of 2 myxomatous aneurysms in a single patient. While acknowledging the rarity of this condition, this report illustrates the clinical manifestations and treatment challenges posed by myxoma and details a successful strategy that could be employed in similar scenarios.
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Affiliation(s)
| | | | | | | | - Kristopher T Kahle
- Departments of3Neurosurgery.,5Pediatrics, and.,6Cellular and Molecular Physiology, Yale University, New Haven, Connecticut
| | | | - Darren B Orbach
- 4Radiology, Boston Children's Hospital, Boston, Massachusetts; and
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Yang E, Storey A, Olson HE, Soul J, Estroff JA, Trenor CC, Cooper BK, Smith ER, Orbach DB. Imaging features and prognostic factors in fetal and postnatal torcular dural sinus malformations, part II: synthesis of the literature and patient management. J Neurointerv Surg 2017; 10:471-475. [PMID: 28965104 DOI: 10.1136/neurintsurg-2017-013343] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 07/24/2017] [Revised: 09/13/2017] [Accepted: 09/13/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Torcular dural sinus malformations (tDSMs) are described as slow flow dural arteriovenous fistulae with frequently poor outcomes in the neuroangiographic literature, but other etiologies have been proposed in the obstetric literature, where outcomes have been more favorable. OBJECTIVE To review tDSMs reported in the literature of multiple specialties for features that support a common etiology, and to identify key prognostic factors, with an emphasis on tDSM trajectory highlighted in part I. METHODS Analysis of imaging features and clinical outcome for 77 prenatal and 22 postnatal tDSMs reported in 37 papers from the literature. RESULTS In addition to large venous lakes, 36% of prenatal and 96% of postnatal tDSMs had evidence of arterialization, where specifically assessed. For fetal cases, where there was an observable natural history, 97% underwent a spontaneous decrease-13% after an initial increase and only 1 case with subsequent enlargement after a decrease. Prenatal cases had 83% survival (62% with a favorable outcome) whereas postnatal cases had 59% survival (29% favorable). In addition to a postnatal diagnosis, unfavorable features included ventriculomegaly, parenchymal injury, arterialization, and need for intervention. Favorable features included decreasing tDSM size, presence of clot, and increasing clot percentage. CONCLUSIONS Neonatal and fetal tDSMs have overlapping imaging appearances, suggesting a common etiology, where neonatal tDSMs represent those rare fetal tDSMs that do not undergo spontaneous regression and have a propensity for worse outcomes. Decrease in tDSM size is a critical observation when managing a tDSM because it is generally irreversible and associated with a favorable outcome.
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Affiliation(s)
- Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Armide Storey
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heather E Olson
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Janet Soul
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Judy A Estroff
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Cameron C Trenor
- Stroke and Cerebrovascular Center and Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin K Cooper
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts, USA
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Yang E, Storey A, Olson HE, Soul J, Estroff JA, Trenor CC, Cooper BK, Smith ER, Orbach DB. Imaging features and prognostic factors in fetal and postnatal torcular dural sinus malformations, part I: review of experience at Boston Children's Hospital. J Neurointerv Surg 2017; 10:467-470. [PMID: 28965107 DOI: 10.1136/neurintsurg-2017-013344] [Citation(s) in RCA: 15] [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] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/13/2017] [Accepted: 09/13/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Even for the most common dural sinus malformation (DSM), the torcular DSM (tDSM), generalizable statements about etiology and prognosis are difficult because neurosurgeons/neuroradiologists and obstetrical imagers have focused on different patient age groups, have reported different outcomes, and have offered differing pathophysiologic explanations. OBJECTIVE To examine the imaging features and outcomes of a local cohort of tDSMs across fetal-neonatal life for commonalities. METHODS Review of imaging and clinical outcome for a local cohort of 12 tDSM patients (9 fetal, 3 postnatal). RESULTS All 12 tDSMs had similar imaging characteristics, including enlargement of the torcular and intraluminal thrombus early on, later evolving to peripheral scar tissue after treatment or spontaneous regression. Spontaneous decrease in size of the tDSM was observed in 6 prenatal and 1 postnatal case, and this decrease appeared to be irreversible once it occurred. One of 9 prenatal tDSMs was demonstrated to have arteriovenous fistulae in utero, while 2 of 3 postnatal diagnoses had arteriovenous fisutlae. All 6 prenatal tDSM diagnoses followed to term and all 3 postnatal diagnoses had a grossly normal neurologic outcome after a median of 12 months of age. CONCLUSIONS Prenatal and postnatal tDSMs have overlapping imaging features suggesting a common etiology, and involution of a tDSM is a key imaging biomarker for a favorable outcome. While there is reason for concern with postnatally diagnosed tDSMs, good outcomes may still be achieved across the fetal-neonatal age spectrum of presentations. These findings are generalized in part II of this article.
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Affiliation(s)
- Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Armide Storey
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heather E Olson
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Janet Soul
- Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Judy A Estroff
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Cameron C Trenor
- Stroke and Cerebrovascular Center and Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin K Cooper
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Advanced Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA.,Cerebrovascular Surgery and Interventions Center, Boston Children's Hospital, Boston, Massachusetts, USA
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