Spontaneous intracranial hemorrhage in children – ruptured lobar arteriovenous malformations: report of two cases

Abstract Brain arteriovenous malformations (AVMs) are lesions thought to be primarily congenital in origin, consisting of fistulous connections of abnormal arteries and veins, without normal intervening capillary beds and no cerebral parenchyma between vessels. In the pediatric population, AVMs represent the most common cause of spontaneous intracranial hemorrhage (ICH), with a high recurrent bleeding risk. The aim of this paper is to report 2 cases of ruptured lobar AVMs in children, presenting with spontaneous ICH. Due to the patients’ neurological status, the only imaging examination performed preoperatively was a CT scan, showing intraparenchymal hemorrhage. Thus, there was no MRI/angiographic examination to prove the existence of a brain AVM prior to the surgical interventions. Also, the cerebral angiography performed after the surgery showed, in both patients, no signs of residual vascular malformations. Therefore, the diagnosis of AVM was certified by macroscopic and microscopic pathological findings, with no brain imaging suggestive of a vascular malformation.

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Initial experience with the Scepter Mini catheter for the embolization of vascular malformations in the pediatric population

The Neuroradiology Journal ◽

10.1177/19714009211049084 ◽

2021 ◽

pp. 197140092110490

Author(s):

Stavros Matsoukas ◽

Devin Bageac ◽

Kurt Yaeger ◽

Alejandro Berenstein ◽

Johanna T Fifi ◽

...

Keyword(s):

Flow Control ◽

Arteriovenous Malformations ◽

Vascular Malformations ◽

Pediatric Population ◽

Balloon Catheter ◽

Retrospective Chart Review ◽

Endovascular Embolization ◽

Uneventful Recovery ◽

Initial Experience ◽

Low Profile

Background Achieving distal access and flow control are of significant importance for the treatment of intracerebral arteriovenous shunting lesions. The Scepter Mini catheter is a low-profile, dual-lumen balloon catheter, designed to provide navigability in small-caliber, tortuous intracranial vessels. Objective To describe the initial experience of the Scepter Mini catheter in the treatment of pediatric arteriovenous malformations and fistulas. Methods A single-institution, retrospective chart review identified all consecutive uses of the Scepter Mini catheter for endovascular embolization of vascular malformations in the pediatric population. Results Three different arterial pedicles were embolized with the Scepter Mini catheter in two different patients. One patient was diagnosed with a vein of Galen malformation that had undergone multiple treatments and the other with a torcular dural arteriovenous fistula. All cases encompassed quite challenging tortuosity of small-caliber feeders which prevented the use of another microcatheter. The Scepter Mini catheter navigated into feeding arteries of diameters 0.65, 1.9, and 1.25 mm, and its balloon was inflated to achieve excellent blood flow control. Total obliteration (100%) of the shunting lesion was achieved in both cases. No reflux, pedicle rupture or other untoward effects were observed. Both patients had an uneventful recovery. Conclusion The Scepter Mini catheter afforded fast and safe distal access, flow control, and treatment of arteriovenous malformations in this initial pediatric cohort. The catheter’s low profile and easy navigability should support its use in tortuous and small arterial feeders, especially in the pediatric population.

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Abstract 1122‐000090: Initial Experience with the Scepter Mini; Embolization of Vascular Malformations in the Pediatric Population

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000090 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Stavros Matsoukas ◽

Devin Bageac ◽

Kurt Yaeger ◽

Alejandro Berenstein ◽

Johanna Fifi ◽

...

Keyword(s):

Flow Control ◽

Arteriovenous Malformations ◽

Vascular Malformations ◽

Pediatric Population ◽

Balloon Catheter ◽

Retrospective Chart Review ◽

Endovascular Embolization ◽

Uneventful Recovery ◽

Initial Experience ◽

Low Profile

Introduction : Achieving distal access and flow control provides a significant advantage for the treatment of intracerebral arteriovenous shunting lesions. The Scepter Mini Catheter (SMC) is a low‐profile, dual‐lumen balloon catheter, designed to provide navigability in small‐caliber, tortuous intracranial vessels. We sought to describe the initial experience of the SMC in the treatment of pediatric arteriovenous malformations and fistulas. Methods : A single‐institution, retrospective chart review identified all consecutive uses of the SMC for endovascular embolization of vascular malformations in the pediatric population. Results : Three different arterial pedicles were embolized with the SMC in two different patients. One patient was diagnosed with a vein of Galen malformation that had undergone multiple treatments and the other with a torcular dural arteriovenous fistula. All cases encompassed quite challenging tortuosity of small‐caliber feeders which precluded the use of another balloon microcatheter. The SMC navigated into feeding arteries of diameters 0.65, 1.9 and 1.25 mm, and its balloon was inflated to achieve excellent blood flow control. Total obliteration (100%) of the shunting lesion was achieved in both cases. No reflux, pedicle rupture or other untoward effects were observed. Both patients had an uneventful recovery. Conclusions : The SMC afforded fast and safe distal access, flow control and treatment of arteriovenous malformations in this initial pediatric cohort. The catheter’s low profile and easy navigability should support its use in tortuous and small arterial feeders, especially in the pediatric population.

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Intramedullary spinal cord cavernous malformations in the pediatric population

Surgical Neurology International ◽

10.25259/sni_494_2020 ◽

2020 ◽

Vol 11 ◽

pp. 275

Author(s):

Brian Fiani ◽

Taylor Reardon ◽

Ryne Jenkins ◽

Claudia Covarrubias ◽

Manraj Sekhon ◽

...

Keyword(s):

Spinal Cord ◽

Vascular Malformations ◽

Pediatric Population ◽

Age Groups ◽

Single Layer ◽

Neurological Status ◽

Outcome Data ◽

Pediatric Age ◽

Intramedullary Spinal Cord ◽

Cavernous Malformations

Background: Intramedullary spinal cavernous malformations (ISCM) account for just 1% of all intramedullary pediatric spinal cord lesions. Pathologically, they are well-circumscribed vascular malformations that typically appear dark blue or reddish-brown, often coming to the spinal cord surface. With regard to the histopathology findings, ISCMs are comprised sinusoidal vascular spaces lined by a single layer of endothelial cells within a loose connective tissue stroma. As these lesions are often misdiagnosed in the pediatric population, appropriate treatment may be unduly delayed. Methods: The authors performed an extensive review of the published literature (PubMed) focusing on ISCM in the pediatric age group. Results: The search yielded 17 articles exclusively pertaining to ISCM affecting the pediatric population. Conclusion: Here, we reviewed the clinical, radiographic, surgical, and outcome data for the treatment of ISCM in the pediatric age groups. Notably, over 50% of pediatric patients with ISCM experienced an improvement in their neurological status after a mean postoperative follow-up duration of 4 years. Future meta-analyses are needed to highlight the potential presence of ISCM and, thereby, decrease the rate of misdiagnosis of these lesions in the pediatric population presenting with recurrent intramedullary spinal cord hemorrhages.

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Computed tomography angiography in the diagnosis of arteriovenous malformations

Journal of Health Sciences ◽

10.17532/jhsci.2017.521 ◽

2018 ◽

Vol 8 (1) ◽

pp. 73-77

Author(s):

Zulejha Merhemic ◽

Lidija Lincender ◽

Emir Guso ◽

Emina Bicakcic ◽

Edin Avdagic ◽

...

Keyword(s):

Computed Tomography ◽

Intracranial Hemorrhage ◽

Volume Rendering ◽

Computed Tomography Angiography ◽

Gold Standard ◽

Arteriovenous Malformations ◽

Vascular Malformations ◽

Younger Patients ◽

Traumatic Intracranial Hemorrhage ◽

Contrast Ct

Introduction: The most common cause of intracranial bleeding in younger patients and children are vascular anomalies. Digital subtractions angiography presents a gold standard in diagnostics of aneurisms and vascular malformations. Our aim is to present our experience in using computed tomography angiography in diagnosing arteriovenous malformations. Methods: We included 150 patients with acute non-traumatic intracranial hemorrhage diagnosed by non-contrast CT examination, after which they were subjected to CT angiography of the cerebral vessels, and then underwent maximum intense projection and volume rendering reconstruction. Results: Out of 150 patients with non-traumatic intracranial hemorrhage, in 121 (81%) a diagnosis of aneurysm was rendered, while in 8 (5%) arteriovenous malformation was found. In 29 (14%) patients cause of bleeding was not identified. Patients with arteriovenous malformations, were age 17-77 years, with mean age 42.75 years. Five (62.5%) of them were female patients and three (37.5%) were male. Conclusion: Spontaneous non-traumatic intracranial hemorrhage is a significant cause of morbidity and mortality. Computed tomography angiography is sufficiently specific and sensitive in diagnosis of arteriovenous malformations in our experience.

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Cerebral Arteriovenous Malformations in Pediatric Patients with Hereditary Hemorrhagic Telangiectasia: Re-evaluating Appearance, Bleeding Risk, and Treatment Necessity in a Selective Meta-analysis

Journal of Pediatric Neurology ◽

10.1055/s-0040-1715499 ◽

2020 ◽

Vol 18 (06) ◽

pp. 279-285

Author(s):

Oliver Mueller ◽

Ekkehard Kasper ◽

Freya Droege ◽

Sophia Goericke ◽

Klaus-Peter Stein ◽

...

Keyword(s):

Hereditary Hemorrhagic Telangiectasia ◽

Arteriovenous Malformations ◽

Pediatric Patients ◽

Vascular Malformations ◽

Meta Analysis ◽

Treatment Algorithm ◽

Rare Event ◽

Bleeding Risk ◽

Disease Diagnosis ◽

Capillary Telangiectasia

AbstractPediatric patients suffering from cerebral nidal arteriovenous malformations are a unique population due to the rare occurrence of the disease. Diagnosis of hereditary hemorrhagic telangiectasia (HHT) in children is a rare event and mainly restricted to coincidental detection from screening of possibly afflicted family members. In patients with HHT, it is well known that the incidence of cerebral vascular malformations (CVMs) is higher than expected when compared with the nonafflicted population. Even though CVMs comprise a variety of different distinct anatomical and radiographic entities (e.g., capillary telangiectasia, nidal arteriovenous malformation [AVM], cavernous malformation, dural or pial as well as mixed fistula, and vein of Galen malformation), they are mostly summarized and analyzed all in one category due to the low number of individual cases identified in single centers. Nevertheless, the best treatment algorithm will likely vary significantly between different CVMs as does the clinical presentation and the natural course of the CVM. It is therefore the objective of this article to focus on nidal AVMs in pediatric patients suffering from HHT. To this end, we performed a systematic selective literature research to estimate incidence, clinical and radiological appearance, as well as classification according to established grading system, and to evaluate the necessity of treatment of these lesions in light of their respective outcomes. Our line of arguments explains why we recommend to follow these lesions expectantly and suggest to keep pediatric patients under surveillance with sequential scans until they reach adulthood.

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Treatment of pediatric intracranial vascular malformations using Onyx-18

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/2/9/171 ◽

2008 ◽

Vol 2 (3) ◽

pp. 171-176 ◽

Cited By ~ 20

Author(s):

Brian T. Jankowitz ◽

Nirav Vora ◽

Tudor Jovin ◽

Michael Horowitz

Keyword(s):

Arteriovenous Malformations ◽

Vascular Malformations ◽

Pediatric Population ◽

Embolic Agent ◽

Vein Of Galen ◽

High Output Heart Failure ◽

Long Term Follow Up ◽

Liquid Embolic Agent ◽

Repeat Angiography

Object Onyx-18 is a relatively new liquid embolic agent. The initial success with this polymer will result in increased utilization in children, but its use and safety in the pediatric population have not been firmly established. Methods Between December 2005 and January 2008, the cerebral vascular malformations in 6 children were embolized using Onyx-18. The ages of the patients ranged from 1 day to 12 years. Pathological types of the vascular malformations included 4 arteriovenous malformations and 2 vein of Galen malformations. Clinical presentations included intracranial hemorrhage in 2 patients, papilledema in 1 patient, and high-output heart failure in 3 patients. Results In 6 pediatric patients, 21 embolization procedures were performed utilizing a combination of Onyx-18, platinum coils, and Embosphere microspheres. The average estimated size reduction for the arteriovenous malformations was 60%. Total obliteration of a malformation was achieved in 1 patient. Two patients received adjuvant radiosurgery. Of the 2 vein of Galen malformations, one was completely embolized and the other had an ~ 50% reduction in flow. No open surgical intervention was used. Clinical follow-up ranged from 7 to 12 months. Angiographic follow-up data were obtained at 1, 6, and 7 months in 3 patients, whereas 1 patient awaits repeat angiography. Complications included a transient monoparesis with complete resolution in 1 patient. Two patients died within 24 hours of an embolization procedure due to intracranial hemorrhages. Conclusions Onyx-18 is a feasible embolization agent for use in intracranial vascular malformations in the pediatric population, but long-term follow-up data will be necessary to assess the continued efficacy and safety of this agent.

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Transarterial embolization of peripheral arteriovenous malformations with ethylenevinyl alcohol copolymer - feasibility, technical outcomes, and clinical outcomes

VASA ◽

10.1024/0301-1526/a000571 ◽

2016 ◽

Vol 45 (6) ◽

pp. 497-504 ◽

Cited By ~ 11

Author(s):

Tom De Beule ◽

Jan Vranckx ◽

Peter Verhamme ◽

Veerle Labarque ◽

Marie-Anne Morren ◽

...

Keyword(s):

Clinical Outcomes ◽

Clinical Improvement ◽

Arteriovenous Malformations ◽

Clinical Success ◽

Transarterial Embolization ◽

Recurrent Bleeding ◽

Complete Disappearance ◽

Ethylene Vinyl Alcohol ◽

Initial Symptoms

Abstract. Background: The technical and clinical outcomes of catheter-directed embolization for peripheral arteriovenous malformations (AVM) using Onyx® (ethylene-vinyl alcohol copolymer) are not well documented. The purpose of this study was to retrospectively assess the safety, technical outcomes and clinical outcomes of catheter-directed Onyx® embolisation for the treatment of symptomatic peripheral AVMs. Patients and methods: Demographics, (pre-)interventional clinical and radiological data were assessed. Follow-up was based on hospital medical records and telephone calls to the patients’ general practitioners. Radiological success was defined as complete angiographic eradication of the peripheral AVM nidus. Clinical success was defined as major clinical improvement or complete disappearance of the initial symptoms. Results: 25 procedures were performed in 22 patients. The principal indications for treatment were pain (n = 10), limb swelling (n = 6), recurrent bleeding (n = 2), tinnitus (n = 3), and exertional dyspnoea (n = 1). Complete radiological success was obtained in eight patients (36 %); near-complete eradication of the nidus was achieved in the remaining 14 patients. Adjunctive embolic agents were used in nine patients (41 %). Clinical success was observed in 18 patients (82%). Major complications were reported in two patients (9 %). During follow-up, seven patients (32 %) presented with symptom recurrence, which required additional therapy in three patients. Conclusions: Catheter-directed embolisation of peripheral AVMs with Onyx® resulted in major clinical improvement or complete disappearance of symptoms in the vast majority of patients, although complete angiographic exclusion of the AVMs occurred in only a minority of patients.

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Involvement of Microglia in the Pathophysiology of Intracranial Aneurysms and Vascular Malformations—A Short Overview

International Journal of Molecular Sciences ◽

10.3390/ijms22116141 ◽

2021 ◽

Vol 22 (11) ◽

pp. 6141

Author(s):

Teodora Larisa Timis ◽

Ioan Alexandru Florian ◽

Sergiu Susman ◽

Ioan Stefan Florian

Keyword(s):

Immune Cells ◽

Arteriovenous Malformations ◽

Intracranial Aneurysms ◽

Immune Cell ◽

Vascular Malformations ◽

Cerebral Injury ◽

Future Research ◽

Mortality And Morbidity ◽

The Central Nervous System ◽

The Brain

Aneurysms and vascular malformations of the brain represent an important source of intracranial hemorrhage and subsequent mortality and morbidity. We are only beginning to discern the involvement of microglia, the resident immune cell of the central nervous system, in these pathologies and their outcomes. Recent evidence suggests that activated proinflammatory microglia are implicated in the expansion of brain injury following subarachnoid hemorrhage (SAH) in both the acute and chronic phases, being also a main actor in vasospasm, considerably the most severe complication of SAH. On the other hand, anti-inflammatory microglia may be involved in the resolution of cerebral injury and hemorrhage. These immune cells have also been observed in high numbers in brain arteriovenous malformations (bAVM) and cerebral cavernomas (CCM), although their roles in these lesions are currently incompletely ascertained. The following review aims to shed a light on the most significant findings related to microglia and their roles in intracranial aneurysms and vascular malformations, as well as possibly establish the course for future research.

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