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Cerebral cavernous malformations with diffuse manifestation: A benign entity?
Journal of the Neurological Sciences 367 (2016) 335–341
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Cerebral cavernous malformations with diffuse manifestation: A benign entity? Satoshi Tsutsumi a,⁎, Ikuko Ogino b, Masakazu Miyajima b, Hajime Arai b, Masanori Ito a, Yukimasa Yasumoto a a b
Department of Neurological Surgery, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan Department of Neurological Surgery, Juntendo University School of Medicine, Tokyo, Japan
a r t i c l e
i n f o
Article history: Received 6 May 2016 Received in revised form 30 May 2016 Accepted 6 June 2016 Available online 15 June 2016 Keywords: Cerebral cavernous malformations Diffuse manifestation Familial Prognosis
a b s t r a c t Purpose: Cerebral cavernous malformations (CCMs) are a distinct cerebrovascular disease. A fraction of CCMs present as diffuse manifestations distributed over the cerebral hemispheres, cerebellum, and brainstem. The purpose of the present study was to explore the clinical picture of such CCMs. Methods: This study assessed the appearance of CCMs on magnetic resonance (MR) images, the presence of genetic mutations using the polymerase chain reaction method, and disease course over long-term follow-up in a total of 10 patients with diffuse CCMs. Results: The 10 patients were Japanese and comprised 5 males and 5 females with a mean age of 48.7 years. Three of them presented with seizures, two with headache and intracerebral hemorrhage, two with numbness, and one with dizziness, while the remaining two were asymptomatic. Genetic analysis revealed CCM1 mutations in four patients, CCM2 mutations in three, and a CCM3 mutation in one. In a family with 2 CCM2 patients, the appearance of sustained diffuse CCMs on MR images significantly differed between the 2 patients despite the mutation being identical. During the mean follow-up period of 13.7 years, none of the 10 patients showed evidence of neurological deterioration or symptomatic hemorrhage. The appearance of their CCMs on MRI did not show significant changes. Eight patients maintained normal neurological function. Conclusions: CCMs with diffuse manifestation is a hereditary disease with satisfactory prognosis. Unrecognized genomic mutations may be involved in the genesis of these CCMs. © 2016 Elsevier B.V. All rights reserved.
1. Introduction Cerebral cavernous malformations (CCMs) are a distinct entity of cerebrovascular diseases that affect approximately 0.5% of the general population [1]. The annual hemorrhage rate of CCMs has been reported to be 0.7–2.4%, which were based on inconsistent approaches for evaluating the clinical picture and neuroimaging classifications of the hemorrhages [2–4]. Prior hemorrhage, brainstem location, and associated developmental venous malformations are thought to be the significant risk factors for symptomatic hemorrhage from CCMs [5,6]. CCMs can occur in sporadic or familial form with autosomally dominant trait. Mutations in the CCM1, CCM2, and CCM3 genes, located in the 7q, 7p, and 3q, respectively, are thought to be responsible for the genesis of familial CCMs [7–12]. Annual hemorrhage rate in patients with familial CCMs is estimated to be 2.5%, reflecting the higher proportion of patients developing clinical symptoms in the familial compared to sporadic type [13, 14]. Neuroimaging penetrance of familial CCMs is reported to be much higher than the clinical penetrance [14,15]. If a patient without obvious ⁎ Corresponding author at: Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan. E-mail address: [email protected] (S. Tsutsumi).
http://dx.doi.org/10.1016/j.jns.2016.06.012 0022-510X/© 2016 Elsevier B.V. All rights reserved.
family history of CCM has been found to have multiple CCMs on imaging examination, in 75% the case is actually a familial type [14]. T2-weighted gradient-echo magnetic resonance (MR) images and susceptibilityweighted sequence are thought to be highly sensitive for detecting CCMs and accompanying hemosiderin deposition [15–17]. A fraction of familial CCMs show unusually diffuse and extensive manifestations involving the cerebral hemispheres, cerebellum, and brainstem, which can perplex clinicians when encountered these patients. To our knowledge, there have been few reports documenting these CCMs [18]. The present study aimed to explore the clinical picture of these diffusely manifesting CCMs based on their appearance on magnetic resonance imaging, the presence of genetic mutations, and longterm follow-up. 2. Materials and methods 2.1. Patients This prospective study initially evaluated 30 familial CCM patients who presented to our institution between November 2006 and March 2016. Their symptoms at the onset were seizure, headache, numbness, and dizziness. The diagnosis of familial CCMs was based on a detailed
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interview of family history, medical records provided by referring physicians, and MR imaging examinations of the brain and spinal cord using a 3.0T MR scanner (Achieva R2.6; Philips Medical Systems, Best, The Netherlands), including T2*-weighted images and/or susceptibilityweighted sequences. Of these 30 patients, 10 with an unusual presentation of multiple CCMs involving the cerebral hemispheres, cerebellum, and brainstem were diagnosed as patients with diffuse manifestation of CCM. Patients with multiple CCMs who did not present involving all the above-mentioned brain areas were excluded. In 9 of these 10 patients, peripheral blood was collected from the antecubital vein for genetic analysis, carried out as described below. The present study was performed in accordance with our institution's guidelines for human research. Written informed consent for this study was obtained from all 10 patients. 2.2. Genetic analysis 1. DNA extraction, polymerase chain reaction (PCR), and sequencing Whole venous blood was collected in a PAXgene DNA Tube (PreAnalytiX, Hombrechtikon, Switzerland) and the genomic DNA was extracted using the PAXgene Blood DNA Kit (PreAnalytiX). Mutations in the CCM1, CCM2, and CCM3 genes were identified using a previously documented PCR method [7,9,11]. Amplifications were carried out in 25 μl 2 × AmpliTaq Gold 360 Master Mix (Applied Biosystems), with 20 pmol of each primer and 100 ng of DNA. Cycling conditions consisted of an initial 12.5-min denaturation step at 95 °C and subsequent extension for 7.5 min at 72 °C. PCR products were visualized by ethidium bromide staining on 2% agarose gel. Amplicons were purified using Microcon (Millipore, Bedford, MA, USA) and sequenced using the BigDye Terminator v3.1 Cycle Sequencing Kit (Applied Biosystems). Sequencing reactions were loaded on ABI3100 capillaries (Applied Biosystems) and analyzed with Seqscape v2.6 (Applied Biosystems). 2. Reverse transcription PCR
Whole venous blood was collected in a PAXgene RNA Tube (PreAnalytiX) and the RNA extracted with RNA purification kit (PAXgene Blood RNA Kit; PreAnalytiX). PCR products were visualized by ethidium bromide staining on 1.5% agarose gels. Amplicons were purified using Microcon and sequenced using the BigDye Terminator v3.1 Cycle Sequencing Kit. Sequencing reactions were loaded on ABI3100 capillaries and analyzed using Seqscape v2.6. 3. Results 3.1. Demographics and clinical symptoms at onset The study population comprised 5 males and 5 females aged between 20 to 68 years (mean: 48.7 years). Their age at the initial onset or presentation was between 10 to 58 years (mean: 39.4 years). All the subjects were Japanese and belonged to 6 different families in total. Three of these 10 patients presented with seizures, 2 with headache and intracerebral hemorrhage, 2 with numbness in the face or upper extremity, and 1 with dizziness. The other two were asymptomatic and found coincidentally on MR images performed for a brain check-up and minor head trauma, respectively. 3.2. Neuroimaging findings On T2-weighted gradient-echo images and susceptibility-weighted sequences, all patients showed a diffuse CCMs represented by many or innumerable hypointense spots and nodular masses of varying sizes. Most of the brainstem lesions were tiny with a diameter of less than 3 mm. Notably, CCMs were not compressive to the surrounding brain, regardless of the size and location. Concurrent vascular malformations
were not found. Spinal cord involvement was identified in 4 patients; the cervical cord was affected in 1, thoracic cord in 2, and cervicothoracic cord in 1. In 4 patients, spinal cord involvement was not identified. The remaining 2 patients did not undergo spinal MR imaging (Fig. 1). 3.3. Genetic features: presence of CCM gene family mutations Genetic analysis revealed a CCM1 mutation in 4 patients, CCM2 mutation in 3 patients, and CCM3 mutation in 1 patient. In another patient belonging to a CCM1 family, genetic analysis was not conducted and the type of CCM mutation was defined as “unknown” (Patient No. 3 in Table 1). In one of the families, 3 patients (Nos. 1, 2, and 4) had the same CCM1 mutation and their CCM lesions exhibited a characteristic appearance on MR images that was represented by innumerable nodular lesions of varying sizes over the whole brain (Fig. 2). By contrast, two patients in another family (Nos. 5 and 6) had an identical CCM2 mutation, but the appearance of CCMs on neuroimaging was significantly different between the two cases (Fig. 3). 3.4. Follow-up results and disease course Five (Nos. 2, 3, 4, 5, and 6) of the 10 patients were initially treated by outside physicians. These individuals were diagnosed with familial CCMs based on an interview of the family history and MR imaging examination. Until referral to our institute, all had followed an uneventful course without neurological deterioration or symptomatic hemorrhage. The period from the diagnosis of familial CCMs to the latest interview ranged from 1.4–29 years (mean: 13.7 years). The follow-up period at our institution ranged from 1.4–9.4 years (mean: 7.1 years). During the period, no patient showed neurological deterioration or a symptomatic hemorrhage. Appearance of CCMs on MR images did not show significant growth of CCMs or compressive hemorrhage in any location of the brain, which was consistently observed for all CCM types (Figs. 4-6). These results and details of CCM mutations are summarized in Table 1. Two patients who presented with seizures as the initial symptom were well controlled during the follow-up period with constant medication. Modified Rankin Scale (mRS) scores at the latest interview were 0 in 8 patients and 1 in 2; 1 patient exhibited a sustained fine movement disturbance in the right hand and another presented intermittent trigeminal pain. 4. Discussion The present investigation suggests that patients with diffuse CCMs may follow a stable clinical course without neurological deterioration. In spite of the impressive appearance on MR images, patients with diffuse CCMs may maintain favorable neurological function for a long time even after initial symptomatic onset. In our study, these patients did not sustain neurological deterioration or symptomatic hemorrhages during a long-term follow-up. MR appearance of these CCMs did not show significant changes in any location of the brain. Furthermore, all the patients who manifested diffuse CCMs and underwent genomic analysis possessed genomic mutations in CCM1, CCM2, and CCM3. Thus, we surmise that diffuse CCMs are typically a hereditary disease with a reasonably favorable prognosis. Relative to other locations in the central nervous system, CCMs located in the brainstem are thought to be more likely to cause a symptomatic hemorrhage [5,6]. The10 patients in our study did not show significant growth or symptomatic hemorrhages even when there were multiple, pre-existing lesions in the brainstem. Most of the lesions were identified as tiny spots on initial MR images and did not enlarge thereafter, which may contribute to the good functional prognosis of patients with diffuse CCMs. This is in contrast to a 36-year-old female who was in the group of 30 patients evaluated at the beginning of the study but not enrolled because brainstem lesions were absent. This patient
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Fig. 1. (A) Susceptibility-weighted MR images in a 47-year-old male with a CCM1 mutation (Patient No. 2) showing innumerable nodular lesions with variable sizes distributed over the cerebral hemispheres, cerebellum, and brainstem. (B, C) Sagittal T2-weighted MR images of the same patient showing lesions in the cervical (B, arrow) and thoracic cords (C, arrows).
presented with seizures as the initial symptom, and was initially diagnosed with unverified (Non-CCM1,2,3) familial CCM because genetic analysis of the patient did not identify mutations in CCM1,2,3. MR images revealed multiple CCMs, but none were in the brainstem. She later sustained symptomatic hemorrhage from a de novo lesion that
had arisen in the center of the midbrain during 58 months' follow-up (Fig. 7). Notably, in a family with a CCM2 mutation, CCM appearance on MR images significantly differed between father and son, in spite of the mutation being identical between them. In contrast, in a family with an
Table 1 Profiles of 10 patients with diffuse CCMs. C: cervical cord, f: female, ICH: intracerebral hemorrhage, m: male, SCI: spinal cord involvement, T: thoracic cord, UK: unknown, UV: unverified. Patient No
Age, Sex
Age at onset
Symptoms
CCM type
Detail
SCI
from D
f/u
1 2 3 4 5 6 7 8 9 10
68,f 47,m 20,m 45,f 68,m 34,m 44,f 51,m 51,f 59,m
58 10 (-) 28 53 34 (-) 45 45 57
Dizziness ICH (-) ICH Seizure Seizure (-) Numbness Numbness Seizure
CCM1 CCM1 CCM1 CCM1 CCM2 CCM2 CCM3 CCM2 UV CCM1
c.1632_1634del TAC p.Tyr544, heterozygous deletion c.1632_1634del TAC p.Tyr544, heterozygous deletion (-) c.1632_1634del TAC p.Tyr544, heterozygous deletion c.319 CNT p.Gln107 c.319 CNT p.Gln107 c.103 CNT p.Arg35 c.193_204delAAGGAGGTAAAG p.Lys65_Lys68de (-) c.1477 GNT p.Glu493
T C,T UK UK (-) (-) (-) UK T C
9.4 37 10 17 13.5 29 8.8 5.5 5.3 1.4
9.4 9.4 9.4 9.4 6.3 6.3 8.8 5.5 5.3 1.4
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Fig. 2. Susceptibility-weighted MR images in a family with a CCM1 mutation. Note that the appearances of CCMs in the images, as represented by innumerable nodular lesions of varying sizes, are the characteristic findings in the mother (upper row, No. 1) and her son (lower row, No. 2).
identical CCM1 mutation, all the members showed a similar CCM appearance on MR images. Given these findings, mutations in genes other than CCM1, CCM2, and CCM3 may contribute to the genesis of diffuse CCMs, because the same mutation identified in these genes may not necessarily produce CCMs with a similar appearance. There are unsolved questions concerning diffuse CCMs that showed a stable appearance on MR images for a long period. How old were these patients when the CCMs had initially appeared in the brain? How long did it take for diffuse manifestations to present after the initial
appearance of these lesions? Did the lesions appear in a consecutive or multicentric manner? At the present time, reasonable explanations for these queries are not at hand. Although almost patients in the present study showed a stable clinical course and satisfactory outcome on mRS Score, the distribution of CCMs over the brain seems to be too extensive to conclude that normal brain function was retained. In addition, the results of the present study were provided by a small number of patients. Higher cerebral and neuropsychological function should be evaluated in a sufficiently large
Fig. 3. Susceptibility-weighted MR images in a family with a CCM2 mutation. The father (upper row, No. 5) presented multiple nodular lesions of varying sizes while his son (lower row, No. 6) showed large masses in the both cerebral hemispheres and tiny lesions in the cerebellum and brainstem (lower row, arrows).
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Fig. 4. Serial susceptibility-weighted MR images of a female with a CCM1 mutation (No. 1) showing no significant changes in CCM appearance after 106 months.
number of patients in a future investigation. The present study was of a small Japanese cohort and the results can be influenced by the genomic peculiarities of individuals with Japanese ethnicity, which should be considered when interpreting the results.
Recent investigations have further progressed the understanding of CCMs. Familial CCM1 carriers have an increased number of T2 hyperintensities in the white mater, which are spatially distinct from CCMs. These hyperintensities exceeded those typically observed in the
Fig. 5. Serial susceptibility-weighted MR images of a male with a CCM2 mutation (No. 8) showing no significant changes after 54 months in the appearance of a CCM characterized as a lesion in the dorsal midbrain (arrow).
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Fig. 6. Serial susceptibility-weighted MR images of a female with a CCM3 mutation (No. 7) showing no significant changes in CCM appearance after 63 months.
Fig. 7. T2*-weighted images showing a compressive hemorrhage from a de novo lesion that arose in the center of the midbrain (lower row, arrow), which was not identified 58 months prior (upper row).
S. Tsutsumi et al. / Journal of the Neurological Sciences 367 (2016) 335–341
healthy population, but did not have any association with clinical findings [19]. Vascular permeability and iron deposition of CCMs was quantitatively evaluated with MR imaging [20]. Furthermore, brain permeability, rather than permeability of CCM, was proposed as a potential biomarker that may reflect disease activity [21]. Identification of unrecognized CCM mutations based on a comprehensive genomic analysis coupled with case accumulation may lead to a better understanding of familial CCMs. 5. Conclusions CCM with diffuse manifestation is a hereditary disease with stable clinical course and satisfactory prognosis. Unrecognized genomic mutations may be involved in the genesis of these CCMs. Author contributions All the authors equally contributed to the manuscript. Conflict of interest The authors have no conflict of interest concerning the materials or methods in this study or the findings specified in this paper. Acknowledgement There was no grant funding for this work. Ethical standards and patient consent We declare that all human and animal studies have been approved by the institution's guidelines for human research in our institution and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all patients gave informed consent prior to inclusion in this study. References [1] S. Bacigaluppi, S.F. Retta, S. Pileggi, M. Fontanella, L. Goitre, L. Tassi, A. La Camera, A. Citterio, M.C. Patrosso, G. Tredici, S. Penco, Genetic and cellular basis of cerebral cavernous malformations: implications for clinical management, Clin. Genet. 83 (2013) 7–14. [2] B.A. Gross, N. Lin, R. Du, A.L. Day, The natural history of intracranial cavernous malformations, Neurosurg. Focus. 30 (2011), E24. [3] J.R. Robinson, I.A. Awad, J.R. Little, Natural history of the cavernous angioma, J. Neurosurg. 75 (1991) 709–714. [4] R. Al-Shahi Salman, M.J. Berg, L. Morrison, I.A. Awad, A.S.A. Board, Hemorrhage from cavernous malformations of the brain: definition and reporting standards. Angioma Alliance Scientific Advisory Board, Stroke 39 (2008) 3222–3230.
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[5] B.A. Gross, R. Du, D.B. Orbach, R.M. Scott, E.R. Smith, The natural history of cerebral cavernous malformations in children, J. Neurosurg. Pediatr. (2015 Oct 16) (Epub ahead of print). [6] M.H. Poorthuis, C.J. Klijn, A. Algra, G.J. Rinkel, R. Al-Shahi Salman, Treatment of cerebral cavernous malformations: a systematic review and meta-regression analysis, J. Neurol. Neurosurg. Psychiatry 85 (2014) 1319–1323. [7] F. Bergametti, C. Denier, P. Labauge, M. Arnoult, S. Boetto, M. Clanet, P. Coubes, B. Echenne, R. Ibrahim, B. Irthum, G. Jacquet, M. Lonjon, J.J. Moreau, J.P. Neau, F. Parker, M. Tremoulet, E. Tournier-Lasserve, ; Société Française de Neurochirurgie, Mutations within the programmed cell death 10 gene cause cerebral cavernous malformations, Am. J. Hum. Genet. 76 (2005) 42–51. [8] H.D. Craig, M. Günel, O. Cepeda, E.W. Johnson, L. Ptacek, G.K. Steinberg, C.S. Ogilvy, M.J. Berg, S.C. Crawford, R.M. Scott, E. Steichen-Gersdorf, R. Sabroe, C.T. Kennedy, G. Mettler, M.J. Beis, A. Fryer, I.A. Awad, R.P. Lifton, Multilocus linkage identifies two new loci for a menderian form of stroke, cerebral cavernous malformation, at 7p15-13 and 3q25.2-27. Hum. Mol. Genet. 7 (1998) 1851–1858. [9] C. Danier, S. Goutagny, P. Labauge, V. Krivosic, M. Arnoult, A. Cousin, A.L. Benabid, J. Comoy, P. Frerebeau, B. Gilbert, J.P. Houtteville, M. Jan, F. Lapierre, H. Loiseau, P. Menei, P. Mercier, J.J. Moreau, A. Nivelon-Chevallier, F. Parker, A.M. Rendondo, J.M. Scarabin, M. Tremoulet, M. Zerah, J. Maciazek, E. Tournier-Lasserve, Société Française de Neurochirurgie, Mutations within the MGC4607 gene cause cerebral cavernous malformations, Am. J. Hum. Genet. 74 (2004) 326–337. [10] J. Dubovsky, J.M. Zabramski, J. Kurth, R.F. Spetzler, S.S. Rich, H.T. Orr, J.L. Weber, A gene responsible for cavernous malformations of the brain maps to chromosome 7q, Hum. Mol. Genet. 4 (1995) 453–458. [11] V. Guamieri, L.A. Muscarella, R. Amoroso, A. Quattrone, M.E. Abate, M. Coco, D. Catapano, V.A. D'Angelo, L. Zelante, L. D'Agruma, Identification of two novel mutations and of a novel critical region in the KRIT 1 gene, Neurogenetics 8 (2007) 29–37. [12] M. Günel, I.A. Awad, J. Anson, R.P. Lifton, Mapping a gene causing cerebral cavernous malformation to 7q11.2-q21, Proc. Natl. Acad. Sci. U. S. A. 92 (1995) 6620–6624. [13] P. Labauge, L. Brunereau, C. Lévy, S. Laberge, J.P. Houtteville, The natural history of familial cerebral cavernomas: a retrospective MRI study of 40 patients, Neuroradiology 42 (2000) 327–332. [14] P. Labauge, S. Laberge, L. Brunereau, C. Levy, E. Tourier-Lasserve, Hereditary cerebral cavernous angiomas: clinical and genetic features in 57 French families. Société Française de Neurochirurge, Lancet 352 (1998) 1892–1897. [15] L. Brunereau, P. Labauge, E. Tourier-Lasserve, S. Laberge, C. Levy, J.P. Houtteville, Familial form of intracranial cavernous angioma: MR imaging findings in 51 families. French Society of Neurosurgery, Radiology 241 (2000) 209–216. [16] P.G. Campbell, P. Jabbour, S. Yadla, I.A. Awad, Emerging clinical imaging techniques for cerebral cavernous malformations: a systematic review, Neurosurg. Focus. 29 (2010), E6. [17] N.M. de Champfleur, C. Langlois, W.J. Ankenbrandt, E. Le Bars, M.A. Leroy, H. Duffau, A. Bonafé, J. Jaffe, I.A. Awad, P. Labauge, Magnetic resonance imaging evaluation of cerebral cavernous malformations with susceptibility-weighted imaging, Neurosurgery 68 (2011) 641–648. [18] H. Kuwahara, Y. Noguchi, Y. Saito, A. Inaba, Multiple cavernous angiomas in the brain and spinal cord, Arch. Neurol. 67 (2010) 1405–1406. [19] M.J. Golden, L.A. Morrison, H. Kim, B.L. Hart, Increased number of white matter lesions in patients with familial cerebral cavernous malformations, AJNR Am. J. Neuroradiol. 36 (2015) 899–903. [20] A.G. Mikati, H. Tan, R. Shenkar, L. Li, L. Zhang, X. Guo, H.B. Larsson, C. Shi, T. Liu, Y. Wang, A. Shah, R.R. Edelman, G. Christoforidis, I. Awad, Dynamic permeability and quantitative susceptibility: related imaging biomarkers in cerebral cavernous malformations, Stroke 45 (2014) 598–601. [21] A.G. Mikati, O. Khanna, L. Zhang, R. Girard, R. Shenkar, X. Guo, A. Shah, H.B. Larsson, H. Tan, L. Li, M.S. Wishnoff, C. Shi, G.A. Christoforidis, A. Awad, Vascular permeability in cerebral cavernous malformations, J. Cereb. Blood Flow Metab. 35 (2015) 1632–1639.
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Cerebral cavernous malformations with diffuse manifestation: A benign entity? Satoshi Tsutsumi a,⁎, Ikuko Ogino b, Masakazu Miyajima b, Hajime Arai b, Masanori Ito a, Yukimasa Yasumoto a a b
Department of Neurological Surgery, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan Department of Neurological Surgery, Juntendo University School of Medicine, Tokyo, Japan
a r t i c l e
i n f o
Article history: Received 6 May 2016 Received in revised form 30 May 2016 Accepted 6 June 2016 Available online 15 June 2016 Keywords: Cerebral cavernous malformations Diffuse manifestation Familial Prognosis
a b s t r a c t Purpose: Cerebral cavernous malformations (CCMs) are a distinct cerebrovascular disease. A fraction of CCMs present as diffuse manifestations distributed over the cerebral hemispheres, cerebellum, and brainstem. The purpose of the present study was to explore the clinical picture of such CCMs. Methods: This study assessed the appearance of CCMs on magnetic resonance (MR) images, the presence of genetic mutations using the polymerase chain reaction method, and disease course over long-term follow-up in a total of 10 patients with diffuse CCMs. Results: The 10 patients were Japanese and comprised 5 males and 5 females with a mean age of 48.7 years. Three of them presented with seizures, two with headache and intracerebral hemorrhage, two with numbness, and one with dizziness, while the remaining two were asymptomatic. Genetic analysis revealed CCM1 mutations in four patients, CCM2 mutations in three, and a CCM3 mutation in one. In a family with 2 CCM2 patients, the appearance of sustained diffuse CCMs on MR images significantly differed between the 2 patients despite the mutation being identical. During the mean follow-up period of 13.7 years, none of the 10 patients showed evidence of neurological deterioration or symptomatic hemorrhage. The appearance of their CCMs on MRI did not show significant changes. Eight patients maintained normal neurological function. Conclusions: CCMs with diffuse manifestation is a hereditary disease with satisfactory prognosis. Unrecognized genomic mutations may be involved in the genesis of these CCMs. © 2016 Elsevier B.V. All rights reserved.
1. Introduction Cerebral cavernous malformations (CCMs) are a distinct entity of cerebrovascular diseases that affect approximately 0.5% of the general population [1]. The annual hemorrhage rate of CCMs has been reported to be 0.7–2.4%, which were based on inconsistent approaches for evaluating the clinical picture and neuroimaging classifications of the hemorrhages [2–4]. Prior hemorrhage, brainstem location, and associated developmental venous malformations are thought to be the significant risk factors for symptomatic hemorrhage from CCMs [5,6]. CCMs can occur in sporadic or familial form with autosomally dominant trait. Mutations in the CCM1, CCM2, and CCM3 genes, located in the 7q, 7p, and 3q, respectively, are thought to be responsible for the genesis of familial CCMs [7–12]. Annual hemorrhage rate in patients with familial CCMs is estimated to be 2.5%, reflecting the higher proportion of patients developing clinical symptoms in the familial compared to sporadic type [13, 14]. Neuroimaging penetrance of familial CCMs is reported to be much higher than the clinical penetrance [14,15]. If a patient without obvious ⁎ Corresponding author at: Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan. E-mail address: [email protected] (S. Tsutsumi).
http://dx.doi.org/10.1016/j.jns.2016.06.012 0022-510X/© 2016 Elsevier B.V. All rights reserved.
family history of CCM has been found to have multiple CCMs on imaging examination, in 75% the case is actually a familial type [14]. T2-weighted gradient-echo magnetic resonance (MR) images and susceptibilityweighted sequence are thought to be highly sensitive for detecting CCMs and accompanying hemosiderin deposition [15–17]. A fraction of familial CCMs show unusually diffuse and extensive manifestations involving the cerebral hemispheres, cerebellum, and brainstem, which can perplex clinicians when encountered these patients. To our knowledge, there have been few reports documenting these CCMs [18]. The present study aimed to explore the clinical picture of these diffusely manifesting CCMs based on their appearance on magnetic resonance imaging, the presence of genetic mutations, and longterm follow-up. 2. Materials and methods 2.1. Patients This prospective study initially evaluated 30 familial CCM patients who presented to our institution between November 2006 and March 2016. Their symptoms at the onset were seizure, headache, numbness, and dizziness. The diagnosis of familial CCMs was based on a detailed
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interview of family history, medical records provided by referring physicians, and MR imaging examinations of the brain and spinal cord using a 3.0T MR scanner (Achieva R2.6; Philips Medical Systems, Best, The Netherlands), including T2*-weighted images and/or susceptibilityweighted sequences. Of these 30 patients, 10 with an unusual presentation of multiple CCMs involving the cerebral hemispheres, cerebellum, and brainstem were diagnosed as patients with diffuse manifestation of CCM. Patients with multiple CCMs who did not present involving all the above-mentioned brain areas were excluded. In 9 of these 10 patients, peripheral blood was collected from the antecubital vein for genetic analysis, carried out as described below. The present study was performed in accordance with our institution's guidelines for human research. Written informed consent for this study was obtained from all 10 patients. 2.2. Genetic analysis 1. DNA extraction, polymerase chain reaction (PCR), and sequencing Whole venous blood was collected in a PAXgene DNA Tube (PreAnalytiX, Hombrechtikon, Switzerland) and the genomic DNA was extracted using the PAXgene Blood DNA Kit (PreAnalytiX). Mutations in the CCM1, CCM2, and CCM3 genes were identified using a previously documented PCR method [7,9,11]. Amplifications were carried out in 25 μl 2 × AmpliTaq Gold 360 Master Mix (Applied Biosystems), with 20 pmol of each primer and 100 ng of DNA. Cycling conditions consisted of an initial 12.5-min denaturation step at 95 °C and subsequent extension for 7.5 min at 72 °C. PCR products were visualized by ethidium bromide staining on 2% agarose gel. Amplicons were purified using Microcon (Millipore, Bedford, MA, USA) and sequenced using the BigDye Terminator v3.1 Cycle Sequencing Kit (Applied Biosystems). Sequencing reactions were loaded on ABI3100 capillaries (Applied Biosystems) and analyzed with Seqscape v2.6 (Applied Biosystems). 2. Reverse transcription PCR
Whole venous blood was collected in a PAXgene RNA Tube (PreAnalytiX) and the RNA extracted with RNA purification kit (PAXgene Blood RNA Kit; PreAnalytiX). PCR products were visualized by ethidium bromide staining on 1.5% agarose gels. Amplicons were purified using Microcon and sequenced using the BigDye Terminator v3.1 Cycle Sequencing Kit. Sequencing reactions were loaded on ABI3100 capillaries and analyzed using Seqscape v2.6. 3. Results 3.1. Demographics and clinical symptoms at onset The study population comprised 5 males and 5 females aged between 20 to 68 years (mean: 48.7 years). Their age at the initial onset or presentation was between 10 to 58 years (mean: 39.4 years). All the subjects were Japanese and belonged to 6 different families in total. Three of these 10 patients presented with seizures, 2 with headache and intracerebral hemorrhage, 2 with numbness in the face or upper extremity, and 1 with dizziness. The other two were asymptomatic and found coincidentally on MR images performed for a brain check-up and minor head trauma, respectively. 3.2. Neuroimaging findings On T2-weighted gradient-echo images and susceptibility-weighted sequences, all patients showed a diffuse CCMs represented by many or innumerable hypointense spots and nodular masses of varying sizes. Most of the brainstem lesions were tiny with a diameter of less than 3 mm. Notably, CCMs were not compressive to the surrounding brain, regardless of the size and location. Concurrent vascular malformations
were not found. Spinal cord involvement was identified in 4 patients; the cervical cord was affected in 1, thoracic cord in 2, and cervicothoracic cord in 1. In 4 patients, spinal cord involvement was not identified. The remaining 2 patients did not undergo spinal MR imaging (Fig. 1). 3.3. Genetic features: presence of CCM gene family mutations Genetic analysis revealed a CCM1 mutation in 4 patients, CCM2 mutation in 3 patients, and CCM3 mutation in 1 patient. In another patient belonging to a CCM1 family, genetic analysis was not conducted and the type of CCM mutation was defined as “unknown” (Patient No. 3 in Table 1). In one of the families, 3 patients (Nos. 1, 2, and 4) had the same CCM1 mutation and their CCM lesions exhibited a characteristic appearance on MR images that was represented by innumerable nodular lesions of varying sizes over the whole brain (Fig. 2). By contrast, two patients in another family (Nos. 5 and 6) had an identical CCM2 mutation, but the appearance of CCMs on neuroimaging was significantly different between the two cases (Fig. 3). 3.4. Follow-up results and disease course Five (Nos. 2, 3, 4, 5, and 6) of the 10 patients were initially treated by outside physicians. These individuals were diagnosed with familial CCMs based on an interview of the family history and MR imaging examination. Until referral to our institute, all had followed an uneventful course without neurological deterioration or symptomatic hemorrhage. The period from the diagnosis of familial CCMs to the latest interview ranged from 1.4–29 years (mean: 13.7 years). The follow-up period at our institution ranged from 1.4–9.4 years (mean: 7.1 years). During the period, no patient showed neurological deterioration or a symptomatic hemorrhage. Appearance of CCMs on MR images did not show significant growth of CCMs or compressive hemorrhage in any location of the brain, which was consistently observed for all CCM types (Figs. 4-6). These results and details of CCM mutations are summarized in Table 1. Two patients who presented with seizures as the initial symptom were well controlled during the follow-up period with constant medication. Modified Rankin Scale (mRS) scores at the latest interview were 0 in 8 patients and 1 in 2; 1 patient exhibited a sustained fine movement disturbance in the right hand and another presented intermittent trigeminal pain. 4. Discussion The present investigation suggests that patients with diffuse CCMs may follow a stable clinical course without neurological deterioration. In spite of the impressive appearance on MR images, patients with diffuse CCMs may maintain favorable neurological function for a long time even after initial symptomatic onset. In our study, these patients did not sustain neurological deterioration or symptomatic hemorrhages during a long-term follow-up. MR appearance of these CCMs did not show significant changes in any location of the brain. Furthermore, all the patients who manifested diffuse CCMs and underwent genomic analysis possessed genomic mutations in CCM1, CCM2, and CCM3. Thus, we surmise that diffuse CCMs are typically a hereditary disease with a reasonably favorable prognosis. Relative to other locations in the central nervous system, CCMs located in the brainstem are thought to be more likely to cause a symptomatic hemorrhage [5,6]. The10 patients in our study did not show significant growth or symptomatic hemorrhages even when there were multiple, pre-existing lesions in the brainstem. Most of the lesions were identified as tiny spots on initial MR images and did not enlarge thereafter, which may contribute to the good functional prognosis of patients with diffuse CCMs. This is in contrast to a 36-year-old female who was in the group of 30 patients evaluated at the beginning of the study but not enrolled because brainstem lesions were absent. This patient
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Fig. 1. (A) Susceptibility-weighted MR images in a 47-year-old male with a CCM1 mutation (Patient No. 2) showing innumerable nodular lesions with variable sizes distributed over the cerebral hemispheres, cerebellum, and brainstem. (B, C) Sagittal T2-weighted MR images of the same patient showing lesions in the cervical (B, arrow) and thoracic cords (C, arrows).
presented with seizures as the initial symptom, and was initially diagnosed with unverified (Non-CCM1,2,3) familial CCM because genetic analysis of the patient did not identify mutations in CCM1,2,3. MR images revealed multiple CCMs, but none were in the brainstem. She later sustained symptomatic hemorrhage from a de novo lesion that
had arisen in the center of the midbrain during 58 months' follow-up (Fig. 7). Notably, in a family with a CCM2 mutation, CCM appearance on MR images significantly differed between father and son, in spite of the mutation being identical between them. In contrast, in a family with an
Table 1 Profiles of 10 patients with diffuse CCMs. C: cervical cord, f: female, ICH: intracerebral hemorrhage, m: male, SCI: spinal cord involvement, T: thoracic cord, UK: unknown, UV: unverified. Patient No
Age, Sex
Age at onset
Symptoms
CCM type
Detail
SCI
from D
f/u
1 2 3 4 5 6 7 8 9 10
68,f 47,m 20,m 45,f 68,m 34,m 44,f 51,m 51,f 59,m
58 10 (-) 28 53 34 (-) 45 45 57
Dizziness ICH (-) ICH Seizure Seizure (-) Numbness Numbness Seizure
CCM1 CCM1 CCM1 CCM1 CCM2 CCM2 CCM3 CCM2 UV CCM1
c.1632_1634del TAC p.Tyr544, heterozygous deletion c.1632_1634del TAC p.Tyr544, heterozygous deletion (-) c.1632_1634del TAC p.Tyr544, heterozygous deletion c.319 CNT p.Gln107 c.319 CNT p.Gln107 c.103 CNT p.Arg35 c.193_204delAAGGAGGTAAAG p.Lys65_Lys68de (-) c.1477 GNT p.Glu493
T C,T UK UK (-) (-) (-) UK T C
9.4 37 10 17 13.5 29 8.8 5.5 5.3 1.4
9.4 9.4 9.4 9.4 6.3 6.3 8.8 5.5 5.3 1.4
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Fig. 2. Susceptibility-weighted MR images in a family with a CCM1 mutation. Note that the appearances of CCMs in the images, as represented by innumerable nodular lesions of varying sizes, are the characteristic findings in the mother (upper row, No. 1) and her son (lower row, No. 2).
identical CCM1 mutation, all the members showed a similar CCM appearance on MR images. Given these findings, mutations in genes other than CCM1, CCM2, and CCM3 may contribute to the genesis of diffuse CCMs, because the same mutation identified in these genes may not necessarily produce CCMs with a similar appearance. There are unsolved questions concerning diffuse CCMs that showed a stable appearance on MR images for a long period. How old were these patients when the CCMs had initially appeared in the brain? How long did it take for diffuse manifestations to present after the initial
appearance of these lesions? Did the lesions appear in a consecutive or multicentric manner? At the present time, reasonable explanations for these queries are not at hand. Although almost patients in the present study showed a stable clinical course and satisfactory outcome on mRS Score, the distribution of CCMs over the brain seems to be too extensive to conclude that normal brain function was retained. In addition, the results of the present study were provided by a small number of patients. Higher cerebral and neuropsychological function should be evaluated in a sufficiently large
Fig. 3. Susceptibility-weighted MR images in a family with a CCM2 mutation. The father (upper row, No. 5) presented multiple nodular lesions of varying sizes while his son (lower row, No. 6) showed large masses in the both cerebral hemispheres and tiny lesions in the cerebellum and brainstem (lower row, arrows).
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Fig. 4. Serial susceptibility-weighted MR images of a female with a CCM1 mutation (No. 1) showing no significant changes in CCM appearance after 106 months.
number of patients in a future investigation. The present study was of a small Japanese cohort and the results can be influenced by the genomic peculiarities of individuals with Japanese ethnicity, which should be considered when interpreting the results.
Recent investigations have further progressed the understanding of CCMs. Familial CCM1 carriers have an increased number of T2 hyperintensities in the white mater, which are spatially distinct from CCMs. These hyperintensities exceeded those typically observed in the
Fig. 5. Serial susceptibility-weighted MR images of a male with a CCM2 mutation (No. 8) showing no significant changes after 54 months in the appearance of a CCM characterized as a lesion in the dorsal midbrain (arrow).
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Fig. 6. Serial susceptibility-weighted MR images of a female with a CCM3 mutation (No. 7) showing no significant changes in CCM appearance after 63 months.
Fig. 7. T2*-weighted images showing a compressive hemorrhage from a de novo lesion that arose in the center of the midbrain (lower row, arrow), which was not identified 58 months prior (upper row).
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healthy population, but did not have any association with clinical findings [19]. Vascular permeability and iron deposition of CCMs was quantitatively evaluated with MR imaging [20]. Furthermore, brain permeability, rather than permeability of CCM, was proposed as a potential biomarker that may reflect disease activity [21]. Identification of unrecognized CCM mutations based on a comprehensive genomic analysis coupled with case accumulation may lead to a better understanding of familial CCMs. 5. Conclusions CCM with diffuse manifestation is a hereditary disease with stable clinical course and satisfactory prognosis. Unrecognized genomic mutations may be involved in the genesis of these CCMs. Author contributions All the authors equally contributed to the manuscript. Conflict of interest The authors have no conflict of interest concerning the materials or methods in this study or the findings specified in this paper. Acknowledgement There was no grant funding for this work. Ethical standards and patient consent We declare that all human and animal studies have been approved by the institution's guidelines for human research in our institution and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all patients gave informed consent prior to inclusion in this study. References [1] S. Bacigaluppi, S.F. Retta, S. Pileggi, M. Fontanella, L. Goitre, L. Tassi, A. La Camera, A. Citterio, M.C. Patrosso, G. Tredici, S. Penco, Genetic and cellular basis of cerebral cavernous malformations: implications for clinical management, Clin. Genet. 83 (2013) 7–14. [2] B.A. Gross, N. Lin, R. Du, A.L. Day, The natural history of intracranial cavernous malformations, Neurosurg. Focus. 30 (2011), E24. [3] J.R. Robinson, I.A. Awad, J.R. Little, Natural history of the cavernous angioma, J. Neurosurg. 75 (1991) 709–714. [4] R. Al-Shahi Salman, M.J. Berg, L. Morrison, I.A. Awad, A.S.A. Board, Hemorrhage from cavernous malformations of the brain: definition and reporting standards. Angioma Alliance Scientific Advisory Board, Stroke 39 (2008) 3222–3230.
341
[5] B.A. Gross, R. Du, D.B. Orbach, R.M. Scott, E.R. Smith, The natural history of cerebral cavernous malformations in children, J. Neurosurg. Pediatr. (2015 Oct 16) (Epub ahead of print). [6] M.H. Poorthuis, C.J. Klijn, A. Algra, G.J. Rinkel, R. Al-Shahi Salman, Treatment of cerebral cavernous malformations: a systematic review and meta-regression analysis, J. Neurol. Neurosurg. Psychiatry 85 (2014) 1319–1323. [7] F. Bergametti, C. Denier, P. Labauge, M. Arnoult, S. Boetto, M. Clanet, P. Coubes, B. Echenne, R. Ibrahim, B. Irthum, G. Jacquet, M. Lonjon, J.J. Moreau, J.P. Neau, F. Parker, M. Tremoulet, E. Tournier-Lasserve, ; Société Française de Neurochirurgie, Mutations within the programmed cell death 10 gene cause cerebral cavernous malformations, Am. J. Hum. Genet. 76 (2005) 42–51. [8] H.D. Craig, M. Günel, O. Cepeda, E.W. Johnson, L. Ptacek, G.K. Steinberg, C.S. Ogilvy, M.J. Berg, S.C. Crawford, R.M. Scott, E. Steichen-Gersdorf, R. Sabroe, C.T. Kennedy, G. Mettler, M.J. Beis, A. Fryer, I.A. Awad, R.P. Lifton, Multilocus linkage identifies two new loci for a menderian form of stroke, cerebral cavernous malformation, at 7p15-13 and 3q25.2-27. Hum. Mol. Genet. 7 (1998) 1851–1858. [9] C. Danier, S. Goutagny, P. Labauge, V. Krivosic, M. Arnoult, A. Cousin, A.L. Benabid, J. Comoy, P. Frerebeau, B. Gilbert, J.P. Houtteville, M. Jan, F. Lapierre, H. Loiseau, P. Menei, P. Mercier, J.J. Moreau, A. Nivelon-Chevallier, F. Parker, A.M. Rendondo, J.M. Scarabin, M. Tremoulet, M. Zerah, J. Maciazek, E. Tournier-Lasserve, Société Française de Neurochirurgie, Mutations within the MGC4607 gene cause cerebral cavernous malformations, Am. J. Hum. Genet. 74 (2004) 326–337. [10] J. Dubovsky, J.M. Zabramski, J. Kurth, R.F. Spetzler, S.S. Rich, H.T. Orr, J.L. Weber, A gene responsible for cavernous malformations of the brain maps to chromosome 7q, Hum. Mol. Genet. 4 (1995) 453–458. [11] V. Guamieri, L.A. Muscarella, R. Amoroso, A. Quattrone, M.E. Abate, M. Coco, D. Catapano, V.A. D'Angelo, L. Zelante, L. D'Agruma, Identification of two novel mutations and of a novel critical region in the KRIT 1 gene, Neurogenetics 8 (2007) 29–37. [12] M. Günel, I.A. Awad, J. Anson, R.P. Lifton, Mapping a gene causing cerebral cavernous malformation to 7q11.2-q21, Proc. Natl. Acad. Sci. U. S. A. 92 (1995) 6620–6624. [13] P. Labauge, L. Brunereau, C. Lévy, S. Laberge, J.P. Houtteville, The natural history of familial cerebral cavernomas: a retrospective MRI study of 40 patients, Neuroradiology 42 (2000) 327–332. [14] P. Labauge, S. Laberge, L. Brunereau, C. Levy, E. Tourier-Lasserve, Hereditary cerebral cavernous angiomas: clinical and genetic features in 57 French families. Société Française de Neurochirurge, Lancet 352 (1998) 1892–1897. [15] L. Brunereau, P. Labauge, E. Tourier-Lasserve, S. Laberge, C. Levy, J.P. Houtteville, Familial form of intracranial cavernous angioma: MR imaging findings in 51 families. French Society of Neurosurgery, Radiology 241 (2000) 209–216. [16] P.G. Campbell, P. Jabbour, S. Yadla, I.A. Awad, Emerging clinical imaging techniques for cerebral cavernous malformations: a systematic review, Neurosurg. Focus. 29 (2010), E6. [17] N.M. de Champfleur, C. Langlois, W.J. Ankenbrandt, E. Le Bars, M.A. Leroy, H. Duffau, A. Bonafé, J. Jaffe, I.A. Awad, P. Labauge, Magnetic resonance imaging evaluation of cerebral cavernous malformations with susceptibility-weighted imaging, Neurosurgery 68 (2011) 641–648. [18] H. Kuwahara, Y. Noguchi, Y. Saito, A. Inaba, Multiple cavernous angiomas in the brain and spinal cord, Arch. Neurol. 67 (2010) 1405–1406. [19] M.J. Golden, L.A. Morrison, H. Kim, B.L. Hart, Increased number of white matter lesions in patients with familial cerebral cavernous malformations, AJNR Am. J. Neuroradiol. 36 (2015) 899–903. [20] A.G. Mikati, H. Tan, R. Shenkar, L. Li, L. Zhang, X. Guo, H.B. Larsson, C. Shi, T. Liu, Y. Wang, A. Shah, R.R. Edelman, G. Christoforidis, I. Awad, Dynamic permeability and quantitative susceptibility: related imaging biomarkers in cerebral cavernous malformations, Stroke 45 (2014) 598–601. [21] A.G. Mikati, O. Khanna, L. Zhang, R. Girard, R. Shenkar, X. Guo, A. Shah, H.B. Larsson, H. Tan, L. Li, M.S. Wishnoff, C. Shi, G.A. Christoforidis, A. Awad, Vascular permeability in cerebral cavernous malformations, J. Cereb. Blood Flow Metab. 35 (2015) 1632–1639.