Term Neonate with Intracranial Hemorrhage and Hereditary Hemorrhagic Telangiectasia: a Case Report and Review of the Literature

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Journal of Perinatology (2012) 32, 642–644 r 2012 Nature America, Inc. All rights reserved. 0743-8346/12 www.nature.com/jp PERINATAL/NEONATAL CASE PRESENTATION Term neonate with intracranial hemorrhage and hereditary hemorrhagic telangiectasia: a case report and review of the literature

HM Delaney1, VJ Rooks2, SQ Wolfe3 and TL Sawyer1 1Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, USA; 2Department of Radiology, Tripler Army Medical Center, Honolulu, HI, USA and 3Department of Neurosurgery, Tripler Army Medical Center, Honolulu, HI, USA

suspected AVM who survived with aggressive medical management Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant and surgical intervention. disorder characterized by mucocutaneous telangiectases and arteriovenous malformations (AVMs). The disease rarely presents in the neonatal period, primarily manifesting with epistaxis and gastrointestinal bleeding in Case adulthood. Occasionally, HHT can also present with symptoms related to AVMs A 37-week gestation female was born via urgent Cesarean section to in the cerebral, pulmonary or gastrointestinal vasculature. In prior reports, a primiparous 28-year-old woman secondary to late fetal intracranial hemorrhage (ICH) secondary to cerebral AVM in neonates with decelerations. Maternal history was notable for HHT with normal HHT has been catastrophic and uniformly fatal. Here we report a case of a prenatal ultrasounds. At delivery, the infant had poor respiratory newborn with HHT and ICH from a suspected AVM who survived with effort and was transferred to the neonatal intensive care unit for aggressive medical management and surgical intervention, and provide a further management. On admission, the infant’s weight and comprehensive review of the literature on ICH in neonates with HHT. occipital–frontal circumference was 50th percentile with an open Journal of Perinatology (2012) 32, 642–644; doi:10.1038/jp.2011.146 and flat fontanelle. Her exam was otherwise notable for moderate Keywords: arteriovenous malformations; endoglin gene; hereditary respiratory distress with normal cardiac exam. No skin hemorrhagic telangiectasia telangiectases were noted. Chest X-ray was consistent with transient tachypnea of the newborn and she was quickly weaned from respiratory support but was noted to have difficulty with oral feeds Introduction and early jaundice. On the second day of life, the infant developed Hereditary hemorrhagic telangiectasia (HHT) is an autosomal seizures, persistent downward deviation of the eyes and a bulging dominant disorder with a high degree of penetrance and variable fontanelle. A non-sedated magnetic resonance imaging (MRI) expressivity. It is characterized by mucocutaneous telangiectases revealed a massive hematoma with mass effect within the fourth and arteriovenous malformations (AVMs) most often found in the ventricle, obstructive hydrocephalus and transverse cerebral venous cerebral, pulmonary and gastrointestinal circulations.1 Symptoms sinus thrombosis (Figures 1a and b). Computed tomography (CT) are rare in children and typically present in early adulthood with venogram revealed partial thrombosis of the transverse sinuses epistaxis and gastrointestinal bleeding by the fifth or sixth decade. (Figures 2a and b). CT angiography and magnetic resonance In the adult population with HHT, 20% have cerebrovascular angiography (MRA) failed to define a source for the bleeding, but malformations with the annual risk of intracranial hemorrhage because of the maternal history, an AVM in the fourth ventricle was (ICH) from unruptured AVMs of 2–4%.2 The prevalence of cerebral suspected. An emergent external ventriculostomy was placed to AVMs among children with HHT is unknown and ICH secondary to decompress the ventricles and the clinical status of the infant HHT has been rarely reported in neonates. In these cases, the improved. Postoperatively the infant was managed with aggressive ICH is catastrophic and uniformly fatal, with most cases of AVM hydration to augment flow through the partially thrombosed diagnosed on autopsy.2,3 Here we report a newborn found to have transverse sinuses and relative hypernatremia and albumin HHT presenting with seizures and diagnosed with ICH from a infusions to provide an osmotic gradient to decrease cerebral edema. An internal ventricular access device was later placed Correspondence: HM Delaney, Department of Neonatology, Tripler Army Medical Center, 1 followed by a ventriculoperitoneal shunt at 6 weeks. Serial head Jarrett White Road, Honolulu, HI 96859-5000, USA. E-mail: [email protected] ultrasounds demonstrated persistent patency of the cerebral venous Received 10 August 2011; revised 30 August 2011; accepted 31 August 2011 sinus system with complete resolution of the partial transverse Infant with hereditary hemorrhagic telangiectasia HM Delaney et al 643

Figure 1 (a) Patient was initially evaluated with non-sedated magnetic resonance imaging (MRI) for seizures on the second day of life. Sagittal MRI T1 Figure 3 (a) Three month follow-up magnetic resonance imaging (MRI) weighted image demonstrates peripheral high T1, central isointense signal Sagittal T1 image demonstrates central cerebellar parenchymal loss (arrows). midline posterior fossa consistent with thrombus causing mass effect and Cerebrospinal ﬂuid signal on Axial T2 image, (b), consistent with ventriculomegaly. (b) Axial T2 MRI demonstrates hypointense clot centrally encephalomalacic change from prior hemorrhage. Magnetic resonance ﬁlling fourth ventricle with intermediate signal extending along the transverse angiography (MRA) demonstrated no vascular malformation at that time (not sinuses bilaterally consistent with cerebral venous sinus thrombus (arrows). shown).

are seven reports in the literature of neonates and young infants with known or suspected HHT with symptomatic cerebral AVMs. Their outcomes are presented in Table 1 of the Supplementary Information. To the author’s knowledge, this case represents the first reported survival of a neonate with HHT and ICH. The locality of the AVM to the fourth ventricle resulting in intraventricular hemorrhage may have been this infant’s life-saving feature, which allowed for emergent surgical intervention. Given the associated mortality risks of ICH in neonates with HHT, this case highlights the importance of early neuroimaging to Figure 2 (a) Head computed tomography (CT) demonstrates the large rounded search for cerebral AVMs in this at-risk population. Although it has central dense posterior fossa hemorrhage obscuring the fourth ventricle and been previously recommended that genetic screening via causing ventriculomegaly with (b) contrast enhanced CT arterial and venous phase demonstrating contrast flow along the anterior aspects of the partially amniocentesis or chorionic villous sampling, as well as prenatal clotted transverse sinus consistent with incomplete cerebral venous sinus occlusion imaging such as MRI should be provided for children of HHT (arrows). families by 1 year of age, this case argues that even earlier screening for detection of the disease-causing mutation and its manifestations may be beneficial and potentially life-saving.1 Given sinus thromboses on CT venogram at 2 weeks. Genetic studies the genetic heterogeneity of the disease, genetic analysis does not revealed a heterozygous mutation of c.872_883del12bp in the always establish the diagnosis of HHT due to unknown or complex Endoglin gene; the same mutation was found in the mother. mutations. Therefore, even without genetic confirmation of HHT, Repeat MRA at 3 months of age revealed near resolution of the consideration should be given to delivery in a hospital that is able fourth ventricle thrombus (Figures 3a and b). Follow-up MRA at 1 to provide tertiary medical care and emergency neurosurgical year revealed no apparent AVM. The infant is now 13 months old interventions. Such infants should undergo strict monitoring for and by report suffers from mild coordination difficulties but is subtle abnormalities that may indicate early signs of ICH. If signs otherwise developmentally appropriate. of ICH are present, imaging with MRI or CT, rather than ultrasound, should be considered to provide the best details of the anatomy and pathology and to better visualize the subarachnoid Discussion space and venous sinuses. HHT rarely presents with ICH in the neonatal period. Although In this case, although posthemorrhage imaging failed to define children and adult patients with HHT who have ICH typically have an AVM, it is not uncommon for small AVMs near the ventricular good functional outcomes with minimal residual deficits, the wall to spontaneously thrombose due to the pressure of the clot and contrary has been observed in the neonatal population.4–9 There subsequent hydrocephalus. These types of AVMs that are not

Journal of Perinatology Infant with hereditary hemorrhagic telangiectasia HM Delaney et al 644 visualized by serial cerebral angiography are known as References ‘angiographically occult intracranial vascular malformations’ and 1 Giordano P, Nigro A, Lenato GM, Guanti G, Suppressa P, Lastella P et al. Screening for 10 are well described in the literature. Therefore, with the diagnosis children from families with Rendu-Osler-Weber disease: from geneticist to clinician. of HHT and the location of the hemorrhage, AVM remains the most J Thromb Haemost 2006; 4: 1237–1245. likely diagnosis. A previous study reported the occurrence of ICH in 2 Morgan T, McDonald J, Anderson C, Ismail M, Miller F, Mao R et al. Intracranial an older child with a family history of HHT whose AVM was not hemorrhage in infants and children with hereditary haemorrhagic telangiectasia present on initial angiogram or during evacuation of the (Osler-Weber-Rendu syndrome). Pediatrics 2002; 109: E12. hematoma, although was identified on follow-up angiography, 3 Bourdeau A, Cymerman U, Paquet M-E, Meschino W, McKinnon WC, Guttmacher AE confirmed that after hemorrhage these lesions may be obscured by et al. Endoglin expression is reduced in normal vessels but is still detectable in arteriovenous malformations of patients with hereditary hemorrhagic telangiectasia the ictal event.4 type I. Am J Pathol 2000; 156: 911–923. In conclusion, we present the first reported case of survival in a 4 Kuo Y-H, Santoreneos S, Roos D, Brophy BP. Treatment of multiple arteriovenous neonate with HHT and ICH from a suspected AVM. There is no malformations in pediatric patients with hereditary hemorrhagic telangiectasia and question that ICH in these infants can be catastrophic with a spontaneous hemorrhage. Report of two cases. J Neurosurg 2007; 107: 489–494. reported high level of mortality. It is our recommendation that 5 Maher CO, Piepgras DG, Brough Jr RD, Friedman JA, Pollock BE. Cerebrovascular infants born to a parent with HHT undergo an early genetic and manifestations in 321 cases of hereditary hemorrhage telangiectasia. Stroke 2001; 32: radiological evaluation for HHT and its manifestations. Without 877–882. question, the serendipitous transient respiratory distress that 6 Boynton R, Morgan B. Cerebral arteriovenous fistula withpossible hereditary telangiectasia. Am J Dis Child 1973; 125: 99–101. affected this infant requiring transitioning in the neonatal 7 Roy C, Noseda G, Arzimanoglou A, Harpey JP, Binet MH, Vaur C et al. Maladie de intensive care unit with close monitoring was life-saving. Without Rendu-Osler re´ve´leé par la rupture d’un ane´vrysme arte´riel ce´re´bral chez un early detection, imaging and aggressive management the outcome nourrisson. Arch Fr Pediatr 1990; 47: 741–742. of this case could have proven devastating. 8 Putman C, Chaloupka J, Fulbright R, Awad A, White R, Favad P et al. Exceptional multiplicity of cerebral arteriovenous malformations associated with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome). AJNR Am J Neuroradiol Conflict of interest 1996; 17: 1733–1742. The authors declare no conflict of interest. 9 Krings T, Ozanne A, Chng SM, Alvarez H, Rodesch G, Lasjaunias PL. Neurovascular phenotypes in hereditary haemorrhagic telangiectasia patients according to age. Review of 50 consecutive patients aged 1 day-60 years. Neuroradiology 2005; 47: Disclaimer 711–720. The views expressed in this abstract/manuscript are those of the author(s) and do 10 Lobato RD, Perez C, Rivas JJ, Cordobes F. Clinical, radiological, and pathological not reflect the official policy or position of the Department of Army, Department of spectrum of angiographically occult intracranial vascular malformations. Analysis of Defense or the US Government. 21 cases and review of the literature. J Neurosurg 1988; 68: 518–531.

Supplementary Information accompanies the paper on the Journal of Perinatology website (http://www.nature.com/jp)

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