Key biomarkers in cerebral arteriovenous malformations: Updated review

The formation of vascular networks consisting of arteries, capillaries, and veins is vital in embryogenesis. It is also crucial in adulthood for the formation of a functional vasculature. Cerebral arteriovenous malformations (CAVMs) are linked with a remarkable risk of intracerebral hemorrhage because arterial blood is directly shunted into the veins before the arterial blood pressure is dissipated. The underlying mechanisms responsible for arteriovenous malformation (AVM) growth, progression, and rupture are not fully known, yet the critical role of inflammation in AVM pathogenesis has been noted. The proinflammatory cytokines are upregulated in CAVM, which stimulates overexpression of cell adhesion molecules in endothelial cells (ECs), leading to improved leukocyte recruitment. It is well-known that metalloproteinase-9 secretion by leukocytes disrupts CAVM walls resulting in rupture. Moreover, inflammation alters the angioarchitecture of CAVMs by upregulating angiogenic factors impacting the apoptosis, migration, and proliferation of ECs. A better understanding of the molecular signature of CAVM might allow us to identify biomarkers predicting this complication, acting as a goal for further investigations that may be potentially targeted in gene therapy. The present review is focused on the numerous studies conducted on the molecular signature of CAVM and the associated hemorrhage. The association of numerous molecular signatures with a higher risk of CAVM rupture is shown through inducing proinflammatory mediators, as well as growth factors signaling, Ras-mitogen-activated protein kinase-extracellular signal-regulated kinase, and NOTCH pathways, which are accompanied by cellular level inflammation and endothelial alterations resulting in vascular wall instability. According to the studies, it is assumed that matrix metalloproteinase, interleukin-6, and vascular endothelial growth factor are the biomarkers most associated with CAVM and the rate of hemorrhage, as well as diagnostic methods, with respect to enhancing the patient-specific risk estimation and improving treatment choices.     

Fractal dimension and cheek teeth crown complexity in the giant rodent Eumegamys paranensis

In this work, we analyse cheek teeth crown complexity through the calculation of fractal dimension in the giant caviomorph rodent Eumegamys paranensis (Late Miocene of Argentina) and evaluate its functional significance. Our results indicate that, in all teeth of Eumegamys paranensis, the fractal dimension was around 1.5, similar to the Koch quadratic curve type two. The anterior portions of the molars, with the highest values of fractal dimension, are interpreted as areas that supported greater occlusal pressures. Crown complexity in E. paranensis is related to the increased mechanical capacity to process relatively demanding food items and to allow more food to be divided in each masticatory cycle. Eumegamys paranensis would have been a mixed feeder, consuming a variable diet obtained close to the ground. This feeding behaviour is compatible with the heterogeneous environment inferred for the Mesopotamic area during the Late Miocene. E. paranensis was probably a wide ranging species, being able to eat close to water bodies and in gallery forests that occurred in the surrounding of the pre‐Paraná river system.     

Experience of proton stereotactic therapy for cerebral arteriovenous malformations in children

The authors present the results of proton stereotactic therapy (using continuous double-axis pendulum irradiation) in 27 children with cerebral arteriovenous malformations (AVM). At the moment of therapy, the children's age was 6 to 15 years. The volume of AVM was 0.2 to 31.2 cm3. The absorbed doses in the maximum of a dose field were 40 to 80 Gy. Complete AVM obliteration (the mean volume in the group was 3.03 cm3) was obtained in 11 (41%) patients. A 50% or more reduction in AVM volume (mean volume, 10.6 cm3) was seen in 8 (30%) patients. There was a less than 50% reduction in AVM volumes (mean volume 9.6 cm3) in 2 (7%) patients and no effect could be achieved in 6 (22%) (mean AMV volume 19.7 cm3).     

Fractal dimension in endometrial carcinoma

OBJECTIVE: To mathematically assess in a pilot study, endometrial glandular margin irregularity in simple hyperplasia, complex atypical hyperplasia and well-differentiated endometrial carcinoma with the help of box counting of fractal dimension and to discriminate these lesions on the basis of box counting of fractal dimension of the gland. STUDY DESIGN: Ten cases each of endometrial simple hyperplasia (without atypia), complex hyperplasia with atypia and endometrial carcinoma (well-differentiated, endometrioid) were assessed in the study. Five fields at 20 x magnification from each case were randomly selected, and the glands were outlined with the help of a pointer. Using the box counting method, the fractal dimension of each case was measured. RESULTS: Mean fractal dimension in simple hyperplasia, complex atypical hyperplasia and endometrial carcinoma was, 0.899 +/- 0.13, 0.932 +/- 0.042 and 0.939 +/- 0.02, respectively. Statistical analysis showed that the fractal dimension of glands of simple hyperplasia were significantly different from that of complex atypical hyperplasia and endometrial carcinoma (P = .041 and .013, respectively, ANOVA). However, there was no significant difference in fractal dimension between glands of complex hyperplasia and of endometrial carcinoma (P = .659, ANOVA). CONCLUSION: This study provides mathematical (objective) assessment of the measurement of glandular margin irregularities in simple hyperplasia, complex atypical hyperplasia and endometrial carcinoma. Fractal dimension of gland margin may have diagnostic potential in the future.     

Fractal dimension in health and heart failure.

BACKGROUND: Non-linear analysis of heart rate variability (HRV) can give additional information about autonomic control of the heart rate. This study applied the fractal dimension (FD) in a congestive heart failure (CHF) population. METHODS: FD and HRV were evaluated in a healthy population (n=21) and an end-stage heart failure population (n=21) using 1-h segments during the day and night from Holter recordings. RESULTS: CHF patients presented a loss of circadian variation in both FD and conventional time- and frequency-domain HRV indices. FD was higher in the CHF population both during the day and night. In the CHF population the correlation between FD and high-frequency power of HRV was lost. CONCLUSION: Day-night variations of heart rate fluctuations are lost in heart failure. Changes in FD reflecting physiological and pathophysiological changes were observed.     

RASA1: variable phenotype with capillary and arteriovenous malformations

Capillary malformation-arteriovenous malformation (CM-AVM) is a newly discovered hereditary disorder. Its defining features are atypical cutaneous multifocal capillary malformations often in association with high-flow lesions: cutaneous, subcutaneous, intramuscular, intraosseous and cerebral arteriovenous malformations and arteriovenous fistulas. Some patients have Parkes Weber syndrome - a large congenital cutaneous vascular stain in an extremity, with bony and soft tissue hypertrophy and microscopic arteriovenous shunting. In the past, arteriovenous malformations and arteriovenous fistulas had been considered non-hereditary. A classical genetic approach was used to identify the locus. Candidate gene screening pinpointed mutations in RASA1 (p120-RASGAP) - a RasGTPase. RASA1 reverts active GTP-bound Ras into inactive GDP-bound form. Murine Rasa1 knockout and tetraploid-aggregated embryos with RNA interference exhibited abnormal vascular development. Lack of RASA1 activity caused inhibition of cell motility, possibly through p190-RhoGAP. Thus, RASA1 defects probably cause abnormal angiogenic remodeling of the primary capillary plexus that cannot be compensated for by other RasGAPs: RASA2, RASAL and NF1. Signaling pathways involving RASA1 might offer novel targets for treatment of high-flow vascular anomalies.     

Notch receptor expression in human brain arteriovenous malformations

The roles of the Notch pathway proteins in normal adult vascular physiology and the pathogenesis of brain arteriovenous malformations are not well‐understood. Notch 1 and 4 have been detected in human and mutant mice vascular malformations respectively. Although mutations in the human Notch 3 gene caused a genetic form of vascular stroke and dementia, its role in arteriovenous malformations development has been unknown. In this study, we performed immunohistochemistry screening on tissue microarrays containing eight surgically resected human brain arteriovenous malformations and 10 control surgical epilepsy samples. The tissue microarrays were evaluated for Notch 1–4 expression. We have found that compared to normal brain vascular tissue Notch‐3 was dramatically increased in brain arteriovenous malformations. Similarly, Notch 4 labelling was also increased in vascular malformations and was confirmed by western blot analysis. Notch 2 was not detectable in any of the human vessels analysed. Using both immunohistochemistry on microarrays and western blot analysis, we have found that Notch‐1 expression was detectable in control vessels, and discovered a significant decrease of Notch 1 expression in vascular malformations. We have demonstrated that Notch 3 and 4, and not Notch 1, were highly increased in human arteriovenous malformations. Our findings suggested that Notch 4, and more importantly, Notch 3, may play a role in the development and pathobiology of human arteriovenous malformations.     

Elevated circulating microRNA-210 levels in patients with hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations: a potential new biomarker

Pulmonary arteriovenous malformations (PAVMs), which can lead to life-threatening bleeding and other complications, have been reported to occur in 30–50% of patients with hereditary hemorrhagic telangiectasia (HHT). Circulating microRNAs (miRNAs) have emerged as new biomarkers for human diseases. This study was conducted to explore circulating miRNAs as biomarkers for the screening of HHT patients with PAVMs. MicroRNA array analysis revealed eight altered circulating miRNAs in patients with PAVMs. Real time RT-PCR showed that the levels of circulating miR-210 were significantly elevated in HHT patients with PAVMs but not changed in patients without PAVMs as compared with healthy controls. Circulating miR-210 therefore may be used as a new and sensitive biomarker for the screening of patients with HHT for clinically significant PAVMs.     

Fractal dimension in aspiration cytology smears of breast and cervical lesions

OBJECTIVE: To standardize the automated measurement of fractal dimension on cytologic smears and compare the fractal dimension of benign and malignant breast cells and cervical lesions on cytologic material to evaluate its role in the discrimination of benign from malignant cells. STUDY DESIGN: We randomly selected fine needle aspiration cytology smears of 42 cases of infiltrating duct carcinoma and 38 cases of fibroadenoma of the breast. Similarly, 16 cervical carcinoma and 20 normal cervical smears were selected for study. Ten cells were selected randomly from each case. Box counting of fractal dimension of malignant and benign cells was achieved with an image cytometer (Leica, Cambridge, England) using Quantimet 600 software (Leica). Then a well-spaced grid with multiple small boxes of a particular pixel length was superimposed on the cell. The dimension of the box was selected as 4, 8 and 16 pixels. With the help of a logical "AND" operation, we counted the number of boxes touching the peripheral margin of the cell nuclei. For each cell, the log-log graph of 1 per box size was plotted against the number of boxes touching the peripheral rim of the cell. The slope of each graph was identified using the least-squares method of regression analysis. RESULTS: The mean fractal dimension of malignant cells was 0.8536 +/- 0.1120 as compared to 0.8403 +/- 0.1115 in benign cell groups. The Mann-Whitney U test showed a significant difference in fractal dimension in these 2 groups (P = .05). The mean fractal dimension of malignant cells from the cervix was 0.8656 +/- 0.1499 as compared to 0.8315 +/- 0.1312 in benign cells. The Mann-Whitney U test showed a significant difference in fractal dimension in these 2 groups (P < .02). CONCLUSION: Fractal dimension may be a helpful adjunctive technique to discriminate between benign and malignant cells.     

Suppression of MMP-9 by doxycycline in brain arteriovenous malformations

Background  

The primary aim of this study is to demonstrate the feasibility of utilizing doxycycline to suppress matrix metalloproteinase-9 (MMP-9) in brain arteriovenous malformations (AVMs).     

Stereotactic localization of deep-seated arteriovenous malformations in the functional area

The authors approached 5 arteriovenous malformations (AVMs) located deep in functional areas of the cortex with major draining veins found in the mesial hemisphere by using the stereotactic method. This procedure is a useful adjunct to total resection of these AVMs. No mortality or significant morbidity was noted after the surgical procedure. The authors believe that direct attack on AVMs in areas of critical function is the procedure of choice in order to preserve neurological function.     

Fractal dimension of electroencephalographic time series and underlying brain processes

 Fractal dimension has been proposed as a useful measure for the characterization of electrophysiological time series. This paper investigates what the pointwise dimension of electroencephalographic (EEG) time series can reveal about underlying neuronal generators. The following theoretical assumptions concerning brain function were made (i) within the cortex, strongly coupled neural assemblies exist which oscillate at certain frequencies when they are active, (ii) several such assemblies can oscillate at a time, and (iii) activity flow between assemblies is minimal. If these assumptions are made, cortical activity can be considered as the weighted sum of a finite number of oscillations (plus noise). It is shown that the correlation dimension of finite time series generated by multiple oscillators increases monotonically with the number of oscillators. Furthermore, it is shown that a reliable estimate of the pointwise dimension of the raw EEG signal can be calculated from a time series as short as a few seconds. These results indicate that (i) The pointwise dimension of the EEG allows conclusions regarding the number of independently oscillating networks in the cortex, and (ii) a reliable estimate of the pointwise dimension of the EEG is possible on the basis of short raw signals. Received: 1 September 1994/Accepted in revised form: 16 May 1995     

Fractal dimension in human cerebellum measured by magnetic resonance imaging

Fractal dimension has been used to quantify the structures of a wide range of objects in biology and medicine. We measured fractal dimension of human cerebellum (CB) in magnetic resonance images of 24 healthy young subjects (12 men and 12 women). CB images were resampled to a series of image sets with different 3D resolutions. At each resolution, the skeleton of the CB white matter was obtained and the number of pixels belonging to the skeleton was determined. Fractal dimension of the CB skeleton was calculated using the box-counting method. The results indicated that the CB skeleton is a highly fractal structure, with a fractal dimension of 2.57 +/- 0.01. No significant difference in the CB fractal dimension was observed between men and women.     

Fractal analysis reveals reduced complexity of retinal vessels in CADASIL

The Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) affects mainly small cerebral arteries and leads to disability and dementia. The relationship between clinical expression of the disease and progression of the microvessel pathology is, however, uncertain as we lack tools for imaging brain vessels in vivo. Ophthalmoscopy is regarded as a window into the cerebral microcirculation. In this study we carried out an ophthalmoscopic examination in subjects with CADASIL. Specifically, we performed fractal analysis of digital retinal photographs. Data are expressed as mean fractal dimension (mean-D), a parameter that reflects complexity of the retinal vessel branching. Ten subjects with genetically confirmed diagnosis of CADASIL and 10 sex and age-matched control subjects were enrolled. Fractal analysis of retinal digital images was performed by means of a computer-based program, and the data expressed as mean-D. Brain MRI lesion volume in FLAIR and T1-weighted images was assessed using MIPAV software. Paired t-test was used to disclose differences in mean-D between CADASIL and control groups. Spearman rank analysis was performed to evaluate potential associations between mean-D values and both disease duration and disease severity, the latter expressed as brain MRI lesion volumes, in the subjects with CADASIL. The results showed that mean-D value of patients (1.42±0.05; mean±SD) was lower than control (1.50±0.04; p = 0.002). Mean-D did not correlate with disease duration nor with MRI lesion volumes of the subjects with CADASIL. The findings suggest that fractal analysis is a sensitive tool to assess changes of retinal vessel branching, likely reflecting early brain microvessel alterations, in CADASIL patients.     

Fractal and spectral dimension analysis of liver fibrosis in needle biopsy specimens

OBJECTIVE: To evaluate the usefulness of a reliable and reproducible mathematical scoring system based on fractal geometry for quantifying the irregular pattern in fibrosis commonly seen in liver biopsy specimens from chronic liver diseases. STUDY DESIGN: The study used 26 standard liver biopsy specimens obtained from patients with chronic hepatitis C virus-related liver disease. The degree of fibrosis in each specimen was estimated using a quantitative scoring system based on the computer-assisted evaluation of both the fractal and spectral dimensions of deposited collagen. The fractal dimension was then compared with the percent area of collagen measured using an image analysis system. RESULTS: The fractional dimension of its irregular shape defines fibrosis as a natural fractal structure. The complex distribution of its collagenous components (unmeasurable by means of the usual morphometric parameters) can be optimally quantified using a single numerical score that seems to be a better alternative to the semiquantitative methods adopted so far. The proposed method is reproducible, rapid and inexpensive; furthermore, supported by specific software, its mathematical approach excludes subjectivity and eliminates the external factors capable of influencing staging and classification. CONCLUSION: This study demonstrated that it is possible to quantify the irregularity of the structures of the liver in an objective manner and that the box-counting fractal dimension does not depend on the amount of collagen deposited on the slide. Furthermore, as has been found in other fields of investigation, study of the fractal properties of the liver is likely to reveal more about its structure and the pathogenesis of liver diseases.