Capillary malformation-arteriovenous malformation, a new clinical and genetic disorder caused by RASA1 mutations

Capillary malformation (CM), or "port-wine stain," is a common cutaneous vascular anomaly that initially appears as a red macular stain that darkens over years. CM also occurs in several combined vascular anomalies that exhibit hypertrophy, such as Sturge-Weber syndrome, Klippel-Trenaunay syndrome, and Parkes Weber syndrome. Occasional familial segregation of CM suggests that there is genetic susceptibility, underscored by the identification of a large locus, CMC1, on chromosome 5q. We used genetic fine mapping with polymorphic markers to reduce the size of the CMC1 locus. A positional candidate gene, RASA1, encoding p120-RasGAP, was screened for mutations in 17 families. Heterozygous inactivating RASA1 mutations were detected in six families manifesting atypical CMs that were multiple, small, round to oval in shape, and pinkish red in color. In addition to CM, either arteriovenous malformation, arteriovenous fistula, or Parkes Weber syndrome was documented in all the families with a mutation. We named this newly identified association caused by RASA1 mutations "CM-AVM," for capillary malformation-arteriovenous malformation. The phenotypic variability can be explained by the involvement of p120-RasGAP in signaling for various growth factor receptors that control proliferation, migration, and survival of several cell types, including vascular endothelial cells.     

Histologic change of arteriovenous malformations of the face and scalp after free flap transfer

In three patients with long-standing vascular malformations of the face and scalp, radial forearm free flaps were transferred after a near-total excision of the lesion. All patients had typical high-flow malformations with thrill and bruit. The onset and progression of the malformations were analyzed through clinical and histologic studies. After free flap transfer, the vascular malformations were followed up grossly and histologically for between 4 and 9 years. There was no recurrence of arteriovenous malformation after free flap transfer. The portion of the residual lesion adjacent to the transferred free flap disappeared, and the remaining discoloration also vanished grossly. Histologic comparison of immediate postoperative and 4-month postoperative specimens from the margin and residual lesion using Victoria blue staining showed that the typical preoperative findings for arteriovenous malformation-an intermingling of thick-walled vessels with abundant elastic fibers and thin-walled vessels without elastic fibers-had undergone change, resulting in the disappearance of the thick-walled vessels and leaving only homogeneous, thin-walled vasculature. The highly vascularized free flap, which does not contain abnormal fistulas, impacted the histologic change of the arteriovenous malformation by blocking the vicious cycle of ischemia and anatomic replacement of disfigured skin and subcutaneous tissues.     

Update on the molecular genetics of vascular anomalies

Genetic factors play a critical role in the pathogenesis of vascular anomalies. Significant advances have been made in recent years in identifying the genetic and molecular determinants of a variety of vascular anomalies using a molecular genetic approach. Several genes for vascular anomalies have been identified. These genes include AGGF1 for Klippel-Trenaunay syndrome, RASA1 for capillary malformations, KRIT1, MGC4607, PDCD10 for cerebral cavernous malformations, glomulin for glomuvenous malformations, TIE2 for multiple cutaneous and mucosal venous malformations, VEGFR-3, FOXC2, NEMO, SOX18 for lymphedema or related syndromes, ENG, ACVRLK1, MADH4 for HHT or related syndromes, NDP for Coats' disease, Notch3 for CADASIL, and PTEN for Proteus Syndrome. These findings have made genetic testing possible in some clinical cases, and may lead to the development of therapeutic strategies for vascular anomalies. Furthermore, these studies have identified critical genes involved in vascular morphogenesis, and provided fundamental understanding of the molecular mechanisms underlying vasculogenesis and angiogenesis.     

Vascular malformations

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the nomenclature and classification system of vascular malformations. 2. Evaluate these patients diagnostically. 3. Outline the surgical and nonsurgical options for treating these lesions. SUMMARY: Vascular anomalies can be classified into two unique groups-hemangiomas and vascular malformations-based on their endothelial properties. The present review focuses on vascular malformations rather than hemangiomas. The authors address capillary malformations, lymphatic malformations, venous malformations, and arteriovenous malformations. Diagnostic and therapeutic modalities are discussed with relevant case examples. A MEDLINE search was performed to gather all pertinent references. The physician treating these challenging lesions should ideally use a multidisciplinary team-based approach with multispecialty experience in diagnostic and therapeutic modalities for the management of vascular malformations.     

A locus for hereditary capillary malformations mapped on chromosome 5q

Capillary malformations (port-wine stains) are the most common vascular malformations occurring in 0.3% of live births. Most capillary malformations occur sporadically and present as a solitary lesion. Capillary malformations can also occur as a component of well-described syndromes. Familial occurrence of multiple capillary malformations has been described in the literature, suggesting autosomal dominant inheritance with variable expression in this subgroup. A hereditary basis underlying the development of solitary capillary malformations has not been found, but may well be possible. We have mapped a locus for an autosomal dominant disorder in a three-generation family that manifested itself with multiple cutaneous capillary malformations to chromosome 5q13-22. This locus spans 48 cM between the markers D5S647 and D5S659 and harbours several candidate genes. By defining the gene(s) responsible for capillary malformations, we will gain more insight in the pathogenesis of this disorder. It is likely that genes implicated in these familial cases may be involved in the more sporadic cases.     

Use of magnetic resonance imaging for the evaluation of vascular malformations of the lower extremity

Vascular malformations are anatomically subdivided according to the predominant channel anomaly into either capillary, arterial, venous, lymphatic, or combinations. They can be further subdivided into high- or low-flow malformations. Any lesion that has an arterial component is considered a high-flow malformation. Once the diagnosis of a vascular malformation is made, it is of paramount importance to define not only the flow characteristics but also the full range of extension, because the prognosis and appropriate treatment vary substantially for each type of anomaly. The two most useful noninvasive imaging techniques for assessing vascular malformations are magnetic resonance imaging (MRI) and ultrasonography. The aim of this review is to give surgeons involved in treating patients with vascular malformations an opportunity to gain some background on MRI scans when assessing vascular malformations. Although MRI is a powerful modality for assessing vascular malformations, we will also discuss some of the limitations of MRI. We further suggest a diagnostic flow chart developed on the basis of MRI features designed to help determine the composition of a vascular birthmark when intervention is anticipated.     

Histologic investigation of vascular malformations of the face after transarterial embolization with ethibloc and other agents

Twenty-one vascular malformations located in the facial area, 11 high-flow arteriovenous malformations and 10 slow-flow malformations, underwent combined treatment by embolization and later surgery. Embolization was performed simultaneously with superselective angiography of the branches of the external carotid artery. The new biodegradable fibrosing agent Ethibloc was used in 16 cases. Histologic examination of the surgical specimens confirmed the good target orientation by the transarterial injection of Ethibloc. Limitations of this technique are discussed. The agent proved to have thrombogenic and fibrogenic properties. Some of the vascular walls degenerated and ruptured following the embolization, but there were no instances of necrosis of interstitial tissue or skin. Embolization treatment of vascular malformations of the face was not curative, but it facilitated subsequent surgery in all examined cases.     

Magnetic resonance imaging findings of vascular malformations of the lower extremity

Vascular malformations are congenital lesions resulting from a defect during embryogenesis. Magnetic resonance imaging (MRI) is a very effective method for demonstrating detailed information regarding involved structures, extent, and flow characteristics of vascular malformations. In previous MRI studies, most of the emphasis is laid on the difference between high- and low-flow lesions, whereas little detailed information is available about the extent of local tissue involvement. These additional characteristics may influence the approach in treating these malformations and improve understanding of the pathogenesis. We retrospectively reviewed MRI scans of 40 patients with vascular malformations of the lower extremity. Thirty-four patients had low-flow lesions, and six had high-flow lesions. Of the low-flow lesions, 23 patients (67.6 percent) had muscle infiltration, with four of the six high-flow lesions having muscle infiltration. Nine of the 11 male patients (81.8 percent) with low-flow lesions had associated muscle infiltration, in comparison with 14 of the 23 female patients (60.9 percent) with low-flow lesions (p = 0.206). Eighty percent of the vascular malformations located on the thigh with muscle involvement had involvement of the anterior muscle group, whereas 86.6 percent of the patients with a vascular malformation located on the leg and with associated muscle involvement had at least the posterior muscle group involved (p = 0.0049). Ten patients (25 percent) of the whole group had bone infiltration. Low-flow lesions often had multifocal lesions (20.6 percent), whereas associated muscle atrophy was visible in 10 low-flow lesions and in two high-flow lesions. In low-flow lesions with muscle infiltration (n = 23), 43 percent (n = 10) had associated surrounding muscle atrophy (p = 0.009). Hypertrophy of the subcutaneous tissue was visible in 11 low-flow patients (32.4 percent). The high amount of muscle and bone involvement in vascular malformations of the lower extremity is emphasized with this study. Of particular interest was the difference in affected muscle groups. The angiosome concept is used to explain this preponderance, and we feel the angiosome concept could also be used when assessing possible intervention. The surrounding muscle atrophy and multifocal nature of these anomalies are further important considerations when assessing the possibility of intervention.     

miR-382-3p靶向RASA1基因调控骨关节炎软骨细胞增殖和凋亡

目的:探讨mi R-382-3p对骨关节炎软骨细胞增殖和凋亡的影响及其机制。方法:用100 ng/mL的脂多糖(LPS)处理软骨细胞,记为LPS组,以正常培养的软骨细胞作为正常对照(NC)组。mi R-NC、mi R-382-3p、anti-miR-NC、anti-miR-382-3p转染至软骨细胞中,记为mi R-NC组、mi R-382-3p组、anti-miR-NC组、anti-miR-382-3p组;将mi R-NC、mi R-382-3p、si-NC、si-RASA1转染至软骨细胞后再用100 ng/mL的LPS处理,记为mi R-NC+LPS组、mi R-382-3p+LPS组、si-NC+LPS组、si-RASA1+LPS组;将mi R-382-3p分别与pcDNA-NC、pcDNA-RASA1共转染至软骨细胞后再用100 ng/mL的LPS处理,记为mi R-382-3p+pcDNA-NC+LPS组、mi R-382-3p+pcDNA-RASA1+LPS组。实时荧光定量PCR(RT-qPCR)检测mi R-382-3p和Ras p21蛋白活化因子1(RASA1)m RNA表达水平;蛋白质印迹(Western blot)法检测RASA1、细胞周期蛋白D1(CyclinD1)、裂解的半胱氨酸天冬氨酸蛋白酶-3(Cleaved-caspase-3)蛋白表达;四甲基偶氮唑盐比色法(MTT)检测细胞存活率;流式细胞术检测细胞凋亡;荧光素酶报告实验检测mi R-382-3p和RASA1的靶向关系。结果:LPS诱导的软骨细胞中mi R-382-3p表达水平显著降低,RASA1表达水平显著升高,CyclinD1表达水平显著降低,Cleaved-caspase-3表达水平显著升高,细胞存活率显著降低,细胞凋亡率显著升高(P0.05)。过表达mi R-382-3p和敲减RASA1,LPS诱导的软骨细胞中CyclinD1表达水平显著升高,Cleaved-caspase-3表达水平显著降低,细胞存活率显著升高,细胞凋亡率显著降低(P0.05)。mi R-382-3p靶向调控RASA1,高表达RASA1部分逆转了mi R-382-3p高表达对LPS处理的软骨细胞增殖和凋亡的影响。结论:过表达mi R-382-3p促进软骨细胞增殖,抑制LPS诱导的软骨细胞凋亡,其机制可能与RASA1有关。     

Coronary artery embryogenesis in cardiac defects induced by retinoic acid in mice

BACKGROUND: Although normal coronary artery embryogenesis is well described in the literature, little is known about the development of coronary vessels in abnormal hearts. METHODS: We used an animal model of retinoic acid (RA)-evoked outflow tract malformations (e.g., double outlet right ventricle [DORV], transposition of the great arteries [TGA], and common truncus arteriosus [CTA]) to study the embryogenesis of coronary arteries using endothelial cell markers (anti-PECAM-1 antibodies and Griffonia simplicifolia I (GSI) lectin). These markers were applied to serial sections of staged mouse hearts to demonstrate the location of coronary artery primordia. RESULTS: In malformations with a dextropositioned aorta, the shape of the peritruncal plexus, from which the coronary arteries develop, differed from that of control hearts. This difference in the shape of the early capillary plexus in the control and RA-treated hearts depends on the position of the aorta relative to the pulmonary trunk. In both normal and RA-treated hearts, there are several capillary penetrations to each aortic sinus facing the pulmonary trunk, but eventually only 1 coronary artery establishes patency with 1 aortic sinus. CONCLUSIONS: The abnormal location of the vessel primordia induces defective courses of coronary arteries; creates fistulas, a single coronary artery, and dilated vessel lumens; and leaves certain areas of the heart devoid of coronary artery branches. RA-evoked heart malformations may be a useful model for elucidating abnormal patterns of coronary artery development and may shed some light on the angiogenesis of coronary artery formation.     

The role of magnetic resonance imaging in the management of vascular malformations of the trunk and extremities

Vascular malformations can usually be diagnosed on clinical grounds. They have a well-defined appearance on magnetic resonance imaging, which can effectively determine their tissue and flow characteristics. However, the role of cross-sectional imaging in the management of vascular malformations is not well defined. Most reviews suggest that magnetic resonance imaging should be reserved for cases in which the extent of the lesion cannot be estimated on physical examination. However, to date no group has compared the accuracy of physical examination alone to that of magnetic resonance imaging in determining this extent. A review was performed of all the patients evaluated for vascular malformations at the New York University Trunk and Extremity Vascular Anomalies Conference between July of 1994 and August of 1999. Patients who underwent magnetic resonance evaluation at other institutions and whose images were not available for review were excluded. All study patients either underwent magnetic resonance imaging examination at New York University Medical Center or had outside films reviewed at the center. The physical examination findings were compared with the magnetic resonance findings and the surgeon and radiologist made a joint decision about whether there was a correlation between the magnetic resonance and physical examination findings. Fifty-eight patients met the study criteria, 44 (76 percent) of whom were found to have more extensive disease on magnetic resonance examination than appreciated on physical examination. Of the 51 patients with low-flow vascular malformations (venous vascular malformations, lymphatic malformations, and capillary malformations), 39 (76 percent) had more extensive disease on magnetic resonance examination than on physical examination. Of the seven patients with high-flow arteriovenous malformations, five had more extensive disease on magnetic resonance. In all of the 44 patients whose magnetic resonance imaging findings did not correlate with those of the physical examination, therapeutic decision making was affected. Contrary to the conventional wisdom of published reviews, physical examination findings significantly underestimated the extent of vascular malformations in the majority of cases. Magnetic resonance imaging should be performed in all patients with vascular malformations of the trunk and extremities before therapy is planned. In an age when physicians are asked to justify their decisions, especially where the use of expensive diagnostic modalities is concerned, the situations in which these tests are indispensable must be clearly defined or else patients will be denied access to them.     

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.     

Notch1 activation in mice causes arteriovenous malformations phenocopied by ephrinB2 and EphB4 mutants

Notch signaling is essential for embryonic vascular development in mammals and other vertebrates. Here we show that mouse embryos with conditional activation of the Notch1 gene in endothelial cells (Notch1 gain of function embryos) exhibit defects in vascular remodeling increased diameter of the dorsal aortae, and form arteriovenous malformations. Conversely, embryos with either constitutive or endothelial cell‐specific Notch1 gene deletion also have vascular defects, but exhibit decreased diameter of the dorsal aortae and form arteriovenous malformations distinctly different from the Notch1 gain of function mutants. Surprisingly, embryos homozygous for mutations of the ephrinB/EphB pathway genes Efnb2 and Ephb4 exhibit vascular defects and arteriovenous malformations that phenocopy the Notch1 gain of function mutants. These results suggest that formation of arteriovenous malformations in Notch1 gain of function mutants and ephrinB/EphB pathway loss of function mutant embryos occurs by different mechanisms. genesis 48:146–150, 2010. © 2010 Wiley‐Liss, Inc.     

Interventional neuroradiology.

A wide variety of diseases affecting the central nervous system and head and neck can be treated using interventional neuroradiologic techniques. These new treatments have depended on advances in radiologic imaging, catheter technology, and the development of new embolic agents. These procedures may be an adjunct to other therapy, palliative or curative. Diseases for which interventional neuroradiologic techniques have been major advances in treatment include cerebral aneurysms, vasospasm after subarachnoid hemorrhage, cerebral arteriovenous malformations, dural arteriovenous fistulas, dural sinus thrombosis, atherosclerosis, scalp arteriovenous fistulas, carotid-cavernous fistulas, and stroke. This field is rapidly evolving as advances are made in catheter technology and new embolic agents are developed.     

Mutations in a novel factor, glomulin, are responsible for glomuvenous malformations ("glomangiomas")

Glomuvenous malformations (GVMs) are cutaneous venous lesions characterized by the presence of smooth-muscle--like glomus cells in the media surrounding distended vascular lumens. We have shown that heritable GVMs link to a 4--6-cM region in chromosome 1p21-22. We also identified linkage disequilibrium that allowed a narrowing of this VMGLOM locus to 1.48 Mb. Herein, we report the identification of the mutated gene, glomulin, localized on the basis of the YAC and PAC maps. An incomplete cDNA sequence for glomulin had previously been designated "FAP48," for "FKBP-associated protein of 48 kD." The complete cDNA for glomulin contains an open reading frame of 1,785 nt encoding a predicted protein of 68 kD. The gene consists of 19 exons in which we identified 14 different germline mutations in patients with GVM. In addition, we found a somatic "second hit" mutation in affected tissue of a patient with an inherited genomic deletion. Since all but one of the mutations result in premature stop codons, and since the localized nature of the lesions could be explained by Knudson's two-hit model, GVMs are likely caused by complete loss of function of glomulin. The abnormal phenotype of vascular smooth-muscle cells (VSMCs) in GVMs suggests that glomulin plays an important role in differentiation of these cells--and, thereby, in vascular morphogenesis--especially in cutaneous veins.     

Generation of mice with a conditional allele of the p120 Ras GTPase-activating protein

p120 Ras GTPase-activating protein (RasGAP) encoded by the rasa1 gene in mice is a prototypical member of the RasGAP family of proteins involved in negative-regulation of the p21 Ras proto-oncogene. RasGAP has been implicated in signal transduction through a number of cell surface receptors. In humans, inactivating mutations in the coding region of the RASA1 gene cause capillary malformation arteriovenous malformation. In mice, generalized disruption of the rasa1 gene results in early embryonic lethality associated with defective vasculogenesis and increased apoptosis of neuronal cells. The early lethality in this mouse model precludes its use to further study the importance of RasGAP as a regulator of cell function. Therefore, to circumvent this problem, we have generated a conditional rasa1 knockout mouse. In this mouse, an exon that encodes a part of the RasGAP protein essential for catalytic activity has been flanked by loxP recognition sites. With the use of different constitutive and inducible Cre transgenic mouse lines, we show that deletion of this exon from the rasa1 locus results in effective loss of expression of catalytically-active RasGAP from a variety of adult tissues. The conditional rasa1 mouse will be useful for the analysis of the role of RasGAP in mature cell types.     

Endoglin is expressed in the chicken vasculature and is involved in angiogenesis.

Endoglin is a component of the transforming growth factor beta (TGF-beta) receptor complex, highly expressed by endothelial cells. Mutations in the endoglin gene are responsible for hereditary hemorrhagic telangiectasia type 1 (HHT1), an autosomal dominant vascular disorder caused by a haploinsufficiency mechanism. Vascular lesions (telangiectasia and arteriovenous malformations) in HHT1 are associated with loss of the capillary network, suggesting the involvement of endoglin in vascular repair processes. Using the chick chorioallantoic membrane (CAM) as an angiogenic model, we have analyzed the expression and function of chicken endoglin. A pan-specific polyclonal antibody (pAb) recognized chicken endoglin as demonstrated by immunostaining and Western blot analysis. In ovo treatment of chicken embryos with this pAb resulted in a significantly increased area of CAM. This effect was likely mediated by modulation of the ligand binding to endoglin as this pAb was able to inhibit TGF-beta1 binding. These results support the involvement of endoglin in the angiogenic process.     

Increased tissue perfusion promotes capillary dysplasia in the ALK1-deficient mouse brain following VEGF stimulation

Loss-of-function activin receptor-like kinase 1 gene mutation (ALK1+/-) is associated with brain arteriovenous malformations (AVM) in hereditary hemorrhagic telangiectasia type 2. Other determinants of the lesional phenotype are unknown. In the present study, we investigated the influence of high vascular flow rates on ALK1+/- mice by manipulating cerebral blood flow (CBF) using vasodilators. Adult male ALK1+/- mice underwent adeno-associated viral-mediated vascular endothelial growth factor (AAVVEGF) or lacZ (AAVlacZ as a control) gene transfer into the brain. Two weeks after vector injection, hydralazine or nicardipine was infused intraventricularly for another 14 days. CBF was measured to evaluate relative tissue perfusion. We analyzed the number and morphology of capillaries. Results demonstrated that hydralazine or nicardipine infusion increased focal brain perfusion in all mice. It was noted that focal CBF increased most in AAVVEGF-injected ALK1+/- mice following hydralazine or nicardipine infusion (145+/-23% or 150+/-11%; P<0.05). There were more detectable dilated and dysplastic capillaries (2.4+/-0.3 or 2.0+/-0.4 dysplasia index; P<0.01) in the brains of ALK1+/- mice treated with AAVVEGF and hydralazine or nicardipine compared with the mice treated with them individually. We concluded that increased focal tissue perfusion and angiogenic factor VEGF stimulation could have a synergistic effect to promote capillary dysplasia in a genetic deficit animal model, which may have relevance to further studies of AVMs.     

Skeletal changes associated with vascular malformations

Five hundred and eighty birthmarks were reviewed; 356 were hemangiomas and 224 were malformations. Bony alterations occurred in association with only 1 percent of hemangiomas, in contrast with 34 percent of patients with vascular malformations. These alterations in bone development were classified according to size, shape, and density changes. Hypertrophy and distortion were typical of lymphatic malformations. Hypoplasia and demineralization were characteristic findings in the extremity venous malformations. Destructive and intraosseous changes were more commonly noted in the arterial or high-flow lesions. Possible mechanisms of altered skeletal growth include mechanical, physiological, and developmental processes.     

A role for p120 RasGAP in thymocyte positive selection and survival of naive T cells

Activation of the Ras small GTP-binding protein is necessary for normal T cell development and function. However, it is unknown which Ras GTPase-activating proteins (RasGAPs) inactivate Ras in T cells. We used a T cell-specific RASA1-deficient mouse model to investigate the role of the p120 RasGAP (RASA1) in T cells. Death of CD4(+)CD8(+) double-positive thymocytes was increased in RASA1-deficient mice. Despite this finding, on an MHC class II-restricted TCR transgenic background, evidence was obtained for increased positive selection of thymocytes associated with augmented activation of the Ras-MAPK pathway. In the periphery, RASA1 was found to be dispensable as a regulator of Ras-MAPK activation and T cell functional responses induced by full agonist peptides. However, numbers of naive T cells were substantially reduced in RASA1-deficient mice. Loss of naive T cells in the absence of RASA1 could be attributed in part to impaired responsiveness to the IL-7 prosurvival cytokine. These findings reveal an important role for RASA1 as a regulator of double-positive survival and positive selection in the thymus as well as naive T cell survival in the periphery.