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Classification of
congenital vascular
lesions
Prior to 1980, the study of the
congenital vascular lesions was in a
state of confusion.
In 1982, Mulliken and Glowacki
introduced a biological classification.
This classification recognized two
distinct entities, hemangioma
&vascular malformation.
• Hemangioma:Are usually not present at birth
(30% may be present or may appear many
days later) .
• Proliferate during the first year of life and then
involutes.
• The endothelial cells, responsible for this
proliferation show high rate of epithelial
turnover during this period.
Vascular malformation on the other
hand are always present at birth
,never proliferate nor involutes.The
rate of epithelial turnover is normal.
Hemangiomas
• May be present in any organ, but the vast
majority are found in or just deep to skin or
mucous membrane.
• Hemangioma that originate in the papillary
dermis usually stretch skin and present as
bright red macular mass or papular.It was
called Straw berry or capillary hemangioma.
Hemangiomas present within the
reticular dermis or subcutaneous tissue
may also stretch skin but may appear
bluish hue or colorless
It was called
Cavernous hemangioma.
The lesion contains both types was
termed capillary cavernous
hemangioma.
The new terminology include
Straw berry or capillary
hemangiomaSuperficial
hemangioma
Cavernous hemangioma Deep
hemangioma
Capillary cavernous Compound
hemangioma.
Histology
• During proliferation ,lesion is formed from tubules of
plump proliferating endothelial cells.
• At the end of proliferation must cells become more
abundant and endothelial cells less active.
• During involution lesion is formed from flat inactive
endothelial cells surrounding large ectatic vascular
channels in matrix of fibroepithelial tissues.In this
phase it is similar in shape to vascular malformation.
Vascular malformation
• Always present at birth (may or may not appear).
• Not proliferate nor involutes,but slow and
continuous expansion occurs during life.
• The diameters of the constituent vessels increase not
their number.
• It expands by hypertrophy (enlargement due to
increase in size(hemangioma enlarges by hyperplasia
i.e.increase in cell number).
Vascular malformations
• Venous malformation
• Venular malformation
• Artriovenous (capillary)
• Lymphatic
• Mixedvenous-lymphatic
• venous- venular
Venous malformation
• Superficial or deep
• Localized or diffuse
• Unilocular or multilocular
• Superficial lesions tends to expand toward mucous
membrane or skin and appear purple in color
• Deep lesions are blue in color
• Generally , soft,compressible,expand with raised
venous pressure.Bleeding is common with minor
trauma.
Venular malformation
• Early pediatric,port wine stains .Pink ,macular ,
dermal vascular malformation.Involving one or more
sensory dermatosis. If affect second or third branch
of trigeminal nerve ,oral manifistations usually
appears (May affect mandible,maxilla or only
covering gingiva.
Lymphatic malformations
• May be localized or diffuse,superficial or deep,
microcystic or macrocystic.
• Coetaneous or mucosal involvement manifests
as multiple small vesicle filled with lymph(may
coordinate with deep lesion).
Artriovenous malformation
• May appear later in life during the fourth or
even fifth decade of life .The nidus of
artriovenous malformation usually palpable as
a firm subcutaneous mass often warmer than
surrounding tissues.
Diagnosis
Clinical approach
• Was it present at birthyes(vm)
• no(h)
• Has it in size During 1st year yes(h)
• no(vm)
• Has itin size yes(h)
• no(vm)
• Computerized Tomography(C.T)
• C.T with contrast –enhanced scans are useful
in evaluating artriovenous lesions
• Can determine the extension of the lesion.
• With contrast we can differentiate between
high and low flow lesions.
Magnetic resonance imaging(MRI)
• The best technique to determine the extent of the
lesion.
• Can differentiation between hemangiomas
(intermediate signal on T1 and high signal intensity at
T2.
• Arteriovenous malformation display intermediate
single intensity on T2.
• Venous malformations display low single intensity on
T1 and high intensity on T2
Angiography
• This technique manly used after reaching final
diagnosis with MRI in case of artriovenous
malformation to map out the blood supply of
the lesion.
Treatment
Diode laser(980nm)
Diode laser(980nm)
Interferon
• Dose not have to be given in proliferating
phase .Its action is very slow.
• High toxicity
• May cause dermal necrosis
Steroids
• As prednisone may be given systemically or
intralesional.It affects only proliferating
hemangioma.Its action by potentiate the
effect of epinephrine and norepinephrin on
vascular smooth muscles
LASERS
• Superficial Lesions
• The vessels may be large,small or
intermediate.
• Small and intermediate respond well to
treatment with flash lamp pumped-dye laser
• Larger vessels are more resistant and require
more energy or time.
Deep hemangiomas
• Apfelberg (1995) developed a technique
whereby the thermal energy generated by
Nd:YAG is used in non specific way to
coagulate deep lesions .
• A bar quartz fiber is introduced inside the
lesion and rise temperature 60Cº-80Cº .
Selective Photothermolysis
• It is a process whereby ectatic blood vessels
are selectively destroyed .
• The term selective implies that there is no
damage to surrounding tissue.
• To do this we need two requirements
• 1-Appropriate wave length
• 2-Appropriate exposure time.
Nonselective photothermolysis
• Ectatic blood vessels in this process not selectively
destroyed(I.e the neighboring structures may be
affected.
• It is used in case of deep lesions and large vessels .
• It may be considered as adjunctive to surgery.
• N.B tissue necrosis will occur due to thermal
conduction rather than optical penetration .
Types of lasers
• 1The continues Argon laser,with 488nm and
514nm wavelengths.has exlent absorbtion by
hemoglobin and skin pigments.Penetration
depth 1.5mm
• Nd:Yag 1064nm coagulate vessels up to 2-
3mm and penetration depth 5-7mm.But may
cause tissue necrosis in surface lesions.
• Q-switched Nd:YAG with short pulse can produce
wave length of 1064nm with less heat production
.and the second harmonic(KTP) with wave length
532nm absorbed well in hemoglobin and melanin.
• Dye lasers , emit many wave lengths as 510nm(for
pigmented lesions)and 577nm,585nm with super
selective absorption by vascular tissues.
• Diode lasers .Provides good hemostasis,depth of
penetration 2-3mm according to wave length.
Thank you

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د حاتم البيطار استشاري وجراح الفم والاسنان 01005684344 اتصل للحجز بالعيادة Dr.Hatem EL-Bitar

  • 1.
  • 2. Classification of congenital vascular lesions Prior to 1980, the study of the congenital vascular lesions was in a state of confusion.
  • 3. In 1982, Mulliken and Glowacki introduced a biological classification. This classification recognized two distinct entities, hemangioma &vascular malformation.
  • 4. • Hemangioma:Are usually not present at birth (30% may be present or may appear many days later) . • Proliferate during the first year of life and then involutes. • The endothelial cells, responsible for this proliferation show high rate of epithelial turnover during this period.
  • 5. Vascular malformation on the other hand are always present at birth ,never proliferate nor involutes.The rate of epithelial turnover is normal.
  • 6. Hemangiomas • May be present in any organ, but the vast majority are found in or just deep to skin or mucous membrane. • Hemangioma that originate in the papillary dermis usually stretch skin and present as bright red macular mass or papular.It was called Straw berry or capillary hemangioma.
  • 7. Hemangiomas present within the reticular dermis or subcutaneous tissue may also stretch skin but may appear bluish hue or colorless It was called Cavernous hemangioma. The lesion contains both types was termed capillary cavernous hemangioma.
  • 8. The new terminology include Straw berry or capillary hemangiomaSuperficial hemangioma Cavernous hemangioma Deep hemangioma Capillary cavernous Compound hemangioma.
  • 9. Histology • During proliferation ,lesion is formed from tubules of plump proliferating endothelial cells. • At the end of proliferation must cells become more abundant and endothelial cells less active. • During involution lesion is formed from flat inactive endothelial cells surrounding large ectatic vascular channels in matrix of fibroepithelial tissues.In this phase it is similar in shape to vascular malformation.
  • 10. Vascular malformation • Always present at birth (may or may not appear). • Not proliferate nor involutes,but slow and continuous expansion occurs during life. • The diameters of the constituent vessels increase not their number. • It expands by hypertrophy (enlargement due to increase in size(hemangioma enlarges by hyperplasia i.e.increase in cell number).
  • 11. Vascular malformations • Venous malformation • Venular malformation • Artriovenous (capillary) • Lymphatic • Mixedvenous-lymphatic • venous- venular
  • 12. Venous malformation • Superficial or deep • Localized or diffuse • Unilocular or multilocular • Superficial lesions tends to expand toward mucous membrane or skin and appear purple in color • Deep lesions are blue in color • Generally , soft,compressible,expand with raised venous pressure.Bleeding is common with minor trauma.
  • 13. Venular malformation • Early pediatric,port wine stains .Pink ,macular , dermal vascular malformation.Involving one or more sensory dermatosis. If affect second or third branch of trigeminal nerve ,oral manifistations usually appears (May affect mandible,maxilla or only covering gingiva.
  • 14. Lymphatic malformations • May be localized or diffuse,superficial or deep, microcystic or macrocystic. • Coetaneous or mucosal involvement manifests as multiple small vesicle filled with lymph(may coordinate with deep lesion).
  • 15. Artriovenous malformation • May appear later in life during the fourth or even fifth decade of life .The nidus of artriovenous malformation usually palpable as a firm subcutaneous mass often warmer than surrounding tissues.
  • 17. Clinical approach • Was it present at birthyes(vm) • no(h) • Has it in size During 1st year yes(h) • no(vm) • Has itin size yes(h) • no(vm)
  • 18. • Computerized Tomography(C.T) • C.T with contrast –enhanced scans are useful in evaluating artriovenous lesions • Can determine the extension of the lesion. • With contrast we can differentiate between high and low flow lesions.
  • 19. Magnetic resonance imaging(MRI) • The best technique to determine the extent of the lesion. • Can differentiation between hemangiomas (intermediate signal on T1 and high signal intensity at T2. • Arteriovenous malformation display intermediate single intensity on T2. • Venous malformations display low single intensity on T1 and high intensity on T2
  • 20. Angiography • This technique manly used after reaching final diagnosis with MRI in case of artriovenous malformation to map out the blood supply of the lesion.
  • 22.
  • 23.
  • 25.
  • 26.
  • 27. Interferon • Dose not have to be given in proliferating phase .Its action is very slow. • High toxicity • May cause dermal necrosis
  • 28.
  • 29. Steroids • As prednisone may be given systemically or intralesional.It affects only proliferating hemangioma.Its action by potentiate the effect of epinephrine and norepinephrin on vascular smooth muscles
  • 30. LASERS • Superficial Lesions • The vessels may be large,small or intermediate. • Small and intermediate respond well to treatment with flash lamp pumped-dye laser • Larger vessels are more resistant and require more energy or time.
  • 31. Deep hemangiomas • Apfelberg (1995) developed a technique whereby the thermal energy generated by Nd:YAG is used in non specific way to coagulate deep lesions . • A bar quartz fiber is introduced inside the lesion and rise temperature 60Cº-80Cº .
  • 32. Selective Photothermolysis • It is a process whereby ectatic blood vessels are selectively destroyed . • The term selective implies that there is no damage to surrounding tissue. • To do this we need two requirements • 1-Appropriate wave length • 2-Appropriate exposure time.
  • 33. Nonselective photothermolysis • Ectatic blood vessels in this process not selectively destroyed(I.e the neighboring structures may be affected. • It is used in case of deep lesions and large vessels . • It may be considered as adjunctive to surgery. • N.B tissue necrosis will occur due to thermal conduction rather than optical penetration .
  • 34. Types of lasers • 1The continues Argon laser,with 488nm and 514nm wavelengths.has exlent absorbtion by hemoglobin and skin pigments.Penetration depth 1.5mm • Nd:Yag 1064nm coagulate vessels up to 2- 3mm and penetration depth 5-7mm.But may cause tissue necrosis in surface lesions.
  • 35. • Q-switched Nd:YAG with short pulse can produce wave length of 1064nm with less heat production .and the second harmonic(KTP) with wave length 532nm absorbed well in hemoglobin and melanin. • Dye lasers , emit many wave lengths as 510nm(for pigmented lesions)and 577nm,585nm with super selective absorption by vascular tissues. • Diode lasers .Provides good hemostasis,depth of penetration 2-3mm according to wave length.