Intracranial Arteriovenous Malformations as a Possible Cause of Endocranial Bone Lesions and Associated Neurological Disorder

Abstract

Endocranial bone lesions have attracted intensive scientific debate on their aetiology. In recent literature, the lesions were almost exclusively interpreted as of infectious origin. In this paper, we give new insight into the aetiology of endocranial lesions, distinguishing the lesions of vascular origin from those caused by tuberculosis or other conditions. The analysis is based on a rare case of a young female individual who displayed multiple endocranial lesions with 'serpens endocrania symmetrica' morphology. The lesions were associated with an uncommon branching pattern of the middle meningeal artery and marked side differences in teeth pathology. Postcranial skeleton showed signs of the left upper limb weakness. The macroscopic finding of the endocranial lesions along with the skeletal evidence of neurological damage, together with characteristic radiological and histological features, can lead to diagnosis of arteriovenous malformations. This study aims to improve understanding of the aetiology of endocranial bone lesions.

Insights into the diagnostic efficacy and macroscopic appearance of endocranial bony changes indicative of tuberculous meningitis: Three example cases from the Robert J. Terry Anatomical Skeletal Collection

“…Although GIs, ABVIs, PAs, and APDIs were used as diagnostic criteria for TBM in a number of paleopathological studies on osteoarchaeological series (e.g., Abegg et al, 2020; Jankauskas, 1999; Lei et al, 2019; Teschler‐Nicola et al, 2015) since the late 20th century, their diagnostic value has been questioned (Janovic et al, 2015; Lewis, 2004; Roberts et al, 2009). As part of a comprehensive research project (Spekker, 2018), 427 human pre‐antibiotic era skeletons from the Robert J. Terry Anatomical Skeletal Collection (Department of Anthropology, National Museum of Natural History, Smithsonian Institution, Washington, DC, USA) were analyzed to evaluate the diagnostic value of the four endocranial alteration types indicative of TBM (i.e., GIs, ABVIs, PAs, and APDIs)—234 individuals who died of TB (TB group) and 193 individuals who died of non‐TB causes (NTB group) (Table S1).…”

Evaluation of endocranial bony changes in relation to tuberculosis in the Robert J. Terry Anatomical Skeletal Collection (Washington, DC, USA)

“…Mariotti et al, 2015; Masson et al, 2015; Molnár et al, 2015; Schultz & Schmidt- were performed on osteoarchaeological series and documented skeletal collections since the late 20 th century that have revealed a positive correlation between different types of tuberculosis (e.g., skeletal TB, pulmonary TB and/or TB pleurisy, and TBM) and subtle bony alterations, including vertebral hypervascularisation, PNBFs on the visceral surface of ribs, and endocranial alterations (i.e., abnormally pronounced digital impressions; periosteal appositions; abnormal blood vessel impressions, including serpens endocrania symmetrica; and granular impressions). However, the diagnostic value of different endocranial alteration types possibly associated with TBM has more recently been questioned (e.g.,Lewis, 2004;Roberts et al, 2009;Janovic et al, 2015), as their precise aetiology is still a matter of controversy, and additionally, similar or even the same morphological features can be found in non-TB-related cases, such as in non-specific inflammatory (e.g., non-specific meningitis) and haemorrhagic (e.g., epidural haematoma) processes.Detailed analysis of well-documented collections of pre-antibiotic era skeletons of known cause of death (e.g., Hamann-Todd Human Osteological Collection, Robert J. Terry Anatomical Skeletal Collection, and Coimbra Identified Skeletal Collection) can serve as a unique and important basis for determining the appropriate palaeopathological diagnostic criteria for TB in past human populations, since bone remains of specimens identified to have died of tuberculosis and not treated with antibiotics may exhibit similar TB-related bony changes to those of observable in skeletons of people lived in the past; in contrast to recent cases with tuberculosis, they can be surveyed not only with medical imaging techniques but also directly with macromorphological methods; and even subtle bony changes can be recognised in them (Santos & Roberts, 2001, 2006; Hunt & Albanese, 2005; Matos & Santos, 2006; Mariotti et al, 2015). In the last three decades, the Terry Collectionhas been used to define and refine palaeopathological diagnostic criteria for tuberculosis in several studies (e.g., Roberts et al, 1994; Winland et al, 1997; Rothschild & Rothschild, 1998, 1999; Pálfi et al, 2012); nevertheless, the possible TBM-associated endocranial alteration types were beyond the scope of the aforementioned research projects.…”

“…modern medical knowledge, palaeopathologists attempt to establish a retrospective diagnosis of prehistoric and historic TB cases by identifying pathological conditions in bone remains of people lived in the past that may be related to tuberculosis (e.g., vertebral changes, rib lesions, and endocranial alterations). However, on the one hand,Roberts et al, 2009;Janovic et al, 2015)…”