Infantile Hemangioma: Case Discussion

Today, at early morning, we admitted a case of infantile hemangioma to our pediatrics intensive care unit for respiratory and hemodynamic monitoring in the setting of possible ongoing airway obstruction. She's a 2 months old girl who was born with a small red lesion on her right cheek which progressed over the last few weeks. Now, she has multiple vascular lesions on both cheeks, right eyelids, forehead, nose bridge, and neck. She presented with acute onset, moderate-in-severity stridor.

The differential diagnosis of stridor at this age is wide, but in the setting of these multiple hemagiomas on the head and neck, a vascular lesion that is compressing the airway was high on the list. So, we did a CT head and neck with contrast.

The pictures showed:

• Subglottic hemangioma
• Bilateral parotid glands hemangiomas
• Right orbital hemangioma
• Small arterio-venous malformation (AVM) arising from the anterior cerebral artery
• Possible stenotic carotic arteries

Evaluation and Management

In ER setting, we should be alert that the mild or moderate stridor caused by possible hemangioma in the airway or surrounding it could deteroriate suddenly. The intubation and tracheostomy set should be at bedside. Continous respiratory monitoring should be done (esp pulse oxemetry). Pateint should be started on systemic glucocorticoids. We started dexamethasone at 2 mg/kg/day and nebulized epinephrine to decrease the airway edema. The stridor disappeared after the first few doses of dexamethasone and epinephrine. Further workup will include:

• MR arteriogram, MR venography, and brain MRI with contrast: to look for AV malformations, stenotic carotid arteries and the brain parenchyma more accurately. 
• ENT consultation: they recommended to continue dexamethasone and to follow her up in the clinic in one week.
• Neurosurgical consultation: for their suggestions about the management of AV malformations
• Opthalmology consultation: to rule out other ocular malformations in the view of the right ocular hemangioma

Propranolol

Propranolol, a nonselective beta-blocker, inhibits the growth of infantile hemangiomas. Potential mechanisms of action for propranolol include vasoconstriction, decreased expression of vascular endothelial growth factor and basic fibroblast growth factor, and/or triggering of apoptosis. It's  a very effective medication in infantile hemangiomas BUT, what about its use in our case?

We know that we have a possible bilateral stenotic carotid arteries which could lead to  decreased blood flow to the brain. If we start propranolol at its usual dose now, this could result in ischemic strokes in the brain because it could cause a vasoconstricion on the already stenotic carotid arteries. So, we elected to delay the use of propranolol until we have the MR arteriogram tomorrow. We could start it at a 25% of the usual dose used for infantile hamangioma and then gradually increase the dose if tolerated. I think it's better to start it in the hospital to monitor for any side effects. Propranolol also needs a cardiology clearance.

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Typed few months ago