Klippel-Trenaunay-Weber Syndrome Associated with Multiple Cerebral Arteriovenous Malformations: Usefulness of Gamma Knife Stereotactic Radiosurgery in This Syndrome

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is characterized by the presence of a combined vascular malformation of capillaries, veins, and lymphatic vessels; congenital venous abnormalities; and limb hypertrophy. Its association with neurovascular abnormalities is infrequent, and the presence of intracranial arteriovenous malformations (AVMs) is extremely rare.

CASE DESCRIPTION

We report a case of a 48-year-old male diagnosed with KTWS who spontaneously presented with a cerebral hemorrhage. Computed tomography scan and angio-computed tomography studies revealed bleeding associated with AVM rupture. In the conventional arteriography study, 10 small (<1 cm) AVMs were observed. The patient presented a good clinical recovery. These multiple small lesions were not considered susceptible to surgical or endovascular treatments. Therefore all lesions were treated with Gamma Knife stereotactic radiosurgery since it attains the highest dose drop and minimal irradiation of the healthy parenchyma. One year after the treatment, the lesions have shrunk.

CONCLUSIONS

Cerebral AVMs are extremely rare in KTWS cases; however, their presence can have serious consequences if they are treated. We find it advisable to include brain imaging tests, such as nuclear magnetic resonance imaging, to diagnose and monitor KTWS. Furthermore, a Gamma Knife may be useful when multiple AVMs are present.

Late puerperal hemorrhage of a patient with Klippel-Trenaunay syndrome: A case report

INTRODUCTION

The Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder. The obstetric course of women with KTS varies. Complications include bleeding, disseminated intravascular coagulation (DIC), thromboembolic events, etc. PATIENT CONCERNS:: Here, we report a case of late puerperal hemorrhage of a Chinese puerpera with KTS. The repeating severe hemorrhage, the DIC, and the Kasabach-Merrit syndrome made the treatment more difficult.

DIAGNOSIS

KTS is a mixed malformation with a vascular component that is characterized by abnormal development of veins, capillaries, and lymphatics. Our patient was first diagnosed with KTS at the last trimester of pregnancy.

INTERVENTIONS

Massive infusion of blood products, two laparotomies, as well as bilateral internal iliac artery embolization was carried out.

OUTCOMES

Although the patient survived from the life-threatening hemorrhage, she lost her uterus forever.

CONCLUSION

An interdisciplinary cooperation of obstetrician, anesthesiologist, vascular surgeon, and intensive care physician is highly recommended. Prophylactic anticoagulation is generally advised in the gestational and postpartum period.

Prehepatic portal hypertension of a vascular origin: Klippel-Trenaunay syndrome

Female of 17 years-old with Klippel-Trenaunay syndrome: port-wine stain, overgrowth of bone and soft tissue in limbs, dental malposition and intellectual disability. Moreover, severe portal hypertension due to portal vein malformation. The Klippel-Trenaunay syndrome includes venous and capillary malformations in the skin, hypertrophy of bones and soft tissue in a limb and, in some patients, lymphatic malformations. Structural abnormalities of the deep venous system can also occur in addition to the key clinical features, although there are few case reports with portal hypertension due to portal vein malformation published.

Multimodality imaging approach in a patient with Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder presenting with asymmetric limb hypertrophy, cutaneous capillary malformations and lower extremity varicosities. We discuss a 27-year-old man born with varicosities on both lower extremities, which progressively enlarged. Physical examination showed a grossly enlarged right hand. There were multiple compressible varicosities, diffuse port-wine stains on the right leg and limb-length discrepancy on the left leg. CT angiogram and Doppler ultrasound revealed several venous varicosities. Ectatic veins in the right leg converge into the lateral marginal vein of Servelle, an embryonic vein, typically seen in KTS patients. KTS is diagnosed clinically and imaging plays a role in differentiating this from other disease entities that present similarly. Doppler ultrasound is the initial imaging of choice to characterise varicosities and to identify thrombosis and reflux. Plain radiographs confirm limb hypertrophy. MRI and CT angiograms are useful to evaluate vascular anomalies and its accompanying soft tissue changes.

Penile prosthesis implant for primary erectile dysfunction in patient with Klippel-Trenaunay syndrome complicated by consumptive coagulopathy: A case report

RATIONALE

Klippel-Trenaunay syndrome (KTS) is a congenital disorder characterized by cutaneous port wine capillary malformations, varicose veins with hemihypertrophy of soft tissue and bone.Pelvic and retroperitoneal vascular malformations have been described up to the 30% of patients with KTS while hemangiomas of the urinary tract have been reported in 6% PATIENT CONCERNS:: A 30-year-old man with KTS was referred to our center for primary erectile dysfunction (ED) associated with varicosities of unusual distribution and asymmetry of the lower limbs. Furthermore, he suffered from hypertension and autosomal dominant polycystic kidney disease.During penile prosthesis implantation, a significant intraoperative bleeding (1 liter) due to large scrotal venous malformations and profuse bleeding from both corpora was recorded. One month later, the day after the first prosthesis training session, the patient returned with swelling in the penoscrotal region. A large inguino-scrotal hematoma was drained. There was a complete bilateral dehiscence of corpora cavernosa with a spread venous bleeding in the scrotum.

DIAGNOSES

CT scan showed hypertrophy of the right hypogastric artery with severe vascular malformations: the right pudendal artery was massively dilated with early visualization of venous drainage without evidence of arteriovenous fistulae; regular bulbocavernous capillary blush; right upper gluteus artery hypertrophic and dilated. Multiple twisting and aneurysms of the right internal pudenda artery were bleeding from multiple points. Cystoscopy showed a fistula between the proximal urethra and the penoscrotal dartos. Coagulation tests revealed the presence of factor XIII deficiency INTERVENTIONS:: The patient underwent several procedures including percutaneous scleroembolization of the internal pudendal arteries, removal of the penile implant, recombinant factor XIII (FXIII) administration, and cord blood platelet gel application.

OUTCOMES

The patient was discharged after almost 3 months in hospital, hemodynamically stable.

LESSONS

Experience regarding management of ED in KTS patient is limited and in case of concomitant factor XIII deficiency, the clinical scenario can be life-threatening. A multidisciplinary approach including a urologist, an interventional radiologist and a hematologist in our experience represented the key approach in case of severe bleeding following surgery for ED.

Klippel-Trenaunay-Weber Syndrome with Atypical Presentation of Cerebral Cavernous Angioma: A Case Report and Literature Review

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare syndrome characterized by the triad of cutaneous hemangiomas, venous varicosities, and osseous-soft tissue hypertrophy of the affected limb. Clinical manifestations, genetic testing, and radiologic imaging are the key steps in diagnosing this syndrome.

CASE DESCRIPTION

An 18-month-old boy was brought for follow-up brain magnetic resonance imaging (MRI) with a history of right lower limb hypertrophy, cutaneous varicosities, and hemangiomas diagnosed at birth. A baseline MRI at 12 months revealed multiple hemorrhagic lesions within the cerebrum, the largest in the right temporal lobe, which was treated surgically at the age of 18 months because of its rapid growth. This is the youngest patient with KTWS treated surgically for intracranial hemangiomas.

CONCLUSION

KTWS is a rare disease with a wide range of manifestations. Multisystemic evaluation of this group of patients should be performed to identify cavernous hemangiomas at the early stage of life and adequately treat them in the future. Treatment of KTWS patients with cavernous hemangiomas should not be different from the treatment of patients with any other hemangiomas, and surgical intervention should be considered on a case-to-case bases.

Outcomes of Infantile-Onset Glaucoma Associated With Port Wine Birthmarks and Other Periocular Cutaneous Vascular Malformation

PURPOSE

The incidence of infantile-onset secondary glaucoma associated with periocular cutaneous vascular malformations is high and the outcomes of these glaucomatous eyes have anecdotally been poor. The purpose of this study was to determine the anatomic and visual outcomes of affected eyes.

DESIGN

Retrospective case series.

METHODS

Consecutive patients with early-onset (younger than 36 months of age) glaucoma associated with cutaneous vascular malformations from 1995‒2015 were included.

RESULTS

Seventeen eyes of 13 patients with Sturge-Weber syndrome (SW, n = 10), Klippel-Trenaunay-Weber syndrome (KTW, n = 1), cutis marmorata telangiectatica congenita (CMTC, n = 1), and phakomatosis pigmentovascularis (PPV, n = 1) were included. Three SW and 1 KTW patient had bilateral glaucoma. At presentation, mean age was 6.5 ± 9.1 months and mean intraocular pressure was 27.2 ± 6.13 mm Hg. The average number of surgical procedures per eye increased from 1.0 ± 0.5 (range, 0‒2) at less than 5 years' follow-up (9 eyes) to 3.5 ± 2.3 (range, 1‒7) with at least 5 years' follow-up (8 eyes). Visual acuity was better than or equal to 20/70 in 2 of 6 eyes (33%) with less than 5 years' follow-up and in 3 of 7 eyes (43%) with at least 5 years' follow-up. Additionally, a higher number of baseline risk factors correlated with poorer visual outcome.

CONCLUSIONS

After a mean follow-up of 6.6 years, visual outcome in infantile-onset secondary glaucoma associated with cutaneous periocular vascular malformation is guarded. Increased numbers of baseline risk factors and procedures are associated with poorer vision.

[Intravenous Ablation for Lower Extremity Varices to Prevent Recurrent Pulmonary Embolism in Klippel-Trenaunay Syndrome;Report of a Case]

Klippel-Trenaunay syndrome( KTS) is a complex congenital anomaly characterized by lower extremity varix and venous malformations, port-wine stains, and soft tissue and bone hypertrophy. We present a case of a 35-year-old man of KTS with pulmonary embolism (PE). The patient was referred to our hospital complaining of the leg pain and sudden onset of dyspnea. Enhanced computed tomography (CT) showed lower extremity varices, superficial thrombophlebitis and bilateral pulmonary thrombi. No venous malformations except for varicose veins were revealed in the limbs or pelvis. The patient received adequate anticoagulant therapy with edoxaban, followed by intravenous radiofrequency ablation for lower extremity varices. Two months after the operation, the patient suffered from thrombophlebitis in the leg again, however, CT showed no pulmonary thrombus. This case report suggests that intravenous ablation for lower extremity varices in KTS prevented recurrent PE.

Rare Association of Klippel-Trenaunay Syndrome with Large Pulmonary Embolism and Asymmetrical Emphysematous Bullae

Klippel-Trenaunay syndrome is a rarely encountered congenital disease characterized by a triad of enlarged arteries and veins, limb hypertrophy and capillary malformations. We are presenting an interesting case of a 23-year male who had been previously diagnosed to have Klippel-Trenaunay syndrome. The patient presented with large pulmonary embolism after having undergone laser surgery for varicose veins. The diagnostic chest computed tomography (CT) performed also revealed the co-existence of severe destructive pulmonary parenchymal disease involving large areas of the pulmonary parenchyma and formation of large emphysematous bullae having an asymmetric involvement of the left lung field. The patient was managed with thrombolysis with a bolus fibrinolytic agent and subsequently underwent an inferior vena cava (IVC) filter implantation to prevent further episodes of embolism in the presence of a compromised lung. The association of Klippel-Trenaunay syndrome with recurrent pulmonary embolism and unexplained pulmonary parenchymal disease leading to almost complete destruction of large areas of lung fields is interesting and has never been previously described.

Deep venous thrombosis and Klippel-Trénaunay syndrome

<strong>Keywords:</strong> Klippel-Trenaunay-Weber Syndrome; Venous Thrombosis.

Klippel–Trenaunay–Weber syndrome (KTWS) and spontaneous spinal CSF leak: coincidence or link

OBJECTIVE

To highlight the occurrence of spontaneous cerebrospinal fluid (CSF) leak in the setting of Klippel–Trenaunay–Weber syndrome (KTWS).

BACKGROUND

KTWS is a congenital multicomponent disorder of angiogenesis plus limb asymmetry. The cause of spontaneous CSF leaks often remains unknown, but the notion of a pre-existing dural weakness related to a disorder of connective tissue matrix is gaining momentum. REPORT OF CASES AND METHODS: Two women with KTWS developed spontaneous CSF leaks. Each underwent extensive head and spine imaging studies. One patient underwent surgery to treat the CSF leak and later an epidural blood patch upon partial recurrence of her symptoms. The other patient, who had intermittent CSF leak, developed cerebral venous thrombosis requiring several months of anticoagulation therapy. Both patients have histories of visceral bleeding: gastrointestinal in 1 patient and genitourinary in the other.

RESULTS

The predominant site of vascular anomaly was the left lower limb in 1 patient and the right upper limb in the other, while the involved limb was larger in 1 patient and smaller in the other. Each patient presented with orthostatic headaches. One had additional choreiform movements and cognitive difficulties that responded to the treatment of the leak. Head magnetic resonance imaging in both patients showed diffuse pachy meningeal enhancement and evidence of sinking of the brain. Computed tomography myelography in 1 patient disclosed the site of the leak; and she underwent surgery to treat the leak, and later an epidural blood patch upon partial recurrence of her symptoms to which she responded well. The other patient had intermittent leak with history of long remission and was reluctant to go through invasive diagnostic or therapeutic measures.

CONCLUSION

The occurrence of an uncommon disorder (spontaneous CSF leak) in the setting of a rare congenital disorder in 2 unrelated patients is intriguing. Whether this represents coincidence or a link is not clear but deserves further observations and investigation.

[Fatal Klippel-Trénaunay syndrome in a child with pulmonary embolism]

Klippel-Trénaunay syndrome is characterized by the venous varicosities, ipsilateral cutaneous capillary malformations, and bony/soft-tissue overgrowth. Potential complications such as hypercoagulability, thrombosis and pulmonary embolism have been casuistically reported. Here, we describe a child with Klippel-Trénaunay syndrome complicated by a pulmonary embolism leading to sudden death.

Venous thromboembolism and prothrombotic parameters in Klippel-Trenaunay syndrome

BACKGROUND

In Klippel-Trenaunay syndrome (KTS), a congenital combined vascular (capillary, venous and lymphatic) malformation with localised disturbed growth, venous thromboembolisms (VTEs) are frequently reported in small cohorts.

DESIGN AND METHODS

We quantified the frequency of VTE by screening a large KTS-patient cohort with duplex compression ultrasonography. Additionally, we performed a case-control study to evaluate whether coagulation alterations were related to VTE and magnitude of vascular malformations as quantified by magnetic resonance imaging (MRI).

RESULTS

Twenty-nine (39%) of 75 patients had signs of current or previous VTE, including superficial venous thrombosis, six (8%) of whom had a deep venous thrombosis or a pulmonary embolism. Compared with 105 controls, 54 adult patients (both: median age 33 years) had higher plasma levels of D-dimer, medians 266 (IQR 195-366) versus 457 (IQR 270-3840) mg÷l (p.

Klippel-Trenaunay syndrome in combination with congenital dislocation of the hip

Klippel-Trenaunay syndrome (KTS) is a rare and sporadic disorder characterized by the triad of capillary malformations, venous varicosities, and limb hypertrophy. The clinical manifestations of KTS are heterogeneous. In this report, we present a unique case of KTS in combination with congenital dislocation of the hip (CDH) in a 4-day-old female neonate. The patient had a widespread port-wine stain surrounded by regions of unaffected skin in a mosaic pattern, cutaneous hemangioma on the upper lip, left-sided hemihypertrophy involving the entire body, and also evidence of left CDH (based on the results of a physical examination and radiographic interpretation). We present this case for the rarity of presentation, discuss the relationship between KTS and CDH, and the treatment options available with a brief review of the literature.

[Epidural block for lower limb amputation in a patient with Klippel-Trenaunay-Weber syndrome]

A 23-year-old man with Klippel-Trenaunay-Weber syndrome (KTWS) was scheduled for left lower limb amputation. He had complained of severe lower limb pain. Oral administration of acetaminophen, duloxetine, and morphine did not alleviate the pain. Epidural block was performed preoperatively after confirming there were no abnormal angiomas in the lumbar spinal canal on CT scan. The pain was alleviated by the epidural block. The epidural block was also useful during the operation and postoperative pain management. There were no complications related to the epidural block. KTWS is a rare congenital malformation characterized by the triad of varicose veins, capillary malformations, and bony or soft tissue hypertrophy in affected limbs. Some patients with KTWS have epidural hemangioma and cerebral or spinal cord arteriovenous fistulas. There have been some reports of rupture of epidural hemangioma resulting in progressive paraplegia. When epidural block is scheduled for patients with KTWS, CT scan should be performed to investigate abnormal vessels in the lumbar spinal canal.