Familial adenomatous polyposis and benign intracranial tumors: a new variant of Gardner's syndrome

INTRODUCTION

Familial adenomatous polyposis (FAP) is associated with malignant tumors of the central nervous system, predominantly medulloblastomas and glioblastoma multiforme (Turcot's syndrome) and with craniofacial osteomas (Gardner's syndrome). This report details the occurrence of benign, intracranial tumors in two related individuals with Gardner's syndrome, an association not previously described.

PATIENTS AND METHODS

A 57-year-old woman (the propositus), her sister, two of her nieces and one of her grandnephews were previously diagnosed with Gardner's syndrome. The propositus came to neurosurgical attention because of vertigo associated with what proved to be an epidermoid cyst of the cerebellopontine angle. Her unaffected children and her relatives with Gardner's syndrome were examined and underwent computed tomography or magnetic resonance imaging.

RESULTS

A 39-year-old woman with Gardner's syndrome, the niece of the propositus, was found to harbor an asymptomatic left frontal meningioma.

DISCUSSION

Familial adenomatous polyposis, Gardner's syndrome, and that variant of Turcot's syndrome in which medulloblastoma predominate, are associated with a mutation of the adenomatous polyposis coli gene. The demonstration that patients with Gardner's syndrome can also have benign, nonneuroglial, intracranial tumors adds to the previously known extracolonic lesions associated with FAP. The molecular characterization of our patients should reveal if benign intracranial tumors represent a pleiotropic manifestation of the adenomatous polyposis coli gene mutation or if other genes are implicated.

High dose tamoxifen and radiotherapy in patients with glioblastoma multiforme: a phase IB study

PURPOSE

To assess the feasibility and the toxicity of adjuvant high dose tamoxifen (TAM) and postoperative brain irradiation for patients with newly-diagnosed glioblastoma multiforme (GBM).

MATERIAL AND METHODS

Twelve patients with histopathologically confirmed GBM entered the study. There were nine males and three females, with median age of 48.8 years (range 30-75 years). Karnofsky performance status (KPS) was 60-70% for four patients and 80-100% for eight patients. Based on the Radiation Therapy Oncology Group recursive partition analysis, there were three class III patients, six class IV, one class V, and two class VI. Eleven patients underwent partial surgical tumor resection and one patient had a near complete resection. Two weeks post surgery, the patients were started on high dose TAM (120 mg/m2 P.O. BID for three months). Two weeks from date of starting TAM, external beam radiotherapy (RT) was given at a dose of 59.4 Gy/33 qd fractions/6.5 weeks. Patients were assessed weekly for toxicity during treatment. Imaging studies were done at the end of two weeks of TAM, then monthly.

RESULTS

Median follow-up was 40 weeks (range 22-84 weeks). In one patient, TAM was associated with significant vomiting, necessitating the TAM dose to be decreased at three weeks and then stopped at two months. One other patient had bilateral deep venous thrombosis after 52 weeks on TAM, although the relationship to TAM was not firmly established. There were no radiological responses after two weeks of TAM or at the end of RT. The median time to progression was 17.7 weeks (range 5.1-43.8 weeks). Median survival time was 33.4 weeks (range 10-79.7). Actuarial survival at 48 and 74 weeks was 40% and 15%, respectively.

CONCLUSION

Our study shows that adjuvant high dose TAM is feasible and relatively well-tolerated. Furthermore, the combined use of high dose TAM and RT postoperatively was not associated with any significant increase in radiation-induced neurological toxicity. However, high dose TAM does not appear to improve treatment results.

Using pattern analysis of in vivo proton MRSI data to improve the diagnosis and surgical management of patients with brain tumors

We have used pattern analysis of proton magnetic resonance spectroscopic imaging (1H MRSI) data in a variety of situations related to the clinical management of patients with brain tumors and other cerebral space-occupying lesions (SOLs). Here, we review how 'leave-one-out' linear discriminant analyses (LDAs) of in vivo 1H MRSI spectral patterns have enabled us to quickly, accurately, and non-invasively: (1) discriminate amongst tissue arising from the five most common types of supratentorial tumors found in adults, and (2) use the metabolic heterogeneity of cerebral SOLs to predict certain pathological characteristics that are useful in guiding stereotaxic biopsy and selective tumor resection. These findings suggest that pattern analysis of 1H MRSI data can significantly improve the diagnostic specificity and surgical management of patients with certain cerebral SOLs.

Diffuse craniospinal seeding from a benign fourth ventricle choroid plexus papilloma. Case report

Choroid plexus papillomas can metastasize to the subarachnoid space, but extensive metastasis has only been reported when the tumors are malignant. The authors report a case of diffuse, extensive metastasis to the craniospinal leptomeninges from a benign fourth ventricular choroid plexus papilloma in an adult. This 19-year-old woman presented with a 2-year history of headache, blurred vision, diplopia, and ataxia. Magnetic resonance imaging of the brain and spinal cord revealed obstructive hydrocephalus caused by a 4-cm, partially calcified, inhomogeneously enhancing tumor of the fourth ventricle that was displacing the pons, medulla oblongata, and cerebellum. Innumerable cystic lesions of varying size were also seen in the cranial and spinal leptomeninges. Histological examination of the resected fourth ventricular tumor and of a few of the leptomeningeal lesions revealed a benign choroid plexus papilloma and leptomeningeal choroid plexus cysts. This singular case of diffuse and extensive metastasis to the craniospinal leptomeninges from a histologically benign fourth ventricular papilloma adds to the available information about the biological potential of these tumors and expands the differential diagnosis of posterior fossa lesions with subarachnoid metastasis.

Magnetic resonance spectroscopy guided brain tumor resection: differentiation between recurrent glioma and radiation change in two diagnostically difficult cases

BACKGROUND

It is often difficult to differentiate a recurrent glioma from the effects of post-operative radiotherapy by means of conventional neurodiagnostic imaging. Proton magnetic resonance spectroscopic imaging (1H-MRSI), that allows in vivo measurements of the concentration of brain metabolites such as choline-containing phospholipids (Cho), may provide in vivo biochemical information helpful in distinguishing areas of tumor recurrence from areas of radiation effect.

PATIENTS AND METHODS

Two patients who had undergone resection and post-operative radiotherapy for a cerebral glioma became newly symptomatic. Computed tomographic (CT) and magnetic resonance imaging (MRI) performed after the intravenous infusion of contrast material, and in one case, [18F]fluorodeoxyglucose positron emission tomography (PET), could not differentiate between the possibilities of recurrent glioma and radiation effect. The patients underwent 1H-MRSI prior to reoperation and the 1H-MRSI results were compared to histological findings originating from the same locations.

RESULTS

A high Cho signal measured by 1H-MRSI was seen in areas of histologically-proven dense tumor recurrence, while low Cho signal was present where radiation changes predominated.

CONCLUSIONS

The differentiation between the recurrence of a cerebral glioma and the effects of post-operative irradiation was achieved using 1H-MRSI in these two patients whose conventional neurodiagnostic imaging was equivocal for such a distinction. Where these two conditions are present, metabolite images from 1H-MRSI, such as that based on Cho, can be co-registered with other imaging modalities such as MRI and may also be integrated with functional MRI or functional PET within a multimodal imaging-guided surgical navigation system to assure maximal resection of recurrent tumor while minimizing the risk of added neurological damage.

Meningeal melanocytoma. Report of a case and a historical comparison

Meningeal melanocytomas are rare tumors of the central nervous system that are found almost exclusively in the posterior fossa and spinal cord and whose natural history is poorly defined. In this report, the authors review the clinical presentation, radiological appearance, operative findings, and histological features in two cases of meningeal melanocytoma: one cranial and one spinal. Two women, aged 21 and 30 years, were admitted to the hospital 60 years apart: the first because of progressive paraplegia and the second because of slowly progressive hearing loss. The first patient had an extradural tumor that was treated by laminectomy, subtotal resection, and postoperative radiotherapy in 1936. Her symptoms recurred 16 years later and she underwent reoperation of the residual tumor, which was found to have an intradural component. The authors' patient, who presented 60 years later, underwent plain and enhanced computerized tomography and magnetic resonance imaging that demonstrated a large posterior fossa lesion indicative of either an acoustic neuroma or a meningioma. She underwent posterior fossa decompression but only partial excision of the tumor could be accomplished because vigorous bleeding limited the extent of the resection. Surgery was followed by radiotherapy. The residual tumor enlarged despite these measures and required repeated resection 6 months later. At the second operation the tumor was much less vascular, perhaps reflecting the effects of radiotherapy, and was removed almost entirely. The patient died 6 months later from an anticoagulant-related cerebellar hemorrhage. In both cases the lesions were jet black, and histological examination revealed melanin-containing hypercellular tumors with rare mitotic figures. Meningeal melanocytomas are being diagnosed with increased frequency in parallel with improvements in neuroimaging and clarification of histological features. Clinical presentation of patients with these tumors typically occurs in their fifth decade and women are affected twice as often as men. The posterior fossa lesions can mimic acoustic neuromas and meningiomas in location and radiological appearance; however, the internal auditory canal is normal. In the spine, meningeal melanocytomas present with the clinical features of myeloradiculopathy. Diagnosis is made intraoperatively from the gross, jet-black appearance of the tumor and from histological examination. Vascularity, size, and location may render complete resection unfeasible. Because of the tumor's propensity to recur, radiotherapy has been recommended but its role remains to be elucidated.

Familial cerebral aneurysms

Familial cerebral aneurysms are currently the subject of burgeoning interest. We review the pertinent, recent reports on this topic in the light of our study of 17 families with familial cerebral aneurysms. The prevalence of familial cerebral aneurysms ranges from 5-28%. The sex distribution displays a female bias. Mothers are more often affected than fathers and daughters more than sons. There is no site predilection for familial cerebral aneurysms but they tend to occur at the same (or mirror) site within families. The age at rupture of familial cerebral aneurysms is younger, especially in females, than for sporadic aneurysms. They tend to rupture within the same decade in families, and within five years of each other in identical twins. The size of ruptured familial cerebral aneurysms appears to be smaller, especially in women, than sporadic aneurysms. The pattern of inheritance is unknown. A poor outcome of rupture is more frequent in familial cerebral aneurysms cases than in sporadic ones. Angiographic screening of family members at risk, especially first degree relatives, appears justified.

Function and organization in dysgenic cortex. Case report

Cerebral dysgenesis is a subject of interest because of its relationship to cerebral development and dysfunction and to epilepsy. The authors present a detailed study of a 16-year-old boy who underwent surgery for a severe seizure disorder. This patient had dysgenesis of the right hemisphere, which was composed of a giant central frontoparietal nodular gray matter heterotopia with overlying large islands of cortical dysplasia around a displaced central fissure. Exceptional insight into the function, biochemistry, electrophysiology, and histological structure of this lesion was obtained from neurological studies that revealed complementary information: magnetic resonance (MR) imaging, [18]fluoro-2-deoxy-D-glucose positron emission tomography (PET), functional PET scanning, proton MR spectroscopic (1H-MRS) imaging, intraoperative cortical mapping and electrocorticography, in vitro electrophysiology, and immunocytochemistry. These studies demonstrated compensatory cortical reorganization and showed that large areas of heterotopia and cortical dysplasia in the central area may retain normal motor and sensory function despite strikingly altered cytoarchitectonic organization and neuronal metabolism. Such lesions necessitate appropriate functional imaging studies prior to surgery and cortical mapping to avoid creating neurological deficits. Integrated studies, such as PET, 1H-MRS imaging, cortical mapping, immunocytochemistry, and electrophysiology may provide information on the function of developmental disorders of cerebral organization.

Periventricular nodular heterotopia and intractable temporal lobe epilepsy: poor outcome after temporal lobe resection

We describe 5 women and 5 men with periventricular nodular heterotopia and electroclinical features suggestive of temporal lobe epilepsy, who were surgically treated for control of medically refractory seizures. Magnetic resonance imaging revealed bilateral periventricular nodular heterotopia in 7 of the 10 patients. Because of the lack of clear localization, 6 patients were studied with intracranial depth electrode recordings. Seizures were of hippocampal onset (3 patients), regional temporal lobe onset (2 patients), or occipital-temporal onset (1 patient). Anterior temporal lobectomy was performed in 6 patients; selective amygdalohippocampectomy, in 1; and anterior temporal lobectomy plus resection of the heterotopic tissue, in 3. None of the 9 patients followed for more than 12 months postoperatively were seizure free. Two patients were initially seizure free for approximately 18 months, but then seizures recurred. One patient had a major reduction in seizure frequency at a 39-month follow-up after most of the unilateral heterotopic tissue was included in the temporal resection. Temporal resection did not lead to a long-term favorable outcome in this group of patients with periventricular nodular heterotopia and epileptogenic discharges involving the temporal lobe. This suggests a more widespread disorder with epileptogenic activity possibly originating in or near the heterotopic tissue. The clinical and electrographic features of periventricular nodular heterotopia pointing to temporal lobe origin are misleading and temporal resection does not result in long-term cessation of seizures.

Marked hyperprolactinemia caused by carotid aneurysm

BACKGROUND

Pituitary dysfunction caused by intracranial aneurysms is rare. We report a patient with the unique feature of hyperprolactinemia to a degree previously seen only with prolactin-secreting tumours.

METHOD

Case report.

RESULT

A 42-year-old woman had a galactorrhea, left-sided headache, reduced vision in the left eye and a left temporal hemianopsia. Serum prolactin was elevated (365 micrograms/L). Cranial computed tomography (CT) revealed a suprasellar mass, which carotid angiography showed to be a left internal carotid artery aneurysm. At craniotomy, this aneurysm and a smaller one of the ophthalmic artery were repaired, and the patient's vision returned to normal. The prolactin level fell to normal. Follow-up CT showed no evidence of pituitary adenoma or hypothalamic lesion.

CONCLUSIONS

Carotid aneurysm can cause reversible pituitary dysfunction. A prolactin level > 300 micrograms/L is not a reliable cut-off for distinguishing prolactin-secreting adenomas from other causes of elevated prolactin. A co-existing prolactinoma was felt to be ruled out by both a normal CT scan and normal prolactin levels following aneurysm repair. Patients with marked hyperprolactinemia should be considered for angiography or MRI to rule out carotid aneurysm, since the consequences of pituitary exploration in this setting are potentially grave.

Hereditary neurocutaneous angiomatosis. Report of four cases

The authors report the coexistence of vascular nevi (hemangiomas and arteriovenous malformations (AVMs) of the skin) with AVMs and venous malformations of the brain in male siblings from two related but nonconsanguineous families of three generations. The proband, his siblings, parents, aunts, uncles, and cousins were examined, underwent magnetic resonance (MR) imaging and MR angiography, and when appropriate, cerebral angiography. A father had vascular nevi and a mother, his sister, had an azygos anterior cerebral artery. No other cutaneous or cerebrovascular malformations were present in the parents. Each of the two families had two boys and one girl, 9 to 18 years of age. All the children had vascular nevi and all of the boys had coexisting cerebrovascular malformations: AVMs in three, and a venous malformation in another. One boy had three cerebral AVMs. Two boys had a cerebral hemorrhage, and one also had focal motor seizures. The skin lesions were not those of the Sturge-Weber-Dimitri, Rendu-Osler-Weber, or Wybum-Mason syndromes. The association of cutaneous and cerebrovascular malformations was seen only in males in these families. but females have also been reported in the literature. The results obtained in these families and three other families reported from Western and Central Europe indicate that the association of cerebral and cutaneous vascular hamartomas constitutes a distinct, hereditary clinicopathological entity with autosomal dominant inheritance and variable penetrance. The clinical manifestations of this syndrome are visible, painful vascular nevi, epilepsy, cerebral hemorrhage, and focal neurological deficits. The preponderance of male patients with the full expression of the syndrome suggests a possible hormonal influence on the expression of the gene.

Functional imaging of cerebral arteriovenous malformations with a comment on cortical reorganization

Functional brain imaging is poised to become a standard diagnostic tool. The authors review their experience using functional positron emission tomography (fPET) in patients with cerebral arteriovenous malformations (AVMs).

Twelve patients, three males and nine females aged 16 to 30 years, 11 with a cerebral AVM and one with a cavernous angioma, of which five were located in the central area and seven in a speech region, underwent fPET and three-dimensional magnetic resonance imaging. These studies were coregistered in stereotactic space and correlated to Brodmann's areas that were identified from the atlas of Talairach and Tournoux. Vibrotactile and/or motor stimulation of the contralateral hand were used to identify the central region in patients whose AVM resided within, or close to, the motor strip, and language tasks specifically designed to activate visual, auditory, expressive, or semantic language were used in patients whose AVM resided within, or close to, Broca's or Wernicke's areas.

Somatosensory and motor activation reliably identified the central region in all cases as validated by identification of Brodmann's areas and by intraoperative cortical mapping, which was performed with the patient under local anesthesia. Similarly, language tasks accurately lateralized major language function to one hemisphere concordantly with neuropsychological assessment, including dichotic listening and intracarotid Amytal tests, and localized language areas appropriately as verified by stereotactic coordinates.

Functional cerebral imaging is feasible in patients with structural brain lesions. It is a reliable method to identify the relationship of a cerebral AVM to the central region. The determination of a similar relationship to language areas is dependent on the development and further validation of language-based tasks designed to activate visual, auditory, expressive, and semantic aspects of language specific to particular sites within the anterior and posterior speech regions.

Familial cerebral aneurysms. A bias for women

BACKGROUND AND PURPOSE

We evaluated the influence of gender on the formation and rupture of familial cerebral aneurysms.

METHODS

We studied 30 patients with ruptured cerebral aneurysms from 14 consecutive families. These patients were compared with the patients with sporadic aneurysms reported by the first Cooperative Study.

RESULTS

Eighty percent of familial aneurysms occurred in women versus 59% of sporadic aneurysms (P < .05, chi 2 test). This overrepresentation of women occurred at below the age of 50 years, where 78% of patients with familial aneurysms were women compared with 45% for sporadic aneurysms (P < .01, chi 2 test). Above this age, there was no statistical difference in incidence of familial aneurysms in men or women compared with sporadic aneurysms. In women with familial aneurysms, rupture occurred before the age of 50 years in 59%, compared with 31% for sporadic aneurysms (P < .01, chi 2 test). In four of five families, aneurysms ruptured within 10 years of each other in sisters (mean, 6 years). Multiple aneurysms were equal in both groups (17%), but multiple familial aneurysms occurred mainly in women. There was no difference in the site of single cerebral aneurysms in either group, but familial aneurysms in females occurred at the same site in five of eight families (62%) and in 11 of 17 mother-daughter or sister pairs (65%), compared with 20% for two randomly selected sporadic aneurysms (P < .01).

CONCLUSIONS

There is an overrepresentation of women with ruptured familial aneurysms compared with those with sporadic aneurysms. Familial aneurysms rupture in females predominantly before the age of 50, in the same decade, and at the same site within families in the majority of cases. These observations support a possible genetic cause for cerebral aneurysms and a possible hormonal contribution to their rupture.

Accurate, noninvasive diagnosis of human brain tumors by using proton magnetic resonance spectroscopy

Although conventional proton magnetic resonance imaging has increased our ability to detect brain tumors, it has not enhanced to nearly the same degree our ability to diagnose tumor type. Proton magnetic resonance spectroscopy is a safe, noninvasive means of performing biochemical analysis in vivo. Using this technique, we characterized and classified tissue from normal brains, as well as tissue from the five most common types of adult supratentorial brain tumors. These six tissue types differed in their pattern across the six metabolites measured. 'Leaving-one-out' linear discriminant analyses based on these resonance profiles correctly classified 104 of 105 spectra, and, whereas conventional preoperative clinical diagnosis misclassified 20 of 91 tumors, the linear discriminant analysis approach missed only 1. Thus, we have found that a pattern-recognition analysis of the biochemical information obtained from proton magnetic resonance spectroscopy can enable accurate, noninvasive diagnosis of the most prevalent types of supratentorial brain tumors.

Low-grade pure and mixed cerebral astrocytomas treated in the CT scan era

From 1974 to 1992, 63 patients diagnosed with low-grade pure or mixed oligo-astrocytoma were seen and treated at our institution. All patients underwent CT scan pre-operatively. There were 20 female and 43 males ranging in age from 12 to 73 years (median age of 33 years). 15 patients had a stereotactic biopsy as the only surgical procedure. 34 had a partial tumor resection and 14 a gross total tumor resection. 43 patients were treated with post-operative radiotherapy whereas 20 patients underwent surgery only as part of the initial management. 50 to 60 Gy (median 59.4 Gy) were given with daily fractions of 1.8 to 2 GY. Tumor volume ranged from 3.4 to 441 cm3. Median tumor volume was larger for radiotherapy treated patients. Median follow-up was 54 months (range of 4 to 240 months). The overall 10 and 15 actuarial survival rates were 37% and 25% respectively. The 5 years survival rate for patients treated at initial diagnosis with surgery alone was 66% and it was 67.3% for patients treated with radiation therapy (P = NS). Prognostic factors having independent significant impact on survival were: extent of surgery, age gender and tumor volume. As well, survival for patients with low-grade astrocytoma in the CT scan era appears to be improved compared to historical controls in the literature.

Retained language in dysgenic cortex: case report

Since the advent of magnetic resonance imaging, there has been renewed interest in disorders of cortical migration in the cause of focal epilepsy. The function of dysplastic cortex is poorly understood. We report a 46-year-old woman in whom this was assessed by intraoperative stimulation. This left-handed patient had a 30-year history of complex partial seizures with secondary generalization. Prolonged electroencephalographic recordings documented an epileptic focus in the right lateral and inferomesiotemporal lobe. Computed tomographic scanning and angiography suggested a right posterotemporal hamartoma. Amytal testing showed major speech representation in the right hemisphere. At craniotomy, an ivory-colored, posterotemporal lesion originating 5 cm from the temporal tip and 4 cm in diameter occupied the posterotemporal region. Electrical stimulation of this lesion produced speech interference. A histological examination of the resected anterotemporal lobe, amygdala, and hippocampus and biopsy specimens of the lesion showed extensive multifocal cortical microdysgenesis and gliovascular and cortical hamartoma. This case shows that grossly dysplastic cortex can remain functional. Cortical mapping under local anesthesia should be performed before resection of dysplastic lesions in putatively functional areas in patients with intractable epilepsy.

Periventricular and subcortical nodular heterotopia. A study of 33 patients

Grey matter heterotopias, demonstrated by MRI, may present with a broad spectrum of clinical severity. We have studied 33 patients with periventricular nodular heterotopias (PNH); 19 (58%) had unilateral and 14 (42%) bilateral lesions. Thirteen of the 19 patients (68%) with unilateral subependymal nodules of grey matter had, in addition, unilateral focal subcortical heterotopias (SNH), comprising 39% of the entire group. Most had normal intellectual and motor function but some presented with mild mental retardation and neurological deficits. Recurrent seizures were described in 82%, mainly partial attacks with temporo-parieto-occipital auras. Nodular heterotopias led to unilateral or bilateral independent temporal epileptic discharges in 47% of epileptic patients with PNH alone and in 61% of those who had SNH in addition. Extratemporal or multilobar, unilateral or bilateral interictal spiking was present in 10 other patients (36%). Two first degree relatives of patients with seizures were affected but had no seizures, three were investigated for other apparently unrelated neurological symptoms: memory impairment, vertigo or transient ischaemic attacks in one person each. Contiguous ovoid nodules of grey matter, symmetrically lining both lateral ventricles, were described in nine patients. Seven of them were female, including four with familial incidence of PNH. Such lesions may explain the familial occurrence of epilepsy in some families. Seven patients underwent anterior temporal resection: two patients with unilateral subependymal and focal subcortical heterotopias were seizure free or significantly improved. Four patients, three with PNH alone and one with additional subcortical nodules, did not improve significantly after surgery. The remaining patient was followed for less than 6 months.

Familial cerebral aneurysms: a study of 13 families

Despite the recent interest in familial cerebral aneurysms, the epidemiology, natural history, pattern of inheritance, screening of asymptomatic relatives, and the search for a biochemical marker remain problematic. To assess these issues, we report the results of our prospective study of 30 patients with 38 aneurysms (27 ruptured) and of the angiographic screening of asymptomatic relatives, all from 13 families seen consecutively since 1986. Women were over-represented (77%), and patients with multiple aneurysms (17%) were under-represented, compared with sporadic cases. Only 16% of the aneurysms were at the anterior communicating artery. Aneurysms occurred at the same or at the mirror site in 10 of 16 siblings (62%) and in 50% of mother-daughter pairs versus 20% for randomly selected, sporadic aneurysm patients. Rupture occurred in the same decade in 10 of 12 siblings (83%) versus the expected 21% for randomly selected, sporadic aneurysms. The average age at rupture was 47.2 years, and 60% of patients with a ruptured aneurysm were 50 years of age or younger. Seventy percent of patients died or were disabled from aneurysmal rupture. Screening of 41 individuals, including 2 dizygous twins, identified 1 aneurysm and 2 infundibula. A specific pattern of inheritance could not be ascertained from the pedigrees. The presence of an aneurysm was not associated with a specific human leukocyte antigen haplotype or antigen, and collagen Type III was qualitatively and quantitatively normal. Until a biological marker is identified, angiographic screening by intra-arterial digital subtraction or magnetic resonance angiography remains the only way to identify patients at risk of harboring a familial cerebral aneurysm.