The radiographic spectrum in neurofibromatosis

Plexiform neurofibroma causing an ossifying subperiosteal haematoma: a rare case in the tibia of an 11-year-old girl

Ossifying subperiosteal haematoma is an exceedingly rare manifestation of Neurofibromatosis type 1 (NF-1). We report an interesting case of plexiform neurofibroma causing a rapidly growing tibial mass as a result of subperiosteal haemorrhage, in an 11-year-old girl with previously undiagnosed NF-1. This reflects a precursor of the more mature periosteal ossification seen in cases traditionally termed "subperiosteal cysts". A previously well young girl was referred by her general practitioner with an increasingly large, mildly tender, soft lump on the anterior aspect of her right tibia. Plain radiographs demonstrated soft tissue thickening overlying the anterior tibia, without appreciable periosteal ossification. Magnetic resonance imaging (MRI) illustrated a single central fluid-fluid level and periosteal elevation with saucerisation of the anterior tibial cortex and mild surrounding oedema. Histopathology revealed a large plexiform neurofibroma. Interestingly, this was associated with haemorrhagic change and a peripheral rim of florid reactive new bone formation. This unusual presentation was discussed at a multidisciplinary bone and soft tissue tumour meeting, where in combination with the clinical history of café au lait spots and positive family history, a consensus diagnosis of NF-1 was made. To date, there have only been limited case reports of this rare pathological process. In summary, this case report accounts an acute presentation of this rare osseous manifestation of NF-1, being the first to clearly demonstrate a timeline of subperiosteal haematoma with subsequent subperiosteal bone proliferation. The clinical reasoning and radiological features for such a presentation are also described.

MR Imaging of Spinal Neurofibromatosis

The MR findings in 7 patients with neurofibromatosis involving the spine were evaluated. Six patients had paraspinal tumors at multiple levels. In 4 they were bilateral. Five patients had multiple intraspinal lesions, frequently with growth through the neural foramen. In one patient paraspinal tumors were found in the lumbar sacral plexus and in another bony dysplasia and meningoceles but no tumors were disclosed. In 2 patients the lesions were associated with bilateral acoustic neuromas and multiple intracranial meningeomas. In one of these a spinal meningeoma with signal characteristics close to spinal cord was found. The other tumors had a signal that was equal to or slightly lower than the spinal cord and slightly higher than muscle on T1-weighted images. On T2-weighted images the tumors had a markedly increased signal compared to surrounding tissue. In 3 patients with tumors larger than 4 cm the signal intensity was inhomogeneous with decreased signal in the center on T2-weighted images, indicating the presence of increased fibrous tissue. Gadolinium-DTPA was given to one patient with marked increase in intensity of small tumors on T1-weighted images. The study shows that MR imaging is the modality of choice for evaluating most aspects of spinal and paraspinal neurofibromatosis.

Neurofibromatosis: chronological history and current issues

Neurofibromatosis, which was first described in 1882 by Von Recklinghausen, is a genetic disease characterized by a neuroectodermal abnormality and by clinical manifestations of systemic and progressive involvement which mainly affect the skin, nervous system, bones, eyes and possibly other organs. The disease may manifest in several ways and it can vary from individual to individual. Given the wealth of information about neurofibromatosis, we attempted to present this information in different ways. In the first part of this work, we present a chronological history, which describes the evolution of the disease since the early publications about the disorder until the conclusion of this work, focusing on relevant aspects which can be used by those wishing to investigate this disease. In the second part, we present an update on the various aspects that constitute this disease.

Intraarticular Neurofibroma of the Hip

The magnetic resonance imaging findings in 2 cases of pathologically proven hepatocellular carcinoma that mimicked focal nodular hyperplasia are presented. Both cases were found in patients with cirrhosis, a condition in which focal nodular hyperplasia is unlikely to occur. Recognition that hepatocellular carcinoma may mimic focal nodular hyperplasia in patients with cirrhosis may prevent misdiagnosis and allow for earlier intervention.

Radiation-induced moyamoya syndrome

PURPOSE

The moyamoya syndrome is an uncommon late complication after radiotherapy (RT).

METHODS AND MATERIALS

A PubMed search of English-language articles, with radiation, radiotherapy, and moyamoya syndrome used as search key words, yielded 33 articles from 1967 to 2002.

RESULTS

The series included 54 patients with a median age at initial RT of 3.8 years (range, 0.4 to 47). Age at RT was less than 5 years in 56.3%, 5 to 10 years in 22.9%, 11 to 20 years in 8.3%, 21 to 30 years in 6.3%, 31 to 40 years in 2.1%, and 41 to 50 years in 4.2%. Fourteen of 54 patients (25.9%) were diagnosed with neurofibromatosis type 1 (NF-1). The most common tumor treated with RT was low-grade glioma in 37 tumors (68.5%) of which 29 were optic-pathway glioma. The average RT dose was 46.5 Gy (range, 22-120 Gy). For NF-1-positive patients, the average RT dose was 46.5 Gy, and for NF-1-negative patients, it was 58.1 Gy. The median latent period for development of moyamoya syndrome was 40 months after RT (range, 4-240). Radiation-induced moyamoya syndrome occurred in 27.7% of patients by 2 years, 53.2% of patients by 4 years, 74.5% of patients by 6 years, and 95.7% of patients by 12 years after RT.

CONCLUSIONS

Patients who received RT to the parasellar region at a young age (<5 years) are the most susceptible to moyamoya syndrome. The incidence for moyamoya syndrome continues to increase with time, with half of cases occurring within 4 years of RT and 95% of cases occurring within 12 years. Patients with NF-1 have a lower radiation-dose threshold for development of moyamoya syndrome.

Vascular complications of cranial radiation

OBJECTIVES

Cerebral vascular disease has been reported as a long-term complication of cranial radiotherapy. The purpose of this study was to examine the frequency and risk factors associated with development of cerebral vascular disease in children after cranial radiation.

MATERIALS AND METHODS

A retrospective chart review of all cancer patients treated between 1985 and 2003 who were under the age of 18 years at the time of initial radiotherapy was performed. Variables examined include diagnosis and site of malignancy, age at the time of radiotherapy, sex, total radiation dosage, number of fractions, duration, and whether the patient had proven cerebral vascular event.

RESULTS

Two hundred and forty-four patients met the study criteria. One hundred and 13 cases involved tumors of the central nervous system. The remaining patients had systemic neoplastic disease. Post radiation cerebral vascular disease occurred in 11 (5%) patients, and all but one patient had a tumor involving the central nervous system (mainly in the posterior fossa and supratentorial midline).

CONCLUSION

There is an increased risk of cerebral vascular disease after radiation therapy in childhood, especially in children who received high dose radiation at the posterior fossa and supratentorial axial region.

A neurofibromatosis type 1 patient with severe kyphoscoliosis and intrathoracic meningocele

The patient presented with neurofibromatosis and a dystrophic kyphoscoliosis around the cervico-thoracic junction. When the patient was 59 years old, he started to suffer from dyspnea caused by an intrathoracic meningocele in the upper left thoracic cavity. A wide laminectomy from T2 to T5 was performed and the meningocele was resected. Although the dyspnoea disappeared postoperatively, the patient started to neurologically deteriorate. Laminectomy alone caused instability around the apex of the kyphosoliosis and spinal cord compression. Halo cast was applied and brought remarkable recovery of neurologic deficits. This result encouraged us to perform posterior fusion in situ from C3 to L2 with bone graft from the iliac crests and the Luque technique in conjunction with the Isola system. This resulted in the patient being able to walk again. The removal of the posterior element predisposes the patient to unstable postlaminectomy kyphosis and removes valuable bone stock required for posterior spinal fusion. For this reason, spinal fusion should have been conducted during surgery for the patient's meningocele.

Prevalência de achados radiográficos da neurofibromatose tipo 1: estudo de 82 casos

A neurofibromatose tipo 1 é uma das enfermidades genéticas mais comuns da espécie humana com padrão de herança autossômica dominante. As alterações radiológicas encontradas com maior freqüência são: escoliose, cifose, cifoescoliose, áreas de erosão óssea, crescimento anormal do osso, pseudo-artrose, meningocele, deformidade da parede posterior dos corpos vertebrais ("scalloping"), peito escavado, lesões osteolíticas nos ossos longos e alterações do sistema nervoso central. Os autores apresentam dados estatísticos dos achados radiográficos prevalentes em 82 pacientes com neurofibromatose tipo 1 acompanhados pelo Centro de Pesquisa e Atendimento em Neurofibromatose, de São José do Rio Preto, SP, um centro multidisciplinar de estudo e tratamento dos portadores da doença.

Keep your eyes on the ribs: the spectrum of normal variants and diseases that involve the ribs

A variety of normal variants or pathologic conditions of the ribs may be overlooked at chest radiography if the ribs are not evaluated carefully. Rib lesions may simulate pulmonary disease as well. Normal rib variants include cervical, intrathoracic, and pelvic ribs; forked rib; fusion and bridging; and pseudarthrosis of the first rib. Trauma-related lesions are common and usually occur in isolation but can alert the radiologist to other injuries. Metastases may appear as vague areas of increased opacity overlying the lung if seen en face and typically have a smooth interface with the lung on oblique images. Chondroid lesions nearly always arise at or near the anterior end of the rib. Osteochondroma (exostosis) typically manifests as a deformity or expansion of the rib with calcification of the cartilaginous cap. Acute rib infections are seen as focal areas of bone destruction, whereas chronic infections may manifest as periosteal reaction or a bone sequestrum. Inferior rib notching may be seen in a wide variety of pathologic conditions. Rib abnormalities may also be seen in fibrous dysplasia, Langerhans cell histiocytosis, Paget disease, and various hemoglobinopathies. In most cases, radiography is sufficient for the identification and diagnosis of normal variants and pathologic conditions of the ribs.

Cerebral aneurysm associated with von Recklinghausen's neurofibromatosis: a case report

BACKGROUND

von Recklinghausen's neurofibromatosis is a hereditary disease that may affect any organ or system of the body primarily or secondarily, including the vascular system. Among the rare cerebrovascular abnormalities, the most common is stenosis or occlusion of the cerebral artery. Intracranial aneurysms are uncommon.

CASE DESCRIPTION

A case of an intracranial cerebral aneurysm associated with von Recklinghausen's neurofibromatosis is reported. A 55-year-old woman presented with a history of intermittent headache for 2 months and right oculomotor nerve palsy for 1 month. Widespread cutaneous neurofibromas and angiomas were found over her trunk and limbs with prominent cafe-au-lait spots. X-ray showed that her left lung was compressed by a large mass in the left chest with rib defects and lateral spinal curvature. Right internal carotid angiography revealed a saccular aneurysm between C1 and C2. Craniotomy to clip the aneurysm could not be performed because the mass in her chest made intubation for general anaesthesia almost impossible.

CONCLUSION

The clinical features of this case are discussed together with a review of 15 similar cases in the literature. There are different theories about this disorder. We agree that the malformations are derived not only from ectodermal, but also from mesodermal pathology. In terms of our case, we consider the progression of this disease to be slow.

Radiographic features of the mandible in neurofibromatosis: a report of 10 cases and review of the literature

The radiographs of 10 cases with a diagnosis of neurofibromatosis involving the mandible were evaluated by two reviewers to document common radiographic characteristics. The most common findings included increase in bone density, enlarged mandibular foramen, lateral bowing of the mandibular ramus, increase in dimensions of the coronoid notch, and a decrease in the mandibular angle. The six cases for which computed tomography scans were available, enlargement of the mandibular foramen and concavity of the medial surface of the ramus were seen. In five of these cases, there was no associated tumor mass adjacent to the concavity; instead a soft tissue mass with density of fat was found. This supports the theory that neurofibromatosis may have manifestations of a mesodermal dysplasia.

Progressive cerebral occlusive disease after radiation therapy

BACKGROUND

A case of progressive irradiation-induced cerebral vasculopathy with abnormal netlike vessels and transdural anastomoses (moyamoya syndrome) is presented. Radiological findings in an additional 40 cases reported in the literature are analyzed, and their clinical relevance is discussed.

CASE DESCRIPTION

A 19-year-old woman presented with recurrent ischemic brain lesions after radiation therapy for treatment of a craniopharyngioma during childhood. Cerebral angiography 6 and 12 years after completion of radiation therapy revealed progressive cerebral arterial occlusive disease involving the internal carotid artery on either side of the circle of Willis, with abnormal netlike vessels and transdural anastomoses (moyamoya syndrome).

CONCLUSIONS

Extensive similarities between irradiation-induced cerebral vasculopathy and primary moyamoya syndrome (Nishimoto's disease) support the notion that both disorders share common pathophysiological mechanisms. The occurrence of moyamoya-like vascular changes may not depend on specific trigger mechanisms but may rather represent a nonspecific response of the developing vascular system to a number of various noxious events.

Vascular neurofibromatosis affecting the internal carotid artery: a case report

A patient with von Recklinghausen's disease presented with a right sixth nerve palsy. Investigations demonstrated unilateral dolichoectasia of the intracranial carotid artery and sphenoid wing dysplasia. This case demonstrates an association not previously documented, that of unilateral fusiform dilatation of the carotid artery with sphenoid wing dysplasia in the presence of classical neurofibromatosis.

Multiple, symmetrical non-ossifying fibromata without extraskeletal anomalies: report of two related cases

Two patients, mother and daughter, with multiple, symmetrical, non-ossifying fibromata without extraosseous anomalies are reported. We believe that this is a separate syndrome different from multiple non-ossifying fibromata with extraskeletal anomalies (Jaffe-Campanacci syndrome).

Neurocutaneous syndromes

Many of the neurocutaneous disorders are more common than once suspected, in part because patients with milder forms of the disorders are now more likely to be recognized. Improved diagnostic studies and increasingly specific medical and surgical therapy allow some previously untreatable complications to be successfully managed. Genetic linkage analysis has localized the abnormal gene for some of the hereditary neurocutaneous disorders onto specific chromosomes, and newly developed clinical diagnostic criteria have improved our ability to establish a definite diagnosis in less obvious patients. Thus, the outlook for these patients is no longer uniformly pessimistic.

Neurofibromatosis 1 and osseous fibrous dysplasia in a family

We report on the cosegregation of neurofibromatosis 1 (NF 1) and osseous fibrous dysplasia in a family. The father and 3 children by 2 women are affected. A fourth child had neither NF 1 nor osseous fibrous dysplasia. All 4 affected individuals had NF 1, i.e., café-au-lait spots in 4, neurofibromata in 4, Lisch nodules in 3, macrocrania in 3, scoliosis in 2, and curvature of the long bones in 2. Each demonstrated various fibroosseous lesions of the skeleton including non-ossifying fibromas in 3 and both non-ossifying fibromas and fibrous dysplasia in one. This pattern suggests that the fibrous bony lesions are a component of NF 1 in this family. Alternatively, a mutant gene resulting in the fibrous changes in bone could be linked to the gene for NF 1. Another possibility is the coincidence of the 2 non-linked traits segregating in the same family.

Incidence of cerebral infarction after radiotherapy for pituitary adenoma

The incidence of cerebral infarction was studied in 156 patients irradiated for treatment of pituitary adenomas. Seven patients experienced strokes at intervals of 3.2 to 14.6 years after irradiation. The observed incidence was not significantly greater than the expected value of 3.5 strokes (P = 0.078). Six strokes occurred in patients receiving equivalent doses (ED) of 1070 ret or more (observed to expected ratio 3.87, significantly elevated; P less than 0.001). Univariate log-rank analysis showed that the risk of stroke was significantly higher (P = 0.010) in patients receiving an ED of 1070 ret or more (4180 cGy/22 fractions) than those receiving lower doses. Multivariate analysis, however, demonstrated that the increased risk of stroke was associated only with increasing age (P less than 0.0001), not ED (P = 0.148). Due to these inconsistent statistical results, no definitive conclusions could be reached about the relationship between radiation dose to the pituitary and subsequent cerebral infarction.

MRI of peripheral neurofibromas in children

Magnetic resonance imaging was performed as a preoperative examination in three children with neurofibromatosis and soft-tissue plexiform neurofibromas. In all three patients, MRI showed more widespread soft tissue involvement than was suspected clinically including extension towards the spine in each case. Patient management was changed in each case after MRI was performed.

Ischaemic stroke in the basal ganglia and internal capsule in childhood

Ischaemic stroke in childhood is rare. In particular, there have only been a few reports of lacunar infarcts in children. In this study, four children with true lacunar infarcts and four with larger subcortical infarcts are described. We compare the clinical features and the possible pathogenesis of ischaemic strokes in the basal ganglia and internal capsule in childhood with those in adults, and discuss diagnostic and therapeutic management.

Jaw and skull changes in neurofibromatosis

Thirty-eight patients with neurofibromatosis were examined clinically and radiographically for manifestations of the disease in the head and neck region. Ninety-two percent of the sample had at least one intraoral or radiographic sign of the disease. This suggests that the incidence of jaw and skull involvement in neurofibromatosis may be greater than previously reported in the literature.

Multiple skeletal fibroxanthomas: radiologic-pathologic correlation of 72 cases

Out of a series of 900 biopsy-proven cases of skeletal "fibroxanthoma" (nonossifying fibroma, fibrous cortical defect), we studied 72 patients with more than one lesion. Age, sex, coexistent conditions such as neurofibromatosis, and histologic and radiographic appearance of the lesions were evaluated. Multiple skeletal fibroxanthomas are probably more common than previously suspected. (At least 8% of the 900 patients in our archives had multiple lesions). Only a small percentage (5%) of patients with multiple skeletal fibroxanthomas had coexistent neurofibromatosis. These lesions are histologically indistinguishable from their solitary counterparts and most commonly present in the lower extremities. Four radiographic patterns were noted: clustered lesions--usually about the knee. nonclustered lesions--in opposite ends of long bones. coalescent lesions--several lesions coalescing over time. This observation has not been previously reported. emergent lesions--lesions appearing in previously unaffected bone. Familiarity with these features may obviate biopsy.

Dural ectasia as a cause of widening of the internal auditory canals in neurofibromatosis

Patients with neurofibromatosis have an increased incidence of acoustic neuroma, which is often bilateral. We present three patients with neurofibromatosis and enlarged internal auditory canals secondary to dural ectasia, without associated acoustic neuromata. Air CT cisternography and Metrizamide CT cisternography was needed in differentiating dural ectasia from acoustic neuroma in two patients.

Skeletal overgrowth with modelling error in neurofibromatosis

Ten cases of neurofibromatosis, nine involving the lower extremity and one, the upper extremity, were analysed for growth and modelling errors. The elongated bones showed over-tubulation or under-tubulation. Long as well as short bones were affected. Modelling errors mostly affected the metaphysis but, in a few cases, especially where there was isolated involvement of the fibula, the diaphysis was also affected. In two patients the whole length of paired bones of the leg showed evidence of over-tubulation. The rule of polarity which influences growth and modelling was not applicable to these cases of neurofibromatosis. Soft-tissue masses of neurofibromatosis often determined the segment of the bone involved but, in cases without such an external influence, inherent mesodermal dysplasia was thought to be the causative factor.

The moyamoya syndrome associated with irradiation of an optic glioma in children: report of two cases and review of the literature

We report two cases of the moyamoya syndrome which became clinically apparent after irradiation of an optic glioma during childhood. A summary of 14 cases of this syndrome following irradiation of intracranial tumors is also presented. Nine of these cases were optic gliomas; five were found in children with neurofibromatosis, another disorder that has a strong association with the moyamoya syndrome. The effectiveness of irradiation of optic gliomas in childhood is not definitely established. The possibility of inducing serious vascular disease is a further reason for caution when considering irradiating these tumors.

Abdominal wall CT: a pictorial essay

Abdominal CT demonstrates clearly the anatomy of the abdominal wall. This radiographic technique may provide valuable information when pathology is suspected in this region or in the adjacent peritoneum. The muscles, subcutaneous tissues and vascular structures of the abdominal wall should be examined thoroughly when reading routine abdominal CT films. This paper reviews abnormalities identified involving the abdominal wall including hernias, masses, vessels, hematomas, abscesses, ascites, neuromuscular diseases and miscellaneous entities.

Occlusion of the internal carotid artery after radiation therapy for the chiasmal lesion

Occlusion of the intracranial portion of the internal carotid artery were encountered in two cases with suprasellar tumours, who had received irradiation therapy previously and shown excellent clinical improvement postoperatively. Clinical features and the angiographic characteristics were analysed in these two cases and the results were compared with reports in the literature. The occlusive effect of radiation on the arterial wall was conceived as the cause of carotid obstruction. In order to avoid this side effect of radiation therapy, especially for brain tumours of low malignancy in childhood, careful estimation of the radiation dose should be required and cerebral angiographic follow-up during and after the treatment with radiation is indicated, particularly when the patient develops cerebral transient ischaemic symptoms.

Mandibular abnormalities in neurofibromatosis. Case report and literature review

A patient with von Recklinghausen's neurofibromatosis that was undiagnosed until the sixth decade of life is discussed. He came for evaluation and treatment of multiple radiolucent lesions, bilaterally distributed throughout the mandible. Histologic examination of a cutaneous nodule, as well as of the intrabony radiolucencies, confirmed the diagnosis of neurofibromatosis. Examination of the intrabony radiolucencies revealed fibrous connective tissue with an inflammatory cell infiltrate. Family history revealed marked variation in expression of the clinical features of the disease.

Femoral pain of solitary neurofibromatous origin: a report of three cases

Three patients, each with a solitary neurofibroma in the thigh, are described. The presenting complaint in each case was pain. A neurofibroma of a branch of the femoral nerve was found in two cases and an intraosseous neurofibroma of the femoral shaft was present in the third. An excellent recovery was observed in each of these three patients following surgical excision of the tumour. Attention is drawn to the unduly long interval between the onset of painful symptoms and the achievement of a clinical diagnosis leading to a surgical cure in each instance.

Fetal pancreatic hamartoma

Pancreatic masses are uncommon lesions in the newborn infant. The authors present the first reported case of neonatal pancreatic hamartoma and describe its interesting clinical, histologic, and radiographic aspects.