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Gurses ME, Bahadir S, Bilginer B. Traumatic subgaleal hematoma in patient with Ehlers-Danlos syndrome: A rare case report. Surg Neurol Int 2022; 13:265. [PMID: 35855180 PMCID: PMC9282823 DOI: 10.25259/sni_186_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/01/2022] [Indexed: 11/15/2022] Open
Abstract
Background: A subgaleal hematoma (SGH) describes scalp bleeding in the potential space between the periosteum and the galea aponeurosis. This hematoma generally occurs after vacuum-assisted and forceps delivery, but may also be seen following head trauma. Despite its benign course, SGHs may complicate by life-threatening events. Case Description: We report a case of a 10-year-old male with Ehlers-Danlos syndrome presenting with scalp swelling following minor head trauma. On examination, a small swelling was observed in the occipital region. During the follow up, as the volume of subgaleal hematoma was increasing, we performed needle aspiration to achieve volume reduction, and dressed with a cap like bandage that wrapped and compressed scalp. The patient was hospitalized due to hemodynamic instability and a blood transfusion was performed. Due to extended usage of compressive bandage, a large area of scalp tissue became necrotic. The necrotic scalp tissue was debrided and reconstructed by plastic and reconstructive surgery. After surgery, another hematoma formed extending from the front of the ear to the ipsilateral neck caused facial paralysis, this hematoma was evacuated and a drain was placed. The patient was followed up for 1 year and no recurrent cephalhematoma was observed. Conclusion: Ehlers-Danlos is a rarely encountered connective tissue syndrome, this case underscores the importance for neurosurgery physicians to recognize the potential catastrophes, these patients may present with following even minor injury.
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Makam H, Siddiqui F, Patwardhan A, Darbar A. Peripartum considerations and challenges in the management of type IV Ehlers-Danlos syndrome. BMJ Case Rep 2021; 14:14/7/e239916. [PMID: 34330720 PMCID: PMC8327739 DOI: 10.1136/bcr-2020-239916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ehlers-Danlos syndrome (EDS) is an uncommon heterogenous autosomal dominant multisystemic connective tissue disorder, which may potentially present with life-threatening emergencies. The prevalence of EDS of all subtypes is from 1 in 10 000 to 1 in 20 000. Pregnancy in women with type IV EDS poses significant challenges, necessitating the care of multidisciplinary team. Potential complications of type IV EDS include arterial dissection, arterial aneurysm, visceral rupture, excessive bleeding, tissue fragility and delayed wound healing. We present an interesting case of a pregnant woman with type IV EDS who had previous cerebrovascular complications and had a successful delivery in our tertiary centre following a collaborative approach to her care.
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Affiliation(s)
- Hazarathamma Makam
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Farah Siddiqui
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Asmita Patwardhan
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Anil Darbar
- Department of Anaesthesia and Intensive Care Medicine, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
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Güven S, Kule O, Güleş D, Okumuş H, Oruç M, Celbiş O. Sudden death as a result of colon perforation; Ehlers-Danlos type IV case with postmortem diagnosis. J Forensic Leg Med 2020; 73:101969. [PMID: 32442117 DOI: 10.1016/j.jflm.2020.101969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/01/2020] [Accepted: 04/28/2020] [Indexed: 11/17/2022]
Abstract
Ehlers-Danlos Syndrome (EDS) is a connective tissue disease with heterogeneous subgroups. In type IV EDS, also known as vascular EDS (VEDS), the underlying genetic anomaly consists of a mutation of the COL3A1 gene encoding the type III procollagen. As a result of the mutation, pathological findings due to excessive brittleness of the tubular organs or vessels occur. In our case, we present a patient with sudden death due to colon perforation which was diagnosed with EDS type IV after further examination in the autopsy. Forensic medicine experts should consider the possibility of EDS type IV after the detection of spontaneous ruptures in the internal organs during the autopsy. We think that it would be appropriate to report this autosomal dominant and potentially fatal condition to family members.
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Affiliation(s)
- Salih Güven
- Forensic Council, Malatya Group Chairmanship, Malatya, Turkey
| | - Osman Kule
- Forensic Council, Malatya Group Chairmanship, Malatya, Turkey
| | - Duygu Güleş
- Forensic Council, Malatya Group Chairmanship, Malatya, Turkey
| | - Hasan Okumuş
- Forensic Council, Malatya Group Chairmanship, Malatya, Turkey
| | - Mucahit Oruç
- Inonu University, Faculty of Medicine, Depertmant of Forensic Medicine, Malatya, Turkey.
| | - Osman Celbiş
- Inonu University, Faculty of Medicine, Depertmant of Forensic Medicine, Malatya, Turkey
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Spontaneous Fatal Intraoperative Rupture of Great Vessel During Growing Rod Lengthening: Do Children With Ehlers-Danlos Syndrome Require the Availability of Vascular Expertise? A Case Report and Review of the Literature. J Pediatr Orthop 2017; 37:e4-e9. [PMID: 26422393 DOI: 10.1097/bpo.0000000000000656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ehlers-Danlos syndrome (EDS) is a family of inherited connective tissue diseases. Kyphoscoliotic EDS (kEDS) is associated with severe and early spinal deformity. Very little has been reported regarding the orthopaedic surgical care of kEDS likely due to its rare incidence. A more common subtype is the vascular-type EDS (vEDS, previously labeled type IV), which is associated with reports of vascular complications in the literature. METHODS The case report of a single, fatal complication of spontaneous rupture of the superior vena cava, after extubation, subsequent to revision minimal growing rod lengthening in a child with kEDS. We additionally review prior reported cases of kEDS for pediatric spine surgery and the sentinel event of spontaneous vascular rupture in all EDS patients. RESULTS The anterior thoracoabdominal approach in children with kEDS has been associated with severe intravascular complications, with no deaths reported to date. Posterior spinal procedures were associated with frequent overall complications, but no events of perioperative or spontaneous vascular injury were identified before our case.Reports of spontaneous vessel rupture (n=39) appear more frequently in vEDS, but have been documented in patients with EDS type I (classic EDS or cEDS) and kEDS disease. The 30-day mortality in these patients was 59%. The majority of the deaths occurred on the day of the vascular event. Surviving patients overwhelmingly received intraoperative consultation and treatment from either general or vascular surgeons at their respective institutions for assistance. CONCLUSIONS Providers should consider their proximity to available emergent consultation before operating on patients with EDS of any subtype. LEVEL OF EVIDENCE Level V-expert opinion.
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Wiesmann T, Castori M, Malfait F, Wulf H. Recommendations for anesthesia and perioperative management in patients with Ehlers-Danlos syndrome(s). Orphanet J Rare Dis 2014; 9:109. [PMID: 25053156 PMCID: PMC4223622 DOI: 10.1186/s13023-014-0109-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/02/2014] [Indexed: 01/29/2023] Open
Abstract
Ehlers-Danlos syndrome (EDS, ORPHA98249) comprises a group of clinically and genetically heterogeneous heritable connective tissue disorders, chiefly characterized by joint hypermobility and instability, skin texture anomalies, and vascular and soft tissue fragility. As many tissues can be involved, the underlying molecular defect can manifest itself in many organs and with varying degrees of severity, with widespread implications for anesthesia and perioperative management. This review focuses on issues relevant for anesthesia for elective and emergency surgery in EDS. We searched the literature for papers related to all EDS variants; at the moment most of the published data deals with the vascular subtype and, to a lesser extent, classic and hypermobility EDS. Knowledge is fragmented and consists mostly of case reports, small case series and expert opinion. Because EDS patients commonly require surgery, we have summarized some recommendations for general, obstetrical and regional anesthesia, as well as for hemostatic therapy.
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Abstract
OBJECTIVE To provide the collected evidence from all literature reports. BACKGROUND Vascular Ehlers-Danlos syndrome (EDS) is a rare connective tissue disorder with serious hemorrhagic consequences. Most experience on treatment is based on case reports and small case series. METHOD A systematic literature review was performed. PubMed and reference lists were scrutinized. RESULTS A total of 231 patients were identified with no gender preponderance. Aneurysms were present in 40%, often multiple. In 33%, there was an arterial rupture without an underlying aneurysm. Carotidocavernous fistula was seen in 18%. After open surgery the mortality was 30%; after endovascular procedures, it was 24%; in a group of miscellaneous cases, it was 60%; and the overall mortality was 39%. The median age of patients at death was 31 years. The median follow-up time was 12 months (5 days-7 years), but in 20% cases, it was not reported. In only 29 of the 119 recent patients (24%) the mutation was verified with molecular genetic testing. CONCLUSIONS Vascular EDS is a serious disorder with high mortality, which does not seem to have been influenced by new treatment methods. Invasive methods should be used only when necessary, primarily to save the patients' life. Whenever possible, the genetic molecular defect should be identified. The results of this review may be affected by publications bias. Ideally, a prospective registry should be created.
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Shields LBE, Rolf CM, Davis GJ, Hunsaker JC. Sudden and unexpected death in three cases of Ehlers-Danlos syndrome type IV. J Forensic Sci 2010; 55:1641-5. [PMID: 20707836 DOI: 10.1111/j.1556-4029.2010.01521.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ehlers-Danlos syndrome (EDS) type IV is a connective tissue disorder characterized by the inability to produce sufficient amounts of collagen or a defect in the structure of collagen. The most serious complications include a rupture of a viscus or vascular rupture with or without mural dissection. Death may result from internal hemorrhage. This report describes three cases of sudden and unexpected death caused by EDS type IV. Two cases involved hemothorax as a result of dissection of the subclavian artery and aorta, respectively. The third case represented spontaneous pulmonary rupture and hemorrhage. A detailed family history should be sought, and additional specimens collected to confirm the diagnosis, including skin fibroblasts for collagen testing and blood for DNA testing. The forensic pathologist should consider the possibility of EDS type IV upon discovery of spontaneous visceral or arterial rupture and should alert the family members of this hereditary and potentially fatal condition.
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Affiliation(s)
- Lisa B E Shields
- Medicolegal Research Associate, Norton Neuroscience Institute, 210 E. Gray Street, Suite 1105, Louisville, KY, USA
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Badauy CM, Gomes SS, Sant'Ana Filho M, Chies JAB. Ehlers-Danlos syndrome (EDS) type IV: review of the literature. Clin Oral Investig 2007; 11:183-7. [PMID: 17221206 DOI: 10.1007/s00784-006-0092-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Accepted: 12/04/2006] [Indexed: 10/23/2022]
Abstract
Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue heritable disorders. EDS type IV is a rare form that presents typical clinical signs, such as easy bruising and haematomas at sites of trauma, skin manifestations (translucent skin with visible veins), and joint hyperlaxity. To illustrate the dermatological features and describe an aggressive periodontitis, a symptom not yet reported in this EDS type, we present a case of a 23-year-old young man. This patient has been suffering from bruised skin, haematomas, and varicose veins in his legs. These lesions, typical of EDS type IV, were associated with trauma followed by slow and difficult cicatrization. Teeth loss and clinical attachment loss in all the remaining teeth, a symptom compatible with a severe destruction of the periodontal support, was reported after orthodontic treatment. The treatment is limited to control the disease and teeth loss. Considering this new clinical symptom associated with EDS type IV, we suggest that the use of orthodontic apparatus should be carefully considered in such patients.
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Affiliation(s)
- Cristiano Macabu Badauy
- Department of Oral Pathology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
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Abstract
Vascular Ehlers-Danlos syndrome (EDS) is a life-threatening inherited disorder of connective tissue causing severe arterial and gastrointestinal fragility and rupture, as well as complications of surgical and radiologic interventions. The diagnosis should be considered in patients under the age of 45 years who present with arterial tearing or dissection, colonic perforation, or visceral rupture. As for many orphan diseases, delayed diagnosis can lead to inaccurate care. Therefore, vascular EDS is particularly important to surgeons, radiologists, and obstetricians because knowledge of the diagnosis may help in the management of visceral complications. There are currently no specific treatments for this genetic condition, and medical intervention is limited to symptomatic treatment, precautionary measures, genetic counseling, and prenatal diagnosis. A clinical trial is ongoing to study the effectiveness of beta blockers with vasodilating properties in vascular EDS. Complications require hospitalization, observation in an intensive care unit, and sometimes emergency surgical intervention. CT, echography, and MRI are the most useful imaging modalities. Arteriography is contraindicated. Whenever possible, a wait-and-see attitude with close surveillance is preferable to unwarranted surgery. Surgical treatment carries a high mortality, whereas the mortality rate associated with endovascular treatment is unknown. To improve the likelihood of good surgical outcome, the surgeon must be informed of the patient's condition. The intent of surgery is to control hemorrhage if an artery, with or without aneurysm, has ruptured and to reconstruct the arterial vasculature. For vascular repair, simple procedures should be preferred, because more complex techniques can result in further injury and hemorrhage. Postoperative surveillance must be prolonged with close medical follow-up and serial CT scans. Pregnant women with vascular EDS should be considered high-risk cases and be provided special care.
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Affiliation(s)
- Dominique P Germain
- Clinical Genetics Unit, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris 75015, France.
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Abstract
Vascular Ehlers-Danlos syndrome, also known as Ehlers-Danlos syndrome type IV, is a life-threatening inherited disorder of connective tissue, resulting from mutations in the COL3A1 gene coding for type III procollagen. Vascular EDS causes severe fragility of connective tissues with arterial and gastrointestinal rupture, and complications of surgical and radiological interventions. As for many rare orphan diseases, delay in diagnosis is common, even when the clinical features are typical, leading to inadequate or inappropriate treatment and management. In childhood many individuals with vascular EDS are first thought to have coagulation disorders. In adulthood, four main clinical findings, including a striking facial appearance, easy bruising, translucent skin with visible veins and rupture of vessels, gravid uterus or intestines, contribute to the diagnosis, which can be confirmed by SDS-PAGE studies of type III procollagen molecules synthesis by cultured fibroblasts or by the identification of a mutation in the COL3A1 gene coding for type III procollagen. Vascular EDS is inherited as an autosomal dominant trait. Varied molecular mechanisms have been observed and, of the mutations described to date, most have been unique to each family or "private", with no correlation between genotype and phenotype. Vascular EDS is of particular importance to surgeons, radiologists, obstetricians and geneticists since, although there is currently no specific treatment for the condition, knowledge of the diagnosis may help in the management of visceral complications, pregnancy and genetic counseling.
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Affiliation(s)
- Dominique P Germain
- Clinical Genetics Unit, Hôpital Européen Georges-Pompidou, 20, rue Leblanc, 75015, Paris, France.
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De Felice C, Bianciardi G, DiLeo L, Latini G, Parrini S. Abnormal oral vascular network geometric complexity in Ehlers-Danlos syndrome. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.tripleo.2004.06.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Restrepo R, Ranson M, Chait PG, Connolly BL, Temple MJ, Amaral J, John P. Extracranial aneurysms in children: practical classification and correlative imaging. AJR Am J Roentgenol 2003; 181:867-78. [PMID: 12933496 DOI: 10.2214/ajr.181.3.1810867] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ricardo Restrepo
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada M5G 1X8
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Munz W, Schlembach D, Beinder E, Fischer T. Ehlers-Danlos syndrome type I in pregnancy: a case report. Eur J Obstet Gynecol Reprod Biol 2001; 99:126-8. [PMID: 11604202 DOI: 10.1016/s0301-2115(01)00350-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- W Munz
- Department of Gynecology and Obstetrics, University of Erlangen-Nuremberg, Unviersitaetsstrasse 21-23, 91054 Erlangen, Germany
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Bloch R, Hoffer E, Borsa J, Fontaine A. Ehlers-Danlos syndrome mimicking mesenteric vasculitis: therapy, then diagnosis. J Vasc Interv Radiol 2001; 12:527-9. [PMID: 11287544 DOI: 10.1016/s1051-0443(07)61896-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The etiology of acute intraabdominal bleeding is often unclear at the time emergent arteriography is performed. During localization and embolization, the arteriogram may suggest the diagnosis of vasculitis. However, controlling the bleeding remains the priority. Connective tissue diseases such as Ehlers-Danlos syndrome (EDS) may also cause bleeding and mimic vasculitis and must be included in the differential diagnosis. We present such a case in which the initial findings were misleading.
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Affiliation(s)
- R Bloch
- Department of Radiology, Box 358728, University of Washington School of Medicine, Harborview Medical Center, 325 9th Ave., Seattle, WA 98104, USA.
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Affiliation(s)
- P Gupta
- Department of Accident & Emergency, St George's Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK.
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Abstract
Current concepts in the pathophysiology and predisposing conditions of acute aortic dissection in children, adolescents, and young adults are presented. Timely diagnosis is required for this life-threatening condition. Most children and adolescents with aortic dissection have congenital cardiovascular anomalies. Certain heritable disorders involving connective tissue also predispose to this disorder. Newer associations include cocaine abuse and weight lifting. To facilitate early diagnosis, the salient physical findings of the known predisposing conditions are reviewed. Clinical presentation and diagnostic imaging of aortic dissection are briefly summarized. Physicians working in an acute care setting, particularly in the emergency room, should be aware of disorders predisposing to acute aortic dissection in the pediatric and young adult population. Practitioners conducting school or college preparticipation sports evaluations can make use of such information in their assessment of risk for sudden death.
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Affiliation(s)
- C R Fikar
- New York College of Podiatric Medicine, NY 10035, USA
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