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

Neurofibromatosis type 1 is not associated with subarachnoid haemorrhage

BACKGROUND

The prevalence of intracranial aneurysms (IAs) has been proposed to be elevated in the patients with neurofibromatosis type 1 (NF1). Our aims were to determine the prevalence of NF1 in a large Finnish population based cohort of IA patients and, on the other hand, the occurrences of subarachnoid haemorrhage and unruptured intracranial aneurysms in a nationwide population-based cohort of NF1 patients and its matched ten-fold control cohort.

METHODS

The Kuopio IA Database (www.kuopioneurosurgery.fi) includes all ruptured and unruptured IA cases admitted to the Kuopio University Hospital (KUH) from its defined Eastern Finnish catchment population since 1980. In this registry-based study, we cross-linked the Kuopio IA database with the Finnish national registry covering all hospital diagnoses. The NF1 diagnoses of the 4543 patients with either saccular of fusiform IA were identified from 1969 to 2015 and verified from patient records. Our second approach was to analyze the occurrence of aneurysmal subarachnoid haemorrhage (aSAH) and unruptured IAs in a nationwide population-based database of 1410 NF1 patients and its ten-fold matched control cohort (n = 14030) using national registry of hospital diagnoses between 1987 and 2014.

RESULTS

One NF1 patient was identified among the 4543 IA patients. Three verified IA cases (one unruptured IA and two aSAH cases) were identified in the cohort of 1410 NF1 patients, with similar occurrences in the control cohort.

CONCLUSIONS

We found no evidence in our population-based cohorts to support the conception that NF1 is associated with IAs. Our results indicate that the incidence of aSAH is not elevated in patients with NF1. Further studies are required to confirm that there is no association between NF1 and unruptured IAs.

A Review of the Genetics of Intracranial Berry Aneurysms and Implications for Genetic Counseling

Here we review the current understanding of the genetic architecture of intracranial berry aneurysms (IBA) to aid in the genetic counseling of patients at risk for this condition. The familial subtype of IBA, familial intracranial aneurysms (FIA), is associated with increased frequency of IBA, increased risk of rupture, and increased morbidity and mortality after rupture. Family history is the strongest predictor for the development of IBA. However, a genetic test is not yet available to assess risk within a family. Studies using linkage analysis, genome-wide association, and next-generation sequencing have found several candidate loci and genes associated with disease onset, but have not conclusively implicated a single gene. In addition to family history, a separate or concurrent diagnosis of autosomal dominant polycystic kidney disease is a strong genetic risk factor for IBA formation. We also discuss the relative risk for developing IBA in several Mendelian syndromes including vascular Ehlers-Danlos syndrome, Marfan syndrome, Neurofibromatosis Type I, and Loeys-Dietz syndrome.

Multiple aneurysms of the radial artery in a woman with neurofibromatosis type 1 presenting as aneurysm rupture

A 48-year-old woman with neurofibromatosis type 1 (NF1) experienced progressive forearm swelling coupled with impending compartment syndrome. Computed tomography angiography revealed a ruptured aneurysm of the proximal radial artery, multiple fusiform radial artery aneurysms, and a high independent ulnar artery origin. Compartment syndrome required prompt hematoma evacuation. Radial artery reconstruction, technically demanding due to vessel wall fragility, was deemed unnecessary because of satisfactory blood supply to the hand. Histologic findings indicated NF1-related vascular abnormalities also in the apparently normal radial artery as well as in a forearm vein, suggesting diffused vasculopathy. This case report is the first on ruptured radial artery aneurysm in NF1-related polianeurysmatic degeneration.

Giant extracranial aneurysm of the internal carotid artery in neurofibromatosis type 1. A case report and review of the literature

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.

Giant intercostal aneurysm complicated by Stanford type B acute aortic dissection in patients with type 1 neurofibromatosis

Vascular involvement is rare in neurofibromatosis type 1 (NF1). It is often missed because it is usually asymptomatic. We report a case of a 42 years old male with neurofibromatosis type 1 who presented with left back discomfort. CT angiography revealed a massive 42 mm aneurysm of left 11th intercostal artery. After a discussion between radiologists and cardiothoracic surgeons, endovascular coil embolization was chosen to treat this patient. Percutaneous aneurysm embolization was successfully performed. However, the procedure was complicated by Stanford type B acute aortic dissection. Stanford type B acute aortic dissection was medically managed and patient remained well after discharge. Fragile vascular nature was thought to be one of the causes of this unreported complication.

Rupture of a Left Internal Jugular Vein

A 60-year-old woman with neurofibromatosis type 1 presented with a nonpainful swelling in the left laterocervical region that had suddenly arisen after mild exertion the previous evening. Computed tomography with and without contrast enhancement revealed a rupture of the wall of the left internal jugular vein, with a diffuse subcutaneous hematoma. Postoperative histopathologic examination reported diffuse proliferation of plexiform neurofibromatous tissue within the vessel wall.

Internal Carotid Artery Aneurysms in a Patient With Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by café au lait macules, neurofibromas, and iris hamartomas. Internal carotid artery aneurysms rarely affect patients with NF-1 but may be associated with rupture or neurologic complications. We report a 42-year-old female patient with NF-1 and a bilobed right internal carotid artery aneurysm extending to C2. The aneurysm was excised with high exposure of the carotid artery and reconstruction was performed using saphenous vein graft. We review the literature relevant to internal carotid aneurysms associated with NF-1.

Giant extracranial aneurysms of both internal carotid arteries with aberrant jugular veins in a patient with neurofibromatosis type 1

Although neurofibromatosis type 1 (NF-1) is commonly considered neurocutaneous, severe arterial and venous abnormalities have been noted. Our patient, a 28-year-old woman, had bilateral giant extracranial aneurysms of the internal carotid arteries as well as skull base meningoceles involving the jugular foramina and aberrant jugular veins. CT and MR imaging, as well as digital subtraction and/or other angiography techniques, may be required to clarify pathology in patients with suggested vascular lesions.

Vascular abnormalities in patients with neurofibromatosis syndrome type I: clinical spectrum, management, and results

PURPOSE

Neurofibromatosis type I (NF-I) is an autosomal dominant disorder affecting one in 3000 individuals. Vascular abnormalities are a well-recognized manifestation of NF-I. The purpose of this study is to review the spectrum, management, and clinical outcome of patients with vascular abnormalities and NF-I.

METHODS

We retrospectively reviewed 31 patients (15 males, 16 females) with clinical NF-I and vascular abnormalities identified from imaging or operative findings between 1976 and 2005.

RESULTS

The diagnosis of NF-I was made at a mean age of 11 +/- 10 years with vascular lesions identified at a mean age of 38 +/- 16 years. There were 76 vascular abnormalities, including 38 aneurysms, 20 arterial stenoses, 5 arteriovenous malformations (AVM), 5 arteries compressed or invaded by neural tumors, and 6 abnormalities of the heart valves. Arterial lesions were located in the aorta (n = 17) and in the renal (n = 12), mesenteric (n = 12), carotid-vertebral (n = 10), intracerebral (n = 4), and subclavian-axillary and iliofemoral arteries (3 each). Interventions were required in 23 patients (74%); 15 underwent 24 arterial reconstructions, including 9 renal, 8 aortic, 4 mesenteric, 2 carotid, and 1 femoral. The other eight patients had excision of AVM in three, vessel ligation in two, and clipping of cerebral aneurysms, coil embolization of hepatic aneurysms, and left thoracotomy in one patient each. One patient died of ruptured abdominal aortic aneurysm. Six patients (26%) had postoperative complications, including pneumonia in two, and stroke, acalculous cholecystitis, brachial plexopathy and chylothorax in one patient each. The median follow up was 4.1 years (range, 6 months to 20 years). Late vascular problems developed in three patients, including graft stenoses in two and rupture of another aortic aneurysm in one. Freedom from graft-related complications was 83% at 10 years. Patient survival at 10 years was 77%, less than the 86% expected survival for the general population (P < .001).

CONCLUSION

Patients with NF-I have a wide spectrum of vascular abnormalities, most notably aneurysms or stenoses of the aortic, renal, and mesenteric circulation. Operative treatment of symptomatic patients with vascular lesions or large aneurysms is safe, effective, and durable.

Extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. A case report

SUMMARY

Extracranial vertebral artery aneurysm associated with neurofibromatosis (NF1) is very rare. The aneurysm was successfully treated by endovascular trapping of the aneurysm and proximal vertebral artery with coils.

Neurofibromatosis-associated nerve sheath tumors

In this paper the authors describe a patient with neurofibromatosis Type 1 (NF1) who presented with sequelae of this disease. They also review the current literature on NF1 and NF2 published between 2001 and 2005.

The method used to obtain information for the case report consisted of a family member interview and a review of the patient's chart. For the literature review the authors used the search engine Ovid Medline to identify papers published on the topic between 2001 and 2005. Neurofibromatosis Type 1 appears in approximately one in 2500 to 4000 births, is caused by a defect on 17q11.2, and results in neurofibromin inactivation. The authors reviewed the current literature with regard to the following aspects of this disease: 1) diagnostic criteria for NF1; 2) criteria for other NF1-associated manifestations; 3) malignant peripheral nerve sheath tumors (PNSTs); 4) the examination protocol for a patient with an NF1-related NST; 5) imaging findings in patients with NF1; 6) other diagnostic studies; 7) surgical and adjuvant treatment for NSTs and malignant PNSTs; and 8) hormone receptors in NF1-related tumors. Pertinent illustrations are included.

Neurofibromatosis Type 2 occurs much less frequently than NF1, that is, in one in 33,000 births. Mutations in NF2 occur on 22q12 and result in inactivation of the tumor suppressor merlin. The following data on this disease are presented: 1) diagnostic criteria for NF2; 2) criteria for other NF2 manifestations; 3) malignant PNSTs in patients with NF2; 4) examination protocol for the patient with NF2 who has an NST; and 5) imaging findings in patients with NF2. Relevant illustrations are included.

It is important that neurosurgeons be aware of the sequelae of NF1 and NF2, because they may be called on to treat these conditions.

Aneurisma da artéria vertebral extracraniana em puérpera portadora de neurofibromatose clássica

Paciente de 26 anos, no 10º dia de puerpério, apresentou dor súbita em região cervical esquerda irradiada para região supraclavicular do mesmo lado, seguida de aparecimento de massa pulsátil. Relatava hipertensão sistólica média de 160 mmHg, e diastólica média de 130 mmHg na gravidez e neurofibromatose. Ao exame físico, apresentava massa pulsátil em região supraclavicular esquerda, sem frêmitos e/ou sopros. Um alargamento do mediastino foi detectado através de raio-x de tórax. Uma tomografia computadorizada (região cervical e torácica) evidenciou tumoração em território de artéria subclávia esquerda na sua porção proximal, sem limites definidos pelo extravasamento de contraste, além de hemotórax gigante à esquerda. A paciente evoluiu com choque hipovolêmico, sendo submetida à cirurgia de urgência, com toracotomia seguida de cervicotomia, onde se evidenciou lesão aneurismática rota da artéria vertebral esquerda logo após sua emergência. Após controle do sangramento, procedeu-se à sua ligadura. A paciente evoluiu satisfatoriamente, estando em acompanhamento ambulatorial.

Frequency of incidental intracranial aneurysms in neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is often mentioned among the heritable connective tissue disorders associated with intracranial aneurysms, but the association has not been firmly established. We therefore reviewed a contemporary series of hospitalized patients with NF1, many of whom underwent brain magnetic resonance imaging (MRI). We identified patients with NF1 who were hospitalized at Cedars-Sinai Medical Center, Los Angeles, California, between January 1, 1997 and December 31, 2001 through the hospital's centralized medical records system using DRG codes. The mean age of the 39 patients was 30.4 years, and 22 patients had undergone MRI of the brain for the evaluation of symptoms due to the presence of central or peripheral nervous system tumors. Incidental intracranial aneurysms were detected in 2 (5%) of the 39 patients. Limiting the patient population to the 22 patients who had undergone MRI examination, the detection rate was 9%. This was significantly (P < 0.005) higher than the aneurysm detection rate in a control population (0/526 [0%]) of patients hospitalized for primary or secondary brain tumors, all of whom had undergone MRI examination. Our study suggests that patients with NF1 are at an increased risk of developing intracranial aneurysms.

EXTRACRANIAL VERTEBRAL ARTERY ANEURYSM RUPTURED INTO THE THORACIC CAVITY WITH NEUROFIBROMATOSIS TYPE 1: CASE REPORT

OBJECTIVE AND IMPORTANCE

We are sometimes involved in the care of patients with neurofibromatosis Type 1 because of the associated disorders of cervicocerebral vessels. However, extracranial vertebral artery aneurysm in neurofibromatosis Type 1 is very rare. We present the first reported case of a rupture of an extracranial vertebral artery aneurysm into the thoracic cavity in a patient with neurofibromatosis Type 1.

CLINICAL PRESENTATION

A 52-year-old woman who presented with a decrease in left-sided grip and numbness of the left upper limb was admitted. During history taking, she developed shock. Radiological examination revealed that a left extracranial vertebral artery aneurysm had ruptured into the thoracic cavity. With consciousness decreasing gradually because of hemorrhagic shock, the patient became comatose.

INTERVENTION

Balloon occlusion of the vertebral artery proximal to the aneurysm was performed and surgical ligation was attempted, but cardiac arrest occurred immediately after the beginning of surgery, and the patient died. The vertebral artery proximal to the aneurysm was removed for pathological examination.

CONCLUSION

In this case, the changes noted were interpreted as changes showing fragility of the vascular wall secondary to neurofibromatosis Type 1. Patients with neurofibromatosis Type 1 exhibit disorders of cervicocerebral vessels, and in some cases progression may follow a violent course. Periodic follow-up of such patients and early diagnosis are important.

Noninvasive evaluation of arterial abnormalities in young patients with neurofibromatosis type 1

Neurofibromatosis regroups at least two different autosomal dominant genetic disorders: neurofibromatosis type 1 (NF1) and neurofibromatosis type 2 (NF2). Vascular disease is an underestimated complication of NF1. Few studies are available on this, all based on case reports. Neurofibromin, NF1 protein product, has also been detected in aortic smooth muscle. The purpose of this study was to evaluate the physical properties of the vessels, by measuring the carotid-femoral pulse wave velocity (PWV). This parameter was assessed by the Complior, a new noninvasive, validated device, used to screen a large population. The authors studied 64 neurofibromatosis patients (34 boys and 30 girls) with a mean age of 12 years (range 5-25 years). To investigate the presence of vascular lesions, aortic stiffness was evaluated by carotid-femoral PWV by using an automatic processor (Complior). They compared data from the PWV with a control group (30 healthy children, 17 boys and 13 girls, mean age 11 years, range 5-23 years). The calculated mean PWV in the control group was 6.5 +/- 1.15 m/s. The mean PWV of the 64 young patients with NF1 was 6.3 +/- 1.02 m/s. There was no difference between the two groups (p=0.39). Nevertheless, analysis of the linear regression has shown a linear relationship between systolic blood pressure (SBP) and PWV in the control group, while in NF1 patients this relationship is not present. The authors suggest that the coexistence of different factors, such as intimal proliferation, thinning media, fragmentation of the elastic tissue, irregularity, stenosis and tortuosity of the vessels, dysplasia of the small vessels, that counterbalance PWV, normalize the mean value. They emphasize the importance of a careful vascular evaluation, using noninvasive method, such as Complior. This device is well accepted by NF1 patients.