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Henson JW, Benkers T, McCormick C. Brainstem ischemic syndrome in juvenile NF2. Neurol Genet 2020; 6:e446. [PMID: 32637630 PMCID: PMC7323477 DOI: 10.1212/nxg.0000000000000446] [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: 03/21/2020] [Accepted: 04/22/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE A new case of brainstem ischemic necrosis in a young woman with de novo neurofibromatosis type 2 (NF2) is reported, and given notable similarities to 7 prior cases of brainstem stroke in the literature, features defining a possible syndrome were sought. METHODS Case review including detailed clinical assessment, neuroimaging analysis, genetic testing, and brain biopsy, followed by a multicase analysis. RESULTS Brainstem ischemia in juvenile NF2 typically occurs in teenagers without previously known NF2 as an acute, monophasic presentation with restricted diffusion in the midbrain or pons following a recent hypoperfusion event, normal vascular imaging, obvious intracranial imaging features of NF2, typical inactivating NF2 alterations, biopsy showing necrosis without small vessel pathology, and subsequent aggressive NF2 lesion progression. CONCLUSIONS Brainstem ischemia in juvenile NF2 is a rare syndrome of unclear etiology, possibly reflecting an unknown underlying vascular abnormality; a digenic effect is not excluded.
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Affiliation(s)
- John W Henson
- Swedish Neurofibromatosis Center (J.W.H); Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment (J.W.H., T.B.); and University of Washington School of Medicine (C.M.), Seattle
| | - Tara Benkers
- Swedish Neurofibromatosis Center (J.W.H); Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment (J.W.H., T.B.); and University of Washington School of Medicine (C.M.), Seattle
| | - Connor McCormick
- Swedish Neurofibromatosis Center (J.W.H); Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment (J.W.H., T.B.); and University of Washington School of Medicine (C.M.), Seattle
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Lascelles K, Afridi S, Siddiqui A, Hemingway C, Ferner R, Ganesan V. Cerebral vasculopathy in childhood neurofibromatosis type 2: cause for concern? Dev Med Child Neurol 2018; 60:1285-1288. [PMID: 29781505 DOI: 10.1111/dmcn.13920] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2018] [Indexed: 11/28/2022]
Abstract
Unlike adult neurofibromatosis type 2 (NF2), which presents with symptoms related to bilateral vestibular schwannomas, children with NF2 most frequently present with ocular, dermatological, and neurological symptoms. Arteriopathy, a well-established feature in neurofibromatosis type 1, is not a widely recognized feature of NF2. Here we report three children with NF2 with cerebral arteriopathy and/or arterial ischaemic stroke. Bevacizumab, a vascular endothethial growth factor inhibitor, is an established treatment for rapidly growing vestibular schwannomas; however, it carries a risk of both ischaemic and haemorrhagic stroke. Thus, the role of screening and risk to benefit ratio of bevacizumab in NF2 merit further consideration. WHAT THIS PAPER ADDS: Children with neurofibromatosis type 2 (NF2) may be at increased risk of cerebral vasculopathy and arterial ischaemic stroke. Targeted magnetic resonance angiography should be performed in children with NF2 who are being considered for bevacizumab therapy.
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Affiliation(s)
- Karine Lascelles
- Children's Neuroscience Centre, Evelina London Children's Hospital, London, UK.,Department of Neurology, National Neurofibromatosis Service, Guys and St Thomas, NHS Foundation Trust, London, UK
| | - Shazia Afridi
- Department of Neurology, National Neurofibromatosis Service, Guys and St Thomas, NHS Foundation Trust, London, UK
| | - Ata Siddiqui
- Children's Neuroscience Centre, Evelina London Children's Hospital, London, UK
| | - Cheryl Hemingway
- Department of Neurology, Great Ormond Street Children's Hospital, London, UK
| | - Rosalie Ferner
- Department of Neurology, National Neurofibromatosis Service, Guys and St Thomas, NHS Foundation Trust, London, UK
| | - Vijeya Ganesan
- Department of Neurology, Great Ormond Street Children's Hospital, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
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Anand G, Vasallo G, Spanou M, Thomas S, Pike M, Kariyawasam DS, Mehta S, Parry A, Durie-Gair J, Nicholson J, Lascelles K, Everett V, Gibbon FM, Jarvis N, Elston J, Evans DG, Halliday D. Diagnosis of sporadic neurofibromatosis type 2 in the paediatric population. Arch Dis Child 2018. [PMID: 29535107 DOI: 10.1136/archdischild-2017-313154] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Onset of symptoms in severe sporadic neurofibromatosis type 2 (NF2) is typically within childhood; however, there is poor awareness of presenting features in young children, potentially resulting in delayed diagnosis and poorer outcome. We have reviewed presentation of sporadic paediatric NF2 to raise awareness of early features, highlighting those requiring further investigation. DESIGN Patients diagnosed with NF2 at age ≤16 and seen between 2012 and 2015 were notified via the British Paediatric Neurology Surveillance Unit or identified through the English NF2 service. RESULTS Epidemiological data estimate that 1 in 110 611 births are affected with childhood-onset NF2. Notes of 32 patients with sporadic NF2 were reviewed. Of those presenting under the age of 5, 89% (17/19) had ocular, 74% (14/19) dermatological and 58% (11/19) neurological signs; in 84% (16/19) features were multisystemic. Sixty-six per cent (21/32) had ≥1 atypical feature, including cerebellar hypoplasia in three cases (9%) and focal cortical dysplasia in five out of seven seizure-related presentations. Five cases presented with a sometimes transient or intermittent cranial nerve mononeuropathy. The mean delay to diagnosis was 3.16 years; in eight cases (25%) this exceeded 6 years. Most significant delay occurred in mononeuropathy, ophthalmological and/or seizure presentations, with a mean delay of 3, 4.5 and 6 years, respectively. Eighty-four per cent (27/32) of cases needed intervention in childhood. CONCLUSIONS All non-vestibular schwannoma NF2 presentations in childhood had significant diagnostic delay. We emphasise the importance of detailed assessment of skin and eyes in unusual presentations and propose an aide to prompt timely referral to specialist services.
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Affiliation(s)
- Geetha Anand
- Department of Paediatrics, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Grace Vasallo
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maria Spanou
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Oxford, UK
| | - Saumya Thomas
- Department of Paediatrics, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael Pike
- Department of Paediatric Neurology, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Didu Sanduni Kariyawasam
- Department of Paediatric Neurology, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sanjay Mehta
- Department of Paediatrics, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Allyson Parry
- Department of Neurosciences, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Juliette Durie-Gair
- Department of ENT, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Nicholson
- Department of Paediatric Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Karine Lascelles
- Department of Paediatric Neurology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vanessa Everett
- Department of Paediatric Neurology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Frances Mary Gibbon
- Department of Paediatric Neurology, University Hospital of Wales, Cardiff, UK
| | - Nicola Jarvis
- Genomic Medicine, Division of Evolution and Genomic Sciences, MAHSC, University of Manchester, St Mary's Hospital, Manchester, UK
| | - John Elston
- Department of Ophthalmology, Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dafydd Gareth Evans
- Genomic Medicine, Division of Evolution and Genomic Sciences, MAHSC, University of Manchester, St Mary's Hospital, Manchester, UK
| | - Dorothy Halliday
- Oxford Centre for Genomic Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
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Afridi SK, Thomson S, Connor SEJ, Walsh DC, Ferner RE. Aneurysms in neurofibromatosis type 2: Evidence for vasculopathy? Am J Med Genet A 2017; 173:1562-1565. [DOI: 10.1002/ajmg.a.38221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 02/16/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Shazia K. Afridi
- Department of Neurology; Guy's and St. Thomas’ NHS Trust; London UK
| | - Suki Thomson
- Department of Radiology; King's College and Neurofibromatosis Unit; London UK
| | - Steve E. J. Connor
- Department of Radiology; King's College and Neurofibromatosis Unit; London UK
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Naik S, Shetty GS, Kumar S, Phadke RV. Leptomeningeal Angiomatosis in a Case of Neurofibromatosis Type 2: An Unusual Finding. Pediatr Neurosurg 2016; 51:79-82. [PMID: 26510155 DOI: 10.1159/000439437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 08/09/2015] [Indexed: 11/19/2022]
Abstract
Neurofibromatosis type 2 (NF2) is an autosomal dominant disorder characterised by multiple neoplasms of the central and peripheral nervous system associated with ocular abnormalities. Leptomeningeal angiomatosis has not been described with this tumour predisposition syndrome. This report documents an unusual association of leptomeningeal angiomatosis in a case of NF2.
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Affiliation(s)
- Suprava Naik
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Hornigold RE, Golding JF, Ferner RE, Ferner RE. Neurofibromatosis 2: a novel risk factor for hypertension? Am J Med Genet A 2011; 155A:1721-2. [PMID: 21638762 DOI: 10.1002/ajmg.a.34035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 03/12/2011] [Indexed: 11/12/2022]
Abstract
There are anecdotal reports of neurofibromatosis 2 (NF2) patients and vascular disease, but no previous studies have compared blood pressure (BP) in people with NF2 and in the general population. This study is the first to show that BP is significantly higher in patients with NF2 than in matched control patients. This is important for the management of patients with NF2, and in the differential diagnosis of secondary hypertension.
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Neurofibromatosis 2 [Bilateral acoustic neurofibromatosis, central neurofibromatosis, NF2, neurofibromatosis type II]. Genet Med 2009; 11:599-610. [PMID: 19652604 DOI: 10.1097/gim.0b013e3181ac9a27] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Neurofibromatosis 2 is a dominantly inherited tumor predisposition syndrome caused by mutations in the NF2 gene on chromosome 22. Affected individuals inevitably develop schwannomas typically affecting both vestibular nerves leading to deafness. Rehabilitation with brainstem implants is improving this outcome. Schwannomas also occur on other cranial nerves, on spinal nerve roots, and on peripheral nerves. Meningiomas and ependymomas are other tumor features. In excess of 50% of patients represent new mutations and as many as one third are mosaic for the underlying disease causing mutation. Although truncating mutations (nonsense and frameshifts) are the most frequent germline event and cause the most severe disease, single and multiple exon deletions are common. A strategy for detection of the latter is vital for a sensitive analysis. NF2 represents a difficult management problem with most patients facing substantial morbidity and reduced life expectancy. Surgery remains the focus of current management, although watchful waiting and occasionally radiation treatment have a role. In the future, the development of tailored drug therapies aimed at the genetic level are likely to provide huge improvements for this devastating, life limiting condition.
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Ng J, Mordekar SR, Connolly DJA, Baxter P. Stroke in a child with neurofibromatosis type 2. Eur J Paediatr Neurol 2009; 13:77-9. [PMID: 18406647 DOI: 10.1016/j.ejpn.2008.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 01/31/2008] [Accepted: 02/05/2008] [Indexed: 10/22/2022]
Abstract
Neurofibromatosis types 1 (NF1) and 2 (NF2) are genetically distinct conditions caused by mutations in tumour suppressor genes that share a number of phenotypic features. Childhood stroke and vasculopathy have been associated with NF1, but not with NF2. We describe a case of brainstem stroke in a child with NF2.
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Affiliation(s)
- Joanne Ng
- Department of Paediatric Neurology, Sheffield Children's Hospital, Western Bank, Sheffield, UK.
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Abstract
Renovascular disease is an uncommon but important cause of hypertension in children. It is usually diagnosed after a long delay because blood pressure is infrequently measured in children and high values are generally dismissed as inaccurate. Many children with renovascular disease have abnormalities of other blood vessels (aorta, cerebral, intestinal, or iliac). Individuals suspected of having the disorder can be investigated further with CT, MRI, or renal scintigraphy done before and after administration of an angiotensin-converting-enzyme inhibitor, but angiography is still the gold standard. Most children with renovascular disease will need interventional or surgical treatment. Endovascular treatment with or without stenting will cure or reduce high blood pressure in more than half of all affected children. Surgical intervention, if needed, should be delayed preferably until an age when the child is fully grown. Modern treatment provided by a multidisciplinary team of paediatric nephrologists, interventional radiologists, and vascular surgeons offers good long-term treatment results.
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Affiliation(s)
- Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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