Aortic aneurysms in children and young adults with tuberous sclerosis: report of two cases and review of the literature

Exploring Cardiovascular Involvement in Tuberous Sclerosis: Insights for Pediatric Clinicians

Tuberous sclerosis is a rare genetic disorder involving mainly the nervous and cardiovascular systems. The early recognition of the cardiovascular manifestations by the pediatrician allows an appropriate management and therefore enhances the quality of life of the affected children. Cardiac rhabdomyomas and the associated arrhythmias are the first cardiac features and they might represent a diagnosis challenge given their wide spectrum of clinical manifestations. We aimed to provide the paediatric practitioners with current knowledge regarding the cardiovascular complications in children with tuberous sclerosis. We overviewed the antenatal and postnatal evolution of cardiovascular manifestations, the systematic screening and long-term follow-up strategy of cardiac rhabdomyomas and arrhythmias in children with tuberous sclerosis.

Saccular abdominal aortic aneurysm in adolescence with tuberous sclerosis

Key clinical message

Abdominal aortic aneurysm complicated by tuberous sclerosis is rare, particularly in patients over the age of 10. It is important to screen for abdominal aortic aneurysm in adolescents diagnosed with tuberous sclerosis regularly.

Abstract

A 15-year-old girl who was diagnosed with tuberculous sclerosis complicated with a saccular aortic abdominal aneurysm (AAA), measuring 19 × 18 mm in diameter. The patient underwent open repair of AAA using a 11 mm straight prosthetic graft. It is important to screen for AAA in adolescents diagnosed with tuberous sclerosis regularly.

Open repair of a ruptured abdominal aorta with an aortoiliac vein fistula in a 7-month-old infant and review of the literature

Ruptured abdominal aortic aneurysms are extremely rare in the pediatric population. In this video case report, we describe the successful repair of a ruptured abdominal aortic aneurysm in a 7-month-old female infant.

An Autopsy Case of Abdominal Aortic Aneurysm in a Pediatric Decedent With Tuberous Sclerosis Complex

ABSTRACT

Vascular involvement in tuberous sclerosis complex (TSC) is uncommon and even more so in pediatric patients. When asymptomatic, these vascular abnormalities carry increased risk of rupture with increased morbidity and mortality. Here, we describe a case of a ruptured unrecognized abdominal aortic aneurysm in an 11-month-old patient with a history of TSC. The abdominal aortic aneurysm was discovered at autopsy and highlights the rarity of abdominal aortic aneurysm in pediatric patients diagnosed with TSC and the importance of screening for associated aneurysmal disease in the pediatric population with TSC. Furthermore, the extensive retroperitoneal hemorrhage seen in this case also highlights a rare but potential mimic of abuse in the pediatric population.

Open Emergency Repair of a Thoracoabdominal Aortic Aneurysm on a 12-Year-Old Boy With Tuberous Sclerosis

Tuberous sclerosis complex is a neurocutaneous syndrome caused by an autosomal dominant genetic disorder. This condition can lead to the expression of many vascular anomalies especially, in the pediatric population. Likewise, it has been linked with aortic aneurysm development. We report a case of a 12-year-old boy who presented a 97 × 70 mm Crawford type IV thoracoabdominal aortic aneurysm. Satisfactory open surgical repair was performed with an 18-mm multibranched dacron tube graft. Clinical and imaging findings revealed a de novo tuberous sclerosis diagnosis. The patient was discharged uneventfully during a 1-month follow-up.

Recurrent symptomatic aortic aneurysm in a young girl with tuberous sclerosis complex and review of the literature

An abdominal aortic aneurysm is a rare occurrence in pediatric populations. When present, it is usually associated with an underlying etiology such as a connective tissue disorder, inflammatory process, or noninflammatory medial degeneration. In the present report, we describe the case of a girl with tuberous sclerosis complex who underwent successful emergency open repair of a symptomatic infrarenal abdominal aortic aneurysm and recurrent type IV thoracoabdominal aortic aneurysm.

Multiple Interventions to Thoracoabdominal Aortic Aneurysm in a Child With Tuberous Sclerosis

Thoracoabdominal aortic aneurysms in toddlers are extremely rare. However, we experienced an extent III thoracoabdominal aortic aneurysm in a boy with tuberous sclerosis who underwent 3 open repairs and 1 endovascular aortic repair between the ages of 4 years and 18 years. This case highlights the potential for severe recurrent vascular aneurysms in the thoracic and abdominal aorta as a complication of tuberous sclerosis in children. Although aortic aneurysms in children are rare, it is vital to recognize these cases to prevent death due to rupture.

Computed tomography for aortic assessment in children

Because the aorta is the major vessel of the body, basic knowledge of aortic pathology is essential to the pediatric imager. This review divides aortic pathology into anatomical (e.g., congenital abnormalities) and acquired (e.g., vasculitis, trauma) entities, providing a brief description of pathology, technical considerations in CT acquisition and processing, and some pearls and pitfalls of interpretation. The objective of this paper is to familiarize general pediatric imagers with imaging features of common as well as high-impact aortic pathology on CT and prepare them for acquisition and reporting.

Abdominal aortic aneurysm in a child with tuberous sclerosis

Abdominal aortic aneurysm is rare in the pediatric population and even more uncommon in association with tuberous sclerosis. We have presented a unique case of a 3-year, 8-month-old girl who was successfully treated. She was admitted because of breakthrough seizures. A painless pulsatile abdominal mass on examination prompted an abdominal ultrasound scan, which identified a large saccular abdominal aortic aneurysm. Urgent replacement of the abdominal aorta with a 12-mm woven Dacron graft was undertaken. A postoperative ultrasound evaluation confirmed the successful repair. She was growing well when examined 7 months after surgery.

Popliteal artery aneurysm in a 14-year-old boy with tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is rarely associated with aneurysms. We have described a patient with a popliteal artery aneurysm that was associated with TSC and occlusion of the right posterior tibial artery. The patient underwent aneurysm resection and vein graft replacement, with an uneventful postoperative course and no recurrence at 11 months of follow-up. Patients with TSC could have aneurysms in areas that will not be recognized on abdominal imaging. Physical examination of the lower extremities should be performed owing to the possibility of a popliteal artery aneurysm, and imaging studies should be performed if an aneurysm is suspected.

Endovascular Repair of a Descending Thoracic Aortic Aneurysm in a Pediatric Patient with Tuberous Sclerosis: A Case Report and Review of the Literature

Aortic aneurysm in children is rare, but has been described in the tuberous sclerosis complex (TSC) population. While surgical repair has been utilized as the primary means of intervention, we present the first known case reporting exclusion of a descending thoracic aortic aneurysm with percutaneous covered stent implantation in a pediatric patient with TSC. A review of the literature is also included herein.

Aortic Thrombus Embolization in A Patient with Tuberous Sclerosis

Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder affecting many organ systems. Patients commonly develop a variety of benign tumors as well as neurological disease, including seizures, autism, and cognitive delay. We report here the case of an adolescent patient with TSC and a history of mild COVID-19 who presented with a 1-day history of altered mental status. The patient was found to have ischemic cerebral infarction of the right MCA and ACA territories. Initial angiography showed an occlusion of the right internal carotid artery without a demonstrable etiology, with follow-up echocardiography and angiography revealing a large aortic thrombus. The patient was not a candidate for thrombus removal due to her cerebral infarct and received medical anticoagulation. Thrombosis progressed to involve the left ICA, with left cerebral infarction and subsequent death. Aortic thrombus embolization as a cause of cerebrovascular accident (CVA) is a novel finding in the setting of TSC and should be considered for pediatric patients with CVA of unknown etiology. It is unclear whether this was related to the prior COVID-19 infection.

Increased depression risk in patients with abdominal aortic aneurysm: a nationwide cohort study

Purpose

Abdominal aortic aneurysm (AAA) is a critical disease. Most studies of AAA consider reoperation rate, complications, or mortality, but do not consider a patient's mental state. However, there is a possibility of interaction between AAA and depression in disease development and prognosis. We investigated the incidence and risk ratio of depression in patients with AAA using nationwide data.

Methods

We selected subjects from National Health Insurance System database who were diagnosed with AAA between 2009 and 2015 and survived at least 1 year after diagnosis or AAA surgery (n = 10,373). We determined the control group using propensity score matching by age and sex. The control group had about 3 times the number of subjects as the AAA cohort (n = 31,119).

Results

The incidence of depression was 1.4 times higher in the AAA group than the control group. We further analyzed the incidence of depression in the AAA group according to treatment modalities (nonsurgical vs. surgical or nonsurgical vs. open surgical aneurysm repair vs. endovascular aneurysm repair) but found no significant difference among them. The incidence of depression was significantly higher in patients aged <65 years than in patients aged ≥65 years (hazard ratio, 1.539 vs. 1.270; P < 0.001).

Conclusion

The incidence of depression was higher in the AAA group, with an especially high risk for depression in patients aged <65 years. The psychiatric status of patients with AAA should be carefully monitored for clinicians to intervene when appropriate.

A Rare Case of Homocysteinemia Presenting With Multiple Aneurysms in an Adolescent Boy

Thoracoabdominal aortic aneurysm (TAAA) is primarily a disorder of the elderly; the condition, however, is rare in children, for whom the misdiagnosis is not uncommon. It is one of the leading causes of death in the older age group worldwide, with a 4:1 male to female ratio. There are no real data about the incidence of aortic aneurysms in childhood. Although rare, an aortic aneurysm can be an important cause of mortality in children and adolescents. We present a case of an adolescent boy with a left coronary artery aneurysm, left axillary artery aneurysm, and TAAA type-IV caused by the metabolic disease homocysteinemia. He was referred to our facility when the complicated picture of the disease was discovered.

Resolving the biological paradox of aneurysm formation in children with tuberous sclerosis complex

Aortic aneurysms are rare manifestations in children with tuberous sclerosis complex (TSC) with life threating implications. Although an association between TSC, aortic and other aneurysms has been recognized, mechanistic insights explaining the pathophysiology behind aneurysm development and genetic aberrations in TSC have so far been lacking. Here, we summarize existing knowledge on aneurysms in TSC and present a case of a 2-year-old boy with an infrarenal aortic aneurysm, successfully treated with open aortic reconstruction. Histologic examination of the excised aneurysm wall showed distortion of vessel wall structure with loss of elastin and a pathologic accumulation of smooth muscle cells. Until now, these pathologic features have puzzled researchers as proliferating smooth muscle cells would rather be expected to preserve vessel wall integrity. Recent reports exploring the biological consequences of the dysregulated intracellular signaling pathways in patients with TSC provide plausible explanations to this paradox, which may support the development of future therapeutic strategies.

TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.

Simultaneous rupture of two renal artery aneurysms in a patient with tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem neurocutaneous genetic condition. It is characterized by TSC-associated neuropsychiatric disorders, epilepsy, tumors, and angiomyolipoma in multiple organs, such as the skin, lungs, and kidneys. TSC is also associated with the development of aneurysms of the medium and large arteries, including the renal arteries. This condition will usually be diagnosed early in life, and active surveillance is required of tumor and aneurysm growth to prevent life-threatening events. We have presented the case of a 41-year-old patient with TSC that had not been previously diagnosed. The patient had presented with retroperitoneal hematoma secondary to the rupture of two left renal artery branch aneurysms that had likely developed within the angiomyolipoma.

Ruptured abdominal aortic aneurysm in an 11-year-old with multiple peripheral artery aneurysms

Pediatric abdominal aortic aneurysms (AAAs) are rarely encountered in clinical practice. The combination of a pediatric AAA in a patient with multiple peripheral artery aneurysms is even more rare. We report the management of an 11-year-old boy who presented with a ruptured AAA who also had multiple peripheral arterial aneurysms. Infectious, genetic, and inflammatory workup was negative, classifying this aneurysm as congenital.

A systematic review on the burden of illness in individuals with tuberous sclerosis complex (TSC)

Objective

This review will summarize current knowledge on the burden of illness (BOI) in tuberous sclerosis complex (TSC), a multisystem genetic disorder manifesting with hamartomas throughout the body, including mainly the kidneys, brain, skin, eyes, heart, and lungs.

Methods

We performed a systematic analysis of the available literature on BOI in TSC according to the PRISMA guidelines. All studies irrespective of participant age that reported on individual and societal measures of disease burden (e.g. health care resource use, costs, quality of life) were included.

Results

We identified 33 studies reporting BOI in TSC patients. Most studies (21) reported health care resource use, while 14 studies reported quality of life and 10 studies mentioned costs associated with TSC. Only eight research papers reported caregiver BOI. Substantial BOI occurs from most manifestations of the disorder, particularly from pharmacoresistant epilepsy, neuropsychiatric, renal and skin manifestations. While less frequent, pulmonary complications also lead to a high individual BOI. The range for the mean annual direct costs varied widely between 424 and 98,008 International Dollar purchasing power parities (PPP-$). Brain surgery, end-stage renal disease with dialysis, and pulmonary complications all incur particularly high costs. There is a dearth of information regarding indirect costs in TSC. Mortality overall is increased compared to general population; and most TSC related deaths occur as a result of complications from seizures as well as renal complications. Long term studies report mortality between 4.8 and 8.3% for a follow-up of 8 to 17.4 years.

Conclusions

TSC patients and their caregivers have a high burden of illness, and TSC patients incur high costs in health care systems. At the same time, the provision of inadequate treatment that does not adhere to published guidelines is common and centralized TSC care is received by no more than half of individuals who need it, especially adults. Further studies focusing on the cost effectiveness and BOI outcomes of coordinated TSC care as well as of new treatment options such as mTOR inhibitors are necessary.

A Rare Case of an Abdominal Aneurysm in a Patient with Lymphangioleiomyomatosis: A Case Report

INTRODUCTION

Lymphangioleiomyomatosis (LAM) is a multisystemic disorder characterized by the proliferation, metastasis, and infiltration of smooth muscle cells in the lung and other tissues. Although LAM is rarely seen in men, it is usually detected in women during the third decade of life. Renal microaneurysms have been reported in patients with LAM, but abdominal aneurysms have not. We describe a patient with a diagnosis of LAM who had an unusual aneurysm in the inferior pancreaticoduodenal artery.

CASE PRESENTATION

A 47-year-old Ecuadorian woman self-referred for a routine visit to her family physician. She had a history of allergy to nonsteroidal anti-inflammatory drugs, pneumothorax, bilateral pleurodesis, and LAM since 2007. For her annual follow-up, an ultrasonogram was recommended. The abdominal ultrasonographic report described "a mass with blood flow in the midabdomen." An abdominal computed tomography angiogram was performed and revealed a 2.6-cm aneurysm of the inferior pancreaticoduodenal artery. After diagnosis of arterial aneurysm, she underwent transcatheter arterial embolization and stent placement. She is currently healthy and carries out her activities normally.

DISCUSSION

Lymphangioleiomyomatosis is a rare lung disease of unknown etiology. Extrapulmonary manifestations include abdominal aneurysm. This type of lesion should be added to a search for aneurysms in all patients with LAM.

Thoracic aortic aneurysm in a patient with tuberous sclerosis

Tuberous sclerosis is a genetic disease with autosomal dominant transmission. Its classic presentation comprises epilepsy, mental deficiencies, and sebaceous adenomas. Aneurysms of the aorta can be detected in people with tuberous sclerosis ranging from children a few months old to young adults. We report the case of a young patient diagnosed with a saccular thoracic aortic aneurysm and tuberous sclerosis who was successfully treated using an endovascular approach.

Tuberous sclerosis complex: new insights into clinical and therapeutic approach

Tuberous sclerosis complex (TSC) is a complex disease with many different clinical manifestations. Despite the common opinion that TSC is a rare condition, with a mean incidence of 1/6000 live births and a prevalence of 1/20,000, it is increasingly evident that in reality this is not true. Its clinical sequelae span a range of multiple organ systems, in particular the central nervous system, kidneys, skin and lungs. The management of TSC patients is heavily burdensome in terms of time and healthcare costs both for the families and for the healthcare system. Management options include conservative approaches, surgery, pharmacotherapy with mammalian target of rapamycin inhibitors and recently proposed options such as therapy with anti-EGFR antibody and ultrasound-guided percutaneous microwaves. So far, however, no systematically accepted strategy has been found that is both clinically and economically efficient. Thus, decisions are tailored to patients' characteristics, resource availability and clinical and technical expertise of each single center. This paper reviews the pathophysiology and the clinical (diagnostic-therapeutic) management of TSC.

Thoracoabdominal imaging of tuberous sclerosis

Imaging of tuberous sclerosis complex has rapidly evolved over the last decade in association with increased understanding of the disease process and new treatment modalities. Tuberous sclerosis complex is best known for the neurological symptoms and the associated neuroimaging findings, and children with tuberous sclerosis complex require active surveillance of associated abnormalities in the chest, abdomen and pelvis. Common findings that require regular imaging surveillance are angiomyolipomas in the kidneys and lymphangioleiomyomatosis in the chest. However multiple rarer associations have been attributed to tuberous sclerosis complex and should be considered by radiologists reviewing any imaging in these children. In this review the authors discuss the spectrum of imaging findings in people with tuberous sclerosis complex, focusing on MR imaging findings in the chest, abdomen and pelvis.

Hereditary Renal Cystic Disorders: Imaging of the Kidneys and Beyond

The purpose of this article is to review the hereditary renal cystic diseases that can manifest in children and adults, with specific attention to pathogenesis and imaging features. Various common and uncommon hereditary renal cystic diseases are reviewed in terms of their underlying etiology, including the involved genetic mutations and the affected proteins and cellular structures. Focus is placed on the morphologic findings in each condition and the features that distinguish one disorder from another. The two most common categories of hereditary renal cystic disease are (a) the ciliopathic disorders, which are related to mutations affecting the primary cilia (called "ciliopathies"), and (b) the phakomatoses. Autosomal dominant polycystic kidney disease, autosomal recessive polycystic kidney disease, and the "medullary cystic disease complex" are all ciliopathies but have different phenotypes. Tuberous sclerosis complex and the associated "contiguous gene syndrome," as well as von Hippel-Lindau syndrome, are phakomatoses that can manifest with cystic renal lesions but have uniquely different extrarenal manifestations. Finally, DICER1 mutations can manifest with renal cystic lesions (typically, cystic nephromas) in patients predisposed to other malignancies in the chest, ovaries, and thyroid. Although some overlap exists in the appearance of the renal cysts associated with each of these diseases, there are clear morphologic differences (eg, cyst size, location, and complexity) that are emphasized in this review. To improve patient outcomes, it is important for the radiologist to recognize the various hereditary renal cystic diseases so that a correct diagnosis is assigned and so that the patient is adequately evaluated and followed up. ^©RSNA, 2017.

Open Repair for Abdominal Aortic Aneurysm in a Young Boy with Tuberous Sclerosis and Review of the Literature

BACKGROUND

Abdominal aortic aneurysms (AAAs) are very rare in pediatric patients and can rarely be associated with tuberous sclerosis (TS). Open surgery is the first-line therapy. We report our experience added by a review on current literature.

CASE REPORT

A 9-year-old boy with TS and history of 2 earlier open repairs for AAA presented to our department with a recurrent juxtarenal aortic aneurysm. We performed a polytetraflourethylene patch plasty. Postoperative course was uneventful. After 8 months, reconstruction was stable, and no recurrent aneurysm developed.

CONCLUSIONS

Recurrent aneurysms may develop after open surgery for TS-associated AAA. However, open surgery is the recommended therapy but requires special techniques and experience in pediatric patients.

Tuberous Sclerosis Complex Associated with Vascular Anomalies or Overgrowth

BACKGROUND

Dysregulation of the mammalian target of rapamycin pathway is the underlying pathogenic mechanism in tuberous sclerosis complex (TSC). Other syndromes caused by genetic alterations in this pathway frequently manifest as vascular anomalies or asymmetric overgrowth. Rarely, these features have been documented in TSC.

OBJECTIVE

To collate cases of TSC with vascular anomaly or overgrowth that have been published and to assemble additional recent cases, as this finding has been underreported.

METHODS

TSC cases from three pediatric dermatology referral centers on two continents were reviewed to identify individuals noted to have hemihypertrophy or vascular anomalies.

RESULTS

We report five additional cases of TSC associated with vascular anomalies or overgrowth that contribute to our understanding of some of the pathways and treatments involved in vascular anomalies.

CONCLUSION

Hemihypertrophy and vascular anomalies may be more frequent in the setting of TSC than previously appreciated. A common pathogenetic mechanism may tie these manifestations together.

[Tuberous sclerosis complex]

Tuberous sclerosis complex is an autosomal dominant disorder with variable affection of the central nervous system (CNS) and many other organ systems. Radiological features include various lesions of the brain as well as lesions of the lungs, kidneys and the heart. Imaging is important for the early detection of complications. This article provides an overview of the clinical features and therapy as well as the specific imaging of tuberous sclerosis complex.

Tsc1 deficiency-mediated mTOR hyperactivation in vascular endothelial cells causes angiogenesis defects and embryonic lethality

This is a study on the role of tuberous sclerosis complex1 (TSC1) mutation and mTOR activation in endothelial cells during angiogenic and embryonic development. Past studies had shown that Tsc1/Tsc2 mutant genes lead to overactivation of mTOR in the regulating pathways in developing fetus. We used conditional Cre-loxp gene knockout approach to delete Tsc1 in mice's endothelial cells in our experimental models. Similarly, activation of mTOR signaling in endothelial cells of these embryos (Tie2-Cre/Tsc1(-/-)) was found. Majority of Tie2-Cre/Tsc1(-/-) embryos died at embryonic day 14.5 in utero. Cardiovascular defects, subcutaneous edema and hemorrhage were present among them. Whole-mount immunostaining in these embryos revealed a disorganized vascular network, defective sprouting of vessels in yolk sac and thickening of the labyrinth layer in the placenta. A thinner ventricular wall with disorganized trabeculae was present in the hearts of Tie2-Cre/Tsc1(-/-) embryos. Endothelial cells in Tsc1-deficient mice showed defective mitochondrial and endoplasmic reticular morphology, but no significant change was observed in cell junctions. The mutant embryos displayed significantly reduced cell proliferation, increased apoptosis and disturbed expression of angiogenic factors. A cohort of mice was treated prenatally with mTOR inhibitor rapamycin. The offspring of these mutant mice survived up to 22 days after birth. It was concluded that physiological TSC1-mTOR signaling in endothelial cells is crucial for vascular development and embryogenesis. We postulated that disruption of normal angiogenic pathways through hyperactive mTOR signaling maybe the mechanism that lead to deranged vascular pathogenesis in the tuberous sclerosis complex.

Abdominal manifestations of neurologic disorders

A variety of disorders-including infectious, inflammatory, hereditary, and metabolic diseases-may affect both the brain and abdominal cavity, and the findings in one region may help establish the diagnosis or limit the differential diagnosis. Establishing an accurate early diagnosis enables clinicians to adequately manage these unusual diseases and potentially avert life-threatening complications. For example, an early diagnosis of Gardner syndrome enables annual sigmoid- or colonoscopy and ultrasonography. In many conditions, abdominal manifestations precede neurologic manifestations and may have prognostic significance. Patients with celiac disease more often present with abdominal manifestations such as duodenitis, slow transit time, reversal of the jejunal-ileal fold pattern, and transient small bowel intussusception than with intracranial manifestations. In other conditions, the neurologic manifestations may be the same as the presenting symptoms. For example, patients with Gardner syndrome may initially present with multiple mandibular or sinonasal osteomas. In addition, sarcoidosis may manifest with multifocal enhancing dural masses. Abdominal and neurologic manifestations may even occur simultaneously, as in several of the phakomatoses such as neurofibromatosis type 1, tuberous sclerosis complex, and von Hippel-Lindau syndrome. Ultimately, familiarity with the appearances of these conditions allows radiologists to pinpoint a diagnosis, even when imaging findings in either location are nonspecific.

Aortic Dissection in the Young: A Case Report and Review of the Differential Diagnostic Considerations

Aortic dissection is a rare cause of death in young adults, which may be caused by acquired or congenital factors. We present the case of a 21-year-old man who died as a result of spontaneous aortic dissection and cardiac tamponade. At autopsy, signs of Marfan syndrome were evident both grossly and microscopically. Hodgkin lymphoma was also discovered, though was noncontributory to death. We review the causes of aortic dissection in young individuals, with a focus on the key differentiating features of predisposing inheritable connective tissue disorders. Given the implications for surviving family members, it is the obligation of the diligent forensic pathologist to be aware of these conditions, such that families may be alerted to the need for genetic counseling.

Multiple pulmonary artery aneurysms in tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is a rare genetic disorder characterised by multiple hamartomas, caused by inactivating mutations of the TSC1/TSC2 tumour suppressor genes. Classical pulmonary involvement in tuberous sclerosis complex (TSC) consists of lymphangioleiomyomatosis and/or multiple micronodular pneumocyte hyperplasia (MMPH). Association of TSC with pulmonary artery aneurysm (PAA) has been only exceptionally described. We report here the first case of TSC with multiple PAA in combination with MMPH, cardiac rhabdomyomas and bone, skin and brain involvement.

Coil embolization of an intracranial aneurysm in an infant with tuberous sclerosis complex: A case report and literature review

BACKGROUND

Tuberous sclerosis (TS) is a multiorgan neurocutaneous syndrome. Vascular manifestations are often extracranial. There is a paucity of cases involving TS combined with intracranial aneurysms reported in the literature. As a result, treatment has not been well described.

CASE DESCRIPTION

We report the case of a 13-month-old female infant with a prior diagnosis of TS that was found to have new onset of left eye ptosis, anisocoria, and papillary mydriasis indicative of left third cranial nerve palsy. A magnetic resonance angiogram (MRA) of the brain revealed a left internal carotid artery (ICA) aneurysm. Endovascular embolization was determined to be the best option for treatment. After a successful balloon test occlusion with neuromonitoring, the left internal carotid artery was sacrificed via coil embolization.

CONCLUSIONS

This is only the third case report of endovascular coil embolization of an intracranial aneurysm in an infant with TS. We report no complications during the procedure, and the patient was discharged with resolving left third cranial nerve palsy. Neither surgical nor endovascular outcomes have been well described in the literature. Follow-up on this patient will be useful for establishing protocols of treatment.

Cavernous sinus syndrome from an internal carotid artery aneurysm in an infant with tuberous sclerosis

Aneurysms are associated with tuberous sclerosis complex. We describe the first case of cavernous sinus syndrome from an intracavernous internal carotid artery aneurysm in a 9-month-old boy with tuberous sclerosis. The presence of an intracranial aneurysm should be considered in the differential diagnosis of children with tuberous sclerosis who develop cranial nerve deficits.

Thoracic computed tomographic manifestations of tuberous sclerosis in adults

The purpose of this article is to illustrate the various manifestations that can be encountered on thoracic computed tomography of tuberous sclerosis in adults. The pulmonary findings include lymphangioleiomyomatosis and multifocal micronodular pneumocyte hyperplasia. The extrapulmonary manifestations are divided into cardiac, vascular, mediastinal, osseous, and upper abdominal findings.

Vascular involvement in tuberous sclerosis

Vascular involvement in tuberous sclerosis (TS) is rare. Central and peripheral aneurysms and large and medium size arterial stenotic-occlusive disease have been reported in patients with TS. We present here three pediatric patients with TS and severe vascular abnormalities, followed by a review of the literature. The three cases include a 14-month-old girl with polycystic kidneys and cerebral tubers who had a large asymptomatic abdominal aortic aneurysm, a 2-year-old boy with multiple features of TS who had hypertension and was found to have mid-aortic syndrome with bilateral renal artery stenosis, and an 18-year-old girl with abdominal pain and TS features who had greater than 70% celiac artery stenosis. In all cases, noninvasive vascular imaging modalities were utilized for either initial diagnosis, surveillance, or both. These cases highlight the collaborative roles of the pediatric nephrologist and cardiovascular imager in the diagnosis and management of the vascular complications in TS patients. Appropriate care can only be made through a high index of suspicion.

Thoracic aortic disease in tuberous sclerosis complex: molecular pathogenesis and potential therapies in Tsc2+/- mice

Tuberous sclerosis complex (TSC) is a genetic disorder with pleiotropic manifestations caused by heterozygous mutations in either TSC1 or TSC2. One of the less investigated complications of TSC is the formation of aneurysms of the descending aorta, which are characterized on pathologic examination by smooth muscle cell (SMC) proliferation in the aortic media. SMCs were explanted from Tsc2(+/-) mice to investigate the pathogenesis of aortic aneurysms caused by TSC2 mutations. Tsc2(+/-) SMCs demonstrated increased phosphorylation of mammalian target of rapamycin (mTOR), S6 and p70S6K and increased proliferation rates compared with wild-type (WT) SMCs. Tsc2(+/-) SMCs also had reduced expression of SMC contractile proteins compared with WT SMCs. An inhibitor of mTOR signaling, rapamycin, decreased SMC proliferation and increased contractile protein expression in the Tsc2(+/-) SMCs to levels similar to WT SMCs. Exposure to alpha-elastin fragments also decreased proliferation of Tsc2(+/-) SMCs and increased levels of p27(kip1), but failed to increase expression of contractile proteins. In response to artery injury using a carotid artery ligation model, Tsc2(+/-) mice significantly increased neointima formation compared with the control mice, and the neointima formation was inhibited by treatment with rapamycin. These results demonstrate that Tsc2 haploinsufficiency in SMCs increases proliferation and decreases contractile protein expression and suggest that the increased proliferative potential of the mutant cells may be suppressed in vivo by interaction with elastin. These findings provide insights into the molecular pathogenesis of aortic disease in TSC patients and identify a potential therapeutic target for treatment of this complication of the disease.

Symptomatic 7-cm abdominal aortic aneurysm in an otherwise healthy 31-year-old woman

Abdominal aortic aneurysms are rare in young women. We report the case of a 31-year-old woman who underwent open surgical repair of a symptomatic 7-cm abdominal aortic aneurysm (AAA). The patient had no identifiable AAA risk factors. Laboratory and pathological analyses demonstrated a nonspecific inflammatory component.

Anatomical repair of a congenital aneurysm of the distal abdominal aorta in a newborn

Congenital (primary) neonatal abdominal aortic aneurysm (AAA) is an extremely rare truncular arterial abnormality among numerous congenital vascular malformations. Only seven cases have been reported as congenital origin in newborns. This report presents the case of a male infant in whom a 33-mm congenital AAA was diagnosed prenatally and was successfully treated 10 days after birth without exogenous graft material or aneurysmorrhaphy. Follow-up study at 39 months demonstrated excellent clinical, ultrasound scan, and computed tomography scan findings. Anatomic reconstruction with native vessels is the preferred surgical technique to ensure the child's potential for harmonious growth.