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Han Y, Chen M, Wang H. Management of lateral meningocele syndrome in a child without neurological symptoms and literature review. Childs Nerv Syst 2022; 38:903-907. [PMID: 35128567 DOI: 10.1007/s00381-022-05466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/30/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Lateral meningocele syndrome (LMS) is a rare genetic connective tissue disorder which is associated with meningocele-related neurologic dysfunction. Several patients with LMS have been reported. But, guidelines for screening and treatment of LMS have not been established. METHOD AND RESULTS We review the current knowledge of LMS in the article. Then, we describe a boy for whom a genomic analysis which allowed us to make a diagnosis of LMS and to begin monitoring of his condition for possible neurological complications. CONCLUSION It would be difficult to make a diagnosis of LMS on the basis of clinical manifestations alone. The natural history of dural ectasia in patients with LMS needs to be better defined to establish surgical indications. Based upon the current literature, ventriculoperitoneal shunting (V-Ps) has been recommended as the first-line surgical treatment option for patients with symptomatic thoracolumbar meningoceles.
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Affiliation(s)
- Yong Han
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Min Chen
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Hangzhou Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China.
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2
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Abstract
Notch (Notch1 through 4) are transmembrane receptors that determine cell differentiation and function, and are activated following interactions with ligands of the Jagged and Delta-like families. Notch has been established as a signaling pathway that plays a critical role in the differentiation and function of cells of the osteoblast and osteoclast lineages as well as in skeletal development and bone remodeling. Pathogenic variants of Notch receptors and their ligands are associated with a variety of genetic disorders presenting with significant craniofacial and skeletal manifestations. Lateral Meningocele Syndrome (LMS) is a rare genetic disorder characterized by neurological manifestations, meningoceles, skeletal developmental abnormalities and bone loss. LMS is associated with NOTCH3 gain-of-function pathogenic variants. Experimental mouse models of LMS revealed that the bone loss is secondary to increased osteoclastogenesis due to enhanced expression of receptor activator of nuclear factor kappa B ligand by cells of the osteoblast lineage. There are no effective therapies for LMS. Antisense oligonucleotides targeting Notch3 and antibodies that prevent the activation of NOTCH3 are being tested in preclinical models of the disease. In conclusion, LMS is a serious genetic disorder associated with NOTCH3 pathogenic variants. Novel experimental models have offered insight on mechanisms responsible and ways to correct the disease.
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Affiliation(s)
- Ernesto Canalis
- Department of Orthopaedic Surgery and Medicine, UConn Musculoskeletal Institute, UConn Health, Farmington, CT, United States
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3
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Cuoco JA, Klein BJ, Busch CM, Gosnell HL, Kar A, Marvin EA, Apfel LS. Neurosurgical Management of Lateral Meningocele Syndrome: A Clinical Update for the Pediatric Neurosurgeon. Pediatr Neurosurg 2020; 55:2-11. [PMID: 31838470 DOI: 10.1159/000504060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lateral meningocele syndrome (LMS) is an exceedingly rare connective tissue disease with phenotypic anomalies similar to those seen in Marfan syndrome, Ehler-Danlos syndrome, and Loeys-Dietz syndrome. However, this syndrome is invariably associated with the presence of multiple lateral thoracolumbar spinal meningoceles: a distinct point of phenotypic divergence from other connective tissue disorders. The etiopathogenesis of this syndrome has recently been linked to truncating mutations within exon 33 of NOTCH3. Despite numerous reports, neurosurgical management of multiple spinal meningoceles remains poorly defined in the literature. We conducted a literature review to provide insight into the nosology, clinical significance, and neurosurgical management strategies of this distinct connective tissue disorder. SUMMARY Our literature search revealed 11 articles (16 cases) of LMS, which included 9 males and 7 females, belonging to 14 different families. Half of these cases underwent genetic screening: all of which were discovered to exhibit a truncating mutation within exon 33 of NOTCH3. All patients exhibited multiple lateral thoracolumbar spinal meningoceles with craniofacial dysmorphisms. Other clinical characteristics included pathologic changes in spine morphology, Chiari I malformation, syringomyelia, hydrocephalus, and tethered cord. Operative management of multiple spinal meningoceles in LMS is complicated by the presence of such coexisting structural neurologic pathologies, which may alter cerebrospinal fluid flow dynamics and, ultimately, impact operative intervention. Key Messages: LMS is an exceedingly rare connective tissue disorder with severe spinal dural involvement. Neurosurgical management of multiple spinal meningoceles is complex, which is further complicated by the presence of coexisting neuropathology, such as pathologic transformation of spine morphology and Chiari I malformation. Patients with a connective tissue disorder phenotype found to have multiple spinal meningoceles on imaging studies may benefit from evaluation by a medical geneticist and a pediatric neurosurgeon.
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Affiliation(s)
- Joshua A Cuoco
- Carilion Clinic, Section of Neurosurgery, Roanoke, Virginia, USA, .,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA, .,Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA, .,Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA,
| | - Brendan J Klein
- Carilion Clinic, Section of Neurosurgery, Roanoke, Virginia, USA.,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA.,Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA.,Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Christopher M Busch
- Carilion Clinic, Section of Neurosurgery, Roanoke, Virginia, USA.,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA.,Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA.,Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Hailey L Gosnell
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Ayesha Kar
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Eric A Marvin
- Carilion Clinic, Section of Neurosurgery, Roanoke, Virginia, USA.,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA.,Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA.,Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Lisa S Apfel
- Carilion Clinic, Section of Neurosurgery, Roanoke, Virginia, USA.,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA.,Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA.,Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
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4
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Abstract
Lateral meningocele syndrome (LMS) is a rare genetic connective tissue disorder. It is associated with morphological changes similar to those of other connective tissue disorders, with the unique distinction of multiple, often bilateral and large, lateral meningoceles herniating through the spinal foramina. In some cases, these lateral meningoceles can cause pain and discomfort due to their presence within retroperitoneal tissues or cause direct compression of the spinal nerve root exiting the foramen; in some cases compression may also involve motor weakness. The presence of lateral meningoceles imposes unique challenges related to CSF flow dynamics, especially with concurrent Chiari malformation, which also occurs with increased frequency in individuals with LMS. The authors present the case of a 6-month-old female with LMS with multiple lateral meningoceles throughout the thoracic and lumbar spine. The infant experienced a focal neurological abnormality due to enlargement of her lateral meningoceles following decompression of a symptomatic Chiari malformation and endoscopic third ventriculostomy. The finding was reversed through implantation of a ventriculoperitoneal shunt, which reduced the burden of CSF upon the lateral meningoceles. Such a case compels consideration that CSF flow dynamics in addition to altered connective tissue play a role in the presence of lateral meningoceles in patients within this and similar patient populations.
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Affiliation(s)
- Erik C Brown
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Kunal Gupta
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Christina Sayama
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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5
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Ejaz R, Qin W, Huang L, Blaser S, Tetreault M, Hartley T, Boycott KM, Carter MT. Lateral meningocele (Lehman) syndrome: A child with a novel NOTCH3 mutation. Am J Med Genet A 2016; 170A:1070-5. [PMID: 26754023 DOI: 10.1002/ajmg.a.37541] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 12/21/2015] [Indexed: 12/12/2022]
Abstract
Lateral meningocele syndrome (LMS), or Lehman syndrome, is a rare disorder characterized by multiple lateral spinal meningoceles, distinctive facial features, joint hypermobility and hypotonia, along with skeletal, cardiac, and urogenital anomalies. Heterozygous NOTCH3 mutations affecting the terminal exon 33 were recently reported as causative in six families with LMS. We report a boy with LMS, the fourteenth reported case, with a de novo 80 base pair deletion in exon 33 of NOTCH3. Our patient's prenatal findings, complex cardiac anomalies, and severe feeding difficulties further expand our understanding of this rare condition.
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Affiliation(s)
- Resham Ejaz
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wen Qin
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Lijia Huang
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Susan Blaser
- Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martine Tetreault
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,McGill University and Genome Quebec Innovation Center, Montreal, Quebec, Canada
| | - Taila Hartley
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kym M Boycott
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Melissa T Carter
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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6
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Gripp KW, Robbins KM, Sobreira NL, Witmer PD, Bird LM, Avela K, Makitie O, Alves D, Hogue JS, Zackai EH, Doheny KF, Stabley DL, Sol-Church K. Truncating mutations in the last exon of NOTCH3 cause lateral meningocele syndrome. Am J Med Genet A 2015; 167A:271-81. [PMID: 25394726 PMCID: PMC5589071 DOI: 10.1002/ajmg.a.36863] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/15/2014] [Indexed: 12/30/2022]
Abstract
Lateral meningocele syndrome (LMS, OMIM%130720), also known as Lehman syndrome, is a very rare skeletal disorder with facial anomalies, hypotonia and meningocele-related neurologic dysfunction. The characteristic lateral meningoceles represent the severe end of the dural ectasia spectrum and are typically most severe in the lower spine. Facial features of LMS include hypertelorism and telecanthus, high arched eyebrows, ptosis, midfacial hypoplasia, micrognathia, high and narrow palate, low-set ears and a hypotonic appearance. Hyperextensibility, hernias and scoliosis reflect a connective tissue abnormality, and aortic dilation, a high-pitched nasal voice, wormian bones and osteolysis may be present. Lateral meningocele syndrome has phenotypic overlap with Hajdu-Cheney syndrome. We performed exome resequencing in five unrelated individuals with LMS and identified heterozygous truncating NOTCH3 mutations. In an additional unrelated individual Sanger sequencing revealed a deleterious variant in the same exon 33. In total, five novel de novo NOTCH3 mutations were identified in six unrelated patients. One had a 26 bp deletion (c.6461_6486del, p.G2154fsTer78), two carried the same single base pair insertion (c.6692_93insC, p.P2231fsTer11), and three individuals had a nonsense point mutation at c.6247A > T (pK2083*), c.6663C > G (p.Y2221*) or c.6732C > A, (p.Y2244*). All mutations cluster into the last coding exon, resulting in premature termination of the protein and truncation of the negative regulatory proline-glutamate-serine-threonine rich PEST domain. Our results suggest that mutant mRNA products escape nonsense mediated decay. The truncated NOTCH3 may cause gain-of-function through decreased clearance of the active intracellular product, resembling NOTCH2 mutations in the clinically related Hajdu-Cheney syndrome and contrasting the NOTCH3 missense mutations causing CADASIL.
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Affiliation(s)
- Karen W. Gripp
- Division of Medical Genetics, A.I. duPont Hospital for Children, Wilmington, Delaware, and Sidney Kimmel Medical School at T. Jefferson University, Philadelphia, Pennsylvania
| | - Katherine M. Robbins
- Department of Biomedical Research, A.I. duPont Hospital for Children, Wilmington, Delaware
- Department of Biological Sciences, University of Delaware, Newark, Delaware
| | - Nara L. Sobreira
- Johns Hopkins University School of Medicine, Institute of Genetic Medicine, Baltimore, Maryland
| | - P. Dane Witmer
- Center for Inherited Disease Research, Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lynne M. Bird
- University of California San Diego and Rady Children's Hospital, San Diego, California
| | - Kristiina Avela
- Department of Clinical Genetics, Helsinki University Central Hospital, Helsinki, Finland
| | - Outi Makitie
- Children's Hospital, Helsinki University Central Hospital and University of Helsinki, and Folkhälsan Institute of Genetics, Helsinki, Finland
| | - Daniela Alves
- Neurogenetics Unit, Department of Medical Genetics, Centro Hospitalar de São João, Porto, Portugal
| | | | - Elaine H. Zackai
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kimberly F. Doheny
- Center for Inherited Disease Research, Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah L. Stabley
- Department of Biomedical Research, A.I. duPont Hospital for Children, Wilmington, Delaware
| | - Katia Sol-Church
- Department of Biomedical Research, A.I. duPont Hospital for Children, Wilmington, Delaware
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Mushtaq G, Hussain I, Khan JA, Kamal MA. Lateral meningocele with asymmetric canal stenosis: A case study. Saudi J Biol Sci 2014; 22:102-5. [PMID: 25561891 DOI: 10.1016/j.sjbs.2014.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 08/31/2014] [Accepted: 09/01/2014] [Indexed: 12/12/2022] Open
Abstract
Lateral meningocele is a very rare disorder of unknown aetiology typified by the presence of protrusions of the arachnoid and the dura matter extending laterally through inter- or intra-vertebral foramina. We report here the case of a 52-year old male with abnormality of spine when presented with low back pain. The patient did not appear to have any neurological disorder. A computerized tomography (CT) scan was acquired from T12 to mid sacrum with multiplanar reformations. The results showed the presence of a left sided paraspinal cystic lesion projecting from the left neural foramen and extending into the left psoas muscle suggesting a lateral meningocele. In addition, a broad based central and left paracentral disc protrusion was also observed resulting in asymmetric canal stenosis. The patient is on regular follow-up while undergoing palliative treatment.
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Affiliation(s)
- Gohar Mushtaq
- Department of Biochemistry, College of Science, King Abdulaziz University, Jeddah, Saudi Arabia ; Metabolomics, LC/MS Metabolite Identification Division, 8865 Los Altos Dr, Buena Park, CA 90620, USA
| | - Iqbal Hussain
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Jalaluddin A Khan
- Department of Biochemistry, College of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad A Kamal
- Metabolomics & Enzymology Unit, Fundamental and Applied Biology Group, King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia ; Enzymoic, 7 Peterlee Place, Hebersham, NSW 2770, Australia
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8
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Graff-Radford SB, Schievink WI. High-pressure headaches, low-pressure syndromes, and CSF leaks: diagnosis and management. Headache 2014; 54:394-401. [PMID: 24433511 DOI: 10.1111/head.12283] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Headache resulting from idiopathic intracranial hypertension (IIH) in a population of moderately to obese women of childbearing age. The causes overall remain unclear. With this review, we provide an overview of clinical treatment and management strategies. RESULTS IIH management is dependent on the signs and symptoms presented. Symptomatic treatment should attempt to lower intracranial pressure, reduce pain, and protect the optic nerves. Consideration for lumbar puncture and draining fluid as an option for reducing pressure may be helpful; however, repeated treatment is not usually favored by patients. Traditional prophylactic medications used in migraine may help reduce the primary headache often induced by raised intracranial pressure. We suggested surgical intervention for patients experiencing visual loss or impending visual loss and not responding to medication therapy. CONCLUSION In this review, we discuss headache associated with IIH and spontaneous intracranial hypotension. Much needs to be learned about treatment options for patients with cerebrospinal fluid leaks including methods to strengthen the dura.
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9
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Castori M, Morlino S, Ritelli M, Brancati F, De Bernardo C, Colombi M, Grammatico P. Late diagnosis of lateral meningocele syndrome in a 55-year-old woman with symptoms of joint instability and chronic musculoskeletal pain. Am J Med Genet A 2013; 164A:528-34. [PMID: 24311540 DOI: 10.1002/ajmg.a.36301] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 09/23/2013] [Indexed: 12/29/2022]
Abstract
Lateral meningocele syndrome (LMS) is a rare hereditary connective tissue disorder characterized by pan-spinal meningoceles, specific facial dysmorphism, skeletal and soft tissue abnormalities, and hypotonia and/or muscle weakness. LMS has been observed in eleven patients with two instances of vertical transmission, and seven sporadic cases with an age at diagnosis ranging from 25 months to 33 years. We report on a further observation of LMS in a 55-year-old woman presenting with a long history of joint instability, chronic musculoskeletal pain, and iatrogenic bladder and anorectal dysfunction due to irreversible nerve damage after surgical excision of a meningeal cyst. Her clinical characteristics are compared with those of previously reported patients, as well as two further cases originally diagnosed with Hajdu-Cheney and Ehlers-Danlos syndromes, but displaying typical features of LMS.
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Affiliation(s)
- Marco Castori
- Division of Medical Genetics, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
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10
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Correia-Sá I, Horta R, Neto T, Amarante J, Marques M. Lehman syndrome: a new syndrome for pierre robin sequence. Cleft Palate Craniofac J 2013; 52:369-72. [PMID: 23962060 DOI: 10.1597/13-063] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lehman syndrome, or lateral meningocele syndrome, is characterized by facial dysmorphism, multiple lateral meningoceles, and skeletal abnormalities. Only nine cases have been described. We present a case of a 2-year-old boy presenting with micrognathia, glossoptosis, and hypertelorism as well as associated severe obstructive sleep apnea. He was submitted to bilateral mandibular distraction with external nonresorbable devices to correct Pierre Robin sequence (PRS). Later, multiple lateral meningoceles were identified, and a diagnosis of Lehman syndrome was made. Lehman syndrome must be considered in syndromic infants with PRS. Distraction osteogenesis is a safe procedure that is effective as a first choice in the treatment of patients with Lehman syndrome presenting with micrognathia.
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11
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Alves D, Sampaio M, Figueiredo R, Leão M. Lateral meningocele syndrome: Additional report and further evidence supporting a connective tissue basis. Am J Med Genet A 2013; 161A:1768-72. [DOI: 10.1002/ajmg.a.35968] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 03/14/2013] [Indexed: 01/09/2023]
Affiliation(s)
- Daniela Alves
- Department of Pediatrics; Centro Hospitalar de S. João; Porto; Portugal
| | - Mafalda Sampaio
- Pediatric Neurology Unit, Department of Pediatrics; Centro Hospitalar de S. João; Porto; Portugal
| | - Rita Figueiredo
- Department of Neuroradiology; Centro Hospitalar de S. João; Porto; Portugal
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12
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Gripp KW. Lateral meningocele syndrome and Hajdu-Cheney syndrome: different disorders with overlapping phenotypes. Am J Med Genet A 2011; 155A:1773-4; author reply 1775. [PMID: 21671395 DOI: 10.1002/ajmg.a.34075] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 04/02/2011] [Indexed: 11/05/2022]
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13
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Albayram S, Asik M, Hasiloglu ZI, Dikici AS, Erdemli HE, Altintas A. Pathological contrast enhancement of the oculomotor and trigeminal nerves caused by intracranial hypotension syndrome. Headache 2011; 51:804-8. [PMID: 21521210 DOI: 10.1111/j.1526-4610.2010.01825.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The typical symptom of intracranial hypotension syndrome is orthostatic headache. The headache may also be accompanied by neck pain and stiffness, low backache, radicular symptoms, quadriplegia, interscapular pain, nausea/vomiting, and cranial nerve involvement symptoms (hearing and visual problems, face pain and numbness, hypogeusia). Radiologically, on cranial magnetic resonance imaging, intracranial hypotension syndrome is characterized by dural thickening and contrast enhancement, subdural effusion, engorgement of the venous structures, sagging or downward displacement of the brain, and pituitary hyperemia. Although clinical findings related to cranial nerves 3 and 5 have been described in intracranial hypotension, pathological contrast enhancement of these nerves has not. We present a 32-year-old patient whose cranial magnetic resonance imaging shows bilateral pathological contrast enhancement of cranial nerves 3 and 5 and describe a new imaging finding in intracranial hypotension syndrome.
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Affiliation(s)
- Sait Albayram
- Istanbul University, Cerrahpasa Medical School-Radiology Department, Neuroradiology Division, Istanbul, Turkey
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14
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Seddighi A, Seddighi AS. Lateral sacral meningocele presenting as a gluteal mass: a case report. J Med Case Rep 2010; 4:81. [PMID: 20205707 PMCID: PMC2845143 DOI: 10.1186/1752-1947-4-81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 03/05/2010] [Indexed: 12/02/2022] Open
Abstract
Introduction Lateral meningocele is a very rare disorder. It has been reported in patients with neurofibromatosis or Marfan's syndrome. Previous reports have described lateral meningoceles in the thoracic or cervical region. Lateral meningocele in the sacral area was reported in the literature only once. Case presentation We describe a 3.5-year-old Iranian girl who presented with a lateral gluteal mass. Neuroimaging and intra-operative evaluation showed that the mass was a lateral sacral meningocele with spinal communication through the iliac bone. We also present a review of the literature about this entity. Conclusions Although lateral meningoceles especially in the sacral region are rare disorders, their possibility should always be considered in young patients presenting with a paravertebral or gluteal mass.
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Affiliation(s)
- Afsoun Seddighi
- Department of Neurosurgery, Rajaie Hospital, Padegan Street, Qazvin, Iran.
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15
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Abstract
Spontaneous intracranial hypotension is an uncommon but not rare cause of new onset daily persistent headaches. A delay in diagnosis is the norm. Women are affected more commonly than men and most are in the fifth or sixth decade of life. The underlying cause is a spontaneous spinal cerebrospinal fluid (CSF) leak. Typically the headache is orthostatic in nature but other headache patterns occur as well. Associated symptoms are common and include neck pain, a change in hearing, diplopia, facial numbness, cognitive abnormalities and even coma. Typical imaging findings consist of subdural fluid collections, pachymeningeal enhancement, pituitary hyperaemia and brain sagging, but magnetic resonance imaging may be normal. Myelography is the study of choice to identify the CSF leak but is not always necessary to make the diagnosis. Treatment consists of bedrest, abdominal binder, epidural blood patching, percutaneous fibrin glue injection or surgical CSF leak repair. Outcomes have been poorly studied.
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Affiliation(s)
- WI Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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16
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Chen CP. Syndromes, Disorders and Maternal Risk Factors Associated with Neural Tube Defects (II). Taiwan J Obstet Gynecol 2008; 47:10-7. [DOI: 10.1016/s1028-4559(08)60049-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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17
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Chen KM, Bird L, Barnes P, Barth R, Hudgins L. Lateral meningocele syndrome: vertical transmission and expansion of the phenotype. Am J Med Genet A 2005; 133A:115-21. [PMID: 15666314 DOI: 10.1002/ajmg.a.30526] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Lateral meningoceles were first described by Lehman et al. [(1977); J Pediatr 90: 49-54] in a patient with other skeletal findings and distinctive craniofacial features. Subsequently, six more patients with the so-called lateral meningocele syndrome (LMS) have been reported. We describe the findings in three new cases and expand the phenotype. The existence of an affected mother and daughter supports the hypothesis that LMS is a dominant disorder affecting primarily the connective tissue.
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Affiliation(s)
- Kelly M Chen
- Department of Pediatrics, Division of Genetics, Stanford University, 300 Pasteur Drive, Stanford, CA 94305-5208, USA
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18
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Affiliation(s)
- Erin M Simon
- Department of Radiology, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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19
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Binder DK, Dillon WP, Fishman RA, Schmidt MH. Intrathecal Saline Infusion in the Treatment of Obtundation Associated with Spontaneous Intracranial Hypotension: Technical Case Report. Neurosurgery 2002. [DOI: 10.1227/00006123-200209000-00045] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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20
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Intrathecal Saline Infusion in the Treatment of Obtundation Associated with Spontaneous Intracranial Hypotension: Technical Case Report. Neurosurgery 2002. [DOI: 10.1097/00006123-200209000-00045] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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21
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Schrijver I, Schievink WI, Godfrey M, Meyer FB, Francke U. Spontaneous spinal cerebrospinal fluid leaks and minor skeletal features of Marfan syndrome: a microfibrillopathy. J Neurosurg 2002; 96:483-9. [PMID: 11883832 DOI: 10.3171/jns.2002.96.3.0483] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Spontaneous spinal cerebrospinal fluid (CSF) leaks are increasingly recognized as a cause of postural headaches. The authors examined a group of patients suffering from spontaneous spinal CSF leaks who also had minor skeletal features of Marfan syndrome for abnormalities of fibrillin-containing microfibrils. METHODS Patients with spontaneous CSF leaks were evaluated for the clinical characteristics of connective tissue disorders. Skin biopsies were obtained in three patients with skeletal manifestations that constitute part of the Marfan syndrome phenotype. Cultured fibroblasts were studied for fibrillin-1 synthesis and incorporation into the extracellular matrix (ECM) by performing quantitative metabolic labeling and immunohistochemical analysis. Among 20 consecutive patients found to have spinal CSF leaks, four (20%) exhibited minor skeletal features of Marfan syndrome, but lacked any ocular or cardiovascular abnormalities. The mean age of these patients (30 years) was lower than that of the 16 patients without skeletal abnormalities (44 years; p = 0.01). Abnormalities in fibrillin-1 metabolism and immunostaining were detected in all three patients with the skeletal abnormalities who underwent examination, but not in a control patient without these skeletal manifestations. CONCLUSIONS Twenty percent of patients who experience spontaneous spinal CSF leaks have minor skeletal features of Marfan syndrome. The authors demonstrated abnormalities in fibrillin-1 protein deposition in all patients examined, but only one person was found to have a fibrillin-1 abnormality typically found in classic Marfan syndrome. The results indicate that there is a heterogeneous involvement of other components of ECM microfibrils at the basis of this cerebrospinal manifestation. In addition, the authors identified a connective-tissue etiological factor in a group of disorders not previously classified as such.
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Affiliation(s)
- Iris Schrijver
- Howard Hughes Medical Institute and Department of Genetics, Stanford University School of Medicine, California, USA
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22
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Abstract
Spontaneous intracranial hypotension has become a well-recognized clinical entity, but it remains an uncommonly, and probably underdiagnosed, cause of headache; its estimated prevalence is only one in 50,000 individuals. The clinical spectrum of spontaneous intracranial hypotension is quite variable and includes headache, neck stiffness, cranial nerve dysfunction, radicular arm pain, and symptoms of diencephalic or hindbrain herniation. Leakage of the spinal cerebrospinal fluid (CSF) is the most common cause of spontaneous intracranial hypotension. A combination of an underlying weakness of the spinal meninges and a more or less trivial traumatic event is often found to cause this event in these patients. Typical magnetic resonance imaging findings include diffuse pachymeningeal enhancement, sub-dural fluid collections, and downward displacement of the brain, sometimes mimicking a Chiari I malformation. Opening pressure is often, but not always, low, and examination of CSF may reveal pleocytosis, an elevated protein count, and xanthochromia. The use of myelography computerized tomography scanning is the most reliable method for the accurate localization of the CSF leak. Most CSF leaks are found at the cervicothoracic junction or in the thoracic spine. The initial treatment of choice is a lumbar epidural blood patch, regardless of the location of the CSF leak. If the epidural blood patch fails, the blood patch procedure can be repeated at the lumbar level, or a blood patch can be directed at the exact site of the leak. Surgical repair of the CSF leak is safe and generally successful, although a distinct structural cause of the leak often is not found.
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Affiliation(s)
- W I Schievink
- Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Neurosurgical Institute, Los Angeles, California 90048, USA
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23
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Schievink WI, Morreale VM, Atkinson JL, Meyer FB, Piepgras DG, Ebersold MJ. Surgical treatment of spontaneous spinal cerebrospinal fluid leaks. J Neurosurg 1998; 88:243-6. [PMID: 9452231 DOI: 10.3171/jns.1998.88.2.0243] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. METHODS Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22-61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. CONCLUSIONS All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3-58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.
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Affiliation(s)
- W I Schievink
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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24
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Gripp KW, Scott CI, Hughes HE, Wallerstein R, Nicholson L, States L, Bason LD, Kaplan P, Zderic SA, Duhaime AC, Miller F, Magnusson MR, Zackai EH. Lateral meningocele syndrome: Three new patients and review of the literature. ACTA ACUST UNITED AC 1997. [DOI: 10.1002/(sici)1096-8628(19970613)70:3<229::aid-ajmg4>3.0.co;2-r] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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25
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Mingarelli R, Castriota Scanderbeg A, Dallapiccola B. Two sisters with a syndrome of ocular, skeletal, and abdominal abnormalities (OSA syndrome). J Med Genet 1996; 33:884-6. [PMID: 8933348 PMCID: PMC1050774 DOI: 10.1136/jmg.33.10.884] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Two adult sisters are described who had a unique association of facial, ocular, and skeletal defects, and abdominal muscle hypoplasia, indicating autosomal recessive inheritance. Many of these features overlap those previously found in other malformation syndromes. However, the constellation of defects observed in these patients appears to represent a previously unreported syndrome and autosomal recessive inheritance is likely.
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Affiliation(s)
- R Mingarelli
- Cattedra di Genetica Medica, Università Tor Vergata, Rome, Italy
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