Infant with Loeys-Dietz syndrome treated for febrile status epilepticus with COVID-19 infection: first reported case of febrile status epilepticus and focal seizures in a patient with Loeys-Dietz syndrome and review of literature

Loeys-Dietz syndrome (LDS) is a rare, autosomal dominant multisystem disorder that is caused by mutations of transforming growth factor-β receptors. Mutations inSMAD3andTGFB3have been recently reported.

LDS is characterised by the triad of arterial tortuosity, hypertelorism and a bifid uvula or cleft palate among other cardiovascular, craniofacial and orthopaedic manifestations. Patients with LDS show clinical and genetic variability and there is a significant risk of reduced life expectancy due to widespread arterial involvement, aortic root dilation, aneurysms and an aggressive vascular course. Thus early genetic testing is warranted if clinical signs and history are suggestive of this potentially catastrophic disorder.

LDS predisposes patients to aortic aneurysms and early death due to vascular malformations, but neurological emergencies, such as seizures and febrile status epilepticus, have not been reported.

Febrile status epilepticus is the most common neurological emergency in childhood. Neurological manifestations of COVID-19 in the paediatric population are not as well described in medical literature.

To the best of our knowledge, this is the first reported case of febrile status epilepticus with COVID-19 infection in an infant with LDS. Our patient had focal epileptiform activity emanating over the left posterior hemisphere, which evolved into an electrographic seizure on video EEG. Such patients have a heightened risk of epilepsy in the future, and this occurrence is consistent with a diagnosis of focal epilepsy. Neurological complications such as epilepsy and status epilepticus in a patient with LDS have never been reported before.

A brief review of literature is also given here.

Intracranial Aneurysms in Loeys-Dietz Syndrome: A Multicenter Propensity-Matched Analysis

BACKGROUND

Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by a classic triad of hypertelorism, bifid uvula and/or cleft palate, and generalized arterial tortuosity. There are limited data on the prevalence and rupture risk of intracranial aneurysms (IAs) in the setting of LDS, with no established guidelines.

OBJECTIVE

To analyze the prevalence and rupture risk of IA in LDS.

METHODS

Electronic medical records of patients with a confirmed diagnosis of LDS and available cerebrovascular imaging were reviewed. Patients were divided into 2 groups based on the presence of IA. Unmatched and propensity-matched analyses were used to identify potential risk factors for aneurysm formation.

RESULTS

Records of 1111 patients were screened yielding a total of 60 patients with a diagnosis of LDS. Eighteen (30%) patients had IA, 4 (22.2%) of whom had multiple aneurysms for a total of 24 IAs. Twenty-three (95.8%) aneurysms were located in the anterior circulation; none of them were ruptured. On unmatched analysis, age ( P = .015), smoking history ( P = .034), hypertension ( P = .035), and number of extracranial aneurysms ( P < .001) were significantly higher in patients with IA. After matching for age, sex, race, stroke history, family history, and extracranial aneurysms, smoking history ( P = .009) remained significant.

CONCLUSION

Patients with LDS have an increased risk of IAs, especially with a history of smoking. The prevalence rate of IAs in our series was 30%. Screening imaging should be considered at diagnosis, and patients should be encouraged to abstain from smoking. Further studies are needed to elucidate the risk of IA rupture and treatment considerations in this unique population.

Relationship between phenotypic features in Loeys-Dietz syndrome and the presence of intracranial aneurysms

OBJECTIVE

Loeys-Dietz syndrome (LDS) is a rare autosomal dominant condition characterized by aneurysms of the aorta, aortic branches, and intracranial arteries; skeletal and cutaneous abnormalities; and craniofacial malformations. Previous authors have reported that higher craniofacial severity index (CFI) scores, which indicate more severe craniofacial abnormalities, correlate with the severity of aortic aneurysm pathology. However, the association between syndromic features and the formation of intracranial aneurysms in LDS patients has yet to be determined. In this study, the authors evaluate the incidence of phenotypic abnormalities, craniofacial features, and Chiari malformation type I (CM-I) in a large LDS cohort and explore possible risk factors for the development of intracranial aneurysms.

METHODS

This was a retrospective cohort study of all patients with LDS who had been seen at the Marfan Syndrome and Aortopathy Center at Washington University School of Medicine in St. Louis in 2010–2022. Medical records were reviewed to obtain demographic, clinical, and radiographic data. The prevalence of craniofacial, skeletal, and cutaneous pathologies was determined. Bivariate logistic regression was performed to identify possible risk factors for the formation of an intracranial aneurysm.

RESULTS

Eighty-one patients with complete medical records and intracranial vascular imaging were included in the analysis, and 18 patients (22.2%) had at least 1 intracranial aneurysm. Patients frequently demonstrated the thin or translucent skin, doughy skin texture, hypertelorism, uvular abnormalities, and joint hypermobility typical of LDS. CM-I was common, occurring in 7.4% of the patients. Importantly, the patients with intracranial aneurysms were more likely to have CM-I (22.2%) than those without intracranial aneurysms (3.2%). The mean CFI score in the cohort with available data was 1.81, with higher means in the patients with the TGFBR1 or TGFBR2 disease-causing variants (2.05 and 3.30, respectively) and lower in the patients with the SMAD3, TGFB2, or TGFB3 pathogenic variants (CFI < 1). No significant CFI difference was observed in patients with or without intracranial aneurysms (2.06 vs 1.74, p = 0.61).

CONCLUSIONS

CM-I, and not the CFI, is significantly associated with the presence of intracranial aneurysms in patients with LDS. Surveillance for intracranial aneurysms is essential in all patients with LDS and should not be limited to those with severe phenotypes. Long-term monitoring studies will be necessary to determine whether a correlation between craniofacial abnormalities and adverse outcomes from intracranial aneurysms (growth, intervention, or rupture) exists.

Association between pectus excavatum and congenital genetic disorders: A systematic review and practical guide for the treating physician

BACKGROUND

Pectus excavatum (PE) could be part of a genetic disorder, which then has implications regarding comorbidity, the surgical correction of PE, and reproductive choices. However, referral of a patient presenting with PE for genetic analysis is often delayed because additional crucial clinical signs may be subtle or even missed in syndromic patients. We reviewed the literature to inventory known genetic disorders associated with PE and create a standardized protocol for clinical evaluation.

METHODS

A systematic literature search was performed in electronic databases. Genetic disorders were considered associated with PE if studies reported at least five cases with PE. Characteristics of each genetic disorder were extracted from the literature and the OMIM database in order to create a practical guide for the clinician.

RESULTS

After removal of duplicates from the initial search, 1632 citations remained. Eventually, we included 119 full text articles, representing 20 different genetic disorders. Relevant characteristics and important clinical signs of each genetic disorder were summarized providing a standardized protocol in the form of a scoring list. The most important clinical sign was a positive family history for PE and/or congenital heart defect.

CONCLUSIONS

Twenty unique genetic disorders have been found associated with PE. We have created a scoring list for the clinician that systematically evaluates crucial clinical signs, thereby facilitating decision making for referral to a clinical geneticist.

Treatment of a middle cerebral artery aneurysm in the setting of Loeys-Dietz syndrome: Case report and review of literature

Loeys-Dietz syndrome (LDS) is a connective tissue disorder with associated systemic vasculopathies including intracranial arterial aneurysm formation and dissections. LDS is a relatively less well-known entity compared with other connective tissue disorders, such as Ehlers-Danlos or Marfan syndrome, and consequently experience in the management of the associated intracranial aneurysms is suboptimal. We present a case of surgical clipping of a middle cerebral artery aneurysm in a patient with LDS. A 46-year-old female with LDS (type III) was found to have a right middle cerebral artery (MCA) bifurcation aneurysm following vascular screening. The decision was made to surgically clip the aneurysm after consultation in our neurovascular multidisciplinary team meeting. A standard right pterional craniotomy was performed and the aneurysm was secured with 2 straight Sugita clips. The temporal M2 branch was noted to be thin walled and this prompted application of the second tandem clip, rather than risk re-positioning the initial clip. In our case, the MCA aneurysm neck was robust enough to take a clip without any complications, and therefore we suggest that the presence of LDS is not an absolute contra-indication to perform open craniotomy and clipping.

Cerebral Aneurysms Differ in Patients with Hysterectomies

OBJECTIVE

Female sex is a well-known risk factor for aneurysm formation. Although the role of the ovaries and estrogen in aneurysm development has been supported, other organ-hormone pairs unique between sexes also may be implicated. In this study, we aimed to determine whether intracranial aneurysms microsurgically clipped in patients with previous hysterectomies exhibit any unique aneurysm characteristics from those without hysterectomies.

METHODS

Solitary aneurysms microsurgically treated by the senior author (M.T.L.) were included from a database of patients treated between January 2010 and April 2013 at a tertiary academic medical center. Only female patients and patients equal or older in age to the youngest patient in the hysterectomy group were included in the control group. Patient and aneurysm characteristics were compared using the χ² test for categorical variables and the independent t test analysis for continuous variables.

RESULTS

A total 233 patients were included in the study. Forty-three patients (19%) had undergone a previous hysterectomy; none had oophorectomies recorded. No difference in mean age (P = 0.89), hypertension (P = 0.38), alcohol use (P = 0.87), tobacco use (P = 0.22), or aneurysm location (P = 1) existed. However, patients in the hysterectomy group more often presented in a good neurologic condition before surgery (88% vs. 74%, P = 0.04) and had fewer large aneurysms (8% vs. 24%, P = 0.03). Also, fewer presented with a ruptured aneurysm (28%) then the nonhysterectomy group (51%) (P = 0.004).

CONCLUSIONS

Female patients with a surgical history of a hysterectomy have a lower rate of large aneurysms, present in better neurologic condition, and are less likely to present with a ruptured aneurysm than females without a hysterectomy.

Computer-aided analysis of middle cerebral artery tortuosity: association with aneurysm development

OBJECTIVE

Blood vessel tortuosity may play an important role in the development of vessel abnormalities such as aneurysms. Currently, however, there are no studies analyzing the impact of brain blood vessel tortuosity on the risk of aneurysm formation. Therefore, the authors performed a computer-aided analysis of middle cerebral artery (MCA) tortuosity, especially among patients diagnosed with MCA aneurysms.

METHODS

Anatomy of the MCAs of 54 patients with unruptured MCA aneurysms was retrospectively analyzed, as was that of 54 sex-, age-, and vessel side-matched control patients without MCA aneurysms. From medical records, the authors obtained each patient's medical history including previous and current diseases and medications. For each patient, they calculated the following tortuosity descriptors: relative length (RL), sum of angle metrics (SOAM), triangular index (TI), product of angle distance (PAD), and inflection count metric (ICM).

RESULTS

Patients with an MCA aneurysm had significantly lower RLs (0.75 ± 0.09 vs 0.83 ± 0.08, p < 0.01), SOAMs (0.45 ± 0.10 vs 0.60 ± 0.17, p < 0.01), and PADs (0.34 ± 0.09 vs 0.50 ± 0.17, p < 0.01). They also had significantly higher TIs (0.87 ± 0.04 vs 0.81 ± 0.07, p < 0.01) and ICMs (3.07 ± 1.58 vs 2.26 ± 1.12, p < 0.01). Female patients had significantly higher RLs (0.76 ± 0.11 vs 0.80 ± 0.09, p = 0.03) than male patients.

CONCLUSIONS

Middle cerebral artery aneurysm formation is strongly associated with blood vessel tortuosity parameters, which can potentially be used to screen for patients at risk for MCA aneurysm formation.

Clip ligation for ruptured intracranial aneurysm in a child with Loeys-Dietz syndrome: case report

The authors present the case of a pediatric patient with Loeys-Dietz syndrome (LDS) who underwent craniotomy for clip ligation of a ruptured intracranial aneurysm. To the authors' knowledge, this is the youngest reported patient with LDS who has been treated for a ruptured intracranial aneurysm. The patient presented with aneurysmal subarachnoid hemorrhage even though the results of surveillance screening were negative, and the aneurysm arose from the wall of the parent artery away from an arterial branch point. She was treated with open clip ligation and recovered well. The authors review the other reported cases of treated intracranial aneurysms in patients with LDS.

Endovascular treatment of a dural arteriovenous fistula in a patient with Loeys-Dietz syndrome: A case report

Background Loeys-Dietz syndrome (LDS) is a recently recognized autosomal dominant connective tissue disease. The manifestations of LDS include vascular tortuosity, scoliosis, craniosynostosis, aneurysm and aortic dissections. Clinical presentation A 35-year-old woman treated with Stanford type B aortic dissection and breast cancer was referred to us for Borden type II dural arteriovenous fistula (dAVF) draining to the vein of Galen, involving the midline of tentorium cerebelli. The dAVF was treated successfully by combined transarterial and transvenous embolization. Because of tortuosity of vertebral arteries, a genetic test was conducted confirming LDS type 2. Conclusions To our knowledge, this is the first case report of dAVF associated with LDS. The relationship between LDS and dAVF is unknown but this report shows the possibility that mutation of transforming growth factor β receptors 2 ( TGFBR2) related to LDS may be related to shunt diseases. Because intervention in LDS seems to be feasible compared to Ehlers Danlos syndrome and Marfan syndrome, it is important to make the correct diagnosis.

Neurovascular manifestations of connective-tissue diseases: A review

Patients with connective tissue diseases are thought to be at a higher risk for a number of cerebrovascular diseases such as intracranial aneurysms, dissections, and acute ischemic strokes. In this report, we aim to understand the prevalence and occurrences of such neurovascular manifestations in four heritable connective tissue disorders: Marfan syndrome, Ehlers-Danlos syndrome, Neurofibromatosis Type 1, and Loeys-Dietz syndrome. We discuss the fact that although there are various case studies reporting neurovascular findings in these connective tissue diseases, there is a general lack of case-control and prospective studies investigating the true prevalence of these findings in these patient populations. Furthermore, the differences observed in the manifestations and histology of such disease pathologies encourages future multi-center registries and studies in better characterizing the pathophysiology, prevalence, and ideal treatment options of neurovascular lesions in patents with connective tissue diseases.

Surgical Management of Peripheral Vascular Manifestations of Loeys-Dietz Syndrome

BACKGROUND

Loeys-Dietz syndrome (LDS) is characterized by a triad of aortic aneurysm, vessel tortuosity, and hypertelorism. LDS patients often harbor additional aneurysms and dissections throughout their vasculature. The optimal management of these additional lesions is poorly understood. Accordingly, we sought to analyze our experience with the peripheral arterial manifestations of LDS.

METHODS

Adult and pediatric LDS patients who sought treatment at a single institution from 2005 to 2015 were retrospectively reviewed. Patients were included if radiographic or clinically documented evidence existed of peripheral artery aneurysm or dissection. Standard univariate analyses were performed.

RESULTS

Eighteen LDS patients (aged 1.3-59.3 years, mean age 27.8 years at diagnosis) with aortic (not including root, ascending, or arch) vascular abnormalities were identified. Average follow-up was 5.2 ± 3.8 years. Fourteen (77.8%) patients had peripheral aneurysms, occurring most frequently in the carotid (35.7%), subclavian (35.7%), and visceral (28.6%) segments. Most patients had multiple peripheral segments involved (average 2, range 1-6). Nine (64%) patients with peripheral involvement underwent repair, for a total of 17 operations (average 1.89 operations per patient, range 1-4). Endovascular techniques were used in 4 operations (23.5%), without technical failures. Among patients requiring surgical repair, a history of abdominal aortic repairs was present in 77.8%, yielding a total of 36 vascular repairs (average 4, range 2-7). Perioperative morbidity was 11.8%, with no reported mortalities. Prior aortic dissection was not associated with peripheral surgical repairs (P = 0.58).

CONCLUSIONS

LDS is an aggressive vasculopathy which commonly affects the peripheral vasculature. Our data suggest that open and endovascular procedures may be safe and effective in the LDS periphery and multiple operations are common. As prior aortic dissection did not predict peripheral arterial involvement in LDS, vigilant peripheral arterial surveillance of LDS is warranted regardless of aortic disease state and may be key to early identification and our treatment success.

Curative reconstruction of a cerebral aneurysm by flow diversion with the Pipeline embolisation device in a patient with Loeys-Dietz syndrome

Loeys-Dietz syndrome is a recently described connective tissue disorder with a natural history of extreme vessel tortuosity and aggressive arterial aneurysm formation and rupture. This is the case of a 23-year-old woman with a large, dysplastic cavernous aneurysm who had successful endovascular treatment by flow diversion with the Pipeline embolisation device. Ten-month follow-up demonstrated complete aneurysm occlusion and curative reconstruction of the parent vessel without evidence of vessel injury or dissection. Endovascular treatment with flow-diverting devices is a valid treatment option and can be performed safely and effectively in this complex patient population.

Cerebral arterial angioplasty in a patient with Loeys-Dietz syndrome

A 14-year-old boy with Loeys-Dietz syndrome (LDS) had an acute neurologic decline 6 days after a subarachnoid hemorrhage. Cerebral angiography at presentation did not show an aneurysmal source of the hemorrhage. However, on post-bleed day 6 the patient experienced an acutely worsening headache and subsequently lost consciousness. Head CT showed new subarachnoid blood and repeat angiography demonstrated a basilar tip aneurysm. Endovascular coil embolization was performed and his neurologic status improved postoperatively until post-bleed day 9 when he became unresponsive. A CT angiogram demonstrated severe proximal vasospasm. After an unsuccessful attempt to treat the vasospasm medically, the patient was transported to the neurointerventional suite for intra-arterial vasodilator treatment, which also failed to ameliorate the vasospasm. The endovascular surgeons were then faced with the conundrum of attempting a high-risk cerebral angioplasty in a pediatric patient with LDS or returning to maximal medical treatment for severe refractory vasospasm.

Cerebral arterial angioplasty in a patient with Loeys-Dietz syndrome

A 14-year-old boy with Loeys-Dietz syndrome (LDS) had an acute neurologic decline 6 days after a subarachnoid hemorrhage. Cerebral angiography at presentation did not show an aneurysmal source of the hemorrhage. However, on post-bleed day 6 the patient experienced an acutely worsening headache and subsequently lost consciousness. Head CT showed new subarachnoid blood and repeat angiography demonstrated a basilar tip aneurysm. Endovascular coil embolization was performed and his neurologic status improved postoperatively until post-bleed day 9 when he became unresponsive. A CT angiogram demonstrated severe proximal vasospasm. After an unsuccessful attempt to treat the vasospasm medically, the patient was transported to the neurointerventional suite for intra-arterial vasodilator treatment, which also failed to ameliorate the vasospasm. The endovascular surgeons were then faced with the conundrum of attempting a high-risk cerebral angioplasty in a pediatric patient with LDS or returning to maximal medical treatment for severe refractory vasospasm.

Systemic vascular phenotypes of Loeys-Dietz syndrome in a child carrying a de novo R381P mutation in TGFBR2: a case report

BACKGROUND

Loeys-Dietz syndrome, also known as Marfan syndrome type II, is a rare connective tissue disorder caused by dominant mutations in transforming growth factor-beta receptors (TGFBR1 and 2).

CASE PRESENTATION

We report a 7-year-old Japanese boy with Loeys-Dietz syndrome who carried a novel, de novo missense mutation in TGFBR2 (c.1142g > c, R381P). He showed dysmorphic faces and skeletal malformations that were typical in previous cases with Loeys-Dietz syndrome. The cardiac studies disclosed the presence of markedly dilated aortic root and patent ductus aorteriosus. The cranial magnetic resonance imaging (MRI) and angiography (MRA) detected the tortuous appearances of the bilateral middle cerebral and carotid arteries.

CONCLUSION

This study depicts the systemic vascular phenotypes of a child with Loeys-Dietz syndrome that were caused by a novel heterozygous mutation of TGFR2. A large cohort with serial imaging studies for vascular phenotypes will be useful for delineating the genotype-phenotype correlations of Loeys-Dietz syndrome.

Genetics of thoracic aortic aneurysm: at the crossroad of transforming growth factor-β signaling and vascular smooth muscle cell contractility

Aortic aneurysm, including both abdominal aortic aneurysm and thoracic aortic aneurysm, is the cause of death of 1% to 2% of the Western population. This review focuses only on thoracic aortic aneurysms and dissections. During the past decade, the genetic contribution to the pathogenesis of thoracic aortic aneurysms and dissections has revealed perturbed extracellular matrix signaling cascade interactions and deficient intracellular components of the smooth muscle contractile apparatus as the key mechanisms. Based on the study of different Marfan mouse models and the discovery of several novel thoracic aortic aneurysm genes, the involvement of the transforming growth factor-β signaling pathway has opened unexpected new avenues. Overall, these discoveries have 3 important consequences. First, the pathogenesis of thoracic aortic aneurysms and dissections is better understood, although some controversy still exists. Second, the management strategies for the medical and surgical treatment of thoracic aortic aneurysms and dissections are becoming increasingly gene-tailored. Third, the pathogenetic insights have delivered new treatment options that are currently being investigated in large clinical trials.