Musculoskeletal manifestations of the Marfan syndrome: radiologic features

Discrepancy of echocardiography and computed tomography in initial assessment and 2-year follow-up for monitoring Marfan syndrome and related disorders

Patients with Marfan syndrome and related disorders are at risk for aortic dissection and aortic rupture and therefore require appropriate monitoring. Computed tomography (CT) and transthoracic echocardiography (TTE) are routinely used for initial diagnosis and follow-up. The purpose of this study is to compare whole-heart CT and TTE aortic measurement for initial work-up, 2-year follow-up, and detection of progressive aortic enlargement. This retrospective study included 95 patients diagnosed with Marfan syndrome or a related disorder. All patients underwent initial work-up including aortic diameter measurement using both electrocardiography-triggered whole-heart CT and TTE. Forty-two of these patients did not undergo aortic repair after initial work-up and were monitored by follow-up imaging within 2 years. Differences between the two methods for measuring aortic diameters were compared using Bland-Altman plots. The acceptable clinical limit of agreement (acLOA) for initial work-up, follow-up, and progression within 2 years was predefined as <  ± 2 mm. Bland-Altman analysis revealed a small bias of 0.2 mm with wide limits of agreement (LOA) from + 6.3 to - 5.9 mm for the aortic sinus and a relevant bias of - 1.6 mm with wide LOA from + 5.6 to - 8.9 mm for the ascending aorta. Follow-up imaging yielded a small bias of 0.5 mm with a wide LOA from + 6.7 to - 5.8 mm for the aortic sinus and a relevant bias of 1.1 mm with wide LOA from + 8.1 to - 10.2 mm for the ascending aorta. Progressive aortic enlargement at follow-up was detected in 57% of patients using CT and 40% of patients using TTE. Measurement differences outside the acLOA were most frequently observed for the ascending aorta. Whole-heart CT and TTE measurements show good correlation, but the frequency of measurement differences outside the acLOA is high. TTE systematically overestimates aortic diameters. Therefore, whole-heart CT may be preferred for aortic monitoring of patients with Marfan syndrome and related disorders. TTE remains an indispensable imaging tool that provides additional information not available with CT.

The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management

Purpose of Review

Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4).

Recent Findings

The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS.

Summary

Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.

[Nonneoplastic lesions of the spinal canal]

Numerous vascular, inflammatory, degenerative and tumorous lesions of the spinal canal can cause paraplegic symptoms. In addition to the neurological examination and the leading symptoms, the first topographical classification of the (suspected) disease is essential for further diagnostics. Hence, high-resolution magnet resonance imaging (MRI) is the gold standard for the majority of questions. To avoid diagnostic and therapeutic mistakes, differentiation of intraspinal tumors from tumor-like (nonneoplastic) lesions is indispensable, which is often only possible after follow-up imaging or surgical exploration.

[Spinal cysts : Diagnostic workup and therapy]

CLINICAL ISSUE

Spinal cysts can be classified as meningeal, not meningeal, and tumor-associated cysts. Due to the widespread availability of high-resolution computed tomography and magnet resonance imaging, spinal cysts can be detected with high sensitivity these days. Concerning the variety of potential cystic differential diagnoses, a precise classification is difficult and can often only be realized after surgical inspection or histological examination.

PRACTICAL RECOMMENDATIONS

Spinal cysts are generally incidental findings during a routine diagnostic workup and need no further therapy. Surgical treatment can be necessary if the spinal cyst reaches a certain size and causes neurological symptoms due to the compression of the spinal cord or the nerve root.

Retinal detachments in the pediatric population

In this review, we present a concise summary of the more commonly seen types of retinal detachments (RDs) that one can encounter in pediatric patients. A spectrum of diseases from rhegmatogenous RD in Stickler syndrome, Marfan syndrome, and choroidal coloboma to exudative RD in Coats disease, to tractional RD in persistent fetal vasculature, and combined RDs in familial exudative vitreoretinopathy are described with the management pearls for each.

Rare case of obturator hernia in a patient with Marfan's syndrome

Obturator hernia is a very rare type of abdominal hernia which constitutes <1 % of all the hernias. It is an important cause of small bowel obstruction which is associated with a high mortality rate if left untreated. Obturator hernia typically occurs in an elderly women or patients with chronically raised intraabdominal pressure or previous multiple pregnancies. We report a case of obstructed obturator hernia in a young female patient with Marfan's syndrome complicated with dissecting aortic aneurysm and chronic kidney disease. Though recurrent and incisional hernia constitutes one of the minor diagnostic criteria of Marfan's syndrome, obturator hernia being a very rare entity, has been reported very rarely in a patient with Marfan's syndrome.

Systemic disease involvement of the hand: manifestations on plain radiograph

This educational pictorial review provides an appreciation of the range of radiographic findings seen on a hand radiograph that contribute to a diagnosis of systemic disease, whether in clinical practice or the exam scenario.

Dural ectasia in Marfan syndrome: a case control study

BACKGROUND AND PURPOSE

Dural ectasia (DE) is one of the major criteria of Marfan syndrome (MFS). Our aim was to establish the prevalence of DE in an adult population fulfilling the Ghent criteria for MFS and to assess definitions of DE.

MATERIALS AND METHODS

One hundred five adults with suspected MFS were included. MR imaging at 1.5T was performed unless contraindicated; then CT was obtained. Lumbosacral anteroposterior vertebral body diameters (VBD) and dural sac diameters (DSD) were measured. Dural sac ratios (DSR = DSD/VBD) at levels L3 through S1 were calculated. Anterior meningoceles, herniations of nerve root sleeves, and scalloping were characterized. One hundred one sex- and age-matched patients were included as controls.

RESULTS

We identified 3 patient groups: 1) fulfilling Ghent criteria independent of DE (n = 73), 2); fulfilling Ghent criteria dependent on DE (n = 14), and 3); and suspected MFS, not fulfilling Ghent criteria (n = 18). DE was found in 86% of group 1. At levels L4-S1, mean DSRs were significantly higher in group 1 than in group 3 and controls (P < .001). Herniations of the nerve root sleeves were present in 73% in group 1 versus 1% in controls. Anterior meningoceles were found in 37% and 14% in groups 1 and 2, respectively, but not in group 3 or controls.

CONCLUSIONS

The diagnosis of DE on MR imaging or CT should be based on the presence of at least 1 of the following criteria: anterior meningoceles or nerve root sleeve herniation, DSD at S1 or below larger than DSD at L4, and DSR at S1 >0.59.

Dural ectasia in children with Marfan syndrome: a prospective, multicenter, patient-control study

The clinical diagnosis of Marfan syndrome in childhood is difficult, because symptoms may not have developed to their full expression until adulthood. The Ghent nosology for the diagnosis of Marfan syndrome classifies dural ectasia as a major diagnostic criterion. More than two thirds of adult patients with Marfan syndrome show dural ectasia, while the frequency in childhood is unknown. This prospective multicenter observational patient-control study was performed to identify pathologic changes of the lumbosacral spine in young patients with Marfan syndrome.

DESIGN

Prospective clinical trial, multicentric, cross-sectional.

SETTING

MRI of the lumbosacral spine.

PATIENTS

Twenty patients with proven Marfan syndrome, 20 patients suspicious for Marfan syndrome and 38 healthy controls.

OUTCOME MEASURES

Vertebral body diameter (VBD) from L1 to S1, dural sac diameter (DSD) from L1 to S1, dural sac ratio (DSR), qualitative assessment of the lumbosacral spine.

RESULTS

DSD and VBD in different age groups were higher in patients with proven or suspected Marfan syndrome than in healthy controls (DSD: L1, 6-8 years, P < 0.05). VBD related to body height showed a similar growth related increase in patients with proven or suspected Marfan syndrome and controls. DSD related to body height was elevated in patients with proven or suspected Marfan syndrome at different levels of the lumbar spine. DSD at levels L1, L5, and S1, and DSR at levels L5 and S1 of patients with proven Marfan syndrome were significantly higher (P < 0.05) than in controls.

CONCLUSION

Even during childhood pathologic changes inside the lumbosacral spine of patients with Marfan syndrome can be observed. Dural ectasia, which occurs at different levels of the lumbar spine, can be detected at levels L5 and S1 in up to 40% of patients with Marfan syndrome.

MR Evaluation of Dural Ectasia in Marfan Syndrome: Reassessment of the Established Criteria in Children, Adolescents, and Young Adults

PURPOSE

To retrospectively evaluate known criteria for assessment of dural ectasia by using magnetic resonance (MR) imaging in children, adolescents, and young adults with and those without Marfan syndrome.

MATERIALS AND METHODS

Local ethics committee approval and informed consent were obtained. MR images of the lumbar spine in 28 patients with clinically proved Marfan syndrome (group A; 17 male, 11 female; age range, 4-21 years; mean, 12.1 years), seven patients with suspicion of Marfan syndrome (group B; six male, one female; age range, 6-18 years; mean, 10.4 years), and 55 patients without Marfan syndrome (group C; 26 male, 29 female; age range, 4-20 years; mean, 10.7 years) were evaluated retrospectively for dural ectasia criteria (scalloping, dural sac ratio, nerve root sleeve diameter, sagittal dural sac width at S1 greater than that at L4) and according to classifications by Ahn et al and Fattori et al. For statistical comparison of results, one-way analysis of variance with Scheffe post hoc comparisons was used, with an overall two-tailed significance at alpha = .05.

RESULTS

No significant differences in scalloping and nerve root sleeve diameter were shown between groups. A significant difference was measured for dural sac ratios at L5 and S1 (F test, P = .003 and P < .001 at L5 and S1, respectively; post hoc t test for groups A vs C, P = .004 and P < .001 at L5 and S1, respectively). Significant differences were also obtained between groups A and C for sagittal dural sac width at S1 greater than that at L4 according to the calculated mean difference (for both F test and post hoc t test, P < .001 and P = .003 at S1 and L4, respectively). The Ahn et al and Fattori et al classifications were of limited value.

CONCLUSION

The data suggest that only dural sac ratio at L5 and S1 and a sagittal dural sac width at S1 greater than that at L4 are statistically significant criteria for the assessment of dural ectasia in children, adolescents, and young adults.

The bone mineral status of patients with Marfan syndrome

Osteopenia at the hip and low total body calcium content have been reported in women with Marfan syndrome. Using dual X-ray absorptiometry (DXA), we evaluated the lumbar spine L2-L4 and proximal femur bone mineral density (BMD,/cm2) in 32 women and 16 children with Marfan syndrome. The women were 38 +/- 10 (SD) years old (23-58 years); their mean height was 178.7 +/- 8 cm. The children (9 boys and girls were 9.9-17.5 years old. Children were tall for their ages but of normal weight. All subjects were moderately active, without previous nontraumatic fracture. In the women, BMD was reduced at L2-L4, femoral neck (fnk), trochanter (tr), and intertrochanter (intr) (p < 0.0001-0.006), compared with age-predicted values. Z scores for L2-L4 and for the fnk, tr, and intr, were -0.59 +/- 1.06,-1.25 +/- 0.99,-1.03 +/- 0.91, respectively. The average hip axis length (HAL) of 11.5 +/- 0.093 cm was at the 80th percentile for women. No significant change was observed in 1 year follow-up BMD measurements in 13 women (fnk = -0.23 +/- 2.3%/year; L2-L4 = -0.43 +/- 1.57%/year). In Marfan children, BMD correlated with age, height, and pubertal development. Femoral neck BMG was reduced (Z = -0.74 +/- 1.22,p < 0.05) with a nonsignificant trend toward decreased BMD at L2-L4 (Z = 33 +/- 1.48). Resorption markers in Marfan women were normal and did not correlate with bone status. We conclude that women with Marfan syndrome have both axial and peripheral osteopenia as well as an increased HAL. This combination of findings likely increases substantially their long-term risk for hip fracture. Presence of osteopenia in Marfan children indicates that the skeletal deficits of Marfan syndrome may reflect inadequate bone acquisition.

Bone mineral status of women with Marfan syndrome

PURPOSE

With effective surgical correction of vascular abnormalities, skeletal health is an important issue for patients with Marfan syndrome. Osteopenia has been radiographically described, yet no systematic evaluation of bone status has been published. The purpose of this study was to determine the bone mineral density (BMD, g/cm2) in women with Marfan syndrome.

PATIENTS AND METHODS

Seventeen women, 37.2 +/- 7.3 years old, with Marfan syndrome were studied. Dual energy x-ray absorptiometry (DXA) was used to measure BMD at the lumbar spine (L2-L4), proximal femur, and total body in all subjects. Scoliosis scores were assigned from 0 (no curvature) to 3 (severe curvature).

RESULTS

Highly significant deficits in BMD were observed at the proximal femur (p = 0.0001) as well as of the whole body (p < 0.05). Femoral neck BMD Z-score (mean +/- SD) = -1.36 +/- 0.94, trochanter Z = -1.07 +/- 0.80, and intertrochanter Z = -1.44 +/- 0.71; whole-body BMD Z-score = -0.30 +/- 0.16. BMD at L2-L4, however, did not differ from age-predicted values, Z = -0.48 +/- 1.16. There was no significant association between BMD and scoliosis, nor between BMD and fracture history. To correct for bone size, the bone mineral apparent density (BMAD, g/cm3) was calculated. The femoral neck BMAD values (mean +/- SD) were significantly lower than predicted (0.125 +/- 0.02 versus 0.147 +/- 0.001 g/cm3, p < 0.001). All subjects had normal menarche, and 15 reported regular menses. There was no history of nontraumatic fracture.

CONCLUSIONS

Women with Marfan syndrome have bone deficits at the proximal femur as well as of the whole body. This deficit is not related to scoliosis and persists when corrected for bone size. Women with Marfan syndrome may be at increased risk for proximal femoral fracture.

The extent of man from Vitruvius to Marfan

It is frequently stated that patients with Marfan's syndrome have an arm span greater than height. This implies a characteristic different from the proportions in normal adult man, in whom span and height are often thought to be equal. Such equality of span and height, which allows man to be portrayed within a square, has been a widely held concept, immortalised by Leonardo da Vinci, that dates from the Roman Vitruvius. However, in the past two hundred years, anthropometry has shown that span exceeds height in 59-78% of normal adult white men. Thus not only is the classic concept of equality of span and height generally incorrect, but also a span greater than height cannot be considered characteristic of Marfan's syndrome. Paradoxically, in some affected individuals, Vitruvian equality of height and span may occur.