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Vornetti G, Vara G, Baroni MC, Mariucci E, Donti A, Cirillo L, Ratti S, Cantoni E, Venturi G, Tonon C, Lodi R, Spinardi L. Quantitative measurement of dural ectasia: associations with clinical and genetic characteristics in Marfan syndrome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2561-2568. [PMID: 38615299 DOI: 10.1007/s00586-024-08252-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/31/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE Dural ectasia (DE) may significantly impact Marfan syndrome (MFS) patients' quality of life due to chronic lower back pain, postural headache and urinary disorders. We aimed to evaluate the association of quantitative measurements of DE, and their evolution over time, with demographic, clinical and genetic characteristics in a cohort of MFS patients. METHODS We retrospectively included 88 consecutive patients (39% females, mean age 37.1 ± 14.2 years) with genetically confirmed MFS who underwent at least one MRI or CT examination of the lumbosacral spine. Vertebral scalloping (VS) and dural sac ratio (DSR) were calculated from L3 to S3. Likely pathogenic or pathogenic FBN1 variants were categorized as either protein-truncating or in-frame. The latter were further classified according to their impact on the cysteine content of fibrillin-1. RESULTS Higher values of the systemic score (revised Ghent criteria) were associated with greater DSR at lumbar (p < 0.001) and sacral (p = 0.021) levels. Patients with protein-truncating variants exhibited a greater annual increase in lumbar (p = 0.039) and sacral (p = 0.048) DSR. Mutations affecting fibrillin-1 cysteine content were linked to higher VS (p = 0.009) and DSR (p = 0.038) at S1, along with a faster increase in VS (p = 0.032) and DSR (p = 0.001) in the lumbar region. CONCLUSION Our study shed further light on the relationship between genotype, dural pathology, and the overall clinical spectrum of MFS. The identification of protein-truncating variants and those impacting cysteine content may therefore suggest closer patient monitoring, in order to address potential complications associated with DE.
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Affiliation(s)
- Gianfranco Vornetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giulio Vara
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Diagnostic and Interventional Radiology, Ospedale Civile Umberto I, Lugo, RA, Italy
| | | | | | - Andrea Donti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Stefano Ratti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Elena Cantoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Greta Venturi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Caterina Tonon
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
| | - Luca Spinardi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Naas O, Norajitra T, Lückerath C, Fink MA, Maier-Hein K, Kauczor HU, Rengier F. MRI-Derived Dural Sac and Lumbar Vertebrae 3D Volumetry Has Potential for Detection of Marfan Syndrome. Diagnostics (Basel) 2024; 14:1301. [PMID: 38928716 PMCID: PMC11202825 DOI: 10.3390/diagnostics14121301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/03/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE To assess the feasibility and diagnostic accuracy of MRI-derived 3D volumetry of lower lumbar vertebrae and dural sac segments using shape-based machine learning for the detection of Marfan syndrome (MFS) compared with dural sac diameter ratios (the current clinical standard). MATERIALS AND METHODS The final study sample was 144 patients being evaluated for MFS from 01/2012 to 12/2016, of whom 81 were non-MFS patients (46 [67%] female, 36 ± 16 years) and 63 were MFS patients (36 [57%] female, 35 ± 11 years) according to the 2010 Revised Ghent Nosology. All patients underwent 1.5T MRI with isotropic 1 × 1 × 1 mm3 3D T2-weighted acquisition of the lumbosacral spine. Segmentation and quantification of vertebral bodies L3-L5 and dural sac segments L3-S1 were performed using a shape-based machine learning algorithm. For comparison with the current clinical standard, anteroposterior diameters of vertebral bodies and dural sac were measured. Ratios between dural sac volume/diameter at the respective level and vertebral body volume/diameter were calculated. RESULTS Three-dimensional volumetry revealed larger dural sac volumes (p < 0.001) and volume ratios (p < 0.001) at L3-S1 levels in MFS patients compared with non-MFS patients. For the detection of MFS, 3D volumetry achieved higher AUCs at L3-S1 levels (0.743, 0.752, 0.808, and 0.824) compared with dural sac diameter ratios (0.673, 0.707, 0.791, and 0.848); a significant difference was observed only for L3 (p < 0.001). CONCLUSION MRI-derived 3D volumetry of the lumbosacral dural sac and vertebral bodies is a feasible method for quantifying dural ectasia using shape-based machine learning. Non-inferior diagnostic accuracy was observed compared with dural sac diameter ratio (the current clinical standard for MFS detection).
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Affiliation(s)
- Omar Naas
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Tobias Norajitra
- Division of Medical Image Computing, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Christian Lückerath
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Matthias A. Fink
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Hans-Ulrich Kauczor
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Fabian Rengier
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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Joo PY, Caruana DL, Gouzoulis MJ, Moore HG, Zhu JR, Ameri B, Grauer JN. Marfan syndrome and adolescent idiopathic scoliosis patients have similar 90-day postoperative outcomes and 5-year reoperation rates after spinal deformity surgery. Spine Deform 2022; 10:1169-1174. [PMID: 35362940 DOI: 10.1007/s43390-022-00501-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/19/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks. METHODS Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05. RESULTS In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9). CONCLUSION While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Dennis L Caruana
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Michael J Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Harold G Moore
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Justin R Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Bijan Ameri
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA.
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Pollock L, Ridout A, Teh J, Nnadi C, Stavroulias D, Pitcher A, Blair E, Wordsworth P, Vincent TL. The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management. Curr Rheumatol Rep 2021; 23:81. [PMID: 34825999 PMCID: PMC8626407 DOI: 10.1007/s11926-021-01045-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Lily Pollock
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Ashley Ridout
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Teh
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK
| | - Colin Nnadi
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Alex Pitcher
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Edward Blair
- Department of Clinical Genetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Wordsworth
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tonia L Vincent
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK. .,Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Zeigler SM, Sloan B, Jones JA. Pathophysiology and Pathogenesis of Marfan Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:185-206. [PMID: 34807420 DOI: 10.1007/978-3-030-80614-9_8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disorder that is inherited in an autosomal dominant pattern with variable penetrance. While clinically this disease manifests in many different ways, the most life-threatening manifestations are related to cardiovascular complications including mitral valve prolapse, aortic insufficiency, dilatation of the aortic root, and aortic dissection. In the past 30 years, research efforts have not only identified the genetic locus responsible but have begun to elucidate the molecular pathogenesis underlying this disorder, allowing for the development of seemingly rational therapeutic strategies for treating affected individuals. In spite of these advancements, the cardiovascular complications still remain as the most life-threatening clinical manifestations. The present chapter will focus on the pathophysiology and clinical treatment of Marfan syndrome, providing an updated overview of the recent advancements in molecular genetics research and clinical trials, with an emphasis on how this information can focus future efforts toward finding betters ways to detect, diagnose, and treat this devastating condition.
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Affiliation(s)
- Sanford M Zeigler
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brandon Sloan
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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Ikwuezunma IA, Sponseller PD. Surgical Evaluation and Management of Spinal Pathology in Patients with Connective Tissue Disorders. Neurosurg Clin N Am 2021; 33:49-59. [PMID: 34801141 DOI: 10.1016/j.nec.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Connective tissue disorders represent a varied spectrum of syndromes that have important implications for the spine deformity surgeon. Spine surgeons must be aware of these diverse and global manifestations of disease because they have significant impact on perioperative and postoperative outcomes.
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Affiliation(s)
- Ijezie A Ikwuezunma
- Department of Orthopaedic Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Paul D Sponseller
- Pediatric Orthopaedics, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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Matsushima S, Shimizu T, Baba A, Ojiri H. Physiological pseudo-thickened cauda equina associated with dural sac dilatation on magnetic resonance imaging. Neuroradiol J 2021; 34:401-407. [PMID: 33657903 DOI: 10.1177/1971400921998970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES In daily clinical practice, the assessment of the thickness of the cauda equina on lumbar spine magnetic resonance imaging is an important parameter. However, its relevance to the size of the dural sac in non-pathological conditions is unknown. To examine the relationship between the size of the dural sac and the apparent thickness of the cauda equina nerve root using lumbar spine magnetic resonance imaging in non-pathological conditions. METHODS We retrospectively measured the dural sac diameter and vertebral body diameter, counted the apparent number, and calculated total cross-sectional area of the cauda equina, dural sac ratio and the area of one apparent nerve root of cauda equina in 100 cases. Spearman's rank correlation coefficient (ρ) was used. RESULTS Dural sac ratio and diameter were positively correlated with the area of one apparent nerve root (ρ=0.77, P<0.001; ρ=0.74, P<0.001; respectively) and negatively correlated with the apparent number of cauda equina in a single cross-section (ρ=-0.63, P<0.001; ρ=-0.52, P<0.001; respectively). CONCLUSIONS A larger dural sac ratio and diameter was associated with an apparently thicker cauda equina and lower visible number. In a larger dural sac, the physiologically clumped and apparently thicker cauda equina should not be misdiagnosed as pathological.
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Affiliation(s)
- Satoshi Matsushima
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
| | - Tetsuya Shimizu
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
| | - Akira Baba
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
| | - Hiroya Ojiri
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
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Vanem TT, Böker T, Sandvik GF, Kirkhus E, Smith H, Andersen K, Drolsum L, Lundby R, Røe C, Krohg‐Sørensen K, Geiran OR, Paus B, Rand‐Hendriksen S. Marfan syndrome: Evolving organ manifestations—A 10‐year follow‐up study. Am J Med Genet A 2019; 182:397-408. [DOI: 10.1002/ajmg.a.61441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Thy Thy Vanem
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Tordis Böker
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Gunhild F. Sandvik
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of OphthalmologyOUH Oslo Norway
| | - Eva Kirkhus
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Hans‐Jørgen Smith
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Kai Andersen
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Liv Drolsum
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of OphthalmologyOUH Oslo Norway
| | - Rigmor Lundby
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Radiology and Nuclear MedicineOUH Oslo Norway
| | - Cecilie Røe
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Physical Medicine and RehabilitationOUH Oslo Norway
| | - Kirsten Krohg‐Sørensen
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Odd R. Geiran
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Cardiothoracic SurgeryOslo University Hospital (OUH) Oslo Norway
| | - Benedicte Paus
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- Department of Medical GeneticOUH Oslo Norway
| | - Svend Rand‐Hendriksen
- Faculty of Medicine, University of OsloInstitute of Clinical Medicine Oslo Norway
- TRS, National Resource Centre for Rare DisordersSunnaas Rehabilitation Hospital Nesoddtangen Norway
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Böker T, Vanem TT, Pripp AH, Rand-Hendriksen S, Paus B, Smith HJ, Lundby R. Dural ectasia in Marfan syndrome and other hereditary connective tissue disorders: a 10-year follow-up study. Spine J 2019; 19:1412-1421. [PMID: 30998996 DOI: 10.1016/j.spinee.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/11/2019] [Accepted: 04/11/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Dural ectasia is widening of the dural sac often seen in patients with Marfan syndrome and other hereditary connective tissue disorders. Dural ectasia can cause specific symptoms and is associated with surgical complications. The knowledge on how and at which age dural ectasia develops is incomplete. There is no established gold standard for diagnosing dural ectasia, making it difficult to compare results from different studies. PURPOSE Our primary aim was to explore whether the radiological findings of dural ectasia changed after 10 years in an adult cohort with suspected Marfan syndrome. Our secondary aim was to re-evaluate the radiological criteria of dural ectasia. STUDY DESIGN Prospective cohort study. PATIENT SAMPLE Sixty-two persons from a cross-sectional study of 105 persons with suspected Marfan syndrome were included in a 10-year follow-up of dural ectasia. Forty-six were diagnosed with Marfan syndrome, 7 with Loeys-Dietz syndrome, and 5 with other hereditary connective tissue disorders. For comparison 64 matched hospital controls were evaluated. OUTCOME MEASURES Previously used radiological criteria for dural ectasia based on quantitative measurements of the lumbosacral spine. METHODS MRI of the lumbosacral spine was performed if not contraindicated, and if so then CT was performed. Differences in the study group between baseline and follow-up were assessed with paired Student t test, Wilcoxon rank signed test, and McNemar test. Receiver operating characteristic curves were constructed to assess the ability of radiological measurement to differentiate between the study and control group. RESULTS Fifty-two of 58 patients with hereditary connective tissue disorders and 11 controls had dural ectasia at follow-up. Forty-five Marfan patients had dural ectasia at follow-up vs. 41 at baseline. Five Loeys-Dietz patients had dural ectasia at follow-up vs. four at baseline. Twenty-four Marfan and 2 Loeys-Dietz patients had anterior sacral meningocele at follow-up, compared with 21 and 1, respectively, at baseline. Three Marfan patients developed herniation of a nerve root sleeve during follow-up. This was not seen in other individuals. The dural sac ended significantly lower at follow-up, and the dural sac ratio at level L5 was significantly increased from baseline in the Marfan patients. CONCLUSIONS In Marfan and Loeys-Dietz syndrome, dural ectasia may present or worsen during adulthood. The cut-off value of dural sac ratio at level S1 is suggested elevated to 0.64. The results from the present study may help as guidance for appropriate follow-up of patients with dural ectasia.
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Affiliation(s)
- Tordis Böker
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Radiology and Nuclear Medicine, Oslo University Hospital, Ullevål, PO BOX 4956 Nydalen, Oslo 0424, Norway.
| | - Thy Thy Vanem
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Svend Rand-Hendriksen
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Benedicte Paus
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Hans-Jørgen Smith
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Rigmor Lundby
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Radiology and Nuclear Medicine, Oslo University Hospital, Ullevål, PO BOX 4956 Nydalen, Oslo 0424, Norway
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Sandvik GF, Vanem TT, Rand-Hendriksen S, Cholidis S, Saethre M, Drolsum L. Ten-year reinvestigation of ocular manifestations in Marfan syndrome. Clin Exp Ophthalmol 2018; 47:212-218. [PMID: 30260057 DOI: 10.1111/ceo.13408] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/03/2018] [Accepted: 09/20/2018] [Indexed: 11/28/2022]
Abstract
IMPORTANCE Long-term follow-up of Marfan syndrome (MFS) patients. BACKGROUND Investigate changes in ocular features in MFS patients fulfilling the Ghent-2 criteria following a period of 10 years. DESIGN Repeated cross-sectional study with two observations. PARTICIPANTS Eighty-four MFS patients were investigated in 2003-2004 (baseline). Forty-four of these patients (52%) were examined after 10 years. METHODS A comprehensive ocular examination performed at baseline and follow-up. MAIN OUTCOME MEASURES Development or progression of ectopia lentis (EL). RESULTS At follow-up, mean age was 50.1 ± 11.9 years (range: 30-80 years), 74% were female and 70% of the patients were diagnosed with EL compared to 66% at baseline. Two patients (3 eyes) had developed EL over the decade, representing a 13% risk. Furthermore, one eye had progressed from a subtle tilt of the lens to dislocation. We found no significant change in the axial length (P = 0.96), the corneal curvature (P = 0.64) or the spherical equivalent (P = 0.23). Best corrected visual acuity was improved at follow-up (P = 0.02). There were 7% and 33% risks for development of retinal detachment and cataract between baseline and follow-up, respectively. CONCLUSIONS AND RELEVANCE Our study indicates that even though EL typically occurs at an early stage in most MFS patients, there is still a risk of developing EL in adulthood. The risk of developing vision-threatening complications such as retinal detachment and cataract was much higher than in the normal population, but even so, the visual potential of the MFS patients was relatively good.
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Affiliation(s)
- Gunhild F Sandvik
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Thy T Vanem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Svend Rand-Hendriksen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesodden, Norway
| | - Symira Cholidis
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
| | - Marit Saethre
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
| | - Liv Drolsum
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Assessment of Dural Ectasia Using Computed Tomodensitometry as a Criterion in Marfan Syndrome. J Comput Assist Tomogr 2018; 43:282-287. [PMID: 30371622 DOI: 10.1097/rct.0000000000000822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to reevaluate dural ectasia criteria in Marfan syndrome patients fulfilling the revised Ghent criteria. METHODS Lumbar computed tomography scans of 19 Marfan patients and 30 matched control subjects were retrospectively assessed. Dural sac ratio (DSR), nerve root sleeve diameter, pedicle width, and a scalloping or meningocele presence were each assessed by 2 readers blinded from the diagnosis. Mann-Whitney-Wilcoxon tests compared the patient and control groups. Receiver operating characteristic curve analysis and multivariate models determined the optimal cutoff value. RESULTS A DSR value greater than 0.69 at L5 (DSR-L5) such as L4 scalloping of more than 2.65 mm (scall-L4) and 6 or more vertebrae showing a scalloping of more than 3 mm (6-scall) were found very specific but with limited sensitivity. Multivariate model combining DSR-L5 + scall-L4 showed good positive predictive value, whereas model combining DSR-L5 + 6-scall showed good negative predictive value. CONCLUSIONS Assessment of DSR and vertebral scalloping allows valuable depiction of dural ectasia in Marfan syndrome patients.
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Vacula BB, Gray C, Hofkamp MP, Noonan PT, McAllister RK, Pilkinton KA, Diao Z. Epidural analgesia complicated by dural ectasia in the Marfan syndrome. Proc (Bayl Univ Med Cent) 2017; 29:385-386. [PMID: 27695168 DOI: 10.1080/08998280.2016.11929477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Patients with the Marfan syndrome are considered to be high risk during pregnancy and warrant a complete multidisciplinary evaluation. One goal is to minimize hemodynamic fluctuations during labor since hypertensive episodes may result in aortic dissection or rupture. Although they may prevent these complications, neuraxial techniques may be complicated by dural ectasia. The case of a parturient with the Marfan syndrome and mild dural ectasia is presented. During attempted labor epidural placement, unintentional dural puncture occurred. A spinal catheter was used for adequate labor analgesia, and a resultant postdural puncture headache was alleviated by an epidural blood patch under fluoroscopic guidance.
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Affiliation(s)
- Benjamin B Vacula
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Chelsea Gray
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Michael P Hofkamp
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Patrick T Noonan
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Russell K McAllister
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Kimberly A Pilkinton
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Zhiying Diao
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
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Pierro A, Cilla S, Maselli G, Cucci E, Ciuffreda M, Sallustio G. Sagittal Normal Limits of Lumbosacral Spine in a Large Adult Population: A Quantitative Magnetic Resonance Imaging Analysis. J Clin Imaging Sci 2017; 7:35. [PMID: 28904831 PMCID: PMC5590400 DOI: 10.4103/jcis.jcis_24_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/11/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The objective of this study was to determine, using magnetic resonance imaging (MRI) of the lumbosacral spine from L1 to S1, the values of the normal sagittal diameter of the spinal canal (SCD), sagittal diameter of the dural sac (DSD), and the normal values of dural sac ratio (DSR) in a large nonsymptomatic adult population and to discriminate whether a vertebral canal is pathological or nonpathological for dural ectasia and/or stenosis. MATERIALS AND METHODS Six hundred and four patients were prospectively enrolled. All measurements were performed on MRI sagittal T1- and T2-weighted images. The 95% confidence interval (95% CI), defined as mean ± 1.96 standard deviation, was determined for each metric. The upper limit of 95% CI was considered the cutoff value for the normal DSR; the lower limit of 95% CI was considered the cutoff value for the normal SCD. RESULTS SCD cutoff values from L1 to S1 ranged from 14.5-10.1 mm (males) to 15.0-9.9 mm (females). DSD ratios at S1 and L4 level show a significant difference in male and female groups: 11% of S1/L4 values exceeded 1 in male group while only 4% of S1/L4 values exceeded 1 in female group. Mean DSR at each level was significantly higher in female patients than in male patients (P < 0.001), ranging from 0.70 to 0.56 (male) and from 0.82 to 0.63 (female). CONCLUSIONS We determined the cutoff values for the normal DSR and for the normal SCD. Our findings show the relevant discrepancies with respect to literature data for diagnosis of lumbar stenosis and/or dural ectasia.
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Affiliation(s)
- Antonio Pierro
- Department of Radiology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Oncology Department, Fondazione di Ricerca e Cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Giuseppina Maselli
- Department of Radiology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Eleonora Cucci
- Department of Radiology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Matteo Ciuffreda
- Department of Radiology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Giuseppina Sallustio
- Department of Radiology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
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Epidural Anesthesia for Cesarean Section in a Pregnant Woman with Marfan Syndrome and Dural Ectasia. Case Rep Obstet Gynecol 2017; 2017:2126310. [PMID: 28611929 PMCID: PMC5458362 DOI: 10.1155/2017/2126310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 04/19/2017] [Indexed: 11/29/2022] Open
Abstract
Marfan syndrome (MFS) is a genetic disorder of connective tissue, characterized by variable clinical features and multisystem complications. The anesthetic management during delivery is debated. Regional anesthesia has been used with success during cesarean delivery, but in some MFS patients there is a probability of erratic and inadequate spread of intrathecal local anesthetics as a result of dural ectasia. In these cases, epidural anesthesia may be a particularly useful technique during cesarean delivery because it allows an adequate spread and action of local anesthetic with a controlled onset of anesthesia, analgesia, and sympathetic block and a low risk of perioperative complications. We report the perioperative management of a patient with MFS and dural ectasia who successfully underwent cesarean section using epidural technique anesthesia. The previous pregnancy of this woman ended with cesarean section with a failed spinal anesthesia that was converted to general anesthesia due to unknown dural ectasia at that time.
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Klekamp J. A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias. Neurosurgery 2017; 81:29-44. [DOI: 10.1093/neuros/nyx049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 01/30/2017] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND: The clinical significance of pathologies of the spinal dura is often unclear and their management controversial.
OBJECTIVE: To classify spinal dural pathologies analogous to vascular aneurysms, present their symptoms and surgical results.
METHODS: Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated dural pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed.
RESULTS: Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgery was recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery.
CONCLUSION: The majority of dural pathologies involving root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Type I and type II pathologies were treated with good long-term results occluding their dural defects, while ectasias of the dural sac (type III) were managed conservatively.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus Quakenbrück, Quakenbr-ück, Germany
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Blankart CR, Milstein R, Rybczynski M, Schüler H, von Kodolitsch Y. Economic and care considerations of Marfan syndrome. Expert Rev Pharmacoecon Outcomes Res 2016; 16:591-598. [PMID: 27662508 DOI: 10.1080/14737167.2016.1240619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Marfan syndrome is a rare multisystem disease of the connective tissue, which affects multiple organ systems. advances in healthcare have doubled the life-expectancy of patients over the past three decades. to date, there is no comprehensive review that consolidates economic considerations and care for marfan patients. Areas covered: Present research suggests that there may be a link between treatment pattern, disease progression and economic costs of Marfan syndrome. It indicates that an early detection of the disease and preventive interventions achieve a dual aim. From a patient perspective, it may reduce the amount of emergency surgery or intervention, and inpatient stays. In addition, it slows disease progression, lowers lifestyle restrictions, reduces psychological stress, and improves health-related quality of life. Expert commentary: Early detection and preventive measures are likely to achieve a dual aim by simultaneously containing costs and reducing the number and length of inpatient stays.
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Affiliation(s)
| | - Ricarda Milstein
- a Hamburg Center for Health Economics , Universität Hamburg , Hamburg , Germany
| | - Meike Rybczynski
- b University Heart Center Hamburg , University Hospital Eppendorf , Hamburg , Germany
| | - Helke Schüler
- b University Heart Center Hamburg , University Hospital Eppendorf , Hamburg , Germany
| | - Yskert von Kodolitsch
- b University Heart Center Hamburg , University Hospital Eppendorf , Hamburg , Germany
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Potts MB, McGrath MH, Chin CT, Garcia RM, Weinstein PR. Microsurgical Fenestration and Paraspinal Muscle Pedicle Flaps for the Treatment of Symptomatic Sacral Tarlov Cysts. World Neurosurg 2016; 86:233-42. [DOI: 10.1016/j.wneu.2015.09.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 11/28/2022]
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Velvin G, Bathen T, Rand-Hendriksen S, Geirdal A. Systematic review of chronic pain in persons with Marfan syndrome. Clin Genet 2016; 89:647-58. [DOI: 10.1111/cge.12699] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/20/2015] [Accepted: 11/20/2015] [Indexed: 11/29/2022]
Affiliation(s)
- G. Velvin
- TRS National Resource Centre for Rare Disorders; Sunnaas Rehabilitation Hospital; Nesodden Norway
- Faculty of Social Sciences, Department of Social Work, Child Welfare and Social Policy; Oslo and Akershus University College of Applied Sciences; Oslo Norway
| | - T. Bathen
- TRS National Resource Centre for Rare Disorders; Sunnaas Rehabilitation Hospital; Nesodden Norway
| | - S. Rand-Hendriksen
- TRS National Resource Centre for Rare Disorders; Sunnaas Rehabilitation Hospital; Nesodden Norway
- Institute of clinical medicine, Faculty of Medicine; University of Oslo; Oslo Norway
| | - A.Ø. Geirdal
- Faculty of Social Sciences, Department of Social Work, Child Welfare and Social Policy; Oslo and Akershus University College of Applied Sciences; Oslo Norway
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Nguyen HS, Lozen A, Doan N, Gelsomin M, Shabani S, Maiman D. Marsupialization and distal obliteration of a lumbosacral dural ectasia in a nonsyndromic, adult patient. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2015; 6:219-22. [PMID: 26692704 PMCID: PMC4660503 DOI: 10.4103/0974-8237.167887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Dural ectasia is frequently associated with connective tissue disorders or inflammatory conditions. Presentation in a patient without known risk factors is rare. Moreover, the literature regarding the treatment options for symptomatic dural ectasia is controversial, variable, and limited. A 62-year-old female presents with intractable, postural headaches for years. A lumbar puncture revealed opening pressure 3 cm of water. A computed tomography myelogram of the spine demonstrated erosion of her sacrum due to a large lumbosacral dural ectasia. An initial surgery was attempted to reduce the size of the expansile dura, and reconstruct the dorsal sacrum with a titanium plate (Depuy Synthes, Westchester, PA, USA) to prevent recurrence of thecal sac dilatation. Her symptoms initially improved, but shortly thereafter recurred. A second surgery was then undertaken to obliterate the thecal sac distal to the S2 nerve roots. This could not be accomplished through simple ligation of the thecal sac circumferentially as the ventral dura was noted to be incompetent and attempts to develop an extradural tissue plane were unsuccessful. Consequently, an abundance of fibrin glue was injected into the thecal sac distal to S2, and the dural ectasia was marsupialized rostrally, effectively obliterating the distal thecal sac while further reducing the size of the expansile dura. This approach significantly improved her symptoms at 5 months follow-up. Treatment of dural ectasia is not well-defined and has been variable based on the underlying manifestations. We report a rare patient without risk factors who presented with significant lumbosacral dural ectasia. Moreover, we present a novel method to treat postural headaches secondary to dural ectasia, where the thecal sac is obliterated distal to the S2 nerve roots using an abundance of fibrin glue followed by marsupialization of the thecal sac rostally. This method may offer an effective therapy option as it serves to limit the expansile dura, reducing the cerebrospinal fluid sump and the potential for intracranial hypotension.
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Affiliation(s)
- Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew Lozen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ninh Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Gelsomin
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dennis Maiman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
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von Kodolitsch Y, De Backer J, Schüler H, Bannas P, Behzadi C, Bernhardt AM, Hillebrand M, Fuisting B, Sheikhzadeh S, Rybczynski M, Kölbel T, Püschel K, Blankenberg S, Robinson PN. Perspectives on the revised Ghent criteria for the diagnosis of Marfan syndrome. APPLICATION OF CLINICAL GENETICS 2015; 8:137-55. [PMID: 26124674 PMCID: PMC4476478 DOI: 10.2147/tacg.s60472] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Three international nosologies have been proposed for the diagnosis of Marfan syndrome (MFS): the Berlin nosology in 1988; the Ghent nosology in 1996 (Ghent-1); and the revised Ghent nosology in 2010 (Ghent-2). We reviewed the literature and discussed the challenges and concepts of diagnosing MFS in adults. Ghent-1 proposed more stringent clinical criteria, which led to the confirmation of MFS in only 32%–53% of patients formerly diagnosed with MFS according to the Berlin nosology. Conversely, both the Ghent-1 and Ghent-2 nosologies diagnosed MFS, and both yielded similar frequencies of MFS in persons with a causative FBN1 mutation (90% for Ghent-1 versus 92% for Ghent-2) and in persons not having a causative FBN1 mutation (15% versus 13%). Quality criteria for diagnostic methods include objectivity, reliability, and validity. However, the nosology-based diagnosis of MFS lacks a diagnostic reference standard and, hence, quality criteria such as sensitivity, specificity, or accuracy cannot be assessed. Medical utility of diagnosis implies congruency with the historical criteria of MFS, as well as with information about the etiology, pathogenesis, diagnostic triggers, prognostic triggers, and potential complications of MFS. In addition, social and psychological utilities of diagnostic criteria include acceptance by patients, patient organizations, clinicians and scientists, practicability, costs, and the reduction of anxiety. Since the utility of a diagnosis or exclusion of MFS is context-dependent, prioritization of utilities is a strategic decision in the process of nosology development. Screening tests for MFS should be used to identify persons with MFS. To confirm the diagnosis of MFS, Ghent-1 and Ghent-2 perform similarly, but Ghent-2 is easier to use. To maximize the utility of the diagnostic criteria of MFS, a fair and transparent process of nosology development is essential.
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Affiliation(s)
| | - Julie De Backer
- Centre for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Helke Schüler
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Diagnostic and Interventional Radiology Department and Clinic, Berlin, Germany
| | - Cyrus Behzadi
- Diagnostic and Interventional Radiology Department and Clinic, Berlin, Germany
| | | | | | - Bettina Fuisting
- Department of Ophthalmology, University Hospital Eppendorf, Hamburg, Germany
| | - Sara Sheikhzadeh
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Meike Rybczynski
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Hospital Eppendorf, Hamburg, Germany
| | | | - Peter N Robinson
- Institute of Medical Genetics and Human Genetics, Charité Universitätsmedizin, Berlin, Germany
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Drolsum L, Rand‐Hendriksen S, Paus B, Geiran OR, Semb SO. Ocular findings in 87 adults with Ghent-1 verified Marfan syndrome. Acta Ophthalmol 2015; 93:46-53. [PMID: 24853997 DOI: 10.1111/aos.12448] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/16/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To study ocular characteristics in 87 patients with verified Marfan syndrome (MFS) based on the Ghent criteria from 1996 (Ghent-1). METHODS The position of the lens was noted by observing the eye in different gaze directions in maximal mydriasis during slit lamp examination. Ectopia lentis (EL) was classified as subluxated (dislocation slightly backwards) or luxated (vertical or horizontal displacement). Corneal curvature, axial length (AL), corneal diameter, central corneal thickness, anterior chamber depth, lens thickness, condition of the iris, intraocular pressure, spherical equivalent and visual acuity were also investigated. RESULTS EL was found in 108 eyes (62.1%). Of the 68 phakic eyes with EL, 43 (63.2%) had subluxation. Mean AL was 24.80 ± 2.57 mm, and the AL was above 23.5 mm in 65.3%. Mean keratometry (K) in phakic eyes was 41.79 ± 1.70 diopters (D), and the K value was <41.5D in 46.8%. Iris hypoplasia was found in 3.4%. Myopia above 3D occurred in 38.4% of the phakic eyes. Mean binocular logMAR was 0.10 ± 0.32. Only five patients (5.7%) had a logMAR more than 0.5. These 5 patients had EL, and 4 of them were amblyopic. CONCLUSION In this strictly defined MFS group fulfilling the Ghent-1 criteria, the prevalence of EL was 62.1%. In many cases, the dislocation of the lens was subtle. On average, the corneas were flattened and the globe length was increased. Only a few patients were visually impaired. Children with MFS should have a thorough follow up to avoid amblyopia.
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Affiliation(s)
- Liv Drolsum
- Department of Ophthalmology Oslo University Hospital Oslo Norway
- University of Oslo Oslo Norway
| | - Svend Rand‐Hendriksen
- University of Oslo Oslo Norway
- Sunnaas Rehabilitation Hospital TRS National Resource Centre for Rare Disorders Nesodden Norway
| | - Benedicte Paus
- University of Oslo Oslo Norway
- Department of Medical Genetics Oslo University Hospital Oslo Norway
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Daniels MLA, Lowe JR, Roy P, Patrone MV, Conyers JM, Fine JP, Knowles MR, Birchard KR. Standardization and validation of a novel and simple method to assess lumbar dural sac size. Clin Radiol 2014; 70:146-52. [PMID: 25434773 PMCID: PMC4282821 DOI: 10.1016/j.crad.2014.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 10/14/2014] [Accepted: 10/20/2014] [Indexed: 12/02/2022]
Abstract
AIM To develop and validate a simple, reproducible method to assess dural sac size using standard imaging technology. MATERIALS AND METHODS This study was institutional review board-approved. Two readers, blinded to the diagnoses, measured anterior–posterior (AP) and transverse (TR) dural sac diameter (DSD), and AP vertebral body diameter (VBD) of the lumbar vertebrae using MRI images from 53 control patients with pre-existing MRI examinations, 19 prospectively MRI-imaged healthy controls, and 24 patients with Marfan syndrome with prior MRI or CT lumbar spine imaging. Statistical analysis utilized linear and logistic regression, Pearson correlation, and receiver operating characteristic (ROC) curves. RESULTS AP-DSD and TR-DSD measurements were reproducible between two readers (r = 0.91 and 0.87, respectively). DSD (L1–L5) was not different between male and female controls in the AP or TR plane (p = 0.43; p = 0.40, respectively), and did not vary by age (p = 0.62; p = 0.25) or height (p = 0.64; p = 0.32). AP-VBD was greater in males versus females (p = 1.5 × 10−8), resulting in a smaller dural sac ratio (DSR) (DSD/VBD) in males (p = 5.8 × 10−6). Marfan patients had larger AP-DSDs and TR-DSDs than controls (p = 5.9 × 10−9; p = 6.5 × 10−9, respectively). Compared to DSR, AP-DSD and TR-DSD better discriminate Marfan from control subjects based on area under the curve (AUC) values from unadjusted ROCs (AP-DSD p < 0.01; TR-DSD p = 0.04). CONCLUSION Individual vertebrae and L1–L5 (average) AP-DSD and TR-DSD measurements are simple, reliable, and reproducible for quantitating dural sac size without needing to control for gender, age, or height.
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Affiliation(s)
- M L A Daniels
- Department of Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA.
| | - J R Lowe
- Department of Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - P Roy
- Department of Biostatistics, UNC at Chapel Hill, Chapel Hill, NC 27599, USA
| | - M V Patrone
- Department of Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - J M Conyers
- Department of Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - J P Fine
- Department of Biostatistics, UNC at Chapel Hill, Chapel Hill, NC 27599, USA
| | - M R Knowles
- Department of Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - K R Birchard
- Department of Radiology, UNC School of Medicine, Chapel Hill, NC 27599, USA
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Hayashida E, Utsunomiya D, Sasao A, Yasuda T, Hirai T, Yuki H, Oda S, Urata J, Arakawa A, Yamashita Y. Spinal imaging features in Japanese patients with Marfan syndrome: a case-control study. Jpn J Radiol 2014; 32:205-10. [PMID: 24477527 DOI: 10.1007/s11604-014-0285-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/07/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of our study was to evaluate the morphology of the lumbosacral spine, i.e. the dura and vertebral body shape, of Japanese patients with Marfan syndrome (MFS) by comparing it with sex- and age-matched controls. MATERIALS AND METHODS Spinal MR or CT images of 32 MFS patients and 32 controls were retrospectively reviewed. The anteroposterior dural sac diameter (DSD), anteroposterior vertebral body diameter (VBD), and vertebral body height (VBH) were measured from L1 to S1 levels and the dural sac ratio [DSR = (DSD/VBD)] and vertebral body aspect ratio [VAR = (VBH/VBD)] were calculated. RESULTS At each level, mean DSD and DSR were significantly higher in MFS patients; VBD was not. The cutoff values for DSR to differentiate between MFS patients and the controls were 0.59, 0.46, 0.42, 0.45, 0.47, and 0.47 from the level of L1 to S1. At a sensitivity of 93.8 % and a specificity of 84.4 % the cutoff value at S1 was most diagnostic. In MFS patients VAR was significantly higher at L3 and L4. CONCLUSION Our cutoff value for DSR >0.47 at S1 may help to identify MFS in the Japanese population. A square-like appearance of the L3 and L4 vertebral bodies is a supplementary finding in MFS patients.
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Affiliation(s)
- Eri Hayashida
- Diagnostic Imaging Center, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto-shi, Kumamoto, 861-4193, Japan
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Bassani L, Graffeo CS, Behrooz N, Tyagi V, Wilson T, Penaranda S, Zagzag D, Rifkin DB, Barcellos-Hoff MH, Fatterpekar G, Placantonakis D. Noninvasive diagnosis and management of spontaneous intracranial hypotension in patients with marfan syndrome: Case Report and Review of the Literature. Surg Neurol Int 2014; 5:8. [PMID: 24575323 PMCID: PMC3927088 DOI: 10.4103/2152-7806.125629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 11/06/2013] [Indexed: 11/26/2022] Open
Abstract
Background: Spontaneous intracranial hypotension is an uncommon clinical entity. Heritable connective tissue disorders (HCTD), such as Marfan syndrome, are frequently implicated as an underlying cause, due to dural structural weaknesses that predispose patients to spontaneous cerebrospinal fluid (CSF) leak. Due to the high prevalence of multi-system disease in HCTD, diagnosis and treatment are often complicated. Case Description: We present a 58-year-old female with Marfan syndrome on anticoagulation for a mechanical aortic valve replacement who came to medical attention with severe, acute-onset headache following a straining episode. Noninvasive magnetic resonance (MR) myelography confirmed thoracic CSF extravasations and multiple lumbar diverticula. The patient was treated conservatively and her symptoms resolved. Conclusion: We discuss the common presentation, diagnostic tools, and treatment options for spontaneous CSF leaks in patients with Marfan syndrome or related HCTD with an emphasis on noninvasive modalities and a review of the major radiographic criteria used to diagnose dural abnormalities, such as dural ectasia.
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Affiliation(s)
- Luigi Bassani
- Department of Neurosurgery, University of Utah School of Medicine, USA
| | | | - Navid Behrooz
- Department of Emergency Medicine, New York-Presbyterian Hospital, New York, USA
| | - Vineet Tyagi
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Taylor Wilson
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Saul Penaranda
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - David Zagzag
- Department of Pathology, New York University School of Medicine, New York, USA
| | - Daniel B Rifkin
- Department of Cell Biology, New York University School of Medicine, New York, USA
| | - Mary Helen Barcellos-Hoff
- Department of Cell Biology, New York University School of Medicine, New York, USA ; Department of Radiation Oncology, New York University School of Medicine, New York, USA
| | - Girish Fatterpekar
- Department of Radiology, New York University School of Medicine, New York, USA
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26
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Sheikhzadeh S, Brockstaedt L, Habermann CR, Sondermann C, Bannas P, Mir TS, Staebler A, Seidel H, Keyser B, Arslan-Kirchner M, Kutsche K, Berger J, Blankenberg S, von Kodolitsch Y. Dural ectasia in Loeys-Dietz syndrome: comprehensive study of 30 patients with a TGFBR1 or TGFBR2 mutation. Clin Genet 2013; 86:545-51. [PMID: 24344637 DOI: 10.1111/cge.12308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 10/20/2013] [Accepted: 10/24/2013] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to assess the frequency, severity, and clinical associations of dural ectasia (DE) in Loeys-Dietz syndrome (LDS). Database analysis of three German metropolitan regions identified 30 patients with LDS and TGFBR1 mutation in 6 and a TGFBR2 mutation in 24 individuals (17 men; mean age: 31 ± 19 years), as well as 60 age and sex-matched control patients with Marfan syndrome carrying a FBN1 mutation. DE was present in 22 patients with LDS (73%), and it related to skeletal score points (p = 0.008), non-skeletal score points (p < 0.001), and to the presence of ≥7 systemic score points (p = 0.010). Similarly, the severity of DE was related to body height (p = 0.010) and non-skeletal score points (p = 0.004). Frequency (p = 0.131) and severity of DE (p = 0.567) was similar in LDS and Marfan syndrome. DE is a manifestation of LDS that occurs with similar frequency and severity as in Marfan syndrome. Severity of DE may serve as a marker of the overall connective tissue disease severity. LDS may be considered in patients with DE.
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Affiliation(s)
- S Sheikhzadeh
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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27
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Errando CL, Del Moral A, Cobo I, García-Gregorio N, Pallardó-López MA. Spinal anaesthesia in a patient with post-spine surgery dural ectasia. ACTA ACUST UNITED AC 2013; 61:47-50. [PMID: 24135680 DOI: 10.1016/j.redar.2013.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/09/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
Abstract
Dural sac ectasia is a very infrequent anatomical abnormality, usually caused by connective tissue diseases, as Marfan syndrome. Very few cases have been described being a consequence of a previous spine surgical procedure. We describe the case of an elderly patient who should be operated on twice due to sub-occlusive colon disease. Surgery was performed under spinal anaesthesia. A dural sac ectasia was suspected after the first procedure and the abdominal X-ray was reviewed. The characteristics of the anatomical alteration and the course of both anaesthetic procedures were described. X-ray and CT images were provided.
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Affiliation(s)
- C L Errando
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Del Moral
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - I Cobo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - N García-Gregorio
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - M A Pallardó-López
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
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28
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Kono AK, Higashi M, Morisaki H, Morisaki T, Naito H, Sugimura K. Prevalence of dural ectasia in Loeys-Dietz syndrome: comparison with Marfan syndrome and normal controls. PLoS One 2013; 8:e75264. [PMID: 24086486 PMCID: PMC3783378 DOI: 10.1371/journal.pone.0075264] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 08/12/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Dural ectasia is well recognized in Marfan syndrome (MFS) as one of the major diagnostic criteria, but the exact prevalence of dural ectasia is still unknown in Loeys-Dietz syndrome (LDS), which is a recently discovered connective tissue disease. In this study, we evaluated the prevalence of dural ectasia in LDS according by using qualitative and quantitative methods and compared our findings with those for with MFS and normal controls. MATERIAL AND METHODS We retrospectively studied 10 LDS (6 males, 4 females, mean age 36.3 years) and 20 MFS cases (12 males, 8 females, mean age 37.1 years) and 20 controls (12 males, 8 females, mean age 36.1 years) both qualitatively and quantitatively using axial CT images and sagittal multi-planar reconstruction images of the lumbosacral region. For quantitative examination, we adopted two methods: method-1 (anteroposterior dural diameter of S1> L4) and method-2 (ratio of anteroposterior dural diameter/vertebral body diameter>cutoff values). The prevalence of dural ectasia among groups was compared by using Fisher's exact test and the Tukey-Kramer test. RESULTS In LDS patients, the qualitative method showed 40% of dural ectasia, the quantitative method-1 50%, and the method-2 70%. In MFS patients, the corresponding prevalences were 50%, 75%, and 85%, and in controls, 0%, 0%, and 5%. Both LDS and MFS had a significantly wider dura than controls. CONCLUSIONS While the prevalence of dural ectasia varied depending on differences in qualitative and quantitative methods, LDS as well as MFS, showed, regardless of method, a higher prevalence of dural ectasia than controls. This finding should help the differentiation of LDS from controls.
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Affiliation(s)
- Atsushi K. Kono
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe Japan
- * E-mail:
| | - Masahiro Higashi
- Department of Radiology, National Cardiovascular Research Center, Suita, Japan
| | - Hiroko Morisaki
- Department of Bioscience, National Cardiovascular Research Center, Suita, Japan
| | - Takayuki Morisaki
- Department of Bioscience, National Cardiovascular Research Center, Suita, Japan
| | - Hiroaki Naito
- Department of Radiology, National Cardiovascular Research Center, Suita, Japan
| | - Kazuro Sugimura
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe Japan
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Sheikhzadeh S, Sondermann C, Rybczynski M, Habermann CR, Brockstaedt L, Keyser B, Kaemmerer H, Mir T, Staebler A, Robinson PN, Kutsche K, Berger J, Blankenberg S, von Kodolitsch Y. Comprehensive analysis of dural ectasia in 150 patients with a causative FBN1 mutation. Clin Genet 2013; 86:238-45. [PMID: 23991918 DOI: 10.1111/cge.12264] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to perform a comprehensive study of dural ectasia (DE) related to FBN1 mutations. We performed a database analysis of two German metropolitan regions of 150 patients (68 men, 82 women; mean age 35 ± 16 years). All patients had a FBN1 mutation and underwent dural magnetic resonance imaging. Age was <16 years in 20, 16-25 in 27, 26-35 in 67, and >35 in 36 patients. Prevalence of dural ectasia was 89% with criteria of Oosterhof and Habermann, 83% with Fattori, 78% with Lundby, and 59% with Ahn. DE was less frequent in patients <16 years with Ahn and Fattori. DE related to skeletal manifestations with all criteria, to aortic Z-scores and mitral valve prolapse with criteria of Habermann and Lundby, and to age with criteria of Fattori. The Fattori-grade of DE increased with age, aortic Z-scores, and skeletal score points. There was no consistent relationship of DE with any type of FBN1 mutation. DE is frequent in patients with FBN1 mutations irrespective of age and its severity increases during life. Criteria of Oosterhof and Habermann yielded most consistent diagnostic results. DE relates to skeletal involvement, aortic Z-scores, and mitral valve prolapse.
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30
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Baghirzada L, Krings T, Carvalho JCA. Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases. Can J Anaesth 2012; 59:1052-7. [PMID: 22976428 DOI: 10.1007/s12630-012-9778-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The anesthetic management of women with Marfan syndrome and dural ectasia undergoing Cesarean delivery remains controversial. We present two cases of patients with Marfan syndrome and dural ectasia where neuraxial anesthesia was used successfully. CASE 1: A 31-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 35(3/7) weeks' gestation. The magnetic resonance imaging of her spine revealed significant dural ectasia in the lumbosacral area with a mean lumbar dural sac area of 4.71 cm(2). Intrathecal administration of 0.75% hyperbaric bupivacaine 9 mg produced only limited perineal analgesia. The epidural catheter was titrated, and 0.5% bupivacaine 150 mg were required to achieve a T4 sensory level. CASE 2: A 34-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 37 weeks' gestation. The intrathecal administration of 0.75% hyperbaric bupivacaine 13.5 mg produced a T5 sensory level. Magnetic resonance imaging of her spine prior to discharge confirmed the diagnosis of moderate dural ectasia with a mean lumbar dural sac area of 3.61 cm(2). DISCUSSION The two patients described in this report responded differently to spinal anesthesia, most likely based on the severity of their dural ectasia. Although preoperative magnetic resonance imaging may help to identify patients at risk for a failed spinal, we suggest considering a combined spinal-epidural technique in cases of dural ectasia.
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Affiliation(s)
- Leyla Baghirzada
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
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31
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Lundby R, Rand-Hendriksen S, Hald JK, Pripp AH, Smith HJ. The pulmonary artery in patients with Marfan syndrome: a cross-sectional study. Genet Med 2012; 14:922-7. [DOI: 10.1038/gim.2012.82] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Li-Wan-Po A, Loeys B, Farndon P, Latham D, Bradley C. Preventing the aortic complications of Marfan syndrome: a case-example of translational genomic medicine. Br J Clin Pharmacol 2011; 72:6-17. [PMID: 21276043 DOI: 10.1111/j.1365-2125.2011.03929.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: 01/13/2023] Open
Abstract
The translational path from pharmacological insight to effective therapy can be a long one. We aim to describe the management of Marfan syndrome as a case-example of how pharmacological and genomic insights can contribute to improved therapy. We undertook a literature search for studies of Marfan syndrome, to identify milestones in description, understanding and therapy of the syndrome. From the studies retrieved we then weaved an evidence-based description of progress. Marfan syndrome shows considerable heterogeneity in clinical presentation. It relies on defined clinical criteria with confirmation based on FBN1 mutation testing. Surgical advances have prolonged life in Marfan syndrome. First-line prophylaxis of complications with β-adrenoceptor blockers became established on the basis that reduction of aortic pressure and heart rate would help. Over-activity of proteinases, first suggested in 1980, has since been confirmed by evidence of over-expression of matrix metalloproteinases (MMP), notably MMP-2 and MMP-9. The search for MMP inhibitors led to the evaluation of doxycycline, and both animal studies and small trials, provided early evidence that this widely used antimicrobial agent was useful. Identification of the importance of TGF-β led to evaluation of angiotensin II type I receptor (AT(1) R) blockers with highly promising results. Combination prophylactic therapy would appear rational. Pharmacological and genomic research has provided good evidence that therapy with losartan and doxycycline would prevent the aortic complications of Marfan syndrome. If on-going well designed trials confirm their efficacy, the outlook for Marfan syndrome patients would be improved considerably.
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Affiliation(s)
- Alain Li-Wan-Po
- National Genetics Education and Development Centre, Morris House, C/o Birmingham Women's Hospital, Edgbaston, Birmingham, United Kingdom.
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33
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Health-related quality of life in Marfan syndrome: a cross-sectional study of Short Form 36 in 84 adults with a verified diagnosis. Genet Med 2010; 12:517-24. [PMID: 20613543 DOI: 10.1097/gim.0b013e3181ea4c1c] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To explore health-related quality of life as measured with Short Form 36 in adults with verified Marfan syndrome and to compare with the general population, other groups with chronic problems and studies on Marfan syndrome. Furthermore, to study potential correlations between the scores on the subscales of Short Form 36 and the presence of biomedical criteria and symptoms of Marfan syndrome. METHOD Cross-sectional study. Short Form 36 was investigated in 84 adults with verified Marfan syndrome. RESULTS The study group had reduced scores on all eight subscales of Short Form 36 compared with the general population, comparable with other groups with chronic diseases. Compared with earlier Short Form 36 results in Marfan syndrome, we found lower scores for social function, vitality, general health, bodily pain, and role physical. No correlations of substantial explanatory values were found between the Short Form 36 subscales and gender, body mass index, ascending aortic surgery, use of beta-blockers, visual acuity, joint hypermobility, fulfillment of the five major Ghent criteria, and number of major criteria fulfilled. Potential explanations are discussed. CONCLUSION Persons with Marfan syndrome have reduced scores for health-related quality of life as measured with Short Form 36, comparable with those in other chronic disorders and disabilities. The reduction does not seem to be related to biomedical criteria or symptoms of Marfan syndrome.
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Sznajder M, Krug P, Taylor M, Moura B, Leparc JM, Boileau C, Jondeau G, Chevallier B, Pelage JP, Stheneur C. Spinal imaging contributes to the diagnosis of Marfan syndrome. Joint Bone Spine 2010; 77:445-50. [PMID: 20452804 DOI: 10.1016/j.jbspin.2010.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 02/03/2010] [Indexed: 11/28/2022]
Abstract
UNLABELLED The diagnosis of Marfan syndrome (MFS) is defined by a combination of major and minor criteria, related to the different systems involved, according to the Ghent nosology of the spine. Spinal imaging can detect both skeletal (including scoliosis and spondylolisthesis) and neurological involvement (i.e. dural ectasia). The aim of the present study was to assess the interest of screening the rachis by conventional radiography CR and complementary imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) in patients suspected of MFS, and to modelise the most relevant imaging procedure to diagnose MFS. METHODS Evaluation of the sensitivity and specificity of CR of the lumbosacral spine versus sectional imaging for the detection of dural ectasia (DE) in a subgroup of 92 patients suspected of MFS. Retrospective analysis of the contribution of CR to the diagnosis of MFS in 1992 patients referred to our clinic. RESULTS DE was detected by CR in 12 of the 92 patients (13%) and was always confirmed by CT or MRI. Complementary imaging alone detected 33 DE (35.9%). All patients with DE detected by CR were diagnosed with MFS. Among the 1992 patients, 591 were confirmed MFS; 117 patients had DE detected by CR (19,8%) while 12 (2,0%) were detected by complementary imaging. In MFS patients, 98 (16.6%) had significant scoliosis and 14 (2.4%) had spondylolisthesis. The positive predictive value of DE detected by CR for the diagnosis of MFS was 92.9% (95% IC: 86.8-96.4), and the negative predictive value was 74.6% (95% IC: 72.6-76.5). We conclude that spinal imaging is useful for the diagnosis of MFS.
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Affiliation(s)
- Marc Sznajder
- Service de pédiatrie, hôpital Ambroise-Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92100 Boulogne, France
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