Three Arterial Ruptures in a Patient with Neurofibromatosis Type 1

Therapeutic challenges in transcatheter arterial embolization for an enlarging subcutaneous hematoma in a patient with neurofibromatosis type 1: A case report

A 60-year-old woman with a history of neurofibromatosis type 1, who was admitted with pulmonary hypertension, developed buttock pain and anemia, and contrast-enhanced computed tomography showed a large subcutaneous hematoma with minimal active extravasation. Angiography of the bilateral internal iliac arteries revealed diffuse, irregular blood vessels without extravasation. As the exact bleeding site could not be identified, the patient was managed conservatively. However, the patient's symptoms and anemia worsened the following day. Repeat angiography revealed two pseudoaneurysms in the right inferior gluteal artery, which were embolized using n-butyl-2-cyanoacrylate. Nonetheless, the patient's anemia further worsened the following day. Repeat contrast-enhanced CT revealed another site of extravasation in the enlarging hematoma, but no extravasation was observed on the subsequent angiography. Owing to the worsening anemia and enlarging hematoma, proximal embolization of the irregular bilateral inferior gluteal arteries was performed using gelatin sponge particles. The patient's anemia and symptoms improved. Vasculopathy associated with neurofibromatosis type 1 is rare, with an incidence of approximately 3%. In patients with neurofibromatosis type 1, the blood vessels become fragile because of tunica media thinning and elastic-lamina rupture. Histopathologically, neurofibromatosis type 1-associated vasculopathy is characterized by a mixture of normal and abnormal vessels. Abnormally fragile blood vessels may repeatedly rupture followed by physiological hemostasis, which may explain the diagnostic and therapeutic challenges during angiography in this case. In patients with neurofibromatosis type 1 with acute bleeding, irregular vessels without active extravasation on angiography may be indicated for embolization.

Massive Hemorrhage Following Acupuncture Treatment in a Neurofibromatosis Type 1 Patient

Neurofibromatosis type 1 (NF1) is a genetic disorder involving multiple organs. Vascular involvement is a rare complication among NF1 patients. We report a case of a 59-year-old female NF1 patient who presented with a massive hematoma over the scapular area after undergoing acupuncture treatment. Contrast-enhanced CT and MRI demonstrated a slightly hyperdense mass measuring 24.2 × 10.3 cm in size, and multiple enlarged and tortuous malformed vessels were seen arising from the left subclavian artery. Arterial embolization and subsequent surgical mass resection were successfully performed. This case indicates that minor injuries such as acupuncture-related ones could cause severe hemorrhage in patients with vascular malformation related to NF1. Endovascular angiography and embolization proved to be effective in localizing the culprit vessel and stopping active bleeding in our patient.

Acute hemorrhagic cholecystitis related to diffuse neurofibroma of gallbladder in a patient with neurofibromatosis type 1

BACKGROUND

We report the first case of acute hemorrhagic cholecystitis with large hemoperitoneum related to gallbladder wall fragility caused by neurofibroma cell infiltration.

CASE PRESENTATION

A 46-year-old man with neurofibromatosis type 1 (NF1), who had been hospitalized for retroperitoneal hematoma and treated by transarterial embolization 9 days earlier, complained of right upper quadrant pain, bloating, nausea, and emesis. Computed tomography revealed fluid collection and a distended gallbladder with high-density contents. The patient was taken to the operating room for laparoscopic cholecystectomy, with consideration of the hemodynamic tolerance, for acute hemorrhagic cholecystitis. An initial laparoscopy revealed a significant amount of blood in the abdominal cavity exuding from the gallbladder. Due to its fragility, the gallbladder was easily ruptured by surgical manipulation. After conversion to open surgery, subtotal cholecystectomy was performed. Seventeen days after surgery, the patient was transferred to another hospital for rehabilitation. Histological examination revealed diffuse and nodular proliferation of spindle cells that had replaced the muscularis propria of the gallbladder wall.

CONCLUSION

This clinical case highlights how NF1 can cause various symptoms in the blood vessels and gastrointestinal tract, including the gallbladder.

Intra-cardiac tumour and bicuspid aortic valve in a patient with neurofibromatosis type 1-rare associations: a case report

Background

Neurofibromatosis (NF) is an autosomal dominant neurocutaneous disease with multi-system involvement. Three cardiovascular associations are recognized but infrequently reported: congenital heart disease, vasculopathy, and hypertension. Cardiac outflow tract pathology, pulmonary stenosis, and aortic co-arctation have been described in the literature with varying frequency. The incidence of intra-cardiac tumour is exceeding rare.

Case summary

A 53-year-old man presented to the neurosurgical team with myelopathy secondary to cord compression arising from multiple cervical neurofibromas secondary to NF-1. Further cardiac evaluation with echocardiography and cardiac MRI uncovered the presence of both a bicuspid aortic valve (with mild aortic stenosis and moderate aortic regurgitation) and a concurrent intra-cardiac tumour of the mitral papillary muscle; a combined finding which was not reported previously. Serial evaluation confirmed stable disease with no major progression over time.

Discussion

Our case highlights the importance of recognizing cardiovascular manifestations of NF-1 and instituting appropriate screening and surveillance strategies. Targeted non-invasive imaging strategies may be more suited for this purpose over routine clinical examination alone.