1
|
Choucha A, Tomczak S, Norri N, Hardwigsen J, Dufour H. Successful Management of Multiple Giant Anterior Sacral Meningoceles Through an Anterior Approach in a Patient With Marfan Syndrome: A Case Report and Literature Review. Cureus 2024; 16:e52724. [PMID: 38384626 PMCID: PMC10880581 DOI: 10.7759/cureus.52724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Meningoceles refer to the protrusion of meninges filled with cerebrospinal fluid (CSF) through a bone defect. There is scarce literature on the management of multiple giant anterior sacral meningoceles (ASMs). We report the case of a patient with Marfan syndrome presenting with gait disturbances and dizziness triggered by posture changes due to multiple giant ASMs. The patient was managed through an anterior approach involving a multidisciplinary team of surgeons. Care was taken to limit the persistence of CSF leak using an omental pedicled flap. This technique has only been mentioned twice in the literature for such cases. A literature review was conducted focusing on the evolution course and surgical strategy of meningoceles.
Collapse
Affiliation(s)
- Anis Choucha
- Neurosurgery, Assistance Publique-Hopitaux de Marseille (AP-HM), Marseille, FRA
- Laboratory of Biomechanics and Application, Gustave Eiffel University, Aix Marseille University, Marseille, FRA
| | - Sacha Tomczak
- Plastic and Reconstructive Surgery, Assistance Publique-Hopitaux de Marseille (AP-HM), Marseille, FRA
| | - Nicolo Norri
- Neurosurgery, University of Ferrara - Sant'Anna Hospital, Ferrara, ITA
| | - Jean Hardwigsen
- General Surgery, Assistance Publique-Hopitaux de Marseille (AP-HM), Marseille, FRA
| | - Henry Dufour
- Neurosurgery, Assistance Publique-Hopitaux de Marseille (AP-HM), Marseille, FRA
| |
Collapse
|
2
|
Saddic L, Escopete S, Zilberberg L, Kalsow S, Gupta D, Egbhali M, Parker S. 17 β-estradiol impedes aortic root dilation and rupture in male Marfan mice. bioRxiv 2023:2023.05.09.540071. [PMID: 37215011 PMCID: PMC10197695 DOI: 10.1101/2023.05.09.540071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Marfan syndrome causes a hereditary form of thoracic aortic aneurysms with dilation of the aortic root. Human and animal models suggest a worse phenotype for males compared to females with respect to aneurysm size and risk of dissection. In this study we examine the effects of 17 β-estradiol on aortic dilation and rupture in a Marfan mouse model. Marfan male mice were administered 17 β-estradiol and the growth in aortic root size along with the risk of aortic rupture or dissection with the addition of angiotensin II was measured. Transcriptomic profiling was used to identify enriched pathways from 17 β-estradiol treatment. Aortic smooth muscle cells were then treated with cytokines in order to validate the mechanism of 17 β-estradiol protection. We show that 17 β-estradiol decreased the size and rate of aortic root dilation and improved survival from rupture and dissection after treatment with angiotensin II. The Marfan transcriptome was enriched in inflammatory genes and the addition of 17 β-estradiol modulated a set of genes that function through TNFα mediated NF-κB signaling. These included many proteins known to play a role in the phenotypic shift of aortic smooth muscle cells from a contractile to a more inflammatory-like state such as Vcam-1, Mcp-1, Lgals3, Il-6, Il-1b, and C3. In addition, 17 β-estradiol suppressed the induction of these TNFα induced genes in aortic smooth muscle cells in vitro and this effect appears to be NF-κB dependent. In conclusion, 17 β-estradiol protects against the dilation and rupture of aortic roots in Marfan male mice through the inhibition of TNFα -NF-κB signaling and thus prevents the phenotypic switch of aortic smooth muscle cells from a contractile to an inflammatory state.
Collapse
Affiliation(s)
- Louis Saddic
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sean Escopete
- Cedars-Sinai Medical Center, Smidt Heart Institute, Department of Cardiology, Los Angeles, California
| | - Lior Zilberberg
- Cedars-Sinai Medical Center, Smidt Heart Institute, Department of Cardiology, Los Angeles, California
| | - Shannon Kalsow
- Cedars-Sinai Medical Center, Smidt Heart Institute, Department of Cardiology, Los Angeles, California
| | - Divya Gupta
- Cedars-Sinai Medical Center, Smidt Heart Institute, Department of Cardiology, Los Angeles, California
| | - Mansoureh Egbhali
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sarah Parker
- Cedars-Sinai Medical Center, Smidt Heart Institute, Department of Cardiology, Los Angeles, California
| |
Collapse
|
3
|
Berger JA, Huh DD, Lee T, Wadia RS, Bembea MM, Goswami DK. Perioperative management and considerations in pediatric patients with connective tissue disorders undergoing cardiac surgery. Paediatr Anaesth 2021; 31:820-826. [PMID: 33884693 DOI: 10.1111/pan.14196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/08/2021] [Accepted: 03/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Marfan syndrome and Loeys-Dietz syndrome are connective tissue disorders associated with cardiac and vascular disease. Patients often require surgical repair, but limited data exist to describe their perioperative management. AIMS Our goals were to review the perioperative features of patients with Marfan and Loeys-Dietz syndrome that may affect anesthesia care and to describe the differences in preoperative clinical characteristics and intra-operative anesthetic management. METHODS We conducted a retrospective cohort study of patients with Marfan and Loeys-Dietz syndrome who underwent cardiac surgery at a single institution. We collected demographic and perioperative data from the electronic medical record and performed descriptive statistics to characterize the patient populations and describe their anesthetic management. RESULTS In 71 patients (40 Marfan, 31 Loeys-Dietz), we found significant differences between the Marfan and Loeys-Dietz patients in airway difficulty, preoperative weight, blood utilization, valvular disease, and age at first cardiac surgery. Patients with Loeys-Dietz syndrome had higher preoperative rates of severe noncardiac comorbidities, including gastroesophageal reflux and asthma that required chronic medical therapy. CONCLUSIONS Despite undergoing similar surgical procedures, patients with Marfan and Loeys-Dietz syndrome have different intrinsic patient characteristics and comorbidities that may affect their perioperative care. This retrospective cohort study identified some factors, but additional collection and reporting of patient data based on multicenter experience are essential for the ongoing optimization of perioperative care in these patient populations.
Collapse
Affiliation(s)
- Jessica A Berger
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dana D Huh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teresa Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rajeev S Wadia
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dheeraj K Goswami
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
4
|
Grange T, Aubart M, Langeois M, Benarroch L, Arnaud P, Milleron O, Eliahou L, Gross MS, Hanna N, Boileau C, Gouya L, Jondeau G. Quantifying the Genetic Basis of Marfan Syndrome Clinical Variability. Genes (Basel) 2020; 11:genes11050574. [PMID: 32443863 PMCID: PMC7288268 DOI: 10.3390/genes11050574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/09/2020] [Accepted: 05/15/2020] [Indexed: 01/16/2023] Open
Abstract
Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder with considerable inter- and intra-familial clinical variability. The contribution of inherited modifiers to variability has not been quantified. We analyzed the distribution of 23 clinical features in 1306 well-phenotyped MFS patients carrying FBN1 mutations. We found strong correlations between features within the same system (i.e., ophthalmology vs. skeletal vs. cardiovascular) suggesting common underlying determinants, while features belonging to different systems were largely uncorrelated. We adapted a classical quantitative genetics model to estimate the heritability of each clinical feature from phenotypic correlations between relatives. Most clinical features showed strong familial aggregation and high heritability. We found a significant contribution by the major locus on the phenotypic variance only for ectopia lentis using a new strategy. Finally, we found evidence for the “Carter effect” in the MFS cardiovascular phenotype, which supports a polygenic model for MFS cardiovascular variability and indicates additional risk for children of MFS mothers with an aortic event. Our results demonstrate that an important part of the phenotypic variability in MFS is under the control of inherited modifiers, widely shared between features within the same system, but not among different systems. Further research must be performed to identify genetic modifiers of MFS severity.
Collapse
Affiliation(s)
- Thomas Grange
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
| | - Mélodie Aubart
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
- Service de Neurologie Pédiatrique, Hôpital Necker-Enfants malades, AP-HP, Université de Paris, Faculté de médecine Paris Centre, 75006 Paris, France
| | - Maud Langeois
- Centre national de référence pour le syndrome de Marfan et apparentés, AP-HP, Hôpital Bichat, 75018 Paris, France;
- CHU Toulouse, 31300 Toulouse, France
| | - Louise Benarroch
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
| | - Pauline Arnaud
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
- Centre national de référence pour le syndrome de Marfan et apparentés, Département de génétique, AP-HP, Hôpital Bichat, 75018 Paris, France;
- Université de Paris, UFR Médecine Paris Nord, 75010 Paris, France
| | - Olivier Milleron
- Centre national de référence pour le syndrome de Marfan et apparentés, Service de cardiologie, AP-HP, Hôpital Bichat, 75018 Paris, France; (O.M.); (L.E.)
| | - Ludivine Eliahou
- Centre national de référence pour le syndrome de Marfan et apparentés, Service de cardiologie, AP-HP, Hôpital Bichat, 75018 Paris, France; (O.M.); (L.E.)
| | - Marie-Sylvie Gross
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
| | - Nadine Hanna
- Centre national de référence pour le syndrome de Marfan et apparentés, Département de génétique, AP-HP, Hôpital Bichat, 75018 Paris, France;
| | - Catherine Boileau
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
- Centre national de référence pour le syndrome de Marfan et apparentés, Département de génétique, AP-HP, Hôpital Bichat, 75018 Paris, France;
- Université de Paris, UFR Médecine Paris Nord, 75010 Paris, France
| | - Laurent Gouya
- Centre national de référence pour le syndrome de Marfan et apparentés, AP-HP, Hôpital Bichat, 75018 Paris, France;
- INSERM U1159, 75018 Paris;
| | - Guillaume Jondeau
- INSERM U1148, 75018 Paris, France; (T.G.); (M.A.); (L.B.); (P.A.); (M.-S.G.); (C.B.)
- Université de Paris, UFR Médecine Paris Nord, 75010 Paris, France
- Centre national de référence pour le syndrome de Marfan et apparentés, Service de cardiologie, AP-HP, Hôpital Bichat, 75018 Paris, France; (O.M.); (L.E.)
- Correspondence: ; Tel.: +33-140-256-811
| |
Collapse
|
5
|
Abstract
The Marfan syndrome (MFS) is a pleiotropic, autosomal dominant disorder of connective tissue with highly variable clinical manifestations. It primarily involves the skeletal, cardiovascular, and ocular systems; however, gastrointestinal complications are rare. Herein, we describe the case of a 31-year-old male who initially presented with acute abdominal pain for one day. His imaging features revealed a dilated sigmoid colon, consistent with sigmoid volvulus that was immediately decompressed. Surgical resection was recommended to treat the sigmoid volvulus. Preceding the treatment, the patient underwent an extensive workup, including an echocardiography that revealed aortic root dilatation. His clinical history, physical exam, and echocardiographic findings raised the suspicion for MFS. Subsequently, the diagnosis of MFS was confirmed on genetic testing. This is a case that highlights the multidisciplinary (clinical, radiological, endoscopic, molecular/genetic) approach to diagnose a patient with MFS who presented with symptomatic sigmoid volvulus. As this presentation may be a harbinger of more severe manifestations of MFS, it is important to identify it as such in order to accomodate for timely management.
Collapse
Affiliation(s)
- Faisal Inayat
- Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, NY, USA
| | - Abu Hurairah
- Division of Gastroenterology, Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Faiq Shaikh
- Imaging Informatics, University of Pittsburgh Medical Center, Pittsburgh, PA. ; Molecular Imaging, Cellsight Technologies, Inc., San Francisco, CA
| |
Collapse
|
6
|
Cattalini M, Khubchandani R, Cimaz R. When flexibility is not necessarily a virtue: a review of hypermobility syndromes and chronic or recurrent musculoskeletal pain in children. Pediatr Rheumatol Online J 2015; 13:40. [PMID: 26444669 PMCID: PMC4596461 DOI: 10.1186/s12969-015-0039-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/01/2015] [Indexed: 01/09/2023] Open
Abstract
Chronic or recurrent musculoskeletal pain is a common complaint in children. Among the most common causes for this problem are different conditions associated with hypermobility. Pediatricians and allied professionals should be well aware of the characteristics of the different syndromes associated with hypermobility and facilitate early recognition and appropriate management. In this review we provide information on Benign Joint Hypermobility Syndrome, Ehlers-Danlos Syndrome, Marfan Syndrome, Loeys-Dietz syndrome and Stickler syndrome, and discuss their characteristics and clinical management.
Collapse
Affiliation(s)
- Marco Cattalini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy.
| | - Raju Khubchandani
- Pediatric Rheumatology Clinic, Department of Paediatrics, Jaslok Hospital and Research Centre, Mumbai, India.
| | - Rolando Cimaz
- Anna Meyer Children's Hospital and University of Florence, Florence, Italy.
| |
Collapse
|
7
|
Tocchioni F, Ghionzoli M, Calosi L, Guasti D, Romagnoli P, Messineo A. Rib cartilage characterization in patients affected by pectus excavatum. Anat Rec (Hoboken) 2013; 296:1813-20. [PMID: 24170345 DOI: 10.1002/ar.22824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 09/25/2013] [Indexed: 11/07/2022]
Abstract
Pectus excavatum (PE) is the most frequent anterior chest deformity which may be frequently associated with connective tissue disorders. We performed microscopic analyses to better understand cartilage behavior and obtain clues on its pathogenesis. In 37 PE patients, none with Marfan syndrome, we analyzed costal cartilage by light microscopy, immunohistochemistry and transmission electron microscopy. Control tissue specimens were harvested from four patients without any connective tissue disease. In both control and PE patients, chondrocytes were on the average <15 µm in diameter and occupied <10% of tissue volume; in most cases the extracellular matrix was stained by alcian blue, instead of safranin; no difference between PE and control samples was significant. All samples showed an uneven collagen type II immunolabeling both within the cells and pericellular matrix, and occasionally of the territorial matrix. In all cases numerous cells underwent apoptosis accompanied by matrix condensation as shown by electron microscopy. Our results suggest that matrix composition and the cell number and size of costal cartilage are dependent on the subject and not on the disease; the microscopic organization of cartilage is correlated with the stabilization of the defective shape rather than with the onset of the deformity.
Collapse
Affiliation(s)
- Francesca Tocchioni
- Department of Pediatric Surgery, University of Florence and Children's University Hospital A. Meyer, Florence, Italy
| | | | | | | | | | | |
Collapse
|
8
|
Abstract
Supravalvular aortic stenosis (SVAS), Marfan syndrome (MFS) and Ehlers-Danlos syndrome type IV (EDS IV) are three clinical entities characterized by vascular abnormalities that result from mutations of structural components of the extracellular matrix (ECM). Analyses of naturally occurring human mutations and of artificially generated deficiencies in the mouse have provided insights into the pathogenesis of these heritable disorders of the connective tissue. SVAS is associated with haploinsufficiency of elastin, one of the two major components of the elastic fibers. SVAS is characterized by narrowing of the arterial lumen due to the failure of regulation of cellular proliferation and matrix deposition. Mutations in fibrillin 1 are the cause of dissecting aneurysm leading to rupture of the ascending aorta. Fibrillin-1 is the building block of the microfibrils that span the entire thickness of the aortic wall and are a major component of the elastic fibers that reside in the medial layer. The vascular hallmark of EDS IV is rupture of large vessels. The phenotype is caused by mutations in type III collagen. The mutations ultimately affect the overall architecture of the collagenous network and the biomechanical properties of the adventitial layer of the vessel wall. Altogether, these genotype-phenotype correlations document the diversified contributions of distinct extracellular macroaggregates to the assembly and function of the vascular matrix.
Collapse
Affiliation(s)
- E Arteaga-Solis
- Brookdale Center in the Department of Biochemistry and Molecular Biology, Mount Sinai School of Medicine-New York University, New York 10029, USA
| | | | | |
Collapse
|