Klippel-Trenaunay syndrome

An unusual and extreme case of Klippel-Trenaunay syndrome is presented. The patient has an extensive capillary hemangioma involving the right side of the body, increases in the length and girth of the right lower limb, gross varicosities of the superficial venous system, and complete absence of the deep venous system of the right lower extremity, with suprapubic shunt of the venous blood to the contralateral external iliac vein. Secondary manifestations are increased sweating and compensatory scoliosis.

Magnetic resonance imaging of meningio-angiomatosis

We report the case of a patient with meningio-angiomatosis, a rare disorder of the cerebral cortex often associated with Von Recklinghausen's neurofibromatosis. Previous reports have described a variety of radiological findings but in general they have been of little value in the diagnosis of this disorder. We describe the magnetic resonance image, which identified a well-defined lesion. The imaging techniques are reviewed.

Hippel-Lindau disease: MR imaging

Hippel-Lindau disease is an auto-somal-dominant disorder characterized by tumors arising from the central nervous system and abdominal viscera. Because of its progressive nature, frequent multisystem radiologic evaluation of affected persons and family members at risk is desirable for early detection and treatment. During a 2-year study, magnetic resonance (MR) imaging of the head, spine, and abdomen was used for screening and follow-up in 26 members of nine families with the disease. In addition to 13 previously diagnosed cases, five cases were newly diagnosed during the study. Lesions causing significant morbidity and mortality--such as cerebellar and spinal cord hemangioblastoma, renal cell carcinoma, and pheochromocytoma--were correctly depicted with MR imaging, sometimes before symptoms had developed and before the lesions could be seen with other imaging modalities. Central nervous system abnormalities were most clearly shown, but MR imaging also adequately demonstrated abdominal visceral abnormalities. It is therefore highly useful in the diagnosis and follow-up of Hippel-Lindau disease.

The Sturge-Weber syndrome

The Sturge-Weber syndrome is characterized by angiomas of the leptomeninges overlying the cerebral cortex in association with a facial nevus flammeus. Although frequently included with other neurocutaneous genodermatoses, the syndrome is almost always sporadic in occurrence. The most common associated neurologic abnormality is seizures, which are controlled in more than 50% of patients by the administration of anticonvulsants. Laser therapy is the most promising therapeutic option for cosmetic management of the facial nevus flammeus.

[A case of von Hippel-Lindau disease with multiple abdominal disorders and renal cell carcinoma]

A 52-year-old male underwent right nephrectomy after a clinical diagnosis of renal cell carcinoma. He suddenly lost consciousness 3 days after the nephrectomy and expired 3 weeks later. An autopsy revealed a hemangio-blastoma in the forehead skin. Multiple cysts, cyst-adenomas and an islet cell tumor were also identified in the pancreas. Considering the presence of blindness and the familiar, prevalence of this disease, his case was diagnosed as a rare manifestation of von Hippel Lindau disease associated with renal cell carcinoma, complicated with abdominal disorders.

The syndrome of Klippel-Trenaunay, a polyvalent angiodysplasia

The syndrome of Klippel and Trenaunay remains basically a venous angiodysplasia. Newer investigative methods have however allowed us to distinguish a polyvalence of the vascular morphology. The basic clinical triad: vascular nevus, varicosities and limb hypertrophy remains the main clinical diagnostic characteristic.

Systemic cystic angiomatosis in a woman with hematuria and splenomegaly

Cutaneous hemangiomas are frequently found on routine clinical examination and generally are not important. But when internal organs are involved, these vascular tumours assume greater importance because of associated morbidity. A case is presented of multiple organ involvement by angiomas in a woman with a history of flank hemangioma who was investigated for hematuria and splenomegaly. She subsequently underwent splenectomy. The uncommon systemic syndromes characterized by vascular tumours are discussed, and the case reported is appropriately classified. The clinical picture, pathologic features and investigations appropriate for systemic cystic angiomatosis are briefly reviewed. The authors recommend conservative management when there is splenic involvement unless the size of the spleen makes its rupture likely or when there are hematologic complications.

Diagnosis and therapeutic surgery of the uvea--Part II: Results

Fifty-five patients underwent eye wall biopsy (11) or eye wall resection (44). Eye wall resection was performed for suspected melanoma in 42 cases and large von Hippel angiomas in an additional two patients. Two of the 35 individuals with choroidal melanoma died, representing a 5.7% mortality rate over a mean follow-up period of more than five years. Visual acuity, ocular morbidity, and tumor-associated deaths in this series are compared with results using other treatment modalities for choroidal melanoma.

Von Hippel-Lindau disease in an adolescent

Von Hippel-Lindau disease is a hereditary neoplastic syndrome that generally manifests in early adulthood but does present occasionally in adolescence. In the past, diagnosis and management of this disorder fell within the domain of internists and surgeons. Because pediatricians are now seeing older patients, they must learn to recognize the various components of this disorder. Additionally, they must be able to assure appropriate medical evaluation and follow-up and also arrange for genetic counseling. Pediatricians already attuned to the benefits of preventive medicine should find themselves uniquely qualified to provide the level of care that this disease requires.

[A case of von Hippel-Lindau disease showing only spinal cord symptoms]

A rare case of von Hippel-Lindau disease showing only spinal cord symptoms is reported. This 18-year-old boy was admitted to our clinic because of urinary disturbance, slowly progressive muscle weakness and sensory disturbance of his body and four extremities. Myelography demonstrated an expanding spinal cord and a figure of complete block of contrast medium at the lower cervical level. Dilated syrinx below the level of Th-3 was shown by delayed scan (19 hr.) of metrizamide CT myelography. These findings suggest that metrizamide could pass through the cord substance from the subarachnoid space into a syrinx cavity. Contrast enhancement CT scan revealed a slightly high density mass lesion at the level of Th-1 and a more marked tumor stain at the level of C-5 and 6. Syringo-subarachnoid shunt was done but the spinal intramedullary tumors were so deeply situated in the spinal cord that total removal of them was abandoned. The pathological diagnosis was hemangioblastoma. There were also a hemangioma at the right retina and multiple small tumor stains in the cerebellum, but they presented no clinical symptoms.

[Prenatal diagnosis and obstetric management of a case of Klippel-Trenaunay-Weber syndrome]

A description is given of a case of Klippel-Trenaunay-Weber syndrome diagnosed by sonography in the 28th week of pregnancy. The ultrasound findings established in the course of pregnancy are presented. Whereas minor variants of this syndrome normally do not represent a birth hindrance, a cesarean section was indicated in the present case on the basis of the size of the deformation--especially at the hip--an in order to save the child.

Cerebellar haemangioblastoma and von Hippel-Lindau disease

Von Hippel-Lindau disease is an autosomal dominant multisystem disorder, the commonest presenting manifestations of which are haemangioblastomas of the cerebellum and retina. Affected individuals are at risk of developing a number of other lesions, the most serious of which are renal carcinoma, haemangioblastomas elsewhere in the central nervous system and phaeochromocytoma. Patients with this disease can therefore present to a number of disciplines during their lifetime and unless the possibility of von Hippel-Lindau disease is considered, the patient may wrongly be assumed to have an isolated lesion. Twenty patients with cerebellar haemangioblastomas were seen between 1972 and 1985; the diagnosis of von Hippel-Lindau disease was subsequently established in 8. Although the diagnosis had not previously been considered, in retrospect 7/8 cases were known to be at risk of this syndrome. These cases came from 7 families and an additional 4 relatives are also known to have been affected. Mean age of presentation for the various manifestations of von Hippel-Lindau disease, each of which occurred in one or other of our cases, has been calculated from 9 of our patients and 107 others reported in the literature. Clinically significant manifestations almost invariably developed before the age of 50 years. Limited screening of our index cases and their at-risk relatives demonstrated one asymptomatic renal carcinoma. We propose a protocol for screening all individuals at risk of von Hippel-Lindau disease, which involves annual retinal examination from five years, and biennial computerized tomography of the head and abdomen from fifteen and twenty years, respectively.

Atypical angiomatosis in polyarteritis nodosa

Biopsies from an area of livedo reticularis and adjacent to a leg ulcer in a woman with polyarteritis nodosa showed florid angioendothelial proliferation simulating angiosarcoma. This angioproliferative reaction has not been described previously in polyarteritis nodosa. Its microscopic differentiation from angiosarcoma is important.

[Clinical aspects and course of Sturge-Weber syndrome in childhood]

We report on symptoms, clinical course and prognostic factors of eight children (6 girls and 2 boys) with Sturge-Weber syndrome. The period of observation was 1 to 17 years (mean 8.8 years). All patients had the classical symptoms with facial port-wine stain nevus and intracranial calcifications. In two cases a bilateral distribution of the nevus was found. All patients but one had epileptic seizures which were followed by Todd's palsies in five. Four children additionally suffered from hydrophthalmia. Another patient had an angiomatosis of the retina and cataract. Neurological findings were normal in three patients, minimal signs were found in three, one patient had a spastic hemiplegia and another one hypotone tetraplegia. The mental development was normal in three patients, however severe dyscalculia occurred in one of them. Five patients were mentally retarded, three of them severely. The prognosis was the worse the earlier the cerebral seizures appeared.

[Retinal angiomatoses]

The three classical angiomatoses of the retina are described on the basis of the clinical picture. If early diagnosis is possible, the otherwise inevitable progression to exudative retinal detachment and secondary glaucoma may be avoided through extensive coagulation by laser, xenon or cryopexy. - The prognosis is best in Leber's retinitis; it in much poorer in cases of von Hippel-Lindau angiomatosis and primary Coats' disease.

Rhegmatogenous retinal detachment in angiomatosis retinae

Three patients with von Hippel tumors of the retina developed rhegmatogenous retinal detachments caused by surface traction on the angioma. The break in each case was located at the posterior base of the angioma, between the afferent and efferent vessels. Conventional scleral buckling surgery with cryotherapy and a silicone episcleral sponge successfully reattached the retina in all three cases.

CT and MR of angiomatous malformations of the choroid plexus in patients with Sturge-Weber disease

Eight patients with Sturge-Weber disease were evaluated by CT (six patients), MR (one patient), or both (one patient). CT scans of five of seven patients showed enlargement and increased enhancement of the choroid plexus on the same side as the facial and intracranial lesions. MRI showed similar findings in both patients examined. This enlargement, seen in six of eight cases of Sturge-Weber disease, is compatible with the presence of angiomatous malformations of the choroid plexus. It appears to be a common finding in this disease.

[Bone angiomatoses in children. Apropos of 3 personal cases]

Three observations of skeletal angiomatosis are reported: one diffuse and two focal forms (Gorham's disease). The analysis of these cases and a review of the literature enhance the clinical and radiological presentation of this uncommon disease. The authors point out the interest of indirect lymphoscintigraphy and dwell on the gravity of its course, in spite of therapeutic attempts.

[Retinal angiomatoses]

The three classic angiomatoses of the retina are described according to the clinical picture. If early diagnosis is possible, then the inevitable progression to exudative retinal detachment and secondary glaucoma may be avoided by extensive coagulation with laser, xenon or cryopexy. Prognosis is best with Leber's retinitis, much less so in cases of von Hippel-Lindau angiomatosis and primary Coats' disease.

[Angiomatosis of bone--report of two cases]

Primary angiomatosis of bone is a rare bone tumor. Only 26 cases have been reported previously in literature. The authors add two cases in this paper. In one of them the right calcaneus bone and distal phalanges of the first and second toes were involved, an occurrence not yet been described. From the clinical point of view, the authors made an attempt to put forward a criterion for distinguishing the two types of primary bone angiomatosis--angiomatosis and massive osteolysis. The first type was usually operable with good results. As for the second type, no proper therapy has been found but irradiation might relieve the symptoms and control the development of the tumor. The authors emphasize that the roentgenogram is too equivocal to diagnose and the definite diagnosis almost always depends upon histopathologic examination characterized by the formation of abundant capillaries or cavernous vessels or both.

Invasive pulmonary haemangiomatosis

Invasive pulmonary haemangiomatosis is a recently described disease in which exceedingly thin-walled vessels of capillary or venous dimensions infiltrate the lung parenchyma and pulmonary blood vessels. The angiomatous vessels, of obscure origin, infiltrate the media and intima of muscular pulmonary arteries, pulmonary veins and venules. The occlusion of the veins and venules by the thin-walled vessels, and the reactive intimal fibrosis they provoke, leads to pulmonary capillary dilatation, collections of intra-alveolar siderophages, fibrosis of alveolar walls and osseous nodules. This secondary pulmonary veno-occlusive disease in turn leads to hypertensive pulmonary vascular disease. Hence invasive pulmonary haemangiomatosis represents a fourth cause of 'unexplained pulmonary hypertension', the other three being unexplained plexogenic pulmonary arteriopathy, recurrent pulmonary thromboembolism, and pulmonary veno-occlusive disease. Two previously reported cases of invasive pulmonary haemangiomatosis presented with recurrent haemoptysis and the gradual development of chronic respiratory insufficiency associated with diffuse infiltrates in the chest radiograph. In one of these cases a haemothorax had developed. Such clinical features may be of importance in coming to the correct diagnosis.

Placental chorioangiomatosis--a high risk pregnancy

A case of diffuse chorioangiomatosis leading to fetal hydrops, disseminated intravascular coagulopathy with massive umbilical vein thrombosis and fetal death is described. Although rare, this benign mesenchymatous malformation of the placenta should be kept in mind as a possible cause of neonatal morbidity. Prenatal diagnosis could prevent fetal death.

Regional cerebral blood flow characteristics of the Sturge-Weber syndrome

Four patients with the Sturge-Weber syndrome were studied using the non-invasive Xenon-133 inhalation technique. All four patients had decreased regional cerebral blood flow in the area of their lesion, and in two patients who were subsequently tested with 5% carbon dioxide inhalation, impaired vasomotor reactivity was documented. Diminished regional cerebral blood flow is consistent with previously described nuclide flow studies which demonstrated a delay in the initial perfusion blush in the region of the abnormal vasculature. The focal decrease in blood flow was greatest in the most severely affected patient, but was also prominent in the two younger patients, both of whom have excellent neurologic function. These studies suggest that localized decrease in blood flow and vasomotor dysfunction in Sturge-Weber syndrome can precede the occurrence of severe neurologic impairment and extensive cerebral atrophy and possibly be a major contributing factor in progressive dysfunction. A secondary observation was that the blood flow in the unaffected hemisphere was significantly greater in two children compared to the two adults and was similar to the age-related differences reported for normal children and adults.

Renal carcinoma in Lindau's disease

A case of Lindau's disease is presented where renal carcinoma was detected 2.5 years after surgical removal of a cerebellar haemangioblastoma. This patient had no retinal lesions. The importance of screening for renal carcinoma in patients showing one or more manifestations of the disease and screening relatives is emphasized.

Early prenatal ultrasonic findings in Klippel-Trenaunay-Weber syndrome

Routine sonography prior to genetic amniocentesis revealed the presence of a large complex mass with pulsating channels over the anterior fetal chest wall. This led to early termination of pregnancy in a fetus affected with the rare Klippel-Trenaunay-Weber Syndrome.

von Hippel-Lindau disease: a familial, often lethal, multi-system phakomatosis

A review of 36 cases of von Hippel-Lindau disease underscores the important role of the ophthalmologist in evaluating this phakomatosis. Retinal angiomatosis occurred in almost two-thirds of those affected, was usually diagnosed before other target organs, and frequently led to decreased visual acuity. Common non-ophthalmic manifestations included cerebellar (69%), medullary (11%) and spinal (8%) hemangioblastoma, renal cell carcinoma (22%), and polycythemia (17%). Pheochromocytoma was a les common association. The most common causes of death were cerebellar hemangioblastoma and renal cell carcinoma. For the surveillance of suspected von Hippel-Lindau victims, a detailed family history and retinal examination is recommended. Essential laboratory tests include a complete blood count and computed tomography of the head, upper cervical region, and abdomen. Periodic pre-symptomatic screening is imperative for follow-up investigation of affected individuals to determine possible additional occult manifestations and of non-affected family members at risk to von Hippel-Lindau disease.