Intracranial Aneurysms in Patients with Marfan Syndrome: A Multicenter Propensity-Matched Analysis

Sex- and age-dependent neurovascular abnormalities linked to neuroinflammation lead to exacerbated post-ischemic brain injury in Marfan syndrome mice

Fibrillin 1 gene (Fbn1) mutations cause Marfan syndrome (MFS), triggering life-threatening aortic complications and multi-organ effects. MFS is increasingly linked to neurovascular complications, amplified by aortic surgery risks. However, the impact of MFS on the brain remains unclear, including the roles of sex, aging, and their contribution to cerebral injury. This study examines brain alterations and their role in cerebral ischemic injury in an MFS mouse model. RNA-seq analysis of young (3-month-old) and aged (13-month-old) male and female wild-type and MFS (Fbn1C1041G/+) mice revealed disruptions in TGF-β and extracellular matrix (ECM) pathways in MFS brains, most pronounced in young males and aged females with reduced estrogen levels. Inflammatory pathways were upregulated across all MFS mice. Consequently, changes in TGF-β signaling, ECM turnover, redox stress and inflammatory pathways were assessed through RT-qPCR, immunostaining, Western blot, lucigenin chemiluminescence, spectrophotometry, HPLC, and synchrotron radiation-based microspectroscopy, while cerebrovascular properties were assessed by pressure myography and confocal microscopy in the basilar artery. Aged MFS mice showed decreased brain TGF-β1 levels, while dysregulated collagen turnover was only observed in female MFS mice. Despite increased NADPH oxidase activity and redox damage in the corpus callosum of male MFS mice, brain redox stress levels remain largely unchanged. Young female MFS mice exhibited hypertrophic remodeling of the basilar artery. Remarkably, neuroinflammation driven by reactive gliosis increased in MFS mice, regardless of sex and age. To determine the impact on ischemic vulnerability, young mice underwent bilateral common carotid artery occlusion (5 min)/reperfusion (3 days). MFS mice showed greater post-ischemic brain damage, evidenced by worsened behavioral impairments, hippocampal neurodegeneration, and neuroinflammation. This study identifies sex- and age-dependent disruptions in TGF-β1, ECM, and cerebrovascular integrity in MFS mice. Persistent neuroinflammation and increased vulnerability to post-ischemic brain injury suggests that MFS patients, alongside well-documented aortic complications, have an intrinsic predisposition to cerebral damage.

Neurological abnormalities in individuals with Marfan syndrome: results from a genetically confirmed Italian cohort

BACKGROUND AND AIMS

Neurological abnormalities have been frequently reported in individuals with Marfan Syndrome (MFS). However, available data relies solely on retrospective studies predating current diagnostic criteria.

METHODS

Cross-sectional study comprehensively investigating neurological abnormalities within a prospective cohort of adults (≥ 18 years) with genetically confirmed MFS referred to an Italian hub center for heritable connective tissue diseases (Jan. 1st - Nov. 15th, 2021).

RESULTS

We included a total of 38 individuals (53% female). The commonest neurological symptom was migraine (58%), usually without aura (73%). Neuropsychological testing was generally unremarkable, whilst anxiety and depression were highly prevalent within our cohort (42% and 34%, respectively). The most frequent brain parenchymal abnormality was the presence of cortico-subcortical hypointense spots on brain MRI T2* Gradient-Echo sequences (39%), which were found only in patients with a prior history of aortic surgery. Migraineurs had a higher frequency of brain vessels tortuosity vs. individuals without migraine (73% vs. 31%; p = 0.027) and showed higher average and maximum tortuosity indexes in both anterior and posterior circulation brain vessels (all p < 0.05). At univariate regression analysis, the presence of brain vessels tortuosity was significantly associated with a higher risk of migraine (OR 5.87, CI 95% 1.42-24.11; p = 0.014).

CONCLUSIONS

Our study confirms that neurological abnormalities are frequent in individuals with MFS. While migraine appears to be associated with brain vessels tortuosity, brain parenchymal abnormalities are typical of individuals with a prior history of aortic surgery. Larger prospective studies are needed to understand the relationship between parenchymal abnormalities and long-term cognitive outcomes.

Clinical Approach to Genetic Cerebral Arteriopathy in the Adult Patient With Ischemic Stroke

Genetic arteriopathies leading to stroke in adults constitute a diverse group of cerebrovascular disorders with distinct etiologies, pathophysiologic mechanisms, and clinical presentations. As imaging modalities better delineate subtle changes in cerebral vasculature and access to genetic testing increases, the detection rate for these conditions is expected to rise, particularly among young adults with idiopathic cerebral arteriopathy and stroke. Adults with stroke in the setting of a genetic cerebral arteriopathy often present with few traditional stroke risk factors and, in certain cases, have characteristic clinical features, cerebrovascular imaging findings, and often concurrent systemic vasculopathy, such as aortopathy, which are important to recognize. Given that there are over 50 recognized genetic cerebral arteriopathies that can cause ischemic and hemorrhagic stroke in young adults, it can be a significant diagnostic challenge for the practicing neurologist when faced with a genetic cerebral arteriopathy, because clinical algorithms for a systematic approach to genetic cerebral arteriopathies are lacking. In this review, we present a phenotype-driven, clinically oriented algorithm to guide the diagnostic workup when suspecting a genetic cerebral arteriopathy in an adult patient while highlighting the genetic basis of each disease, molecular mechanisms, clinical manifestations, diagnostic approaches, and emerging therapeutic strategies. Moreover, given the lack of widely available gene panels for diagnostic germline testing for genetic cerebral arteriopathies, we propose key genes to be tested and focused on in each clinical scenario, to better decipher the underlying diagnosis in these rare conditions.

Prevalence of unruptured intracranial aneurysms in patients with Marfan syndrome: A cross-sectional study and meta-analysis

INTRODUCTION

Marfan syndrome (MFS) is the most common inherited connective tissue disorder and its association with intracranial aneurysms (ICAs) has been debated for more than two decades. Here, we report the prevalence of ICAs at screening neuroimaging in a population of genetically confirmed MFS patients and present the results of a meta-analysis including our cohort of patients and those of previous studies.

PATIENTS AND METHODS

We enrolled 100 consecutive MFS patients, who underwent screening with brain magnetic resonance angiography at our tertiary center between August 2018 and May 2022. We did a PubMed and Web of Science search to retrieve all studies on the prevalence of ICAs in patients with MFS published before November, 2022.

RESULTS

Of the 100 patients included in this study (94% Caucasians, 40% females, mean age 38.6 ± 14.6 years), three had an ICA. We pooled the current study with five previously published studies, including a total of 465 patients, 43 of which harbored at least one unruptured ICA, leading to an overall ICA prevalence of 8.9% (95% CI 5.8%-13.3%).

DISCUSSION AND CONCLUSION

In our cohort of genetically confirmed MFS patients, the prevalence of ICAs was 3%, which is substantially lower compared to previous studies based on neuroimaging. The high frequency of ICA found in previous studies could be explained by selection bias and lack of genetic testing, which may have led to the inclusion of patients with different connective tissue disorders. Further studies, including several centers and a large number of patients with genetically confirmed MFS, are needed to confirm our results.

Association between smoking and intracranial artery dissection in patients aged less than 50 years: A propensity score-matched analysis

INTRODUCTION

Smoking is a common risk factor for stroke in the young population. Intracranial artery dissection (ICAD) is a major cause of stroke in this population. However, the association between smoking and ICAD in young patients is not well characterized. We aimed to evaluate the association between smoking and ICAD in young individuals using propensity score-matched analysis.

METHODS

We conducted a retrospective study of consecutive patients aged <50 years with ICAD who were admitted to Beijing Tiantan Hospital between January 2016 and December 2020. Patients with other non-atherosclerotic/non-aneurysmal cerebrovascular diseases were selected as controls. Propensity score matching was based on age and sex. Smoking and other vascular risk factors were compared between the two groups.

RESULTS

The ICAD and control group included 120 and 197 patients, respectively. Propensity score matching resulted in 70 matched pairs. Smoking was the only significant factor association with ICAD in the matched cohort (p=0.031).

CONCLUSIONS

In this propensity score-matched analysis, smoking showed a positive association with ICAD in young patients with common cerebrovascular diseases that were neither atherosclerotic nor aneurysmal. Further studies are required to investigate the predictive role of smoking for ICAD in the young population.

Intracranial Aneurysms in Loeys-Dietz Syndrome: A Multicenter Propensity-Matched Analysis

BACKGROUND

Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by a classic triad of hypertelorism, bifid uvula and/or cleft palate, and generalized arterial tortuosity. There are limited data on the prevalence and rupture risk of intracranial aneurysms (IAs) in the setting of LDS, with no established guidelines.

OBJECTIVE

To analyze the prevalence and rupture risk of IA in LDS.

METHODS

Electronic medical records of patients with a confirmed diagnosis of LDS and available cerebrovascular imaging were reviewed. Patients were divided into 2 groups based on the presence of IA. Unmatched and propensity-matched analyses were used to identify potential risk factors for aneurysm formation.

RESULTS

Records of 1111 patients were screened yielding a total of 60 patients with a diagnosis of LDS. Eighteen (30%) patients had IA, 4 (22.2%) of whom had multiple aneurysms for a total of 24 IAs. Twenty-three (95.8%) aneurysms were located in the anterior circulation; none of them were ruptured. On unmatched analysis, age ( P = .015), smoking history ( P = .034), hypertension ( P = .035), and number of extracranial aneurysms ( P &lt; .001) were significantly higher in patients with IA. After matching for age, sex, race, stroke history, family history, and extracranial aneurysms, smoking history ( P = .009) remained significant.

CONCLUSION

Patients with LDS have an increased risk of IAs, especially with a history of smoking. The prevalence rate of IAs in our series was 30%. Screening imaging should be considered at diagnosis, and patients should be encouraged to abstain from smoking. Further studies are needed to elucidate the risk of IA rupture and treatment considerations in this unique population.