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Ballmann L, Scholl-Bürgi S, Karall T, Odri Komazec I, Karall D, Michel M. Subdural Hygroma in an Infant with Marfan's Syndrome. Neuropediatrics 2021; 52:423-430. [PMID: 34233372 DOI: 10.1055/s-0041-1731801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Based on a patient encounter in which genetically confirmed Marfan's syndrome (MFS) underlay a spontaneously resolving subdural hygroma (SDHy) diagnosed in infancy, we review the literature of MFS clinically manifest in early life (early-onset MFS [EOMFS]) and of differential diagnoses of SDHy and subdural hemorrhage (SDHe) at this age. We found that rare instances of SDHy in the infant are associated with EOMFS. The most likely triggers are minimal trauma in daily life or spontaneous intracranial hypotension. The differential diagnosis of etiologies of SDHy include abusive and nonabusive head trauma, followed by perinatal events and infections. Incidental SDHy and benign enlargement of the subarachnoid spaces must further be kept in mind. SDHy exceptionally also may accompany orphan diseases. Thus, in the infant, EOMFS should be considered as a cause of SDHe and/or SDHy. Even in the absence of congestive heart failure, the combination of respiratory distress syndrome, muscular hypotonia, and joint hyperflexibility signals EOMFS. If EOMFS is suspected, monitoring is indicated for development of SDHe and SDHy with or without macrocephaly. Close follow-up is mandatory.
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Affiliation(s)
- Lisa Ballmann
- Department for Pediatrics III (Pediatric Cardiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine Scholl-Bürgi
- Department for Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Karall
- Department for Pediatrics III (Pediatric Cardiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Irena Odri Komazec
- Department for Pediatrics III (Pediatric Cardiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Karall
- Department for Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Miriam Michel
- Department for Pediatrics III (Pediatric Cardiology), Medical University of Innsbruck, Innsbruck, Austria
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Nisson PL, Schreck R, Graham JM, Maya MM, Schievink WI. Spontaneous intracranial hypotension secondary to congenital spinal dural ectasia and genetic mosaicism for tetrasomy 10p: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE213. [PMID: 35855416 PMCID: PMC9265171 DOI: 10.3171/case213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spontaneous intracranial hypotension has historically been a poorly understood pathology that is often unrecognized and undertreated. Even more rarely has it been described in pediatric patients with an otherwise benign past medical history. OBSERVATIONS Herein the authors describe one of the youngest patients ever reported, a 2-year-old girl who developed severe headaches, nausea, and vomiting and experienced headache relief after lying down. Imaging revealed tonsillar herniation 14 mm below the foramen magnum, presumed to be a Chiari malformation, along with extensive dural cysts starting from thoracic level T2 down to the sacrum. She was found to have streaky skin pigmentary variation starting from the trunk down to her feet. Genetic analysis of skin biopsies revealed mosaicism for an isodicentric marker chromosome (10p15.3–10q11.2 tetrasomy) in 27%–50% of cells. After undergoing a suboccipital and cervical decompression at an outside institution, she continued to be symptomatic. She was referred to the authors’ hospital, where she was diagnosed with spontaneous intracranial hypotension. LESSONS After receiving a series of epidural blood patches, the patient experienced almost complete relief of her symptoms. To the authors’ knowledge, this is the first time this chromosomal anomaly has ever been reported in a living child, and this may represent a new genetic association with dural ectasia.
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Affiliation(s)
| | | | | | - Marcel M. Maya
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, California
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Angelopoulou E, Pantou E, Zacharis G, Rentzos M, Stefanis L, Zouvelou V. Corticosteroids for spontaneous intracranial hypotension: a case-report and critical review focusing on pathophysiology and treatment. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Spontaneous intracranial hypotension (SIH) is characterized by positional headache caused by low CSF pressure, without any major traumatic event. Optimal treatment is still debated; epidural blood patch (EBP) is usually used after unsuccessful conservative treatment with variable efficacy and potentially severe complications. Although steroids have been reported to be beneficial, their effectiveness is still controversial, and more clinical evidence is needed.
Case presentation
A 37-year-old woman was admitted to the neurology department due to severe orthostatic headache with nausea over the last 5 days. No trauma history or spinal manipulation were mentioned. On arrival, neurological examination, brain CT, and laboratory investigation were normal. Intracranial hypotension was clinically suspected, and lumbar puncture revealed low opening pressure. Brain MRI demonstrated pachymeningeal gadolinium enhancement and distended and rounded dural venous sinuses, while cervicothoracic spine MRI revealed thoracic CSF leakage, leading to SIH diagnosis. The patient was treated with high-dose intravenous methylprednisolone, with complete clinical resolution within 24 h.
Conclusions
Our case, combined with literature evidence, supports the high-dose intravenous corticosteroids as a reasonable treatment option in selected cases, before trying EBP or surgical repair. Randomized clinical trials are needed, in order to optimize SIH patients’ outcomes.
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von Kodolitsch Y, Demolder A, Girdauskas E, Kaemmerer H, Kornhuber K, Muino Mosquera L, Morris S, Neptune E, Pyeritz R, Rand-Hendriksen S, Rahman A, Riise N, Robert L, Staufenbiel I, Szöcs K, Vanem TT, Linke SJ, Vogler M, Yetman A, De Backer J. Features of Marfan syndrome not listed in the Ghent nosology – the dark side of the disease. Expert Rev Cardiovasc Ther 2020; 17:883-915. [DOI: 10.1080/14779072.2019.1704625] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yskert von Kodolitsch
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Anthony Demolder
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, VASCERN HTAD European Reference Centre, Ghent, Belgium
| | - Evaldas Girdauskas
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Harald Kaemmerer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich of the Free State of Bavaria, Munich
| | - Katharina Kornhuber
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich of the Free State of Bavaria, Munich
| | - Laura Muino Mosquera
- Department of Pediatric Cardiology and Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Shaine Morris
- Department of Pediatrics-Cardiology, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Enid Neptune
- Division of Pulmonary and Critical Care Medicine and Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Reed Pyeritz
- Departments of Medicine and Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Svend Rand-Hendriksen
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Alexander Rahman
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Hannover
| | - Nina Riise
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Leema Robert
- Department of Clinical Genetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Ingmar Staufenbiel
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Hannover
| | - Katalin Szöcs
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Thy Thy Vanem
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Stephan J. Linke
- Clinic of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Ophthalmological practice at the University Clinic Hamburg-Eppendorf, zentrumsehstärke, Hamburg, Germany
| | - Marina Vogler
- German Marfan Association, Marfan Hilfe Deutschland e.V, Eutin, Germany
| | - Anji Yetman
- Vascular Medicine, Children’s Hospital and Medical Center, Omaha, USA
| | - Julie De Backer
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, VASCERN HTAD European Reference Centre, Ghent, Belgium
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Hoffmann J. Impaired cerebrospinal fluid pressure. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:171-185. [PMID: 29110769 DOI: 10.1016/b978-0-12-804279-3.00011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Abnormalities of cerebrospinal fluid (CSF) pressure are relatively common and may lead to a variety of symptoms, with headache usually being the most prominent one. The clinical presentation of alterations in CSF pressure may vary significantly and show a striking similitude to several primary headache syndromes. While an increase in CSF pressure may be of primary or secondary origin, a pathologic decrease of CSF pressure is usually the result of a meningeal rupture with a resulting leakage of CSF. The pathophysiologic mechanisms of idiopathic intracranial hypertension (IIH) remain largely unknown. However recent evidence indicates that an abnormality in CSF outflow and absorption is likely to play a significant role. Treatment usually consists of a combination of weight loss and a pharmacologic approach using carbonic anhydrase inhibitors. Recent results of the first randomized, double-blind, placebo-controlled trial (RCT) with acetazolamide proved its efficacy in reducing headache and visual disturbances. Clinical evidence suggests efficacy for topiramate and furosemide but no RCT has been conducted to date to confirm these results. In contrast to IIH, spontaneous intracranial hypotension frequently remits spontaneously without specific treatment. If necessary, treatment options range from conservative methods to epidural blood or fibrin sealant patches and surgical interventions.
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Affiliation(s)
- Jan Hoffmann
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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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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Abstract
Marfan syndrome is a systemic, heritable connective tissue disorder that affects many different organ systems and is best managed by using a multidisciplinary approach. The guidance in this report is designed to assist the pediatrician in recognizing the features of Marfan syndrome as well as caring for the individual with this disorder.
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Abstract
CONTEXT Meningeal abnormalities such as dural ectasia are seen in Marfan syndrome, but spinal meningeal cysts are rarely seen. These cysts usually asymptomatic and often found incidentally on magnetic resonance imaging, large cysts may cause neurological deficits and pain secondary to nerve root compression. DESIGN Case reports. FINDINGS Two patients with Marfan syndrome presented with urinary symptoms secondary to dural ectasia and sacral cysts. Patient 1 had a history of low back pain, erectile dysfunction, and occasional urinary incontinence and groin pain with recent symptom worsening. He underwent L5 partial laminectomy and S1-S2 laminectomy with sacral cyst decompression. Nine weeks later, he underwent drainage of a sacral pseudomeningocele. Pain and urinary symptoms resolved, and he remains neurologically normal 2 years after surgery. Patient 2 presented after a fall on his tailbone, complaining of low back pain and difficulty urinating. Physical therapy was implemented, but after 4 weeks, urinary retention had not improved. He then underwent resection of the sacral cyst and S1-S3 laminectomy. Pain and paresthesias resolved and bowel function returned to normal. Other than needing intermittent self-catheterization, all other neurologic findings were normal 30 months after surgery. CONCLUSION/CLINICAL RELEVANCE Surgical goals for sacral cysts include resection as well as closure of the dura, which can be challenging due to thinning from ectasia. Neurosurgical intervention in Marfan syndrome is associated with a high risk of dural tears and osseous complications, and should be performed only when symptoms are severe.
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Affiliation(s)
- Paul M. Arnold
- University of Kansas Medical Center, Kansas City, KS, USA,Correspondence to: Paul M. Arnold MD, Dept. of Neurosurgery, Mail Stop 3021, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA.
| | - Jan Teuber
- Department of Genetics and Molecular Neurobiology, Otto-von-Guericke-University Magdeburg, Faculty of Natural Sciences, Institute of Biology, Magdeburg, Germany
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Spontaneous intracranial hypotension in childhood and adolescence. J Pediatr 2013; 163:504-10. [PMID: 23453548 DOI: 10.1016/j.jpeds.2013.01.055] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/14/2012] [Accepted: 01/24/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the clinical and radiographic manifestations of spontaneous intracranial hypotension, a rarely diagnosed cause of headache in children. STUDY DESIGN This study included patients 19 years of age or younger evaluated between January 1, 2001, and June 30, 2012, for spontaneous intracranial hypotension. RESULTS We evaluated 24 children (18 girls and 6 boys) with spontaneous intracranial hypotension (age at onset of symptoms: 2-19 years, mean 14.3 years). Twenty-three patients presented with orthostatic headaches and 1 presented with a nonpositional headache. A generalized connective tissue disorder was diagnosed in 54% of patients. Magnetic resonance imaging showed the typical changes of spontaneous intracranial hypotension in most patients (79%). Spinal imaging demonstrated a cerebrospinal fluid (CSF) leak with or without an associated meningeal diverticulum in 12 patients (50%) and with dural ectasia or meningeal diverticula in 10 patients (42%), and it was normal in 2 patients (8%). Twenty-three patients initially underwent epidural blood patching, but 8 patients also were treated with percutaneous injections of fibrin glue and 11 patients eventually required surgical correction of the underlying CSF leak. There was no morbidity or mortality associated with any of the treatments, but 5 patients required acetazolamide for rebound high intracranial pressure headache. Overall, outcome was good in 22 patients (92%) and poor in 2 patients (8%). CONCLUSIONS Spontaneous intracranial hypotension in childhood is rare. Most patients can be treated effectively using a combination of epidural blood patching and percutaneous injections of fibrin glue or surgical CSF leak repair in refractory cases.
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Youngblood SC, Tolpin DA, LeMaire SA, Coselli JS, Lee VV, Cooper JR. Complications of cerebrospinal fluid drainage after thoracic aortic surgery: A review of 504 patients over 5 years. J Thorac Cardiovasc Surg 2013; 146:166-71. [DOI: 10.1016/j.jtcvs.2013.01.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/04/2013] [Accepted: 01/28/2013] [Indexed: 11/16/2022]
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Kranz PG, Stinnett SS, Huang KT, Gray L. Spinal meningeal diverticula in spontaneous intracranial hypotension: analysis of prevalence and myelographic appearance. AJNR Am J Neuroradiol 2012; 34:1284-9. [PMID: 23221945 DOI: 10.3174/ajnr.a3359] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal meningeal diverticula have been implicated in the pathogenesis of spontaneous intracranial hypotension and have been proposed as both diagnostic features of and therapeutic targets for the condition. We compared the prevalence and myelographic appearance of spinal diverticula in patients with SIH and healthy controls. MATERIALS AND METHODS Patients satisfying the ICHD-2 criteria for SIH were retrospectively identified. CT myelograms of 19 patients with SIH were compared with CT myelograms of 18 control patients. Images were reviewed by 2 blinded neuroradiologists. The prevalence, morphology (round versus multilobulated), size, and location (cervical, upper thoracic, lower thoracic, or lumbar) of spinal meningeal diverticula were analyzed. RESULTS There was no difference in the proportion of patients with diverticula in the SIH group compared with the control group (68% versus 44%, P = .14) or in the mean number of diverticula per patient (6.3 versus 2.2, P = .099). No difference was seen in the morphology (P = .95) or size (P = .71) of diverticula between groups. There was a difference between groups that just reached statistical significance (P = .050) in the location of the diverticula along the spinal axis, but substantial overlap was seen between groups for all spinal locations. CONCLUSIONS Despite the well-established association between spinal meningeal diverticula and SIH, we found no difference in the prevalence or myelographic appearance of diverticula in patients with SIH compared with controls. Further investigation into the role of diverticula in the diagnosis and treatment of SIH is necessary.
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Affiliation(s)
- P G Kranz
- Departments of Radiology, Duke University Medical Center, Durham, NC 277710, USA.
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El koraichi A, Tsala G, Kharazi H, Tadili J, Benafitou R, Lahlou M, Al Haddoury M, El kettani SE. Hypotension intracrânienne spontanée traitée par blood patch lombaire chez une jeune fille. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0303-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Pabaney AH, Mirza FA, Syed NA, Ahsan H. Spontaneous dural tear leading to intracranial hypotension and tonsillar herniation in Marfan syndrome: a case report. BMC Neurol 2010; 10:54. [PMID: 20584308 PMCID: PMC2906429 DOI: 10.1186/1471-2377-10-54] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 06/28/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We describe the case of a 38 year old male with Marfan syndrome who presented with orthostatic headaches and seizures. CASE PRESENTATION The patient was diagnosed with Spontaneous Intracranial Hypotension secondary to CSF leaks, objectively demonstrated by MR myelogram with intrathecal contrast. Epidural autologous blood patch was administered at the leakage site leading to significant improvement. CONCLUSION Our literature search shows that this is the second reported case of a Marfan patient presenting with symptomatic spontaneous CSF leaks along with tonsillar herniation.
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Affiliation(s)
- Aqueel H Pabaney
- Medical College, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, Pakistan
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Diener HC, Johansson U, Dodick DW. Headache attributed to non-vascular intracranial disorder. HANDBOOK OF CLINICAL NEUROLOGY 2010; 97:547-587. [PMID: 20816456 DOI: 10.1016/s0072-9752(10)97050-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.
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Abstract
Spontaneous intracranial hypotension is an uncommon but not rare cause of new onset daily persistent headaches. A delay in diagnosis is the norm. Women are affected more commonly than men and most are in the fifth or sixth decade of life. The underlying cause is a spontaneous spinal cerebrospinal fluid (CSF) leak. Typically the headache is orthostatic in nature but other headache patterns occur as well. Associated symptoms are common and include neck pain, a change in hearing, diplopia, facial numbness, cognitive abnormalities and even coma. Typical imaging findings consist of subdural fluid collections, pachymeningeal enhancement, pituitary hyperaemia and brain sagging, but magnetic resonance imaging may be normal. Myelography is the study of choice to identify the CSF leak but is not always necessary to make the diagnosis. Treatment consists of bedrest, abdominal binder, epidural blood patching, percutaneous fibrin glue injection or surgical CSF leak repair. Outcomes have been poorly studied.
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Affiliation(s)
- WI Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Kundu A, Sano Y, Pagel PS. Case report: Delayed presentation of postural headache in an adolescent girl after microscopic lumbar discectomy. Can J Anaesth 2008; 55:696-701. [DOI: 10.1007/bf03017746] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Cheuret E, Edouard T, Mejdoubi M, Acar P, Pienkowski C, Cances C, Lebon S, Tauber M, Chaix Y. Intracranial hypotension in a girl with Marfan syndrome: case report and review of the literature. Childs Nerv Syst 2008; 24:509-13. [PMID: 17906865 DOI: 10.1007/s00381-007-0506-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 07/13/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION A 14-year-old girl, followed in our department for Marfan syndrome, presented with postural headache for a month. Neurological examination was normal. The diagnosis of intracranial hypotension syndrome was suspected. DISCUSSION Bilateral subdural hematomas were found on brain magnetic resonance imaging (MRI), and spinal MRI showed large lumbosacral arachnoid diverticula; no cerebrospinal fluid leaks could be found. Despite bed rest and hydration for 2 weeks, postural headache remained. Epidural blood patching was also performed. Subsequently, the patient became asymptomatic and could stand up after 1 day. Brain MRI did not find recurrent subdural hematoma after 1 month. Dural ectasia is one of the major criteria of Marfan syndrome, and it is often poorly symptomatic. Intracranial hypotension is a rare complication especially in children, and management is not standardized. In this case report, blood patching was sufficient. Further research into the diagnosis and management of spontaneous intracranial hypotension is required.
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Affiliation(s)
- E Cheuret
- Unité de Neurologie Pédiatrique, Hôpital Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex, France.
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Albayram S, Baş A, Ozer H, Dikici S, Gulertan SY, Yuksel A. Spontaneous Intracranial Hypotension Syndrome in a Patient With Marfan Syndrome and Autosomal Dominant Polycystic Kidney Disease. Headache 2008; 48:632-6. [DOI: 10.1111/j.1526-4610.2007.01033.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Puget S, Kondageski C, Wray A, Boddaert N, Roujeau T, Di Rocco F, Zerah M, Sainte-Rose C. Chiari-like tonsillar herniation associated with intracranial hypotension in Marfan syndrome. J Neurosurg Pediatr 2007; 106:48-52. [PMID: 17233313 DOI: 10.3171/ped.2007.106.1.48] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the case of a 12-year-old girl with Marfan syndrome, sacral dural ectasia, and tonsillar herniation, who presented with headache. Initially, it was hypothesized that the headaches were secondary to the tonsillar herniation, and the patient consequently underwent surgical decompression of the foramen magnum. Postoperatively, the patient's condition did not improve, and additional magnetic resonance (MR) imaging demonstrated evidence of a cerebrospinal fluid (CSF) leak at the level of the dural ectasia. It was surmised that the girl's symptoms were due to spontaneous intracranial hypotension (SIH) and that the tonsillar herniation was caused by the leakage. The patient responded well to application of a blood patch at the level of the demonstrated leak, and her headache resolved. This appears to be the first reported case of a patient with Marfan syndrome presenting with a symptomatic spontaneous CSF leak complicated by tonsillar herniation. In this rare association of SIH and connective tissue disorders, recognition of the clinical signs and typical MR imaging features of SIH may lead to more appropriate and less invasive treatment, potentially avoiding surgery.
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Affiliation(s)
- Stéphanie Puget
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France.
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Chung SJ, Ki CS, Lee MC, Lee JH. Fibrillin-1 Gene Analysis of Korean Patients With Spontaneous CSF Hypovolemia. Headache 2007; 47:111-5. [PMID: 17355504 DOI: 10.1111/j.1526-4610.2006.00635.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Mutations in different domains of the Fibrillin-1 (FBN1) gene may be responsible for the variable phenotypic expression of Marfan's syndrome that may present with CSF hypovolemia. OBJECTIVES To evaluate the association between mutations in the Fibrillin-1 (FBN1) gene and spontaneous CSF hypovolemia (SCH) in a Korean population. METHODS We studied 10 consecutive patients with SCH without clinical characteristics of Marfan's syndrome. The genetic analysis was performed. RESULTS Direct sequencing analysis of the FBN1 gene identified 15 genetic variations, of which 5 coding (3 synonymous, 2 nonsynonymous) and 8 intronic variations were listed in the single nucleotide polymorphism database (dbSNP). The other 2 variations, c.2728 - 12T > C in intron 21 and c.4582 - 19A > G in intron 35, were also observed in normal controls with estimated frequencies of 0.06 and 0.15, respectively. CONCLUSIONS We could not identify any FBN1 variations possibly associated with SCH in our study population.
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Affiliation(s)
- Sun J Chung
- Department of Neurology, University of Ulsan Asan Medical Center, Seoul, South Korea
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Abstract
OBJECTIVE To study the prevalence of migraine in Marfan's syndrome. MATERIAL AND METHODS Patients were recruited from Landsforeningen (a patient organization) for Marfan's syndrome. A total of 46 persons were eligible for a validated semi-structured telephone interview by a physician trained in headache diagnostics. RESULTS The prevalence of migraine without aura was 13% among men and 40% among women. The prevalence of migraine with aura was 44% among men and 37% among women. The overall prevalence of migraine was 63% with an equal sex ratio. This corresponds to a 3.6- and 2.0-fold significant increased risk among men and women, respectively, compared with the general population. CONCLUSION The high prevalence and equal sex ratio of migraine is puzzling and likely to be secondary to Marfan's syndrome. It might be associated with dural ectasia, as the prevalence of dural ectasia is similar to that of migraine in Marfan's syndrome.
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Affiliation(s)
- S Knudsen
- Department of Neurofysiology, Glostrup University Hospital, Glostrup, Denmark
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