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Padmanaban V, Yee PP, Koduri S, Zaidat B, Daou BJ, Chaudhary N, Gemmete JJ, Thompson BG, Kazmierczak CD, Cockroft KM, Pandey AS, Wilkinson DA. Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review. World Neurosurg 2023; 170:e529-e541. [PMID: 36402305 DOI: 10.1016/j.wneu.2022.11.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS. METHODS We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases. RESULTS Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%. CONCLUSIONS Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Patricia P Yee
- Medical Scientist Training Program, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Bashar Zaidat
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Badih J Daou
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chris D Kazmierczak
- Department of Radiology, Oakland University-William Beaumont School of Medicine, Auburn Hills, Michigan, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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Mehta MM, Garg RK, Rizvi I, Verma R, Goel MM, Malhotra HS, Malhotra KP, Kumar N, Uniyal R, Pandey S, Sharma PK. The Multiple Cranial Nerve Palsies: A Prospective Observational Study. Neurol India 2021; 68:630-635. [PMID: 32643676 DOI: 10.4103/0028-3886.289003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Neurological presentation with isolated multiple cranial nerve palsies is common and its diverse causes include infectious, neoplastic, and inflammatory pathologies. The aetiological spectrum may depend upon geographical regions. We undertook this study to explore clinical spectrum and aetiological profile of multiple cranial nerve palsies. Methods This hospital-based prospective observational study was conducted from August 2015 to August 2017. All the consecutive patients of multiple cranial palsies presenting to the neurology department were included in the studies. Primary objectives were to define anatomical syndromes/cranial nerve combinations and to establish aetiology. Secondary objectives were to study associated factors. The multiple cranial nerve palsy was defined as involvement of two or more non-homologous nerves. Patients of neuromuscular junction disorders, anterior horn cell disorders, myopathies, brain stem syndromes were excluded. All patients underwent structured protocol of clinical evaluation, investigations and few specialized investigations in accordance with clinical suspicion to establish the diagnosis. Results Fifty-four patients with a mean age of 39.9 ± 14.2 years were included. Commonest cranial nerve involved was the abducens (75.9%) among all nerve combinations. The cavernous sinus syndrome (37%), orbital apex syndrome (22.2%) and jugular foramen syndrome (11.1%) were the most frequent anatomical patterns. Infections (40.7%) were the commonest aetiology followed by neoplastic and idiopathic in four patients. Conclusion Cavernous sinus syndrome was the commonest anatomical syndrome of multiple cranial nerve palsies and infections were the commonest cause in this study.
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Affiliation(s)
- Manan Mayur Mehta
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
| | - Ravindra Kumar Garg
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
| | - Imran Rizvi
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
| | - Rajesh Verma
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
| | - Madhu Mati Goel
- Department of Pathology, King George's Medical University, Uttar Pradesh, India
| | | | - Kiran Preet Malhotra
- Department of Pathology, Ram Manohar Lohiya Institute of Medical Sciences Lucknow, Uttar Pradesh, India
| | - Neeraj Kumar
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
| | - Ravi Uniyal
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
| | - Shweta Pandey
- Department of Neurology, King George's Medical University, Uttar Pradesh, India
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Adham S, Trystram D, Albuisson J, Domigo V, Legrand A, Jeunemaitre X, Frank M. Pathophysiology of carotid-cavernous fistulas in vascular Ehlers-Danlos syndrome: a retrospective cohort and comprehensive review. Orphanet J Rare Dis 2018; 13:100. [PMID: 29940997 PMCID: PMC6019721 DOI: 10.1186/s13023-018-0842-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/13/2018] [Indexed: 11/16/2022] Open
Abstract
Background Vascular Ehlers-Danlos syndrome (vEDS) is a rare condition characterized by connective tissue fragility. Direct spontaneous carotid-cavernous fistula (sCCF) is reportedly pathognomonic of vEDS. We conducted this study to understand the possible mechanisms of occurrence of sCCF in this subset of patients. Methods We conducted a retrospective analysis of a monocentric vEDS cohort along with a literature review regarding sCCF in this condition. Results Of 133 patients regularly followed in our centre between 2000 and 2017, 13 (9.8%) had a diagnosis of direct sCCF (92.3% female, median age 33.0 years, interquartile range (IQR) [26.0–39.5]). There were 7 Glycine missense and 6 splice-site variants but no variant leading to haploinsufficiency. The literature search identified 97 vEDS patients with direct sCCF (79.4% female, 7.2% sex not reported, median age 31.0 years, IQR [24.0–39.0]). Increased carotid circumferential wall stress, higher carotid distensibility and lower carotid intima-media thickness could contribute to a higher risk for direct sCCF in vEDS. There is no predictive factor for the occurrence of sCCF apart from female sex in vEDS. Conclusions In vEDS, anatomical and pathophysiological features of the intra-cavernous internal carotid artery make it prone to shunting in the cavernous sinus, due either to a spontaneous rupture or to a spontaneous dissection with pseudoaneurysm formation. Direct sCCF in seemingly healthy young individuals should be highly suggestive of vEDS and prompt further investigation.
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Affiliation(s)
- Salma Adham
- Hôpital Européen Georges Pompidou, Département de Génétique, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges Pompidou, AP-HP, 20-40 rue Leblanc, 75908, Paris Cedex 15, France.,Sorbonne Paris Cité, Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Denis Trystram
- Service d'imagerie morphologique et fonctionnelle, Centre hospitalier Sainte-Anne, Paris, France.,INSERM, U894, IMA-BRAIN, DHU NeuroVasc Sorbonne Paris Cité, Paris, France
| | - Juliette Albuisson
- Hôpital Européen Georges Pompidou, Département de Génétique, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges Pompidou, AP-HP, 20-40 rue Leblanc, 75908, Paris Cedex 15, France.,Sorbonne Paris Cité, Faculté de Médecine, Université Paris Descartes, Paris, France.,INSERM, U970, Paris centre de Recherche Cardiovasculaire - PARCC, Paris, France
| | - Valérie Domigo
- Service d'imagerie morphologique et fonctionnelle, Centre hospitalier Sainte-Anne, Paris, France.,INSERM, U894, IMA-BRAIN, DHU NeuroVasc Sorbonne Paris Cité, Paris, France
| | - Anne Legrand
- Hôpital Européen Georges Pompidou, Département de Génétique, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges Pompidou, AP-HP, 20-40 rue Leblanc, 75908, Paris Cedex 15, France.,Sorbonne Paris Cité, Faculté de Médecine, Université Paris Descartes, Paris, France.,INSERM, U970, Paris centre de Recherche Cardiovasculaire - PARCC, Paris, France
| | - Xavier Jeunemaitre
- Hôpital Européen Georges Pompidou, Département de Génétique, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges Pompidou, AP-HP, 20-40 rue Leblanc, 75908, Paris Cedex 15, France.,Sorbonne Paris Cité, Faculté de Médecine, Université Paris Descartes, Paris, France.,INSERM, U970, Paris centre de Recherche Cardiovasculaire - PARCC, Paris, France
| | - Michael Frank
- Hôpital Européen Georges Pompidou, Département de Génétique, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges Pompidou, AP-HP, 20-40 rue Leblanc, 75908, Paris Cedex 15, France. .,INSERM, U970, Paris centre de Recherche Cardiovasculaire - PARCC, Paris, France.
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Abstract
We discuss the case of a teenage girl who presented with neurologic symptoms suggestive of a peripheral neuropathy, before the development of a central arteriovenous fistula. Electromyography and nerve conduction studies indicated peroneal motor neuropathy, but her comprehensive genetic study results were negative for common Charcot-Marie-Tooth mutations. After 2 years of stable symptoms, she presented with unilateral throbbing headache and tinnitus. Magnetic resonance angiography revealed a carotid cavernous fistula, which was confirmed with conventional angiography. A successful coil embolization of the fistula was performed. Whole exome sequencing demonstrated a de novo heterozygous c.3158G>A (p.G1056D) mutation in the COL31A gene, consistent with Ehlers-Danlos type IV. To our knowledge, this is the first reported case of isolated peroneal motor neuropathy in a patient with Ehlers-Danlos type IV. This case highlights the utility of whole exome sequencing in the diagnosis of patients with neurologic symptoms that do not fit a clear phenotype.
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