Encephalocraniocutaneous lipomatosis, sometimes

Transcription

1 J Neurosurg Pediatrics 8: , 8: , 2011 Encephalocraniocutaneous lipomatosis: a review of its clinical pathology and neurosurgical indications Case report Robert E. Ayer, M.D., and Alexander Zouros, M.D. Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California Encephalocraniocutaneous lipomatosis (ECCL) is a rare neurocutaneous syndrome whose hallmark lesions are benign lipomas of the brain and spinal cord. The authors present a case of a male infant with ECCL who had extensive brainstem and spinal cord lipomas. The management of this patient s hydrocephalus, cervicomedullary compression, tethered cord, and scoliosis over the course of his first 2 years of life is described. This case report and review of the literature is presented to provide a synopsis of the problems likely to be encountered by neurosurgeons who treat patients with this syndrome. (DOI: / PEDS11138) Key Words encephalocraniocutaneous lipomatosis hydrocephalus scoliosis tethered cord syndrome spine Encephalocraniocutaneous lipomatosis, sometimes referred to as Haberland syndrome, is a rare neurocutaneous syndrome first described by Haberland and Perou in Its characterization occurred following an autopsy examination of a severely retarded 5-yearold boy who had unilateral lipomas of the cranium, face, and neck, lipodermoids of the eye, and ipsilateral brain anomalies. Since that initial report, roughly 54 cases have been described, and diagnostic criteria have been developed. 10,14,15 The genetics of the disease are unknown, but because of its sporadic occurrence and phenotypically characteristic skin and bone lesions, ECCL is thought be a genetically mosaic condition. It affects males and females equally, the patients IQ can range from severely retarded to normal, seizure disorders are common, and no familial recurrences have been reported. This is a mesenchymal disorder affecting mostly neural crest derivatives, and all CNS anomalies are caused by mesenchymal defects affecting the tissues surrounding the brain or involving the cerebral vasculature, without a primary abnormality of the nervous tissue. The hallmark lesions of ECCL are benign CNS lipomas. The lipomas of this syndrome are generally stable throughout the patient s life, but the progression or late development of porencephalic cysts, cerebrovascular aneurysms, and cystic bone lesions have been reported. 6,10,14,16 Abbreviations used in this paper: CM = Chiari malformation; ECCL = encephalocraniocutaneous lipomatosis; ETV = endoscopic third ventriculostomy; SSEP = somatosensory evoked potential; VP = ventriculoperitoneal. Previous case reports and reviews regarding this neurocutaneous syndrome have focused on diagnostic criteria, clinical examination findings, and possible pathogenesis The indications for surgical intervention in patients with this syndrome have not been discussed previously, despite reports mentioning the placement of shunts, and the debulking of intraspinal lipomas in some patients. 5,7,15 Neurosurgeons are likely to be consulted regarding the management of the CNS lipomas and ventricular abnormalities present in this syndrome. We present this new case of a patient with ECCL with the intention of focusing on the issues likely to be faced by neurosurgeons, and we aim to provide a reference for the neurosurgical management of ECCL. Our patient first presented to us at 3 months of age, and the results of our neuroradiological evaluation, treatment of the patient s hydrocephalus, cervicomedullary compression, tethered cord, and scoliosis over the course of 2 years are presented. Case Report History and Examination. This African American boy was born at 39 weeks of gestation via a planned cesarean section to a gravida III para II healthy mother and father. There were no complications during delivery. The child s prenatal and neonatal history was unremarkable, This article contains some figures that are displayed in color on line but in black and white in the print edition. 316

2 Surgical indications in encephalocraniocutaneous lipomatosis and his birth weight was 6 lbs, 3 oz. The patient first presented to the neurosurgery service at 3 months of age, when his pediatrician sent him to the emergency room after the parents noted that the child was favoring his left arm, and would only occasionally move his right arm. Prior to this incident the patient had been meeting developmental milestones as expected. Physical examination was significant for a lipomatous mass in the temporal limbus and a coloboma of the iris in the right eye (Fig. 1A). A patch of alopecia over the left occipital skull with an underlying soft tissue mass was present (Fig. 1B). The patient also had dextroscoliosis (Fig. 2A). There was full passive and active range of motion of the right upper extremity on physical examination. His reflexes and muscle tone were normal. The head was normocephalic and in the 89th percentile for the patient s age, at 42 cm. Results of a radiography study of the right upper extremity were unremarkable. A head CT scan was performed, which demonstrated homogeneous low-density lesions in the cistern magna and right cerebellopontine angle. There was mild ventricular dilation. The patient was admitted to obtain an MR imaging study of the lesions. A large lipomatous mass extending from the medulla through the cisterna magna and insinuating into the dorsal aspect of the spinal cord was seen (Fig. 3A D). A second, smaller lipomatous mass ( cm) was seen on the right side near the Meckel cave (Fig. 3E and F). The MR imaging studies of the spinal cord showed a dorsally exophytic lipomatous mass throughout the entire spinal column, with mass effect on a dysplastic cord. There was also tethering of the spinal cord; the conus was low lying, with lipoma extending to the sacrum (Fig. 4). Complete ophthalmological examination revealed a temporal dermolipoma, a colobomatous iris and optic nerve, and 3 chorioretinal lacunae in the right eye (Fig. 1A). Results of examination of the left eye were normal. Outpatient Follow-Up. The patient was neurologically normal for his age, and no deficiency of the right upper extremity was appreciated during the course of the hospital admission. It was decided to follow the child as an outpatient for the potential development of hydrocephalus, progression of his scoliosis, and symptoms of tethered cord. There was also concern that the severe compression at the cervicomedullary junction would affect motor development. Follow-Up Findings and Treatment. The patient be- Fig. 1. A: Photograph of the right eye showing a temporal dermolipoma and iris coloboma, both of which are common findings in patients with ECCL. B: Photograph showing an area of alopecia in the left occipital skull base. There is an underlying lipoma; this is a typical skin lesion in ECCL, and is referred to as nevus psiloliparus. Fig. 2. Radiographs showing progression of scoliosis in an infant with ECCL. A: Anteroposterior radiograph showing a 37 dextroscoliosis at 3 months of age. B: Radiograph taken at 12 months of age showing progression of the scoliosis to a Cobb angle of 60. The VP shunt was placed following the patient s cervicomedullary decompression. gan failing to meet developmental milestones and to have increased irritability, and neuroimaging showed an increase in the size of his ventricles. At 9 months of age, the patient underwent an ETV and had a significant improvement in motor skills over the following months. His head circumference stabilized at 48 cm. The patient was standing independently and beginning to formulate words at approximately 1 year of age. However, he started to develop sleep apnea as well as having continued progression of his scoliosis. Repeat MR imaging of the spinal column demonstrated that the lipomas were unchanged. Operation. At 19 months of age the patient underwent a posterior fossa craniectomy, C1 6 laminectomies, and debulking of the cervicomedullary junction lipoma. The goal of the surgery was to improve the sleep apnea and relieve any compression that might be contributing to his scoliosis. The surgery was completed without complication and the tumor was found to be an intramedullary lipoma (Figs. 5 and 6), despite appearing mostly extramedullary on preoperative imaging (Fig. 3). The patient had normal upper-extremity SSEPs and severely diminished lower-extremity SSEPs at baseline. There were no changes in these recordings throughout surgery, and the patient was moving all 4 extremities and remained at neurological baseline postoperatively. The mass consisted of mature lobulated adipose tissue. Postoperative Course. The postoperative course was complicated by the development of a pseudomeningocele and return of the patient s hydrocephalus, which required a cervical wound revision and VP shunt placement. In the following months, the patient underwent lumbar laminectomy and resection of his terminal lipomyelomeningocele, with spinal cord untethering. Pathological investigation again showed mature lobulated adipose tissue. The patient is currently 2 years old and has fully recovered from his surgeries. He is currently able to stand with minimal assistance and is meeting his other developmental milestones. His scoliosis is continuing to prog- 317

3 R. E. Ayer and A. Zouros Fig. 4. Preoperative MR imaging studies of thoracic and lumbar spine demonstrating extensive lipomas and a dysplastic spinal cord. A: Sagittal T1-weighted image showing a low-lying conus, and a lipoma that extends to the sacrum. B: Axial T1-weighted image of the lumbar spine at the level indicated in panel A. A lobulated lipoma that appears to be intradural and extramedullary surrounds a dysplastic spinal cord. Fig. 3. Admission MR imaging studies of the brain and cervical spine in an infant with ECCL. Sagittal T1-weighted (A) and T2-weighted (B) MR imaging studies showing a dorsal exophytic lipoma extending from the medulla into the cervical cord. Imaging studies (C and D) obtained at the level of the medulla suggesting that the mass is extramedullary. Coronal T1-weighted image with contrast (E) and axial T1-weighted image without contrast (F) showing a lipoma near the Meckel cave on the right side (arrowheads). There is mild dilation of the third ventricle and temporal horns, indicating early hydrocephalus. The patient eventually received an ETV. initial presentation, and could been seen on his earliest brain imaging studies (Fig. 3E). However, the patient had no symptoms of hydrocephalus at initial presentation and was therefore treated with observation. Symptoms did not manifest until several months later, and the patient successfully underwent an ETV. Hydrocephalus is not an uncommon problem in ECCL, and several patients with this syndrome have undergone successful placement of VP shunts.10,15,18 Ventriculomegaly, porencephalic cysts, and macrocephaly are common findings in patients with ECCL, but not all patients with these findings develop hydrocephalus.15 Hydrocephalus is diagnosed in approximately one-third of patients with ECCL and ventriculomegaly, making longitudinal observation of these patients necessary to determine who will need shunt placement. On initial presentation our patient had dextroscoliosis, with a Cobb angle of 37. The presence of scoliosis in patients with ECCL has been described in only 2 cases. Haberland and Perou s description9 was postmortem, and the child died at 5 years of age. Alfonso et al.1 give a brief description of levoscoliosis in the lumbar spine of a 5-yearold child that progressed over years. The last account of the ress and limits his ability to walk (Fig. 2B). He currently has full strength in all extremities and normal reflexes. He is being treated for his scoliosis with a brace, and is likely to undergo corrective surgery in the future. Discussion Our patient presented with many of the classic features of ECCL, such as nevus psiloliparus, ocular choriostoma (lipodermoid), iris coloboma, and intracranial and spinal lipomas (Figs. 1 6). These clinical findings are considered major diagnostic criteria by Hunter, and surpass the requirement of 2 or more major criteria to make a definitive diagnosis of ECCL.10 The first neurosurgical problem our patient presented with was hydrocephalus, which was probably developing prior to his 318 Fig. 5. Intraoperative photographs showing cervicomedullary decompression in an infant with ECCL. A: Dura mater at the cervicomedullary junction has been opened, exposing the lipoma and dysplastic medulla, and the spinal cord. B: View looking superiorly showing the dorsally exophytic mass and the overlying cerebellum.

4 Surgical indications in encephalocraniocutaneous lipomatosis Fig. 6. A: Intraoperative photograph showing the cervicomedullary junction after debulking of the lipoma. B: Retraction of the left lateral aspect of the mass showing exiting nerve roots, indicating that the mass is intramedullary. Only clearly lipomatous tissue was debulked. The SSEPs were unchanged throughout surgery, and the patient was neurologically intact postoperatively. patient was at the age of 17 years, and that individual remained untreated for what is described as severe scoliosis. The patient was severely retarded and wheelchair bound due to spastic quadriplegia. Scoliosis is not mentioned as a common finding in any of the reviews on ECCL, and most case reports fail to mention its presence or absence, making its true incidence in the syndrome unknown.10,14,15 However, given the high incidence of intraspinal malformations in infants with scoliosis, the occurrence of scoliosis in this syndrome is not surprising.13 Spinal cord lipomas have been found in 12 of the 14 cases of ECCL in which spinal images were available, making it a major diagnostic criterion of the syndrome.10 Both intra- and extramedulary lipomas have been described, most of which are asymptomatic.1,2,5,7,9,11,15,16,20 In 2 cases of ECCL with cervical spine lipomas, surgery was done to address compression in the cervical cord; decompressive laminectomies were successfully performed in both cases.1,15 However, those cases do not indicate the presence of any neurological symptoms attributable to spinal cord compression. Neither operation resulted in neurological deficit. In another case, a level T10 11 spinal lipoma was resected in a 9-year-old patient with ECCL and a 2-week history of back pain without neurological deficit.5,7 Postoperatively the patient was paraplegic. In our case, serial imaging studies separated by 9 months demonstrated that the extensive spinal lipomas were stable, but they were severely compressing a dysplastic spinal cord at the cervicomedullary junction (Fig. 3A D). Our indication for surgery was 2-fold. First, the development of sleep apnea, which is also frequently seen in cases of CM as a result of compression at the cervicomedullary junction, was observed.8 In addition, there was concern about the progression of the patient s scoliosis. Chiari malformations, both with and without hydromyelia, have been proposed as a cause of neurogenic scoliois.17 It is theorized that spinal cord dysfunction, either from the compression created at the cervicomedullary junction by the CM, and/or the dysfunction caused by the syrinx, creates an imbalance in the paraspinal musculature that results in scoliosis.17 Studies have shown that decompression of the CM can halt, and sometimes improve, scoliosis in children, particularly those younger than 10 years of age.3,17,19,21 In addition, decompression of the cervicomedullary junction decreases the incidence of neurological complications during subsequent corrective surgery for scoliosis.21 We believed that our patient had neurogenic scoliosis resulting from his cervicomedullary compression, due to a mechanism similar to that imposed by CM as well as by his tethered cord. Surgery was performed to provide a chance at improving his scoliosis as well as reducing the risks associated with future corrective surgeries. Given the benign nature of the lipomas in this syndrome, it would be advisable to observe these tumors if there are no neurological deficits or significant deformity, because these surgeries are not without the risk of neurological injury.5,7 Additionally, tumors may be more difficult to resect than their preoperative imaging suggests. In our case, preoperative MR imaging suggested that the lipoma extending from the medulla through the foramen magnum was extramedullary (Fig. 3A D). However, intraoperative observation revealed that the tumor was intramedullary, and the brainstem and spinal cord were severely dysplastic (Figs. 5 and 6). Following his recovery from cervicomedullary decompression and treatment of his recurrent hydrocephalus, we noted that our patient continued to have progressive scoliosis. We therefore decided to address the patient s tethered cord, and proceeded with the resection of his lipomyelomeningocele and performed a tethered cord release. Tethered cord as a direct cause of scoliosis was first demonstrated by McLone et al.12 in As with CMs, tethered spinal cords have a high association with congenital scoliosis, and untethering the cord is believed to reduce the risks of corrective surgery for scoliosis, and to offer a chance for stabilization or improvement of the deformity.4,17 Surprisingly, tethered cord has not been previously described in ECCL. Currently, our patient has normal intellectual development as well as normal upper- and lower-extremity motor control. His apnea resolved following decompressive surgery. However, his scoliosis is affecting his ability to walk and hindering motor development. With a Cobb angle of 60 that has progressed from 37 over the course of the last year, it is likely to continue and ultimately impede pulmonary function. We are currently planning for corrective surgery. Although our initial MR imaging studies of the brain obtained with and without contrast demonstrated no vascular abnormalities, progressive aneurysmal dilation of cerebral vessels has been described in this syndrome, with 1 patient developing subarachnoid hemorrhage.6 Cerebrovascular dysplasia and leptomeningeal angiomas have been described in 9 patients with ECCL, and vascular anomalies are believed to be responsible for the development of cerebral atrophy, thin white matter, porencephaly, and calcifications that are often seen in the syndrome.14,15 Our patient has not demonstrated any of these characteris319

5 R. E. Ayer and A. Zouros tics, but the prevalence of developing these abnormalities over the lifespan of a patient with ECCL is unknown. It is something that will have to be considered should there be any changes in neurological status, and may warrant performance of routine surveillance imaging. Conclusions This case report and review of relevant literature is the first paper to describe a neurosurgeon s experience with a patient presenting with ECCL. Based on our experience and review of the literature, we believe that the serial observation of patients with ventricular abnormalities is recommended, given that approximately one-third of these patients will develop hydrocephalus. Additionally, baseline neuroimaging is part of the initial assessment, but routine serial imaging of lipomas is probably not warranted, given the benign nature of the masses and their documented lack of growth. Currently, the incidence of symptomatic versus asymptomatic CNS lipomas is unknown. The monitoring of these patients for signs of cervicomedullary compression or myelopathy is probably required for those with imaging findings that are a cause for concern. Changes in the neurological examination should prompt a reevaluation of the patient, and only symptomatic lipomas should be considered for operation. Although the incidence of scoliosis and tethered cord syndrome in patients with ECCL is unknown, it is probably significant. Patients monitored for the development of these conditions, and their families, should be educated on the signs and symptoms of their development. The least-documented and most uncertain CNS condition associated with ECCL is the incidence of aneurysm formation. Any identified lesions should be followed and treated as determined by the patient s caregiver. However, the lifetime incidence of aneurysm formation is unknown. Given that there are limited clinical reports suggesting that patients may be at an increased risk of developing aneurysms over the course of their life, serial lifetime imaging of these patients may be warranted. However, the limited information provided by the literature does not supply enough evidence to support any specific recommendations. Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: both authors. Acquisition of data: both authors. Analysis and interpretation of data: Ayer. Drafting the article: Ayer. Critically revising the article: both authors. Reviewed submitted version of manuscript: both authors. Approved the final version of the manuscript on behalf of both authors: Ayer. Administrative/technical/material support: Ayer. Study supervision: Ayer. References 1. 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Eur Spine J 9: , Torrelo A, Boente MdelC, Nieto O, Asial R, Colmenero I, Winik B, et al: Nevus psiloliparus and aplasia cutis: a further possible example of didymosis. Pediatr Dermatol 22: , Tubbs RS, Doyle S, Conklin M, Oakes WJ: Scoliosis in a child with Chiari I malformation and the absence of syringomyelia: case report and a review of the literature. Childs Nerv Syst 22: , 2006 Manuscript submitted April 5, Accepted June 7, Portions of this work have been accepted for presentation in poster form at the 39th Annual Meeting of the International Society for Pediatric Neurosurgery in Goa, India, to be held October 16 20, Address correspondence to: Robert E. Ayer, M.D., Department of Neurosurgery, Loma Linda University Medical Center, Anderson Street, Room 2562-B, Loma Linda, California rayer77@yahoo.com. 320