Association of Rapidly Progressive Moyamoya Syndrome With Bevacizumab Treatment for Glioblastoma in a Child With Neurofibromatosis Type 1

Department of Neurology, Children's Hospital Boston, Boston, MA 02446, USA.
Journal of child neurology (Impact Factor: 1.72). 02/2011; 26(2):228-30. DOI: 10.1177/0883073810379639
Source: PubMed


Neurofibromatosis type 1 is a common multisystemic disorder that can result in tumors of the central and peripheral nervous system. Individuals with neurofibromatosis type 1 are also at increased risk to develop moyamoya syndrome, which is a cerebrovascular condition that predisposes affected individuals to develop strokes as a result of progressive narrowing of the intracranial internal carotid arteries and failure of adequate blood supply through collateral vessels. We report a case of a young boy with neurofibromatosis type 1 with glioblastoma who developed rapidly progressive moyamoya vasculopathy after treatment with the angiogenesis inhibitor bevacizumab.

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    ABSTRACT: OPINION STATEMENT: Neurofibromatosis type 1 (NF1) and type 2 (NF2) are genetically and medically distinct neurocutaneous disorders that are both associated with tumors affecting the central and peripheral nervous systems. NF1 has a frequency of 1 in 3,000, compared with 1 in 30,000 for NF2. Careful surveillance is important for both conditions, to allow early identification and treatment of complications. The most common and important problems in NF1 are cognitive impairment, optic pathway gliomas, plexiform neurofibromas, and orthopaedic issues. Early intervention and tailored educational programs are indicated for learning difficulties. Attention deficit hyperactivity disorder may be amenable to treatment with stimulant medication. A clinical trial is under way to evaluate lovastatin in the treatment of cognitive problems in children with NF1. Chemotherapy with vincristine and carboplatin is the current standard of care for symptomatic optic pathway gliomas, but new agents with improved efficacy are needed. Plexiform neurofibromas may be treated with surgery, but often recur. To date, no medical therapy has proven effective in limiting plexiform neurofibroma growth, but several candidate medications are under consideration in clinical trials. Malignant peripheral nerve sheath tumors may arise in preexisting plexiform neurofibromas, so changes in tumor growth or an increase in pain or focal neurologic deficit should prompt further investigation and early treatment with wide surgical resection, with or without adjuvant chemotherapy or radiotherapy. Specialist surgical intervention may be needed for scoliosis and tibial pseudoarthrosis. In NF2, surgical treatment remains a cornerstone of management for symptomatic progressive vestibular schwannomas, meningiomas, and spinal tumors. Vascular endothelial growth factor inhibitors show promise for the treatment of vestibular schwannomas, with the aim of delaying surgery, and other targeted molecular therapies are becoming available as investigational options. Hearing aids and brainstem and cochlear implants have a role in optimizing functional hearing in some patients. Specialist ophthalmology input should be arranged to monitor for ophthalmologic complications. A coordinated effort is needed to enroll NF1 and NF2 patients in international multicenter clinical trials of promising new pharmacologic agents. Genetic testing is useful for prenatal diagnosis and may be important in understanding individual responses to novel medical therapies in the future. Effective transition to adult services is important, considering the likelihood of further complications in the adult years.
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    ABSTRACT: Objective: The objective of the study was to determine whether vascular and other complications are more common in pregnant women with neurofibromatosis type 1 (NF1). Study design: We performed a population-based retrospective cohort study using the US Nationwide Inpatient Sample, 1988-2009, defining a cohort of pregnancy-related hospitalizations with an associated diagnosis of NF1 and comparing it with the control group not associated with NF1. Multivariable logistic regression was used to adjust for suspected confounders. Results: Among 19 million pregnancy-related admissions between 1988 and 2009, we identified 1553 associated with NF1 (prevalence 0.008%). A diagnosis of NF1 in delivering mothers was associated with gestational hypertension (adjusted odds ratio [AOR], 1.6, 95% confidence interval [CI], 1.2-2.0), preeclampsia (AOR, 2.8, 95% CI, 2.3-3.4), intrauterine growth restriction (AOR, 4.6, 95% CI, 3.7-5.6), cerebrovascular disease (OR, 8.1, 95% CI, 2.6-25.4), preterm labor (AOR, 1.6, 95% CI, 1.4-1.9), and cesarean delivery (AOR, 2.0, 95% CI, 1.8-2.3). Women with NF1 were not significantly more likely to have deep venous thrombosis/pulmonary embolism, acute cardiac events, or stillbirth or to die during their hospitalizations compared with the general obstetric population. Conclusion: NF1 was associated with increased maternal morbidity in pregnancy (including hypertensive and cerebrovascular complications) but not increased maternal mortality. Obstetricians should be aware of the potential for increased antenatal and peripartum complications among women with NF1.
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