Sturge-Weber syndrome, or encephalotrigeminal angiomatosis, is a phakomatosis characterised by facial port wine stains and pial angiomas.
It is part of a wide spectrum of possible phenotypes included in the craniofacial arteriovenous metameric syndrome (CAMS).
Sturge-Weber syndrome is a rare syndrome, with an incidence estimated at 1 case in 20,000-50,000 persons 11.
The diagnosis is usually obvious on account of a congenital facial cutaneous haemangioma (also known as port wine stain or facial naevus flammeus). This feature is almost always present and usually involves the ophthalmic division (V1) of the trigeminal nerve 3; if this territory is not involved, Sturge-Weber syndrome is unlikely 10. In ~5%, it has intracranial involvement present without associated cutaneous naevus 1,2. In the majority of cases (~70%) the naevus is unilateral and ipsilateral to the intracranial abnormality.
The most common clinical manifestation is with childhood seizures, present in 71-89% of cases 2, which is often refractory to medical therapy 1. These usually begin in the first few years of life and are often associated with developmental delay and hemispheric symptoms including hemiplegia/hemiparesis and hemianopsia.
Approximately a third of patients have choroidal or scleral angiomatous involvement, which may be complicated with retinal detachment, buphthalmos or glaucoma 1.
Unlike most phakomatoses, Sturge-Weber syndrome is sporadic with no definite identifiable hereditary component 4,10. An associated gene mutation has been identified with a nucleotide transition in GNAQ on chromosome 9q21 12.
The leptomeningeal haemangioma results in a vascular steal affecting the subjacent cortex and white matter producing localised ischaemia. In about 80% of the cases, there is unihemispheric involvement.
According to Roach et al. 23 Sturge-Weber syndrome can be classified according to the presence/absence of facial and leptomeningeal angiomas:
- type I: represents classic syndrome, with both facial and leptomeningeal angiomas; may have glaucoma
- type II: facial angioma without evidence of intracranial disease; may have glaucoma
- type III: isolated leptomeningeal angioma; usually no glaucoma
Skull x-rays were historically useful and capable of identifying the gyriform calcification of the subcortical white matter although they no longer play a significant role in the diagnosis or management of this condition. The finding usually becomes evident between 2 and 7 years of age 2.
- detects subcortical calcification at an earlier age than plain film and can also demonstrate associated parenchymal volume loss
- tram-track sign of cortical and subcortical calcification 13,14
- calvarial and regional sinus enlargement may be evident
- ipsilateral choroid plexus may be enlarged
- in severe cases, a Dyke-Davidoff-Masson appearance may be seen
- orbital choroidal haemangiomas may be present
- asymmetric cavernous sinus enlargement 22
- T1: signal of affected region largely normal, with anatomic volume loss evident at older age
T1 C+ (Gd)
- prominent leptomeningeal enhancement in affected area (due to congested internal cerebral veins, a manifestation of the so-called 'pial angiomatosis', resulting in venous congestive ischaemia with infarction and obliteration of cerebral parenchyma)
- much later in life, the angioma may 'burn out' losing enhancement1
- enlarged ipsilateral choroid plexus
- dilatation of transparenchymal veins that communicates between the superficial and deep venous systems
- low signal in white matter subjacent to angioma representing
- postulated accelerated myelination in neonate 1
- calcification later in life
- abnormal deep venous drainage seen as flow voids
- low signal in white matter subjacent to angioma representing
- GE/SWI/EPI: sensitive to calcification, seen as regions of signal drop out
- MR spectroscopy: decreased NAA 6
In most cases (82%), angiography is abnormal and demonstrates absent superficial cortical veins with abnormal and enlarged deep venous drainage 2.
Treatment and prognosis
Treatment revolves primarily around seizure control, with surgical resection only indicated rarely in refractory cases. Ophthalmological examination is also essential to identify and treat ocular involvement 3.
History and etymology
Sturge-Weber syndrome was first described by Sturge in 1879 who argued that there was a direct link between the intracranial haemangioma and the clinical presentation, although this was not accepted by his medical peers. It took until 1901 for Kalischer to provide the pathological confirmation that the pial angioma caused the neurological sequelae 20.
In 1912 Weber and Volland described the intracranial calcification. Radiographic identification of cerebral calcification was first described by Dimitri in 1922 2,18,20. In fact, Schirmer described a male patient with a facial naevus and buphthalmos in 1860, however, he did not recognise that it was a neurological condition 20.
- William Allen Sturge: English physician (1850-1919) 16,18,20
Frederick Parkes Weber: English dermatologist (1863-1962) 17,19
- five different diseases are named after Dr Weber! 19
- Vincente Dimitri: Austrian dermatologist (1885-1955) 18
- Rudolf Schirmer (1831–96): German ophthalmologist 20
- Siegfried Kalischer (1862-1954) German neuropathologist 20,21
- 1. Reiser MF. Magnetic Resonance Tomography. Springer Verlag. (2007) ISBN:354029354X. Read it at Google Books - Find it at Amazon
- 2. Wyllie E, Gupta A, Lachhwani DK. The treatment of epilepsy, principles & practice. Lippincott Williams & Wilkins. (2006) ISBN:0781749956. Read it at Google Books - Find it at Amazon
- 3. Hay WW, Hayward AR, Levin MJ et-al. Current pediatric diagnosis & treatment. McGraw-Hill/Appleton & Lange. (2002) ISBN:0071383840. Read it at Google Books - Find it at Amazon
- 4. Menkes JH, Sarnat HB, Maria BL. Child neurology. Lippincott Williams & Wilkins. (2006) ISBN:0781751047. Read it at Google Books - Find it at Amazon
- 5. Burgener FA, Kormano M. Differential diagnosis in computed tomography. Thieme. (1996) ISBN:0865775478. Read it at Google Books - Find it at Amazon
- 6. Moore GJ, Slovis TL, Chugani HT. Proton magnetic resonance spectroscopy in children with Sturge-Weber syndrome. J. Child Neurol. 1998;13 (7): 332-5. doi:10.1177/088307389801300705 - Pubmed citation
- 7. Pascual-castroviejo I, Viaño J, Moreno F et-al. Hemangiomas of the head, neck, and chest with associated vascular and brain anomalies: a complex neurocutaneous syndrome. AJNR Am J Neuroradiol. 1996;17 (3): 461-71. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 8. Wong-you-cheong JJ, Woodward PJ, Manning MA et-al. From the Archives of the AFIP: neoplasms of the urinary bladder: radiologic-pathologic correlation. Radiographics. 26 (2): 553-80. doi:10.1148/rg.262055172 - Pubmed citation
- 9. Pascual-castroviejo I, Viaño J, Moreno F et-al. Hemangiomas of the head, neck, and chest with associated vascular and brain anomalies: a complex neurocutaneous syndrome. AJNR Am J Neuroradiol. 1996;17 (3): 461-71. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 10. Griffiths PD. Sturge-Weber syndrome revisited: the role of neuroradiology. Neuropediatrics. 1996;27 (06): 284-94. doi:10.1055/s-2007-973796 - Pubmed citation
- 11. Comi AM. Update on Sturge-Weber syndrome: diagnosis, treatment, quantitative measures, and controversies. Lymphat Res Biol. 2007;5 (4): 257-64. doi:10.1089/lrb.2007.1016 - Pubmed citation
- 12. Shirley MD, Tang H, Gallione CJ et-al. Sturge-Weber syndrome and port-wine stains caused by somatic mutation in GNAQ. N. Engl. J. Med. 2013;368 (21): 1971-9. doi:10.1056/NEJMoa1213507 - Free text at pubmed - Pubmed citation
- 13. David M. Yousem, Robert I. Grossman. Neuroradiology. The requisites. Mosby. (2010) ISBN:0323045219. Read it at Google Books - Find it at Amazon
- 14. Akpinar E. The tram-track sign: cortical calcifications. Radiology. 2004;231 (2): 515-6. doi:10.1148/radiol.2312020545 - Pubmed citation
- 15. Gobbi G. Coeliac disease, epilepsy and cerebral calcifications. Brain & development. 27 (3): 189-200. doi:10.1016/j.braindev.2004.05.003 - Pubmed
- 16. Barlow T. WILLIAM ALLEN STURGE, M.V.O., M.D.Lond., F.R.C.P. BMJ. 1919;1(3041): 468–469. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2340779/pdf/brmedj06991-0038b.pdf
- 17. CURTH HO. Frederick Parkes WEBER (1863-1962). (1963) Archives of dermatology. 87: 649-51. Pubmed
- 18. Wolfgang F. Dahnert. Radiology Review Manual. (2017) ISBN: 9781496360717
- 19. DiPoce J, Jimenez G, Weintraub J. Historical perspective: eponyms of vascular radiology. (2014) Radiographics : a review publication of the Radiological Society of North America, Inc. 34 (4): 1120-40. doi:10.1148/rg.344130125 - Pubmed
- 20. Pearce JM. Sturge-Weber syndrome (encephalotrigeminal or leptomeningeal angiomatosis). (2006) Journal of neurology, neurosurgery, and psychiatry. 77 (11): 1291-2. doi:10.1136/jnnp.2006.096578 - Pubmed
- 21. Lazaros C. Triarhou. The Berlin Ophthalmologist Bernhard Pollack. (2019) ISBN: 9781257155132
- 22. Pasquini L, Tortora D, Manunza F, Rossi Espagnet MC, Figà-Talamanca L, Morana G, Occella C, Rossi A, Severino M. Asymmetric cavernous sinus enlargement: a novel finding in Sturge-Weber syndrome. (2019) Neuroradiology. 61 (5): 595-602. doi:10.1007/s00234-019-02182-4 - Pubmed
- 23. Roach ES. Neurocutaneous syndromes. Pediatr Clin North Am. 1992;39(4):591–620.
Related Radiopaedia articles
- neurofibromatosis type 1 (NF1) (von Recklinghausen disease)
- neurofibromatosis type 2 (NF2) (mnemonic)
- tuberous sclerosis (Bourneville-Pringle disease)
- ataxia telangiectasia
- Sturge-Weber syndrome (encephalotrigeminal angiomatosis)
- von Hippel-Lindau disease (retinocerebellar angiomatosis | mnemonic)
- incontinentia pigmenti (Bloch-Sulzberger syndrome)
- basal cell naevus syndrome (Gorlin-Goltz syndrome)
- Wyburn-Mason syndrome (Bonnet-Dechaume-Blanc syndrome)
- encephalocraniocutaneous lipomatosis
- hypomelanosis of Ito
- Nijmegen breakage syndrome
- epidermal naevus syndrome
- neurocutaneous melanosis
- progressive facial hemiatrophy (Parry-Romberg syndrome)
- PHACE syndrome
- Cowden disease/COLD syndrome
- Gomez-Lopez-Hernandez syndrome