Intracranial Arterial Tortuosity in Marfan Syndrome and Loeys-Dietz Syndrome: Tortuosity Index Evaluation Is Useful in the Differential Diagnosis

AJNR Am J Neuroradiol. 2020 Oct;41(10):1916-1922. doi: 10.3174/ajnr.A6732. Epub 2020 Aug 20.


Background and purpose: The association of arterial tortuosity and connective tissue diseases is widely reported in the literature, but only a few studies were based on a quantitative evaluation of this arterial phenotype, and none of the latter examined the intracranial vasculature. The aim of this study was to evaluate the degree of intracranial arterial tortuosity in patients with Marfan syndrome and those with Loeys-Dietz syndrome, and to assess its usefulness in the differential diagnosis.

Materials and methods: We performed a retrospective analysis of 68 patients with genetically confirmed Marfan syndrome (n = 36) or Loeys-Dietz syndrome (n = 32), who underwent at least 1 MRA of the brain at our institution. Fifty-two controls were randomly selected among patients who presented with headache and without any known comorbidity. Tortuosity indexes of 4 intracranial arterial segments were measured on a 3D volume-rendered angiogram by using the following formula: [Formula: see text].

Results: Both Marfan syndrome and Loeys-Dietz syndrome showed a significantly higher tortuosity index compared with controls in all examined vessels. The tortuosity index of the vertebrobasilar system showed an excellent interrater reliability (intraclass correlation coefficient, 0.99) and was the strongest independent predictor of Loeys-Dietz syndrome in patients with connective tissue disease (P = .002), with a 97% specificity for this pathology when its value was > 60.

Conclusions: The tortuosity index of intracranial arteries is an easily calculated and highly reproducible measure, which shows a high specificity for Marfan syndrome and Loeys-Dietz syndrome and may be useful in differentiating these 2 entities.

MeSH terms

  • Adult
  • Arteries / diagnostic imaging
  • Arteries / pathology*
  • Brain / diagnostic imaging
  • Brain / pathology*
  • Cerebral Angiography / methods
  • Diagnosis, Differential
  • Female
  • Humans
  • Image Interpretation, Computer-Assisted / methods
  • Loeys-Dietz Syndrome / diagnostic imaging*
  • Loeys-Dietz Syndrome / pathology*
  • Magnetic Resonance Angiography / methods
  • Male
  • Marfan Syndrome / diagnostic imaging*
  • Marfan Syndrome / pathology*
  • Middle Aged
  • Reproducibility of Results
  • Retrospective Studies
  • Young Adult