title: Cerebral small vessel disease in pseudoxanthoma elasticum: three cases.
abstract: BACKGROUND
  Cerebral small vessel disease is rarely described in association with pseudoxanthoma elasticum (PXE), a hereditary connective tissue disorder with skin, eye and vascular manifestations. This autosomally inherited elastic tissue disease has been attributed to mutations in the ABCC6 gene located on chromosome 16p13.1. Different stroke mechanisms are suggested in PXE patients, arterial hypertension and accelerated atherosclerosis being the leading ones.
  
  
  METHODS
  Case 1: A 49-year-old man with history of mild hypertension presented with recurrent transient ischemic attacks. At the age of 42, evaluation for progressive visual loss and skin changes led to diagnosis of PXE. Brain magnetic resonance imaging (MRI) disclosed multiple lacunar infarctions and confluent periventricular white matter lesions (WML). Case 2: A 71-year-old woman with history of mild hypertension suffered right-sided stroke. Diagnosis of PXE was made at the age of 48 due to severe visual loss and skin changes. Brain MRI revealed multiple lacunar infarctions and subcortical ischemic leukoencephalopathy. Case 3: A 47-year-old woman with prominent skin changes and bilateral amblyopia developed right-sided weakness. Skin biopsy confirmed PXE. Several lacunar infarcts in deep white matter and pons were revealed on MRI.
  
  
  CONCLUSIONS
  We present three patients with clinical and histopathological features of PXE who presented with multiple lacunar strokes, two with extensive confluent WML. These cases illustrate that PXE is a rare but significant risk factor for small vessel disease and stroke in patients of all age groups. Occlusive small vessel disease and subsequent lacunar infarcts and WML represent important PXE manifestations.
authors.affiliation: Institute of Neurology, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Aleksandra M
authors.initials: AM
authors.lastname: Pavlovic
authors.forename: Jasna
authors.initials: J
authors.lastname: Zidverc-Trajkovic
authors.forename: Marija M
authors.initials: MM
authors.lastname: Milovic
authors.forename: Dragan M
authors.initials: DM
authors.lastname: Pavlovic
authors.forename: Zagorka
authors.initials: Z
authors.lastname: Jovanovic
authors.forename: Milija
authors.initials: M
authors.lastname: Mijajlovic
authors.forename: Mirjana
authors.initials: M
authors.lastname: Petrovic
authors.forename: Vladimir S
authors.initials: VS
authors.lastname: Kostic
authors.forename: Nada
authors.initials: N
authors.lastname: Sternic
mesh_terms: D000368:Aged; D001921:Brain / Q000098:blood supply* / Q000000981:diagnostic imaging / Q000473:pathology; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011561:Pseudoxanthoma Elasticum / Q000150:complications*; D011859:Radiography; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology* / Q000473:pathology