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Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
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2
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Hung SC, Guimaraes C. Imaging of Childhood Cerebral Vasculitis. Neuroimaging Clin N Am 2024; 34:149-166. [PMID: 37951700 DOI: 10.1016/j.nic.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Childhood cerebral vasculitis is a condition that affects the blood vessels in the brain of children and is rare but life-threatening. Imaging plays a crucial role in the diagnosis and monitoring of the disease. This article describes the classification, diagnostic algorithm, and various imaging modalities used in the evaluation of childhood cerebral vasculitis and the imaging findings associated with primary and secondary vasculitis. Understanding the imaging features of this condition can assist in early diagnosis, effective treatment, and improve outcomes.
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Affiliation(s)
- Sheng-Che Hung
- Department of Radiology, University of North Carolina, 2000 Old Clinic, CB# 7510, Chapel Hill, NC 27599, USA.
| | - Carolina Guimaraes
- Department of Radiology, University of North Carolina, 2000 Old Clinic, CB# 7510, Chapel Hill, NC 27599, USA
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3
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Pagnini I, Mortilla M, Gentile D, Maccora I, Abu-Rumeileh S, Limbucci N, Simonini G, Rosati A. Mycophenolate mofetil as induction and long-term maintenance therapy in childhood cerebral vasculitis: a case series. Rheumatology (Oxford) 2023; 62:e345-e348. [PMID: 37233120 DOI: 10.1093/rheumatology/kead237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/20/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Ilaria Pagnini
- NEUROFARBA Department, Rheumatology Unit, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
| | | | - Diletta Gentile
- Neuroscience Department, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
| | - Ilaria Maccora
- NEUROFARBA Department, Rheumatology Unit, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
| | - Sarah Abu-Rumeileh
- NEUROFARBA Department, Rheumatology Unit, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, A.O.U. Careggi, Florence, Italy
| | - Gabriele Simonini
- NEUROFARBA Department, Rheumatology Unit, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
| | - Anna Rosati
- Neuroscience Department, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
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4
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Younger DS. Primary central nervous system vasculitis and headache: Ten themes. Curr Opin Neurol 2023; 36:647-658. [PMID: 37865827 PMCID: PMC10624409 DOI: 10.1097/wco.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW The primary central nervous system (CNS) vasculitides refers to clinicopathologic disorders that share the histopathology of inflammation of cerebral or spinal blood vessels. Unrecognized and therefore untreated, vasculitis of the CNS results in irreversible injury and disability making these disorders of paramount importance to clinicians. RECENT FINDINGS Headache is an important clue to vasculitic involvement of CNS vessels. CNS vasculitis can be primary, in which only intracranial or spinal vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. The suspicion of vasculitis based on the history, clinical examination, and laboratory studies warrants prompt evaluation and treatment to prevent cerebral ischemia or infarction. SUMMARY Primary CNS vasculitides can be diagnosed with certainty after intensive evaluation that includes tissue confirmation whenever possible. As in its systemic counterparts, clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, tempered by anticipated medication adverse effects.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York; Department of Neurology, White Plains Hospital, White Plains, New York, USA
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5
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Damer A, Chaudry E, Eftekhari D, Benseler SM, Safi F, Aviv RI, Tyrrell PN. Neuroimaging Scoring Tools to Differentiate Inflammatory Central Nervous System Small-Vessel Vasculitis: A Need for Artificial Intelligence/Machine Learning?-A Scoping Review. Tomography 2023; 9:1811-1828. [PMID: 37888736 PMCID: PMC10610796 DOI: 10.3390/tomography9050144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/26/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023] Open
Abstract
Neuroimaging has a key role in identifying small-vessel vasculitis from common diseases it mimics, such as multiple sclerosis. Oftentimes, a multitude of these conditions present similarly, and thus diagnosis is difficult. To date, there is no standardized method to differentiate between these diseases. This review identifies and presents existing scoring tools that could serve as a starting point for integrating artificial intelligence/machine learning (AI/ML) into the clinical decision-making process for these rare diseases. A scoping literature review of EMBASE and MEDLINE included 114 articles to evaluate what criteria exist to diagnose small-vessel vasculitis and common mimics. This paper presents the existing criteria of small-vessel vasculitis conditions and mimics them to guide the future integration of AI/ML algorithms to aid in diagnosing these conditions, which present similarly and non-specifically.
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Affiliation(s)
- Alameen Damer
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Emaan Chaudry
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Daniel Eftekhari
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Susanne M. Benseler
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Frozan Safi
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Richard I. Aviv
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Pascal N. Tyrrell
- Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
- Institute of Medical Science, Department of Statistical Sciences, University of Toronto, Toronto, ON M5G 1X6, Canada
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6
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Gupta N, Hiremath SB, Aviv RI, Wilson N. Childhood Cerebral Vasculitis : A Multidisciplinary Approach. Clin Neuroradiol 2023; 33:5-20. [PMID: 35750917 PMCID: PMC9244086 DOI: 10.1007/s00062-022-01185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022]
Abstract
Cerebral vasculitis is increasingly recognized as a common cause of pediatric arterial stroke. It can present with focal neurological deficits, psychiatric manifestations, seizures, and encephalopathy. The etiopathogenesis of childhood cerebral vasculitis (CCV) is multifactorial, making an inclusive classification challenging. In this review, we describe the common and uncommon CCV with a comprehensive discussion of etiopathogenesis, the role of various imaging modalities, and advanced techniques in diagnosing CCV. We also highlight the implications of relevant clinical, laboratory, and genetic findings to reach the final diagnosis. Based on the clinicoradiological findings, a stepwise diagnostic approach is proposed to facilitate CCV diagnosis and rule out potential mimics. Identification of key clinical manifestations, pertinent blood and cerebrospinal fluid results, and evaluation of central nervous system vessels for common and disease-specific findings will be emphasized. We discuss the role of magnetic resonance imaging, MR angiography, and vessel wall imaging as the imaging investigation of choice, and reservation of catheter angiography as a problem-solving tool. We emphasize the utility of brain and leptomeningeal biopsy for diagnosis and exclusion of imitators and masqueraders.
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Affiliation(s)
- Neetika Gupta
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
- Clinical Fellow—Pediatric Radiology, Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
| | - Shivaprakash B. Hiremath
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario Canada
| | - Richard I. Aviv
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
| | - Nagwa Wilson
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
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7
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Datyner E, Adeseye V, Porter K, Dryden I, Sarma A, Vu N, Patrick AE, Paueksakon P. Small vessel childhood primary angiitis of the central nervous system with positive anti-glial fibrillary acidic protein antibodies: a case report and review of literature. BMC Neurol 2023; 23:57. [PMID: 36737749 PMCID: PMC9895965 DOI: 10.1186/s12883-023-03093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Small vessel childhood primary angiitis of the central nervous system (SV-cPACNS) is a rare disease characterized by inflammation within small vessels such as arterioles or capillaries. CASE PRESENTATION We report a case of SV-cPACNS in an 8-year-old boy confirmed by brain biopsy. This patient was also incidentally found to have anti-glial fibrillary acidic protein (GFAP) antibodies in the cerebrospinal fluid (CSF) but had no evidence of antibody-mediated disease on brain biopsy. A literature review highlighted the rarity of SV-cPACNS and found no prior reports of CSF GFAP-associated SV-cPACNS in the pediatric age group. CONCLUSION We present the first case of biopsy proven SV-cPACNS vasculitis associated with an incidental finding of CSF GFAP antibodies. The GFAP antibodies are likely a clinically insignificant bystander in this case and possibly in other diseases with CNS inflammation. Further research is needed to determine the clinical significance of newer CSF autoantibodies such as anti-GFAP before they are used for medical decision-making in pediatrics.
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Affiliation(s)
- E Datyner
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - V Adeseye
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - K Porter
- grid.152326.10000 0001 2264 7217Vanderbilt University, Nashville, TN USA
| | - I Dryden
- grid.412807.80000 0004 1936 9916Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21St Avenue South, Nashville, TN MCN C2318B37232-2561 USA
| | - A Sarma
- grid.412807.80000 0004 1936 9916Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN USA
| | - N Vu
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - AE Patrick
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - P Paueksakon
- grid.412807.80000 0004 1936 9916Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21St Avenue South, Nashville, TN MCN C2318B37232-2561 USA
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8
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Gilani A, Kleinschmidt-DeMasters BK. Childhood Small-Vessel Primary Angiitis of the Central Nervous System: Overlap With MOG-Associated Disease. Pediatr Dev Pathol 2023; 26:18-29. [PMID: 36377607 DOI: 10.1177/10935266221121445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Childhood (c) primary angiitis of the central nervous system (PACNS) is a rare condition that most often affects small vessels (SV), is nearly exclusively lymphocytic, and devoid of vessel necrosis. Diagnosis of cSV-PACNS is challenging. We noted possible histological overlap of cSV-PACNS with myelin oligodendrocyte glycoprotein disease (MOGAD) on biopsy, prompting a 10-year retrospective review of our experience. MATERIALS AND METHODS Database-search for brain biopsy cases, age <18 years, performed for an acquired neurological deficit with suspicion of vasculitis, with histological evidence of lymphocytic small-vessel inflammation. RESULTS We identified 7 patients; 2/7 were serum-positive for anti-MOG antibodies and 1/7 for anti-NMDA antibodies. The remaining 4/7 proved to be idiopathic lymphocytic vasculitis/cSV-PACNS. All 7 showed overlapping features of lymphocytes permeating parenchymal SV walls, vessel wall distortion without fibrinoid necrosis, and absence of microglial clusters or intravascular thrombi. Tissue infarction was confined to a single case of idiopathic lymphocytic vasculitis. Although demyelination was diligently sought, only subtle demyelination was identified in the 2 MOGAD cases and absent in the remainder. CONCLUSION There is considerable histological overlap between cSV-PACNS and at least some cases of MOGAD or anti-NMDA-encephalitis; at diagnosis, the differential should include cSV-PACNS but correct classification requires post-biopsy serological testing.
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Affiliation(s)
- Ahmed Gilani
- Children's Hospital Colorado, Aurora, CO, USA.,Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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9
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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10
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Younger DS. Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:305-346. [PMID: 37620077 DOI: 10.1016/b978-0-323-98817-9.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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11
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Moore C, Pollard R, Press CA, Hiller M, Maloney J, Barry M, Kammeyer R. A 14-year-old Girl with Right-Sided Weakness and Speech Difficulty. Neurohospitalist 2022; 12:408-412. [PMID: 35419134 PMCID: PMC8995604 DOI: 10.1177/19418744211073025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We herein report a case of Childhood Primary Central Nervous System (CNS) Angiitis. This case consisted of a 14-year-old girl who presented with right-sided weakness, aphasia, and a fever. A Magnetic Resonance Imaging of the brain showed multifocal areas of ischemia. Magnetic Resonance Angiography of the head and neck showed narrowing and irregularities of the left middle cerebral artery and right posterior cerebral artery. Cerebrospinal Fluid studies showed a lymphocytic pleocytosis and brain biopsy revealed leptomeningeal and perivascular inflammation. The epidemiology, presenting symptoms, work-up, pathophysiology, diagnostic criteria, and treatment of Childhood Primary CNS angiitis are discussed. This case serves as a reminder that when pediatric patients present with stroke-like symptoms inflammatory etiologies including Primary CNS Angiitis must be considered and treated appropriately in a time sensitive manner.
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Affiliation(s)
- Caitlin Moore
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rebecca Pollard
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew Hiller
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Maloney
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Barry
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Kammeyer
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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12
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Kang D, Kim SY, Chae JH, Kim KJ, Park SH, Lim BC. Angiography-negative childhood primary angiitis of the central nervous system diagnosed by open brain biopsy: a case report. ENCEPHALITIS 2022; 2:19-23. [PMID: 37469609 PMCID: PMC10295908 DOI: 10.47936/encephalitis.2021.00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 07/21/2023] Open
Abstract
Childhood primary angiitis of the central nervous system (PACNS) is rare and has been poorly defined, which makes it difficult to diagnose and treat. Herein, we report a case of childhood PACNS that was diagnosed by open brain biopsy. Clinical symptoms and radiologic findings improved after combination treatment with steroid and cyclophosphamide. In this case, a 16-year-old, previously healthy, adolescent male complained of headache, seizure, and right-side weakness with hypoesthesia. Brain magnetic resonance imaging (MRI) showed multifocal, high-signal intensity lesions on T2-weighted scans with patch contrast enhancement. The clinical symptoms improved after intravenous steroid pulse therapy (methylprednisolone, 1,000 mg/day for 3 consecutive days) and subsequent oral steroid maintenance. However, follow-up brain MRI showed aggravation of the previous lesions. Open brain biopsy of the left parietal lobe showed infiltration of lymphoplasma cells to the vessel walls with parenchymal necrosis, consistent with PACNS. The patient received four monthly intravenous cyclophosphamide (1,000 mg/dose at each cycle) treatments along with oral steroid maintenance. After treatment, he was symptom-free, and follow-up MRI revealed marked lesion improvements. This case suggests the important role of brain biopsy and aggressive immunosuppressive treatment in diagnosis and management of childhood PACNS.
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Affiliation(s)
- Dayun Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Joong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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13
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Taylor K, Muscal E, Van Mater H. The Role of Pediatric Rheumatologists in Autoimmune Brain Disease. Rheum Dis Clin North Am 2021; 48:343-369. [PMID: 34798957 DOI: 10.1016/j.rdc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The spectrum of autoimmune and inflammatory brain diseases continues to evolve with medical advances facilitating both the detection of inflammation of the central nervous system and the discovery of novel disease mechanisms. The clinical overlap of these disorders with primary rheumatic diseases and the efficacy of immunotherapy have led to strong partnerships between pediatric rheumatologists, neurologists, psychiatrists, and other providers in the care of children with these conditions. Early diagnosis and initiation of targeted therapy improve clinical outcomes, highlighting the importance of interdisciplinary collaborative care.
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Affiliation(s)
- Kathryn Taylor
- Pediatrics, Division of Neurology, Duke University, Durham, NC, USA.
| | - Eyal Muscal
- Division of Rheumatology and Co-appointment in Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Heather Van Mater
- Pediatrics, Division of Rheumatology, Duke University, Durham, NC, USA
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14
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de Boysson H, Pagnoux C. Vasculiti del sistema nervoso centrale. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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15
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Al-Mansour LS, AlRasheed AA, AlEnezi KR, AlAli HM. Elevated intracranial pressure requiring decompressive craniectomy in a child with progressive primary angiitis of the central nervous system: a case report. J Med Case Rep 2021; 15:418. [PMID: 34353355 PMCID: PMC8344202 DOI: 10.1186/s13256-021-03005-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Elevated intracranial pressure is a potentially catastrophic complication of neurologic injury in children. Successful management of elevated intracranial pressure requires prompt recognition and therapy directed at both reducing intracranial pressure and reversing its underlying cause. A rare condition that causes elevated intracranial pressure is childhood primary angiitis of the central nervous system, which is a rare inflammatory central nervous system disease that poses diagnostic and therapeutic challenges. To our knowledge, this is the first reported case of angiography-positive progressive childhood primary angiitis of the central nervous system requiring decompressive hemicraniectomy for refractory elevated intracranial pressure in children. Case presentation We report the case of a 5-year-old Saudi girl who presented to the pediatric emergency department with fever and new-onset status epilepticus. She had elevated inflammatory markers with radiological and histopathological evidence of angiography-positive progressive childhood primary angiitis of the central nervous system, complicated by elevated intracranial pressure. Despite medical management for both childhood primary angiitis of the central nervous system and elevated intracranial pressure, her neurological status continued to deteriorate and the elevated intracranial pressure became refractory. She developed right uncal, right subfalcine, and tonsillar herniation requiring decompressive hemicraniectomy with a favorable neurological outcome. Conclusion Decompressive craniectomy might be considered in cases of angiography-positive progressive childhood primary angiitis of the central nervous system with elevated intracranial pressure refractory to medication. A multidisciplinary approach for the decision of decompressive craniectomy is advised to ensure patient safety and avoid possible morbidities and mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s13256-021-03005-y.
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Affiliation(s)
- Lama S Al-Mansour
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman A AlRasheed
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khaled R AlEnezi
- Department of Medical Imaging, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hamza M AlAli
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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16
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Keenan P, Brunner J, Quan AS, Smitka M, Hahn G, Pain CE, Häfner R, Speth F, Gerstl L, Hedrich CM. Diagnosis and Treatment of Small Vessel Childhood Primary Angiitis of the Central Nervous System (sv-cPACNS): An International Survey. Front Pediatr 2021; 9:756612. [PMID: 34712632 PMCID: PMC8546335 DOI: 10.3389/fped.2021.756612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Childhood primary angiitis of the Central Nervous System (cPACNS) is a rare autoimmune and inflammatory disease. It can result in significant neuronal damage, neurodevelopmental delay and potentially death. Childhood PACNS is divided into subcategories: angiography-positive p-cPACNS that affects medium and large vessels, and angiography-negative small vessel sv-cPACNS. Due to its rarity, variable clinical representation, and the lack of a diagnostic criteria and therapeutic plans, diagnosis and treatment of cPACNS is challenging and approaches vary. This survey collected information on diagnostic and therapeutic approaches to sv-PACNS. It was shared with international clinician networks, including the German Society for Paediatric Rheumatology, the Paediatric Rheumatology European Society, the "Network Paediatric Stroke," and members of the American College of Rheumatology/CARRA Paediatric Rheumatology list server. This project has shown consensus in numerous diagnostic and therapeutic treatment approaches, highlighting key areas which will be utilised to develop statements in the use of expert consensus meetings to standardise diagnostic and therapeutic approaches in this rare inflammatory disease.
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Affiliation(s)
- Paul Keenan
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jürgen Brunner
- Pädiatrische Rheumatologie, Department Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Angela S Quan
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Martin Smitka
- Klinik und Poliklinik fur Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Hahn
- Institut und Poliklinik für Radiologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Clare E Pain
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
| | - Renate Häfner
- Deutsches Zentrum für Kinder- und Jugendrheumatologie, Garmisch-Partenkirchen, Germany
| | - Fabian Speth
- Zentrum für Geburtshilfe, Kinder- und Jugendmedizin, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Lucia Gerstl
- Division of Paediatric Neurology, Developmental Medicine and Social Paediatrics, Department of Paediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
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17
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Younger DS. Cerebral vasculitis associated with drug abuse. Curr Opin Rheumatol 2021; 33:24-33. [PMID: 33186242 DOI: 10.1097/bor.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review understand the epidemiology, background, neuropharmacology, and histopathology of literature verified cases, and likely etiopathogenic mechanisms. RECENT FINDINGS There are only a handful of histologically confirmed patients in the literature with cerebral vasculitis because of drug abuse. SUMMARY There is little justification for invasive laboratory investigation given the ready availability of highly accurate vascular neuroimaging techniques to dictate management, which usually rests upon avoidance of further exposure and minimizing the secondary neurotoxic effects of the abused substances and polypharmacy use.
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Affiliation(s)
- David S Younger
- City University of New York Medical School, New York, New York, USA
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18
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Nishida H, Kumada S, Komori T, Takai K, Mori H, Morino M, Suzuki H, Mashimo H, Inoue K, Arisaka A, Fukuda M, Nakata Y. IVIG in childhood primary angiitis of the central nervous system: A case report. Brain Dev 2020; 42:675-679. [PMID: 32622763 DOI: 10.1016/j.braindev.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 10/24/2022]
Abstract
Aggressive immunosuppressive therapies have been proposed to treat primary angiitis of the central nervous system (PACNS). Here, we report the first successfully stabilized case of childhood, small-vessel PACNS with intravenous immunoglobulin (IVIG) therapy. A 12-year-old boy was admitted to our hospital complaining of recurrent headaches and upper-left homonymous quadrantanopia, since the age of 11 years. Brain computed tomography scans revealed fine calcification in the right temporal and occipital lobes. Brain magnetic resonance imaging scans revealed white matter lesions, with gadolinium enhancement, which waxed, waned, and migrated for 1 year, without immunomodulatory therapies. A cerebrospinal fluid study showed pleocytosis (12 cells per µl). No clinical or serological findings suggested systemic inflammation or vasculitis. Brain angiography was unremarkable. Brain biopsy revealed thickened and hyalinized small vessels, with intramural infiltration of inflammatory cells, which confirmed the diagnosis of small-vessel PACNS. Because the patient developed surgical site infection following biopsy, the administration of monthly IVIG (2 g/kg) was prescribed, instead of immunosuppressive agents. After IVIG therapy, the patient remained stable, except for a single episode of mild radiological exacerbation at 16 months, which occurred when the IVIG interval was expanded. Oral prednisone was added and gradually tapered. At 50 months, his intellectual abilities and motor functions were normal, although he showed residual upper-left homonymous quadrantanopia and post-exercise headache. A temporary headache, associated with the immunoglobulin infusion, was resolved by slowing the infusion rate. PACNS should be treated aggressively to improve prognosis. However, when immunosuppressants are contraindicated, IVIG may be an alternative therapeutic option.
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Affiliation(s)
- Hiroya Nishida
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan.
| | - Satoko Kumada
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan
| | - Takashi Komori
- Department of Neuropathology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Japan
| | - Harushi Mori
- Department of Radiology, School of Medicine, Jichi Medical University, Japan
| | - Michiharu Morino
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Japan
| | - Hiromi Suzuki
- Department of Neurology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Hideaki Mashimo
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan
| | - Kenji Inoue
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan
| | - Atsuko Arisaka
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan
| | - Mitsumasa Fukuda
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan
| | - Yasuhiro Nakata
- Department of Neuroradiology, Tokyo Metropolitan Neurological Hospital, Japan
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19
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Robertson RL, Palasis S, Rivkin MJ, Pruthi S, Bartel TB, Desai NK, Kadom N, Kulkarni AV, Lam HFS, Maheshwari M, Milla SS, Mirsky DM, Myseros JS, Partap S, Radhakrishnan R, Soares BP, Trout AT, Udayasankar UK, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Cerebrovascular Disease-Child. J Am Coll Radiol 2020; 17:S36-S54. [PMID: 32370977 DOI: 10.1016/j.jacr.2020.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 10/24/2022]
Abstract
Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Susan Palasis
- Panel Chair, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael J Rivkin
- Boston Children's Hospital, Boston, Massachusetts; American Academy of Neurology
| | - Sumit Pruthi
- Panel Vice Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | - Nadja Kadom
- Emory University and Children's of Atlanta (Egleston), Atlanta, Georgia
| | - Abhaya V Kulkarni
- Hospital for Sick Children, Toronto, Ontario, Canada; Neurosurgery expert
| | - H F Samuel Lam
- Sutter Medical Center, Sacramento, California; American College of Emergency Physicians
| | | | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery expert
| | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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20
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Kefalopoulou ZM, Liossis SN, Sagona T, Veltsista D, Zampakis P, Kraniotis P, Solomou A, Ellul J, Chroni E. An ischemic stroke as the presenting manifestation of rapidly progressive primary angiitis of central nervous system in a 17-year-old boy. J Neuroimmunol 2020; 341:577190. [DOI: 10.1016/j.jneuroim.2020.577190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 10/25/2022]
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21
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de Graeff N, Groot N, Brogan P, Ozen S, Avcin T, Bader-Meunier B, Dolezalova P, Feldman BM, Kone-Paut I, Lahdenne P, Marks SD, McCann L, Pilkington C, Ravelli A, van Royen A, Uziel Y, Vastert B, Wulffraat N, Kamphuis S, Beresford MW. European consensus-based recommendations for the diagnosis and treatment of rare paediatric vasculitides - the SHARE initiative. Rheumatology (Oxford) 2020; 58:656-671. [PMID: 30535249 DOI: 10.1093/rheumatology/key322] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/04/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The European initiative Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) aimed to optimize care for children with rheumatic diseases. Systemic vasculitides are very rare in children. Consequently, despite recent advances, paediatric-specific information is sparse. The lack of evidence-based recommendations is an important, unmet need. This study aimed to provide recommendations for diagnosing and treating children with rare forms of childhood systemic vasculitis. METHODS Recommendations were developed by a consensus process in accordance with the European League Against Rheumatism standard operating procedures. A systematic literature review informed the recommendations, which were devised and evaluated by a panel of experts via an online survey, and two consensus meetings using nominal group technique. Recommendations were accepted when ⩾ 80% of experts agreed. RESULTS Ninety-three relevant articles were found, and 78 recommendations were accepted in the two consensus meetings. General, cross-cutting recommendations and disease-specific statements regarding the diagnosis and treatment of childhood-onset PAN, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, and Takayasu arteritis are provided. CONCLUSION These Single Hub and Access point for paediatric Rheumatology in Europe recommendations were formulated through an evidence-based consensus process to support uniform, high-quality standard of care for children with rare forms of paediatric systemic vasculitis.
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Affiliation(s)
- Nienke de Graeff
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Noortje Groot
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht.,Department of Paediatric Rheumatology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Paediatric Rheumatology, Alder Hey Children's Hospital, Liverpool
| | - Paul Brogan
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health and Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
| | - Seza Ozen
- Department of Paediatric Rheumatology, Hacettepe University, Ankara, Turkey
| | - Tadej Avcin
- Department of Paediatric Rheumatology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Brigitte Bader-Meunier
- Department of Paediatric Rheumatology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pavla Dolezalova
- 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Brian M Feldman
- Department of Paediatric Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Isabelle Kone-Paut
- Department of Paediatric Rheumatology, Bicêtre University Hospital, APHP, University of Paris Sud, Paris, France
| | - Pekka Lahdenne
- Department of Paediatric Rheumatology, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Stephen D Marks
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health and Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
| | - Liza McCann
- Department of Paediatric Rheumatology, Alder Hey Children's Hospital, Liverpool
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health and Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
| | - Angelo Ravelli
- Department of Paediatric Rheumatology, Gaslini Children's Hospital, Genoa, Italy
| | - Annet van Royen
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Yosef Uziel
- Meir Medical Center, Kfar Saba, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Bas Vastert
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Nico Wulffraat
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Sylvia Kamphuis
- Department of Paediatric Rheumatology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's Hospital, Liverpool.,Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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22
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Chiu M, Datta A. Childhood Small Vessel Primary Angiitis of the Central Nervous System: A Treatable Cause of Super-refractory Status Epilepticus. J Child Neurol 2020; 35:31-36. [PMID: 31530228 DOI: 10.1177/0883073819872579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Childhood primary angiitis of the central nervous system (cPACNS) is a rare inflammatory disease of brain vessels. The small vessel subtype is diagnosed on brain biopsy and often presents with cognitive and behavioral changes, headaches, and seizures. However, there are few reported cases of super-refractory status epilepticus in children. We present a case of small vessel cPACNS complicated by super-refractory status epilepticus requiring burst suppression for 4 weeks in addition to multiple antiseizure medications and the ketogenic diet. Our patient was also treated with intravenous and oral steroids, intravenous immunoglobulin, and cyclophosphamide before starting maintenance therapy with mycophenolate mofetil. After prolonged rehabilitation, he recovered almost completely and has a normal neurologic examination with rare epileptiform activity on electroencephalogram (EEG). This is one of the longest cases of status epilepticus in small vessel cPACNS in the literature. We illustrate that super-refractory status epilepticus can be the first manifestation of small vessel cPACNS in previously healthy children and that symptomatic management of seizures with concurrent immunosuppression to treat the underlying pathology resulted in favorable neurologic outcomes.
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Affiliation(s)
- Michelle Chiu
- University of British Columbia and BC Children's Hospital, Division of Neurology, Department of Pediatrics, Vancouver, BC, Canada
| | - Anita Datta
- University of British Columbia and BC Children's Hospital, Division of Neurology, Department of Pediatrics, Vancouver, BC, Canada
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23
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Abstract
Perinatal stroke is a heterogeneous syndrome resulting from brain injury of vascular origin that occurs between 20 weeks of gestation and 28 days of postnatal life. The incidence of perinatal stroke is estimated to be between 1:1600 and 1:3000 live births (approximately 2500 children per year in the United States), though its actual incidence is difficult to estimate because it is likely underdiagnosed. Perinatal arterial ischemic stroke (PAIS) accounts for approximately 70% of cases of perinatal stroke. Cerebral sinovenous thrombosis, while less common, also accounts for a large proportion of the morbidity and mortality seen with perinatal stroke. Hemorrhagic stroke leads to disruption of neurologic function due to intracerebral hemorrhage that is nontraumatic in origin. While most cases of PAIS fall into one of these three categories, other patterns of injury should also be considered perinatal stroke. In some cases, the etiology of PAIS is not known but is idiopathic. This chapter will review the classification, risk factors, pathogenesis, clinical presentation, management, and long-term sequelae of perinatal stroke.
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Affiliation(s)
- Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States.
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, United States
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24
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Smitka M, Bruck N, Engellandt K, Hahn G, Knoefler R, von der Hagen M. Clinical Perspective on Primary Angiitis of the Central Nervous System in Childhood (cPACNS). Front Pediatr 2020; 8:281. [PMID: 32719754 PMCID: PMC7349935 DOI: 10.3389/fped.2020.00281] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/04/2020] [Indexed: 12/21/2022] Open
Abstract
Non-arteriosclerotic arteriopathies have emerged as important underlying pathomechanism in pediatric arterial ischemic stroke (AIS). The pathogenesis and classification of cerebral arteriopathies in childhood are heterogeneous. Different classifications base on (i) the anatomic site; (ii) the distribution and size of the affected vessel; (iii) the time course, for example, transient vs. progressive, monophasic vs. recurrent; (iv) the putative pathogenesis; (v) the magnetic resonance imaging morphology of the vasculopathies. Inflammation affecting the cerebral vessels is increasingly recognized as common cause of pediatric AIS. Primary cerebral vasculitis or primary angiitis of the central nervous system (CNS) in childhood (cPACNS) is an important differential diagnosis in pediatric AIS. Primary angiitis of the CNS is a rare disorder, and the pathogenesis is poorly understood so far. The current classification of cPACNS is based on the affected cerebral vessel size, the disease course, and angiographic pattern. Two large subtypes are currently recognized comprising large- and medium-sized vessel CNS vasculitis referred to as angiography-positive cPACNS and angiography-negative small vessel cPACNS. As the clinical manifestations of cPACNS are rather diverse, precise diagnosis can be challenging for the treating pediatrician because of the lack of vital laboratory tests or imaging features. Initial misdiagnosis is common because of overlapping phenotypes and pediatric AIS mimics. As untreated cPACNS is associated with a high morbidity and mortality, timely diagnosis, and induction of immunomodulatory and symptomatic therapy are essential. Survival and neurological outcome depend on early diagnosis and prompt therapy. Primary angiitis of the central nervous system in childhood differs in several aspects from primary cerebral angiitis in adults. The aim of this article is to give a brief comprehensive summary on pediatric primary cerebral vasculitis focusing on the clinical perspective regarding the classification, the putative pathogenesis, the disease course, the diagnostic tools, and emerging treatment options. A modified terminology for clinical practice is discussed.
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Affiliation(s)
- Martin Smitka
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Normi Bruck
- Klinik für Kinder und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kay Engellandt
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Hahn
- Bereich Kinderradiologie, Medizinische Fakultät Carl Gustav Carus, Institut und Poliklinik für Radiologische Diagnostik, Technische Universität Dresden, Dresden, Germany
| | - Ralf Knoefler
- Klinik für Kinder und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maja von der Hagen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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25
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Abstract
The systemic vasculitides are heterogeneous clinicopathologic disorders that share the common feature of vascular inflammation. The resulting disorder can vary depending on involvement of specific organs, caliber of blood vessels, the underlying inflammatory process, and individual host factors. The cumulative result is diminished blood flow, vascular alterations, and eventual occlusion with variable ischemia, necrosis, and tissue damage. An international revised nomenclature system provides the necessary nosology and findings relevant to classify each of the vasculitides. This article is an introduction and overview of the clinical presentation, differential diagnosis, laboratory evaluation, and treatment of systemic and nervous system vasculitides.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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26
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Beelen J, Benseler SM, Dropol A, Ghali B, Twilt M. Strategies for treatment of childhood primary angiitis of the central nervous system. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e567. [PMID: 31355303 PMCID: PMC6624095 DOI: 10.1212/nxi.0000000000000567] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/04/2019] [Indexed: 12/12/2022]
Abstract
Objective Childhood primary angiitis of the CNS (cPACNS) is a devastating neurologic disease. No standardized treatment protocols exist, and evidence is limited to open-label cohort studies and case reports. The aim of this review is to summarize the literature and provide informed treatment recommendations. Methods A scoping review of cPACNS literature from January 2000 to December 2018 was conducted using Ovid, MEDLINE, PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Vasculitis Foundation, European Vasculitis Society, CanVasc, Google Scholar, and Web of Science. Potentially relevant articles were selected for full-text review using the STROBE checklist if they met the following inclusion criteria: (1) reported treatment, (2) addressed pediatrics, (3) focused on the disease of interest, (4) included ≥5 patients, (5) original research, and (6) full-length articles. Reviews, expert opinions, editorials, case reports with <5 patients, articles lacking treatment information, or non-English articles were excluded. A standardized assessment tool measured study quality. Treatment and outcomes were summarized. Results Of 2,597 articles screened, 7 studies were deemed high quality. No trials were available so no meta-analysis was possible. Overall, treatment strategies recommended are induction with acute antithrombotic therapy subsequently followed by high-dose oral prednisone taper over 3–12 months and long-term platelet therapy. In angiography-positive progressive–cPACNS and angiography-negative–cPACNS, we also recommend 6 months of IV cyclophosphamide therapy, with trimethoprim/sulfamethoxazole as part of induction, and maintenance therapy with mycophenolate mofetil/mycophenolic acid. Conclusion No grade-A evidence exists; however, this review provides recommendations for treatment of cPACNS.
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Affiliation(s)
- Jocelyne Beelen
- Cumming School of Medicine (J.B., S.M.B., A.D.), University of Calgary, Alberta, Canada; Section of Rheumatology (S.M.B., M.T.), Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; and University of Calgary (B.G.), Alberta, Canada
| | - Susanne M Benseler
- Cumming School of Medicine (J.B., S.M.B., A.D.), University of Calgary, Alberta, Canada; Section of Rheumatology (S.M.B., M.T.), Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; and University of Calgary (B.G.), Alberta, Canada
| | - Anastasia Dropol
- Cumming School of Medicine (J.B., S.M.B., A.D.), University of Calgary, Alberta, Canada; Section of Rheumatology (S.M.B., M.T.), Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; and University of Calgary (B.G.), Alberta, Canada
| | - Brianna Ghali
- Cumming School of Medicine (J.B., S.M.B., A.D.), University of Calgary, Alberta, Canada; Section of Rheumatology (S.M.B., M.T.), Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; and University of Calgary (B.G.), Alberta, Canada
| | - Marinka Twilt
- Cumming School of Medicine (J.B., S.M.B., A.D.), University of Calgary, Alberta, Canada; Section of Rheumatology (S.M.B., M.T.), Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; and University of Calgary (B.G.), Alberta, Canada
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27
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28
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Younger DS. Neuroophthalmologic Aspects of the Vasculitides. Neurol Clin 2019; 37:383-397. [DOI: 10.1016/j.ncl.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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29
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Abstract
"Neuroimaging plays a vital role in the diagnosis of primary and secondary vasculitic disorders. There multiple neuroimaging options available to accurately describe the underlying clinical deficits of involved cases. Noninvasive neuroimaging modalities provide less risk and when interdigitated, form the basis for a more conclusive understanding of the disease process. There are instances in which invasive cerebral angiography may be needed to image the intricate and at times, small involved vessels. Neuroradiologists should be included in the multidisciplinary team of physicians caring for patients with vasculitides and in research to provide more sensitive and safe modalities for accurate diagnosis."
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30
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Abstract
The vasculitides are diseases characterized by inflammation of blood vessels and inflammatory leukocytes in vessel walls. There is an increased propensity for ischemic stroke, resulting from compromise of vessel lumina with distal tissue ischemia; and hemorrhagic or nonhemorrhagic stroke, and aneurysmal formation and bleeding, due to loss of vessel integrity.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY, USA; School of Public Health, City University of New York, New York, NY, USA.
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31
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Abstract
Granulomatous inflammation, the prototypical histopathology of adult and childhood vasculitis, is characterized by inflammation of blood vessels accompanied by giant cells and epithelioid cells in the walls of cerebral vessels ranging from small leptomeningeal veins to large named cerebral arteries. Headache, hemiparesis, mental changes, abnormal cerebrospinal fluid protein content, and pleocytosis are suggestive features that warrant brain and leptomeningeal biopsy to make the diagnosis certain and begin cytotoxic therapy to improve outcome.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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32
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Relapse rates and long-term outcome in primary angiitis of the central nervous system. J Neurol 2019; 266:1481-1489. [DOI: 10.1007/s00415-019-09285-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/09/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
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33
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Abstract
Vascular injury is increasingly recognized as an important cause of mortality and morbidity in children (29 days to 18 years of age). Since vascular brain injury in children appears to be less common than in adults, the index of suspicion for vascular brain injury is usually lower. In this review article, we describe frequent and rare conditions underlying pediatric stroke including cardioembolic, viral, autoimmune, post-traumatic, and genetic etiologies. Furthermore, we provide a neuroimaging correlate for clinical mimics of pediatric stroke. This review highlights the role of multimodal noninvasive neuroimaging in the early diagnosis of pediatric stroke, providing a problem-solving approach to the differential diagnosis for the neuroradiologist, emergency room physician, and neurologist.
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Patterson K, Iglesias E, Nasrallah M, González-Álvarez V, Suñol M, Anton J, Saiz A, Lancaster E, Armangue T. Anti-MOG encephalitis mimicking small vessel CNS vasculitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e538. [PMID: 30800721 PMCID: PMC6384022 DOI: 10.1212/nxi.0000000000000538] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/19/2018] [Indexed: 12/02/2022]
Abstract
Objective To report 2 patients with anti–myelin oligodendrocyte glycoprotein (MOG)-associated encephalitis who were initially misdiagnosed with small vessel primary CNS vasculitis. Methods Review of symptoms, MRI and neuropathologic features, and response to treatment. MOG antibodies were determined in serum and CSF using a cell-based assay. Results Symptoms included fever, headache, and progressive mental status changes and focal neurologic deficits. CSF studies revealed lymphocytic pleocytosis, and both patients had abnormal brain MRIs. Brain biopsy samples showed prominent lymphocytic infiltration of the wall of small vessels; these findings initially suggested small vessel CNS vasculitis, and both patients were treated accordingly. Although 1 patient had a relapsing-remitting course not responsive to cyclophosphamide, the other one (also treated with cyclophosphamide) did not relapse. Retrospective assessment of serum and CSF demonstrated MOG antibodies in both cases, and review of biopsy specimens showed absence of fibrinoid necrosis (a pathologic requirement for small vessel CNS vasculitis). Conclusions Anti–MOG-associated encephalitis can be mistaken for small vessel CNS vasculitis. This is important because the diagnosis of anti–MOG-associated encephalitis does not require brain biopsy and can be established with a serologic test.
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Affiliation(s)
- Kristina Patterson
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Estibaliz Iglesias
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Maclean Nasrallah
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Verónica González-Álvarez
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Mariona Suñol
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Jordi Anton
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Albert Saiz
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Eric Lancaster
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
| | - Thaís Armangue
- Neurology Department (K.P., E.L.), University of Pennsylvania, Philadelphia; Rheumatology Department, Sant Joan de Deu Children's Hospital (E.I., J.A.), University of Barcelona, Spain; Department of Pathology (M.N.), University of Pennsylvania, Philadelphia; Pediatric Neuroimmunology Unit (V.G.-Á., T.A.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; Department of Pathology (M.S.), Sant Joan de Déu Children's Hospital, University of Barcelona, Spain; and Neuroimmunology Program (A.S., T.A.), IDIBAPS-Hospital Clinic, University of Barcelona, Spain
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Abstract
Brain has been considered as an immune-privileged site for centuries owing to the presence of blood-brain barrier, absent lymphatic drainage, and antigen-presenting cells. However, the present prevailing concept is of immune surveillance where brain is continuously surveyed by immune cells. However, the presence of immune cells in central nervous system (CNS) brings the risk of inflammation and autoimmunity involving both T and B cell mediated pathways. These mechanisms form the underlying pathology in a wide spectrum of pediatric CNS diseases manifesting as acquired neurological deficits. Overlapping, heterogenous, and ambiguous clinical features often delays the diagnosis. Although not always pathognomonic, magnetic resonance imaging can be an important biomarker leading to early diagnosis, prognostication, and systematic follow-up pf these diseases. This review describes the spectrum of different pediatric inflammatory disorders and their pertinent imaging features illustrated with clinical examples.
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Affiliation(s)
| | - Karthik Muthusamy
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manohar Shroff
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
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Marrodan M, Acosta J, Alessandro L, Fernandez V, Carnero Contentti E, Arakaki N, Kohler A, Fiol M, Ameriso S, Correale J. Clinical and imaging features distinguishing Susac syndrome from primary angiitis of the central nervous system. J Neurol Sci 2018; 395:29-34. [DOI: 10.1016/j.jns.2018.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 11/16/2022]
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Limaye K, Samaniego EA, Adams HP. Diagnosis and Treatment of Primary Central Nervous System Angiitis. Curr Treat Options Neurol 2018; 20:38. [PMID: 30076478 DOI: 10.1007/s11940-018-0522-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Primary central nervous system angiitis (PCNSA) is a rare disease. Varying clinical pictures coupled with lack of sensitive and specific diagnostic tests lead to challenges in management of these patients. This unfortunately may lead to both under- or over-diagnosis and unnecessary treatment. It is important to recognize the different conditions that may mimic the clinical and radiologic presentation. We present a contemporary literature review that should update physicians who encounter this patient population. RECENT FINDINGS Recent additions to the literature in form of case reports and single-center series show that digital subtraction angiography was the most widely used test to diagnose PCNSA. It is also important to note that brain biopsy is still considered "gold standard" and should be pursued as it not only has information that establishes the diagnosis but also may help in ruling out the diagnosis from mimics. In around 39% of suspected cases, an alternate diagnosis was eventually confirmed highlighting the importance of a comprehensive work-up. For treatment, almost all the literature supports the use of glucocorticoids as the initial treatment and if the patient has a relapse or develops steroid toxicity then the second most commonly used agent was cyclophosphamide. There are increasing reports of benefits with other agents such as methotrexate, azathioprine, mycophenolate, infliximab, and etanercept. The diagnosis and management of PCNSA continues to be a challenge. Formation of prospective patient registries with continued immunologic research for novel targets and immunomodulatory modalities may hold promise for future care of these patients.
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Affiliation(s)
- Kaustubh Limaye
- Cerebrovascular Diseases, University of Iowa, Iowa City, IA, USA
| | - Edgar A Samaniego
- Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, IA, USA
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Schuster S, Bachmann H, Thom V, Kaufmann-Buehler AK, Matschke J, Siemonsen S, Glatzel M, Fiehler J, Gerloff C, Magnus T, Thomalla G. Subtypes of primary angiitis of the CNS identified by MRI patterns reflect the size of affected vessels. J Neurol Neurosurg Psychiatry 2017; 88:749-755. [PMID: 28705900 DOI: 10.1136/jnnp-2017-315691] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/08/2017] [Accepted: 05/11/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe patterns of diagnostic findings, and identify subgroups of primary angiitis of the central nervous system (PACNS). METHODS We retrospectively analysed 31 patients with PACNS. Cases were selected by predetermined diagnostic criteria and stratified into biopsy-proven and imaging-based PACNS. We compared clinical characteristics, cerebrospinal fluid (CSF) findings and imaging results including high-resolution vessel wall MRI between groups. RESULTS There were 31 cases of PACNS (mean age 45.6 years, 58.1% female), of whom 17 (55%) were biopsy-proven, 14 (45%) were based on imaging findings. Patients with a positive biopsy had fewer infarcts (29.4% vs 85.7%, p=0.003), were more likely to have meningeal and parenchymal contrast enhancement (76.5% vs 28.6%, p=0.012), were less likely to have abnormal MR angiography (11.8% vs 100%, p<0.001) and did not show vessel wall enhancement at the time of diagnosis (0% vs 76.9%, p<0.001). In contrast, patients with imaging-based diagnosis showed more frequently multiple infarcts and vessel abnormalities, with vessel wall enhancement in most of the cases. Clinical characteristics and CSF analysis did not reveal marked differences between groups. INTERPRETATION Multi-parametric MRI distinguishes two subtypes of PACNS that most likely differ concerning the affected vessel size. Biopsy-proven PACNS primarily involves smaller vessels beyond the resolution of vascular imaging, while imaging-based PACNS affects predominantly medium-sized vessels leading to false-negative biopsy results. Using distinct MRI patterns may be helpful for selecting patients for appropriate invasive diagnostic modalities.
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Affiliation(s)
- Simon Schuster
- Department of Neurology, University Hospital Hamburg-Eppendorf, Germany
| | - Henrike Bachmann
- Department of Neurology, University Hospital Hamburg-Eppendorf, Germany
| | - Vivien Thom
- Department of Neurology, University Hospital Hamburg-Eppendorf, Germany
| | | | - Jakob Matschke
- Institute of Neuropathology, University Hospital Hamburg-Eppendorf, Germany
| | - Susanne Siemonsen
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Hospital Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Germany
| | - Christian Gerloff
- Department of Neurology, University Hospital Hamburg-Eppendorf, Germany
| | - Tim Magnus
- Department of Neurology, University Hospital Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology, University Hospital Hamburg-Eppendorf, Germany
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Granata C, Damasio MB, Zaottini F, Airaldi S, Malattia C, Colafati GS, Tomà P, Magnano G, Martinoli C. Imaging of Childhood Vasculitis. Radiol Clin North Am 2017; 55:1131-1143. [DOI: 10.1016/j.rcl.2017.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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de Boysson H, Boulouis G, Parienti JJ, Touzé E, Zuber M, Arquizan C, Dequatre N, Detante O, Bienvenu B, Aouba A, Guillevin L, Pagnoux C, Naggara O. Concordance of Time-of-Flight MRA and Digital Subtraction Angiography in Adult Primary Central Nervous System Vasculitis. AJNR Am J Neuroradiol 2017; 38:1917-1922. [PMID: 28751515 DOI: 10.3174/ajnr.a5300] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/20/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE 3D-TOF-MRA and DSA are 2 available tools to demonstrate neurovascular involvement in primary central nervous system vasculitis. We aimed to compare the diagnostic concordance of vessel imaging using 3D-TOF-MRA and DSA in patients with primary central nervous system vasculitis. MATERIALS AND METHODS We retrospectively identified all patients included in the French primary central nervous system vasculitis cohort of 85 patients who underwent, at baseline, both intracranial 3D-TOF-MRA and DSA in an interval of no more than 2 weeks and before treatment initiation. Two neuroradiologists independently reviewed all 3D-TOF-MRA and DSA imaging. Brain vasculature was divided into 25 arterial segments. Concordance between 3D-TOF-MRA and DSA for the identification of arterial stenosis was assessed by the Cohen κ Index. RESULTS Thirty-one patients met the inclusion criteria, including 20 imaged with a 1.5T MR unit and 11 with a 3T MR unit. Among the 25 patients (81%) with abnormal DSA findings, 24 demonstrated abnormal 3D-TOF-MRA findings, whereas all 6 remaining patients with normal DSA findings had normal 3D-TOF-MRA findings. In the per-segment analysis, concordance between 1.5T 3D-TOF-MRA and DSA was 0.82 (95% CI, 0.75-0.93), and between 3T 3D-TOF-MRA and DSA, it was 0.87 (95% CI, 0.78-0.91). CONCLUSIONS 3D-TOF-MRA shows a high concordance with DSA in diagnostic performance when analyzing brain vasculature in patients with primary central nervous system vasculitis. In patients with negative 3T 3D-TOF-MRA findings, the added diagnostic value of DSA is limited.
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Affiliation(s)
- H de Boysson
- From the Departments of Internal Medicine (H.d.B., B.B., A.A.)
| | - G Boulouis
- Department of Neuroradiology (G.B., O.N.), Centre Hospitalier Sainte-Anne, Université Paris-Descartes, Institut National de la Santé et de la Recherche Médicale Unite Mixte de Recherche 894, Paris, France
| | - J-J Parienti
- Biostatistics and Clinical Research Unit (J.-J.P.), Caen University Hospital, Caen, France
| | - E Touzé
- Neurology (E.T.), Caen University Hospital, University of Caen-Normandie, Institut National de la Santé et de la Recherche Médicale Unite Mixte de Recherche 919, Caen, France
| | - M Zuber
- Department of Vascular Neurology (M.Z.), Centre Hospitalier Saint Joseph, Université Paris-Descartes, Institut National de la Santé et de la Recherche Médicale Unite Mixte de Recherche S 919, Paris, France
| | - C Arquizan
- Department of Neurology (C.A.), Montpellier University Hospital, Institut National de la Santé et de la Recherche Médicale Unite Mixte de Recherche 894, Montpellier, France
| | - N Dequatre
- Department of Neurology (N.D.), Lille University Hospital, Lille, France
| | - O Detante
- Department of Neurology (O.D.), Grenoble Alpes University Hospital, Grenoble, France
| | - B Bienvenu
- From the Departments of Internal Medicine (H.d.B., B.B., A.A.)
| | - A Aouba
- From the Departments of Internal Medicine (H.d.B., B.B., A.A.)
| | - L Guillevin
- Department of Internal Medicine (L.G.), Centre Hospitalier Cochin, Paris, France
| | - C Pagnoux
- Vasculitis Clinic (C.P.), Division of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - O Naggara
- Department of Neuroradiology (G.B., O.N.), Centre Hospitalier Sainte-Anne, Université Paris-Descartes, Institut National de la Santé et de la Recherche Médicale Unite Mixte de Recherche 894, Paris, France
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Edwards HB, Mallick AA, O'Callaghan FJK. Immunotherapy for arterial ischaemic stroke in childhood: a systematic review. Arch Dis Child 2017; 102:410-415. [PMID: 27864289 DOI: 10.1136/archdischild-2016-311034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 10/13/2016] [Accepted: 10/27/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is little evidence about either prevention or treatment of childhood arterial ischaemic stroke (AIS). However, drugs that regulate the immune and inflammatory response could theoretically prevent occurrence or recurrence of AIS. Additionally, as an acute treatment, they may limit the neurological damage caused by AIS. Here, we systematically review the evidence on the use of immunotherapy in childhood AIS. DESIGN A systematic review of publications in databases Embase and Medline from inception. All types of evidence were included from trials, cohorts, case-control and cross-sectional studies and case reports. RESULTS 34 reports were included: 32 observational studies and 2 trials. Immunotherapy was used in two key patient groups: arteriopathy and acute infection. The majority were cases of varicella and primary angiitis of the central nervous system. All three cohorts and 80% of the case studies were treated with steroids. Recurrence rates were low. Analytical studies weakly associated steroids with lower odds of new stroke and neurological deficits, and better cognitive outcomes in the context of Moyamoya disease and tuberculosis. CONCLUSIONS Immunotherapies are used in children with AIS, mainly as steroids for children with arteriopathy. However, there is currently little robust evidence to either encourage or discourage this practice. There is weak evidence consistent with the hypothesis that in certain children at risk, steroids may both reduce the risk of occurrent/recurrent stroke and enhance neurological outcomes. As the potential benefit is still uncertain, this indicates that a trial of steroids in childhood AIS may be justified.
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Affiliation(s)
- Hannah B Edwards
- School of Social and Community Medicine, University of Bristol and National Institute for Health Research (NIHR), Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West, Bristol, UK
| | - Andrew A Mallick
- Department of Paediatric Neurology, University Hospitals Bristol NHS Foundation Trust, Level 6, Education and Research Centre, Bristol, UK
| | - Finbar J K O'Callaghan
- Department of Clinical Neurosciences, University College London and Great Ormond Street Hospital for Children Institute of Child Health, University College London, London, UK
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Abstract
The idiopathic vasculitides are a group of inflammatory and immune-mediated conditions associated with inflammation of blood vessels. They affect multiple organ and body systems, and vary in their clinical manifestations, severity, prognosis, and pathology. They frequently present a diagnostic challenge for clinicians because of their complexity, overlapping features, and similar findings to other noninflammatory, genetic, or infectious conditions. This article summarizes some of the common pediatric vasculitides, emphasizing both the characteristic and unusual clinical manifestations of these diseases.
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Sudhakar SV, Muthusamy K, Mani S, Gibikote S, Shroff M. Imaging in Pediatric Demyelinating and Inflammatory Diseases of Brain- Part 2. Indian J Pediatr 2016; 83:965-82. [PMID: 27130513 DOI: 10.1007/s12098-016-2052-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 01/28/2016] [Indexed: 01/18/2023]
Abstract
Imaging plays an important role in diagnosis, management, prognostication and follow up of pediatric demyelinating and inflammatory diseases of brain and forms an integral part of the diagnostic criteria. This article reviews the spectrum of aquaporinopathies with an in-depth discussion on present criteria and differentiation from other demyelinating diseases with clinical vignettes for illustration; the latter part of article deals with the spectrum of CNS vasculitis.
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Affiliation(s)
- Sniya Valsa Sudhakar
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India.
| | - Karthik Muthusamy
- Department of Neurology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sunithi Mani
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India
| | - Sridhar Gibikote
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India
| | - Manohar Shroff
- Department of Pediatric Neuroimaging, Hospital for Sick Children, Toronto, Canada
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Silva MF, Feitosa AR, Paz JA, Aikawa NE, Silva CA. Intracerebral hemorrhage with a favorable outcome in a patient with childhood primary angiitis of the central nervous system. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:366-70. [PMID: 27476630 DOI: 10.1016/j.rbre.2014.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/21/2014] [Indexed: 11/25/2022] Open
Abstract
Childhood primary angiitis of the central nervous system (cPACNS) is a rare inflammatory brain disease of unknown etiology. Of note, brain hemorrhage has been rarely reported in cPACNS patients, generally associated with a delayed clinical diagnosis, or with a diagnosis only at necropsy. We present the case of a boy with cPACNS that previously suffered an ischemic stroke. At the age of 7 years and 10 months, he presented a sudden and severe headache, vomiting and reduction in consciousness level (Glasgow coma scale 7), requiring prompt tracheal intubation. Brain computed tomography demonstrated intraparenchymal hematoma in the right parieto-occipital lobe and a small focus of bleeding in the right frontal lobe, vasogenic edema, herniation of the uncus and a 10mm deviation to the left from the midline. C-reactive protein (9.2mg/dL) and von Willebrand factor (vWF) antigen (202%) were elevated. Decompressive craniotomy was performed and methylprednisolone and cyclophosphamide were administered. One week later, the patient had left hemiparesis without other sequelae. Importantly, motor deficits have been improving progressively. Our case reinforces the inclusion of this vasculitis as a differential diagnosis in children and adolescents with CNS hemorrhage.
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Affiliation(s)
- Marco Felipe Silva
- Pediatric Rheumatology Unit, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ana Raquel Feitosa
- Pediatric Rheumatology Unit, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José A Paz
- Pediatric Neurology Unit, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nádia Emi Aikawa
- Pediatric Rheumatology Unit, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; Division of Rheumatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; Division of Rheumatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Silva MF, Feitosa AR, Paz JA, Aikawa NE, Silva CA. Hemorragia intracerebral com evolução favorável em paciente com angiíte primária do sistema nervoso central juvenil. REVISTA BRASILEIRA DE REUMATOLOGIA 2016. [DOI: 10.1016/j.rbr.2014.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Background In young patients, vasculitic stenoses of cerebral blood vessels are an important cause of cerebral ischaemia. Diagnosis may prove very difficult. Summary of review The diagnostic process is usually initiated by the detection of brain lesions consistent with cerebral vasculitis. Multiple infarcts of various ages in more than one vascular territory are thought to be suggestive of a vascular inflammatory disease. The next step in the imaging of patients with suspected vasculitis is the search for an underlying vascular stenosis. Today, magnetic resonance angiography is the principal modality for the investigation of patients thought to have intracranial stenoses. At 1·5 T, only large brain arteries can be imaged with a high diagnostic accuracy. Intraarterial DSA remains an indispensable tool for the investigation of medium and small brain artery stenoses. Conclusions However, contrast-enhanced magnetic resonance imaging may be able to demonstrate wall thickening and contrast uptake in large cerebral arteries, obviating biopsy in patients with basal vasculitis.
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Twilt M, Benseler SM. Central nervous system vasculitis in adults and children. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:283-300. [PMID: 27112683 DOI: 10.1016/b978-0-444-63432-0.00016-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Primary angiitis of the central nervous system (PACNS) is an inflammatory brain disease targeting the cerebral blood vessels, leading to a wide spectrum of signs and symptoms, including neurologic deficits, cognitive dysfunction, and psychiatric symptoms. The inflammation could be reversible if diagnosed and treated early. The diagnosis requires the careful consideration and rapid evaluation of systemic underlying conditions and disease mimics. The differential diagnosis is distinctly different for angiography-positive and -negative PACNS subtypes and differs depending on age, so there is childhood PACNS or adult PACNS. Distinct disease subtypes have been described, with characteristic disease course, neuroimaging findings, and histopathologic features. Novel and traditional biomarkers, including von Willebrand factor antigen and cytokine levels, can help diagnose, and define subtype and disease activity. Treatment of PACNS should be tailored to the disease subtypes and clinical symptoms. Beyond immunosuppression it should include medications to control symptoms in order to support and enhance the child's or adult's ability to actively participate in rehabilitation. The mortality of PACNS has decreased; studies determining the morbidity and its determinants are urgently needed.
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Affiliation(s)
- Marinka Twilt
- Division of Rheumatology, Department of Pediatrics, Aarhus University Hospital and Faculty of Medicine, University of Aarhus, Aarhus, Denmark; Division of Rheumatology, Department of Paediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Susanne M Benseler
- Division of Rheumatology, Department of Paediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada.
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Nabower AM, Larsen PD, Love TL, McComb RD, Pavkovic I. Nine-Year-Old Girl With Blank Stares and Recent-Onset Diabetes. Pediatr Neurol 2016; 54:5-10. [PMID: 26590008 DOI: 10.1016/j.pediatrneurol.2015.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 09/26/2015] [Indexed: 11/25/2022]
Affiliation(s)
| | - Paul D Larsen
- University of Nebraska College of Medicine, Omaha, Nebraska; Children's Hospital and Medical Center, Omaha, Nebraska.
| | - Terri L Love
- University of Nebraska College of Medicine, Omaha, Nebraska; Children's Hospital and Medical Center, Omaha, Nebraska
| | | | - Ivan Pavkovic
- University of Nebraska College of Medicine, Omaha, Nebraska; Children's Hospital and Medical Center, Omaha, Nebraska
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Abstract
The diagnosis and treatment of central nervous system (CNS) vasculitis is extremely challenging. Several conditions can mimic CNS vasculitis and require totally different treatment. CNS vasculitis, once confirmed, may result from infections or systemic diseases that will warrant specific treatments, or, more rarely, be primary and isolated (PCNSV). Prospective trials to help determine the optimal treatment for PCNSV are lacking, but data from several cohorts have provided seminal data on its management. The consensus is to use glucocorticoids as first-line agents, combined with additional immunosuppressants for the most severe cases, mainly cyclophosphamide for induction, followed by less-toxic maintenance therapy with azathioprine, methotrexate, or mycophenolate mofetil. The recent identification of PCNSV subgroups and predictors of outcomes might help in deciding the adequate treatment for each patient, keeping in mind that these data are based on a small number of patients. Other agents and biologics can be considered for patients with relapsing and/or refractory disease, but evidence is limited. In practice, the diagnosis must be re-questioned in patients with PCNSV refractory to standard treatment, especially with diagnoses not based on pathology.
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Affiliation(s)
- Christian Pagnoux
- a Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital , University of Toronto , Toronto , ON , Canada
| | - Rula A Hajj-Ali
- b Department of Rheumatic and Immunologic Diseases , Orthopedic and Rheumatologic Institute, Cleveland Clinic , Cleveland , OH , USA
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