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Sun S, Wan Y, Ji H, Shi L. Rare primary angiitis of the central nervous system affecting the clivus: A case report. Int J Rheum Dis 2024; 27:e14902. [PMID: 37737488 DOI: 10.1111/1756-185x.14902] [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: 07/04/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
Diseases involving the clivus are highly variable, and the incidence of each disease is rare. Primary central nervous system vasculitis (PACNS) is a rare disease with very heterogeneous clinical manifestations, its diagnosis is often challenging, and histopathology is the gold standard. We report a patient with PACNS of the clivus, with a 1-month history of headache and diplopia, who was misdiagnosed as having a tumor of the clivus during prior treatment, due to computed tomography findings of clivus occupation and bone destruction. Endoscopic resection of the nasal clivus lesions was performed. Pathological examination revealed a small abscess with hemorrhage, necrosis, extensive infiltration of lymphocytes and plasma cells, and granulation tissue scar formation. After histopathological examination, the diagnosis was confirmed, and oral glucocorticoid and cyclophosphamide were commenced. This study is the first to report a tumor-like PACNS, that occurs in the clivus, thereby enriching our understanding of PACNS.
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Affiliation(s)
- Shujuan Sun
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, China
| | - Yuzhu Wan
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, China
| | - Hongzhi Ji
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, China
| | - Li Shi
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, China
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2
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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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3
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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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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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5
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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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Isolated sixth nerve palsy as an initial presentation of primary angiitis of the central nervous system. Brain Dev 2021; 43:884-888. [PMID: 34053793 DOI: 10.1016/j.braindev.2021.05.003] [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] [Received: 02/11/2021] [Revised: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Primary angiitis of the central nervous system (PACNS) is a newly-emerging disease, and it is known that early diagnosis with treatment is important for the improvement of prognosis. CASE DESCRIPTION Here, we report the case of a previously healthy 13-year-old girl who presented with right eye abduction failure, attributed to isolated right sixth nerve palsy, as the initial symptom of PACNS. Magnetic resonance angiography (MRA) showed stenosis in the distal portion of the right internal carotid artery, and delay alternating with nutation for tailored excitation (DANTE)-prepared contrast-enhanced magnetic resonance imaging confirmed vasculitis at the same site. The patient was subsequently treated with three courses of pulse corticosteroid therapy (methylprednisolone intravenously 30 mg/kg/day for three consecutive days). Diplopia completely resolved within 3 months after three course of steroid pulse therapy, and when taking 10 mg PSL daily. Follow-up MRA confirmed complete resolution of the arterial narrowing, and no relapse was observed after 2 months of steroid cessation. DISCUSSION This case report illustrates an unusual presentation of PACNS with isolated sixth nerve palsy. PACNS was thought to cause insults on a single cranial nerve either through local spread of inflammation or hypoxic-ischemic insults on the nerve root due to involvement of feeding microvessels. The decision to perform imaging studies in cases of isolated sixth nerve palsy remains controversial because of the possibility of spontaneous recovery. Our case supports the existing literature that recommends that even an isolated symptom of unilateral abducens nerve palsy requires timely imaging studies.
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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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8
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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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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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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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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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12
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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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de Boysson H, Parienti JJ, Mawet J, Arquizan C, Boulouis G, Burcin C, Naggara O, Zuber M, Touzé E, Aouba A, Bousser MG, Pagnoux C, Ducros A. Primary angiitis of the CNS and reversible cerebral vasoconstriction syndrome. Neurology 2018; 91:e1468-e1478. [DOI: 10.1212/wnl.0000000000006367] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/13/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectivesTo further improve the distinction between primary angiitis of the CNS (PACNS) and reversible cerebral vasoconstriction syndrome (RCVS).MethodsWe compared 2 large French cohorts of patients with PACNS (n = 110, retrospectively and prospectively enrolled) and RCVS (n = 173, prospectively enrolled).ResultsPatients with RCVS were predominantly female (p < 0.0001), with migraines (p < 0.0001), and were more often exposed to vasoactive substances (p < 0.0001) or postpartum (p = 0.002) than patients with PACNS. Headache, especially thunderclap headache, was more frequent in RCVS (both p < 0.0001). Thunderclap headache was absent in only 6% of patients with RCVS and was mainly recurrent (87%) and provoked (77%) mostly by sexual intercourse, exertion, or emotion. All other neurologic symptoms (motor deficit, seizure, cognitive disorder, or vigilance impairment, all p < 0.0001) were more frequent in PACNS. At admission, brain CT or MRI was abnormal in all patients with PACNS and in 31% of patients with RCVS (p < 0.0001). Acute ischemic stroke was more frequent in PACNS than in RCVS (p < 0.0001). Although intracerebral hemorrhage was more frequent in PACNS (p = 0.006), subarachnoid hemorrhage and vasogenic edema predominated in RCVS (p = 0.04 and p = 0.01, respectively). Multiple small deep infarcts, extensive deep white matter lesions, tumor-like lesions, or multiple gadolinium-enhanced lesions were observed only in PACNS, whereas cervical artery dissection was found only in RCVS.ConclusionsOur study confirms that careful analysis of clinical context, headache features, and patterns of brain lesions can distinguish PACNS and RCVS within the first few days of admission in most cases. However, diagnosis remains challenging in a few cases.
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Beuker C, Schmidt A, Strunk D, Sporns PB, Wiendl H, Meuth SG, Minnerup J. Primary angiitis of the central nervous system: diagnosis and treatment. Ther Adv Neurol Disord 2018; 11:1756286418785071. [PMID: 30034536 PMCID: PMC6048610 DOI: 10.1177/1756286418785071] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
Primary angiitis of the central nervous system (PACNS) represents a rare
inflammatory disease affecting the brain and spinal cord. Stroke,
encephalopathy, headache and seizures are major clinical manifestations. The
diagnosis of PACNS is based on the combination of clinical presentation, imaging
findings (magnetic resonance imaging and angiography), brain biopsy, and
laboratory and cerebral spinal fluid (CSF) values. PACNS can either be confirmed
by magnetic resonance angiography (MRA)/conventional angiography or tissue
biopsy showing the presence of typical histopathological patterns.
Identification of PACNS mimics is often challenging in clinical practice, but
crucial to avoid far-reaching treatment decisions. In view of the severity of
the disease, with considerable morbidity and mortality, early recognition and
treatment initiation is necessary. Due to the rareness and heterogeneity of the
disease, there is a lack of randomized data on treatment strategies.
Retrospective studies suggest the combined administration of cyclophosphamide
and glucocorticoids as induction therapy. Immunosuppressants such as
azathioprine, methotrexate or mycophenolate mofetil are often applied for
maintenance therapy. In addition, the beneficial effects of two biological
agents (anti-CD20 monoclonal antibody rituximab and tumour necrosis factor-α
blocker) have been reported. Nevertheless, diagnosis and treatment is still a
clinical challenge, and further insights into the immunopathogenesis of PACNS
are required to improve the diagnosis and management of patients. The present
review provides a comprehensive overview of diagnostics, differential diagnoses,
and therapeutic approaches of adult PACNS.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, D-48149, Germany
| | - Antje Schmidt
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Daniel Strunk
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Peter B Sporns
- Department of Clinical Radiology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
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Byram K, Hajj-Ali RA, Calabrese L. CNS Vasculitis: an Approach to Differential Diagnosis and Management. Curr Rheumatol Rep 2018; 20:37. [DOI: 10.1007/s11926-018-0747-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Affiliation(s)
- Grace Kim
- From Partners Pediatric Multiple Sclerosis Center (G.K., T.C.), Massachusetts General Hospital; and Partners Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA.
| | - Tanuja Chitnis
- From Partners Pediatric Multiple Sclerosis Center (G.K., T.C.), Massachusetts General Hospital; and Partners Multiple Sclerosis Center (T.C.), Brigham and Women's Hospital, Boston, MA
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de Boysson H, Parienti JJ, Arquizan C, Boulouis G, Gaillard N, Régent A, Néel A, Detante O, Touzé E, Aouba A, Bienvenu B, Guillevin L, Naggara O, Zuber M, Pagnoux C. Maintenance therapy is associated with better long-term outcomes in adult patients with primary angiitis of the central nervous system. Rheumatology (Oxford) 2017; 56:1684-1693. [PMID: 28340158 DOI: 10.1093/rheumatology/kex047] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Indexed: 11/13/2022] Open
Abstract
Objective We aimed to analyse the effect of maintenance therapy after induction on the outcomes of adult patients with primary angiitis of the CNS (PACNS). Methods We analysed long-term outcomes (relapse, survival and functional status) of patients enrolled in the French multicentre PACNS cohort who achieved remission after induction treatment and with ⩾12 months' follow-up, according to whether or not they received maintenance therapy. Good outcome was defined as relapse-free survival and good functional status (modified Rankin scale ⩽ 2) at last follow-up. Results Ninety-seven patients [46 (47%) female, median age: 46 (18-78) years at diagnosis] were followed up for a median of 55 (5-198) months. Induction treatment consisted of glucocorticoids in 95 (98%) patients, combined with an immunosuppressant in 80 (83%) patients, mostly CYC. Maintenance therapy was prescribed in 48 (49%) patients, following CYC in 42 of them. Maintenance therapy was started 4 (3-18) months after glucocorticoid initiation. At last follow-up, good outcomes were observed in 32 (67%) patients who had received maintenance therapy vs 10 (20%) who had not (P < 0.0001). Thirty-two (33%) patients experienced relapse [10 (22%) had received maintenance therapy while 22 (45%) had not, P = 0.01]; four subsequently died from relapse. In the multivariate analysis, maintenance therapy was the only independent predictor of good outcome [odds ratio (OR) = 7.8 (95% CI: 3.21, 20.36), P < 0.0001]. Conclusion The results of this long-term follow-up study suggest that maintenance therapy in adults with PACNS is associated with better functional outcomes and lower relapse rates. Further studies are needed to confirm these findings.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, University of Caen-Basse Normandie
| | | | - Caroline Arquizan
- Department of Neurology, Montpelier University Hospital Gui de Chauliac, INSERM UMR 894, Montpellier
| | - Grégoire Boulouis
- Department of Neuroradiology, Sainte-Anne Hospital Center, AP-HP, University Paris-Descartes, INSERM UMR 894, Paris
| | - Nicolas Gaillard
- Department of Neurology, Montpelier University Hospital Gui de Chauliac, INSERM UMR 894, Montpellier.,Department of Neurology, Perpignan Hospital, Perpignan
| | - Alexis Régent
- Department of Internal Medicine, Cochin Hospital Center, AP-HP, Paris
| | - Antoine Néel
- Department of Internal Medicine, Nantes University Hospital, Nantes
| | - Olivier Detante
- Department of Neurology, Grenoble Alpes University Hospital, Grenoble
| | - Emanuel Touzé
- Department of Neurology, Caen University Hospital, University of Caen-Basse Normandie, Caen
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, University of Caen-Basse Normandie
| | - Boris Bienvenu
- Department of Internal Medicine, Caen University Hospital, University of Caen-Basse Normandie
| | - Loïc Guillevin
- Department of Internal Medicine, Cochin Hospital Center, AP-HP, Paris
| | - Olivier Naggara
- Department of Neuroradiology, Sainte-Anne Hospital Center, AP-HP, University Paris-Descartes, INSERM UMR 894, Paris
| | - Mathieu Zuber
- Department of Neurology, Saint-Joseph Hospital Center, AP-HP, Université Paris-Descartes, INSERM UMR S 919, Paris
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, Toronto
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Neuroradiologic Characteristics of Primary Angiitis of the Central Nervous System According to the Affected Vessel Size. Clin Neuroradiol 2017; 29:37-44. [PMID: 28875326 DOI: 10.1007/s00062-017-0622-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/16/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) has an important impact in diagnosing primary angiitis of the central nervous system (PACNS). However, neuroradiologic findings may vary immensely, making an easy and definite diagnosis challenging. METHODS In this retrospective, single center study, we analyzed neuroradiologic findings of patients with PACNS diagnosed at our hospital between 2009 and 2014. Furthermore, we classified patients according to the affected vessel size and compared imaging characteristics between the subgroups. RESULTS Thirty-three patients were included (mean age 43 [±15.3] years, 17 females) in this study. Patients with positive angiographic findings were classified as either medium or large vessel PACNS and presented more ischemic lesions (p < 0.001) and vessel wall enhancement (p = 0.017) compared to patients with small vessel PACNS. No significant differences were detected for the distribution of contrast-enhancing lesions (parenchymal or leptomeningeal), hemorrhages, or lesions with mass effect. Twenty-five patients underwent brain biopsy. Patients with medium or large vessel PACNS were less likely to have positive biopsy results. DISCUSSION It is essential to differentiate between small and medium/large vessel PACNS since results in MRI, digital subtraction angiography and brain biopsy may differ immensely. Since image quality of MR scanners improves gradually and brain biopsy may often be nonspecific or negative, our results emphasize the importance of MRI/MRA in the diagnosis process of PACNS.
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de Boysson H, Boulouis G, Aouba A, Bienvenu B, Guillevin L, Zuber M, Touzé E, Naggara O, Pagnoux C. Adult primary angiitis of the central nervous system: isolated small-vessel vasculitis represents distinct disease pattern. Rheumatology (Oxford) 2017; 56:439-444. [PMID: 27940585 DOI: 10.1093/rheumatology/kew434] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives We aimed to identify whether presentations and outcomes in adult patients with isolated small-vessel primary angiitis of the CNS (PACNS) would differ from other patients with large/medium-vessel involvement. Methods In the French PACNS cohort, we compared the characteristics, treatments and outcomes of patients with isolated small-vessel disease (normal CT, MR and/or conventional angiograms, brain biopsy positive for vasculitis) with other patients who had large/medium-vessel involvement (vessel abnormalities on CT, MR or conventional angiograms). A good functional outcome was defined as a modified Rankin scale ⩽2 at last follow-up, regardless of the occurrence of relapse. Results Among the 102 patients in the cohort, 26 (25%) had isolated small-vessel PACNS, whereas the 76 others demonstrated large/medium-vessel involvement. Patients with isolated small-vessel PACNS had more seizures (P < 0.0001), cognitive (P = 0.02) or consciousness impairment (P = 0.03) and more dyskinesias (P = 0.002) but less focal deficits (P = 0.0002) than other PACNS patients. They also had more abnormal cerebrospinal fluid analysis (P = 0.008) and gadolinium enhancements on MRI (P = 0.001) but less frequent acute ischaemic lesions (P < 0.0001) than patients with large/medium-vessel involvement. Treatments and modified Rankin scale at last follow-up did not differ between groups. Thirty-two (31%) patients relapsed; 14 (54%) with isolated small-vessel PACNS vs 18 (24%) with large/medium-vessel involvement (P = 0.004). Eight patients died, with no difference between the groups (P = 0.97). Conclusion In our cohort, adult patients with isolated small-vessel PACNS presented some distinct disease features and relapsed more often than other PACNS patients who had large/medium-vessel involvement. Functional outcomes and mortality did not differ.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, University of Caen - Basse Normandie, Caen
| | - Grégoire Boulouis
- Department of Neuroradiology, Sainte-Anne Hospital Center, AP - HP, University Paris-Descartes, INSERM UMR 894
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, University of Caen - Basse Normandie, Caen
| | - Boris Bienvenu
- Department of Internal Medicine, Caen University Hospital, University of Caen - Basse Normandie, Caen
| | - Loïc Guillevin
- Department of Internal Medicine, Cochin Hospital Center, AP - HP
| | - Mathieu Zuber
- Department of Neurology, Saint-Joseph Hospital Center, AP - HP, Université Paris-Descartes, INSERM UMR S 919, Paris
| | - Emmanuel Touzé
- Department of Neurology, Caen University Hospital.,Inserm U919, University of Caen - Basse Normandie, Caen, France
| | - Olivier Naggara
- Department of Neuroradiology, Sainte-Anne Hospital Center, AP - HP, University Paris-Descartes, INSERM UMR 894
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada
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20
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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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Co DO, Bordini BJ, Meyers AB, Inglese C. Immune-Mediated Diseases of the Central Nervous System: A Specificity-Focused Diagnostic Paradigm. Pediatr Clin North Am 2017; 64:57-90. [PMID: 27894452 DOI: 10.1016/j.pcl.2016.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Immune-mediated diseases of the central nervous system show wide variability both symptomatically and with respect to underlying pathophysiology. Recognizing aberrant immunologic activity as the cause of neurologic dysfunction requires establishing as precise a neuroanatomic and functional phenotype as possible, and a diagnostic and therapeutic strategy that stabilizes the patient, excludes broad categories of disease via rapidly available diagnostic assays, and maintains a broad differential diagnosis that includes immune-mediated conditions. This process is aided by recognizing the appropriate clinical circumstances under which immune-mediated disease should be suspected, and how to differentiate these conditions from other causes of similar neurologic dysfunction.
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Affiliation(s)
- Dominic O Co
- Section of Pediatric Rheumatology, Department of Pediatrics, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Brett J Bordini
- Section of Hospital Medicine, Department of Pediatrics, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Arthur B Meyers
- Department of Radiology, University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA
| | - Christopher Inglese
- Section of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA
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Rosati A, Cosi A, Basile M, Brambilla A, Guerrini R, Cimaz R, Simonini G. Mycophenolate mofetil as induction and long-term maintaining treatment in childhood: Primary angiitis of the central nervous system. Joint Bone Spine 2016; 84:353-356. [PMID: 28034820 DOI: 10.1016/j.jbspin.2016.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To report our single centre experience in treating 4 children affected by childhood primary central nervous system vasculitis (cPACNS) using mycophenolate mofetil (MMF). METHODS From December 2011 to August 2015, 4 patients (3 males; age range: 9 months-13 years) affected by cPACNS were collected. Enrolled children received the following treatment protocol: acetylsalicylic acid and/or anticoagulant therapy with low molecular weight heparin (LMWH) 100 U/k BID replaced by acenocoumarol; methyl-prednisolone (30mg/kg/day for 3-5 days) followed by prednisone (2mg/kg/day), tapered and discontinued over 7-8 months; MMF used for induction therapy and subsequent maintenance phase (750-1000mg/m2 BID, half-dose for the first 10-15 days followed by full-dose). RESULTS In all children, no relapse of cerebral vasculitis occurred during the whole follow-up period and all of them improved while in MMF treatment. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), performed at 6, 9 or 12 months intervals, showed no progression or even improvement of the typical radiological findings. Medium period of MMF treatment was 29 months (range: 10-42 months). No major drug-related adverse events were documented. CONCLUSION We report for the first time on the efficacy and safety of MMF in the induction and maintenance of clinical remission in cPACNS. Our single centre experience of MMF use in treating cPACNS seems represent an appealing, alternative and safe option in this clinical setting over a long-term follow-up.
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Affiliation(s)
- Anna Rosati
- Paediatric Neurology Unit, NEUROFARBA Department, Anna Meyer Children's Hospital, University of Florence, 50139 Firenze, Italy
| | - Alessandra Cosi
- Paediatric Neurology Unit, NEUROFARBA Department, Anna Meyer Children's Hospital, University of Florence, 50139 Firenze, Italy
| | - Massimo Basile
- Radiology Unit, Anna Meyer Children's Hospital, 50139 Firenze, Italy
| | - Alice Brambilla
- Rheumatology Unit-Paediatric Section, NEUROFARBA Department, Anna Meyer Children's Hospital, University of Florence, Pieraccini street, # 24, 50139 Firenze, Italy
| | - Renzo Guerrini
- Paediatric Neurology Unit, NEUROFARBA Department, Anna Meyer Children's Hospital, University of Florence, 50139 Firenze, Italy
| | - Rolando Cimaz
- Rheumatology Unit-Paediatric Section, NEUROFARBA Department, Anna Meyer Children's Hospital, University of Florence, Pieraccini street, # 24, 50139 Firenze, Italy
| | - Gabriele Simonini
- Rheumatology Unit-Paediatric Section, NEUROFARBA Department, Anna Meyer Children's Hospital, University of Florence, Pieraccini street, # 24, 50139 Firenze, Italy.
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Chabrier S, Sébire G, Fluss J. Transient Cerebral Arteriopathy, Postvaricella Arteriopathy, and Focal Cerebral Arteriopathy or the Unique Susceptibility of the M1 Segment in Children With Stroke. Stroke 2016; 47:2439-41. [PMID: 27633022 DOI: 10.1161/strokeaha.116.014606] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Stéphane Chabrier
- From the CHU Saint-Étienne, French Center for Pediatric Stroke, Hôpital Bellevue, Saint-Étienne F-42055, France (S.C.); Child Neurology Division, Montreal Children's Hospital, McGill University, Canada (G.S.); and Pediatric Neurology Unit, Geneva University Hospitals, Children's Hospital, Genève, Switzerland (J.F.).
| | - Guillaume Sébire
- From the CHU Saint-Étienne, French Center for Pediatric Stroke, Hôpital Bellevue, Saint-Étienne F-42055, France (S.C.); Child Neurology Division, Montreal Children's Hospital, McGill University, Canada (G.S.); and Pediatric Neurology Unit, Geneva University Hospitals, Children's Hospital, Genève, Switzerland (J.F.)
| | - Joel Fluss
- From the CHU Saint-Étienne, French Center for Pediatric Stroke, Hôpital Bellevue, Saint-Étienne F-42055, France (S.C.); Child Neurology Division, Montreal Children's Hospital, McGill University, Canada (G.S.); and Pediatric Neurology Unit, Geneva University Hospitals, Children's Hospital, Genève, Switzerland (J.F.)
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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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26
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Ohno K, Saito Y, Kurata H, Saiki Y, Ohtahara H, Yoshioka H, Yamashita E, Fujii S, Maegaki Y. Vessel wall enhancement in the diagnosis and management of primary angiitis of the central nervous system in children. Brain Dev 2016; 38:694-8. [PMID: 26852378 DOI: 10.1016/j.braindev.2016.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/07/2016] [Accepted: 01/19/2016] [Indexed: 12/20/2022]
Abstract
We describe two cases of primary angiitis of the central nervous system in children (cPACNS) diagnosed by vessel wall contrast enhancement on magnetic resonance imaging (MRI). Both patients developed acute cerebral infarction after fever and malaise. In patient 1, a 7-month-old boy, MRI revealed extensive cerebral infarction in the right middle cerebral artery (MCA) area and stenosis at the M1 portion of the right MCA. Oral glucocorticoid therapy was initiated. Vessel wall enhancement was ameliorated 3months after onset, and stenosis was mostly restored. Patient 2, a 5-year-old boy, suffered from cerebral infarction in the left MCA area, and stenosis was identified in the left internal carotid artery, left MCA, and left posterior cerebral artery. Although vessel wall enhancement was reduced after glucocorticoid therapy, vessel wall enhancement of left MCA re-emerged, accompanied by increased erythrocyte sedimentation rate (ESR) and, decreased cerebral blood flow (CBF) in the affected hemisphere. Intravenous methylprednisolone therapy followed by oral glucocorticoid and mycophenolate mofetil resulted in resolution of these findings. Vessel wall enhancement is a promising finding in the diagnosis of cPACNS. Disease flares occur rarely in medium-to-large vessel cPACNS during dose tapering. Vessel wall enhancement, ESR, and CBF may be useful for the assessment of the activity of angiitis.
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Affiliation(s)
- Koyo Ohno
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan.
| | - Yoshiaki Saito
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Hirofumi Kurata
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yusuke Saiki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Hiroko Ohtahara
- Department of Pediatrics, Yasugi Municipal Hospital, Yasugi, Japan
| | - Hiroki Yoshioka
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Eijiro Yamashita
- Division of Radiology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Shinya Fujii
- Division of Radiology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshihiro Maegaki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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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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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: 25] [Impact Index Per Article: 3.1] [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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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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Chabrier S, Darteyre S, Mazzola L, Stéphan JL. [Childhood cerebral vasculitis]. Arch Pediatr 2014; 21:884-93. [PMID: 24998326 DOI: 10.1016/j.arcped.2014.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 02/27/2014] [Accepted: 05/12/2014] [Indexed: 12/29/2022]
Abstract
Central nervous system vasculitides are defined as the invasion of the vascular wall by blood-borne inflammatory cells. In childhood, they may be classified according to their trigger event (infectious vs. non-infectious), their temporal course (time-limited vs. chronic), and the size of the affected vessel. Diseases apparently confined to the central nervous system are also distinguished from secondary forms, associated with infection or rheumatic or systemic inflammatory disorders. Large-vessel vasculitis, the most frequent form, causes stroke and presents with acute focal deficits. MR, or more seldom contrast angiography is required for the positive diagnosis, while the child's medical history conveys the etiological diagnosis. The clinical manifestations of small-vessel vasculitis include headaches, seizures, focal deficits, cognitive decline, and behavior changes that can occur insidiously over a few weeks or a few months. The diagnosis is based on the associated clinical and biological symptoms in secondary forms and on cerebromeningeal biopsy in primary forms. Secondary forms of vasculitides are treated according to the etiology. The injury of large basal arteries is often observed after infection, especially varicella, and is also called transient focal cerebral arteriopathy (TCA) or post-varicella arteriopathy (PVA). This focal, monophasic, and time-limited entity is highly specific of childhood. There are no arguments in the current literature supporting the hypothesis that an aggressive immunomodulatory treatment would be more effective, in terms of recurrence rate or functional outcome, than aspirin alone. In contrast, the diffuse, prolonged, and aggressive course of the rare primary vasculitis of the central nervous system requires a prolonged immunosuppressive treatment. The management of associated symptoms, treatment-related adverse effects, and sequelae is based on a multidisciplinary approach.
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Affiliation(s)
- S Chabrier
- Pôle Couple-Mère-Enfant, hôpital Bellevue, CHU de Saint-Etienne, 42055 Saint-Etienne cedex 2, France.
| | - S Darteyre
- Pôle Couple-Mère-Enfant, hôpital Bellevue, CHU de Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - L Mazzola
- Pôle Couple-Mère-Enfant, hôpital Bellevue, CHU de Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - J-L Stéphan
- Pôle Couple-Mère-Enfant, hôpital Bellevue, CHU de Saint-Etienne, 42055 Saint-Etienne cedex 2, France
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Cellucci T, Tyrrell PN, Twilt M, Sheikh S, Benseler SM. Distinct phenotype clusters in childhood inflammatory brain diseases: implications for diagnostic evaluation. Arthritis Rheumatol 2014; 66:750-6. [PMID: 24574236 DOI: 10.1002/art.38274] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 11/05/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify distinct clusters of children with inflammatory brain diseases based on clinical, laboratory, and imaging features at presentation, to assess which features contribute strongly to the development of clusters, and to compare additional features between the identified clusters. METHODS A single-center cohort study was performed with children who had been diagnosed as having an inflammatory brain disease between June 1, 1989 and December 31, 2010. Demographic, clinical, laboratory, neuroimaging, and histologic data at diagnosis were collected. K-means cluster analysis was performed to identify clusters of patients based on their presenting features. Associations between the clusters and patient variables, such as diagnoses, were determined. RESULTS A total of 147 children (50% female; median age 8.8 years) were identified: 105 with primary central nervous system (CNS) vasculitis, 11 with secondary CNS vasculitis, 8 with neuronal antibody syndromes, 6 with postinfectious syndromes, and 17 with other inflammatory brain diseases. Three distinct clusters were identified. Paresis and speech deficits were the most common presenting features in cluster 1. Children in cluster 2 were likely to present with behavior changes, cognitive dysfunction, and seizures, while those in cluster 3 experienced ataxia, vision abnormalities, and seizures. Lesions seen on T2/fluid-attenuated inversion recovery sequences of magnetic resonance imaging were common in all clusters, but unilateral ischemic lesions were more prominent in cluster 1. The clusters were associated with specific diagnoses and diagnostic test results. CONCLUSION Children with inflammatory brain diseases presented with distinct phenotypical patterns that are associated with specific diagnoses. This information may inform the development of a diagnostic classification of childhood inflammatory brain diseases and suggest that specific pathways of diagnostic evaluation are warranted.
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Affiliation(s)
- Tania Cellucci
- McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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de Boysson H, Zuber M, Naggara O, Neau JP, Gray F, Bousser MG, Crassard I, Touzé E, Couraud PO, Kerschen P, Oppenheim C, Detante O, Faivre A, Gaillard N, Arquizan C, Bienvenu B, Néel A, Guillevin L, Pagnoux C. Primary Angiitis of the Central Nervous System: Description of the First Fifty-Two Adults Enrolled in the French Cohort of Patients With Primary Vasculitis of the Central Nervous System. Arthritis Rheumatol 2014; 66:1315-26. [DOI: 10.1002/art.38340] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 12/26/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Hubert de Boysson
- Hôpital Cochin, AP-HP, and Université Paris-Descartes, Paris, France, and Centre Hospitalier Universitaire (CHU) de Caen; Caen France
| | - Mathieu Zuber
- Groupe Hospitalier Saint-Joseph, AP-HP, and Université Paris-Descartes; Paris France
| | - Olivier Naggara
- Université Paris-Descartes, Sorbonne Paris Cité, INSERM UMR S894, and Hôpital St. Anne, AP-HP; Paris France
| | | | - Françoise Gray
- Hôpital Lariboisière, AP-HP, and Université Paris-Diderot; Paris France
| | | | - Isabelle Crassard
- Hôpital Lariboisière, AP-HP, and Université Paris-Diderot; Paris France
| | - Emmanuel Touzé
- Hôpital St. Anne, AP-HP, and Université Paris-Descartes; Paris France
| | | | - Philippe Kerschen
- CHU Henri-Mondor, AP-HP, and Université Paris-Est Créteil; Créteil France
| | - Catherine Oppenheim
- Université Paris-Descartes, Sorbonne Paris Cité, INSERM UMR S894, and Hôpital St. Anne, AP-HP; Paris France
| | | | - Anthony Faivre
- Hôpital d'Instruction des Armées St. Anne; Toulon France
| | | | - Caroline Arquizan
- Hôpital Gui de Chauliac and Université Montpellier; Montpellier France
| | | | | | - Loïc Guillevin
- Hôpital Cochin, AP-HP, and Université Paris-Descartes; Paris France
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Park MS, Marlin AE, Gaskill SJ. Angiography-negative primary angiitis of the central nervous system in childhood. J Neurosurg Pediatr 2014; 13:62-7. [PMID: 24160668 DOI: 10.3171/2013.9.peds13159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Childhood primary angiitis of the CNS is a recently characterized, potentially reversible disease process. A favorable outcome requires early diagnosis and appropriate treatment. The histological findings of childhood primary angiitis of the CNS are characterized by a lymphocytic, nongranulomatous vasculitis. This disorder can lead to neurological deficits, seizures, and strokes. Laboratory and radiographic investigation are part of the evaluation, but are often nonspecific. Conventional angiography can fail to show any abnormality, and biopsy may ultimately be required for diagnosis. Although there can be significant rates of morbidity and mortality if untreated, patients who receive appropriate therapy can experience excellent outcomes, and in many cases will demonstrate near-complete or total clinical and radiographic resolution. The case of a previously healthy 13-year-old girl with new-onset generalized tonic-clonic seizures is presented, with a review of the literature.
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Affiliation(s)
- Michael S Park
- Department of Neurosurgery & Brain Repair, Division of Pediatric Neurosurgery, Morsani College of Medicine, University of South Florida, Tampa, Florida
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Abud-Mendoza C, Herrera-VAN Oostdam D, Martínez-Martínez MU. Neuropsychiatric manifestations of systemic lupus erythematosus. J Rheumatol 2013; 40:204. [PMID: 23378497 DOI: 10.3899/jrheum.121214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Mechanisms of pediatric cerebral arteriopathy: an inflammatory debate. Pediatr Neurol 2013; 48:14-23. [PMID: 23290015 DOI: 10.1016/j.pediatrneurol.2012.06.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 06/27/2012] [Indexed: 11/21/2022]
Abstract
Arteriopathy is the leading cause of childhood arterial ischemic stroke, but its mechanisms are poorly understood. This review explores the possible role of inflammatory mechanisms and evidence for inflammatory pathophysiology in specific pediatric cerebral arteriopathies. Pathologically proven small-vessel central nervous system vasculitis provides a definitive inflammatory model where available treatments are likely improving outcomes. In contrast, a common large-vessel arteriopathy presents many features suggestive of inflammation, but definitive proof remains elusive. Recent advances and future research directions, including biomarker, neuroimaging, and pathologic approaches and how they might address these important clinical questions, are discussed.
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Cellucci T, Tyrrell PN, Pullenayegum E, Benseler SM. von Willebrand factor antigen--a possible biomarker of disease activity in childhood central nervous system vasculitis? Rheumatology (Oxford) 2012; 51:1838-45. [PMID: 22740622 DOI: 10.1093/rheumatology/kes156] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The main objective was to develop a trajectory for von Willebrand factor (vWF) antigen in childhood primary CNS vasculitis (cPACNS) after treatment and compare this with disease activity and other inflammatory markers. METHODS A single-centre cohort study of consecutive children diagnosed with cPACNS was performed. Demographic, clinical, laboratory, imaging and histological data were collected at diagnosis and during standardized clinic visits. Outcome measures included disease activity measured by physician global assessment and serial measures of vWF antigen. Analysis included descriptive statistics and parametric methods. RESULTS The study cohort consisted of 39 children diagnosed with cPACNS: 25 with angiography-negative cPACNS and 14 with angiography-positive disease. Twenty-one patients were female, median age at diagnosis was 9.8 years, and median follow-up was 18 months. All patients presented with neurological deficits. Disease activity and neurological outcome improved significantly during follow-up. vWF antigen levels were increased at diagnosis in 65% of children with cPACNS and were decreased significantly after treatment. In contrast, levels of CRP and ESR fluctuated over time. Higher vWF antigen levels at diagnosis were associated with lower measures of disease activity at 12 months. CONCLUSION In our study, all children with cPACNS improved over time. Changes in CRP and ESR, other laboratory tests, and MRI did not consistently reflect altered disease activity. However, vWF antigen may help clinicians to identify changes in disease activity during follow-up and predict treatment response. Controlled studies are necessary to evaluate the sensitivity and specificity of vWF antigen as a biomarker of disease activity.
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Affiliation(s)
- Tania Cellucci
- Division of Rheumatology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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