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Hoshina Y, Delic A, Wong KH, Lyden S, Kadish R, Smith TL, Wright MA, Shimura D, Clardy SL. Vasculitis in the Central Nervous System: Etiology, Characteristics, and Outcomes in a Large Single-Center Cohort. Neurohospitalist 2024; 14:129-139. [PMID: 38666288 PMCID: PMC11040621 DOI: 10.1177/19418744231223283] [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: 04/28/2024] Open
Abstract
Background and Purpose For the management of central nervous system (CNS) vasculitis, it is crucial to differentiate between primary and secondary CNS vasculitis and to understand the respective etiologies. We assessed the etiology, characteristics, and outcomes of patients with CNS vasculitis. Methods A single-center retrospective chart review was conducted at the University of Utah, Department of Neurology, between February 2011 and October 2022. Results The median age of the 44 included patients at diagnosis was 54 years; 25.0% were men. Compared to primary CNS vasculitis, secondary CNS vasculitis exhibits higher fever incidence (observed in infectious and connective tissue disorder [CTD]-associated vasculitis), low glucose levels (mostly in infectious vasculitis) and unique cerebrospinal fluid oligoclonal bands (observed in infectious and CTD-associated vasculitis). Patients with inflammatory cerebral amyloid angiopathy (CAA) were older and more commonly had microhemorrhage than primary angiitis of the CNS (PACNS). All patients with CTD-associated vasculitis had a known history of CTD at presentation. Brain biopsies were performed on 10 of 17 PACNS patients and 4 of 8 inflammatory CAA patients, confirming vasculitis in 7 and 4 patients, respectively. Intravenous methylprednisolone was the predominant induction therapy (63.6%), and cyclophosphamide was the most used adjunctive therapy. Cyclophosphamide, rituximab, azathioprine, and mycophenolate mofetil were utilized as maintenance therapy, often with concurrent prednisone. Patients with inflammatory CAA had a higher tendency for relapse rates than PACNS. Conclusions This study highlights the variations in patients' characteristics, symptoms, and treatment for CNS vasculitis. Understanding these differences can lead to more efficient diagnostic and management strategies.
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Affiliation(s)
- Yoji Hoshina
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Alen Delic
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Ka-Ho Wong
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Lyden
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Tammy L. Smith
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Melissa A. Wright
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Daisuke Shimura
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Stacey L. Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
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Chen LH, Spagnolo-Allende A, Yang D, Qiao Y, Gutierrez J. Epidemiology, Pathophysiology, and Imaging of Atherosclerotic Intracranial Disease. Stroke 2024; 55:311-323. [PMID: 38252756 PMCID: PMC10827355 DOI: 10.1161/strokeaha.123.043630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide. Among people with stroke, those of East Asia descent and non-White populations in the United States have a higher burden of ICAD-related stroke compared with Whites of European descent. Disparities in the prevalence of asymptomatic ICAD are less marked than with symptomatic ICAD. In addition to stroke, ICAD increases the risk of dementia and cognitive decline, magnifying ICAD societal burden. The risk of stroke recurrence among patients with ICAD-related stroke is the highest among those with confirmed stroke and stenosis ≥70%. In fact, the 1-year recurrent stroke rate of >20% among those with stenosis >70% is one of the highest rates among common causes of stroke. The mechanisms by which ICAD causes stroke include plaque rupture with in situ thrombosis and occlusion or artery-to-artery embolization, hemodynamic injury, and branch occlusive disease. The risk of stroke recurrence varies by the presumed underlying mechanism of stroke, but whether techniques such as quantitative magnetic resonance angiography, computed tomographic angiography, magnetic resonance perfusion, or transcranial Doppler can help with risk stratification beyond the degree of stenosis is less clear. The diagnosis of ICAD is heavily reliant on lumen-based studies, such as computed tomographic angiography, magnetic resonance angiography, or digital subtraction angiography, but newer technologies, such as high-resolution vessel wall magnetic resonance imaging, can help distinguish ICAD from stenosing arteriopathies.
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Affiliation(s)
- Li Hui Chen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Antonio Spagnolo-Allende
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Dixon Yang
- Department of Neurology, Rush University, Chicago, IL, USA
| | - Ye Qiao
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jose Gutierrez
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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3
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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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4
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Artiaga A, Herman F, Arquizan C, Thouvenot E, Loubet P, Le Moing V, Picot MC, Makinson A. Cerebral vasculitis as a complication of pneumococcal meningitis: A cohort study. Infect Dis Now 2023; 53:104772. [PMID: 37619963 DOI: 10.1016/j.idnow.2023.104772] [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: 04/10/2023] [Revised: 07/27/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Cerebral vasculitis (CV) is a severe complication of pneumococcal meningitis (PM); whether dexamethasone use can reduce its occurrence remains to be determined. METHODS This is a retrospective observational bicentric study analyzing all adults with proven PM hospitalized between January 2002 and December 2020 in two tertiary hospitals. Extrapolating from a standardized definition of primary angiitis of the central nervous system, we defined CV as worsened neurological symptoms associated with compatible imaging. All images were analyzed by a radiologist, and two neurologists reviewed all inconclusive cases of suspected CV for adjudication. Factors associated with CV were analyzed, including dexamethasone use. A subgroup analysis was limited to patients with a lumbar puncture at PM diagnosis. RESULTS Among 168 patients with PM, 49 (29.2%) had CV, occurring after a median of 8 days (IQR 5-13) of PM diagnosis. In multivariate analysis (N = 151), initial CRP was associated with CV (OR 1.28 per 50-unit increase, p = 0.003), which was marginally linked with delayed hospital admission more than 48 hours after first symptoms (OR 2.39, p = 0.06) and prior NSAID intake (OR 2.94, p = 0.05). Dexamethasone administration did not impact CV occurrence. In 133 patients having undergone lumbar puncture, CSF protein level > 4.4 g/L (OR 4.50, p = 0.006) was associated with CV. CONCLUSIONS In our cohort, CV was a frequent and severe complication of PM, often occurring in association with unduly delayed medical care, high CRP at admission, and high levels of protein in CSF.
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Affiliation(s)
- Agathe Artiaga
- Infectious and Tropical Diseases Department - University Hospital of Montpellier, France
| | - Fanchon Herman
- Medical Information Department - University Hospital of Montpellier, France
| | - Caroline Arquizan
- Stroke Unit, Department of Neurology, University of Montpellier, France; Paris Descartes University, INSERM 1226, Paris, France
| | - Eric Thouvenot
- Neurology Department - University Hospital of Nimes, France; Functional Genomics Institute, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Paul Loubet
- Infectious and Tropical Diseases Department - University Hospital of Nimes, France; Inserm U1047 University of Montpellier Nimes, France
| | - Vincent Le Moing
- Infectious and Tropical Diseases Department - University Hospital of Montpellier, France; Inserm U1175 University of Montpellier, Montpellier, France
| | - Marie-Christine Picot
- Medical Information Department - University Hospital of Montpellier, France; Clinical Research and Epidemiology Unit, INSERM, Clinical Investigation Centre 1411, University of Montpellier, France
| | - Alain Makinson
- Infectious and Tropical Diseases Department - University Hospital of Montpellier, France; Inserm U1175 University of Montpellier, Montpellier, France.
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Corrêa DG, de Souza SR, Freddi TDAL, Fonseca APA, Dos Santos RQ, Hygino da Cruz LC. Imaging features of neurosyphilis. J Neuroradiol 2023; 50:241-252. [PMID: 36641134 DOI: 10.1016/j.neurad.2023.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/09/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
Syphilis is an infectious disease caused by the spirochete Treponema pallidum, subspecies pallidum. Although its incidence has declined after the widespread availability of penicillin, it has recently re-emerged, especially in men who have sex with men and in people living with human immunodeficiency virus (HIV). The neurological manifestations of syphilis, generally known as neurosyphilis, may appear at any time during the infection, including the initial years after the primary infection. Neurosyphilis can be asymptomatic, only with cerebrospinal fluid abnormalities, or symptomatic, characterized by several different clinical syndromes, such as meningitis, gumma, meningovascular, brain parenchyma involvement, meningomyelitis, tabes dorsalis, and peripheral nervous system involvement. However, these syndromes may simulate several other diseases, making the diagnosis often a challenge. In addition, syphilis can also be vertically transmitted from mother to child during pregnancy, leading to neurological manifestations. Neuroimaging is essential to demonstrate abnormal brain or spinal cord findings in patients with neurosyphilis, aiding in the diagnosis, treatment, and follow-up of these patients. This article aims to review the imaging features of neurosyphilis, including the early and late stages of the infection.
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Affiliation(s)
- Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil; Department of Radiology, Federal Fluminense University, Rua Marquês de Paraná, 303, Centro, Niterói, RJ 24070-035, Brazil.
| | - Simone Rachid de Souza
- Department of Pathology, Federal University of Rio de Janeiro, Cidade Universitária da Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, Rio de Janeiro, RJ 21941-617, Brazil
| | | | - Ana Paula Alves Fonseca
- Department of Radiology, UnitedHealth Group, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
| | - Roberto Queiroz Dos Santos
- Department of Radiology, Hospital dos Servidores do Estado, Rua Sacadura Cabral, 178, Saúde, Rio de Janeiro, RJ 20221-903, Brazil; Department of Radiology, Hospital das Américas, United Health Group, Avenida Jorge Curi, 550, Barra da Tijuca, Rio de Janeiro, RJ 22775-001, Brazil
| | - Luiz Celso Hygino da Cruz
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil
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6
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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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7
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Kim NR, Kang JW, Nam EJ. Tumor-like Presentation of Cerebral Vasculitis in a Patient With Systemic Lupus Erythematosus: A Biopsy-confirmed Case. JOURNAL OF RHEUMATIC DISEASES 2023; 30:53-57. [PMID: 37476529 PMCID: PMC10351352 DOI: 10.4078/jrd.22.0022] [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: 06/15/2022] [Revised: 08/30/2022] [Accepted: 09/16/2022] [Indexed: 07/22/2023]
Abstract
Central nervous system (CNS) manifestations of systemic lupus erythematosus (SLE) are diverse and often difficult to distinguish from SLE-unrelated events. CNS vasculitis is a rare manifestation, which is seen in less than 10% of post-mortem studies, and lesions with multifocal cerebral cortical microinfarcts associated with small-vessel vasculitis are the predominant feature. However, CNS vasculitis presenting as a tumor-like mass lesion in SLE has rarely been reported. Herein, we report a case of cerebral vasculitis mimicking a brain tumor in a 39-year-old female with SLE. A biopsy of the brain mass revealed fibrinoid necrosis and leukocytoclastic vasculitis. The neurological deficits and systemic symptoms improved after treatment with corticosteroids and immunosuppressive agents. To the best of our knowledge, there are no reports of biopsy-proven cerebral vasculitis presenting as a brain mass in patients with SLE in Korea.
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Affiliation(s)
- Na Ri Kim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong Wan Kang
- Division of Rheumatology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Eon Jeong Nam
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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8
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Nehme A, Boulanger M, Aouba A, Pagnoux C, Zuber M, Touzé E, de Boysson H. Diagnostic and therapeutic approach to adult central nervous system vasculitis. Rev Neurol (Paris) 2022; 178:1041-1054. [PMID: 36156251 DOI: 10.1016/j.neurol.2022.05.003] [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: 04/20/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022]
Abstract
The clinical manifestations of central nervous system (CNS) vasculitis are highly variable. In the absence of a positive CNS biopsy, CNS vasculitis is particularly suspected when markers of both vascular disease and inflammation are present. To facilitate the clinical and therapeutic approach to this rare condition, CNS vasculitis can be classified according to the size of the involved vessels. Vascular imaging is used to identify medium vessel disease. Small vessel disease can only be diagnosed with a CNS biopsy. Medium vessel vasculitis usually presents with focal neurological signs, while small vessel vasculitis more often leads to cognitive deficits, altered level of consciousness and seizures. Markers of CNS inflammation include cerebrospinal fluid pleocytosis or elevated protein levels, and vessel wall, parenchymal or leptomeningeal enhancement. The broad range of differential diagnoses of CNS vasculitis can be narrowed based on the disease subtype. Common mimickers of medium vessel vasculitis include intracranial atherosclerosis and reversible cerebral vasoconstriction syndrome. The diagnostic workup aims to answer two questions: is the neurological presentation secondary to a vasculitic process, and if so, is the vasculitis primary (i.e., primary angiitis of the CNS) or secondary (e.g., to a systemic vasculitis, connective tissue disorder, infection, malignancy or drug use)? In primary angiitis of the CNS, glucocorticoids and cyclophosphamide are most often used for induction therapy, but rituximab may be an alternative. Based on the available evidence, all patients should receive maintenance immunosuppression. A multidisciplinary approach is necessary to ensure an accurate and timely diagnosis and to improve outcomes for patients with this potentially devastating condition.
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Affiliation(s)
- A Nehme
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France; Inserm UMR-S U1237 PhIND/BB@C, Caen, France.
| | - M Boulanger
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France; Inserm UMR-S U1237 PhIND/BB@C, Caen, France
| | - A Aouba
- Normandie University, Caen, France; Department of Internal Medicine, Caen University Hospital, Caen, France
| | - C Pagnoux
- Vasculitis clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - M Zuber
- Department of Neurology, Saint-Joseph Hospital, Paris, France; Université Paris Cité, Paris, France
| | - E Touzé
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France; Inserm UMR-S U1237 PhIND/BB@C, Caen, France
| | - H de Boysson
- Normandie University, Caen, France; Department of Internal Medicine, Caen University Hospital, Caen, France
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9
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Abouzied M, AlSalloum R, AlHarbi O, Suhaibani MA, AlMuhaideb A, Sugair AA, Qahtani MA. Fused 18F-Choline PET/MRI: A potential non-invasive biomarker imaging tool in cerebral vasculitis. Radiol Case Rep 2021; 16:3794-3797. [PMID: 34691342 PMCID: PMC8511689 DOI: 10.1016/j.radcr.2021.09.017] [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: 08/29/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022] Open
Abstract
Primary CNS vasculitis is an inflammatory brain disease commonly misdiagnosed affecting the medium and small vessels of the CNS. Due to its broad and non-specific clinical and radiological manifestations; Its diagnosis remains challenging. New diagnostic tools and biomarkers which increase specificity and facilitate the diagnosis for patients with suspected vasculitis are highly desirable to enable physicians to start therapy that can alter its potential aggressive course like immunosuppressant. This case report highlights the potential role of 18F-choline PET/MRI as a novel imaging tool that might help in the right clinical scenario in the diagnosis of this disease. Furthermore, it speculates on its secondary role in monitoring the response to immunosuppressant therapy.
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Affiliation(s)
- Moheieldin Abouzied
- Department of Radiology, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Riyadh AlSalloum
- Department of Radiology, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Omar AlHarbi
- Department of Radiology, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Mohanned Al Suhaibani
- Department of Radiology, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Ahmad AlMuhaideb
- Department of Radiology, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Abdulaziz Al Sugair
- Department of Radiology, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Mohammed Al Qahtani
- Cyclotron & Radiopharmaceuticals Department, King Faisal Specialist Hospital & Research Centre, MBC#28, P.O. Box 3354, Riyadh 11211, Saudi Arabia
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10
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Sung J, Lee D, Song JY, Lee J, Kim JH, Lee J. The Value of High-Resolution Vessel Wall Magnetic Resonance Imaging in the Diagnosis and Management of Primary Angiitis of the Central Nervous System in Children. ANNALS OF CHILD NEUROLOGY 2021. [DOI: 10.26815/acn.2021.00437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Purpose: High-resolution vessel wall-magnetic resonance imaging (VW-MRI) has been used to detect regional vessel wall pathology, significantly contributing to the diagnosis of primary angiitis of the central nervous system (PACNS) from other arteriopathies. In this study, we aimed to describe three cases of PACNS initially presenting as acute ischemic stroke, diagnosed and followed up with VW-MRI. Methods: The medical records of three patients diagnosed with PACNS were retrospectively reviewed. We also reviewed the clinical application of VW-MRI in published articles for the pediatric cases since 2016. Results: The initial presenting symptoms were headache, diplopia, confused mentality, hemiplegia, dysarthria, and dizziness. All patients had acute infarction on brain MRI, with suspicion of vasculopathy on magnetic resonance angiography. VW-MRI revealed narrowing of vessels with concentric wall thickening and diffuse enhancement in the anterior cerebral artery (n=1), middle cerebral artery (n=1), posterior cerebral artery (n=2), lenticulostriate artery (n=1), anterior inferior cerebellar artery (n=1), and vertebral artery (n=1), suggestive of vascular wall pathology. After excluding the possible etiologies of vasculitis, the clinical diagnosis of PACNS was established. Three patients received high-dose steroid and cyclophosphamide therapy. Two patients were treated with long-term azathioprine based upon the findings of persistent vessel enhancement on VW-MRI. All patients were regularly followed up with VW-MRI for more than 1 year. We summarized the clinical and radiological features of the published pediatric cases using VW-MRI to date. Conclusion: High-resolution VW-MRI plays an important role in diagnosing childhood PACNS, as results correlate with disease activity.
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11
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Sánchez-Román E, Monternach-Aguilar F, Reyes-Vaca JG, Rodríguez Leyva I. Challenging presentation of primary vasculitis of the central nervous system. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2021; 2:100027. [PMID: 36324727 PMCID: PMC9616383 DOI: 10.1016/j.cccb.2021.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 05/01/2021] [Accepted: 05/02/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To show a patient with a diagnosis of primary vasculitis of the nervous system and review this entity's literature. CLINICAL CASE Male 32 years, with two events; first, with a transient monoparesis of the right upper extremity, improve with steroids in days. Now, with a motor Jacksonian progression from the upper to the lower right extremities and generalized seizures. After; aphasia, right hemiparesis, and delirium. In the antiresonance, the finding of multiple arterial cerebral "beading." With an in-depth study, the diagnosis of primary cerebral vasculitis was made. The management with levetiracetam, steroids, and Azathioprine offers a satisfactory evolution. DISCUSSION The primary CNS vasculitis is an exclusion diagnosis, with angio-MRI is possible to suspect it, but it is always obligate to discard a secondary etiology by infection, systemic diseases, neoplasia, and drugs. CONCLUSION Although this problem is infrequent, we must consider this possibility. Opportune treatment can restore the quality of life.
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Affiliation(s)
- Edgar Sánchez-Román
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto”, Avenida Venustiano Carranza 2405 L, San Luis Potosi 78210, Mexico
- Biochemistry laboratory, Facultad de Medicina de la Universidad Autónoma de San Luis Potosí, Mexico
| | - Felipe Monternach-Aguilar
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto”, Avenida Venustiano Carranza 2405 L, San Luis Potosi 78210, Mexico
- Biochemistry laboratory, Facultad de Medicina de la Universidad Autónoma de San Luis Potosí, Mexico
| | | | - Ildefonso Rodríguez Leyva
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto”, Avenida Venustiano Carranza 2405 L, San Luis Potosi 78210, Mexico
- Biochemistry laboratory, Facultad de Medicina de la Universidad Autónoma de San Luis Potosí, Mexico
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12
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Diagnosis and follow-up evaluation of central nervous system vasculitis: an evaluation of vessel-wall MRI findings. J Neurol 2021; 269:982-996. [PMID: 34236502 PMCID: PMC8264821 DOI: 10.1007/s00415-021-10683-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/14/2023]
Abstract
Objective To approach the clinical value of MRI with vessel wall imaging (VWI) in patients with central nervous system vasculitis (CNSV), we analyzed patterns of VWI findings both at the time of initial presentation and during follow-up. Methods Stenoocclusive lesions, vessel-wall contrast enhancement (VW-CE) and diffusion-restricted lesions were analyzed in patients with a diagnosis of CNSV. On available VWI follow-up, progression, regression or stability of VW-CE were evaluated and correlated with the clinical status. Results Of the 45 patients included, 28 exhibited stenoses visible on MR angiography (MRA-positive) while 17 had no stenosis (MRA-negative). VW-CE was found in 2/17 MRA-negative and all MRA-positive patients (p < 0.05). 79.1% (53/67) of stenoses showed VW-CE. VW-CE was concentric in 88.3% and eccentric in 11.7% of cases. Diffusion-restricted lesions were found more frequently in relation to stenoses with VW-CE than without VW-CE (p < 0.05). 48 VW-CE lesions in 23 patients were followed over a median time of 239.5 days. 13 VW-CE lesions (27.1%) resolved completely, 14 (29.2%) showed partial regression, 17 (35.4%) remained stable and 4 (8.3%) progressed. 22/23 patients received immunosuppressive therapy for the duration of follow-up. Patients with stable or progressive VW-CE were more likely (p < 0.05) to have a relapse (14/30 cases) than patients with partial or complete regression of VW-CE (5/25 cases). Conclusion Concentric VW-CE is a common finding in medium/large-sized vessel CNSV. VW-CE might represent active inflammation in certain situations. However, follow-up VWI findings proved ambiguous as persisting VW-CE despite immunosuppressive therapy and clinical remission was a frequent finding. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10683-7.
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13
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Abstract
A 47-year-old woman, who was diagnosed to have systemic lupus erythematosus (SLE), was admitted because she suffered a severe ischemic stroke three weeks after experiencing a transient attack of aphasia. Diffusion-weighted MRI revealed high intensity at the borderzone of the middle cerebral artery (MCA), while the proximal portion of the left MCA was occluded with its vascular wall enhanced by gadolinium. Intravenous methylprednisolone and heparin were administrated without any symptomatic benefit. She developed severe right hemiparesis with aphasia. Isolated cerebral vasculitis in the large vessel has been rarely reported in SLE patients. The presence of an enhanced vascular wall in the MRI with gadolinium could support the diagnosis.
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Affiliation(s)
- Sho Takeshita
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
| | - Toshiyasu Ogata
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
| | - Jun Tsugawa
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
| | - Yoshio Tsuboi
- Department of Neurology, Faculty of Medicine, Fukuoka University, Japan
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14
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Jewells VL, Latchaw RE. CNS Vasculitis-An Overview of This Multiple Sclerosis Mimic: Clinical and MRI Implications. Semin Ultrasound CT MR 2020; 41:296-308. [PMID: 32448486 DOI: 10.1053/j.sult.2020.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This article discusses central nervous system vasculitis, a clinical and MRI mimic of multiple sclerosis (MS). There is a paucity of discussion of vasculitis in the radiology literature, and many MS neurologists believe that vasculitis is underdiagnosed. Therefore, the authors hope that the readers will find this paper increases their knowledge about CNS vasculitis and improves their ability to differentiate MS from vasculitis.
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15
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Stroke and temporal arteritis: A study of 6 cases. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2019.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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16
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García-Serrano J, Muñoz de Escalona-Rojas J, Callejas-Rubio J, Barrero-Hernández F. Optical coherence tomography angiography in the early diagnosis of Susac syndrome. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Kalashnikova LA, Dobrynina LA, Legenko MS. [Primary central nervous system vasculitis]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:113-123. [PMID: 31626179 DOI: 10.17116/jnevro2019119081113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Primary vasculitis (angiitis) of the central nervous system (PACNS) is a rare disease targeting the vessels of the brain, spinal cord and leptomeninges without systemic involvement. The etiology is not clear enough. The authors review clinical, laboratory and radiological features of PACNS. Clinical manifestations are variable and depend on the caliber of affected vessels. The main clinical manifestations of small sized vessel vasculitis include encephalopathy (cognitive disorders, epileptic seizures), headache and transient cerebral ischemia. The main clinical presentation of vasculitis of medium/large cerebral arteries is ischemic strokes, which usually develop in different vascular territories. CSF findings in the majority of patients show modest lymphocytic pleocytosis, elevated protein level and occasionally the presence of oligoclonal bands. MRI data are not specific and include infarcts, hyperintensity (FLAIR) and sometimes tumor-like lesions. The gold standard for the verification of PACNS affected small-sized arteries is brain and leptomeningeal biopsy. Cerebral angiography allows the verification of vasculitis of medium and large cerebral arteries revealing segmental narrowings (beading). High resolution black blood MRI before and after contrast injection may visualize intracranial vessel wall contrast enhancement - the sign of inflammation in intracranial arteries. Treatment of PACNS includes corticosteroids and cyclophosphamide. In the case of patient intolerance, rituximab and blockers of tumor necrosis factor may be used.
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Affiliation(s)
| | | | - M S Legenko
- Research Center of Neurology, Moscow, Russia
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18
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Mullin E, Aristotelidou V, Blackburn D, Jenkins T, Hadjivassiliou M. Cognitive deficits in vasculitis of the nervous system: a cross-sectional study. Postgrad Med 2019; 131:546-549. [PMID: 31483199 DOI: 10.1080/00325481.2019.1664256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: To identify the cognitive and functional deficits in a well-characterized group of patients with vasculitis of the nervous system. Methods: Sixty-seven patients diagnosed with Central Nervous System (CNS) or Peripheral nervous System (PNS) vasculitis over a 14-year period were retrospectively identified. Data on clinical presentation, laboratory, radiographic and tissue biopsy investigations, and treatment were collated. Cognitive, functional and quality of life evaluation assessments were performed in 31 patients who agreed to participate and included Addenbrooke's Cognitive Examination-revised (ACE-R), Nottingham Extended Activities of Daily Living (NEADL) and EQ-5D-3L quality of life questionnaires. Results: CNS vasculitis patients exhibited cognitive impairment, with a mean ACE-R score of 74/100 (standard deviation (SD) 16). NEADL and EQ-5D-3L scores were in the impaired range at 41/66 (SD 21) and 57/81 (SD 22), respectively. Patients with just PNS vasculitis exhibited fewer cognitive deficits with ACE-R and NEADL scores of 87 (SD 8) and 46 (SD 16) respectively. EQ-5D-3L score was in the impaired range of 65 (SD 22). Conclusions: Vasculitis of the nervous system and, in particular, CNS vasculitis causes cognitive impairment and deficits in functional ability. Such patients should be targeted for cognitive rehabilitation.
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Affiliation(s)
- Edward Mullin
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK
| | | | - Daniel Blackburn
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital , Sheffield , UK
| | - Thomas Jenkins
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital , Sheffield , UK
| | - Marios Hadjivassiliou
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital , Sheffield , UK
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19
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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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20
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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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21
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Abstract
The landscape of human immunodeficiency virus (HIV) infection is changing with the increasing coverage of antiretroviral therapy (ART). Patients are living longer but continually exposed to a virologically suppressed HIV infection. This has resulted in a decrease in acquired immune deficiency syndrome (AIDS)-related complications such as opportunistic infections, and an increase in non-AIDS complications such as stroke. In this era, stroke is perhaps the most important neurologic complication of HIV infection. Furthermore, stroke is more of a heterogeneous disease in people living with HIV infection and therefore needs to be approached systematically. Many of the etiologies are treatable. HIV-associated vasculopathy is perhaps the most common etiology in this population and our understanding of this is still evolving. Moreover, the treatment of HIV infection may contribute to an excess risk of stroke and interact with stroke therapies.
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Affiliation(s)
- Laura Benjamin
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
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22
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Optical coherence tomography angiography in the early diagnosis of Susac syndrome. Neurologia 2017; 35:62-63. [PMID: 28958398 DOI: 10.1016/j.nrl.2017.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 07/24/2017] [Indexed: 11/24/2022] Open
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23
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Lago A, Tembl JI, Fortea G, Morales L, Nieves C, Campins M, Aparici F. Stroke and temporal arteritis: A study of 6 cases. Neurologia 2017; 35:75-81. [PMID: 28869044 DOI: 10.1016/j.nrl.2017.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/10/2017] [Accepted: 06/15/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Though uncommon, ischaemic stroke due to temporal arteritis carries serious difficulties for diagnosis and subsequent management and requires a high level of suspicion. METHODS We analysed a series of 6 patients with biopsy-proven temporal arteritis presenting with ischaemic stroke. We discuss clinical characteristics, difficulties of assessment, short- and long-term progression, treatment, and the usefulness of new diagnostic techniques. RESULTS Our sample of 6 patients had a mean age of 68.3 years; 50% were women. The majority of patients showed systemic symptoms. Anterior and posterior circulation were affected similarly. MRI angiography, Doppler sonography, and PET-CT proved to be very useful for diagnosis and treatment. Mean follow-up time was 26 months. Clinical outcomes were far from good: 33% scored≥3 on the modified Rankin scale, including one death. Two patients had recurrent stroke despite treatment with full doses of corticosteroids, and 2 underwent angioplasty. CONCLUSIONS Stroke caused by giant cell arteritis is a serious and potentially severe condition which requires a high level of suspicion and early treatment with corticosteroids. New diagnostic techniques contribute to refining patient assessment and identifying the optimal treatment. Endovascular treatment may be a valid therapeutic option in selected patients.
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Affiliation(s)
- A Lago
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España.
| | - J I Tembl
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - G Fortea
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - L Morales
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - C Nieves
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - M Campins
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - F Aparici
- Servicio de Radiología, Hospital Universitario La Fe, Valencia, España
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24
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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: 17] [Impact Index Per Article: 2.4] [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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25
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Taschner CA, Süß P, Sajonz B, Urbach H, Simon-Gabriel CP, Prinz M. Freiburg Neuropathology Case Conference. Clin Neuroradiol 2017; 27:245-250. [DOI: 10.1007/s00062-017-0589-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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26
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Boulouis G, de Boysson H, Zuber M, Guillevin L, Meary E, Costalat V, Pagnoux C, Naggara O. Primary Angiitis of the Central Nervous System. Stroke 2017; 48:1248-1255. [DOI: 10.1161/strokeaha.116.016194] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/18/2017] [Accepted: 02/02/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Primary angiitis of the central nervous system remains challenging. To report an overview and pictorial review of brain magnetic resonance imaging findings in adult primary angiitis of the central nervous system and to determine the distribution of parenchymal, meningeal, and vascular lesions in a large multicentric cohort.
Methods—
Adult patients from the French COVAC cohort (Cohort of Patients With Primary Vasculitis of the Central Nervous System), with biopsy or angiographically proven primary angiitis of the central nervous system and brain magnetic resonance imaging available at the time of diagnosis were included. A systematic imaging review was performed blinded to clinical data.
Results—
Sixty patients met inclusion criteria. Mean age was 45 years (±12.9). Patients initially presented focal deficit(s) (83%), headaches (53%), cognitive disorder (40%), and seizures (38.3%). The most common magnetic resonance imaging finding observed in 42% of patients was multiterritorial, bilateral, distal acute stroke lesions after small to medium artery distribution, with a predominant carotid circulation distribution. Hemorrhagic infarctions and parenchymal hemorrhages were also frequently found in the cohort (55%). Acute convexity subarachnoid hemorrhage was found in 26% of patients and 42% demonstrated pre-eminent leptomeningeal enhancement, which is found to be significantly more prevalent in biopsy-proven patients (60% versus 28%;
P
=0.04). Seven patients had tumor-like presentations. Seventy-seven percent of magnetic resonance angiographic studies were abnormal, revealing proximal/distal stenoses in 57% and 61% of patients, respectively.
Conclusions—
Adult primary angiitis of the central nervous system is a heterogenous disease, with multiterritorial, distal, and bilateral acute stroke being the most common pattern of parenchymal lesions found on magnetic resonance imaging. Our findings suggest a higher than previously thought prevalence of hemorrhagic transformation and other hemorrhagic manifestations.
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Affiliation(s)
- Grégoire Boulouis
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Hubert de Boysson
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Mathieu Zuber
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Loïc Guillevin
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Eric Meary
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Vincent Costalat
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Christian Pagnoux
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
| | - Olivier Naggara
- From the Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France (G.B., E.M., O.N.); Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Basse Normandie, France (H.d.B.); Department of Vascular Neurology, Centre Hospitalier Saint Joseph, Paris, France (M.Z.); Department of Internal Medicine, Centre Hospitalier Cochin, Paris, France (L.G.); Department of Neuroradiology, Centre Hospitalier
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Rodrigues M, Galego O, Costa C, Jesus D, Carvalho P, Santiago M, Malcata A, Inês L. Central nervous system vasculitis in systemic lupus erythematosus: a case series report in a tertiary referral centre. Lupus 2017; 26:1440-1447. [DOI: 10.1177/0961203317694259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Central nervous system (CNS) vasculitis (CNS) in systemic erythematosus lupus (SLE) is a rare and challenging diagnosis. We report four cases of CNS vasculitis that occurred 5 to 16 years after the diagnosis of SLE. Magnetic resonance imaging (MRI) detected different features suggestive of CNS vasculitis: enhancement and thickening of the vascular wall, vascular stenosis, ischemic brain lesions and intracerebral haemorrhage unlikely to correspond to other mimic aetiologies. Three patients received combination therapy with glucocorticoids (GC) and cyclophosphamide (CYC). Intravenous human immunoglobulin (IVIG) was administered when the patient had a past history of serious adverse event to CYC or high infectious risk. All patients showed imagiological improvement, at least partially, 5 to 23 days after starting treatment. We discuss the management of CNS in SLE including the role of magnetic resonance imaging (MRI).
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Affiliation(s)
- M Rodrigues
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - O Galego
- Neuroradiology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - C Costa
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - D Jesus
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - P Carvalho
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - M Santiago
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - A Malcata
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - L Inês
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
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Gaudino S, Gangemi E, Colantonio R, Botto A, Ruberto E, Calandrelli R, Martucci M, Vita MG, Masullo C, Cerase A, Colosimo C. Neuroradiology of human prion diseases, diagnosis and differential diagnosis. Radiol Med 2017; 122:369-385. [PMID: 28110369 DOI: 10.1007/s11547-017-0725-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/03/2017] [Indexed: 01/14/2023]
Abstract
Human transmissible spongiform encephalopathies (TSEs), or prion diseases, are invariably fatal conditions associated with a range of clinical presentations. TSEs are classified as sporadic [e.g. sporadic Creutzfeldt-Jakob disease (sCJD), which is the most frequent form], genetic (e.g. Gerstmann-Straussler-Scheinker disease, fatal familial insomnia, and inherited CJD), and acquired or infectious (e.g. Kuru, iatrogenic CJD, and variant CJD). In the past, brain imaging played a supporting role in the diagnosis of TSEs, whereas nowadays magnetic resonance imaging (MRI) plays such a prominent role that MRI findings have been included in the diagnostic criteria for sCJD. Currently, MRI is required for all patients with a clinical suspicion of TSEs. Thus, MRI semeiotics of TSEs should become part of the cultural baggage of any radiologist. The purposes of this update on the neuroradiology of CJD are to (i) review the pathophysiology and clinical presentation of TSEs, (ii) describe both typical and atypical MRI findings of CJD, and (iii) illustrate diseases mimicking CJD, underlining the MRI key findings useful in the differential diagnosis.
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Affiliation(s)
- Simona Gaudino
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Emma Gangemi
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Raffaella Colantonio
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Annibale Botto
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Emanuela Ruberto
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Rosalinda Calandrelli
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Matia Martucci
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Maria Gabriella Vita
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Carlo Masullo
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Alfonso Cerase
- Unit of Neuroimaging and Neurointervention, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Università Senese, "Santa Maria alle Scotte" University and NHS Hospital, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Cesare Colosimo
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
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Dutra LA, de Souza AWS, Grinberg-Dias G, Barsottini OGP, Appenzeller S. Central nervous system vasculitis in adults: An update. Autoimmun Rev 2017; 16:123-131. [PMID: 28087351 DOI: 10.1016/j.autrev.2016.12.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 09/08/2016] [Indexed: 11/27/2022]
Abstract
Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis includes reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show that data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.
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Affiliation(s)
- Lívia Almeida Dutra
- General Neurology Division, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Simone Appenzeller
- Rheumatology Division, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil.
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Abstract
Cerebral vasculitis can have a variety of origins. Furthermore, there are no vasculitis-specific symptoms or imaging signs and vasculitis of the CNS can mimic many other neurological diseases, which require different treatment approaches. Thus, the clinical and radiological diagnosis of cerebral vasculitis is challenging. Magnetic resonance imaging (MRI) and MR angiography (MRA) should be the radiological imaging methods of choice to assess the degree of parenchymal damage and to detect vessel wall changes. If the results are unclear digital subtraction angiography (DSA) should be pursued in order to also detect changes in medium sized vessels. Vasculitis of small vessels cannot be detected by vascular imaging and requires brain or leptomeningeal biopsy. In this review we present the current diagnostic approach and a variety of imaging findings in cerebral vasculitis and discuss the main radiological differential diagnoses.
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Ferri C, Ramos-Casals M, Zignego AL, Arcaini L, Roccatello D, Antonelli A, Saadoun D, Desbois AC, Sebastiani M, Casato M, Lamprecht P, Mangia A, Tzioufas AG, Younossi ZM, Cacoub P. International diagnostic guidelines for patients with HCV-related extrahepatic manifestations. A multidisciplinary expert statement. Autoimmun Rev 2016; 15:1145-1160. [PMID: 27640316 DOI: 10.1016/j.autrev.2016.09.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 07/19/2016] [Indexed: 02/08/2023]
Abstract
Hepatitis C virus (HCV) infection is responsible for both hepatic and extra-hepatic disorders (HCV-EHDs); these latter are correlated on one hand clearly with HCV lymphotropism causing immune-system dysregulation as well as with viral oncogenic potential, and on the other hand probably with chronic inflammatory status causing cardio-metabolic complications as well as neurocognitive disturbances. The spectrum of HCV-EHDs ranges from mild or moderate manifestations, such as arthralgia, sicca syndrome, peripheral neuropathy, to severe, life-threatening complications, mainly vasculitis and neoplastic conditions. Given the clinical heterogeneity of HCV-EHDs, HCV-infected individuals are inevitably referred to different specialists according to the presenting/prevalent symptom(s); therefore, the availability of comprehensive diagnostic guidelines is necessary for a patient's whole assessment that is decisive for early diagnosis and correct therapeutic approach of various hepatic and HCV-EHDs, regardless of the specific competencies of different physicians or referral centers. In this respect, a multidisciplinary network of experts, the International Study Group of Extrahepatic Manifestations Related to Hepatitis C Virus Infection (ISG-EHCV), was organized with the intention to formulate diagnostic guidelines for the work-up of possible HCV-EHDs. There was a broad consensus among ISG-EHCV members on the proposed guidelines, which essentially are based on two main levels of patient's assessment. At the referral stage, it is proposed that all patients with HCV infection should be invariably examined by means of first-line diagnostic procedures including virological and hepatic parameter evaluation, as well as the detection of clinical findings that may suggest one or more HCV-EHDs. This preliminary assessment should reveal specific HCV-EHDs, which will be deeper analyzed by means of second-line, targeted investigations. The proposed multidisciplinary expert statement represents the first attempt to draw comprehensive diagnostic guidelines for HCV-infected individuals encompassing the entire spectrum of HCV-related disorders, namely typical hepatic manifestations along with less common, often unpredictable HCV-EHDs. The HCV-EHDs may compromise to a substantial degree the overall disease outcome in a significant number of HCV-infected individuals that renders their timely identification and treatment an imperative. In conclusion, the application of standardized but thorough diagnostic guidelines of HCV-EHDs is advisable at the referral stage as well as during the follow-up period of HCV infected patients. It is envisioned that the proposed strategy will result in improvement of clinical outcomes in such patients.
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Affiliation(s)
- Clodoveo Ferri
- Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41124 Modena, Italy.
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD Josep Font Autoimmune Lab, CELLEX-IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Anna Linda Zignego
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luca Arcaini
- Department of Molecular Medicine, University of Pavia, Italy; Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases, and Nephrology and Dialysis Unit, San G. Bosco Hospital and University of Turin, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, Pisa 56126, Italy
| | - David Saadoun
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632 Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - Anne Claire Desbois
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632 Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - Marco Sebastiani
- Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41124 Modena, Italy
| | - Milvia Casato
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185 Rome, Italy.
| | - Peter Lamprecht
- Department of Rheumatology & Vasculitis Center, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Alessandra Mangia
- Liver Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy.
| | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, 75 M. Asias st, Building 16, Room 32, 11527 Athens, Greece.
| | - Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital; Beatty Liver and Obesity Program, Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Patrice Cacoub
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632 Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
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Treitl KM, Maurus S, Sommer NN, Kooijman-Kurfuerst H, Coppenrath E, Treitl M, Czihal M, Hoffmann U, Dechant C, Schulze-Koops H, Saam T. 3D-black-blood 3T-MRI for the diagnosis of thoracic large vessel vasculitis: A feasibility study. Eur Radiol 2016; 27:2119-2128. [PMID: 27510630 DOI: 10.1007/s00330-016-4525-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the feasibility of T1w-3D black-blood turbo spin echo (TSE) sequence with variable flip angles for the diagnosis of thoracic large vessel vasculitis (LVV). METHODS Thirty-five patients with LVV, diagnosed according to the current standard of reference, and 35 controls were imaged at 3.0T using 1.2 × 1.3 × 2.0 mm3 fat-suppressed, T1w-3D, modified Volumetric Isotropic TSE Acquisition (mVISTA) pre- and post-contrast. Applying a navigator and peripheral pulse unit triggering (PPU), the total scan time was 10-12 min. Thoracic aorta and subclavian and pulmonary arteries were evaluated for image quality (IQ), flow artefact intensity, diagnostic confidence, concentric wall thickening and contrast enhancement (CWT, CCE) using a 4-point scale. RESULTS IQ was good in all examinations (3.25 ± 0.72) and good to excellent in 342 of 408 evaluated segments (83.8 %), while 84.1 % showed no or minor flow artefacts. The interobserver reproducibility for the identification of CCE and CWT was 0.969 and 0.971 (p < 0.001) with an average diagnostic confidence of 3.47 ± 0.64. CCE and CWT were strongly correlated (Cohen's k = 0.87; P < 0.001) and significantly more frequent in the LVV-group (52.8 % vs. 1.0 %; 59.8 % vs. 2.4 %; P < 0.001). CONCLUSIONS Navigated fat-suppressed T1w-3D black-blood MRI with PPU-triggering allows diagnosis of thoracic LVV. KEY POINTS • Cross-sectional imaging is frequently applied in the diagnosis of LVV. • Navigated, PPU-triggered, T1w-3D mVISTA pre- and post contrast takes 10-12 min. • In this prospective, single-centre study, T1w-3D mVISTA accurately depicted large thoracic vessels. • T1w-3D mVISTA visualized CWT/CCW as correlates of mural inflammation in LVV. • T1w-3D mVISTA might be an alternative diagnostic tool without ionizing radiation.
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Affiliation(s)
- Karla Maria Treitl
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany. .,German Center for Cardiovascular Disease Research (DZHK e. V.), Pettenkoferstr. 8a, 80336, Munich, Germany.
| | - Stefan Maurus
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Nora Narvina Sommer
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | | | - Eva Coppenrath
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Marcus Treitl
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Michael Czihal
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Ulrich Hoffmann
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Claudia Dechant
- Division of Rheumatology and Clinical Immunology, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Tobias Saam
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany.,German Center for Cardiovascular Disease Research (DZHK e. V.), Pettenkoferstr. 8a, 80336, Munich, Germany
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Vascularite cérébrale : une complication rare de la méningite à Streptococcus pneumoniae. Med Mal Infect 2016; 46:170-1. [DOI: 10.1016/j.medmal.2016.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 11/18/2022]
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Goll C, Thormann M, Hofmüller W, Friebe B, Behrens-Baumann W, Bley TA, Hoffmann MB, Speck O. Feasibility study: 7 T MRI in giant cell arteritis. Graefes Arch Clin Exp Ophthalmol 2016; 254:1111-6. [DOI: 10.1007/s00417-016-3337-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/20/2016] [Accepted: 03/28/2016] [Indexed: 11/24/2022] Open
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Okunomiya T, Kageyama T, Tanaka K, Kambe D, Shinde A, Suenaga T. [Lymphocytic primary angiitis of the central nervous system with fan-shaped linear enhancement converging to the lateral ventricles: a case report]. Rinsho Shinkeigaku 2015; 54:709-14. [PMID: 25283824 DOI: 10.5692/clinicalneurol.54.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of lymphocytic primary angiitis of the central nervous system (PACNS) with a characteristic gadolinium-enhancement pattern on magnetic resonance imaging (MRI). A 48-year-old, right-handed man presented with a 3-month history of tremor and progressing dementia. Neurologic examination revealed cognitive decline with anterograde amnesia and postural tremor of the fingers. Except for the positive result of serum antinuclear antibody, intense investigations for infectious, rheumatic and neoplastic diseases were negative. Analysis of cerebrospinal fluid showed mild pleocytosis (14 cells/μl). Brain MRI revealed diffuse hyperintense areas in the deep cerebral white matter on T2-weighted images. Gadolinium-enhanced T1-weighted images demonstrated fan-shaped multiple linear enhancements converging to the body of the lateral ventricles. Brain biopsy showed intense infiltration of small lymphocytes without atypia or granuloma mainly within the vessel walls and perivascular spaces. The diagnosis of lymphocytic PACNS was made. Administration of corticosteroid markedly improved the tremor and cognitive dysfunction. MRI after the treatment showed resolution of the abnormal fan-shaped linear enhancement. He returned to his previous occupation. PACNS should be included in the differential diagnosis for fan-shaped linear enhancement converging to the lateral ventricles on MRI in patients with unexplained progressing dementia.
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Salamon N. Neuroimaging of cerebral small vessel disease. Brain Pathol 2015; 24:519-24. [PMID: 25323667 DOI: 10.1111/bpa.12179] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 07/14/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Noriko Salamon
- David Geffen School of Medicine, UCLA Health System, Los Angeles, CA
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37
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38
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Mikdashi JA. Primary angiitis of the central nervous system. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00164-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Siemonsen S, Brekenfeld C, Holst B, Kaufmann-Buehler AK, Fiehler J, Bley TA. 3T MRI reveals extra- and intracranial involvement in giant cell arteritis. AJNR Am J Neuroradiol 2014; 36:91-7. [PMID: 25169925 DOI: 10.3174/ajnr.a4086] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The frequency and amount of intracranial, intradural inflammatory vessel wall enhancement in giant cell arteritis remain unclear. The purpose of this work was to prospectively assess the intracranial extent of vasculitic changes in patients with giant cell arteritis using a dedicated MR imaging protocol optimized for assessment of mural changes of intracranial arteries. MATERIALS AND METHODS Twenty-eight patients with suspected giant cell arteritis underwent 3T MR imaging. Imaging included a fat-saturated T1WI pre- and postcontrast application optimized for assessment of intradural vessel wall enhancement and high-resolution fat-saturated T1WI to evaluate superficial extracranial vessels. Temporal artery biopsies were available in 11 cases. Vessel wall enhancement of intradural and extracranial vessels was evaluated by 2 observers independently. RESULTS Twenty patients had giant cell arteritis; 9 cases were biopsy-proved. Clear vessel wall enhancement of superficial extracranial and intradural internal carotid arteries was detected in 16 and 10 patients, respectively. Slight vessel wall enhancement of the vertebral arteries was seen. Of 9 patients with giant cell arteritis with vessel occlusion or stenosis, 2 presented with cerebral ischemic infarcts. Vessel occlusion or stenosis site coincided with the location of vessel wall enhancement of the vertebral arteries in 4 patients and of the intradural ICA in 1 patient. CONCLUSIONS Vessel wall enhancement of intradural arteries, mainly the ICA, can be regularly found in patients with giant cell arteritis. Mural inflammatory changes of the intradural ICA detected on MR imaging may identify a subgroup of patients with giant cell arteritis and should be further evaluated in clinical studies.
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Affiliation(s)
- S Siemonsen
- From the Department of Diagnostic and Interventional Neuroradiology (S.S., T.A.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C Brekenfeld
- Department of Diagnostic and Interventional Radiology (C.B., B.H., A.-K.K.-B., J.F.), University Hospital of Würzburg, Würzburg, Germany
| | - B Holst
- Department of Diagnostic and Interventional Radiology (C.B., B.H., A.-K.K.-B., J.F.), University Hospital of Würzburg, Würzburg, Germany
| | - A-K Kaufmann-Buehler
- Department of Diagnostic and Interventional Radiology (C.B., B.H., A.-K.K.-B., J.F.), University Hospital of Würzburg, Würzburg, Germany
| | - J Fiehler
- Department of Diagnostic and Interventional Radiology (C.B., B.H., A.-K.K.-B., J.F.), University Hospital of Würzburg, Würzburg, Germany
| | - T A Bley
- From the Department of Diagnostic and Interventional Neuroradiology (S.S., T.A.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Noh HJ, Choi JW, Kim JP, Moon GJ, Bang OY. Role of high-resolution magnetic resonance imaging in the diagnosis of primary angiitis of the central nervous system. J Clin Neurol 2014; 10:267-71. [PMID: 25045382 PMCID: PMC4101106 DOI: 10.3988/jcn.2014.10.3.267] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 05/02/2013] [Accepted: 05/03/2013] [Indexed: 11/17/2022] Open
Abstract
Background Primary angiitis of the central nervous system (PACNS) is a rare disorder and is often difficult to diagnose due to the lack of a confirmatory test. PACNS can generally be diagnosed based on typical angiographic findings. We describe herein a patient diagnosed with PACNS despite the presence of normal findings on conventional angiography. Case Report A 44-year-old man with a recent history of ischemic stroke in the right posterior cerebral artery territory developed acute-onset vertigo. Diffusion-weighted imaging revealed an acute infarction within the left posterior inferior cerebellar artery. His medical history was unremarkable except for hyperlipidemia; the initial examination revealed mild gait imbalance. During the 10 days of hospital admission, the patient experienced four recurrent ischemic strokes within the posterior circulation territory (occipital lobe, pons, and cerebellum). He was diagnosed with recurrent cerebral infarctions due to PACNS. The basilar artery exhibited no demonstrable luminal stenosis, but there were direct imaging signs of central nervous system angiitis including wall thickening and contrast enhancement. High-dose intravenous steroid therapy followed by oral prednisolone was administered. There was no further stroke recurrence and follow-up imaging of the arterial walls showed normalization of their characteristics. Conclusions The present case emphasizes the importance of wall imaging in the diagnosis and treatment of PACNS.
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Affiliation(s)
- Hyun Jin Noh
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Wook Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Pyo Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong Joon Moon
- Clinical Research Center, Samsung Biomedical Research Institute, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Mattle HP, Brainin M, Chamorro A, Dichgans M, Lees KR, Leys D, Michel P. Second European Stroke Science Workshop. Stroke 2014; 45:e113-22. [DOI: 10.1161/strokeaha.114.005583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Heinrich P. Mattle
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
| | - Michael Brainin
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
| | - Angel Chamorro
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
| | - Martin Dichgans
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
| | - Kennedy R. Lees
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
| | - Didier Leys
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
| | - Patrik Michel
- From the Department of Neurology, Inselspital, University of Bern, Bern, Switzerland (H.P.M.); Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria (M.B.); Institute of Neurosciences, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain (A.C.); Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany (M.D.); Munich Cluster for Systems Neurology (SyNergy), Munich,
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Abdel Razek AAK, Alvarez H, Bagg S, Refaat S, Castillo M. Imaging Spectrum of CNS Vasculitis. Radiographics 2014; 34:873-894. [DOI: 10.1148/rg.344135028] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Abstract
The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.
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Affiliation(s)
- Harold P Adams
- Division of Cerebrovascular Diseases, Department of Neurology, Carver College of Medicine, University of Iowa Health Care Stroke Center, University of Iowa, Iowa City, IA, USA.
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Affiliation(s)
- Daniel J Boulter
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Pamela W Schaefer
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA.
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Castro Caldas A, Geraldes R, Neto L, Canhão P, Melo TP. Central nervous system vasculitis associated with hepatitis C virus infection: a brain MRI-supported diagnosis. J Neurol Sci 2013; 336:152-4. [PMID: 24211061 DOI: 10.1016/j.jns.2013.10.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/07/2013] [Accepted: 10/18/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND The Hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, being the Central Nervous System (CNS) rarely involved. CASE REPORT We report a case of a 54 year-old black man with arterial hypertension who presented with progressively worsening headaches, apathy, somnolence and left hemiparesis. Brain MRI showed an acute ischemic lesion in the left anterior cerebral artery (ACA) and an old ischemic infarct in the right ACA territory. Brain MRI with gadolinium revealed mural thickening and contrast enhancement of the A1 and A2 segments of the ACAs, of the middle and distal basilar artery and of the P1 segment of the left posterior cerebral artery, suggesting active vasculitis. Digital angiography confirmed those irregularities and stenosis. Laboratory evaluation revealed ESR (73 mm/h), transaminase elevation, elevated HCV viral load genotype 2, positive IGRA, negative cryoglobulins, CSF protein elevation with oligoclonal bands (mirror pattern) and no pleocytosis; investigation excluded other infectious causes. Pegylated interferon alpha-2a and ribavirin, corticotherapy and tuberculosis prophylaxis were started with clinical and imagiological improvement. CONCLUSION The typical inflammation signs of the vascular wall demonstrated by the gadolinium-enhanced MRI strengthened the hypothesis of CNS vasculitis. The association with HCV infection is rare but should be investigated once specific therapeutic is required.
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Affiliation(s)
- A Castro Caldas
- Department of Neurosciences, Stroke Unit, Hospital de Santa Maria, Portugal.
| | - R Geraldes
- Department of Neurosciences, Stroke Unit, Hospital de Santa Maria, Portugal; University of Lisbon, Lisbon, Portugal
| | - L Neto
- Department of Neurosciences, Stroke Unit, Hospital de Santa Maria, Portugal; University of Lisbon, Lisbon, Portugal
| | - P Canhão
- Department of Neurosciences, Stroke Unit, Hospital de Santa Maria, Portugal; University of Lisbon, Lisbon, Portugal
| | - T P Melo
- Department of Neurosciences, Stroke Unit, Hospital de Santa Maria, Portugal; University of Lisbon, Lisbon, Portugal
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Mineyko A, Kirton A, Ng D, Wei XC. Normal intracranial periarterial enhancement on pediatric brain MR imaging. Neuroradiology 2013; 55:1161-9. [DOI: 10.1007/s00234-013-1206-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
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47
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Portanova A, Hakakian N, Mikulis DJ, Virmani R, Abdalla WMA, Wasserman BA. Intracranial Vasa Vasorum: Insights and Implications for Imaging. Radiology 2013; 267:667-79. [DOI: 10.1148/radiol.13112310] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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48
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Guerrero WR, Dababneh H, Hedna S, Johnson JA, Peters K, Waters MF. Vessel wall enhancement in herpes simplex virus central nervous system vasculitis. J Clin Neurosci 2013; 20:1318-9. [PMID: 23517674 DOI: 10.1016/j.jocn.2012.10.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/25/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022]
Abstract
Infection is a well-known cause of cerebral vasculopathy and vasculitis. We report a 36-year-old woman with cerebral vasculitis and ischemic stroke secondary to herpes simplex virus (HSV). MRI studies revealed a pontine stroke with basilar artery stenosis and vessel wall gadolinium enhancement. This case demonstrates the ability of HSV to cause a focal brainstem vasculitis and the utility of enhanced MRI in the diagnosis of stroke related to HSV central nervous system vasculitis.
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Affiliation(s)
- Waldo R Guerrero
- Department of Neurology, University of Florida College of Medicine, 1601 Archer Road, Gainesville, FL 32610-0236, USA.
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Acute Viral Infections of the Central Nervous System in Immunocompetent Adults: Diagnosis and Management. Drugs 2013; 73:131-58. [DOI: 10.1007/s40265-013-0007-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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50
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3-T Magnetic Resonance Angiography in Primary Angiitis of the Central Nervous System. J Comput Assist Tomogr 2013; 37:493-8. [DOI: 10.1097/rct.0b013e31829610e5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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