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Beuker C, Strunk D, Rawal R, Schmidt-Pogoda A, Werring N, Milles L, Ruck T, Wiendl H, Meuth S, Minnerup H, Minnerup J. Primary Angiitis of the CNS: A Systematic Review and Meta-analysis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:e1093. [PMID: 34663675 PMCID: PMC10578363 DOI: 10.1212/nxi.0000000000001093] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES To facilitate and improve the diagnostic and therapeutic process by systematically reviewing studies on patients with primary angiitis of the CNS (PACNS). METHODS We searched PubMed, looking at the period between 1988 and February 2020. Studies with adult patients with PACNS were included. We extracted and pooled proportions using fixed-effects models. Main outcomes were proportions of patients with certain clinical, imaging, and laboratory characteristics and neurologic outcomes. RESULTS We identified 46 cohort studies including a total of 911 patients (41% biopsy confirmed, 43% angiogram confirmed, and 16% without clear assignment to the diagnostic procedure). The most frequent onset symptoms were focal neurologic signs (63%), headache (51%), and cognitive impairment (41%). Biopsy- compared with angiogram-confirmed cases had higher occurrences of cognitive impairment (55% vs 39%) and seizures (36% vs 16%), whereas focal neurologic signs occurred less often (56% vs 95%). CSF abnormalities were present in 75% vs 65% and MRI abnormalities in 97% vs 98% of patients. Digital subtraction angiography was positive in 33% of biopsy confirmed, and biopsy was positive in 8% of angiogram-confirmed cases. In 2 large cohorts, mortality was 23% and 8%, and the relapse rate was 30% and 34%, during a median follow-up of 19 and 57 months, respectively. There are no randomized trials on the treatment of PACNS. The initial treatment usually includes glucocorticoids and cyclophosphamide. DISCUSSION PACNS is associated with disabling symptoms, frequent relapses, and significant mortality. Differences in symptoms and neuroimaging results and low overlap between biopsy and angiogram suggest that biopsy- and angiogram-confirmed cases represent different histopathologic types of PACNS. The optimal treatment is unknown.
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Affiliation(s)
| | | | | | - Antje Schmidt-Pogoda
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Nils Werring
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Lennart Milles
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Tobias Ruck
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Heinz Wiendl
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Sven Meuth
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
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Niu L, Wang L, Yin X, Li XF, Wang F. Role of magnetic resonance imaging in the diagnosis of primary central nervous system angiitis. Exp Ther Med 2017; 14:555-560. [PMID: 28672966 PMCID: PMC5488425 DOI: 10.3892/etm.2017.4572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 03/24/2017] [Indexed: 11/06/2022] Open
Abstract
The present study reported on the use of magnetic resonance imaging (MRI) in the diagnosis of primary angiitis of the central nervous system (PACNS). A total of 19 consecutive patients with a clinical diagnosis of PACNS confirmed by clinical follow-up were enrolled in the present study. All patients underwent unenhanced and enhanced MRI prior to and after steroids or steroids plus immunosuppressive therapy. At baseline, all patients showed lesions on MRI in the grey and white matter. Lesions presented as slightly hypointense on T1-weighted images (T1WI), slightly hyperintense on T2WI, hyperintense on fluid-attenuated inversion recovery, iso- or slightly hyperintense on diffusion-weighted images (DWI) and hyperintense on apparent diffusion coefficient (ADC) mapping. After contrast injection, the lesions showed patchy, cord-like or goral enhancement. Seven cases had unilateral lesions and the other 12 cases had bilateral lesions. On all sequences, indistinct margins characterised most of the lesions, and certain lesions were oedematous. Treatment with steroids or steroids plus immunosuppressive agents resulted in improvement or disappearance of symptoms, and seventeen patients had evidently improved according to MRI. In conclusion, PACNS has unique characteristics on MRI; DWI, ADC mapping and enhanced images are of great importance for the diagnosis and clinical management of early-stage PACNS.
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Affiliation(s)
- Lei Niu
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, P.R. China.,Department of Radiology, Suqian City People's Hospital, Nanjing Drum Tower Hospital Group, Suqian, Jiangsu 223800, P.R. China
| | - Liwei Wang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, P.R. China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, P.R. China
| | - Xiao-Feng Li
- Department of Diagnostic Radiology, University of Louisville, Louisville, KY 40202, USA
| | - Feng Wang
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, P.R. China
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McVerry F, McCluskey G, McCarron P, Muir KW, McCarron MO. Diagnostic test results in primary CNS vasculitis: A systematic review of published cases. Neurol Clin Pract 2017; 7:256-265. [PMID: 30107009 DOI: 10.1212/cpj.0000000000000359] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Primary CNS vasculitis (PCNSV) can be diagnosed using cerebral angiography or histopathology combined with clinical features. The original diagnostic criteria, which weigh each test equally, have not been validated. Limited sensitivity and specificity for biopsy and angiography are recognized. We systematically reviewed results of diagnostic tests performed in patients with an ultimate diagnosis of PCNSV. Methods We searched the OVID Medline database and bibliographies for original cases of PCNSV. We recorded demographics, diagnostic tests used, and assessed agreement between angiography and biopsy when both tests were performed. We also recorded MRI and CSF results. Results We found 701 original cases with PCNSV diagnosed with angiography or pathology. A total of 269 patients (38.4%) had both cerebral angiography and histopathologic testing (biopsy/postmortem). Classic angiographic features of vasculitis were associated with pathologic confirmation in just 32 patients (4.6%). Seventy-four patients (10.6%) with any abnormality on angiography had a normal biopsy, and 99 patients (14.1%) with abnormal biopsies had normal angiography. Brain MRI was abnormal in 505/541 patients (93.3%) and CSF was abnormal in 360/484 patients (74.4%). Increasing use of angiography and decreasing histopathologic testing were found over time. Conclusions Cerebral angiography and pathologic tissue examination were undertaken in a minority of published cases with a diagnosis of PCNSV. When both diagnostic tests were performed, disagreement between them was more than 5 times more likely than agreement. Diagnostic criteria for PCNSV may require revision to classify the clinical, pathologic, and radiologic features of this condition more accurately.
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Affiliation(s)
- Ferghal McVerry
- Altnagelvin Hospital (FM, GM, MOM), Derry; National Drug Treatment Centre (PM), Dublin, Ireland; and University of Glasgow (KWM), Scotland
| | - Gavin McCluskey
- Altnagelvin Hospital (FM, GM, MOM), Derry; National Drug Treatment Centre (PM), Dublin, Ireland; and University of Glasgow (KWM), Scotland
| | - Peter McCarron
- Altnagelvin Hospital (FM, GM, MOM), Derry; National Drug Treatment Centre (PM), Dublin, Ireland; and University of Glasgow (KWM), Scotland
| | - Keith W Muir
- Altnagelvin Hospital (FM, GM, MOM), Derry; National Drug Treatment Centre (PM), Dublin, Ireland; and University of Glasgow (KWM), Scotland
| | - Mark O McCarron
- Altnagelvin Hospital (FM, GM, MOM), Derry; National Drug Treatment Centre (PM), Dublin, Ireland; and University of Glasgow (KWM), Scotland
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Wilson N, Pohl D, Michaud J, Doja A, Miller E. MRI and clinicopathological correlation of childhood primary central nervous system angiitis. Clin Radiol 2016; 71:1160-7. [PMID: 27554617 DOI: 10.1016/j.crad.2016.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 05/30/2016] [Accepted: 07/18/2016] [Indexed: 11/28/2022]
Abstract
AIM To review the long-term clinical and imaging follow-up of eight children with histopathologically proven childhood primary central nervous system angiitis (cPACNS). MATERIALS AND METHODS Eight children (5-17 years, five female and three male patients) with biopsy-proven cPACNS vasculitis were reviewed retrospectively. All children were followed at the Children's Hospital of Eastern Ontario. Magnetic resonance imaging (MRI) images of the brain parenchyma and vessel pattern of the arteries of the circle of Willis were reviewed at baseline and follow-up(s). All MRI images were correlated with clinical and histopathological findings. RESULTS Seven (87.5%) children demonstrated parenchymal abnormalities: five of the seven (71.4%) presented with non-haemorrhagic lesions, one (14.3%) presented with a parenchymal bleed, and one (14.3%) showed diffuse oedema. One child remained negative for brain parenchymal abnormality at baseline and follow-up. Of the seven children with a parenchymal abnormality, parenchymal enhancement was seen in two (28.5%) and leptomeningeal enhancement was seen in one child. Only two children had positive diffusion-weighted imaging (DWI) restriction at baseline. Five of the seven children (71.4%) showed no magnetic resonance angiography (MRA) abnormalities at baseline. In one, MRA detected complete absence of flow. Follow-up MRA (24-74 months) demonstrated that five of the seven (71.4%) children had progressive paucity of the peripheral vascularity. Two children (28.5%) with shorter-term follow-up (7 and 13 months) did not demonstrate MRA changes. CONCLUSION Long-term follow-up MRA demonstrated progressive paucity of peripheral vessels, which could be secondary to the inflammation affecting the peripheral vasculature causing reduction in vessel lumen size beyond the resolution of the maximum intensity projection (MIP) reconstruction.
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Affiliation(s)
- N Wilson
- Diagnostic Imaging Department, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada.
| | - D Pohl
- Diagnostic Imaging Department, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - J Michaud
- Diagnostic Imaging Department, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - A Doja
- Diagnostic Imaging Department, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - E Miller
- Diagnostic Imaging Department, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
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Abstract
The term "systemic vasculitis" encompasses a diverse set of diseases linked by the presence of blood-vessel inflammation that are often associated with critical complications. These diseases are uncommon in childhood and are frequently subjected to a delayed diagnosis. Although the diagnosis and treatment may be similar for adult and childhood systemic vasculitides, the prevalence and classification vary according to the age group under investigation. For example, Kawasaki disease affects children while it is rarely encountered in adults. In 2006, the European League Against Rheumatism (EULAR) and the Pediatric Rheumatology European Society (PReS) proposed a classification system for childhood vasculitis adopting the system devised in the Chapel Hill Consensus Conference in 1993, which categorizes vasculitides according to the predominant size of the involved blood vessels into small, medium and large vessel diseases. Currently, medical imaging has a pivotal role in the diagnosis of vasculitis given recent developments in the imaging of blood vessels. For example, early diagnosis of coronary artery aneurysms, a serious complication of Kawasaki disease, is now possible by magnetic resonance imaging (MRI) of the heart and multidetector computed tomography (MDCT); positron emission tomography/CT (PET/CT) helps to assess active vascular inflammation in Takayasu arteritis. Our review offers a unique approach using the integration of the proposed classification criteria for common systemic childhood vasculitides with their most frequent imaging findings, along with differential diagnoses and an algorithm for diagnosis based on common findings. It should help radiologists and clinicians reach an early diagnosis, therefore facilitating the ultimate goal of proper management of affected children.
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Affiliation(s)
- Magdy Soliman
- Department of Medical Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G1X8, Canada
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Gitiaux C, Krug P, Grevent D, Kossorotoff M, Poncet S, Eisermann M, Oualha M, Boddaert N, Salomon R, Desguerre I. Brain magnetic resonance imaging pattern and outcome in children with haemolytic-uraemic syndrome and neurological impairment treated with eculizumab. Dev Med Child Neurol 2013; 55:758-65. [PMID: 23659643 DOI: 10.1111/dmcn.12161] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to describe the magnetic resonance imaging (MRI) findings and the neurological and neuropsychological outcomes in paediatric, diarrhoea-associated haemolytic-uraemic syndrome (D+HUS) with central nervous system impairment treated with eculizumab, a monoclonal antibody. METHOD The 14-month single-centre prospective study included seven children (three males, four females; age range 16 mo-7 y 8 mo; median age 3 y 7 mo) with typical D+HUS and acute neurological impairment. In the acute phase of the disease, neurological assessment and brain magnetic resonance imaging (MRI), including measurement of the apparent diffusion coefficient (ADC), were performed, and neuropsychological evaluation and brain MRI were also carried out 6 months after disease onset. RESULTS In the acute phase, basal ganglia and white matter abnormalities with ADC restriction were a common and reversible MRI finding. In all the surviving patients (5/7), follow-up MRI after 6 months was normal, indicating reversible lesions. Clinical and neuropsychological evaluations after 6 months were also normal. INTERPRETATION This specific brain MRI pattern consisting of an ADC decrease in basal ganglia and white matter without major T2/fluid-attenuated inversion recovery (FLAIR) injury may be a key finding in the acute phase of the disease in favour of a vasculitis hypothesis. These reversible lesions were associated with a good neurological outcome. These results call for further evaluation of the potential role of eculizumab in the choice of treatment for severe D+HUS, particularly in the case of early neurological signs.
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Affiliation(s)
- Cyril Gitiaux
- Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France.
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