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Kharal GA, Ibrikji SE, Farag YM, Shoskes A, Kiczek MP, Sheth R, Hussain MS. Predictive Value of Clinical, CSF and Vessel Wall MRI Variables in Diagnosing Primary Angiitis of the CNS. Neurol Clin Pract 2024; 14:e200321. [PMID: 38855713 PMCID: PMC11160479 DOI: 10.1212/cpj.0000000000200321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/02/2024] [Indexed: 06/11/2024]
Abstract
Background and Objectives Without brain biopsy, there are limited diagnostic predictors to differentiate primary angiitis of the CNS (PACNS) from intracranial atherosclerotic disease (ICAD). We examined the utility of clinical, CSF, and quantitative vessel wall magnetic resonance imaging (VWMRI) variables in predicting PACNS from ICAD. Methods In this cross-sectional design, observational study, we reviewed electronic medical records to identify patients (18 years and older) who presented to our medical center between January 2015 and December 2021 for ischemic stroke due to intracranial vasculopathy. Patients with biopsy-proven PACNS, probable PACNS, or ICAD were included. Patients with secondary CNS vasculitis or no VWMRI data were excluded. On VWMRI, for each patient, a total of 20 vessel wall segments were analyzed for percent concentricity, percent irregularity, and concentricity to eccentricity (C/E) ratios. We also collected several clinical and CSF variables. Using logistic regression models, we assessed the diagnostic value of VWMRI, CSF, and clinical variables in predicting PACNS in patients with biopsy-proven disease. We then performed a sensitivity analysis to assess predictors of biopsy-proven and probable PACNS. Results Thirty-two patients with ICAD (54.2%) and 27 patients with PACNS (45.8%) were included. Of the patients with PACNS, 21 (77.8%) were not biopsied and considered probable PACNS. Twenty-four patients with ICAD (75%) and 6 biopsy-proven patients with PACNS (22.2%) showed large vessel involvement and were included in the primary analysis. Encephalopathy (odds ratio [OR], 7.60; 95% CI 1.07-54.09) and seizure (OR 23.00; 95% CI 1.77-298.45) were significantly associated with PACNS. All patients were included in the sensitivity analysis, in which headache significantly predicted PACNS (OR 7.60; 95% CI 1.07-54.09). In the primary analysis, for every 1 white blood cell/µL increase in CSF, there was a 47% higher odds of PACNS (OR 1.47; 95% CI 1.04-2.07). On VWMRI, a C/E ratio >1 (OR 115.00; 95% CI 6.11-2165.95), percent concentricity ≥50% (OR 55.00; 95% CI 4.13-732.71), and percent irregularity <50% (OR 55.00; 95% CI 4.13-732.71) indicated significantly higher odds of PACNS compared with ICAD. Discussion Our results suggest that quantitative VWMRI metrics, CSF pleocytosis, and clinical features of encephalopathy, seizure, and headache significantly predict a diagnosis of probable PACNS when compared with ICAD.
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Affiliation(s)
- G Abbas Kharal
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
| | - Sidonie E Ibrikji
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
| | - Youssef M Farag
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
| | - Aaron Shoskes
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
| | - Matthew P Kiczek
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
| | - Richa Sheth
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
| | - Muhammad S Hussain
- Cerebrovascular Center (GAK, SEI, MSH), Neurological Institute, Cleveland Clinic, OH; Department of Epidemiology (YMF), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology (AS), University of Utah, Salt Lake City; Section of Neuroradiology (MPK), Imaging Institute, Cleveland Clinic, OH; and Northeast Ohio Medical School (RS), Rootstown
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Guo A, Zhang Z, Dong GH, Su L, Gao C, Zhang M, Shi X, Wang H, Zhang X, Lu DH, Fu Y, Jing J, Shi FD, Tian DC. Cortical Microhemorrhage Presentation of Small Vessel Primary Angiitis of the Central Nervous System. Ann Neurol 2024; 96:194-203. [PMID: 38661030 DOI: 10.1002/ana.26940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/29/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Primary angiitis of the central nervous system (PACNS) is a rare vasculitis restricted to the brain, spinal cord, and leptomeninges. This study aimed to describe the imaging characteristics of patients with small vessel PACNS (SV-PACNS) using 7 T magnetic resonance imaging (MRI). METHODS This ongoing prospective observational cohort study included patients who met the Calabrese and Mallek criteria and underwent 7 T MRI scan. The MRI protocol includes T1-weighted magnetization-prepared rapid gradient echo imaging, T2 star weighted imaging, and susceptibility-weighted imaging. Two experienced readers independently reviewed the neuroimages. Clinical data were extracted from the electronic patient records. The findings were then applied to a cohort of patients with large vessel central nervous system (CNS) vasculitis. RESULTS We included 21 patients with SV-PACNS from December 2021 to November 2023. Of these, 12 (57.14%) had cerebral cortical microhemorrhages with atrophy. The pattern with microhemorrhages was described in detail based on the gradient echo sequence, leading to the identification of what we have termed the "coral-like sign." The onset age of patients with coral-like sign (33.83 ± 9.93 years) appeared younger than that of patients without coral-like sign (42.11 ± 14.18 years) (P = 0.131). Furthermore, the cerebral lesions in patients with cortical microhemorrhagic SV-PACNS showed greater propensity toward bilateral lesions (P = 0.03). The coral-like sign was not observed in patients with large vessel CNS vasculitis. INTERPRETATION The key characteristics of the coral-like sign represent cerebral cortical diffuse microhemorrhages with atrophy, which may be an important MRI pattern of SV-PACNS. ANN NEUROL 2024;96:194-203.
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Affiliation(s)
- Ai Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhe Zhang
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ge-Hong Dong
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Su
- Department of Neurology, Tianjin General Hospital, Tianjin, China
| | - Chenyang Gao
- Department of Neurology, Tianjin General Hospital, Tianjin, China
| | - Mengting Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Shi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huabing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinghu Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - De-Hong Lu
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Fu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu-Dong Shi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Tianjin General Hospital, Tianjin, China
| | - De-Cai Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Isolated Central Nervous System Vasculitides in COVID-19: A Systematic Review of Case Reports and Series. REPORTS 2022. [DOI: 10.3390/reports5030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cerebral vasculitides, both isolated or in systemic disorders, could be triggered by infections, and few cases have been associated to coronavirus disease 2019 (COVID-19). This study searched for publications in Pubmed, EMBASE, and Cochrane library databases for case reports and series of isolated central nervous system (CNS) vasculitides triggered by severe acute respiratory syndrome coronavirus-2. We included 12 studies (published from June 2020 to July 2022) and collected 39 adult patients (5/39 pathologically or radiologically proven, 34/39 suggestive for primary CNS vasculitis or PCNSV). All cases had a positive real-time polymerase chain reaction on a nasopharyngeal swab or a respiratory tract specimen. About the 85% of the included cases were males, and disease onset occurred later than 50 years old in all but three subjects. In total, 33/39 patients presented severe COVID-19 pneumonia, frequently requiring intensive care unit care. The most common neurological features were headache, obnubilation, and coma. PCNSV was suspected mainly on radiological findings, whereas the cerebrospinal fluid analysis was minimally altered. Magnetic resonance imaging showed vessel wall enhancement in 32/39 cases, generally with the concomitant presence of microbleeds, subarachnoid haemorrhages, and/or multiple ischemic lesions. Despite the severe respiratory and neurological disease course, most cases (93%) improved spontaneously or after a course of high-dose intravenous steroids with no need for immunosuppression. In conclusion, PCNSV could rarely relate to COVID-19 and independently from pulmonary disease severity. Adults with COVID-19-related PCNSV could have a favourable prognosis.
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Sarhan FMA, Al-Jasim A, Alaraj RSN, Abedalkhader SFA, Ghanim Z. Right arm weakness and mouth deviation as a presentation of Primary Angiitis of the Central Nervous System treated with rituximab: A case-report. Ann Med Surg (Lond) 2022; 79:104040. [PMID: 35860065 PMCID: PMC9289388 DOI: 10.1016/j.amsu.2022.104040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/18/2022] [Accepted: 06/18/2022] [Indexed: 11/01/2022] Open
Abstract
Introduction Case presentation Clinical discussion Conclusion Presentations of Primary Angiitis of the Central Nervous System (PACNS) can range from headache to stroke-like presentations, thus should be listed on the differential diagnosis whenever the index of suspicion is high. MRI is the imaging modality of choice and would show an ischemic pattern in the affected areas of the CNS. The gold standard for diagnosis is done with a lesion biopsy showing lymphocytic infiltration in a granulomatous inflammatory pattern with multinucleated giant cells. Acute management includes methylprednisolone, cyclophosphamide, rituximab. Maintenance therapy includes methotrexate, mycophenolate mofetil, rituximab, or azathioprine.
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