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Sheikh TS, Rozenberg A, Merhav G, Shifrin A, Stein P, Shelly S. Primary CNS vasculitis: insights into clinical, neuropathological, and neuroradiological characteristics. Front Neurol 2024; 15:1363985. [PMID: 38651108 PMCID: PMC11034515 DOI: 10.3389/fneur.2024.1363985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 02/26/2024] [Indexed: 04/25/2024] Open
Abstract
Background and objectives Primary CNS vasculitis (PCNSV) is a rare inflammatory disorder that affects the blood vessels of the central nervous system (CNS). We aimed to analyze the neurological presentations, clinical follow-up, and long-term outcomes of patients with primary central nervous system vasculitis. Methods We conducted a retrospective analysis of medical records to assess the neurological presentation, rate of remission, and functional status at the last follow-up in patients with primary central nervous system vasculitis seen in our center in the last 13 years (2010-2023). Results We identified five patients, whose median age at symptom onset was 31 years (range: 15-41 years), including four male individuals (80%) from Muslim Arab (n = 4) and Ashkenazi Jewish (n = 1) backgrounds. Symptoms persisted for a median of 36 weeks (range: 3 weeks to 4 years) before diagnosis, with one case exceeding 3 years. Follow-up lasted a median of 56 months (range: 20-161 months). Clinical symptoms varied, presenting unilateral weaknesses (n = 2), cognitive and gait abnormality (n = 1), headaches (n = 1), and epileptic seizures (n = 1). MRI scans revealed abnormalities in the basal ganglia, corona radiata, parietal, and frontal lobes, showing hemorrhage, vasogenic edema, restricted diffusion, and enhancement post-gadolinium. All patients reported progressive holocephalic headaches and cognitive changes with overall progressive symptoms. Initial neurological examinations revealed abnormalities in all patients and included one or more of the following: cognitive or visual impairment (n = 2), seizures (n = 1), and unilateral UMN signs (n = 2) at the initial neurological examination, all but one patient required walking aids including (cane 2, wheelchair, bedridden 1). Patients were stable (n = 2), deteriorated (n = 1), or improved (n = 2). Following treatment, two patients still required ambulatory aids, with one using a cane and the other using a wheelchair, while the remaining three did not require any ambulatory aids. Discussion The study on PCNSV highlights varied symptoms and diagnostic challenges, including delayed diagnosis and a spectrum of neurological issues from cognitive impairments to seizures. Brain biopsies showed lymphocytic infiltration, thrombi, and necrosis. Immunotherapy significantly improved clinical and radiological outcomes. Over 56 months of follow-up, outcomes varied from stability and deterioration to improvement.
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Affiliation(s)
| | - Ayal Rozenberg
- Department of Neurology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Goni Merhav
- Department of Neuropathology, Rambam Medical Center, Haifa, Israel
| | - Alla Shifrin
- Department of Neurology, Rambam Medical Center, Haifa, Israel
| | - Polina Stein
- Department of Neuropathology, Rambam Medical Center, Haifa, Israel
| | - Shahar Shelly
- Department of Neurology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Institute of Pathology, Rambam Medical Center, Haifa, Israel
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2
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Agarwal S, Sebastian LJD, Gaikwad S, Srivastava MVP, Sharma MC, Singh M, Bhatia R, Agarwal A, Sharma J, Dash D, Goyal V, Srivastava AK, Tripathi M, Suri V, Singh MB, Sarkar C, Suri A, Singh RK, Vibha D, Pandit AK, Rajan R, Gupta A, Elavarasi A, Radhakrishnan DM, Das A, Tandon V, Doddamani R, Upadhyay A, Vishnu VY, Garg A. The role of susceptibility-weighted imaging & contrast-enhanced MRI in the diagnosis of primary CNS vasculitis: a large case series. Sci Rep 2024; 14:4718. [PMID: 38413676 PMCID: PMC10899183 DOI: 10.1038/s41598-024-55222-2] [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: 10/23/2023] [Accepted: 02/21/2024] [Indexed: 02/29/2024] Open
Abstract
Primary CNS Vasculitis (PCNSV) is a rare, diverse, and polymorphic CNS blood vessel inflammatory condition. Due to its rarity, clinical variability, heterogeneous imaging results, and lack of definitive laboratory markers, PCNSV diagnosis is challenging. This retrospective cohort analysis identified patients with histological diagnosis of PCNSV. Demographic data, clinical presentation, neuroimaging studies, and histopathologic findings were recorded. We enrolled 56 patients with a positive biopsy of CNS vasculitis. Most patients had cerebral hemisphere or brainstem symptoms. Most brain MRI lesions were bilateral, diffuse discrete to confluent white matter lesions. Frontal lobe lesions predominated, followed by inferior cerebellar lesions. Susceptibility-weighted imaging (SWI) hemorrhages in 96.4% (54/56) of patients, either solitary microhemorrhages or a combination of micro and macrohemorrhages. Contrast-enhanced T1-WIs revealed parenchymal enhancement in 96.3% (52/54 patients). The most prevalent pattern of enhancement observed was dot-linear (87%), followed by nodular (61.1%), perivascular (25.9%), and patchy (16.7%). Venulitis was found in 19 of 20 individuals in cerebral DSA. Hemorrhages in SWI and dot-linear enhancement pattern should be incorporated as MINOR diagnostic criteria to diagnose PCNSV accurately within an appropriate clinical context. Microhemorrhages in SWI and venulitis in DSA, should be regarded as a potential marker for PCNSV.
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Affiliation(s)
- Sushant Agarwal
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Shailesh Gaikwad
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M C Sharma
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Jyoti Sharma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepa Dash
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vinay Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Achal K Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vaishali Suri
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta B Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Chitra Sarkar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh K Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh K Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Roopa Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Anu Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - A Elavarasi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Animesh Das
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Tandon
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Upadhyay
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Venugopalan Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
| | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India.
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3
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Vandelli G, Giacobazzi L, Ciolli L, Dell’Acqua ML, Vandelli L, Picchetto L, Rosafio F, Borzì GM, Ricceri R, Meletti S, Vallone S, Salvarani C, Sebastiani M, Sacchetti F, Verganti L, Merolla S, Zelent G, Bigliardi G. Intracranial Stenosis Treated with Stenting in Patients with Suspected Cerebral Vasculitis: Two Case Reports. Case Rep Neurol 2023; 15:100-107. [PMID: 37476369 PMCID: PMC10355127 DOI: 10.1159/000529942] [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: 11/26/2022] [Accepted: 02/03/2023] [Indexed: 07/22/2023] Open
Abstract
Central nervous system vasculitis (CNSV) is an uncommon and poorly understood form of vasculitis. Early recognition is important because medical treatment might improve the outcome. However, randomized clinical trials on CNSV treatment do not exist. Endovascular treatment has been reported in few cases, but no data exist for intracranial stenting. We report 2 cases of patients with suspected CNSV and recurrent clinical episodes, treated with intracranial stenting. A 48-year-old man had relapsing episodes of right hemiparesis. Neuroradiological exams showed severe left carotid terminus stenosis. Despite immunosuppressive therapy, neuroradiological follow-up exams showed a worsening of the aforementioned stenosis with many transient episodes of weakness in the right limbs and aphasia. A 64-year-old woman had a sudden onset of dysarthria and transient aphasia. Neuroradiological exams showed a severe arterial stenosis involving the origin of left anterior cerebral artery and middle cerebral artery (MCA). Despite dual antiplatelet therapy, she presented an acute onset of severe aphasia, due to an occlusion of the left carotid terminus and proximal MCA. In both cases, endovascular procedure and intracranial stenting was performed, with marked improvement of cerebral blood flow. No more clinical episodes were reported. Intracranial stenting may be a valid therapeutic option in selected patients with CNSV and involvement of medium or large size vessels with clinical worsening despite best medical treatment.
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Affiliation(s)
- Gabriele Vandelli
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Giacobazzi
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Ludovico Ciolli
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Luisa Dell’Acqua
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Vandelli
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Livio Picchetto
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Francesca Rosafio
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Giuseppe Maria Borzì
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Riccardo Ricceri
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Stefano Meletti
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Vallone
- Neuroradiology, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Carlo Salvarani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Modena, Italy
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Federico Sacchetti
- Neuroradiology, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Luca Verganti
- Neuroradiology, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Stefano Merolla
- Neuroradiology, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Gabriele Zelent
- Neuroradiology, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Guido Bigliardi
- Neurology Clinic, Stroke Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
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Primary Central Nervous System Vasculitis Following Alemtuzumab Treatment for Multiple Sclerosis: A Case Report and Literature Review. Neurologist 2022:00127893-990000000-00050. [PMID: 36728655 DOI: 10.1097/nrl.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Cerebral vasculitides are often devastating conditions that require immediate diagnosis and treatment. CASE REPORT We report a pathologically proven clinical case of primary central nervous system vasculitis in a 50-year-old man with a diagnosis of relapsing-remitting multiple sclerosis after alemtuzumab therapy, which required additional immunosuppression to control this life-threatening condition. CONCLUSION In patients presenting subacute neurological deterioration after alemtuzumab therapy, primary central nervous system vasculitis should be considered as a differential diagnosis among other autoimmune conditions.
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Ramasubramanian B, Reddy VS, Chellappan V, Ramakrishna S. Emerging Materials, Wearables, and Diagnostic Advancements in Therapeutic Treatment of Brain Diseases. BIOSENSORS 2022; 12:1176. [PMID: 36551143 PMCID: PMC9775999 DOI: 10.3390/bios12121176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
Among the most critical health issues, brain illnesses, such as neurodegenerative conditions and tumors, lower quality of life and have a significant economic impact. Implantable technology and nano-drug carriers have enormous promise for cerebral brain activity sensing and regulated therapeutic application in the treatment and detection of brain illnesses. Flexible materials are chosen for implantable devices because they help reduce biomechanical mismatch between the implanted device and brain tissue. Additionally, implanted biodegradable devices might lessen any autoimmune negative effects. The onerous subsequent operation for removing the implanted device is further lessened with biodegradability. This review expands on current developments in diagnostic technologies such as magnetic resonance imaging, computed tomography, mass spectroscopy, infrared spectroscopy, angiography, and electroencephalogram while providing an overview of prevalent brain diseases. As far as we are aware, there hasn't been a single review article that addresses all the prevalent brain illnesses. The reviewer also looks into the prospects for the future and offers suggestions for the direction of future developments in the treatment of brain diseases.
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Affiliation(s)
- Brindha Ramasubramanian
- Department of Mechanical Engineering, Center for Nanofibers & Nanotechnology, National University of Singapore, Singapore 117574, Singapore
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), #08-03, 2 Fusionopolis Way, Innovis, Singapore 138634, Singapore
| | - Vundrala Sumedha Reddy
- Department of Mechanical Engineering, Center for Nanofibers & Nanotechnology, National University of Singapore, Singapore 117574, Singapore
| | - Vijila Chellappan
- Institute of Materials Research and Engineering (IMRE), Agency for Science, Technology and Research (A*STAR), #08-03, 2 Fusionopolis Way, Innovis, Singapore 138634, Singapore
| | - Seeram Ramakrishna
- Department of Mechanical Engineering, Center for Nanofibers & Nanotechnology, National University of Singapore, Singapore 117574, Singapore
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Primary CNS vasculitis (PCNSV): a cohort study. Sci Rep 2022; 12:13494. [PMID: 35931755 PMCID: PMC9355950 DOI: 10.1038/s41598-022-17869-7] [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: 02/07/2022] [Accepted: 08/02/2022] [Indexed: 11/08/2022] Open
Abstract
Primary CNS Vasculitis (PCNSV) is a rare inflammatory disorder affecting the blood vessels of the central nervous system. Patients present with a combination of headaches, seizures, and focal neurological deficits. There is usually a diagnostic delay. Treatment is based on observational studies and expert opinion. Our objective was to identify clinical, laboratory, neuroimaging, pathologic or management-related associations with 2 year outcome in patients with primary CNS vasculitis. We conducted a cohort study at a single tertiary care referral centre of prospectively (2018-2019) and retrospectively (2010-2018) identified individuals with primary CNS vasculitis (diagnosis was proven by either brain biopsy or cerebral digital subtraction angiography). Clinical, imaging and histopathologic findings, treatment, and functional outcomes were recorded. Univariate and stepwise multiple logistic regression were applied. P-value<0.05 was considered statistically significant. The main outcome measures were documentation of clinical improvement or worsening (defined by mRS scores) and identification of independent predictors of good functional outcome (mRS 0-2) at 2 years. We enrolled eighty-two biopsy and/or angiographically proven PCNSV cases. The median age at presentation was 34 years with a male predilection and a median diagnostic delay of 23 months. Most patients presented with seizures (70.7%). All patients had haemorrhages on MRI. Histologically lymphocytic subtype was the commonest. Corticosteroids with cyclophosphamide was the commonest medication used. The median mRS at follow-up of 2 years was 2 (0-3), and 65.2% of patients achieved a good functional outcome. Myelitis and longer duration of illness before diagnosis were associated with poorer outcomes. The presence of hemorrhages on SWI sequence of MRI might be a sensitive imaging marker. Treatment with steroids and another immunosuppressant probably reduced relapse rates in our cohort. We have described the third largest PCNSV cohort and multi-centre randomised controlled trials are required to study the relative efficacy of various immunosuppressants.Study registration: CTRI/2018/03/012721.
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7
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Benjamin LA, Lim E, Sokolska M, Markus J, Zaletel T, Aggarwal V, Luder R, Sanchez E, Brown K, Sofat R, Singh A, Houlihan C, Nastouli E, Losseff N, Werring DJ, Brown MM, Mason JC, Simister RJ, Jäger HR. Vessel wall magnetic resonance and arterial spin labelling imaging in the management of presumed inflammatory intracranial arterial vasculopathy. Brain Commun 2022; 4:fcac157. [PMID: 35813881 PMCID: PMC9263889 DOI: 10.1093/braincomms/fcac157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 02/08/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022] Open
Abstract
Optimal criteria for diagnosing and monitoring response to treatment for infectious and inflammatory medium–large vessel intracranial vasculitis presenting with stroke are lacking. We integrated intracranial vessel wall MRI with arterial spin labelling into our routine clinical stroke pathway to detect presumed inflammatory intracranial arterial vasculopathy, and monitor disease activity, in patients with clinical stroke syndromes. We used predefined standardized radiological criteria to define vessel wall enhancement, and all imaging findings were rated blinded to clinical details. Between 2017 and 2018, stroke or transient ischaemic attack patients were first screened in our vascular radiology meeting and followed up in a dedicated specialist stroke clinic if a diagnosis of medium–large inflammatory intracranial arterial vasculopathy was radiologically confirmed. Treatment was determined and monitored by a multi-disciplinary team. In this case series, 11 patients were managed in this period from the cohort of young stroke presenters (<55 years). The median age was 36 years (interquartile range: 33,50), of which 8 of 11 (73%) were female. Two of 11 (18%) had herpes virus infection confirmed by viral nucleic acid in the cerebrospinal fluid. We showed improvement in cerebral perfusion at 1 year using an arterial spin labelling sequence in patients taking immunosuppressive therapy for >4 weeks compared with those not receiving therapy [6 (100%) versus 2 (40%) P = 0.026]. Our findings demonstrate the potential utility of vessel wall magnetic resonance with arterial spin labelling imaging in detecting and monitoring medium–large inflammatory intracranial arterial vasculopathy activity for patients presenting with stroke symptoms, limiting the need to progress to brain biopsy. Further systematic studies in unselected populations of stroke patients are needed to confirm our findings and establish the prevalence of medium–large artery wall inflammation.
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Affiliation(s)
- L A Benjamin
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
- Laboratory of Molecular and Cell Biology, UCL, Gower St, Kings Cross , London WC1E 6BT , UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
- University of Liverpool, Brain Infections Group, Liverpool , Merseyside, L69 7BE , UK
| | - E Lim
- Department of Imaging, University College London Hospitals NHS foundation trust , London, NW1 2PG , UK
| | - M Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
| | - J Markus
- Department of Imaging, University College London Hospitals NHS foundation trust , London, NW1 2PG , UK
| | - T Zaletel
- Department of Medicine, University of Cambridge , Cambridge, CB2 1TN , UK
| | - V Aggarwal
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
| | - R Luder
- Department of Medicine, North Middlesex University Hospital , London, N18 1QX , UK
| | - E Sanchez
- Department of clinical virology, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
| | - K Brown
- Department of Virology, UK Health Security Agency , London, NW9 5EQ , UK
| | - R Sofat
- Department of Pharmacology and Therapeutics, University of Liverpool , Liverpool L69 7BE , UK
- Health Data Research , London, NW1 2BE , UK
| | - A Singh
- Department of Medicine, Royal Free Hospital Foundation Trust , London, NW3 2QG , UK
| | - C Houlihan
- Department of clinical virology, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
| | - E Nastouli
- Department of clinical virology, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
- Crick Institute , London, NW1 1AT , UK
| | - N Losseff
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
| | - D J Werring
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
| | - M M Brown
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
| | - J C Mason
- Department of Medicine, Hammersmith Hospital , London, W12 0HS , UK
- National Heart and Lung Institute, Imperial College London , London, SW3 6LY , UK
| | - R J Simister
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
| | - H R Jäger
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
- Department of Imaging, University College London Hospitals NHS foundation trust , London, NW1 2PG , UK
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London , London, WC1N 3BG , UK
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8
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Lauzier DC, Osbun JW, Chatterjee AR, Moran CJ, Kansagra AP. Safety of pediatric cerebral angiography. J Neurosurg Pediatr 2022; 29:192-199. [PMID: 34740194 DOI: 10.3171/2021.8.peds21301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Catheter-based cerebral angiography is commonly used for neurovascular diagnosis in children. In this work, the authors aimed to quantify the complication rate of cerebral angiography in children, characterize these complications, and identify risk factors for complications. METHODS Relevant clinical data were retrospectively obtained for 587 consecutive cerebral angiography procedures performed in 390 children from March 2002 to March 2020. Complications were categorized as neurological or nonneurological, and severity was graded using a standard schema. Incidences of complications were reported as point estimates. Associations between risk factors and complications were characterized in univariate analysis using the two-tailed Fisher exact test and in multivariate analysis using multiple logistic regression with bidirectional elimination based on the Akaike information criterion. In both univariate and multivariate analyses, statistical significance was corrected for multiple comparisons using the Benjamini-Hochberg method. RESULTS Complications occurred in 6.5% of procedures, including neurological complications in 1.9% and nonneurological complications in 4.8%. Permanent deficits occurred in only 0.2% of cases. Overall, 0.5% of procedures resulted in major complications, while 6.0% resulted in minor complications. Female sex and a history of hypertension or ischemic stroke were associated with an increased risk of complications, while femoral artery access was associated with a decreased risk of complications. CONCLUSIONS Pediatric cerebral angiography was shown to have a low rate of major or permanent complications. Children who were female and those with a history of hypertension or ischemic stroke were shown to be at higher risk of complications, while the use of femoral access carried a lower risk of complications.
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Affiliation(s)
- David C Lauzier
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis; and
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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Ayvacıoğlu Cagan C, Temucin CM, Arslan D, Gocmen R, Bolek EC, Söylemezoğlu F, Topçuoğlu MA. Isolated spinal cord granulomatous angiitis: a case report and review of the literature. J Neurol 2022; 269:3175-3179. [PMID: 34999955 DOI: 10.1007/s00415-021-10912-z] [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: 10/29/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Isolated spinal cord angiitis (ISCA) is very rare disease. But, it is frequently encountered in the differential diagnosis of atypical spinal cord syndromes. CASE PRESENTATION AND REVIEW OF THE LITERATURE We present a 31-year-old male who presented with progressive paraparesis, and diagnosed with pathologically confirmed ISCA. Longitudinal cystic transverse myelitis was documented in spinal MRI. He responded well to cyclophosphamide and steroid combination, and no relapse was noted during the 4-year follow-up. A standard systematic analysis of the germane literature disclosed 15 more ISCA cases. In total 16 cases (mean age: 46.5, 10 males), ISCA was diagnosed with pathological evaluation in all (Biopsy in 11, Autopsy in 5). MRI lesion is characterized by usually multisegmental longitudinal and sometimes cystic expansile lesions. In seven cases, it was described as "(pseudo)tumoral" by the authors. Albeit absence of elevation of CSF protein/WBC or "compatible" spinal MRI lesion may aid to exclude ISCA to some extent, pathological confirmation is currently necessary for the diagnosis. In 11 cases, ISCA was treated similar to primary supratentorial vasculitis. Mortality rate is 31%. DISCUSSION ISCA diagnosis, a typical example of which we have presented here, can only be established by tissue examination. However, noninvasive diagnostic criteria are critically needed. Our data suggest that this can only be possible with multinational multicenter prospective registry.
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Affiliation(s)
- Cansu Ayvacıoğlu Cagan
- Department of Neurology, Hacettepe University Faculty of Medicine, Hacettepe University Hospitals, 06230, Ankara, Turkey
| | - Cagri Mesut Temucin
- Department of Neurology, Hacettepe University Faculty of Medicine, Hacettepe University Hospitals, 06230, Ankara, Turkey
| | - Doruk Arslan
- Department of Neurology, Hacettepe University Faculty of Medicine, Hacettepe University Hospitals, 06230, Ankara, Turkey
| | - Rahsan Gocmen
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ertugrul Cagri Bolek
- Department of Internal Medicine (Rheumatology), Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Figen Söylemezoğlu
- Department of Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - M Akif Topçuoğlu
- Department of Neurology, Hacettepe University Faculty of Medicine, Hacettepe University Hospitals, 06230, Ankara, Turkey.
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Feasibility of Ultra-High Resolution Supra-Aortic CT Angiography: An Assessment of Diagnostic Image Quality and Radiation Dose. Tomography 2021; 7:711-720. [PMID: 34842838 PMCID: PMC8628996 DOI: 10.3390/tomography7040059] [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: 10/06/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: To evaluate diagnostic image quality and radiation exposure of ultra-high resolution cerebral Computed-Tomography (CT) angiography (CTA) obtained on an ultra-high resolution computed tomography scanner (UHR-CT). (2) Methods: Fifty consecutive patients with UHR-CTA were enrolled. Image reconstruction was processed with a 1024 × 1024 matrix and a slice thickness of 0.25 mm. Quantitative analyses comprising CT values, contrast-noise ratio (CNR) and signal-to-noise ratio (SNR) were performed. Subjective assessment of image quality, vessel contrast, noise, artefacts and delineation of different sized vessels were assessed by two readers on a 4-point scale. Radiation exposure was determined. (3) Results: Hounsfield values (ACI: 461.8 ± 16.8 HU; MCA: 406.1 ± 24.2 HU; BA: 412.2 ± 22.3 HU), SNR (ACI: 35.4 ± 13.1; MCA: 20.8 ± 12.4; BA: 23.7 ± 12.9) and CNR (ACI: 48.7 ± 21; MCA: 63.9 ± 26.9; BA: 48.1 ± 21.4) were remarkably high in all segments. Subjective analysis by two raters (fair agreement, k = 0.26) indicated excellent image qualities (image quality = 4; contrast = 4; noise = 3; artefacts = 4).Our analysis revealed a notably high traceability of the cerebral perforators (3 Points). Radiation exposure was at moderate dose levels (effective dose = 2.5 ± 0.6mSv). (4) Conclusions: UHR-CTA generates highly valuable image qualities that allow the depiction of vessels including cerebral perforators at acceptable dose levels. The UHR-CTA may therefore enhance the detection of small cerebral pathologies and may improve interpretability, especially in settings where high image qualities are crucial for the diagnostic accuracy.
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11
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Al-Khafaji M, Podbicanin S, Ghaghda D, Basi S, Punekar S. Simultaneous multifocal intracranial haemorrhage (ICH) and subarachnoid haemorrhage (SAH) in the setting of long-term cocaine usage. BMJ Case Rep 2021; 14:14/6/e241311. [PMID: 34140326 DOI: 10.1136/bcr-2020-241311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 45-year-old Caucasian man was admitted to hospital following a collapse at home. On admission, this patient was noted to have a Glasgow Coma Scale (GCS) Score of 9 out of 15, fever and tachypnoea. The patient was identified to have bilateral limb weakness, predominately on the left side, with associated dysphagia. Radiological imaging demonstrated bilateral multifocal intracranial haemorrhage and subarachnoid haemorrhage. Neurosurgical input was sought; the outcome of this was a decision to manage the patient conservatively, without surgical intervention. Of note, his urine drug testing revealed a positive result for a cocktail of drugs including cocaine, benzoylecgonine (cocaine metabolite), methadone, heroin, norbuprenorphine and benzodiazepine. Throughout the admission, the patient was monitored in an intensive care setting. The patient received support with feeding, speech and mobilisation. The patients' GCS improved throughout the admission. Following a 30-day admission, the patient walked home.
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Affiliation(s)
| | | | - Deep Ghaghda
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Saajan Basi
- General Internal Medicine, Royal Derby Hospital, Derby, UK
- Acute Stroke Department, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - Shuja Punekar
- Sherwood Forest Hospitals NHS Trust, Nottinghamshire, UK
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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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Rice CM, Scolding NJ. The diagnosis of primary central nervous system vasculitis. Pract Neurol 2019; 20:109-114. [DOI: 10.1136/practneurol-2018-002002] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 12/25/2022]
Abstract
The diagnosis of primary central nervous system (CNS) vasculitis is often difficult. There are neither specific clinical features nor a classical clinical course, and no blood or imaging investigations that can confirm the diagnosis. Contrast catheter cerebral angiography is neither specific nor sensitive, yet still underpins the diagnosis in many published studies. Here we describe an approach to its diagnosis, emphasising the importance of obtaining tissue, and present for discussion a new, binary set of diagnostic criteria, dividing cases into only ‘definite’ primary CNS vasculitis, where tissue proof is available, and ‘possible,’ where it is not. We hope that these criteria will be modified and improved by discussion among experts, and that these (improved) criteria may then be adopted and used as the basis for future prospective studies of the clinical features and diagnosis of this difficult and dangerous disorder, particularly for coordinated multicentre therapeutic trials.
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