Diagnostic approach to central and peripheral nervous system vasculitis

Progressive manifestations of reversible cerebral vasoconstriction syndrome presenting with subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset headache with focal neurologic deficit and prolonged but reversible multifocal narrowing of the distal cerebral arteries. Stroke, either hemorrhagic or ischemic, is a relatively frequent presentation in RCVS, but progressive manifestations of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction in a patient is seldom described. We report a rare case of a 56-year-old woman with reversible cerebral vasoconstriction syndrome consecutively presenting as cortical subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction. When she complained of severe headache with subtle cortical subarachnoid hemorrhage, her angiography was non-specific. But, computed tomographic angiography showed typical angiographic features of this syndrome after four days. Day 12, she suffered mental deterioration and hemiplegia due to contralateral intracerebral hematoma, and she was surgically treated. For recurrent attacks of headache, medical management with calcium channel blockers has been instituted. Normalized angiographic features were documented after 8 weeks. Reversible cerebral vasoconstriction syndrome should be considered as differential diagnosis of non-aneurysmal subarachnoid hemorrhage, and repeated angiography is recommended for the diagnosis of this under-recognized syndrome.

Syndrome de vasoconstriction cérébrale segmentale réversible ou angéite primitive du Systeme nerveux central?

Background:

Reversible Cerebral Vasoconstriction Syndrome (RCVS) may present as thunderclap headache (TCH), accompanied by reversible cerebral vasospasm and focal neurological deficits, often without a clear precipitant. RCVS may be mistaken for Primary Angiitis of the Central Nervous System (PACNS) due to the presence of similar angiographic features of segmental narrowing of cerebral arteries. We discuss the clinical features of a young female migraine patient who developed TCH and was found to have RCVS following initial treatment with corticosteroids for PACNS, in the context of a systematic review of the available medical literature.

Methods:

A Medline™ search was performed to identify all case reports since 1966 describing RCVS and PACNS that provide sufficient clinical detail to permit diagnostic classification according to published criteria. RCVS included case studies in which there was angiographic or transcranial Doppler ultrasound evidence of near-to-complete resolution of cerebral vasoconstriction in the absence of a well-recognized secondary cause. PACNS included reports of histologically confirmed PACNS either through biopsy or necropsy.

Results:

Reversible Cerebral Vasoconstriction Syndrome occurs primarily in females and is characterized by sudden, severe headache at onset, normal CSF analysis, vasoconstriction involving the Circle of Willis and its immediate branches, and angiographic or TCD ultrasound evidence of near-to-complete vasospastic resolution within 1-4 weeks. It occurs typically in the context of vasoconstrictive drug use, the peripartum period, bathing, and physical exertion.

Conclusion:

Initial and follow-up (within 4 weeks) non-invasive angiographic studies are indicated in patients who present with TCH or who have clinical presentations that could be consistent with RCVS or PACNS in the absence of a well-recognized secondary cause, such as subarachnoid haemorrhage. Early reversibility of cerebral vasospasm is the key neuroradiological feature that supports the clinical diagnosis of RCVS.

Headache attributed to infections nosography and differential diagnosis

Headache is a very frequent symptom of infection. It has many possible underlying mechanisms, of which two or more can coexist in a single patient. It can be caused by direct stimulation of intracranial pain-producing structures, as in the case of brain abscesses, by irritation of the pachy- and leptomeninges, as in cases of bacterial or viral meningitis, or by a state of intracranial hypertension, as seen in obstructive hydrocephalus. There is no doubt that headache is often the first or the predominant symptom of serious, sometimes life-threatening, infectious diseases; certainly, it is a condition frequently encountered in all epidemiological studies. Indeed, it is estimated that over 60% of people have, at some point in their lives, experienced headache during an infection. This evidence leads to the need for a systematic approach to headache secondary to infection. This chapter provides some elements on pain mechanisms in systemic and intracranial infections and on the possible role of antimicrobial agents in the genesis of headache. The first section provides a detailed "etiology-based" description of the International Classification of Headache Disorders, 2nd edition (ICHD-II: Headache Classification Subcommittee of the International Headache Society, 2004), while the second section presents a "symptom-based" algorithm applicable in the first diagnostic assessment, according to the headache features and to the most frequently associated clinical manifestations during infections of the central nervous system (CNS).

Primary angiitis of the central nervous system: report of five biopsy-confirmed cases from Colombia

INTRODUCTION

Primary (isolated) angiitis of the central nervous system (PACNS) is a rare cause of cerebrovascular disease (CVD), and few leptomeningeal and brain biopsy (LBB)-confirmed cases have been reported from South America.

METHODS

We retrospectively reviewed charts of patients with diagnosis of cerebral angiitis admitted between March 1991 and July 2001 to a single university hospital in Medellin, Colombia. Patients with definitive diagnosis of PACNS by Alrawi et al.'s LBB criteria were selected. We excluded other causes of cerebral angiitis as well as cases without LBB confirmation.

RESULTS

We report five patients, four men and one woman, with a mean age at onset of 24.4 years, and an average disease progression of 12.4 days. Four presented with headache and motor weakness, three had seizures, and two had alterations of consciousness. Cerebral MRI was abnormal in all five cases; brain CT in four, and cerebral angiography in two. The cerebrospinal fluid (CSF) was abnormal in two patients. Leptomeningeal and brain biopsies revealed mononuclear infiltration in the wall of small blood vessels in all. Three had concurrent meningeal and cerebral involvement, two had necrotizing angiitis, and one had vascular and encephalitic lesions. All received only steroid treatment; the 1-year follow-up revealed good prognosis without relapses.

CONCLUSION

We report five biopsy-proven cases of PACNS from Colombia associated with neurological and neuroimaging abnormalities; these patients presented a mild inflammatory disease that was correlated with few CSF abnormalities and good response to single steroid treatment without relapses. Leptomeningeal and brain biopsy is mandatory for a definitive diagnosis.

Ischemic stroke: carotid and vertebral artery disease

Ischemic strokes may have distinct aetiologies, including several different intrinsic arterial pathological disorders. The diagnosis and understanding of these arterial diseases is critical for the correct management of stroke as different treatment approaches are undertaken according to the aetiology. Atherosclerosis is by far the most common arterial disease among adults, and other pathological processes include arterial dissection, small vessel disease, inflammatory and non-inflammatory vasculopathy and vasomotor disorders. In children, there are several vasculopathies responsible for vaso-occlusive disease such as sickle-cell anemia, acute regressive angiopathy and Moya-Moya disease, neurofibromatosis, dissections, vasculitis associated with intracranial and systemic infections. An overview of the major carotid and vertebral pathological diseases responsible for ischemic stroke in adults and children, highlighting the accuracy of the different imaging modalities for its diagnosis and the imaging appearance of these diseases, is given.

Review of severe vaso-occlusive retinopathy in systemic lupus erythematosus and the antiphospholipid syndrome: associations, visual outcomes, complications and treatment

PURPOSE

To discuss the pathogenesis of severe vaso-occlusive retinopathy in systemic lupus erythematosus (SLE), the association with antiphospholipid antibodies, and its implications for management and prognosis.

METHODS

An illustrative case history of a woman with SLE and severe vaso-occlusive retinopathy in the presence of antiphospholipid antibodies is presented. A literature review of previously reported cases and previously published data on the topic was performed and forms the basis for discussion.

RESULTS

This is a rare form of retinopathy in SLE as distinct from the more common, benign form, being classically a microangiopathy with diffuse capillary non-perfusion and small arterial or arteriolar occlusions in the retina. Poor visual outcomes with visual loss are reported in 80% of cases with neovascularization occurring in 40% of cases. It is associated with antiphospholipid antibodies, typically characterized by microthrombosis and immune complex mediated vasculopathy rather than a true vasculitis. There is a strong association between this severe form of retinopathy and central nervous system manifestations of SLE. Anticoagulation has a role in the secondary prevention of thrombosis in the presence of antiphospholipid antibodies, but the role of aspirin and immunosuppression is unclear in the treatment of this condition. Vigilant ophthalmic follow up and aggressive treatment of neovascularization and vitreous haemorrhage can prevent further visual loss. These points are highlighted in the brief case report presented.

CONCLUSION

Severe vaso-occlusive retinopathy is a rare form of retinopathy in SLE often associated with poor visual prognosis and neovascularization. It may be a manifestation of the antiphospholipid syndrome. Treatment is aimed at preventing further thrombosis and complications arising from neovascularization.

Cerebrospinal fluid neurofilament and glial fibrillary acidic protein in patients with cerebral vasculitis

Few diseases in clinical medicine cause as much diagnostic consternation as central nervous system (CNS) vasculitis because of its varying modes of presentation and frequently overlapping clinical and pathological features. There are no pathognomonic clinical or laboratory findings. The purpose of the present retrospective study was to validate the use of the light subunit of neurofilament triplet protein (NFL) and glial fibrillary acidic protein (GFAP) as markers of CNS tissue damage for patients with systemic or isolated CNS vasculitis. Levels of cerebrospinal fluid (CSF) NFL and GFAP were measured using ELISAs. Both CSF NFL and CSF GFAP concentrations were significantly higher in a patient group diagnosed with CNS vasculitis (P < 0.01 and P < 0.05, respectively) than in a patient group for whom CNS vasculitis was excluded. In the future, analysis of CSF NFL in particular, but also GFAP, may be a useful complement in the difficult clinical task of diagnosing CNS vasculitis.

Brain involvement in systemic immune mediated diseases: magnetic resonance and magnetisation transfer imaging study

OBJECTIVE

Magnetisation transfer imaging (MTI) provides information about brain damage with increased pathological specificity over conventional MRI and detects subtle abnormalities in the normal appearing brain tissue, which go undetected with conventional scanning. Brain MRI and MTI findings were compared in patients with multiple sclerosis (MS) and systemic immune mediated diseases (SIDs) affecting the CNS to investigate their roles in understanding the nature of brain damage in these diseases.

METHODS

Brain dual echo, T1 weighted and MTI scans were obtained in patients affected by systemic lupus erithematosus (SLE) with (NSLE, n=9) and without clinical CNS involvement (n=15), Behçet's disease (BD) (n=5), Wegener's granulomatosis (WG) (n=9), and antiphospholipid antibody syndrome (APLAS) (n=6). Ten patients with clinically definite MS and 15 healthy controls also underwent the same scanning protocol. Brain MRI and MT ratio (MTR) images of the same subject were coregistered and postprocessed to obtain MTR histograms of the whole brain and of the NABT.

RESULTS

Brain hyperintense lesions were found in all patients with MS and with NSLE and in 5/15 patients with SLE, 5/9 with WG, 1/5 with BD, and 3/6 with APLAS. The lesion burden in the brain was significantly higher in patients with MS compared with all the other disease groups. All MTR histogram parameters were significantly different among patient subgroups. Patients with MS had significantly lower average MTR than all except patients with NSLE and significantly lower peak height and location than patients with SLE. patients with NSLE had significantly lower average MTR than patients with SLE.

CONCLUSIONS

Microscopic brain tissue damage is relevant in patients with MS, but, apart from patients with NSLE, it seems to be absent in systemic immune mediated diseases, even in the presence of macroscopic MRI lesions or clinical evidence of CNS involvement.

Vasculitic neuropathy

The pathogenesis of primary vasculitides, which are assumed to have an autoimmune pathogenesis, is not well understood. The endothelial cell adhesion molecules seem to play an active role, which varies according to the histopathologic stage of vascular lesions. The role of genetic factors also seems quite important, at least in an experimental model. The reliability of antineutrophil cytoplasmic antibodies testing in diagnosis and follow-up of patients with vasculitis is reviewed. The conclusion is that antineutrophil cytoplasmic antibodies status can be a very useful diagnostic adjunct to the evaluation of patients with suspected Wegener's granulomatosis, but is not a substitute for clinical expertise and histopathologic data during the course of providing patient care. The neurological manifestations of Churg-Strauss syndrome (a variant of polyarteritis nodosa) are very similar to those that occur in polyarteritis nodosa. A role for vasculitis has been confirmed in proximal diabetic neuropathy, which may pave the way for new therapeutic developments.