CNS vasculitis and vasculopathy: efficacy and usefulness of diffusion-weighted echoplanar MR imaging

Unique presentation of acute neuro-Behçet's disease involving a cytotoxic edema core surrounded by vasogenic edema

A 53-year-old woman with recurrent stomatitis, genital ulcers, and folliculitis was admitted to our hospital after experiencing visual disturbances for the past two weeks, and a non-throbbing headache for the past three days. She had also developed numbness in her left extremities. An ophthalmological examination revealed inflammatory changes in the eye. Cerebrospinal fluid analysis showed increased cell counts, protein, and interleukin-6 levels. Brain magnetic resonance imaging revealed multiple high signal intensities on T2-weighted (T2W)/fluid-attenuated inversion recovery (FLAIR) images of the pons and occipital and parietal lobes. The T2W/FLAIR high-signal-intensity lesion in the pons was hyperintense on diffusion-weighted imaging (DWI) and hypointense on apparent diffusion coefficient mapping (ADC), suggesting cytotoxic edema. Another high-signal-intensity lesion on T2W/FLAIR was isointense to hyperintense on DWI and hyperintense on ADC, indicating vasogenic edema. The vasogenic edema in the left occipital lobe contained a small core that was hyperintense on DWI and hypointense on ADC, suggesting cytotoxic edema. The patient was diagnosed with acute neuro-Behçet's disease (neuro-BD) and responded well to high-dose glucocorticoid and colchicine treatment. The present report emphasizes that patients with acute neuro-BD may present with cytotoxic edema in the pons and cerebral spheres. Further reports of similar cases would contribute to a better understanding of the role of cytotoxic edema in the pathophysiology of neuro-BD and help elucidate the mechanisms underlying a unique presentation characterized by a central cytotoxic edema core within vasogenic edema. (233 words).

Neuroimaging findings in rheumatologic disorders

Patients with rheumatological diseases may present with neurological manifestations of peripheral and/or central nervous system (CNS). Symptoms may be related to underlying rheumatological disease or CNS effects of immune-modulating drugs. Early diagnosis and therapy may help prevent serious complications. Magnetic resonance imaging (MRI), given its excellent soft tissue details, is the preferred imaging modality when evaluating patients with rheumatological disease and suspected CNS involvement. We present a review of the neuroimaging manifestations of various rheumatic diseases with emphasis on the imaging findings on MRI.

Characteristics of mass lesion presentation of primary angiitis of the central nervous system: A single center 11-year retrospective case-series study

OBJECTIVE

Mass lesion presentation of primary angiitis of the central nervous system (ML-PACNS) is a special subtype of primary central nervous system vasculitis, which is difficult to be differentiated from other space-occupying disorders. We aimed to summarize our experience and improve diagnostic techniques of ML-PACNS.

PATIENTS AND METHODS

Case records for 16 patients treated in the Department of Neurology of Six Medical Center of Chinese PLA General Hospital from December 2008 to November 2019 were examined. All patients were diagnosed with ML-PACNS by pathology. Clinical manifestations, neuroimaging results and pathological features were retrospectively analyzed.

RESULTS

The 16 patients with ML-PACNS in the cohort (8 males) had a median age of 32 (range 19-56 years). On T1WI and T2WI, 12 cases showed mixed signals and 4 cases showed T1WI hypointense and T2WI hyperintense. Fifteen patients showed DWI hyperintense, of which 9 cases showed hypointense in the middle of the lesion. Gadolinium enhancement of all cases was irregular. All patients had a brain biopsy (stereotactic procedure in 10 and open-wedge surgery in 6) which showed lymphocytic vasculitis in the majority of patients (15/16) and necrotizing vasculitis in one patient.

CONCLUSIONS

ML-PACNS is an important differential candidate for tumefactive demyelinating lesions, CNS infections and brain tumors. Mixed T1WI and T2WI signals as well as central hypointense surrounded by hyperintense lesions on DWI may be useful imaging features for the diagnosis of ML-PACNS which has implications for those who have not yet had a biopsy. ML-PACNS may have different pathological type from PACNS.

Evaluation of brain changes in systemic sclerosis (SSc) patients using two different techniques of MRI: Is it really worthy?

BACKGROUND

Systemic sclerosis (SSc) is a rare chronic multi-system autoimmune disease of unknown cause and a complex pathogenesis. The hallmark of the disease is microvascular vasculopathy which results in tissue ischemia with recurrent episodes of reperfusion. Diffusion-weighted (DW) Magnetic Resonance imaging (MRI) is an excellent tool for the detection of activity of any vascular or inflammatory lesions.

OBJECTIVES

Detect brain changes in systemic sclerosis patients with asymptomatic CNS manifestations using fluid attenuation inversion recovery (FLAIR) weighted sequence and diffusion-weighted (DW) sequence MRI.

METHODS

Fifteen systemic sclerosis female patients aged 27-60 years old with disease duration of 1-20 years with no CNS clinical manifestations were included. A controlled group of 14 clinically normal persons, age and sex matched. Both groups were subjected to brain MR examination at 1.5T; a FLAIR weighted sequence and a DW sequence. SPSS (version 20) was used for statistical analysis.

RESULTS

37 white matter hyperintense lesions (≤2 to ≥ 5mm in diameter) were detected in patient group using FLAIR weighted MRI while diffusion-weighted MRI failed to detect the same lesions. A non-significant relation (P=.259) between the presence of white matter hyperintense lesions and the severity of peripheral vascular affection of the disease was observed.

CONCLUSIONS

Asymptomatic central nervous system vasculopathy is detected in systemic sclerosis using FLAIR MRI, while diffusion MRI failed to detect such lesions. These findings suggest a non-inflammatory form of central nervous system microvasculopathy in SSc patients.

Role of magnetic resonance imaging in the diagnosis of primary central nervous system angiitis

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.

Diffusion-Weighted Imaging of the Brain: Beyond Stroke

Diffusion-weighted imaging provides image contrast that is different from that provided by conventional magnetic resonance imaging techniques. It is highly sensitive for detection of cytotoxic oedema, and as such has gained favor in the detection of acute infarcts. However, diffusion-weighted imaging is underrepresented in the characterisation of many other disease processes. Our objective is to differentiate diseases that manifest with various neurological disorders, based on diffusion contrast and apparent diffusion coefficient values and review of hyper- and hypointense lesions on diffusion-weighted imaging.

Primary CNS vasculitis masquerading as glioblastoma: A case report and review

Isolated angitis of the central nervous system (IACNS)/primary angitis of central nervous system vasculitis (PACNS) is an uncommon vascular disease, sparingly presenting as an isolated inflammatory lesion on magnetic resonance imaging (MRI). The disease usually manifests as a long-drawn and progressive ischemic event. Delay in diagnosis due to focal nature of the lesion also contributes to the poor prognosis as the dismal natural history and immunosuppressive therapy. To date, only a few cases with tumor-like isolated angitis of CNS have been reported with clear and definitive diagnostic workup.

Review: Neuropsychiatric involvement in pediatric systemic lupus erythematosus

Neuropsychiatric (NP) manifestations are found in approximately 25% of children and adolescents with pediatric SLE (pSLE). In 70% of those, NP involvement will occur within the first year from the time of diagnosis. Headaches (66%), psychosis (36%), cognitive dysfunction (27%) and cerebrovascular disease (24%) are the most common presentations. The support of a psychiatrist is often required. Anti-phospholipid antibodies are associated with distinct NP disease entities and may be implicated in the pathogenesis of several manifestations of NP-pSLE including chorea, cerebrovascular disease and seizures. The role of novel auto-antibodies and imaging modalities is currently explored. The treatment of NP-pSLE is not based on prospective studies; however, an immunosuppressive combination therapy consisting of high doses of prednisone and a second line agent such as cyclophosphamide or azathioprine is commonly suggested for children with NP-pSLE. The role of novel therapies is currently studied. The outcome of children with NP-pSLE is relatively good. The overall survival is 95—97%, 20% of children experience a disease flare during childhood and 25% have evidence of permanent neuropsychiatric damage. Lupus (2007) 16, 564—571.

Imaging of Cerebral Vasculitis

Background

In young patients, vasculitic stenoses of cerebral blood vessels are an important cause of cerebral ischaemia. Diagnosis may prove very difficult.

Summary of review

The diagnostic process is usually initiated by the detection of brain lesions consistent with cerebral vasculitis. Multiple infarcts of various ages in more than one vascular territory are thought to be suggestive of a vascular inflammatory disease. The next step in the imaging of patients with suspected vasculitis is the search for an underlying vascular stenosis. Today, magnetic resonance angiography is the principal modality for the investigation of patients thought to have intracranial stenoses. At 1·5 T, only large brain arteries can be imaged with a high diagnostic accuracy. Intraarterial DSA remains an indispensable tool for the investigation of medium and small brain artery stenoses.

Conclusions

However, contrast-enhanced magnetic resonance imaging may be able to demonstrate wall thickening and contrast uptake in large cerebral arteries, obviating biopsy in patients with basal vasculitis.

Intensity-Corrected Dual-Echo Echo-Planar Imaging (DE-EPI) for Improved Pediatric Brain Diffusion Imaging

Here we investigate the utility of a dual-echo Echo-Planar Imaging (DE-EPI) Diffusion Weighted Imaging (DWI) approach to improve lesion conspicuity in pediatric imaging. This method delivers two ‘echo images’ for one diffusion-preparation period. We also demonstrate how the echoes can be utilized to remove transmit/receive coil-induced and static magnetic field intensity modulations on both echo images, which often mimic pathology and thereby pose diagnostic challenges. DE-EPI DWI data were acquired in 18 pediatric patients with abnormal diffusion lesions, and 46 pediatric patient controls at 3T. Echo1 [TE = 45ms] and Echo2 [TE = 86ms] were corrected for signal intensity variation across the images by exploiting the images equivalent coil-sensitivity and susceptibility-induced modulations. Two neuroradiologists independently reviewed Echo1 and Echo2 and their intensity-corrected variants (cEcho1 and cEcho2) on a 7-point Likert scale, with grading on lesion conspicuity diagnostic confidence. The apparent diffusion coefficient (ADC) map from Echo1 was used to validate presence of true pathology. Echo2 was unanimously favored over Echo1 for its sensitivity for detecting acute brain injury, with a mean respective lesion conspicuity of 5.7/4.4 (p < 0.005) and diagnostic confidence of 5.1/4.3 (p = 0.025). cEcho2 was rated higher than cEcho1, with a mean respective lesion conspicuity of 5.5/4.3 (p < 0.005) and diagnostic confidence of 5.4/4.4 (p < 0.005). cEcho2 was favored over all echoes for its diagnostic reliability, particularly in regions close to the head coil. This work concludes that DE-EPI DWI is a useful alternative to conventional single-echo EPI DWI, whereby Echo2 and cEcho2 allows for improved lesion detection and overall higher diagnostic confidence.

Angiography-negative primary angiitis of the central nervous system in childhood

Childhood primary angiitis of the CNS is a recently characterized, potentially reversible disease process. A favorable outcome requires early diagnosis and appropriate treatment. The histological findings of childhood primary angiitis of the CNS are characterized by a lymphocytic, nongranulomatous vasculitis. This disorder can lead to neurological deficits, seizures, and strokes. Laboratory and radiographic investigation are part of the evaluation, but are often nonspecific. Conventional angiography can fail to show any abnormality, and biopsy may ultimately be required for diagnosis. Although there can be significant rates of morbidity and mortality if untreated, patients who receive appropriate therapy can experience excellent outcomes, and in many cases will demonstrate near-complete or total clinical and radiographic resolution. The case of a previously healthy 13-year-old girl with new-onset generalized tonic-clonic seizures is presented, with a review of the literature.

Successful use of intensive immunosuppressive therapy for treating simultaneously occurring cerebral lesions and pulmonary arterial hypertension in a patient with systemic lupus erythematosus

A 59-year-old woman who had been diagnosed with systemic lupus erythematosus (SLE) was admitted to our hospital due to paralysis in all of her limbs. The patient presented with dysarthria, cerebellar ataxia and hypoxia. Magnetic resonance imaging (MRI) revealed vasogenic edema in the brain stem and the cerebellum. She was diagnosed with neuropsychiatric lupus syndrome (NPSLE) and pulmonary arterial hypertension (PAH), and was successfully treated using immunosuppressive therapy. To our knowledge, this is the first reported case of simultaneously developing NPSLE and PAH.

Pediatric Inflammatory Diseases. Part III: Small Vessels Vasculitis

Central nervous system (CNS) vasculitis can affect both adults and children, but some of these occur almost exclusively in childhood. In children may develop as a primary condition or secondary to an underlying systemic disease. Cerebral vasculitis can be classified on the basis of the diameter of the involved vessels, although there is no univocal consensus. The diagnosis of CNS vasculitis is particularly difficult because the available investigative modalities have limited sensitivities and specificities. The most helpful diagnostic tests include cerebrospinal fluid analysis, MRI (MR angiography/venography (MRA/MRV) of the brain, and angiography. However, brain biopsy may be required to diagnose small vessel vasculitis in order to make differential diagnosis with a wide range of conditions, such as degenerative vasculopathies, embolic diseases, or coagulation disorders. This paper discusses on current understanding of most frequent primary and secondary central nervous system vasculitis in children in which are involved small vessel.

Atherosclerosis in sickle cell disease - a review

Acute, vaso-occlusive crises are the most common and earliest clinical manifestations of sickle cell disease. Recent thoughts about development of atherosclerosis as a result of this disease are presented. Current insights into the pathogenesis of atherosclerosis in sickle cell disease are reviewed, in particular the role of endothelial dysfunction, homocysteine and platelets. Common and uncommon sites of atherosclerosis are described. Radiological assessment and potential therapeutic agents to slow the progression of atherosclerosis are discussed. Finally, treatment of atherosclerosis in certain sites is evaluated and reviewed.

Childhood primary angiitis of the central nervous system: identifying disease trajectories and early risk factors for persistently higher disease activity

OBJECTIVE

To compare clinical, laboratory, and imaging characteristics of childhood primary angiitis of the central nervous system (PACNS) subtypes at diagnosis and during followup; to characterize disease activity trajectories in childhood PACNS subtypes; and to identify early risk factors for higher disease activity.

METHODS

We performed a single-center cohort study of consecutive children diagnosed as having childhood PACNS. Demographic, clinical, laboratory, and imaging data were collected at diagnosis and during standardized clinic visits. Outcome measures included disease activity measured by physician's global assessment. Descriptive statistics were used to assess characteristics of the study cohort, and longitudinal data were analyzed using linear mixed-effects regression.

RESULTS

The study cohort consisted of 45 patients with childhood PACNS; 26 had angiography-negative childhood PACNS and 19 had angiography-positive childhood PACNS. There were 24 females, the median age at diagnosis was 9.8 years, and the median followup period was 1.8 years. Patients with angiography-negative childhood PACNS were more likely to be female and to present with seizures, cognitive dysfunction, vision abnormalities, high levels of inflammatory markers, and bilateral findings on magnetic resonance imaging (MRI). Motor deficits and ischemic MRI lesions were more common in angiography-positive disease. Disease activity decreased significantly after treatment in all patients. Distinct trajectories of disease activity over time were identified for both childhood PACNS subtypes. Patients with angiography-negative childhood PACNS had persistently higher disease activity. Seizures at presentation also predicted higher disease activity over time.

CONCLUSION

Distinct subtypes of childhood PACNS have unique disease activity trajectories. Patients with angiography-negative disease and seizures at presentation experience higher disease activity. Early recognition of this high-risk cohort may enable the treating physician to initiate targeted therapies and prevent long-term brain injury.

Brain perfusion MRI findings in patients with Behcet's disease

Objective. To search brain perfusion MRI (pMRI) changes in Behcet's disease (BD) with or without neurological involvement. Materials and Method. The pMRI were performed in 34 patients with BD and 16 healthy controls. Based on neurologic examination and post-contrast MRI, 12 patients were classified as Neuro-Behcet (group 1, NBD) and 22 patients as BD without neurological involvement (group 2). Mean transit time (MTT), time to peak (TTP), relative cerebral blood volume (rCBV), and relative cerebral blood flow (rCBF) were obtained and compared to those of healthy control group (group 3). Results. There was a significant difference in the MTT and rCBF within the pons and parietal cortex in groups 1 and 2. rCBV increased in cerebral pedicle in group 1 compared with groups 2 and 3. In the temporal lobe white matter, prolonged MTT and decreased rCBF were found in groups 1 and 2. In the corpus striatum, internal capsule, and periventricular white matter, rCBF increased in group 1 compared with group 3 and decreased in groups 1 and 2. Conclusion. Brain pMRI is a very sensitive method to detect brain involvement in patients with BD and aids the clinical diagnosis of NBD, especially in patients with negative MRI findings.

Diagnosing central nervous system vasculitis in children

PURPOSE OF REVIEW

To review the current literature of childhood central nervous system vasculitis, and to discuss a tailored approach to diagnosis and treatment based on recent evidence.

RECENT FINDINGS

Primary angiitis of the central nervous system in children (cPACNS) is an increasingly recognized inflammatory brain disease with potentially devastating neurological consequences. The diagnostic approach should be tailored to the clinical presentation of the child with suspected cPACNS and should address the expanding spectrum of inflammatory and noninflammatory brain diseases with overlapping clinical features. New evidence has confirmed that elective brain biopsies in children have a higher diagnostic yield than in adults and improve our ability to diagnose angiography-negative cPACNS. Finally, observational studies have shown that early diagnosis and aggressive treatment lead to improved neurological outcomes and lower mortality rates in patients with cPACNS.

SUMMARY

This review summarizes the recent data on diagnosis, classification, treatment, and outcomes in cPACNS. Our improved understanding of cPACNS facilitates a tailored diagnostic approach that results in earlier diagnosis and initiation of therapy for this potentially reversible condition.

Intra-axial pseudotumors in the central nervous system: clinicopathological analysis

Intra-axial pseudotumors in the central nervous system often mimic malignant brain tumors and cause difficulty in diagnosis and treatment. The present study investigates their radiologic and histological features to elucidate diagnostic clues. Six cases were included in the study, one man and five women, ranging in age from 44 to 87 years (mean age, 61 years). Histologically, three cases had demyelination, and one case each had abscess, angiitis, and non-Langerhans cell histiocytosis. All cases were evaluated radiologically on MRI, most of them by thallim-201 single photon emission tomography ((201)Tl-SPECT). These cases were examined using H&E, special stains, and immunohistochemical studies with a variety of antibodies. MRI demonstrated perifocal edema and ring-like or solid enhancement, mimicking the malignant tumors. Diffusion-weighted MRI showed a hypo-iso-intensity with a hyperintensity on the apparent diffusion coefficient. A (201)Tl-SPECT study revealed no uptake. Although there were various kinds of pathology, inflammatory cells were observed, associated with vascular proliferation and reactive astrocytosis. In addition, some cases showed demyelinating or destructive changes. These results suggested that intra-axial pseudotumors in the central nervous system contain various kinds of pathology, and detailed clinicopathological analysis is important from the point of view of differential diagnosis.

Primary angiitis of the central nervous system: differential diagnosis and treatment

While primary angiitis of the central system (PACNS) remains a rare entity, the poor specificity of the available diagnostic tests and its multiple mimics create a major diagnostic challenge. Recently, there have been advances in understanding PACNS and differentiating it from its mimics. A recent breakthrough is the proposal of reversible cerebral vasoconstriction syndromes (RCVS) as a unifying concept for a group of disorders that highly mimics PACNS. RCVS are characterised by acute-onset, recurrent headaches, with or without additional neurologic events, with reversible vasoconstriction of the central nervous system (CNS) vasculatures, mimicking CNS vasculitis. RCVS are considered the most common mimics of PACNS. Advances in our understanding of RCVS have allowed for identification of patients previously confused with PACNS. The scope of this article focusses on the work-up, differential diagnosis and evaluation of PACNS, as well as a discussion of the secondary CNS vasculitides with emphasis on their clinical findings, diagnoses and treatment.

The impact and implications of neuropsychiatric systemic lupus erythematosus in adolescents

Signs and symptoms of neuropsychiatric systemic lupus erythematosus (NPSLE), as defined by the American College of Rheumatology case definitions, occur commonly in adolescents with lupus. Thought and mood disorders are more difficult to identify than specific central or peripheral nervous system injuries. Furthermore, thought and mood disorders must be differentiated from other causes, including traumatic, metabolic, endocrinologic, toxic, and infectious etiologies. It is also important to recognize that primary mood and thought disorders can present in adolescence. The effects of chronic disease during adolescent development can also trigger alterations in mood and cognitive function. This article reviews proposed etiologies of injury, diagnosis, and differential diagnosis of NPSLE. At this time, no specific test identifies NPSLE as the cause of mood and cognitive changes; however, current efforts to standardize evaluation of cognitive function and develop imaging techniques that identify anatomic brain changes will improve the practice of rheumatology.

Immunologically mediated dementias

Although most dementias are due to neurodegenerative or vascular disease, it is important to diagnose immunologically mediated dementias quickly because they can be both rapidly progressive and readily treatable. They usually affect function of limbic and cortical structures, but subcortical involvement can also occur. Because of the variety of symptoms and the rapid course, these dementias present a particular challenge to the clinician and may require evaluation and intervention in the inpatient setting. Diagnostic workup typically reveals evidence of an autoimmune process and, in some cases, cancer. In contrast to the neurodegenerative processes, many of the immunologically mediated dementias respond to immunomodulatory therapy.

[Imaging techniques for the evaluation of systemic manifestations of vasculitis]

Vasculitides create a local inflammatory process in the vessel wall, which determines the different organic manifestations according to vessel size and location. Imaging techniques play a key role in the characterization and detection of large and medium size vessel vasculitides. Imaging is able to detect the vessel wall edema and to monitor the therapeutic response. In small vessel vasculitis, imaging can indirectly analyse the organic and/or systemic manifestations, because at present, none of the imaging techniques has the necessary spatial resolution to directly visualize small vessels.

Silent white matter lesion in linear scleroderma en coup de sabre

We report a patient with linear scleroderma en coup de sabre without neurological symptoms despite the presence of large white matter lesions. The patient underwent 3.0-T magnetic resonance (MR) examinations including diffusion tensor imaging, time-resolved contrast-enhanced MR angiography, susceptibility-weighted imaging, and proton MR spectroscopy. These imaging findings suggested increased vascular permeability and microbleeding without abnormalities of metabolites. Our observation is consistent with vasculopathy and may be helpful in the proper diagnosis and treatment of linear scleroderma en coup de sabre.

Steroid-responsive encephalopathy associated with autoimmune thyroiditis presenting with diffusion MR imaging changes

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) presents with focal or diffuse nonenhancing MR imaging abnormalities in 50% of patients with SREAT during subacute exacerbation. Vasculitic changes in biopsy studies as well as the elevation of antithyroid antibodies and CSF protein suggests an inflammatory cause. We report the case of a patient with SREAT with changes on diffusion-weighted MR imaging, which improved with corticosteroid therapy and plasmapheresis, supporting the theory of inflammatory changes in exacerbation of presumptive SREAT.

Rapidly progressive dementia

In contrast with more common dementing conditions that typically develop over years, rapidly progressive dementias can develop subacutely over months, weeks, or even days and be quickly fatal. Because many rapidly progressive dementias are treatable, it is paramount to evaluate and diagnose these patients quickly. This review summarizes recent advances in the understanding of the major categories of RPD and outlines efficient approaches to the diagnosis of the various neurodegenerative, toxic-metabolic, infectious, autoimmune, neoplastic, and other conditions that may progress rapidly.

Churg-strauss syndrome in the pediatric age group

The rate of reporting of childhood Churg-Strauss syndrome (CSS) has increased lately because of either increased awareness to the disease or a real increase in incidence. It is defined as one of the antineutrophil cytoplasmic antibody-associated vasculitides, but the antineutrophil cytoplasmic antibody positivity is less reported in pediatric cases. The cause of CSS remains unknown. Several lines of evidence suggest genetic predisposition, which may entail inherited tendency to dysregulation of the cellular immune system. With the addition of leukotriene receptor antagonists to the treatment regimen of asthma, an association to CSS was presumed. However, the nature of this relationship remains to be elucidated. In addition, some environmental factors seem to provoke transient effects that resemble the disease. Patients' symptoms are defined by various degrees of eosinophilic inflammation and necrotizing vasculitis, which may affect any organ. Three clinical stages have been described in the clinical evolution of CSS: prodromal phase involving allergic rhinitis and asthma (usually without family history of atopy), a second phase that involves peripheral eosinophilia and eosinophilic tissue infiltration, and the hallmark of the final phase is systemic vasculitis. Pulmonary disease is a central feature of pediatric CSS, but other manifestations include skin lesions, testicular pain, hypertension, seizures, and nephropathy. More subtle presentations in children include cervical lymphadenopathy, acute abdominal pain, deep venous thrombosis, oral ulceration, multiple colonic ulcers, chorea, bilateral optic neuropathy, and retinal artery occlusions. Churg-Strauss syndrome patients usually respond well to corticosteroid therapy. Several trials reported additional benefit from cyclophosphamide, azathioprine, and methotrexate, whereas the therapeutic effects of etanercept, plasma exchange, and intravenous immunoglobulin therapy are controversial. The relapse rate is approximately 25% to 30%, but corticosteroids have significantly increased survival, which now approaches greater than 75% at 5 years. However, there is limited information about survival or long-term outcome in childhood.

Diffusion-weighted imaging of the brain in infants and children

During the last decade, diffusion-weighted imaging (DWI) has become an important tool in the evaluation of a variety of disorders of the central nervous system in children. DWI relies on variability in the diffusivity of water molecules in the presence of a supplemental diffusion-sensitizing gradient to produce image contrast. Pathologic states alter the diffusion characteristics of brain water in a reproducible fashion. In this review, the DWI appearances of a number of common abnormalities of the brain in infants and children are presented.

Diffusion weighted MR imaging in non-infarct lesions of the brain

Diffusion weighted imaging (DWI) is a relatively new method in which the images are formed by the contrast produced by the random microscopic motion of water molecules in different tissues. Although DWI has been tried for different organ systems, it has been found its primary use in the central nervous system. The most widely used clinical application is in the detection of hyperacute infarcts and the differentiation of acute or subacute infarction from chronic infarction. Recently DWI has been applied to various other cerebral diseases. In this pictorial paper the authors demonstrated different DWI patterns of non-infarct lesions of the brain which are hyperintense in the diffusion trace image, such as infectious, neoplastic and demyelinating diseases, encephalopathies - including hypoxic-ischemic, hypertensive, eclamptic, toxic, metabolic and mitochondrial encephalopathies - leukodystrophies, vasculitis and vasculopathies, hemorrhage and trauma.

Cerebral vasculitis: imaging signs revisited

Inflammatory stenoses of cerebral blood vessels, although rare in general, are an important cause of cerebral ischemia in younger patients. The diagnosis is often difficult. The first step in the diagnostic process is the identification of brain lesions consistent with cerebral vasculitis. Brain lesions are frequently found in this patient group, especially if modern imaging tools such as diffusion and perfusion-weighted imaging are employed. Although no specific pattern for this entity exists, multiple infarcts of various ages in more than one vascular territory should raise this suspicion. The next step in the imaging of patients with suspected vasculitis is the demonstration of the underlying vascular pathology. MR angiography is the mainstay of investigating patients for intracranial vascular stenoses. However, at 1.5 T it is only diagnostic for stenoses of large brain arteries. Hence, conventional angiography is still required to investigate stenoses of medium and small-sized brain arteries. Recent work suggests that MRI can directly demonstrate mural thickening and contrast enhancement in basal brain arteries, rendering biopsy obsolete in this patient group. A classification for cerebral vasculitis is proposed according to the size of the affected brain vessels, analogous to the pertinent nomenclature of primary systemic vasculitis.

High-dose methotrexate is beneficial in parenchymal brain masses of uncertain origin suspicious for primary CNS lymphoma

In patients with parenchymal brain masses of uncertain origin responsive to corticosteroids, primary CNS lymphoma (PCNSL) should be considered. PCNSL is a rare but aggressive brain tumor that is highly sensitive to high-dose methotrexate (HDMTX)-based chemotherapy. We report a series of six patients with brain masses without histologic confirmation suspicious for PCNSL based on clinical and radiomorphologic criteria after exclusion of some infectious conditions. All patients were treated with HDMTX. We observed two complete responses, two partial responses, and one stable disease. One patient had progressive disease and received rescue whole-brain irradiation. All patients were alive without disease progression 12-48 months after HDMTX start. No symptoms of late neurotoxicity have occurred so far. The response and survival data in this small series of patients are encouraging and suggest a benefit for patients with suspected PCNSL after initial treatment with HDMTX.

Systemic lupus erythematosus and the brain: what mice are telling us

Neuropsychiatric symptoms occur in systemic lupus erythematosus (SLE), a complex, autoimmune disease of unknown origin. Although several pathogenic mechanisms have been suggested to play a significant role in the etiology of the disease, the exact underlying mechanisms still remain elusive. Several inbred strains of mice are used as models to study SLE, which exhibit a diversity of central nervous system (CNS) manifestations similar to that observed in patients. This review will attempt to give a brief overview of the CNS alterations observed in these models, including biochemical, structural and behavioral changes.

Transient encephalopathy complicating poststreptococcal glomerulonephritis in an adult with diagnostic findings consistent with cerebral vasculitis

We report the case of a young woman who had transient encephalopathy with nausea, cognitive impairment, 2 generalized seizures accompanied by visual impairment, and stenotic alterations of cerebral vessels lasting for weeks until complete resolution. These findings were associated with an elevated antideoxyribonuclease B level and biopsy-proven poststreptococcal glomerulonephritis. At the time of the encephalopathy, the patient had no electrolyte level disturbances, an only mildly elevated urea level, and moderate arterial hypertension and was on methylprednisolone therapy. For a couple of days, cranial magnetic resonance imaging showed multiple disseminated asymmetric hyperintensities on T(2)-weighted and fluid-attenuated inversion recovery, suggesting vasogenic edema. However, Doppler ultrasound examinations showed stenoses of extracerebral and multiple intracerebral arteries that persisted for several weeks, lasting considerably longer than the cerebral edema. This finding does not fit the context of hypertensive or steroid-induced encephalopathy, but is consistent with diagnosis of an accompanying vasculitis. Treatment with methylprednisolone for several weeks was associated with resolution of arterial stenoses and neurological symptoms, complete reversibility of Doppler sonographic findings, and significant improvement in renal function.

Diffusion-weighted MR imaging: pediatric clinical applications

We have summarized the diffusion-weighed imaging (DWI) findings in a number of different cerebral disorders. In many cases, DWI with the accompanying apparent diffusion coefficient (ADC) map provides additional useful information to the standard imaging sequences. Pathophysiologic mechanisms resulting in baseline normal ADC values and changes with disease processes are not well understood; therefore, caution should be used when prognosticating the outcome of regions with abnormal ADCs. DWI should be used as an adjunct to routine imaging and interpreted in the context of the routine imaging findings and clinical scenario. As our understanding of ADC mechanisms increases and we begin to incorporate information about tissue organization from diffusion tensor imaging or diffusion spectrum imaging, the role of these methods in clinical diagnosis should continue to increase.

Non-Atherosclerotic Vascular Disease in the Young

There are a large variety of non-atherosclerotic causes of ischemic stroke in the young. Arterial dissection, most commonly associated with non-traumatic causes, is among the most common. Both the carotid and vertebrobasilar circulations can be affected. The vasculitidies represent a rare, but potentially treatable series of conditions that can lead to stroke through diverse mechanisms. Moyamoya is a nonatherosclerotic, noninflammatory, nonamyloid vasculopathy characterized by chronic progressive stenosis or occlusion of the distal internal carotid arteries and/or proximal portions of the middle and/or anterior cerebral arteries. Moyamoya can be idiopathic (moyamoya disease) or the result of other conditions. An appreciation of the unusual causes of stroke in the young is important when considering secondary prevention measures.