Neuro-Behçet Disease

Prevalence, types, and characteristics of headache in Behcets disease without involvement of the central nervous system in the Syrian population: a case-cohort study

Introduction

Oral ulcers, genital ulcers, and uveitis represent the typical trial of Behcet's disease (BD). It is well common on the Old Silk Road. The mucocutaneous lesions are the hallmark of BD, but neurological involvement is one of the severe symptoms. Headaches may be an early sign of BD neurological involvement. This study aims to investigate the headache prevalence and its types, and characteristics in a Syrian sample of BD patients.

Methods

BD patients were clinically interviewed and examined to collect their information, symptoms, and signs. the International Study Group for Behcet's Disease diagnosis criteria was used to confirm the BD diagnosis. The International Classification of headaches was used when classifying the headaches.

Results

One hundred twenty participants were included in the study. half of them were BD patients and the control group was also 60 participants. Among Syrian BD patients, 36.7% suffer from primary headaches and 36.7% suffer from secondary headaches. These findings were not significantly different between the BD patients and the healthy population. Our results showed that there was no statistically significant difference between the two groups.

Conclusion

Headache should not be considered a predictor for neurological involvement among BD patients. Additional attention to BD patients or the specific treatment for headaches is not required and does not differ from the general population.

Ocular involvement in pediatric Behçet's disease: is it different than in adults? (a short case series and mini review)

BACKGROUND

Pediatric Behçet's disease (PBD) is rarer than BD and can be a challenging diagnosis as clinical picture may be incomplete. As in adult patients, sight-threatening ocular manifestations may lead to diagnosis. In this study, we aimed to report a series of cases of PBD with ocular manifestations and provide a review of the literature.

METHODS

Retrospective case series of PBD patients with ocular manifestations. Demographic, ophthalmological and systemic data at presentation and during follow-up were collected and analyzed.

RESULTS

Four patients, aged 13.0 ± 2.9 years (9-16) were included. Posterior uveitis with retinal vasculitis, papillitis and macular edema was present in all patients, with associated anterior uveitis in 2 cases. Other features included occlusive vasculitis (2/4) and necrotizing retinitis (2/4). All patients were improved by systemic treatments except one patient with severe bilateral optic neuropathy. Ocular manifestations were the presenting symptoms in 3/4 cases.

CONCLUSION

Ocular manifestations and systemic associations of PBD are comparable to those encountered in adult patients. The lack of complains in pediatric patients may lead to a longer diagnosis delay, especially in unilateral uveitis. Aggressive and long-term treatment is mandatory to prevent vision loss and recurrences.

Intramedullary Spinal Hemorrhage in Behcet's Syndrome: A Case Report and Systematic Review

Acute neurological manifestations in patients with Behcet's syndrome are rare yet may lead to devastating outcomes. Distinguishing primary neurological deficits from spontaneous hemorrhagic insults is of particular importance for the prognosis of patients with Behcet's syndrome. Here, we investigate the clinical characteristics, management, and outcomes of nontraumatic hemorrhagic injury in patients with Bechet's syndrome. Following the case presentation, a systematic review of the literature identified cases of spontaneous hemorrhage among patients with Behcet's syndrome. Variables of interest were collected from each article to characterize patient demographics, clinical manifestations, management, and reported outcomes. Additionally, a rare case of nontraumatic intramedullary spinal bleeding in a young male with Behcet's syndrome is presented. Including our case, we analyzed 12 cases of spontaneous bleeding associated with Behcet's syndrome in 12 articles. Patient age ranged from 16 to 71 (median = 36), with a male predominance (n = 11, 91.7%). Involvement of cardiothoracic structures (n = 3, 25%), pulmonary (n = 4, 33.3%), and gastrointestinal or genitourinary vasculature (n = 3, 25%) was most common, followed by extracranial (n = 2, 16.7%) and central nervous system vasculature (n = 1, 8.3%). Clinical presentation varied depending on which specific systems or anatomical structures were involved. Anticoagulation or antiplatelet therapy was mentioned in three cases (27.3%). Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) were noted to be elevated in six cases (54.5%). Most cases were managed surgically (n = 8, 66.7%); four cases were managed conservatively (33.3%). In our case, the patient's intramedullary bleed was allowed to dissolve without further manipulation. Of the reported outcomes, major recovery was achieved in 10 patients (83.3%), and two patients died from aneurysm or pseudoaneurysm rupture (16.7%). New-onset neurological findings in patients with Behcet's syndrome should raise suspicion for possible spontaneous hemorrhage. Our case presents the first reported instance of an abrupt onset of neurological injury secondary to intramedullary spinal cord bleed in Behcet's syndrome. A systematic review of the literature demonstrates no difference in mortality for patients managed conservatively compared to those who undergo surgical treatment.

Neuro-Behçet With a Thalamic Lesion: A Case Report

Behçet's disease (BD) is an autoimmune disease characterized by multisystemic variable-vessel vasculitis and oral, genital, and intestinal ulcers. Neurological involvement or "Neuro-Behçet" (NB) manifests due to parenchymal inflammation. We present the case of a 21-year-old male with a five-year-old history of intermittent chronic oral and genital ulcers who presented with headache, right hemiparesis, progressive loss of visual acuity, and a thalamic tumor-like lesion on magnetic resonance imaging (MRI). A brain biopsy showed multiple perivascular infarcts associated with vasculitis affecting arterioles, venules, and capillaries.

Neuro-Behçet - Clinical and radiological findings in a Patient of Sub-saharan African origin

Behçet's disease is a rare, systemic variable vessel vasculitis mostly seen in patients from the Middle East, Northern Africa and Central Asia. Neuro-Behçet disease (NBD) is often diagnosed in patients with known Behçet's disease who present with neurological symptoms and radiological features of central nervous system involvement. There are very few cases with neuro-Behçet reported from Sub-Saharan Africa in the literature. We report a case of severe parenchymal neuro-Behçet with pseudo-tumoral brainstem lesions in a young male patient of South African origin.

High-Resolution Magnetic Resonance Vessel Wall Imaging for the Evaluation of Intracranial Vascular Pathology

Intracranial vessel wall imaging (IVWI) is an advanced MR imaging technique that allows for direct visualization of the walls of intracranial blood vessels and detection of subtle pathologic vessel wall changes before they become apparent on conventional luminal imaging. When performed correctly, IVWI can increase diagnostic confidence, aid in the differentiation of intracranial vasculopathies, and assist in patient risk stratification and prognostication. This review covers the essential technical underpinnings of IVWI and presents emerging clinical research highlighting its utility for the evaluation of multiple intracranial vascular pathologies.

Neuro-Sweet syndrome - a rare differential diagnosis in aseptic meningoencephalitis

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is a dermatological entity, which may be associated with malignancies, drugs, and infections and which is characterized by high fever, elevated neutrophils, and tender erythematous skin lesions. Involvement of the nervous system - Neuro-Sweet syndrome (NSS) - is rare, manifesting most commonly with an encephalitic syndrome in addition to fever and dermal lesions. Here, we report an unusual case of NSS in a Caucasian male patient in the setting of B-cell-lymphocytosis, with encephalitis preceding dermal lesions. Symptoms resolved completely in response to corticoids. NSS is a rare, but important differential diagnosis in the work-up of febrile aseptic meningoencephalitis unresponsive to anti-infectious treatment. Due to its rarity and clinical variability, diagnosis of NSS might be challenging. Knowledge of this entity may facilitate proper diagnosis and differentiation from conditions with similar clinical presentation, especially Neuro-Behçet's disease. It may further lead to early detection of a potentially underlying malignancy and help in initiating adequate therapy.

Neuro-Behcet's disease: An update on diagnosis, differential diagnoses, and treatment

Neuro-Behcet's disease (NBD) is defined as a combination of neurologic symptoms and/or signs in a patient with Behcet's disease (BD). Relevant syndromes include brainstem syndrome, multiple-sclerosis like presentations, movement disorders, meningoencephalitic syndrome, myelopathic syndrome, cerebral venous sinus thrombosis (CVST), and intracranial hypertension. Central nervous involvement falls into parenchymal and non-parenchymal subtypes. The parenchymal type is more prevalent and presents as brainstem, hemispheric, spinal, and meningoencephalitic manifestations. Non-parenchymal type includes CVST and arterial involvement. Perivascular infiltration of polymorphonuclear and mononuclear cells is seen in most histo-pathologic reports. In parenchymal NBD, cerebrospinal fluid (CSF) generally exhibits pleocytosis, increased protein and normal glucose. In NBD and CVST, CSF pressure is increased but content is usually normal. The typical acute NBD lesions in brain magnetic resonance imaging (MRI) are mesodiencephalic lesions. The pattern of extension from thalamus to midbrain provides a cascade sign. Brain MRI in chronic NBD usually shows brain or brainstem atrophy and/or black holes. The spinal MRI in the acute or subacute myelopathies reveals noncontiguous multifocal lesions mostly in cervical and thoracic lesions. In chronic patients, cord atrophy can also be seen. Brain MRI (particularly susceptibility-weighted images), MR venography (MRV) and computerized tomographic venography (CTV) can be used to diagnose CVST. Parenchymal NBD attacks can be treated with glucocorticoids alone or in combination with azathioprine. For patients with relapsing-remitting or progressive courses, shifting to more potent immunosuppressive drugs such as mycophenolate, methotrexate, cyclophosphamide, or targeted therapy is warranted. For NBD and CVST, immunosuppressive drugs with or without anticoagulation are suggested.

Clinical and Radiographic Characteristics of Neuro-Behçet's Disease in South Korea

Background and Purpose

Neurological involvement in Behçet's disease [neuro-Behçet's disease (NBD)] is uncommon, but it is worth investigating since it can cause substantial disability. However, difficulties exist in understanding the clinical features of NBD due to regional variations and the lack of studies utilizing well-established diagnostic criteria. We therefore analyzed the clinical features of patients with NBD based on the recent international consensus recommendation.

Methods

We retrospectively searched electronic databases for patients with Behçet's disease (BD) between 2000 and 2017, and reviewed their medical records. Based on the recent international consensus recommendation, patients with definite or probable NBD were included.

Results

Of 9,817 patients with the diagnosis code for BD, 1,682 (17.1%) visited the neurology clinic and 110 (1.1%) were classified as NBD. Ninety-eight patients exhibited parenchymal NBD and 12 exhibited nonparenchymal NBD. Their age at the onset of NBD was 37.6±10.6 years and the male-to-female ratio was 1.24:1. Brainstem syndrome (43.9%) was the most common condition in the 98 patients with parenchymal NBD, followed by multifocal (32.7%) and spinal cord (12.2%) syndromes. 72.4% exhibited acute NBD and 27.6% exhibited a progressive disease course. Frequent manifestations included pyramidal signs (52.0%), headache (45.9%), dysarthria (42.9%), and fever (31.6%). A frequent pattern in brain MRI was an upper brainstem lesion extending to the thalamus and basal ganglia.

Conclusions

Approximately 1% of the patients with suspected BD exhibited NBD. Neurologists must understand the clinical characteristics of NBD in order to perform the differential diagnosis and management of these patients.

Ptosis and Mass Like Lesions in Behçet's Disease: A Rare Presentation

In this article, we describe a case of neuro-Behçet's disease presenting with unilateral ptosis and facial paresis due to an intracranial mass lesion. A 25-year-old male patient with a history of Behçet's disease presented with headache, vertigo, double vision, ptosis in his right eyelid and slurred speech. Cranial magnetic resonance imaging scan revealed a right-sided capsulothalamic lesion, which was extending to the right cerebral pedicle, pons and superior cerebellar pedicle. This lesion was interpreted as neuro-Behçet's disease involvement of central nervous system. Cerebral mass- like lesion is a rare form of neuro-Behçet's disease. Review of the literature revealed a limited number of cases. Ptosis related with Behçet's disease is also a very rare presentation. This case shows that this symptom might be a part of the clinical presentation of neuro-Behçet's disease.

Behcet’s disease: from heat shock proteins to infections

Background: Behcet’s disease (BD) is a chronic, inflammatory multisystemic condition of unknown etiology. Although the cause of BD is not clear, it is believed to be the result of an autoimmune process triggered by an infectious or environmental agent (possibly local to a geographic region) in a genetically predisposed individual.

Objective: To detail current knowledge of the role of microorganisms in the pathogenesis of BD and review the infectious etiology of this disease.

Methods: The review based on publication in SCOPUS, Science direct, and PubMed.

Results: A microbial infection has been implicated in the development of the disease to explain the strong inflammatory reactions observed, the activation of monocytes and macrophages, and the induction of proinflammatory cytokines and chemokines detected. Common factors linking some of the possible pathogenetic agents are extrinsically induced tissue stress or heat shock proteins, which react with host tissues and elicit significant T-helper type 1 cell responses.

Conclusion: Based on collected data, we conclude that the microorganisms discussed seem to participate and, at least in part, act as triggers during the course of BD. By clarifying the microbial associations of BD and finding its etiology, particularly the causative antigens leading to BD, it would be easier to suggest more effective treatment and preventive strategies for this disease.

Headache in Behcet's disease: types and characteristics

BACKGROUND

Behcet's disease involves several systems in the body. Neurological involvement is identified by different symptoms. Headache is one of the common complaints of patients with Behcet's disease. It might be a part of neurological involvement or may arise independently in the course of disease. Studies with small sample size have resulted in various findings in this field. Since the prevalence of Behcet's disease is relatively high in Iran, this study was carried out to compare the features of headache between an acceptable number of patients with this rare disease and a control group.

METHODS

The current case-control study was performed to compare the features of headache between 312 patients with definite Behcet's disease who referred to a Behcet's clinic and healthy individuals. Patients with Behcet's disease were randomly selected. Controls were matched for age and sex. They were personally examined and interviewed meticulously using a questionnaire that met the standards of the International Headache Society classification for different types of headache.

RESULTS

The incidence of headache in the case and control groups was 28.3 % (n = 120) and 18.6 % (n = 59), respectively (p < 0.05; OR 2.73). Tension-type headache was observed in 12.2 % (n = 38) of cases which was significantly higher than control group (n = 6.3 %) (p = 0.011; OR 2.05). The most frequent type of headache in the case group was tension-type headache (12.2 %). In the control group, however, migraine without aura was the most common type (9.1 %). A correlation between ophthalmological involvement and headache was observed in 11 patients in the case group. In addition, a significantly higher systolic blood pressure was found in the case group compared to the controls (125.1 vs. 121.7 mmHg; p = 0.007). There was no major correlation between prednisolone consumption in patients with Behcet's disease and the type and frequency of headache.

CONCLUSIONS

Headache, especially tension-type headache, is more common in patients with Behcet's disease. This might be the result of specific types of uveitis-related and non-structural headaches seen in Behcet's disease.

Behçet's Disease and Nervous System Involvement

OPINION STATEMENT

Management of neuro-Behçet's disease can be divided into two stages: treatment of acute attacks and prevention of relapses. Treatment of acute attacks is accomplished by high-dose intravenous corticosteroids followed by maintenance treatment with oral steroids for 6-12 months depending on the type and severity of the neurological involvement. Relapses can be prevented by using immunosuppressants. Oral immunosuppressants such as azathioprine and mycophenolate are the most widely utilized agents for this purpose. Patients who are refractory or who cannot tolerate these medications can be managed by cyclophosphamide, interferon alpha, or anti-TNF-α monoclonal antibodies such as infliximab, etanercept, and adalimumab. Recent reports showed that newer agents such as tocilizumab, canakinumab, and anakinra, which exert their biological activity through IL-1 and IL-6 pathways, are also promising treatment alternatives for progressive or relapsing patients.

A brain mass in a patient with Behcet's disease: a case report

Introduction

This case report describes an uncommon presentation of Behcet’s disease which manifested as neuro-Behcet’s disease. Although it is not the first reported case in the medical literature, it is a possible differential in a patient presenting with a brain tumor. Since the diagnosis of neuro-Behcet’s disease depends largely on the clinical picture and medical history, it should be considered prior to opting for invasive diagnostic methods.

Case presentation

Our patient is a 36-year-old white man from Kuwait. He presented with acute onset of headache, vomiting, and right-sided weakness. Magnetic resonance imaging of his brain showed a mass in the brain stem. He then revealed that he had a history of recurrent painful oral and genital ulcers for the past 10 years, which suggested a diagnosis of Behcet’s disease. A brain biopsy was recommended by a neurosurgeon at the time, but the patient refused the procedure. After initiating steroid therapy, the mass began to regress and, eventually, was undetectable on subsequent imaging of his brain.

Conclusions

This case of neuro-Behcet’s disease reflects the need to consider this diagnosis in a patient of less than 40 years of age presenting with a suspected brain tumor. This may delay the need for invasive diagnostic methods, especially if such methods are not desired by the patient. In the management of suspected neuro-Behcet’s disease, initiating steroid therapy and measuring the response is a reasonable option before seeking a definitive diagnosis via brain biopsy. If the response to steroids is minimal then a brain biopsy should be performed.

Neuro-Behçet's Disease Presenting as Hypertrophic Pachymeningitis

A 25-year-old man presented with blurred vision and chronic headache. His brain MRI revealed bilateral frontal pachymeningeal enhancement with leptomeningeal enhancement. The patient had experienced recurrent oral ulcer and had anterior uveitis and papulopustules skin lesion. We diagnosed him with hypertrophic pachymeningitis (HP) associated with neuro-Behçet's disease (NBD). There have been few reports describing HP in patients with NBD. We report a case of NBD presenting as HP.

Neuro-Behçet: Pons Involvement with Longitudinal Extension to Midbrain and Hypertrophic Olivary Degeneration

A 21-year-old right-handed man developed progressive dysarthria and gait disturbance over 4 months (associated with intermittent hiccups). During that time, he also suffered from uveitis. A physical examination showed pseudobulbar and pyramidal signs and genital and oral ulcers. A brain MRI revealed an extensive lesion mainly located in the ventral pons, with an extension upwards to the midbrain. The inferior olivary nucleus also showed hyperintensity. After the treatment with intravenous methylprednisolone and pulses of cyclophosphamide, he improved. As observed on his MRI, his lesions also improved, except for an increase of the inferior olivary nucleus, consistent with hypertrophic olivary degeneration. Neuro-Behçet tropism for ventral brainstem explains the usual presentation with pyramidal syndrome. Hypertrophic olivary degeneration due to pons involvement could explain the hiccup attacks in a few known cases.

Radiological findings in Behçet disease

Between 5 and 30% of patients with Behçet's disease will present neurological signs during the course of their illness. In order to evaluate the radiological signs on neuro-behçet disease, we studied consecutive patients in whom the diagnosis of this disease was retained, and who referred from January 2004 to December 2011 to the neurology and internal medicine departments in Mohammed VI universitary hospital in Marrakesh. Using 1.5T magnetic resonance imaging (MRI) with axial and coronal T2- weighted, axial Fluid Attenuated Inversion Recovery (FLAIR), pre- and post-contrast axial, coronal and sagittal T1-weighted sequences. The final number of patients in whom the diagnosis criteria of behçet disease were fulfilled and in whom an MRI was performed was 68 cases. Among these patients, 52 had parenchymal form of neuro-behçet with abnormalities in the MRI, 12 had vascular form and 4 patients had normal MRI. The brainstem, cerebral white matter, basal ganglia, internal capsule, thalamus and spinal cord were involved in forty four, thirty one, thirty, twenty nine, seventeen and four patients, respectively. The cerebral peduncle was the brainstem structure mainly involved with thirty cases followed by the pons with, twenty cases. Midbrain involvement interested forty patients. Brainstem atrophy was seen in eighteen cases. Finally, control MRI were obtained in four cases only, and showed changes in lesions size and shape.

Radiological findings in Behçet disease

Between 5 and 30% of patients with Behçet's disease will present neurological signs during the course of their illness. In order to evaluate the radiological signs on neuro-behçet disease, we studied consecutive patients in whom the diagnosis of this disease was retained, and who referred from January 2004 to December 2011 to the neurology and internal medicine departments in Mohammed VI universitary hospital in Marrakesh. Using 1.5T magnetic resonance imaging (MRI) with axial and coronal T2- weighted, axial Fluid Attenuated Inversion Recovery (FLAIR), pre- and post-contrast axial, coronal and sagittal T1-weighted sequences. The final number of patients in whom the diagnosis criteria of behçet disease were fulfilled and in whom an MRI was performed was 68 cases. Among these patients, 52 had parenchymal form of neuro-behçet with abnormalities in the MRI, 12 had vascular form and 4 patients had normal MRI. The brainstem, cerebral white matter, basal ganglia, internal capsule, thalamus and spinal cord were involved in forty four, thirty one, thirty, twenty nine, seventeen and four patients, respectively. The cerebral peduncle was the brainstem structure mainly involved with thirty cases followed by the pons with, twenty cases. Midbrain involvement interested forty patients. Brainstem atrophy was seen in eighteen cases. Finally, control MRI were obtained in four cases only, and showed changes in lesions size and shape.

Neuro-Behçet's disease: an unusual cause of headache

Neuro-Behçet's disease (NBD) is a potentially fatal complication of Behçet's disease (BD) that can sometimes masquerade as a primary neoplasm, aseptic meningitis or multiple sclerosis. Headache in patients with BD may portend onset of NBD, but the majority of headache in BD is benign. Clinicians who are unaware of the specific neurological manifestations of systemic inflammatory disorders like BD may fail to consider the possibility of serious intracranial pathology. We illustrate these challenges with the case of a 50-year-old woman with a history of BD who presented with headache in the absence of initial focal neurological deficits. The diagnosis of NBD was missed on multiple occasions before the correct diagnosis was made. We describe the etiology of headache in BD, the specific neurological manifestations of BD that suggest NBD, and the utility of routine neurological exams for BD patients with chronic headache. We further discuss the appropriate use of neuroimaging for headache in BD, and we recommend consideration of NBD as a diagnosis for headache in patients suspected of having an underlying systemic disease.

Neurodermatology

Since the skin and the central and/or peripheral nervous system share a common source (the ectoderm), numerous genetic and acquired diseases (infectious, tumoral or autoimmune disorders) equally affect both. Neurologic diseases or symptoms such as stroke, cerebral or medullary vascular malformations, peripheral, brain or medullary tumors, epilepsy, ataxia, neurologic infections, or cognitive disorders (dementia, mental retardation) may be associated with specific cutaneous manifestations of which the discovery can facilitate the final diagnosis, thereby leading to specific treatment and/or genetic investigations. Careful examination of the skin, hair, and nails by the neurologist is consequently of the utmost importance; when unusual abnormalities of the skin are discovered or when greater expertise is required, consultation with a dermatologist is frequently advisable.

Mass-like lesions as a rare form of neuro-Behçet's disease: A case report and review of the literature

Cerebral mass-like lesion (MLL) is a rare form of Neuro-Behçet's (NB) disease. There is currently no detailed knowledge on this issue in the literature. Our aim was to describe a Behçet's disease (BD) patient with MLL, followed by a clinical analysis in light of the available literature regarding BD patients who suffered from an MLL or tumefactive lesion in the brain. We conducted a review of the English literature to analyse data on MLL in BD. The Pub-Med, Web of Science, Proquest and Ovid databases were searched for articles or abstracts using the term "Behçet's disease" combined with one of the following terms: mass-like lesion, tumour-like lesion and tumefactive lesion. We compared clinical and laboratory features of BD patients with MLL with NB patients. We found 12 cases plus our case (6 male, 7 female; mean age: 40 years) with BD who developed MLL alongside BD. Five out of 13 BD patients (38%) had a history of BD before the onset of neurological symptoms. In 8 patients (62%), BD was diagnosed after the onset of neurological involvement. Headache, hemiparesis, dizziness, aphasia, nausea and vomiting were the presenting manifestations of NB patients with MLL. Genital ulceration, eye involvement, skin lesion and arthritis/arthralgia were less commonly reported in NB patients with MLL compared to NB patients without MLL. NB disease should be considered in the differential diagnosis of cerebral MLL even when other cardinal manifestations of BD are absent. Mucocutaneous manifestations, eye and joint involvement may be seen less often in these patients.

Diagnosis and management of Neuro-Behçet's disease: international consensus recommendations

Neuro-Behçet’s disease (NBD) is one of the more serious manifestations of Behçet’s disease (BD), which is a relapsing inflammatory multisystem disease with an interesting epidemiology. Though NBD is relatively uncommon, being potentially treatable, neurologists need to consider it in the differential diagnosis of inflammatory, infective, or demyelinating CNS disorders. Evidence-based information on key issues of NBD diagnosis and management is scarce, and planning for such studies is challenging. We therefore initiated this project to develop expert consensus recommendations that might be helpful to neurologists and other clinicians, created through an extensive literature review and wide consultations with an international advisory panel, followed by a Delphi exercise. We agreed on consensus criteria for the diagnosis of NBD with two levels of certainty in addition to recommendations on when to consider NBD in a neurological patient, and on the use of various paraclinical tests. The management recommendations included treatment of the parenchymal NBD and cerebral venous thrombosis, the use of disease modifying therapies, prognostic factors, outcome measures, and headache in BD. Future studies are needed to validate the proposed criteria and provide evidence-based treatments.

Systemic inflammatory and autoimmune disorders

Systemic disorders with possible involvement of the nervous system include a variety of diseases with presumed inflammatory and autoimmune pathomechanisms, among them Behçet disease, sarcoidosis, systemic lupus erythematosus, juvenile idiopathic arthritis, scleroderma, and Sjögren syndrome. This disease group encompasses systemic inflammatory disorders with a genetically defined dysregulation of the innate immune system as well as systemic autoimmune disorders characterized by alterations of the adaptive immunity such as autoantibodies and autoreactive T cells. Although more commonly diagnosed in adults, all of these diseases can manifest in childhood and some as early as infancy. Neurological involvement may represent the initial manifestation, and nearly every neurological symptom can be caused by inflammatory/autoimmune diseases. In a child with (sub)acute onset of otherwise unexplained neurological findings, consideration of inflammatory/autoimmune disorders may be of crucial therapeutic and prognostic importance. In the absence of disease-specific clinical features, the initial diagnostic workup is broad. Basic blood tests include inflammatory markers and autoantibodies. Cerebral magnetic resonance imaging and a lumbar puncture with measurement of opening pressure as well as cerebrospinal fluid analysis are indicated in most patients with central nervous system (CNS) involvement. Skin, muscle, or organ biopsies (e.g., renal) may provide additional information. Especially in patients with isolated CNS involvement, a brain biopsy may be indicated. Timely recognition and treatment of CNS inflammation may improve or even reverse clinical symptoms and prevent secondary brain injury.

Fractalkine (CX3CL1) levels in patients with Behçet's disease and neuro-Behçet's disease

OBJECTIVE

The aim of the present study was to assess the role of CX3CL1 in patients with active and inactive Behçet's Disease (BD), Neuro-Behçet's Disease (NBD) and control subjects.

METHODS

Fifty-six patients admitted to the BD and NBD Outpatient Clinics, and 30 healthy controls were enrolled in the study. Serum CX3CL1 levels were measured by an enzyme linked immunosorbent assay (ELISA).

RESULTS

No significant difference was found between the serum CX3CL1 levels of control subjects, and patients with active and inactive BD or NBD, regardless of treatment.

CONCLUSION

To our knowledge, this is the first study analyzing CX3CL1 levels in patients with BD and NBD. Our results demonstrated that serum CX3CL1 levels were not changed in active and inactive BD and NBD. However, further large-scale studies are needed to confirm our results.

Association of amyotrophic lateral sclerosis and Behcet's disease: is there a relationship? A multi-national case series

Neurological involvement may be seen in 5-30% of the patients with Behcet's disease (BD). Occasionally, parenchymal neurological involvement in BD can present as a spinal cord syndrome. However, motor neuron disease-like presentation is extremely uncommon. Here we are reporting five patients (all male; median age, 38) fulfilling both International Study Group criteria for BD and El Escorial criteria for amyotrophic lateral sclerosis (ALS). These patients were identified by a questionnaire sent to the members of the Neuro-Behcet Study Group of the International Study Group for BD. Three out of five patients had only motor presentations. In two patients, sensory and urinary manifestations were present as well. Spinal cord MRIs were normal in all, and brain MRIs were normal in four patients; one patient had nonspecific white matter changes. Two patients passed away 1-3 years after diagnosis of ALS, and two patients were lost to follow-up 3 and 11 years after admission; one patient is still alive 3 years after onset. The patients that are presented here might represent a rare form of neurological involvement in BD as well as sole coincidence. Larger prospective series are needed to further answer this issue.

Behcet's disease presenting with sudden-onset paraplegia due to anterior spinal artery involvement: 1-year follow-up of rehabilitation in conjunction with medication

A 26-year-old male patient with sudden-onset paraplegia was presented. Clinical and imaging evaluation revealed isolated spinal cord lesions at thoracal levels and anterior spinal arterial involvement. Diagnosis of Behcet's disease was established with associating clinical findings with medical history. Vigorous medication and rehabilitation program were performed. Through the 1-year rehabilitation period in conjunction with medication, strength and functions improved gradually. A satisfactory functional gain as a rehabilitative goal in independence in activities of daily living and long-distance ambulation achieved around 4 months. The patient reached full independence after 1-year. As conclusion, Behcet's disease can present with sudden-onset paraplegia. In case of no evident etiology for paraplegia in young male, neuro-Behcet's disease also should be kept in mind. Contrary to assumption, early aggressive treatment and continuous rehabilitation in conjunction with medication might provide good prognosis with excellent clinical outcome in spinal cord involvement. Satisfactory functional recovery should be expected only after 3-4 months, and complete independence can be achieved after 1 year.

Rapid Atypical Progression of Neuro-Behçet's Disease Involving Whole Brainstem and Bilateral Thalami

We present a case of Neuro-Behçet's disease with an unpredictable clinical course. A 47-year-old man was admitted to the neurosurgery department of our hospital with a mild headache. Three days after admission, his consciousness suddenly decreased and respiratory distress progressed rapidly. A brain MRI revealed that the previously observed abnormal signal had extended markedly to both the thalamic areas and the entire brain stem, and the surrounding brain parenchyma were compressed by cerebral edema. Based on the patient's symptoms of recurrent oral and genital ulcers, skin lesions, and uveitis, a rheumatologist made a diagnosis of Behçet's disease with CNS involvement. The patient was treated with high-dose methylprednisolone with respiratory assistance in the intensive care unit for 9 days and his neurologic symptoms improved remarkably. Neuro-Behçet's disease must be considered in the differential diagnosis in rapidly deteriorated young neurological patients along with a stroke, low-grade glioma, multiple sclerosis, and occlusive venous disease.

Evaluation of parenchymal neuro-behçet disease by using susceptibility-weighted imaging

BACKGROUND AND PURPOSE

Neurologic involvement in Behçet disease, also known as NBD, is one of the most devastating manifestations of the disease. The precise pathologic mechanism of parenchymal NBD lesions has not been established. We evaluated lesion characteristics and probable venous hemorrhage in parenchymal NBD by using SWI, and we compared the imaging results with conventional MR imaging sequences.

MATERIALS AND METHODS

We performed cranial MR imaging by using a 1.5T scanner in 23 patients with a definitive diagnosis of parenchymal NBD. We compared the proportion of lesion detection and the performance of hemorrhagic detection with the T2 FSE, T2*GE, and SWI magnitude, and SWI mIP by using the χ(2) test.

RESULTS

The proportion of lesion detection with both SWI magnitude and SWI MinMIP was significantly larger than that with T2*GE. The proportions of lesion detection among all other pairs of methods were not significantly different according to the corresponding P value (χ(2) = 17.4929, df = 3, P = .0006). Proportions of hypointense hemorrhagic lesions with T2 FSE and T2*GE were not significantly different, and likewise for the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP. In contrast, the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP were significantly larger than that with T2 FSE and T2*GE (χ(2) = 108.5396, df = 3, P < .0001).

CONCLUSIONS

Most of the lesions in parenchymal NBD were found to be hemorrhagic with SWI, supporting the proposed venous theory in pathology. In addition, compared with T2 FSE and T2*GE sequences, SWI was more successful in the determination of widespread involvement of the disease, particularly in nonchronic cases.

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.