Cerebral vasculitis in adults: what are the steps in order to establish the diagnosis? Red flags and pitfalls

The Contribution of Vessel Wall Magnetic Resonance Imaging to the Diagnosis of Primary and Secondary Central Nervous System Vasculitis

BACKGROUND

To describe high-resolution brain vessel wall MRI (VW-MRI) patterns and morphological brain findings in central nervous system (CNS) vasculitis patients.

METHODS

Fourteen patients with confirmed CNS Vasculitis from two tertiary centers underwent VW-MRI using a 3T scanner. The images were reviewed by two neuroradiologists to assess vessel wall enhancement characteristics and locations.

RESULTS

Fourteen patients were included (six females; average age 48 ± 19 years). Diagnoses included primary CNS vasculitis (PCNSV) in six patients and secondary CNS vasculitis (SCNSV) in eight, half of which were infection-related. Thirteen patients showed vessel wall enhancement, which was intense in eleven patients (84.6%) and concentric in twelve (92.3%), affecting the anterior circulation in nine patients (69.2%), posterior in two patients (15.4%), and both circulations in two patients (15.4%). The enhancement patterns were similar across different CNS vasculitis types. DWI changes corresponded with areas of vessel wall enhancement in 77% of patients. Conclusions: CNS vasculitis is often associated with intense, concentric vessel wall enhancement in VW-MRI, especially in the anterior circulation. The consistent presence of DWI alterations in affected territories suggests a possible link to microembolization or hypoperfusion. These imaging findings complement parenchymal brain MRI and MRA/DSA data, potentially increasing the possibility of a clinical diagnosis of CNS vasculitis.

Primary angiitis of the CNS and ANCA-associated vasculitis: from pathology to treatment

Vasculitis of the central nervous system can be a localized process, such as primary angiitis of the central nervous system (PACNS), or systemic vasculitis, such as ANCA-associated vasculitis (AAV). Since both conditions share neurological manifestations, the following review will discuss the neurological aspects of both. This review aims to provide a comprehensive comparison of the pathogenesis, clinical manifestation and assessment, diagnostic workup, and treatment protocol for both PACNS and AAV with central nervous system involvement. To provide a comprehensive comparison and update, a literature review was conducted using PubMed and Ovid databases (Embase and Medline). Then, the references were retrieved, screened, and selected according to the inclusion and exclusion criteria. PACNS and AAV share similarities in clinical presentation and neurological symptoms, especially in terms of headache, focal deficits, and cognitive impairment. Additionally, both conditions may exhibit similarities in laboratory and radiological findings, making brain biopsy the gold standard for differentiation between the two conditions. Moreover, the treatment protocols for PACNS and AAV are nearly identical. Comparing PACNS and AAV with CNS involvement highlights the similarities in clinical presentation, radiological findings, and treatment protocols between the two conditions. Further research should focus on establishing a practical diagnostic protocol.

European Stroke Organisation (ESO) guidelines on Primary Angiitis of the Central Nervous System (PACNS)

The European Stroke Organisation (ESO) guideline on Primary Angiitis of the Central Nervous System (PACNS), developed according to ESO standard operating procedures (SOP) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, was elaborated to assist clinicians in the diagnostic and treatment pathway of patients with PACNS in their decision making. A working group involving vascular neurologists, neuroradiologists, rheumatologists, a neuropathologist and a methodologist identified 17 relevant clinical questions; these were addressed according to the patient/population, intervention, comparison and outcomes (PICO) framework and systematic literature reviews were performed. Notably, each PICO was addressed with respect to large vessel (LV)-PACNS and small vessel (SV)-PACNS. Data to answer many questions were scarce or lacking and the quality of evidence was very low overall, so, for some PICOs, the recommendations reflect the ongoing uncertainty. When the absence of sufficient evidence precluded recommendations, Expert Consensus Statements were formulated. In some cases, this applied to interventions in the diagnosis and treatment of PACNS which are embedded widely in clinical practice, for example patterns of cerebrospinal fluid (CSF) and Magnetic Resonance Imaging (MRI) abnormalities. CSF analysis for hyperproteinorrachia and pleocytosis does not have evidence supporting their use as diagnostic tools. The working group recommended that caution is employed in the interpretation of non-invasive vascular imaging due to lack of validation and the different sensitivities in comparison with digital subtraction angiography (DSA) and histopathological analyses. Moreover, there is not a neuroimaging pattern specific for PACNS and neurovascular issues are largely underreported in PACNS patients. The group's recommendations on induction and maintenance of treatment and for primary or secondary prevention of vascular events also reflect uncertainty due to lack of evidence. Being uncertain the role and practical usefulness of current diagnostic criteria and being not comparable the main treatment strategies, it is suggested to have a multidisciplinary team approach in an expert center during both work up and management of patients with suspected PACNS. Highlighting the limitations of the currently accepted diagnostic criteria, we hope to facilitate the design of multicenter, prospective clinical studies and trials. A standardization of neuroimaging techniques and reporting to improve the level of evidence underpinning interventions employed in the diagnosis and management of PACNS. We anticipate that this guideline, the first comprehensive European guideline on PACNS management using GRADE methodology, will assist clinicians to choose the most effective management strategy for PACNS.

PRIMARY ANGIITIS OF THE CENTRAL NERVOUS SYSTEM - A DIAGNOSTIC CHALLENGE

Primary angiitis of the central nervous system (PACNS) is a rare and severe disease confined to the central nervous system, i.e., the brain and spinal cord. The etiology, pathogenesis and immune mechanism of PACNS have not yet been completely elucidated. The diagnosis is challenging; it is based upon constellation of clinical picture, cerebrospinal fluid analysis, imaging methods or tissue biopsy as the gold standard. In differential diagnosis of PACNS, it is necessary to rule out infectious, malignant or systemic inflammatory diseases, as well as reversible cerebral vasoconstriction syndrome. Immunosuppressants are cornerstone therapy for PACNS, although evidence-based strategies for the management are lacking so far. PACNS is an entity with considerable morbidity and mortality. Awareness of this rare and heterogeneous disease is crucial for establishing early diagnosis and treatment initiation.

Evaluation of vessel-wall contrast-enhancement on high-resolution MRI in European patients with Moyamoya disease

OBJECTIVES

Data regarding MR vessel-wall imaging (VWI) in patients with Moyamoya disease (MMD) is sparse, particularly in non-asian cohorts. We contribute data regarding the frequency of vessel wall contrast-enhancement (VW-CE) and its potential clinical significance in a European patient group.

MATERIALS AND METHODS

Patients with a diagnosis of MMD who were examined by VWI were included in the study. VW-CE of stenoocclusive lesions of the terminal internal carotid artery and/or its proximal branches was rated qualitatively. Changes of VW-CE on available follow-up were recorded. VW-CE was correlated with diffusion-restricted lesions and magnetic resonance angiography (MRA) findings.

RESULTS

Eleven patients (eight female, three male) were included. Twenty-eight stenoocclusive lesions were analyzed, of which 16 showed VW-CE (57.1%). VW-CE was mostly concentric (n=15), rather than eccentric (n=1). In all three patients in whom follow-up VWI was available, changes of VW-CE were documented. Diffusion-restricted lesions were more frequently related to stenoocclusive lesions with VW-CE (n=9) than without VW-CE (n=2), bordering statistical significance. The affected arteries were assessed as stenotic and as occluded in 14 cases each and VW-CE was seen significantly more often in stenotic (n=12) than in occluded arteries (n=4). No correlation was found between the presence of VW-CE and moyamoya stages determined by MRA.

CONCLUSIONS

Our data suggest that concentric VW-CE is a relatively frequent finding in European MMD patients. VW-CE may change over time and occur in certain stages, possibly representing "active stenosing". Larger studies are needed to validate these findings and determine the clinical relevance of VW-CE in MMD.

Mycophenolate mofetil as induction and maintenance immunosuppressive therapy in adult primary central nervous system vasculitis: A prospective observational study

To observe the clinical and angiographic effectiveness of mycophenolate mofetil (MMF) as induction and maintenance immunosuppressive therapy in primary central nervous system vasculitis (PCNSV). In this open-label prospective study done at a tertiary care neurology centre, adult patients with PCNSV, diagnosed by Calabrese's criteria, were recruited from 2017 to 2021 and treated with glucocorticoids, MMF and standard of care. Patients were followed-up and clinical and angiographic changes were recorded. Total 26 patients were recruited with median age 39 years (34-49) with a slight female predilection (61.5%). Angiographic diagnoses were: small vessels disease 11.5%; large vessels disease 42.3% and both in 46.2%. Median duration of follow-up was 24.5 months (14.25-38). Proportion of patients with severe disability (modified Rankin Score (mRS) 4-6) at baseline was 73.08% (19/26) which reduced to 7.69% (2/26) (p < 0.001). At the last follow-up mRS = 0 was achieved in 38.5% (10/26) and mRS of ≤ 1 was achieved in 69.2% (18/26). Median time to achieve a mRS ≤ 1 was 12 months (95% CI: 6.8-17.2). Angiography was repeated in 16 patients after a median duration of 13 months (10.5-19.7), out of which 10 (62.5%) showed improvement and 5 (31.2%) showed non-progression of lesions. MMF may be an effective immunosuppressive therapy in adult PCNSV as both induction and maintenance. Serial DSA of brain may be useful to monitor the effect of treatment. Key Points • Mycophenolate mofetil is effective as induction and maintenance immunosuppressive therapy in PCNSV. • Repeat angiogram may be useful to monitor treatment response in PCNSV.

Childhood Cerebral Vasculitis : A Multidisciplinary Approach

Cerebral vasculitis is increasingly recognized as a common cause of pediatric arterial stroke. It can present with focal neurological deficits, psychiatric manifestations, seizures, and encephalopathy. The etiopathogenesis of childhood cerebral vasculitis (CCV) is multifactorial, making an inclusive classification challenging. In this review, we describe the common and uncommon CCV with a comprehensive discussion of etiopathogenesis, the role of various imaging modalities, and advanced techniques in diagnosing CCV. We also highlight the implications of relevant clinical, laboratory, and genetic findings to reach the final diagnosis. Based on the clinicoradiological findings, a stepwise diagnostic approach is proposed to facilitate CCV diagnosis and rule out potential mimics. Identification of key clinical manifestations, pertinent blood and cerebrospinal fluid results, and evaluation of central nervous system vessels for common and disease-specific findings will be emphasized. We discuss the role of magnetic resonance imaging, MR angiography, and vessel wall imaging as the imaging investigation of choice, and reservation of catheter angiography as a problem-solving tool. We emphasize the utility of brain and leptomeningeal biopsy for diagnosis and exclusion of imitators and masqueraders.

Etiologies of spontaneous acute intracerebral hemorrhage: A pictorial review

Spontaneous acute intracerebral hemorrhage (SAIH) is a common and life-threatening condition that affects more than three million patients each year. Of these, one in three patients die within one month of onset and the remaining two in three patients have varying degrees of disability and neurological impairment. The role of radiology is paramount in optimizing patient outcomes by diagnosing SAIH, its potential complications, and the most likely etiology. While the positive diagnosis of SAIH is straightforward, the etiologic diagnosis is broad, covering primary SAIH (hypertension, cerebral amyloid angiopathy) and secondary SAIH (vascular malformations, nonatheromatous vasculopathies, neoplasia, coagulation disorders, toxicants). This pictorial review illustrates the imaging of spontaneous SAIH with an emphasis on etiologic workup.

Close, but no cigar: an unfortunate case of primary angiitis of the central nervous system

Primary angiitis of the central nervous system (PACNS) is an uncommon and misunderstood disease, where little is known regarding its immunopathogenesis and appropriate treatment. Due to the constellation of nonspecific clinical features and imaging findings, PACNS is a diagnostic conundrum for clinicians and can be very difficult to treat.

Case Presentation

A 64-year-old male with a history of prostate cancer presented to the emergency department with expressive aphasia and severe headache. Previously, he was diagnosed with ischemic strokes at outside hospitals and was subsequently initiated on anticoagulation medication but was later readmitted with a new onset of nontraumatic subarachnoid hemorrhage and later was found to have ischemic changes in the right temporoparietal lobe. He was suspected to have hypercoagulability of malignancy, as he was unresponsive to a wide variety of anticoagulants and his symptoms continued to deteriorate. On presentation, the physical examination was significant for right homonymous hemianopia, with positive antinuclear antibodies and notable erythrocyte sedimentation rate. The results from the full serologic workup was negative. Subsequent imaging of the brain revealed multifocal stenoses in multiple arteries. On further examination, digital subtraction angiography was concerning for vasculopathy, and was initiated on corticosteroids and cyclophosphamide.

Discussion

This is one of the first cases of PACNS in which recurrent strokes were the presenting symptom for PACNS. Vasculitis should be a considered differential in patients with recurrent ischemic strokes and failed anticoagulant therapy. It is important to rule out malignancy and infectious causes due to the wide spectrum of conditions that cause central nervous system vasculitis.

RCVS: by clinicians for clinicians-a narrative review

BACKGROUND/OBJECTIVE

Reversible cerebral vasoconstriction syndrome may be underdiagnosed. It can be accompanied by various complications, mainly intracerebral hemorrhage and ischemic stroke. The clinical presentation of this condition varies according to its localization. The aims of this review are to raise awareness of the disease, especially in the presence of corresponding risk factors; to connect its precipitating factors, pathophysiology, and complications; and to compare various differential diagnoses of vasoconstriction.

METHODS

A review of the literature in PubMed/MEDLINE and Google Scholar was conducted from May 1997 until May 2022.

RESULTS

Reversible cerebral vasoconstriction syndrome, which is a clinical-radiological syndrome, is mainly characterized by the occurrence of thunderclap headache and widespread vasoconstriction. The most common precipitating factors are the use of vasoactive substances and postpartum status. The pathophysiology is currently assumed to include two mechanisms: sympathetic overactivity and endothelial dysfunction. From these mechanisms, it is possible to derive potential complications as well as the most important differential diagnoses: posterior reversible encephalopathy syndrome, convexity subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and primary angiitis of the central nervous system.

CONCLUSION

In general, the outcome of reversible cerebral vasoconstriction syndrome is very good. Vasospasm as well as thunderclap headache attacks can be fully reversible, and > 90% of patients are functionally independent at discharge.

Multiple recurrent aneurysms with angiitis of the central nervous system in a girl: A case report

INTRODUCTION

Primary central nervous system (CNS) vasculitis is a rare immune inflammatory disease confined to the blood vessels of the brain and spinal cord. The total number reported in the world is about 500[1]. Most are negative in cerebral angiography or vascular stenosis and only 1 case of aortic aneurysms reported.

PATIENT CONCERNS

A 12-year-old female experienced sudden headache and vomiting. Previous findings of vascular stenosis. Diagnosed as a ruptured aneurysm bleeding. The aneurysm recurred a short time after treatment.

DIAGNOSIS

Multiple recurrent aneurysms with angiitis of the central nervous system.

INTERVENTIONS

The patient underwent 2 aneurysm clipping operations, both of which completely clipped the aneurysm.

OUTCOMES

The patient recovered well after surgery. Three months after discharge, DSA reexamination in our hospital showed that the aneurysm was completely clipped without recurrence.

CONCLUSION

Subarachnoid hemorrhage after acute cerebral infarction is rare. In addition, the patient had recurrent aneurysms after the first aneurysm clipping, which emphasized the importance of postoperative drug therapy and blood pressure control.

Recovery of intracranial stenoses in varicella zoster virus vasculitis after long-term treatment with valacyclovir and prednisolone

BACKGROUND AND PURPOSE

Optimal treatment of intracranial stenoses in varicella zoster virus (VZV)-associated vasculitis is unknown. This study aims to evaluate the merits and potential pitfalls of a specific therapeutic strategy, initially proposed by Don Gilden in 2015.

METHODS

We describe three patients with intracranial stenoses caused by VZV vasculitis successfully treated by a long-term combination of valacyclovir and prednisolone.

RESULTS

All three patients were young men suffering from stroke. Only one reported a first contact to VZV in adulthood. All three presented stenoses in the intracranial part of the internal carotid artery or the proximal segments of the middle cerebral artery as well as an elevated cell count and positive VZV antibody index in cerebrospinal fluid. They received a combination therapy regimen with prednisone and valacyclovir about a minimum of one year. Intracranial stenoses improved markedly in one and almost resolved completely in the other two patients. Side effects of corticosteroid treatment occurred in two patients.

CONCLUSIONS

Long-term combination treatment with prednisone and valacyclovir proved to be effective in three young men suffering from intracranial stenosis due to VZV vasculitis.

Neurologic Toxicity of Immune Checkpoint Inhibitors: A Review of Literature

Immune checkpoint inhibitors have entailed a change of paradigm in the management of multiple malignant diseases and are acquiring a key role in an increasing number of clinical sceneries. However, since their mechanism of action is not limited to the tumor microenvironment, their systemic activity may lead to a wide spectrum of immune-related side effects. Although neurological adverse events are much less frequent than gastrointestinal, hepatic, or lung toxicity, with an incidence of <5%, their potential severity and consequent interruptions to cancer treatment make them of particular importance. Despite them mainly implying peripheral neuropathies, immunotherapy has also been associated with an increased risk of encephalitis and paraneoplastic disorders affecting the central nervous system, often appearing in a clinical context where the appropriate diagnosis and early management of neuropsychiatric symptoms can be challenging. Although the pathogenesis of these complications is not fully understood yet, the blockade of tumoral inhibitory signals, and therefore the elicitation of cytotoxic T-cell-mediated response, seems to play a decisive role. The aim of this review was to summarize the current knowledge about the pathogenic mechanisms, clinical manifestations, and therapeutic recommendations regarding the main forms of neurotoxicity related to checkpoint inhibitors.

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

Cerebrovascular diseases are a leading cause of disability and death worldwide. The definition of stroke etiology is mandatory to predict outcome and guide therapeutic decisions. The diagnosis of pathological processes involving intracranial arteries is especially challenging, and the visualization of intracranial arteries’ vessel walls is not possible with routine imaging techniques. Vessel wall magnetic resonance imaging (VW-MRI) uses high-resolution, multiparametric MRI sequences to directly visualize intracranial arteries walls and their pathological alterations, allowing a better characterization of their pathology. VW-MRI demonstrated a wide range of clinical applications in acute cerebrovascular disease. Above all, it can be of great utility in the differential diagnosis of atherosclerotic and non-atherosclerotic intracranial vasculopathies. Additionally, it can be useful in the risk stratification of intracranial atherosclerotic lesions and to assess the risk of rupture of intracranial aneurysms. Recent advances in MRI technology made it more available, but larger studies are still needed to maximize its use in daily clinical practice.

Intracranial vessel wall imaging

PURPOSE OF REVIEW

To give an overview regarding the potential usefulness of vessel wall imaging (VWI) in distinguishing various intracranial vascular diseases, their common imaging features, and potential pitfalls.

RECENT FINDINGS

VWI provides direct visualization of the vessel wall and allows the discrimination of different diseases such as vasculitis, atherosclerosis, dissection, Moyamoya disease, and reversible cerebral vasoconstriction syndrome. Recent studies showed that concentric and eccentric involvement in the vessel wall, as well as the enhancement pattern were found important for the distinguishing these diseases and evaluating their activity.

SUMMARY

Most of the imaging techniques currently used are based on luminal imaging. However, these imaging methods are not adequate to distinguish different diseases that can demonstrate similar radiological findings. VWI is being increasingly used as a noninvasive imaging method to offset this limitation.

Reversible Cerebral Vasoconstriction Syndrome without Headache That Was Initially Suspected of Being Primary Angiitis of the Central Nervous System

A 48-year-old man had convulsions, and magnetic resonance angiography (MRA) showed diffuse constriction of the cerebral arteries. He was suspected of having primary angiitis of the central nervous system (PACNS) and treated with steroid for three days. The MRA abnormality disappeared after a week. After 69 days, he developed dizziness, and MRA revealed recurrence of cerebral artery stenosis. Nevertheless, the symptoms and abnormal MRA findings recovered promptly without treatment. He was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) without headache. This case suggests that RCVS should be a differential diagnosis in patients without headache whose MRA findings show multiple cerebral artery stenosis.

Diagnosis and follow-up evaluation of central nervous system vasculitis: an evaluation of vessel-wall MRI findings

Objective

To approach the clinical value of MRI with vessel wall imaging (VWI) in patients with central nervous system vasculitis (CNSV), we analyzed patterns of VWI findings both at the time of initial presentation and during follow-up.

Methods

Stenoocclusive lesions, vessel-wall contrast enhancement (VW-CE) and diffusion-restricted lesions were analyzed in patients with a diagnosis of CNSV. On available VWI follow-up, progression, regression or stability of VW-CE were evaluated and correlated with the clinical status.

Results

Of the 45 patients included, 28 exhibited stenoses visible on MR angiography (MRA-positive) while 17 had no stenosis (MRA-negative). VW-CE was found in 2/17 MRA-negative and all MRA-positive patients (p < 0.05). 79.1% (53/67) of stenoses showed VW-CE. VW-CE was concentric in 88.3% and eccentric in 11.7% of cases. Diffusion-restricted lesions were found more frequently in relation to stenoses with VW-CE than without VW-CE (p < 0.05). 48 VW-CE lesions in 23 patients were followed over a median time of 239.5 days. 13 VW-CE lesions (27.1%) resolved completely, 14 (29.2%) showed partial regression, 17 (35.4%) remained stable and 4 (8.3%) progressed. 22/23 patients received immunosuppressive therapy for the duration of follow-up. Patients with stable or progressive VW-CE were more likely (p < 0.05) to have a relapse (14/30 cases) than patients with partial or complete regression of VW-CE (5/25 cases).

Conclusion

Concentric VW-CE is a common finding in medium/large-sized vessel CNSV. VW-CE might represent active inflammation in certain situations. However, follow-up VWI findings proved ambiguous as persisting VW-CE despite immunosuppressive therapy and clinical remission was a frequent finding.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10683-7.

Novel method using DW-MRI and ADC images to guide stereotactic biopsy for the diagnosis small primary angiitis of the central nervous system: a case report

Objective

To determine the role of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) imaging to guide stereotactic biopsy for the diagnosis of intracranial angiitis.

Case presentation

In a 28-year-old woman who had experienced inactive headache and right limbs numbness for 4 days, preoperative magnetic resonance (MR) scanning, enhanced scanning, diffusion tensor imaging, magnetic resonance spectroscopy, diffusion-weighted imaging (DWI), and ADC image scanning were performed. Stereotactic biopsy was performed in one target where the area of edema detected with MR FLAIR, and two targets where the area shown as a high-value and a lower value area in the DWI/ADC image. Pathological examinations together with computed tomographic and enhanced MRI scans were conducted after surgery. A preoperative enhanced MRI scan showed a uniform low-intensity lesion in the patient’s left centrum semiovale, with a volume of 3.1 cm³. The DWI and ADC images showed uneven high-intensity signals and different ADC values in the lesion area, respectively. During surgery, tissues around the lesion and the lesion center were sampled at the three selected targets. The postoperative pathological diagnosis was primary angiitis of the central nervous system, and the patient was given anti-inflammatory medication and hormone therapy. The 3-year follow-up confirmed that the patient had recovered well, with a Glasgow Outcome Scale score of five.

Conclusion

DW-MRI and ADC images can be reliably used to determine the location of small intracranial lesions, and guide stereotactic biopsy to facilitate the diagnosis of primary vasculitis of the central nervous system.

Primary central nervous system vasculitis - An update on diagnosis, differential diagnosis and treatment

IMPORTANCE

Primary angiitis of the central nervous system (PACNS) is a rare condition which is often misdiagnosed. In order to avoid mistakes in the management, a step by step approach is necessary.

OBSERVATIONS

The most common presenting symptoms of PACNS are encephalopathy-related cognitive and affective abnormalities, headaches and multifocal symptoms associated with recurrent episodes of ischemia or hemorrhage. Seizures and spinal cord lesions may also occur. Diagnostic work up includes MRI, CSF examination, angiography and brain biopsy. Since all reported signs and findings lack specificity, the exclusion of differential diagnoses is essential before immunosuppressive therapy is started. Important differential diagnoses include reversible cerebral vasoconstriction syndrome, cerebral involvement of systemic vasculitides or rheumatic diseases, moyamoya angiopathy and infectious vasculopathies Effective treatment has been reported with glucocorticoids in combination with cyclophosphamide or rituximab; however, randomized clinical trials of PACNS treatment do not exist.

CONCLUSIONS AND RELEVANCE

PACNS is an important but rare differential diagnosis in daily neurological practice. The strict adherence to diagnostic criteria and the avoidance of inappropriate therapies in non-inflammatory vasculopathies and infectious diseases are essential.

Primary Central Nervous System Vasculitis as an Unusual Cause of Intracerebral Hemorrhage: A Case Report

A 64-year-old male with a history of transverse myelitis presented to the hospital with a decreased level of consciousness of one day's duration. CT of the head revealed intracranial hemorrhage measuring 2 x 1.2 cm in the right temporal lobe and multiple small hemorrhages in the left hemisphere, suggestive of vasculitis. Initial vasculitis workup was negative for antinuclear antibody (ANA), complement component 3 (C3), and antineutrophil cytoplasmic antibodies: P-ANCA, C-ANCA. Syphilis, hepatitis B and C, West Nile virus antibody [immunoglobulin G (IgG) and immunoglobulin M (IgM)], herpes simplex virus (HSV) polymerase chain reaction (PCR), and HIV 1 and 2 were also negative. In view of the CT scan findings suggestive of vasculitis and the vague presentation of primary central nervous system vasculitis (PCNSV), a brain biopsy was performed. It revealed angiocentric granulomatous inflammation with focal vessel disruption and associated parenchymal hemorrhage, consistent with a diagnosis of granulomatous vasculitis. The patient received levetiracetam, multiple high doses of steroids, and six cycles of cyclophosphamide for a six-month duration. After induction, he has remained in remission without any maintenance therapy until now (eight years post-presentation).

The diagnostic contribution of intracranial vessel wall imaging in the differentiation of primary angiitis of the central nervous system from other intracranial vasculopathies

PURPOSE

The aim of this study is to demonstrate the diagnostic effect of VWI in differentiating PACNS from other vasculopathies and its role in post-treatment follow-up in PACNS patients in this study.

METHODS

In this prospective study, we included patients with clinical suspicion of PACNS who presented with new-onset ischemic events and had significant intracranial large vessel stenosis on DSA or MRA. VWI was performed on all patients. The imaging findings and final diagnoses were recorded. Control VWI was performed on patients with PACNS diagnosis after at least 3 months of treatment, and the change in findings was also evaluated.

RESULTS

Twenty-three patients were included in the study had a median age of 40 (range 12-58). The most common clinical manifestations were focal neurologic deficits. According to the initial clinical evaluation, 10 patients (43.5%) were classified as PACNS and 13 patients (56.5%) as indeterminate for PACNS. After incorporating the VWI findings, the diagnosis of PACNS was confirmed in all clinically diagnosed PACNS patients. Concentric wall thickening and contrast enhancement were statistically significant in the PACNS group (p <0.001). According to concentric thickening and VWE features, sensitivity and specificity in distinguishing PACNS and other vasculopathies were 95.2%, 75% and 95.2%, 68.8%, respectively. Vessel wall enhancement regressed in 7 of 9 patients during a median follow-up period of 8 months (range 5.5-11.5) in PACNS patients who followed up.

CONCLUSION

VWI seems a new and useful imaging method in the differential diagnosis of PACNS and might be a useful adjunct for post-treatment follow-up.

Extended stereotactic brain biopsy in suspected primary central nervous system angiitis: good diagnostic accuracy and high safety

OBJECTIVE

To evaluate the diagnostic accuracy and safety of extended stereotactic brain biopsy (ESBB) in a single center cohort with suspected primary angiitis of the central nervous system (PACNS).

METHODS

A standardized stereotactic biopsy targeting MRI-positive lesions and collecting samples from the meninges and the cortex as well as from the white matter was performed in 23 patients with clinically suspected PACNS between 2010 and 2017. The relationship between biopsy yield and clinical characteristics, cerebrospinal fluid parameters, MR-imaging, time point of biopsy and exact localization of biopsy as well as number of tissue samples were examined.

RESULTS

PACNS was confirmed in 7 of 23 patients (30.4%). Alternative diagnoses were identified in 7 patients (30%). A shorter time period between the onset or worsening of symptoms (p = 0.018) and ESBB significantly increased the diagnostic yield. We observed only minor and transient postoperative complications in 3 patients (13.0%). ESBB led to a direct change of the therapeutic regime in 13 of 23 patients (56.5%). Careful neuropathological analysis furthermore revealed that cortical samples were crucial in obtaining a diagnosis.

CONCLUSION

ESBB is a safe approach with good feasibility, even in critically ill patients, and high diagnostic accuracy in patients with suspected PACNS changing future therapies in 13 of 23 patients (56.5%). Early biopsy after symptom onset/worsening is crucial and (sub)acute MRI-lesions should be targeted with a particular need for biopsy samples from the cortical layer.

S, MUREȘANU FD. The twisted role of natalizumab and rehabilitation in an aggressive form of multiple sclerosis: a case report

Multiple sclerosis is one of the main causes of neurological disability among young people, severely influencing life’s quality. Motor deficit is one of the most invalidating symptoms in multiple sclerosis. Motor involvement at onset, spinal demyelinating lesion distribution, highly active lesions, high frequency of relapses in the first 2 years after disease onset and post relapse residual disability with poor recovery, later age at onset and male gender represent unfavorable prognostic factors. Considering the significant role of prognostic factors in predicting the evolution of the disease, an induction treatment approach should always be considered. In this report we present the case of a middle-aged male patient presenting severe weakness and sensitive symptoms with a challenging therapeutic decision that had a favorable recovery after reconsidering the initial therapy. The recognition of aggressive forms of multiple sclerosis is mandatory in preventing further disability, improving the patient’s quality of life. Natalizumab is a monoclonal antibody used for the aggressive forms of multiple sclerosis, reducing the lymphocytes traffic through the blood brain barrier, with a great impact on relapses frequency and disease evolution. Keywords: aggressive multiple sclerosis, brain derived neurotrophic factor, natalizumab, rehabilitation,

Binswanger's disease: Case presentation and differential diagnosis

Establishing a diagnosis of Binswanger's disease requires a multimodal approach. As new pathophysiological mechanisms are revealed, tests that should yield greater specificity will become available in the years to come.

Beyond Giant Cell Arteritis and Takayasu's Arteritis: Secondary Large Vessel Vasculitis and Vasculitis Mimickers

PURPOSE OF REVIEW

To provide an overview of mimickers of large vessel vasculitis (LVV), by the main presenting manifestation, i.e., systemic, vascular, and cranial manifestations.

RECENT FINDINGS

The main differential diagnoses in patients with giant cell arteritis (GCA) and Takayasu arteritis (TAK) presenting with systemic manifestations (i.e., fever, anorexia, weight loss, night sweats, arthralgia/myalgia, and/or increased inflammatory indexes) are neoplastic, infectious, or other inflammatory conditions. In patients with vascular manifestations (such as peripheral ischemia, vascular stenoses, or aneurysms), atherosclerosis and non-inflammatory vascular diseases should be excluded. In those presenting with predominant cranial symptoms (i.e., temporal headache, jaw claudication, scalp tenderness, transient or permanent vision loss), other causes of headache, cerebrovascular accidents, optic neuropathy, and neuromuscular syndromes need to be considered. The diagnosis of LVV maybe challenging, especially when patients present with atypical or incomplete clinical forms. In these cases, a multidisciplinary approach is strongly recommended.

Bacillus cereus Subacute Native Valve Infective Endocarditis and Its Multiple Complications

Bacillus cereus causing infective endocarditis (IE) in a native valve is an extremely rare event, but it is reported mostly in intravenous drug abusers and other risk factors as immunosuppression, malignancy, and valvular heart disease including prosthetic heart valves. We report a case of B.cereus native mitral valve infective endocarditis in a 58-year-old Sri Lankan male who is not a drug abuser who presented with painless hematuria with reduced urine output. During hospital stay, he developed frequent episodes of brief focal seizures. He had undergone multiple investigations that revealed splenic abscesses, cerebral vasculitis, and glomerular nephritis with positive rheumatoid factor, cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA), and cryoglobulin. The appropriate antibiotic was the prime therapeutic intervention which carried an excellent prognosis. This case highlights an unusual organism in the blood culture that caused IE warranting thorough physical examination and investigations.

Heritable and non-heritable uncommon causes of stroke

Despite intensive investigations, about 30% of stroke cases remains of undetermined origin. After exclusion of common causes of stroke, there is a number of rare heritable and non-heritable conditions, which often remain misdiagnosed, that should be additionally considered in the diagnosis of cryptogenic stroke. The identification of these diseases requires a complex work up including detailed clinical evaluation for the detection of systemic symptoms and signs, an adequate neuroimaging assessment and a careful family history collection. The task becomes more complicated by phenotype heterogeneity since stroke could be the primary or unique manifestation of a syndrome or represent just a manifestation (sometimes minor) of a multisystem disorder. The aim of this review paper is to provide clinicians with an update on clinical and neuroradiological features and a set of practical suggestions for the diagnostic work up and management of these uncommon causes of stroke. The identification of these stroke causes is important to avoid inappropriate and expensive diagnostic tests, to establish appropriate management measures, including presymptomatic testing, genetic counseling, and, if available, therapy. Therefore, physicians should become familiar with these diseases to provide future risk assessment and family counseling.

Capillary microscopy in Europeans with idiopathic Moyamoya angiopathy

OBJECTIVE

In Europe, MMA is a very rare non-inflammatory vasculopathy. MMA is an important differential diagnosis of cerebral vasculitis. Systemic manifestations, such as livedo racemosa or renal artery stenosis, associated with Moyamoya variants suggest the involvement also of non-cerebral vessels. Hypothetically, capillary microscopy could be a promising non-invasive screening method to visualize microcirculation, for example prior to cerebral angiography.

METHODS

Standardized capillary microscopic images were taken in European patients with MMA and subsequently evaluated in a blinded analysis, using data obtained from a large NP cohort and a large SLE cohort by the same blinded Investigator as controls.

RESULTS

Twenty-four European MMD patients and 14 healthy accompanying controls were included in this study. The results were compared to 116 SLE patients and 754 NP subjects. In MMD patients, no capillary morphological differences were found in comparison with NP, in particular no density reduction or increased neoangiogenesis. The pattern observed in the SLE cohort was clearly distinct from NP and MMD with regard to vascular density, vascular damage, and neoangiogenesis.

CONCLUSIONS

MMD is not associated with microvascular changes of the nailfold capillaries. In this respect, it is clearly distinct from SLE.

An atypical case of acute posterior multifocal placoid pigment epitheliopathy with recurrent strokes

Purpose

To report an atypical case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with central nervous system (CNS) vasculitis and recurrent strokes.

Observations

A 57 year-old female presented with APMPPE after a febrile illness and rash. She developed an acute infarct on magnetic resonance imaging. Computed tomography angiography of the cerebral vasculature was normal. Cerebrospinal fluid (CSF) analysis and an extensive serum lab workup were also unremarkable. She was treated with high-dose corticosteroids and eventually transitioned to methotrexate. A month after being on treatment she developed a second stroke. A cerebral angiogram was obtained and did not show evidence of CNS vasculitis. The methotrexate was eventually stopped and the prednisone was tapered. Approximately 3 months later she developed a third stroke and worsening APMPPE-associated maculopathy in both eyes. She was eventually started on oral cyclophosphamide.

Conclusions & importance

Although rare, CNS vasculitis is a known complication of APMPPE. This case is atypical given the development of multiple recurrent strokes, lack of inflammatory evidence on CSF analysis, and normal imaging of the cerebral vasculature. This report highlights the need for a high level of clinical suspicion for CNS vasculitis with APMPPE despite noncontributory cerebral angiographic imaging and normal CSF analysis.

Magnetic resonance vessel wall imaging in cerebrovascular diseases

Cerebrovascular diseases manifest as abnormalities of and disruption to the intracranial vasculature and its capacity to carry blood to the brain. However, the pathogenesis of many cerebrovascular diseases begins in the vessel wall. Traditional luminal and perfusion imaging techniques do not provide adequate information regarding the differentiation, onset, or progression of disease. Intracranial high-resolution MR vessel wall imaging (VWI) has emerged as an invaluable technique for understanding and evaluating cerebrovascular diseases. The location and pattern of contrast enhancement in intracranial VWI provides new insight into the inflammatory etiology of cerebrovascular diseases and has potential to permit earlier diagnosis and treatment. In this report, technical considerations of VWI are discussed and current applications of VWI in vascular malformations, blunt cerebrovascular injury/dissection, and steno-occlusive cerebrovascular vasculopathies are reviewed.

Primary Angiitis of the Central Nervous System: From Psychiatry to Neurology

We present a case of a 54-year-old man with primary angiitis of the central nervous system (PACNS) who was initially admitted to a psychiatric clinic with a diagnosis of delirium. We discuss the difficulty in establishing the diagnosis of PACNS and provide the reader with some recommendations on how to promptly and correctly diagnose this disease in order to avoid potentially lethal outcomes.

Primary Angiitis of the Central Nervous System Mimicking Glioblastoma: A Case Report and Literature Review

Primary angiitis of the central nervous system (PACNS) is a rare disorder resulting in idiopathic inflammation affecting the parenchymal and leptomeningeal vessels confined to the central nervous system (CNS), of which a tumor-like mass lesion is an even rare subtype. We described a case of PACNS initially misdiagnosed as glioblastoma. The patient was a 35 year-old female with right-sided weakness and expressive dysphasia. Brain MRI showed a tumor-like lesion highly suggestive of glioblastoma, therefor surgical removal was done. After a resection and an exhaustive workup, PACNS was ultimately diagnosed. The case illustrates a type of imaging presentation of PACNS that is often misdiagnosed as high-grade glioma. Differentiation between tumor-like PACNS lesions and actual CNS tumors is challenging due to similar MR images. To avoid unnecessary surgical interventions, we summarized previously reported mass-forming PACNS cases in adults from January 1, 2000, to December 31, 2018 and the imaging characteristics of PACNS. Some less commonly used diagnostic methods such as MR spectroscopy may also help clinicians distinguish PACNS from its mimics.

[Primary central nervous system vasculitis]

Primary vasculitis (angiitis) of the central nervous system (PACNS) is a rare disease targeting the vessels of the brain, spinal cord and leptomeninges without systemic involvement. The etiology is not clear enough. The authors review clinical, laboratory and radiological features of PACNS. Clinical manifestations are variable and depend on the caliber of affected vessels. The main clinical manifestations of small sized vessel vasculitis include encephalopathy (cognitive disorders, epileptic seizures), headache and transient cerebral ischemia. The main clinical presentation of vasculitis of medium/large cerebral arteries is ischemic strokes, which usually develop in different vascular territories. CSF findings in the majority of patients show modest lymphocytic pleocytosis, elevated protein level and occasionally the presence of oligoclonal bands. MRI data are not specific and include infarcts, hyperintensity (FLAIR) and sometimes tumor-like lesions. The gold standard for the verification of PACNS affected small-sized arteries is brain and leptomeningeal biopsy. Cerebral angiography allows the verification of vasculitis of medium and large cerebral arteries revealing segmental narrowings (beading). High resolution black blood MRI before and after contrast injection may visualize intracranial vessel wall contrast enhancement - the sign of inflammation in intracranial arteries. Treatment of PACNS includes corticosteroids and cyclophosphamide. In the case of patient intolerance, rituximab and blockers of tumor necrosis factor may be used.

Leading symptoms in cerebrovascular diseases: what about headache?

Headache is a milestone in cerebrovascular disorders; indeed, it may represent the only symptom at onset or predominates over the other neurological features. Unfortunately, headache associated with cerebrovascular diseases lacks clear-cut characteristics as it may resemble a migraine attack, tension-type headache, or cluster headache; pain localization is also misleading along with drug (analgesic) response. However, in this review, we have analyzed and described the most common patterns of headache for different vascular disorders: it is known that headache due to subarachnoid aneurysmal hemorrhage presents peculiar characteristics (thunderclap, acute presentation, and high intensity), whereas in cerebral vasoconstriction syndrome, the short duration and the relapsing-remitting course of the thunderclap headache are key points for the diagnosis; in cervicocerebral artery, dissection pain is most commonly ipsilateral to the dissected vessel and is mainly perceived in the temporal area in case of carotid artery dissection and in the occipital area in case of vertebral artery dissection; in cerebral venous thrombosis, pain is often acute or subacute and severe; unfortunately, it may resemble a typical migraine attack or a tension-type episode; by the contrary, in primary angiitis of the central nervous system, pain is always subacute or chronic with mild-to-moderate intensity; finally, in brain arteriovenous shunts such as malformation or fistula, pain is more frequently a clue for disease complication such as hemorrhage from the malformation or thrombosis of the draining vein.

Biomarkers in Vasculitides of the Nervous System

Besides being affected by the rare and severe primary angiitis of the central nervous system (PACNS) the nervous system is also affected by primary systemic vasculitides (PSV). In contrast to PACNS, PSV affect not only the central but also the peripheral nervous system, resulting in a large array of potential symptoms. Given the high burden of disease, difficulties in distinguishing between differential diagnoses, and incomplete pathophysiological insights, there is an urgent need for additional precise diagnostic tools to enable an earlier diagnosis and initiation of effective treatments. Methods available to date, such as inflammatory markers, antibodies, cerebrospinal fluid (CSF) analysis, imaging, and biopsy, turn out to be insufficient to meet all current challenges. We highlight the use of biomarkers as an approach to extend current knowledge and, ultimately, improve patient management. Biomarkers are considered to be useful for disease diagnosis and monitoring, for predicting response to treatment, and for prognosis in clinical practice, as well as for establishing outcome parameters in clinical trials. In this article, we review the recent literature on biomarkers which have been applied in the context of different types of nervous system vasculitides including PACNS, giant-cell arteritis, Takayasu's arteritis, polyarteritis nodosa, ANCA (anti-neutrophil cytoplasm antibody)-associated vasculitides, cryoglobulinemic vasculitis, IgA vasculitis, and Behçet's disease. Overall, the majority of biomarkers is not specific for vasculitides of the nervous system.

CSF Neurofilament light chain level predicts axonal damage in cerebral vasculitis

The rarity of primary angiitis of the central nervous system (PACNS) demands diagnostic and prognostic biomarkers. We retrospectively measured Neurofilament light chain (NFL) concentrations in cerebrospinal fluid in a severely relapsing PACNS patient at multiple time points during the course of the disease. A marked increase in NFL levels preceding the onset of neuro‐axonal damage and arterial‐vessel abnormalities was observed with magnetic resonance imaging as well as with MR‐ and conventional angiography. Thus, marked elevation of NFL in PACNS seems to occur ahead of definitive radiological abnormalities and might serve as a diagnostic biomarker.

Cerebral involvement in systemic vasculitides: Extracts from the guideline of the German neurological society

Cerebral vasculitis is a rare disorder but plays a major role in the differential diagnosis of stroke, encephalopathy and headache. This guideline was developed in order to support clinicians in the diagnosis and treatment of cerebral manifestations of systemic vasculitides and rheumatic diseases. It is based on a medline research and was developed in a modified Delphi process and approved by the involved societies. This article is an abridged and translated version of the guideline published in DGNeurologie: Berlit, P. & Krämer, M. DGNeurologie (2018) 1: 17. 10.1007/s42451-018-0001-y.

Primary angiitis of the CNS (PACNS) and Behçet disease

Cerebral vasculitis is a rare disorder but plays a major role in the differential diagnosis of stroke, encephalopathy and headache. This guideline was developed in order to support clinicians in the diagnosis and treatment of primary angiitis of the CNS (PACNS) and Neuro-Behçet. It is based on a medline research and was developed in a modified Delphi process and approved by the involved societies.

This article is an abridged and translated version of the guideline published in DGNeurologie: Berlit, P. & Krämer, M. DGNeurologie (2018) 1: 17. 10.1007/s42451-018-0001-y

Vessel Wall MRI for Targeting Biopsies of Intracranial Vasculitis

Central nervous system vasculitides are elusive diseases that are challenging to diagnose because brain biopsies have high false-negative rates. We sought to test the ability of contrast-enhanced, high-resolution 3D vessel wall MR imaging to identify vascular inflammation and direct open biopsies of intracranial target vessels and adjacent brain parenchyma. Eight of 9 specimens revealed vascular inflammation. We conclude that vessel wall MR imaging can identify inflamed intracranial vessels, enabling precise localization of biopsy targets.

Cerebrospinal fluid findings in reversible cerebral vasoconstriction syndrome: a way to differentiate from cerebral vasculitis?

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by an acute onset of severe headache and multi-focal segmental vasoconstriction of cerebral arteries resolving within 12 weeks. Diagnostic criteria include normal or near-normal findings in cerebrospinal fluid (CSF) analysis, especially leucocyte levels < 10/mm³. Distinguishing RCVS from primary angiitis of the central nervous system (PACNS) is essential to avoid unnecessary and sometimes unfavourable immunosuppressive treatment. We reviewed retrospectively the clinical and diagnostic data of 10 RCVS patients who presented in our neurological department from 1 January 2013 to February 2017. The main purpose was to verify whether CSF leucocyte counts < 10/mm³ serve to discriminate RCVS from PACNS. Five of six patients who underwent lumbar puncture presented with CSF leucocyte levels ≥ 10/mm³. Two patients had a history of misinterpretation of CSF pleocytosis as cerebral vasculitis and of immunosuppressive treatment. A complete restitution of cerebral vasoconstriction was evident in all. No patient had further cerebral strokes or bleedings without immunosuppressive treatment over more than 12 weeks. Despite the established diagnostic criteria, RCVS can manifest with CSF leucocyte levels > 10/mm³. Careful anamnesis and the response of 'vasculitis-like angiography' to nimodipine given as a test during angiography and as oral medication are key to differentiate RCVS from cerebral vasculitis.

Primary angiitis of the central nervous system: diagnosis and treatment

Primary angiitis of the central nervous system (PACNS) represents a rare inflammatory disease affecting the brain and spinal cord. Stroke, encephalopathy, headache and seizures are major clinical manifestations. The diagnosis of PACNS is based on the combination of clinical presentation, imaging findings (magnetic resonance imaging and angiography), brain biopsy, and laboratory and cerebral spinal fluid (CSF) values. PACNS can either be confirmed by magnetic resonance angiography (MRA)/conventional angiography or tissue biopsy showing the presence of typical histopathological patterns. Identification of PACNS mimics is often challenging in clinical practice, but crucial to avoid far-reaching treatment decisions. In view of the severity of the disease, with considerable morbidity and mortality, early recognition and treatment initiation is necessary. Due to the rareness and heterogeneity of the disease, there is a lack of randomized data on treatment strategies. Retrospective studies suggest the combined administration of cyclophosphamide and glucocorticoids as induction therapy. Immunosuppressants such as azathioprine, methotrexate or mycophenolate mofetil are often applied for maintenance therapy. In addition, the beneficial effects of two biological agents (anti-CD20 monoclonal antibody rituximab and tumour necrosis factor-α blocker) have been reported. Nevertheless, diagnosis and treatment is still a clinical challenge, and further insights into the immunopathogenesis of PACNS are required to improve the diagnosis and management of patients. The present review provides a comprehensive overview of diagnostics, differential diagnoses, and therapeutic approaches of adult PACNS.