Behcet syndrome presenting as cerebrovascular disease

[A case of Behçet disease developing recurrent ischemic stroke with fever and scrotal ulcers]

A 30-year-old man, who was diagnosed with Behçet disease at 10 years of age, was hospitalized because of transient right hemiparesis after presenting with high fever and scrotal ulcers. Brain MRI revealed ischemic lesions in the area supplied by the anterior cerebral arteries. Analysis of cerebrospinal fluid (CSF) showed pleocytosis and a high interleukin-6 (IL-6) concentration (668 pg/ml). The patient was diagnosed with acute ischemic stroke associated with exacerbation of Behçet disease. After initiation of corticosteroid therapy, his clinical symptoms improved, and the CSF IL-6 concentration decreased. One year later, the patient developed high fever and scrotal ulcers after the onset of transient left upper limb plegia. Brain MRI showed an acute ischemic lesion in the right putamen, and CSF analysis showed an elevated IL-6 concentration (287 pg/ml). Brain CT angiography revealed stenosis of the left anterior cerebral artery and occlusion of the right anterior cerebral artery, which had been well visualized one year previously. Involvement of the intracranial cerebral arteries in Behçet disease is extremely rare. To the best of our knowledge, this is the first case report of a patient with recurrent symptomatic ischemic stroke associated with high fever and scrotal ulcers, which suggests exacerbation of Behçet disease.

Neuro-Behçet's disease: a report of sixteen patients

BACKGROUND

Neurologic involvement in Behçet's disease (BD), also known as neuro-Behcet's disease (NBD), is one of the most devastating manifestations of the disease. The etiology of BD remains obscure and speculative. NBD usually occurs 1-10 years after the first symptom of BD has occurred, and its incidence is 18% (range of 4%-49%).

OBJECTIVE

This study was conducted to describe the clinical and prognostic aspects of neurologic involvement in BD among patients attending a multidisciplinary hospital clinic.

METHODS

Eighty patients with BD were diagnosed according to the International Study Group Criteria for BD at our hospital. Sixteen patients (20%, including 11 men and five women) had evidence of and fulfilled the diagnostic criteria for NBD. These patients underwent laboratory and imaging investigations, including human leukocyte antigen-typing, lumbar puncture, electroencephalographic studies, and computed tomography scanning.

RESULTS

Fourteen of the 16 patients received high-dose steroids, and four of these 14 patients were treated with a combination of steroids and cytotoxic agents. Relief was observed in 14 of 16 patients (87.5%). The remaining two patients were untreated males who suffered severe brainstem lesions, and later died.

CONCLUSION

In contrast with previous reports of a poor prognosis with NBD, our study shows that early aggressive intervention with corticosteroids and cytotoxic agents may ameliorate the prognosis in these patients, and can diminish and stabilize the negative effect of neurologic involvement.

Changes in cerebral and ocular hemodynamics in Behçet's disease assessed by color-coded duplex sonography

AIM

To quantify the cerebral and retrobulbar hemodynamics in Behçet's disease with and without ocular involvement and compared with that of healthy controls.

MATERIALS AND METHODS

Of 51 people studied, 17 had Behçet's disease with ocular involvement, 17 had Behçet's disease without ocular involvement, and 17 were healthy controls. A single eye was examined in each patient. Peak systolic velocity (PSV), end-diastolic velocity (EDV), time-averaged maximum velocity (Tamax), and resistance index (RI) were evaluated in the ophthalmic (OA), posterior ciliary (PCA), central retinal (CRA) and middle cerebral artery (MCA). Additionally, the average blood flow velocities in the central retinal vein (CRV), and acceleration time (AT) and pulsatility index (PI) in the MCA were calculated.

RESULTS

The mean EDV in the PCA was 25% lower and RI was higher in patients with ocular involvement of BD than in patients without involvement (p = 0.006 and p = 0.005, respectively) and in healthy controls (p = 0.003 and p = 0.004, respectively). Differences were smaller in comparisons of the CRA and absent on comparisons of the OA and MCA. The acceleration time of the MCA was significantly higher in patients with Behçet's disease than in healthy controls (p = 0.03).

CONCLUSION

This study suggests that the flow hemodynamics in retrobulbar circulation has more altered Behçet's disease with ocular involvement than without ocular involvement and healthy control. Additionally, the cerebral hemodynamic might be affected in patients with Behçet's disease compared with healthy controls.

Magnetic Resonance Spectroscopic Findings in Neuro-Behçet Disease

BACKGROUND

Behçet disease is a heterogeneous, multisystem disorder with elements of both environmental and autoimmune pathologic processes. Neuro-Behçet, found in 10%-25% of Behçet patients, has been characterized as a vasculitis primarily affecting the brain stem. On magnetic resonance imaging, some cases demonstrate extension to the bilateral cerebral cortices and/or the spinal cord, often with a degree of mass effect. Content of this paper provides a case study, along with review of the literature regarding this disease entity, and proceeds to outline the appearance of neuro-Behçet on magnetic resonance spectroscopy.

CONCLUSION

In essence, a drop in the N-acetyl aspartate peak indicative of axonal loss in concert with elevations in lipid myoinositol and choline/creatine ratios (nonspecific markers of myelin breakdown) is found, indicating that a possible demyelinating process is complexed with the vasculitic pathology neuro-Behçet is traditionally ascribed to.

Cerebral vasculitis and ischaemic stroke in Behçet's disease: report of one case and review of the literature

INTRODUCTION

Behçet's disease (BD) is a multisystemic, recurrent, inflammatory disorder. Neurological involvement is well-known but cerebral vasculitis and ischaemic stroke are unusual.

CASE DESCRIPTION

A 43-year-old male patient presented with acute left hemiparesis, he had recurrent oral aphthae and scrotal ulcerations. Two episodes of transient brainstem ischaemia and an episode of right hemiparesis were reported in the past 2 years. Cranial magnetic resonance (MR) imaging showed a right striatocapsular infarction and multiple segmental stenosis, fusiform enlargement and beading of the arteries of the polygone of Willis were seen on angiography. Cerebro-spinal fluid (CSF) examination disclosed lymphocytic pleocytosis. Skin pathergy test was positive. A diagnosis of BD with cerebral vasculitis was made and immunosuppressive therapy was started. Some improvement of the arterial lesions on MR angiography and normalization of CSF were observed after 1 year of treatment.

DISCUSSION

Low grade chronic meningo-encephalitis is the core neuropathological process in neuro-Behçet's disease. Nevertheless BD is a systemic disease known to cause vasculitis and can exceptionally lead to cerebral vasculitis and brain infarction. While BD is usually not part of the differential diagnosis of cerebral vasculitis, it should be borne in mind especially in endemic areas of the disease and in patients from these areas.

CNS involvement in neuro-Behçet syndrome: an MR study

BACKGROUND AND PURPOSE

Behçet disease (BD) is a multisystem vasculitis of unknown origin in which neurologic involvement has been reported in the range of 5% to 10% in large series. Reports on clinical and radiologic aspects of neuro-Behçet syndrome (NBS) are in general limited in number. Our purpose was to determine the MR patterns in patients with NBS who had neural parenchymal involvement and to correlate our findings with possible vascular pathophysiology.

METHODS

The MR images of 65 patients with NBS and neural parenchymal involvement were reviewed. In a subgroup of patients who had serial MR studies, we evaluated the anatomic-radiologic location and distribution of the lesions and whether they corresponded to any vascular territory, and studied their extension, enhancement patterns, and temporal course.

RESULTS

The most common imaging finding in NBS patients who had neural parenchymal involvement was a mesodiencephalic junction lesion with edema extending along certain long tracts in the brain stem and diencephalon in 46% of the patients. The next most common location of involvement was the pontobulbar region, seen in 40% of the cases. Three primary cervical spinal cord lesions and one case of isolated optic nerve involvement were observed.

CONCLUSION

The parenchymal distribution of lesions in NBS appears to support the hypothesis of small-vessel vasculitis; mainly, venular involvement. The anatomic distribution of intraaxial veins of the CNS explains the predominant involvement of the brain stem structures observed in our patients. This pattern of lesion distribution might help to differentiate NBS from other vasculitides as well as from the inflammatory-demyelinating diseases of the CNS, such as multiple sclerosis.

Retinocochleocerebral vasculopathy

We report 10 patients with retinocochleocerebral vasculopathy and review the clinical and diagnostic considerations in previously reported patients with this uncommonly recognized disease. The clinical manifestations include acute and subacute multifocal and diffuse encephalopathic symptoms, hearing loss, and visual loss attributable to microangiopathy affecting the arterioles of the brain, retina, and cochlea. Diagnosis is facilitated by demonstration of retinal arteriolar occlusions without uveitis or keratoconjunctivitis, mid- to low-frequency unilateral or bilateral sensorineural hearing loss, and numerous small foci of increased signal in the white and gray matter on T2 weighted brain magnetic resonance imaging. Because many conditions may produce any combination of strokelike cerebral symptoms, encephalopathy, hearing loss, and visual loss, the differential diagnosis for retinocochleocerebral vasculopathy includes connective tissue disease, demyelinating disease, procoagulant state, infection, neoplasm, and more routine mechanisms of cerebral and retinal ischemia. Brain biopsy specimens demonstrate only minimal nonspecific periarteriolar chronic inflammatory cell infiltration with or without microinfarcts. The demonstration of subclinical arteriolar microangiopathy in muscle biopsy specimens, documented in 3 of our patients may assist in making the diagnosis. The clinical course appears to be monophasic. In addition to corticosteroids, treatment options include immunosuppressant agents (cyclophosphamide or azathioprine) aspirin, calcium channel blockers (nimodipine), intravenous immunoglobulin, and plasmapheresis. The etiology of the disease is unknown, but histopathologic and laboratory evidence suggests that an immune-mediated mechanism may be involved.

Cerebrovascular complications of rheumatic disease

Cerebral ischemia and infarction, intracerebral hemorrhage, subarachnoid hemorrhage, cerebral venous thrombosis, and cerebral vasculitis are dreaded but largely uncommon complications of most rheumatic diseases. In some conditions, however, such as the antiphospholipid syndrome or Behcet's disease, stroke may be the presenting complaint. A format for approaching the patient and localizing the cerebrovascular lesion has been presented along with a summary of the specific rheumatologic diseases implicated for each stroke subtype.

Adamantiadis-Behçet's syndrome: central nervous system involvement

The prevalence of CNS involvement of Adamantiadis-Behçet's syndrome (A-Bs) vary widely. Long-term follow-up studies of CNS involvement have rarely been reported. Five patients with CNS involvement, who were followed up from 2 to 9 years, are presented. Clinicolaboratory investigations (cerebrospinal fluid examination, electroencephalogram, brain CAT scan and MRI) were carried out. One patient had four and two patients had two attacks of CNS involvement with various clinical manifestations. The other two patients had a rather chronic course with a single slight CNS attack. Raised proteins and IgG were found in the CSF. Abnormal electroencephalographic findings were detected in three patients. Communicating hydrocephalus and various other abnormalities on CT scan and MRI were noted. All patients received corticosteroids and immunosuppressants during the attack period.

Cerebral angio- and neuro-Behçet's syndrome: neuroradiological and pathological study of one case

Cerebral angio-Behçet's syndrome is extremely rare and pathological studies are scarce. We describe a 63-year-old man who developed left homonymous hemianopsia and hemiparesis 16 years after the onset of cardinal symptoms of Behçet's syndrome. CT, MRI and PET studies disclosed cerebral lesion with reduced neuronal metabolism in the right hemisphere, which was resolved by glucocorticoid therapy. Cerebral angiography showed no filling of the right Rolandic, anterior and posterior parietal and angular arteries. The postmortem study revealed: (a) occlusive panarteritis of some medium-sized pial branches of the right middle cerebral artery, considered as angio-Behçet's pathology, and small infarctions due to the vascular occlusion; (b) patchy or confluent demyelinated foci with perivascular lymphocytic infiltration in the bilateral brain basis, predominantly in the right retro- and sublenticular structures, being equivalent to neuro-Behçet's pathology. Cerebral angio- and neuro-Behçet's syndromes could have occurred and progressed concomitantly, which suggests a close relationship between the two subclassified processes.

PET and MR imaging in a neuro-Behçet syndrome

Positron emission tomography (PET) and magnetic resonance imaging (MRI) studies were performed on a case of neuro-Behçet's syndrome. In accordance with the clinical signs, FDG PET (using 18F-labeled 2-F-2'-desoxyglucose) revealed disseminated storage defects in the cerebrum and cerebellum. Focal regions of enhanced signal intensity were demonstrated in the parietal white matter of the cerebrum in T2-weighted images and in the brain stem by MRI.