Computed tomography of systemic lupus erythematosus

High-grade spheno-orbital meningioma in patients with systemic lupus erythematosus: Two case reports and literature review

Background:

Spheno-orbital meningiomas (SOMs) are often benign. The association of meningioma and systemic lupus erythematosus (SLE) is rarely discussed in the literature. Here, we report two patients with high-grade, SOMs with a prolonged history of SLE and review the literature.

Case Description:

The first case is a 52-year-old female patient with a 15-year history of SLE diagnosis who was referred to our center with a 1-year history of proptosis and excessive tearing of the left eye. This patient was operated for the left SOM with histopathological diagnosis of the World Health Organization (WHO) Grade III rhabdoid meningioma. The second case is a 36-year-old female patient with a 12-year history of SLE diagnosis who presented to our clinic with a 5-year-history of progressive right eye proptosis and occasional headaches. She was operated for the right SOM with histopathological diagnosis of the WHO Grade II chordoid meningioma.

Conclusion:

Rhabdoid and chordoid SOMs are uncommon and no previous report discussed their occurrence in patients with SLE. The association of high-grade meningiomas and SLE deserves further exploration.

Multiple brain calcifications in a patient with systemic lupus erythematosus

We describe a rare case of severe neuropsychiatric systemic lupus erythematosus with cerebral atrophy and multiple paraventricular, basal ganglia, cortex, cerebral white matter, and cerebellum calcifications detected on cerebral CT. These calcifications are probably secondary to necrosis focus of repeated episodes of vessels inflammation.

The neuroimaging features of the cardiolipin antibody syndrome

The purpose of our study was to define the neuroimaging features of the cardiolipin antibody syndrome. Thirty-eight patients with elevated anticardiolipin antibody titers were studied with magnetic resonance imaging or computed tomography or both. Two patients underwent cerebral angiography. All patients had recurrent transient ischemic attacks, amaurosis, or strokes. One patient had normal imaging findings. The remaining patients had a combination of infarction and atrophy. Focal infarcts, the most common finding, were seen in 32 patients. Cerebral atrophy was seen in 26 patients and was the only radiographic finding in 5. Angiography demonstrated dramatic abnormalities in the distal portions of the anterior and posterior circulations, with multiple stenosis and occlusions and extensive pial and transdural collateral networks. The cardiolipin antibody syndrome should be suspected in young patients with transient ischemic attacks or strokes in the absence of the usual risk factors for cerebrovascular disease. The presence of raised anticardiolipin antibody titers or the cardiolipin antibody syndrome in patients with lupus, in those with other connective tissue diseases, and in patients without overt manifestations of an autoimmune disorder should be viewed as a risk factor for future ischemic cerebrovascular events. Further understanding of the precise role of these antibodies in the pathogenesis of vascular thrombosis may lead to a better understanding of the mechanisms underlying certain forms of stroke.

Neuropsychiatric manifestations of systemic lupus erythematosus

The authors critically review the literature describing the varied neuropsychiatric syndromes associated with systemic lupus erythematosus (SLE). Factors that have complicated the identification and treatment of affective, behavioral, and cognitive disturbances in these patents are identified, and the utility of various diagnostic interventions is examined. Finally, the authors outline the role of the consultation-liaison psychiatrist in the clinical management of the SLE patient with neuropsychiatric disturbances.

Controversies in lupus: nervous system involvement

What have we learned about CNS lupus in recent years? An enormous amount of knowledge on pathophysiology of antiphospholipid antibodies, in particular, has been gathered. Although hard evidence of a direct pathogenetic role of these antibodies in cerebral lupus is still lacking, it is generally felt that the multiple microinfarctions found in the brains of lupus patients are related to their presence. Better understanding of the pathogenesis of cerebral lupus will come from the study of experimental models, as it has been possible to develop an antiphospholipid antibody syndrome in mice. Because no specific laboratory test for CNS lupus is yet available, diagnosing the condition remains a challenge to every clinician. Techniques including neuropsychometric testing, quantitative EEG, and SPECT scans have taught us more about cognitive dysfunction and psychosis in patients with SLE. These categories remain the most difficult to define. The concept of hypercoagulability in SLE patients has diverted the direction of therapy from immunosuppression towards anticoagulation. It is of utmost importance that randomised trials are commenced in order to determine the optimal mode of anticoagulation for various groups of lupus patients. It will be necessary to conduct such trials under strict inclusion criteria, based on well defined patient categories. Such an enterprise will require international co-operation of investigators.

Systemic lupus erythematosus: neuropsychiatric signs and symptoms related to cerebral MRI findings

A 76.2% prevalence of abnormalities was found in the cerebral MR scans of 21 patients with systemic lupus erythematosus (SLE). These patients were enrolled in the study consecutively as they presented at an immunological out-patient unit. They were not selected on the basis of neuro/psychiatric findings. Circumscribed non-periventricular brain lesions were found in 12 patients (57.1%), mainly in the frontal white or gray matter. Periventricular lesions directly adjacent to the ventricles were detected in 10 patients (47.6%). Eleven patients (52.4%) showed signs of cerebral atrophy. MRI detected more lesions in patients with clinically focal CNS lupus than in patients with seizures or patients without clinically localized findings. Eleven patients had abnormal neuropsychiatric CNS findings; there was no clear correlation between neuropsychiatric signs and symptoms and brain abnormalities as shown by MRI. Seven patients had asymptomatic lesions. Cerebral MRI proved to be the method of choice for the non-clinical diagnosis of neuropsychiatric SLE.

Dementia with leukoencephalopathy in systemic lupus erythematosus

Neurologic manifestations, afflicting up to 70% of SLE patients, include psychosis, seizures, chorea, neuropathies, and stroke. MRI is useful in evaluation of lupus patients and several reports have documented cerebral atrophy or focal hyperintensities. We report an unusual MRI appearance in a 56-year-old woman with SLE, diagnosed on the basis of pleuritis, lymphopenia, anti-DNA antibodies, and neurologic involvement. She reported recent onset of Raynaud's phenomenon and generalized macular rash. She presented after two months of gradual deterioration with memory loss, flattened affect, dysphagia, dysarthria, anomia, and somnolence, without focal neurologic signs. Investigations included elevated ESR, reduced complement, normal CSF without oligoclonal bands, negative viral serology, normal hormone and vitamin levels, normal renal and hepatic function. Neuropsychologic testing showed widespread impairment (WAIS-R: FSIQ-63; WMS-69; DRS-98; RCPM-14; WAB AQ-78.8). CT was normal but MRI showed strikingly symmetric, confluent hyperintensities extensively involving cerebral and cerebellar white matter on T1 and T2 weighted scans. Basal ganglia and subependymal and subcortical white matter were spared. Treated with prednisone, the patient made a gradual, but incomplete, recovery. These MRI findings may reflect widespread vasculopathy or direct immunologic brain insult with or without immunologic blood-brain barrier disruption.

Depletion of high-energy phosphates in the central nervous system of patients with systemic lupus erythematosus, as determined by phosphorus-31 nuclear magnetic resonance spectroscopy

Systemic lupus erythematosus (SLE) can produce profound disturbances in the central nervous system, characterized by encephalopathy, focal neurologic deficits, cerebral infarction, psychosis, and seizures. We used 31P nuclear magnetic resonance (NMR) spectroscopy to determine the in vivo levels of high-energy phosphates in the central nervous system of 10 patients with SLE and 10 age-matched normal controls. 31P NMR spectroscopy was performed on a 1.5-Tesla unit equipped with a dual-tuned 1H-31P surface coil and a software-directed DRESS (depth resolved surface coil spectroscopy) pulse sequence. This procedure detected ADP, ATP, sugar phosphates, phosphocreatine (PCr), inorganic phosphate, phosphomonoesters, and phosphodiesters in the brain tissue of all study subjects. Levels of ATP in the deep white matter of 10 SLE patients were significantly decreased compared with the levels in 10 normal controls, as quantitated by the ratio of ATP:ATP + ADP (mean +/- SD 0.81 +/- 0.11 versus 0.91 +/- 0.05; P less than 0.02). In a subgroup of 4 patients, PCr levels were decreased to a greater extent than the ATP levels. NMR spectroscopic alterations were not related to obvious anatomic lesions, as determined by standard cranial proton magnetic resonance imaging. In 4 SLE patients with markedly abnormal 31P NMR spectra, treatment with prednisone (80 mg/day) normalized the levels of ATP and PCr. Restoration of a normal 31P profile was accompanied by an obvious improvement in the patients' mental status and clinical symptoms. 31P NMR spectroscopy is a powerful new technique for monitoring high-energy phosphate metabolism, and may be particularly useful for characterizing central nervous system disease in patients with neuropsychiatric SLE.

Magnetic resonance and computed tomographic imaging in the evaluation of acute neuropsychiatric disease in systemic lupus erythematosus

Magnetic resonance (MR) imaging and computed tomography (CT) are useful for the evaluation of central nervous system (CNS) lupus. This report describes the use of cranial MR and CT in 21 patients with systemic lupus erythematosus (SLE) with acute neuropsychiatric symptoms manifested by headache, seizures, focal neurological deficits, psychosis, or organic brain syndrome. Computed tomography was found to be insensitive and detected only diffuse atrophy (two cases), cerebral infarct (one case), and intracerebral haemorrhage (one case) in the 21 patients. Cranial MR images obtained with a General Electric 1.5 tesla Signa unit detected labile and fixed areas of increased proton intensity interpreted as focal oedema (eight cases), infarct (10 cases), haemorrhage (one), atrophy (seven), and acute sinusitis (two). Focal oedema was characterised by labile, high intensity lesions in the gray or white matter of the cerebellum, cerebrum, or brain stem, which completely resolved after aggressive corticosteroid treatment. Most high intensity reversible or fixed lesions evident on MR were not apparent on cranial CT images. In several patients sequential MR images were valuable in monitoring the efforts of treatment. Although histological confirmation of the high intensity brain lesions apparent on MR is desirable, prior necropsy studies suggest that pathological confirmation may be difficult owing to the paucity of recognisable brain lesions in patients with CNS lupus. It is concluded that for the evaluation of acute neuropsychiatric SLE MR is useful and provides more information than cranial CT.

Solitary paraventricular calcification in cerebral lupus erythematosus: a report of two cases

Paraventricular calcification not previously reported in systemic lupus erythematosus was seen in cranial computed tomograms of two patients with this disorder.

Identification of brain lesions in neuropsychiatric systemic lupus erythematosus by magnetic resonance scanning

Cranial magnetic resonance imaging in 28 systemic lupus erythematosus patients who had experienced 30 acute neuropsychiatric events showed focal brain lesions in 16 of 30 events (53%) and low brain volume (atrophy) in 20 of 30 events (67%). Definite focal lesions were significantly more frequent in patients with clinically localized neurologic deficits (8 of 8, 100%), or seizures (5 of 6, 83%) than in patients without such localizing signs (3 of 16, 19%). Many of these lesions were occult on intravenous contrast-enhanced x-ray computed tomography. In 2 patients, lesions in gray matter resolved within 2 or 3 weeks, in association with clinical improvement. Magnetic resonance imaging is an important technique for detecting the extent of brain injury in cerebral lupus.

Systemic lupus erythematosus and primary cerebral lymphoma

A woman with a 21 year old history of systemic lupus erythematosus (SLE) is presented. During a period of low connective tissue disease activity she developed sudden difficulty in walking and after much investigation was found to have a primary lymphoma of the brain. She died 6 months after this diagnosis from meningeal spread, despite radiotherapy to the tumour. The association between SLE and lymphoma is discussed.

Clinical neurophysiology in the assessment of neurological symptoms in systemic lupus erythematosus

Neurophysiological studies were performed on 22 randomly selected patients with systemic lupus erythematosus in order to determine whether this form of assessment might be of value in the diagnosis and management of neurological lupus. Sixteen patients described neurological lupus. In eight, neurological symptoms were present at the time of neurophysiological testing. All eight had neurophysiological abnormalities. In six the abnormality was of central origin manifesting as a disorder of either visual evoked response (VER) or brain-stem auditory evoked response (BAER). In the remaining two, an isolated disorder of peripheral nerve conduction (PNC) was present. In the eight patients with previous neurological symptoms five (63%) had neurophysiological abnormalities, but a central disorder was observed in only one and abnormal PNC was present in all. Of the six patients with no neurological symptoms, three (50%) had central neurophysiological disorders. No correlation between individual neurophysiological disorders and specific neurological symptoms was observed. However, all four patients with active vasculitis and all seven with lymphopenia had a neurophysiological disorder. If these observations are extended and confirmed, neurophysiological studies may provide a useful test to the clinician in the evaluation and management of neurological lupus.

The association between the lupus anticoagulant and cerebral infarction in systemic lupus erythematosus

The lupus anticoagulant (LAC) is associated with the occurrence of thromboembolic complications. Assuming that thrombosis may underlie manifestations of the central nervous system (CNS) in patients with systemic lupus erythematosus (SLE), we studied 20 patients with SLE and CNS manifestations for the presence of LAC. In 8 patients (40%) including 4 with overt cerebral infarction, LAC was demonstrated. The 4 patients with LAC and cerebral infarction all had thrombocytopenia, 2 had a history of peripheral thrombosis, and one recurrent abortion. In the 4 LAC-positive patients without overt cerebral infarction, thrombocytopenia was present in 3, a history of thrombosis in 2, and fetal wastage in one. We conclude that LAC identifies within the CNS-SLE group a subpopulation of patients in whom CNS manifestations are caused by cerebral infarction. This subpopulation is further characterized by increased prevalence of thrombocytopenia, peripheral thrombosis and fetal wastage. A possible pathogenetic role of LAC may be related to a hypercoagulable state occurring in this subgroup of SLE patients.

The cranial computed tomographic findings in patients with neurologic manifestations of systemic lupus erythematosus

The clinical and computed tomographic (CT) findings in 17 patients with neurological manifestations of systemic lupus erythematosus were analyzed. Two patients presented with stroke syndromes; they did not have systemic manifestations of SLE at the time the neurological disturbances developed. Of 15 patients with prominent systemic evidence of SLE, 9 presented with stroke syndromes or seizures. CT showed a hypodense lesions representing infarction (7 cases) or hyperdense lesions representing intracerebral hematomas (2 cases). Six patients with gradual onset of neurobehavioral symptoms showed cerebral atrophy without infarction or hemorrhage.

A syndrome of arterial-occlusive retinopathy and encephalopathy

An analysis of two new cases and four previously reported cases produced evidence for a syndrome of arterial-occlusive retinopathy and encephalopathy. All six patients were women; they ranged in age from 21 to 40 years. The clinical features of this condition include multiple branch retinal arterial occlusions and encephalopathy in which behavioral and memory disturbances predominate early. Hearing loss is frequent. Except for cerebrospinal fluid pleocytosis and an increased cerebrospinal fluid protein level, there are few laboratory or radiographic abnormalities. The disease may be responsive to corticosteroid therapy. There are some similarities between this syndrome and systemic lupus erythematosus but it appears to be a distinct disease entity. A comparison of the retinal findings with those described in experimental allergic encephalitis suggests that this may be a virally induced immune-mediated disease. Although only four clearly documented examples of this syndrome have been reported, we suspect that cases may have been overlooked because of failure to recognize arterial branch occlusions in the peripheral retina.

Psychiatric manifestations of systemic lupus erythematosus in children and adolescents. A review

The purpose of this article is to review the psychiatric conditions associated with systemic lupus erythematosus (SLE) in children and adolescents. Emphasis is placed on clinical presentation and the differential diagnosis between organic psychiatric disorder, toxic psychiatric disorder, and functional psychological symptoms.

Can determination of lactic acid and pyruvic acid in cerebrospinal fluid help in diagnosing central nervous system involvement in systemic lupus erythematosus?

The central nervous system (CNS) is frequently affected by systemic lupus erythematosus (SLE). Other causes, especially infection, may also originate CNS disease in SLE patients. Our findings indicate that measurement of lactic acid and pyruvic acid in cerebrospinal fluid (CSF) may be of help in separating inactive CNS-SLE from active CNS-SLE. Also it may be of help in differentiating sterile meningitis caused by SLE from bacterial meningitis. Because of the special risk on tuberculous and fungal infections in SLE patients, also some findings concerning these specific forms of meningitis are given.

Neurological complications of connective tissue and other "collagen-vascular" diseases

A variety of neurological complications may occur in the various connective tissue and "collagen-vascular" diseases. Most of these complications are due to vasculitis affecting various sites in the central or peripheral nervous system. While the evidence for definitive vasculitis in SLE is not strong, small vessel damage usually is present in anatomic sites which correlate well with clinical features. Although patients with rheumatoid arthritis also may have vasculitis, neurological complications are usually related to nerve compression by rheumatoid nodules or the arthritic process itself. Considerable controversy exists regarding the accuracy of various diagnostic tests. While corticosteroids are the mainstay of therapy for these conditions, there are no definitive studies proving their efficacy.

The neuropsychiatric disorder in systemic lupus erythematosus: evidence for both vascular and immune mechanisms

As part of a prospective survey of systemic lupus erythematosus (SLE) a detailed collaborative study of the clinical, psychiatric, and laboratory features in 15 patients with nonfocal neuropsychiatric disease has been undertaken. In addition to conventional clinical and psychometric evaluation, electroencephalograph, and cerebrospinal fluid analysis, the study included the assessment of cerebral blood flow with oxygen-15 brain scans and serological testing for the presence of antineuronal and lymphocytotoxic antibodies. Of the 15 patients 12 had psychiatric manifestations, while 13 had various neurological abnormalities. All except 2 episodes of cerebral disease were transient. Striking abnormalities in cerebral blood flow and metabolism were seen in 12 patients, even in the presence of subtle clinical features. Sequential scans showed that improvement in clinical features was accompanied by a reversal of scan abnormalities. All sera contained brain-reactive antibody, either antineuronal IgG antibody (13) or lymphocytotoxic IgM antibody (12) or both (10), though there was an inconsistent association between clinical features and antibody titre. It is suggested that transient disturbances of cerebral vascular function in SLE might allow brain-reactive antibodies from the circulation access to cerebral tissue. In this way the nature of the neuropsychiatric abnormalities would depend on both vascular and immunopathogenic mechanisms.

Cranial computed tomography in the diagnosis of systemic lupus erythematosus

The cranial computed tomograms of 29 patients with systemic lupus erythematosus (SLE) were reviewed. Twenty-two patients had a clinical course consistent with central nervous system involvement. Of these, 20 had abnormal CT studies during the course of their CNS symptoms. The most common finding was sulcal enlargement, either with or without ventricular enlargement, and it was prominent in patients with either psychosis or dementia. Infarcts and intracranial hemorrhages were seen as well. Seven CT studies were obtained in SLE patients without a clear diagnosis of CNS involvement. Only one of these was abnormal.

Oxygen-15 brain scanning for detection of cerebral involvement in systemic lupus erythematosus

In 47 patients with systemic lupus erythematosus seen during fifty-one clinical episodes, oxygen-15, a short-lived gamma-emitting isotope, has been employed in a scannng technique to study cerebral oxygen utilisation and blood-flow. Abnormalities in regional distribution of oxygen utilisation and blood-flow were seen in twenty-three out of twenty-four instances of definite central-nervous-system disease, in fourteen out of fifteen instances of suspected C.N.S. lupus, and in ten out of twelve instances in which C.N.S. disease was not clinically apparent. The technique reflected remissions and relapses. It may prove valuable in diagnosis of subclinical cerebral disease, in monitoring of responses to therapy, and in study of the pathophysiology of cerebral lupus.