1
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Sherri A, Mortada MM, Makowska J, Lewandowska-Polak A. Primary angiitis of the CNS and ANCA-associated vasculitis: from pathology to treatment. Rheumatol Int 2024; 44:211-222. [PMID: 37777632 PMCID: PMC10796583 DOI: 10.1007/s00296-023-05461-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023]
Abstract
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.
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Affiliation(s)
- Alaa Sherri
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland.
| | | | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
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2
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Siala S, Rahoui N, Cho B, Zamora CA. Pathology of Primary Angiitis of the Central Nervous System. Neuroimaging Clin N Am 2024; 34:31-37. [PMID: 37951703 DOI: 10.1016/j.nic.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Primary angiitis of the central nervous system (PACNS) is a rare and potentially severe form of vasculitis that is limited to the brain, spinal cord, and meninges. Despite extensive research, the etiology and underlying immunologic mechanisms of PACNS remain largely unknown. PACNS presents with a variety of clinical, radiological, and pathologic features, but it is generally characterized by inflammation and destruction of the walls of blood vessels in the CNS, which can lead to tissue ischemia and/or hemorrhage. Three main histopathologic patterns have been identified, namely granulomatous, lymphocytic, and necrotizing vasculitis.
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Affiliation(s)
- Selima Siala
- Department of Radiology, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC 27514, USA.
| | - Nabil Rahoui
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Benjamin Cho
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Carlos A Zamora
- Department of Radiology, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC 27514, USA
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3
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Lu P, Cui L, Zhang X. Primary Angiitis of the Central Nervous System in Adults: A Comprehensive Review of 76 Biopsy-Proven Case Reports. J Inflamm Res 2023; 16:5083-5094. [PMID: 37953861 PMCID: PMC10638941 DOI: 10.2147/jir.s434126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023] Open
Abstract
Purpose Primary angiitis of the adult central nervous system (PACNS) is an increasingly recognized but limited disease. Using previous case reports, we sought to summarize the clinical symptoms, imaging manifestations, treatment, and prognosis of patients with biopsy-confirmed PACNS to guide clinical diagnosis and management. Methods We searched the Web of Science database for studies published from January 2000 to April 2023, with the language set to English and the document type limited to [Article or Review or Letter or Editorial Material]. A systematic review of all case reports met the inclusion and exclusion criteria was performed. These patients' clinical, pathological, and imaging characteristics were analyzed, and treatment and prognostic data were summarized. Results We analyzed 69 articles, including 76 patients with biopsy-confirmed PACNS. And 57.9% of the patients were male, the median age at presentation was 47.0 years, and focal neurological deficits were the most common symptom in patients (78.9%), followed by headache (52.6%). The median duration of biopsy was 1.1 months, of which 49 (64.5%) patients were lymphocytic, 13 (17.1%) were granulomatous, 11 (14.5%) were amyloidotic, and 3 (3.9%) were necrotizing PACNS. Relapse events occurred in 41 (53.9%) patients, including 34 (44.2%) relapses and 8 (10.5%) deaths. Univariate logistic regression analysis revealed that symptomatic epilepsy, prolonged biopsy time window, and CD20 expression in pathological tissues might be independent risk factors for recurrent events in patients (HR=4.69, 95% CI: 1.51-14.54, p=0.007; HR=1.11, 95% CI: 1.00-1.22, p=0.043; HR=5.33, 95% CI: 1.07-26.61, p=0.041). Conclusion Adult PACNS is associated with frequent relapses and high mortality. Symptomatic epilepsy, prolonged biopsy time window, and CD20 expression in pathological tissue may be associated with recurrent events.
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Affiliation(s)
- Ping Lu
- Center for Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People’s Republic of China
| | - Lingyun Cui
- Center for Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People’s Republic of China
| | - Xinghu Zhang
- Department of Neuroinfection and Neuroimmunology, Center for Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People’s Republic of China
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4
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Salvarani C, Paludo J, Hunder GG, Ansell SM, Giannini C, Parisi JE, Huston J, Koster MJ, Warrington KJ, Croci S, Brown RD. Exploring Gene Expression Profiles in Primary Central Nervous System Vasculitis. Ann Neurol 2023; 93:120-130. [PMID: 36264136 DOI: 10.1002/ana.26537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study was undertaken to explore the gene expression profile of primary central nervous system vasculitis (PCNSV). METHODS Brain specimens of 4 patients with granulomatous vasculitis (GV), 5 with lymphocytic vasculitis (LV), 4 with amyloid β-related angiitis (ABRA), and 4 normal controls were studied. RNA-sequencing was performed using the Illumina Hiseq-4,000 platform and the Illumina TruSeq Total-RNA library. Student t test and false discovery rate tests were performed for each of the differentially expressed transcripts. Ingenuity Pathway Analysis was used for the pathway expression analysis. CIBERSORT was used to estimate the abundances of different immune cell subsets in the tissues based on gene expression data. RESULTS Transcripts differentially expressed between PCNSV and normal brain indicated that endosomal, mitochondrial, and ribosome dysfunction, alterations in protein synthesis, and noncoding RNAs might be involved in PCNSV. Pathway analysis revealed the activation of dendritic cell maturation and antigen processing as well as neuroinflammation in PCNSV versus normal brain, whereas oxidative phosphorylation was inhibited. CIBERSORT estimation of immune cell subsets suggested that activated NK cells, M1 macrophages, memory B cells, and follicular helper T cells were likely to be more prevalent in PCNSV samples. Naïve CD4 T cells and monocytes were mainly estimated to be present in GV and ABRA. Plasma cell and γδ T-cell signatures were mainly found in LV and normal brain. GV showed higher levels of genes associated with macrophage activities and T cells. ABRA showed higher levels of long noncoding RNAs and miR-616. LV showed higher levels of genes encoding immunoglobulins. INTERPRETATION RNA sequencing confirmed PCNSV heterogeneity. ANN NEUROL 2023;93:120-130.
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Affiliation(s)
- Carlo Salvarani
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Division of Rheumatology, Local Health Unit Company-Institute of Hospitalization and Scientific Care, Reggio Emilia, Italy
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Gene G Hunder
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Joseph E Parisi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Stefania Croci
- Clinical Immunology, Allergy and Advanced Biotechnologies Unit, USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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5
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Li EW, Krishnaswamy M, El-Wahsh S, Balgobind S, Trotman J, Tan I, Hardy TA. Paraneoplastic primary CNS angiitis secondary to nodular lymphocyte predominant Hodgkin lymphoma. Pathology 2022; 55:547-551. [PMID: 36443120 DOI: 10.1016/j.pathol.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/08/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
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6
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Gutierrez J, Katan M, Elkind MS. Inflammatory and Infectious Vasculopathies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00036-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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7
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Borcheni M, Abdelazeem B, Malik B, Gurugubelli S, Kunadi A. Primary Central Nervous System Vasculitis as an Unusual Cause of Intracerebral Hemorrhage: A Case Report. Cureus 2021; 13:e13847. [PMID: 33854857 PMCID: PMC8038648 DOI: 10.7759/cureus.13847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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).
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Affiliation(s)
- Mariem Borcheni
- Internal Medicine, University of Sfax Faculty of Medicine, Sfax, TUN
| | - Basel Abdelazeem
- Internal Medicine, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | - Bilal Malik
- Internal Medicine, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | | | - Arvind Kunadi
- Internal Medicine/Nephrology, McLaren Health Care, Flint/Michigan State University, Flint, USA
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8
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Blackburn PR, Lin WL, Miller DA, Lorenzo-Betancor O, Edwards ES, Zimmermann MT, Farrugia LP, Freeman WD, Soto AI, Walton RL, Klee EW, Atwal PS, Abraham RS, Billadeau DD, Ross OA, Dickson DW, Meschia JF. X-Linked Lymphoproliferative Syndrome Presenting as Adult-Onset Multi-Infarct Dementia. J Neuropathol Exp Neurol 2020; 78:460-466. [PMID: 30990878 DOI: 10.1093/jnen/nlz018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pathogenic hemizygous variants in the SH2D1A gene cause X-linked lymphoproliferative (XLP) syndrome, a rare primary immunodeficiency usually associated with fatal Epstein-Barr virus infection. Disease onset is typically in early childhood, and the average life expectancy of affected males is ∼11 years. We describe clinical, radiographic, neuropathologic, and genetic features of a 49-year-old man presenting with central nervous system vasculitis that was reminiscent of adult primary angiitis but which was unresponsive to treatment. The patient had 2 brothers; 1 died of aplastic anemia at age 13 and another died of diffuse large B-cell lymphoma in his sixties. Exome sequencing of the patient and his older brother identified a novel hemizygous variant in SH2D1A (c.35G>T, p.Ser12Ile), which encodes the signaling lymphocyte activation molecule (SLAM)-associated protein (SAP). Molecular modeling and functional analysis showed that this variant had decreased protein stability, similar to other pathogenic missense variants in SH2D1A. The family described in this report highlights the broadly heterogeneous clinical presentations of XLP and the accompanying diagnostic challenges in individuals presenting in adulthood. In addition, this report raises the possibility of a biphasic distribution of XLP cases, some of which may be mistaken for age-related malignancies and autoimmune conditions.
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Affiliation(s)
- Patrick R Blackburn
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Wen-Lang Lin
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida
| | - David A Miller
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | | | - Michael T Zimmermann
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - Ronald L Walton
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida
| | - Eric W Klee
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Paldeep S Atwal
- Department of Clinical Genomics, Mayo Clinic, Jacksonville, Florida
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (RSA)
| | - Daniel D Billadeau
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
| | - Owen A Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida
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9
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Bersano A, Kraemer M, Burlina A, Mancuso M, Finsterer J, Sacco S, Salvarani C, Caputi L, Chabriat H, Oberstein SL, Federico A, Lasserve ET, Hunt D, Dichgans M, Arnold M, Debette S, Markus HS. Heritable and non-heritable uncommon causes of stroke. J Neurol 2020; 268:2780-2807. [PMID: 32318851 DOI: 10.1007/s00415-020-09836-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- A Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - M Kraemer
- Department of Neurology Alfried, Krupp-Hospital, Essen, Germany.,Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - A Burlina
- Neurological Unit, St. Bassano Hospital, Bassano del Grappa, Italy
| | - M Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - J Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria
| | - S Sacco
- Department of Neurology, Avezzano Hospital, University of L'Aquila, L'Aquila, Italy
| | - C Salvarani
- University of Modena and Reggio Emilia, and Azienda USL-IRCCS, Reggio Emilia, Italy
| | - L Caputi
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - H Chabriat
- Department of Neurology and CERVCO, DHU Neurovasc, INSERM U1141, University of Paris, Paris, France
| | - S Lesnik Oberstein
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Federico
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - E Tournier Lasserve
- Department of Genetics, Lariboisière Hospital and INSERM U1141, Paris-Diderot University, Paris, France
| | - D Hunt
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - M Dichgans
- Institute for Stroke and Dementia Research, Klinikum Der Universität München, Munich, Germany
| | - M Arnold
- Inserm Centre Bordeaux Population Health (U1219), University of Bordeaux, Bordeaux, France
| | - S Debette
- Department of Neurology, INSELSPITAL, University Hospital Bern, Bern, Switzerland
| | - H S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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10
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Kon T, Funamizu Y, Suzuki C, Sato T, Kurotaki H, Kurihara A, Kurose A, Wakabayashi K, Tomiyama M. A Long Interval from a Spinal Cord Lesion to a Subsequent Brain Lesion in Primary Central Nervous System Vasculitis. Intern Med 2019; 58:1485-1489. [PMID: 30449796 PMCID: PMC6548925 DOI: 10.2169/internalmedicine.1667-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Primary central nervous system vasculitis (PCNSV) is an uncommon vasculitis restricted to the small- and medium-sized vessels in the brain and spinal cord. Previously, only 9 cases have been reported that initially manifested as an isolated spinal cord lesion with subsequent brain involvement, where the longest interval from the onset to brain involvement was 1 year and 11 months. We herein report the case of an isolated spinal cord lesion with subsequent brain involvement appearing seven years and five months later. This case shows that brain lesions can develop after an extended interval from spinal onset in PCNSV.
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Affiliation(s)
- Tomoya Kon
- Department of Neurology, Aomori Prefectural Central Hospital, Japan
- Department of Neuropathology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan
| | | | - Chieko Suzuki
- Department of Neurology, Aomori Prefectural Central Hospital, Japan
| | - Tsugumi Sato
- Department of Pathology, Aomori Prefectural Central Hospital, Japan
| | | | | | - Akira Kurose
- Department of Anatomic Pathology, Hirosaki University Graduate School of Medicine, Japan
| | - Koichi Wakabayashi
- Department of Neuropathology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan
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11
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Beuker C, Schmidt A, Strunk D, Sporns PB, Wiendl H, Meuth SG, Minnerup J. Primary angiitis of the central nervous system: diagnosis and treatment. Ther Adv Neurol Disord 2018; 11:1756286418785071. [PMID: 30034536 PMCID: PMC6048610 DOI: 10.1177/1756286418785071] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, D-48149, Germany
| | - Antje Schmidt
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Daniel Strunk
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Peter B Sporns
- Department of Clinical Radiology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
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12
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Edgell RC, Sarhan AE, Soomro J, Einertson C, Kemp J, Shirani P, Malmstrom TK, Coppens J. The Role of Catheter Angiography in the Diagnosis of Central Nervous System Vasculitis. INTERVENTIONAL NEUROLOGY 2016; 5:194-208. [PMID: 27781050 DOI: 10.1159/000445255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/05/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Central nervous system vasculitis (CNSV) is a rare disorder, the pathophysiology of which is not fully understood. It involves a combination of inflammation and thrombosis. CNSV is most commonly associated with headache, gradual changes in mental status, and focal neurological symptoms. Diagnosis requires the effective use of history, laboratory testing, imaging, and biopsy. Catheter angiography can be a powerful tool in the diagnosis when common and low-frequency angiographic manifestations of CNSV are considered. We review these manifestations and their place in the diagnostic algorithm of CNSV. SUMMARY We reviewed the PubMed database for case series of CNSV that included 5 or more patients. Demographic and angiographic findings were collected. Angiographic findings were dichotomized between common and low-frequency findings. A system for incorporating these findings into clinical decision-making is proposed. KEY MESSAGE CNSV is a diagnostic challenge due to the absence of a true gold standard test. In the absence of such a test, catheter angiography remains a central piece of the diagnostic puzzle when appropriately employed and interpreted.
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Affiliation(s)
- Randall C Edgell
- Department of Neurology, Saint Louis University, Saint Louis, Mo, USA
| | - Ahmed E Sarhan
- Department of Neurology, Saint Louis University, Saint Louis, Mo, USA
| | - Jazba Soomro
- Department of Neurology, Saint Louis University, Saint Louis, Mo, USA
| | | | - Joanna Kemp
- Department of Neurosurgery, Saint Louis University, Saint Louis, Mo, USA
| | - Peyman Shirani
- Department of Neurology, Saint Louis University, Saint Louis, Mo, USA
| | - Theodore K Malmstrom
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, Saint Louis, Mo, USA
| | - Jeroen Coppens
- Department of Neurosurgery, Saint Louis University, Saint Louis, Mo, USA
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13
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Gutierrez J, Katan M, Elkind MS. Collagen Vascular and Infectious Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Mikdashi JA. Primary angiitis of the central nervous system. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00164-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Okeda R, Ito K, Tsumura K, Eishi Y. Primary granulomatous angiitis of the CNS preferentially involving small veins with a granulomatous leukoencephalitis-like lesion in the cerebrum. Neuropathology 2013; 33:547-52. [PMID: 23279573 DOI: 10.1111/neup.12006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 10/26/2012] [Accepted: 11/12/2012] [Indexed: 11/29/2022]
Abstract
We have reported an autopsy case of primary granulomatous angiitis of the CNS preferentially involving the small veins with a granulomatous leukoencepalitis-like lesion in the cerebral white matter of a 48-year-old man. The latter lesion was ischemic necrosis due to circumferential multiple perivenous granulomas in the adjacent Virchow-Robin space. Multifocal progressive involvement of venular adventitia by granulomas, leaving behind mural fibrosis and luminal stenosis, was related clinically to the prolonged stepwise deterioration observed in the patient, and pathologically to diffuse loosening with dilated veins in the deep cerebral white matter and subcortical hemorrhagic infarction in the left parietal lobe through chronic venous stagnation. PCR demonstrated negativity for Mycobacterium tuberculosis and Propionibacterium acnes, and in situ hybridization with EBV-encoded small nuclear RNA probe was also negative. The possibility of subarachnoidal latent infection with an unknown avirulent agent causing exclusively perivascular granulomas is proposed. It will be necessary to examine by autopsy whether the type (artery or vein) and size of the involved vessels and the pathological subtype of angiitis is related to the etiopathogenesis and prognosis. It is also pointed out that the entity of lymphocytic angiitis is problematic.
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Affiliation(s)
- Riki Okeda
- Department of Pathology, Kawasaki Saiwai Hospital, Kawasaki, Japan
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16
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Abstract
Primary CNS vasculitis is an uncommon disorder of unknown cause that is restricted to brain and spinal cord. The median age of onset is 50 years. The neurological manifestations are diverse, but generally consist of headache, altered cognition, focal weakness, or stroke. Serological markers of inflammation are usually normal. Cerebrospinal fluid is abnormal in about 80-90% of patients. Diagnosis is unlikely in the presence of a normal MRI of the brain. Biopsy of CNS tissue showing vasculitis is the only definitive test; however, angiography has often been used for diagnosis even though it has only moderate sensitivity and specificity. The size of the affected vessels varies and determines outcome and response to treatment. Early recognition is important because treatment with corticosteroids with or without cytotoxic drugs can often prevent serious outcomes. The differential diagnosis includes reversible cerebral vasoconstriction syndromes and secondary cerebral vasculitis.
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Affiliation(s)
- Carlo Salvarani
- Unit of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy.
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Giannini C, Salvarani C, Hunder G, Brown RD. Primary central nervous system vasculitis: pathology and mechanisms. Acta Neuropathol 2012; 123:759-72. [PMID: 22421812 DOI: 10.1007/s00401-012-0973-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 02/29/2012] [Accepted: 03/03/2012] [Indexed: 12/16/2022]
Abstract
Primary vasculitis of the central nervous system (PCNSV) is a rare and diagnostically challenging form of vasculitis limited to the brain and/or spinal cord. It is a complex and often severe disease with multifaceted clinical and pathological appearances, suggesting multiple disease subtypes and the potential existence of multiple etiologic pathways. We describe in detail the clinical, imaging, and neuropathological findings of PCNSV summarizing literature data and our observations from a cohort of 131 patients diagnosed at Mayo Clinic over a 25-year period (1983-2007). Unlike systemic vasculitis, little is known regarding PCNSV pathogenesis and the involved immunological mechanisms. Increased recognition of the disease spectrum and in-depth characterization of its histopathologic and immunological phenotype will be critical to eventually understanding the underlying derangements and mechanisms driving PCNSV. Improved understanding of the pathogenetic mechanisms of the disease may also help determine whether the different histologic patterns and clinical subsets represent more than one disease and ultimately may permit development of novel diagnostic and therapeutic strategies for it.
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Affiliation(s)
- Caterina Giannini
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
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You G, Yan W, Zhang W, Li S, Li G, Jiang T. Isolated angiitis of the central nervous system with tumor-like lesion, mimicking brain malignant glioma: a case report and review of the literature. World J Surg Oncol 2011; 9:97. [PMID: 21867556 PMCID: PMC3178486 DOI: 10.1186/1477-7819-9-97] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 08/26/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isolated angiitis of the central nervous system (IACNS) is a rare but severe vascular disease, which could present like an isolated inflammatory lesion on magnetic resonance imaging (MRI). To date, only a few such cases with tumor-like IACNS have been reported. CASE PRESENTATION A 35-year-old woman presented with headache and left-sided weakness. MRI scans initially mislead us to a diagnosis of glioblastoma (GBM). Surgery was performed. The mass was sub-totally resected. Pathological examination confirmed a cerebral vasculitis. Radiological features, such as disproportionate mass effect, striped hemorrhage and abnormal enhancement of adjacent vessels, could be helpful to distinguish a tumor-like IACNS from a GBM. Single therapy with high doses of steroid did not improve the patient's condition. Combined therapy with prednisolone and cyclophosphamide showed great benefit to the patient. No relapse occurred during the period of 18 months follow-up. CONCLUSIONS Although a tumor-like IACNS has no established imaging features, a diagnosis of tumor-like IACNS should be suspected when MRI shows inappropriate presentations of a tumor. Greater awareness of this potential manifestation of IACNS may facilitate more prompt diagnosis and treatment.
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Affiliation(s)
- Gan You
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Myung J, Kim B, Yoon BW, Lee SK, Sung JJ, Chung CK, Chang KH, Park SH. B-cell dominant lymphocytic primary angiitis of the central nervous system: Four biopsy-proven cases. Neuropathology 2010; 30:123-30. [DOI: 10.1111/j.1440-1789.2009.01051.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Arias M, Osorio XR, Dapena D, Arias-Rivas S, Vázquez F. Recurrent leukoencephalopathy with microhemorrhages: gradient-echo MRI study diagnostic value in CNS primary angiitis. Mult Scler 2008; 14:1139-41. [DOI: 10.1177/1352458508094642] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diagnosis of primary angiitis of the central nervous system (PACNS) is difficult in relation to variability in its clinical manifestations and absence of specific signs in neuroimaging. A young patient presented with a recurrent encephalopathic clinical course. T2 and fluid-attenuated inversion recovery-magnetic resonance imaging (FLAIR-MRI) showed hyperintense lesions in the cerebral white matter suggesting demyelination. Those lesions decreased or even disappeared after treatment with steroids and immunoglobulins. In echo gradient MRI (T2*-MRI), there were permanent cortical-subcortical petechial hypointense lesions (microhemorrhages). Definite diagnosis was established after cerebral biopsy. Intravenous cyclophosphamide was administrated with no new relapses in more than 18 months of follow-up. In a compatible clinical course, the finding of petechial hemorrhages in T2*-WI could play an important role in early diagnosis of PACNS.
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Affiliation(s)
- M Arias
- Department of Neurology, Complexo Hospitalario, Universitario, Santiago de Compostela, Spain
| | - XR Osorio
- Department of Neurology, Complexo Hospitalario, Universitario, Santiago de Compostela, Spain
| | - D Dapena
- Department of Neurology, Complexo Hospitalario, Universitario, Santiago de Compostela, Spain
| | - S Arias-Rivas
- Department of Neurology, Complexo Hospitalario, Universitario, Santiago de Compostela, Spain
| | - F Vázquez
- Department of Radiology, Complexo Hospitalario, Universitario, Santiago de Compostela, Spain
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Benseler SM, deVeber G, Hawkins C, Schneider R, Tyrrell PN, Aviv RI, Armstrong D, Laxer RM, Silverman ED. Angiography-negative primary central nervous system vasculitis in children: A newly recognized inflammatory central nervous system disease. ACTA ACUST UNITED AC 2005; 52:2159-67. [PMID: 15986347 DOI: 10.1002/art.21144] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Inflammatory central nervous system (CNS) diseases in childhood comprise a wide spectrum of heterogeneous conditions. We studied 4 children with primary CNS vasculitis in whom results of magnetic resonance imaging studies were abnormal but results of conventional angiography were normal. We determined that angiography-negative, biopsy-confirmed primary small-vessel CNS vasculitis is a previously unrecognized distinct disease entity in children. The diagnosis must be considered in a child with a progressive, acquired diffuse or focal neurologic deficit, even if the results of conventional angiography are normal. A lesional brain biopsy is required to confirm the diagnosis. Use of immunosuppressive therapy plus aspirin leads to an excellent neurologic outcome.
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Abstract
Vasculitis of the central nervous system (CNS) is classified as primary angiitis or as vasculitis secondary to a variety of diseases. A wide spectrum of clinical features may occur. A definite diagnosis is hampered by the difficulty in obtaining tissue for histology. Consequently, a diagnosis is frequently made on the basis of clinical presentation, brain magnetic resonance imaging, and cerebral angiography without pathologic confirmation. Recent experience shows that there are multiple other conditions that can mimic CNS vasculitis, many of which have different therapies. Most patients with CNS vasculitis should be treated aggressively with a combination of immunosuppressive medications. The prognosis is greatly improved with early recognition and therapy.
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Affiliation(s)
- Sterling G West
- Division of Rheumatology, University of Colorado Health Sciences Center, Denver 80262, USA.
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