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Sagnelli M, Alkabie S, Franceschi AM. 18F-FDG Brain PET/MRI in Granulomatous Primary Angiitis of the Central Nervous System. Clin Nucl Med 2024:00003072-990000000-01164. [PMID: 38861373 DOI: 10.1097/rlu.0000000000005334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
ABSTRACT An 18-year-old man presented with encephalopathy, headache, tremor, and left hemiparesis. 18F-FDG brain PET/MRI revealed pronounced hypometabolism in the right cerebral hemisphere corresponding to extensive T2/FLAIR signal abnormality, with accompanying miliary enhancement and microhemorrhages in this region. The differential diagnosis favored an autoimmune or inflammatory origin, rather than an infectious or neoplastic etiology. Brain biopsy demonstrated nonnecrotizing granulomatous inflammation affecting the vessel walls, without evidence of glial neoplasm, lymphoma, or infection. Treatment with corticosteroids was subsequently initiated, with favorable clinical response.
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Affiliation(s)
- Matthew Sagnelli
- From the Neuroradiology Division, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Samir Alkabie
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Ana M Franceschi
- From the Neuroradiology Division, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
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Cheng Y, Zachariah J. Clinical Reasoning: A 54-Year-Old Woman With Progressive Headache and Neurologic Decline. Neurology 2024; 102:e209190. [PMID: 38330283 DOI: 10.1212/wnl.0000000000209190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/05/2024] [Indexed: 02/10/2024] Open
Abstract
A 54-year-old woman presented with headache and vasculopathy. She was treated for reversible cerebral vasoconstriction syndrome but continued to have clinicoradiographic decline with headache, seizures, systemic symptoms, and progression of vasculopathy on imaging. We present the diagnosis of a rare genetic disease with its various neurologic complications and systemic manifestations. Our case also illustrates the importance of differences in the metabolism of various antiseizure medications, recognition of which may avoid precipitating the disease.
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Affiliation(s)
- Yao Cheng
- From Corewell Health, Grand Rapids, MI
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Zedde M, Napoli M, Moratti C, Pezzella FR, Seiffge DJ, Tsivgoulis G, Caputi L, Salvarani C, Toni D, Valzania F, Pascarella R. The Hemorrhagic Side of Primary Angiitis of the Central Nervous System (PACNS). Biomedicines 2024; 12:459. [PMID: 38398061 PMCID: PMC10886751 DOI: 10.3390/biomedicines12020459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/29/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024] Open
Abstract
Primary Angiitis of the Central Nervous System (PACNS) is a rare cerebrovascular disease involving the arteries of the leptomeninges, brain and spinal cord. Its diagnosis can be challenging, and the current diagnostic criteria show several limitations. Among the clinical and neuroimaging manifestations of PACNS, intracranial bleeding, particularly intracerebral hemorrhage (ICH), is poorly described in the available literature, and it is considered infrequent. This review aims to summarize the available data addressing this issue with a dedicated focus on the clinical, neuroradiological and neuropathological perspectives. Moreover, the limitations of the actual data and the unanswered questions about hemorrhagic PACNS are addressed from a double point of view (PACNS subtyping and ICH etiology). Fewer than 20% of patients diagnosed as PACNS had an ICH during the course of the disease, and in cases where ICH was reported, it usually did not occur at presentation. As trigger factors, both sympathomimetic drugs and illicit drugs have been proposed, under the hypothesis of an inflammatory response due to vasoconstriction in the distal cerebral arteries. Most neuroradiological descriptions documented a lobar location, and both the large-vessel PACNS (LV-PACNS) and small-vessel PACNS (SV-PACNS) subtypes might be the underlying associated phenotypes. Surprisingly, amyloid beta deposition was not associated with ICH when histopathology was available. Moreover, PACNS is not explicitly included in the etiological classification of spontaneous ICH. This issue has received little attention in the past, and it could be addressed in future prospective studies.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (R.P.)
| | - Claudio Moratti
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (R.P.)
| | | | - David Julian Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Luigi Caputi
- Neurology Unit, Department of Cardio-Cerebrovascular Diseases, Maggiore Hospital ASST-Crema, 26013 Crema, Italy;
| | - Carlo Salvarani
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, University La Sapienza, 00189 Rome, Italy;
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (R.P.)
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Abstract
PURPOSE OF REVIEW Drug-induced vasculitis (DIV) is a rare form of vasculitis related to the use of various drugs. DIV primarily affects small to medium size vessels, but it can potentially involve vessels of any size. Differentiating between primary systemic vasculitis and DIV can be challenging; however, it is crucial, so that the offending agent can be discontinued promptly. RECENT FINDINGS The clinical phenotype of DIV is protean and depends on the size of the affected vessels. It ranges from arthralgias, to an isolated cutaneous rash, to severe single or multi-organ involvement. While withdrawal of the offending drug is the most important step in management, a significant number of patients require immunosuppressive therapy for varying periods of time. DIV can affect any vascular bed size, leading to protean vasculitic syndromes. Increased awareness among general practitioners, specialty, and subspecialty physicians is crucial for early recognition, and withdrawal of drug for better outcomes.
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Chen SP, Wang SJ. Pathophysiology of reversible cerebral vasoconstriction syndrome. J Biomed Sci 2022; 29:72. [PMID: 36127720 PMCID: PMC9489486 DOI: 10.1186/s12929-022-00857-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a complex neurovascular disorder being recognized during the past two decades. It is characterized by multiple abrupt severe headaches and widespread cerebral vasoconstrictions, with potential complications such as ischemic stroke, convexity subarachnoid hemorrhage, intracerebral hemorrhage and posterior reversible encephalopathy syndrome. The clinical features, imaging findings, and dynamic disease course have been delineated. However, the pathophysiology of RCVS remains elusive. Recent studies have had substantial progress in elucidating its pathogenesis. It is now believed that dysfunction of cerebral vascular tone and impairment of blood–brain barrier may play key roles in the pathophysiology of RCVS, which explains some of the clinical and radiological manifestations of RCVS. Some other potentially important elements include genetic predisposition, sympathetic overactivity, endothelial dysfunction, and oxidative stress, although the detailed molecular mechanisms are yet to be identified. In this review, we will summarize what have been revealed in the literature and elaborate how these factors could contribute to the pathophysiology of RCVS.
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Affiliation(s)
- Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 11217, Taiwan. .,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan. .,Brain Research Center & School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 11217, Taiwan. .,Brain Research Center & School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Lopez-Arevalo H, Romero Noboa ME, Joseph D, Edigin E, Arora S, Manadan A. Primary angiitis of the central nervous system and reversible cerebral vasoconstriction syndrome: analysis of the National Inpatient Sample. Clin Rheumatol 2022; 41:2467-2473. [PMID: 35411414 DOI: 10.1007/s10067-022-06172-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Primary angiitis of the central nervous system (PACNS) and reversible cerebral vasoconstriction syndrome (RCVS) are two rare syndromes that affect the cerebral vasculature. Both conditions have been shown to cause severe neurologic complications. Distinguishing these two conditions in clinical practice is often challenging. Here, we compare the clinical features and outcomes of RCVS and PACNS hospitalizations against the general adult inpatient population. MATERIALS AND METHODS We conducted a retrospective review of hospitalizations with a diagnosis of PACNS or RCVS from 2016 to 2018 in the National Inpatient Sample (NIS) database. Multivariate analysis was performed to calculate adjusted odds ratios (ORadj) for hospital outcomes. RESULTS In the NIS, 3305 hospitalizations had a diagnosis of RCVS and 6035 hospitalizations had a diagnosis of PACNS. RCVS hospitalizations had a significantly greater association with cerebral aneurysms (ORadj 23.80), hemiplegia/hemiparesis following subarachnoid hemorrhage (SAH) (ORadj 324.09), ischemic stroke (ORadj 7.59), and nontraumatic SAH (ORadj 253.61). PACNS hospitalizations had a significantly greater association with hemiplegia/hemiparesis following cerebrovascular accident (CVA) (ORadj 6.16), ischemic stroke (ORadj 11.55), nontraumatic SAH (ORadj 7.29), seizure (ORadj 2.49), and in-hospital mortality (ORadj 2.85). CONCLUSIONS We performed an analysis of the NIS to better understand RCVS and PACNS hospitalizations. Severe neurologic events including CVA and SAH were elevated in both, but SAH and related hemiplegia/hemiparesis were extremely common among RCVS hospitalizations. In-hospital mortality was elevated in PACNS but not RCVS. This information can be used to help clinicians better understand, distinguish, and diagnose these conditions. Key Points • Despite clear description of RCVS and PACNS in the medical literature, there remains a scarcity of national population-based studies comparing these two entities against the general adult inpatient population. • This study aims to fill knowledge gaps in this area. • Here, we compare the clinical features and outcomes of RCVS and PACNS hospitalizations against the general adult inpatient population.
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Affiliation(s)
- Hugo Lopez-Arevalo
- Department of Medicine, John H. Stroger Hospital of Cook County, 1950 W. Polk, Chicago, IL, 60612, USA.
| | - Maria Emilia Romero Noboa
- Department of Medicine, John H. Stroger Hospital of Cook County, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Dijo Joseph
- Division of Rheumatology, Rush University Medical Center, 1611 W. Harrison St., Suite 510, Chicago, IL, 60612, USA
| | - Ehizogie Edigin
- Department of Rheumatology, Loma Linda University Health, Loma Linda, CA, USA
| | - Shilpa Arora
- John H. Stroger Hospital of Cook County, 1950 W. Polk, 5th floor, Chicago, IL, 60612, USA
| | - Augustine Manadan
- Division of Rheumatology, Rush University Medical Center, 1611 W. Harrison St., Suite 510, Chicago, IL, 60612, USA
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Biscetti L, De Vanna G, Cresta E, Corbelli I, Gaetani L, Cupini L, Calabresi P, Sarchielli P. Headache and immunological/autoimmune disorders: a comprehensive review of available epidemiological evidence with insights on potential underlying mechanisms. J Neuroinflammation 2021; 18:259. [PMID: 34749743 PMCID: PMC8573865 DOI: 10.1186/s12974-021-02229-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 12/31/2022] Open
Abstract
Several lines of evidence support a role of the immune system in headache pathogenesis, with particular regard to migraine. Firstly, alterations in cytokine profile and in lymphocyte subsets have been reported in headache patients. Secondly, several genetic and environmental pathogenic factors seem to be frequently shared by headache and immunological/autoimmune diseases. Accordingly, immunological alterations in primary headaches, in particular in migraine, have been suggested to predispose some patients to the development of immunological and autoimmune diseases. On the other hand, pathogenic mechanisms underlying autoimmune disorders, in some cases, seem to favour the onset of headache. Therefore, an association between headache and immunological/autoimmune disorders has been thoroughly investigated in the last years. The knowledge of this possible association may have relevant implications in the clinical practice when deciding diagnostic and therapeutic approaches. The present review summarizes findings to date regarding the plausible relationship between headache and immunological/autoimmune disorders, starting from a description of immunological alteration of primary headaches, and moving onward to the evidence supporting a potential link between headache and each specific autoimmune/immunological disease.
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Affiliation(s)
- Leonardo Biscetti
- Istituto Nazionale di Riposo e Cura dell'Anziano a carattere scientifico, IRCSS- INRCA, Ancona, Italy
| | - Gioacchino De Vanna
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Elena Cresta
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Ilenia Corbelli
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Lorenzo Gaetani
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Letizia Cupini
- Headache Center, UOC Neurologia-Stroke Unit, Emergency Department, Ospedale S. Eugenio, Rome, Italy
| | - Paolo Calabresi
- Department of Neuroscience, Università Cattolica Sacro Cuore, Rome, Italy
| | - Paola Sarchielli
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
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Vo ML. Commonly Used Drugs for Medical Illness and the Nervous System. Continuum (Minneap Minn) 2020; 26:716-731. [DOI: 10.1212/con.0000000000000854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rocha EA, Topcuoglu MA, Silva GS, Singhal AB. RCVS 2 score and diagnostic approach for reversible cerebral vasoconstriction syndrome. Neurology 2019; 92:e639-e647. [PMID: 30635475 DOI: 10.1212/wnl.0000000000006917] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/14/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To develop a method to distinguish reversible cerebral vasoconstriction syndrome (RCVS) from other large/medium-vessel intracranial arteriopathies. METHODS We identified consecutive patients from our institutional databases admitted in 2013-2017 with newly diagnosed RCVS (n = 30) or non-RCVS arteriopathy (n = 80). Admission clinical and imaging features were compared. Multivariate logistic regression modeling was used to develop a discriminatory score. Score validity was tested in a separate cohort of patients with RCVS and its closest mimic, primary angiitis of the CNS (PACNS). In addition, key variables were used to develop a bedside approach to distinguish RCVS from non-RCVS arteriopathies. RESULTS The RCVS group had significantly more women, vasoconstrictive triggers, thunderclap headaches, normal brain imaging results, and better outcomes. Beta coefficients from the multivariate regression model yielding the best c-statistic (0.989) were used to develop the RCVS2 score (range -2 to +10; recurrent/single thunderclap headache; carotid artery involvement; vasoconstrictive trigger; sex; subarachnoid hemorrhage). Score ≥5 had 99% specificity and 90% sensitivity for diagnosing RCVS, and score ≤2 had 100% specificity and 85% sensitivity for excluding RCVS. Scores 3-4 had 86% specificity and 10% sensitivity for diagnosing RCVS. The score showed similar performance to distinguish RCVS from PACNS in the validation cohort. A clinical approach based on recurrent thunderclap headaches, trigger and normal brain scans, or convexity subarachnoid hemorrhage correctly diagnosed 25 of 37 patients with RCVS2 scores 3-4 across the derivation and validation cohorts. CONCLUSION RCVS can be accurately distinguished from other intracranial arteriopathies upon admission, using widely available clinical and imaging features. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that the RCVS2 score accurately distinguishes patients with RCVS from those with other intracranial arteriopathies.
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Affiliation(s)
- Eva A Rocha
- From the Department of Neurology (E.A.R., A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.R., G.S.S.), Universidade Federal de São Paulo, Brazil; Hospital Israelita Albert Einstein (G.S.S.), São Paulo, Brazil; and Department of Neurology (M.A.T.), Hacettepe University, Ankara, Turkey
| | - M Akif Topcuoglu
- From the Department of Neurology (E.A.R., A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.R., G.S.S.), Universidade Federal de São Paulo, Brazil; Hospital Israelita Albert Einstein (G.S.S.), São Paulo, Brazil; and Department of Neurology (M.A.T.), Hacettepe University, Ankara, Turkey
| | - Gisele S Silva
- From the Department of Neurology (E.A.R., A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.R., G.S.S.), Universidade Federal de São Paulo, Brazil; Hospital Israelita Albert Einstein (G.S.S.), São Paulo, Brazil; and Department of Neurology (M.A.T.), Hacettepe University, Ankara, Turkey
| | - Aneesh B Singhal
- From the Department of Neurology (E.A.R., A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.R., G.S.S.), Universidade Federal de São Paulo, Brazil; Hospital Israelita Albert Einstein (G.S.S.), São Paulo, Brazil; and Department of Neurology (M.A.T.), Hacettepe University, Ankara, Turkey.
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