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Amin M, Uchino K, Hajj-Ali RA. Central Nervous System Vasculitis: Primary Angiitis of the Central Nervous System and Central Nervous System Manifestations of Systemic Vasculitis. Rheum Dis Clin North Am 2023; 49:603-616. [PMID: 37331735 DOI: 10.1016/j.rdc.2023.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Central nervous system vasculitis (CNSV) is a group of disorders leading to inflammatory vasculopathy within the brain, spinal cord, and leptomeninges. CNSV is divided into primary angiitis of the central nervous system (PACNS) and secondary CNSV based on the underlying etiology. PACNS is a rare inflammatory disorder with poorly understood pathophysiology and heterogeneous and highly variable clinical features. The diagnosis depends on a combination of clinical and laboratory variables, multimodal imaging, and histopathological examination as well as exclusion of mimics. Several systemic vasculitides, infectious etiologies and connective tissue disorders have been shown to cause secondary CNSV and require prompt recognition.
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Affiliation(s)
- Moein Amin
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ken Uchino
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Rula A Hajj-Ali
- Cleveland Clinic Center for Vasculitis Care and Research, Cleveland Clinic, 9500 Euclid Avenue, A50, Cleveland, OH 44195, USA.
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Santos M, Roque R, Rainha Campos A, Albuquerque L, Pimentel J. Impact of brain biopsy on management of nonneoplastic brain disease. BRAIN AND SPINE 2022; 2:100863. [PMID: 36248174 PMCID: PMC9560663 DOI: 10.1016/j.bas.2022.100863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/09/2022] [Accepted: 01/16/2022] [Indexed: 11/09/2022]
Abstract
Introduction Diagnostic yield of brain biopsy in neoplastic brain disease is high and its clinical impact is well established. In nonneoplastic brain disease with negative conventional investigation, decision to undergo invasive procedures is difficult due to its inherent risk and known lower diagnostic yield. Research question: What is the clinical impact of brain biopsy results on management of nonneoplastic brain disease ? Material and methods A multidisciplinary team retrospectively reviewed and included all nonneoplastic brain disease cases submitted to biopsy between 2009 and 2019, in a tertiary hospital in Lisbon. Baseline characteristics were registered, including immunosuppression status, diagnostic workup, and treatment prior to biopsy. Diagnostic yield, clinical impact and in-hospital complication rates were assessed. Results Sixty-four patients were included, 20 (31.3%) of them immunosuppressed (15 HIV + patients). Thirty-five (67.7%) were previously treated with steroids or antiinfectious agents, with higher percentage (93.3%) in the immunosuppressed group. Biopsy results were diagnostic in 46 (71.9%) cases. More frequent diagnosis was infectious in 20 (31.2%), neoplastic in 12 (18.8%) and inflammatory diseases in 8 (12.5%). Brain biopsy resulted on impact on patient's clinical management in 56 (87.5%), of which 37(57.8%) were submitted to treatment change. In-hospital complications were registered in 4 (6.6%) patients. Discussion and conclusion Brain biopsy had clinical impact, including a change in treatment, in most patients studied, and may be considered a useful diagnostic option in nonneoplastic brain disease. However, associated complication rate is not negligible, and previous thorough workup, patient selection and risk-benefit assessment are important. In selected cases, diagnostic success of brain biopsy in nonneoplastic brain disease is high. Most diagnosis had a significant clinical impact on patient management. Although not neglectable, procedure-related complication rate was low.
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Mathon B, Le Joncour A, Bielle F, Mokhtari K, Boch AL, Peyre M, Amoura Z, Cacoub P, Younan N, Demeret S, Shotar E, Burrel S, Fekkar A, Robert J, Amelot A, Pineton de Chambrun M. Neurological diseases of unknown etiology: Brain-biopsy diagnostic yields and safety. Eur J Intern Med 2020; 80:78-85. [PMID: 32654880 DOI: 10.1016/j.ejim.2020.05.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/04/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND For nonneoplastic neurological diseases, no recommendation exists regarding the place or appropriate timing of brain biopsy. The aim of this study was to evaluate the diagnostic yield and safety of brain biopsies from patients with neurological diseases of unknown etiology. METHODS We performed a retrospective cohort study from January 1, 2008 to December 31, 2018. We analyzed 1847 brain-biopsied patients, including 178 biopsies indicated for neurological diseases of unknown etiology. Specific histological and final diagnosis rates, positive diagnosis-associated factors, complication rate and complication-associated factors were assessed. RESULTS Specific histological diagnosis and final diagnosis rates were 71.3% and 83.1%, respectively, leading to therapeutic management change(s) for 75.3% of patients. Brain- biopsy-related mortality and permanent neurological morbidity occurred in 1.1% and 0.6% of the patients, respectively. The multivariable logistic-regression model retained (odds ratio [95% CI] only immunodepression (2.2 [1.1-4.7]; P=.04) as being independently associated with specific histological diagnosis, while supratentorial biopsy-targeted lesions (4.1 [1.1-15.2]; P=.04) were independently associated with a final diagnosis. Biopsies obtained from comatose patients were less contributive to the diagnosis (0.2 [0.05-0.7]; P=.01). Prebiopsy platelet count <100 G/L (28.5 [1.8-447]; P=.02), hydrocephalus (6.3 [1.2-15.3]; P=.02) and targeted lesions <1 cm (4.3 [1.2-15.3]; P=.03) were independently associated with brain biopsy-related complications. CONCLUSION For highly selected patients with neurological diseases of unknown etiology, brain biopsy has a high diagnostic yield and low frequency of severe complications. We advocate that this procedure be considered early in the diagnosis algorithm of these patients.
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Affiliation(s)
- Bertrand Mathon
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France; Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; Institut du Cerveau et de la Moelle Epinière (ICM; INSERM, UMRS 1127; CNRS, UMR 7225), Paris, France.
| | - Alexandre Le Joncour
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Médecine Interne et d'Immunologie Clinique, F-75013, Paris, France
| | - Franck Bielle
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; Institut du Cerveau et de la Moelle Epinière (ICM; INSERM, UMRS 1127; CNRS, UMR 7225), Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuropathologie, F-75013, Paris, France
| | - Karima Mokhtari
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuropathologie, F-75013, Paris, France
| | - Anne-Laure Boch
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France
| | - Matthieu Peyre
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France; Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; Institut du Cerveau et de la Moelle Epinière (ICM; INSERM, UMRS 1127; CNRS, UMR 7225), Paris, France
| | - Zahir Amoura
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, F-75013, Paris, France
| | - Patrice Cacoub
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Médecine Interne et d'Immunologie Clinique, F-75013, Paris, France; INSERM, UMR_S 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; Département d'Inflammation-Immunopathologie-Biothérapie (DHU i2B), UMR 7211, Sorbonne Université, F-75005, Paris, France
| | - Nadia Younan
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuro-Oncologie, F-75013, Paris, France
| | - Sophie Demeret
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Département de neurologie, Unité de Médecine Intensive Réanimation Neurologique, F-75013, Paris, France
| | - Eimad Shotar
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neuroradiologie, F-75013, Paris, France
| | - Sonia Burrel
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Virologie, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), F-75013, Paris, France
| | - Arnaud Fekkar
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Parasitologie, F-75013, Paris, France
| | - Jérôme Robert
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Laboratoire de Bactériologie, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, and INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, F-75013, Paris, France
| | - Aymeric Amelot
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Service de Neurochirurgie, F-75013, Paris, France; Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, F-75013, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, F-75013, Paris, France
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Abstract
PURPOSE OF REVIEW Prion diseases are rapidly progressive neurodegenerative conditions that can be difficult to diagnose and are transmissible under specific circumstances. The authors will provide background regarding prion disease and focus on diagnostic tools. RECENT FINDINGS Prion disease is caused by misfolded prion protein. The three possible causes of prion disease include sporadic (85%), genetic (10-15%), and acquired (<1%). Acquired prion diseases include kuru, iatrogenic, and variant Creutzfeldt-Jakob disease. Prion diseases differ in their clinical manifestation, neuropathology, and diagnostic test results. A variety of recent diagnostic tools have evolved that allow more reliable antemortem diagnosis of prion disease such as brain MRI and cerebrospinal fluid real-time quaking-induced conversion. Special infectivity guidelines must be followed when dealing with central nervous system tissue, but only standard precautions are needed for routine clinical care of patients with prion disease. SUMMARY The only way to definitely diagnose prion disease and determine its type is via neuropathologic examination. However, brain MRI and cerebrospinal fluid real-time quaking-induced conversion have drastically increased diagnostic accuracy and are important tests to use when evaluating patients with suspected prion disease.
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Clinical Laboratory Tests Used To Aid in Diagnosis of Human Prion Disease. J Clin Microbiol 2019; 57:JCM.00769-19. [PMID: 31366689 DOI: 10.1128/jcm.00769-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Prion diseases are a group of rapidly progressive and always fatal neurodegenerative disorders caused by misfolded prion protein in the brain. Although autopsy remains the gold-standard diagnostic tool, antemortem laboratory testing can be performed to aid in the diagnosis of prion disease. This review is meant to help laboratory directors and physicians in their interpretation of test results. Laboratory assays to detect both nonspecific biomarkers of prion disease and prion-specific biomarkers can be used. The levels of nonspecific biomarkers in cerebrospinal fluid (CSF) are elevated when rapid neurodegeneration is occurring in the patient, and these markers include 14-3-3, tau, neuron-specific enolase, S100B, and alpha-synuclein. These markers have various sensitivities and specificities but are overall limited, as the levels of any of these analytes can be elevated in nonprion disease that is causing rapid damage of brain tissue. Prion-specific assays used in clinical laboratory testing are currently limited to two options. The first option is second-generation real-time quaking-induced conversion (RT-QuIC) performed on CSF, and the second option is Western blotting of a brain biopsy specimen used to detect protease-resistant prion protein. Although both tests have exquisite specificity, RT-QuIC has a sensitivity of 92 to 97.2% in symptomatic individuals, compared to the brain biopsy Western blot sensitivity of 20 to 60%. RT-QuIC was added to the Centers for Disease Control and Prevention's diagnostic criteria for prion disease in 2018. Other caveats of laboratory testing need to be considered, as sporadic, genetic, and acquired forms of prion disease have different clinical and laboratory presentations, and these caveats are discussed. Laboratory testing plays an important role in the diagnosis of prion disease, which is often challenging to diagnose.
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Noronha C, Figueiredo G, Pinheiro C, Carvalho E, Calheiros A, Pires MM, Taipa R. Brain biopsy in suspected non-neoplastic neurological disease. Acta Neurochir (Wien) 2019; 161:1139-1147. [PMID: 31016453 DOI: 10.1007/s00701-019-03910-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/10/2019] [Indexed: 12/18/2022]
Abstract
Brain biopsy has a well-established role in the diagnosis of CNS neoplasia. Nevertheless, despite being essential for the diagnosis of some benign neurological diseases, little consensus exists regarding its indications for disease diagnosis and patient orientation. Our aim was to assess brain biopsy diagnostic yield in patients with neurological deterioration of unknown etiology, to identify the clinical characteristics associated with an increased likelihood of achieving a diagnostic biopsy as well as the characteristics linked to a particular diagnosis. METHODS A retrospective analysis of 62 consecutive brain biopsies performed at a single tertiary care center between January 2004 and December 2015 for suspected non-neoplastic neurological disease was performed. The clinical presentation, imaging, and laboratory results were collected and compared between diagnostic groups. RESULTS Sixty-eight percent of the biopsies led to a definitive diagnosis. The most common histological diagnosis was central nervous system lymphoma (eight cases), followed by astrocytoma, demyelinating disease, and progressive multifocal leukoencephalopathy (four cases each). No clinical characteristics were found to predict a diagnostic biopsy or to correlate with a specific diagnosis. Importantly, a distinct diagnosis from the initially suspected was achieved in 52% of cases and biopsy findings led to a change of therapeutic orientation in 78% of the cases. CONCLUSIONS Our results suggest that brain biopsies have a significant impact on patient management and should be considered early in selected cases in which less invasive testing was unable to reach a definitive diagnosis.
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Affiliation(s)
- Carolina Noronha
- Neurosurgery Department, Hospital Santo Antonio, Centro Hospitalar e Universitario do Porto, Largo Prof Abel Salazar, Porto, 4099-001, Portugal.
- i3s Institute for Research and Innovation in Health, Universidade do Porto, Porto, Portugal.
| | - Gonçalo Figueiredo
- Neurosurgery Department, Hospital Santo Antonio, Centro Hospitalar e Universitario do Porto, Largo Prof Abel Salazar, Porto, 4099-001, Portugal
| | - Célia Pinheiro
- Neurosurgery Department, Hospital Santo Antonio, Centro Hospitalar e Universitario do Porto, Largo Prof Abel Salazar, Porto, 4099-001, Portugal
| | - Ernesto Carvalho
- Neurosurgery Department, Hospital Santo Antonio, Centro Hospitalar e Universitario do Porto, Largo Prof Abel Salazar, Porto, 4099-001, Portugal
| | - Alfredo Calheiros
- Neurosurgery Department, Hospital Santo Antonio, Centro Hospitalar e Universitario do Porto, Largo Prof Abel Salazar, Porto, 4099-001, Portugal
| | - Manuel Melo Pires
- Neuropathology Unit, Hospital de Santo Antonio, Centro Hospitalar e Universitario do Porto, Porto, Portugal
| | - Ricardo Taipa
- Neuropathology Unit, Hospital de Santo Antonio, Centro Hospitalar e Universitario do Porto, Porto, Portugal
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8
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Abstract
Neuroinfectious diseases continue to cause morbidity and mortality worldwide, with many emerging or reemerging infections resulting in neurologic sequelae. Careful clinical evaluation coupled with appropriate laboratory investigations still forms the bedrock for making the correct etiologic diagnosis and implementing appropriate management. The treating physician needs to understand the individual test characteristics of each of the many conventional candidate-based diagnostics: culture, pathogen-specific polymerase chain reaction, antigen, antibody tests, used to diagnose the whole array of neuroinvasive infections. In addition, there is a growing need for more comprehensive, agnostic testing modalities that can identify a diversity of infections with a single assay.
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Affiliation(s)
- Prashanth S Ramachandran
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, 675 Nelson Rising Lane, NS212A, Campus Box 3206, San Francisco, CA 94158, USA
| | - Michael R Wilson
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, 675 Nelson Rising Lane, NS212A, Campus Box 3206, San Francisco, CA 94158, USA.
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Brett FM, Looby S, Chalissery A, Chen D, Heaney C, Heffernan J, Cunningham F, Howley R, Loftus T, Kearney H, Farrell MA. Brain biopsies requiring Creutzfeldt-Jakob disease precautions in the Republic of Ireland 2005-2016. Ir J Med Sci 2017; 187:515-520. [PMID: 28803271 DOI: 10.1007/s11845-017-1673-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
AIMS Creutzfeldt-Jakob disease (CJD) risk precautions are required when performing brain biopsies on patients with a dementing illness and in 'risk' groups. The impact on a diagnostic neuropathology service is considerable. We sought to determine if better case selection might reduce the necessity for application of CJD risk precautions. METHODS We reviewed the clinical information, contributory investigations and final neuropathologic diagnosis in a cohort of patients (n = 21), referred to the National CJD Surveillance Centre between January 1, 2005, and December 31, 2016. RESULTS Of this 21-patient cohort, five were positive for CJD, four belonged to the 'at risk of CJD' category requiring brain surgery, while the remaining 12 were referred to the National CJD Surveillance Unit with CJD as part of their differential diagnosis. CJD was confirmed in 5/21 (three sporadic [s]CJD, one variant [v]CJD and one iatrogenic [i] CJD). CJD was clinically probable in 4/5 proven CJD patients (80%). The patients (n = 4) in the 'at risk of CJD' group were diagnosed with tumour (n = 2), inflammation (n = 1) and non-specific changes (n = 1). Of the remaining 12 patients (in whom CJD was included in the differential diagnosis), the final neuropathologic diagnoses included tumour (n = 2), neurodegenerative (n = 2), inflammatory (n = 1), metabolic (n = 2), vascular (n = 2) and non-specific gliosis (n = 3). CONCLUSIONS More often than not, the clinical suspicion of CJD was not borne out by the final neuropathological diagnosis. Failure by clinicians to adhere to the recommended CJD investigation algorithm impacts adversely on the neuropathology workload and causes unnecessary concern among operating theatre, laboratory and nursing personnel.
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Affiliation(s)
- F M Brett
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland.
| | - S Looby
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - A Chalissery
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - D Chen
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - C Heaney
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - J Heffernan
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - F Cunningham
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - R Howley
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - T Loftus
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - H Kearney
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - M A Farrell
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
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Rusina R, Netuka D, Johanidesová S, Smětáková M, Mouchová Z, Matěj R. Superficial bedside brain biopsy can be a safe and practical approach to confirm a rare form of prion disease in cerebellar ataxia: A case study. J Neurol Sci 2017; 375:73-75. [PMID: 28320192 DOI: 10.1016/j.jns.2017.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/20/2016] [Accepted: 01/15/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Robert Rusina
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University, General University Hospital in Prague, Czech Republic; Department of Neurology, Thomayer Hospital, Prague, Czech Republic.
| | - David Netuka
- Department of Neurosurgery, First Faculty of Medicine, Charles University, Military University Hospital in Prague, Czech Republic
| | | | - Magdalena Smětáková
- Department of Pathology and Molecular Medicine, Thomayer Hospital, Prague, Czech Republic
| | - Zuzana Mouchová
- Department of Pathology and Molecular Medicine, Thomayer Hospital, Prague, Czech Republic; Department of Pathology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Czech Republic
| | - Radoslav Matěj
- Department of Pathology and Molecular Medicine, Thomayer Hospital, Prague, Czech Republic; Department of Pathology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Czech Republic
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Long-term utility and complication profile of open craniotomy for biopsy in patients with idiopathic encephalitis. J Clin Neurosci 2016; 37:69-72. [PMID: 27979652 DOI: 10.1016/j.jocn.2016.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
Neurosurgeons are often asked to perform open biopsy for diagnosis of encephalitis after medical investigations are non-diagnostic. These patients may be critically ill with multiple comorbidities. Patients and their families often request data regarding the success rates and complication profile of biopsy, but minimal literature exists in this area. Retrospective chart review of all patients undergoing open brain biopsy (burr hole or craniotomy) for encephalitis refractory to medical diagnosis between January 2009 and December 2013 was undertaken. Pathology records and outpatient follow-up were reviewed to determine most recent clinical status of each patient. A total of 59 patients were included with mean follow up of 20months. The average age at biopsy was 55years. The most common unconfirmed diagnoses leading to biopsy were vasculitis (44%), neoplasm (27%), infection (12%), autoimmune (12%), amyloidosis (5%). Tissue pathology was diagnostic in 42% of all cases. Overall, biopsy confirmed the preoperative diagnosis in 46% of cases and refuted the preoperative leading diagnosis in 25% of cases. At last follow-up, the tissue pathology resulted in a medical treatment change in 25% of cases. There was a 14% major neurological complication rate (postoperative stroke, hemorrhage, or neurological deficit) and 9% cardiopulmonary complication rate (delayed extubation and re-intubation) attributable to surgical intervention. In this limited series, diagnostic utility of biopsy in patients with idiopathic encephalitis is less than 50% and the major complication rate is 23%. Patients and providers must be counseled accordingly and weigh the risks and benefits of open biopsy for encephalitis cautiously.
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Torres J, Loomis C, Cucchiara B, Smith M, Messé S. Diagnostic Yield and Safety of Brain Biopsy for Suspected Primary Central Nervous System Angiitis. Stroke 2016; 47:2127-9. [PMID: 27354225 DOI: 10.1161/strokeaha.116.013874] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The utility and safety of brain biopsy for suspected primary angiitis of the central nervous system (PACNS) are uncertain. Factors predictive of a positive biopsy have not been well described. Our aim was to evaluate the diagnostic yield and safety of brain biopsy in suspected PACNS and determine whether any prebiopsy variables are associated with a positive biopsy. METHODS This is a retrospective study of consecutive patients who underwent diagnostic brain biopsy for PACNS at a single institution. The relationship between biopsy yield and patient demographics, surgical technique, laboratory testing, neuroimaging, biopsy characteristics, and prebiopsy immunosuppressive therapy were examined. RESULTS PACNS was confirmed in 9 of 79 patients (11%). Biopsy identified alternative diagnoses in 24 patients (30%), with cerebral amyloid angiopathy (8 patients), encephalitis (5 patients), demyelination (3 patients), and CNS lymphoma (3 patients) most commonly found. There was no correlation between a positive biopsy and cerebrospinal fluid results, neuroimaging, surgical technique, biopsy characteristics, or preoperative immunosuppressive therapy. Smaller biopsies (P=0.02) and closed procedures (P=0.013) were less likely to yield a diagnosis. Postoperative complications occurred in 13 patients (16%), 3 (4%) of which were serious. CONCLUSIONS Brain biopsy leads to pathological confirmation of vasculitis in a minority of suspected PACNS cases but alternative diagnoses are often identified. Importantly, rare but meaningful complications may occur.
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Affiliation(s)
- Jose Torres
- From the Department of Neurology, NYU Langone Medical Center, NY (J.T.); Department of Neurology, Yale-New Haven Hospital, CT (C.L.); Department of Neurology (B.C.), Department of Neurosurgery (M.S.), and Department of Neurology (S.M.), University of Pennsylvania, Philadelphia, PA.
| | - Caitlin Loomis
- From the Department of Neurology, NYU Langone Medical Center, NY (J.T.); Department of Neurology, Yale-New Haven Hospital, CT (C.L.); Department of Neurology (B.C.), Department of Neurosurgery (M.S.), and Department of Neurology (S.M.), University of Pennsylvania, Philadelphia, PA
| | - Brett Cucchiara
- From the Department of Neurology, NYU Langone Medical Center, NY (J.T.); Department of Neurology, Yale-New Haven Hospital, CT (C.L.); Department of Neurology (B.C.), Department of Neurosurgery (M.S.), and Department of Neurology (S.M.), University of Pennsylvania, Philadelphia, PA
| | - Michelle Smith
- From the Department of Neurology, NYU Langone Medical Center, NY (J.T.); Department of Neurology, Yale-New Haven Hospital, CT (C.L.); Department of Neurology (B.C.), Department of Neurosurgery (M.S.), and Department of Neurology (S.M.), University of Pennsylvania, Philadelphia, PA
| | - Steven Messé
- From the Department of Neurology, NYU Langone Medical Center, NY (J.T.); Department of Neurology, Yale-New Haven Hospital, CT (C.L.); Department of Neurology (B.C.), Department of Neurosurgery (M.S.), and Department of Neurology (S.M.), University of Pennsylvania, Philadelphia, PA
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Bai HX, Zou Y, Lee AM, Lancaster E, Yang L. Diagnostic Value and Safety of Brain Biopsy in Patients With Cryptogenic Neurological Disease: A Systematic Review and Meta-analysis of 831 Cases. Neurosurgery 2016; 77:283-95; discussion 295. [PMID: 25856111 DOI: 10.1227/neu.0000000000000756] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The role of brain biopsy in patients with cryptogenic neurological disease is uncertain. OBJECTIVE To determine the risks and benefits of diagnostic brain biopsy for nonneoplastic indications in immunocompetent patients. METHODS Appropriate studies were identified by searching electronic databases. RESULTS We screened 3645 abstracts and included 20 studies with a total of 831 patients. Indications for biopsy were: (1a) severe neurological disease of unknown etiology in adults (n = 7) and (1b) in children (n = 2); (2) suspected primary angiitis of the central nervous system (PACNS) (n = 3); (3) chronic meningitis of unknown cause (n = 3); (4) atypical dementia (n = 4); and (5) nonneoplastic disease (n = 1). Diagnostic success rates calculated for subgroups were 51.3% (34.5-68.1) for 1a, 53.8% (42.9-64.5) for 1b, 74.7% (64.0-84.1) for 2, 30.3% (17.2-45.4) for 3, and 60.8% (41.2-78.8) for 4. Clinical impact rates were 30.5% (13.6-50.6) for 1a (n = 6), 67.1% (42.8-87.3) for 1b (n = 2), 8.3% (2.3-20.0) for 3 (n = 1), and 14.2% (6.5-24.3) for 4 (n = 2). Lymphoma (n = 32) and Creutzfeldt-Jakob disease (n = 30) were the most common diagnoses on the final histopathology reports of positive brain biopsies in 1a. In 1b, encephalitis (n = 7), PACNS (n = 6), and demyelination (n = 6) were the most common. The odds ratio for achieving a diagnostic biopsy when there was a radiological target was 3.70 (P = .014, 95% confidence interval, 1.31-10.42). CONCLUSION Brain biopsy in cryptogenic neurological disease was associated with the highest diagnostic yield in patients with suspected PACNS. The greatest clinical impact was seen in children with cryptogenic neurological disease. The presence of a radiological target was associated with a higher diagnostic yield.
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Affiliation(s)
- Harrison Xiao Bai
- ‡Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; §Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia; ¶Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Manix M, Kalakoti P, Henry M, Thakur J, Menger R, Guthikonda B, Nanda A. Creutzfeldt-Jakob disease: updated diagnostic criteria, treatment algorithm, and the utility of brain biopsy. Neurosurg Focus 2015; 39:E2. [DOI: 10.3171/2015.8.focus15328] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative condition with a rapid disease course and a mortality rate of 100%. Several forms of the disease have been described, and the most common is the sporadic type. The most challenging aspect of this disease is its diagnosis—the gold standard for definitive diagnosis is considered to be histopatho-logical confirmation—but newer tests are providing means for an antemortem diagnosis in ways less invasive than brain biopsy. Imaging studies, electroencephalography, and biomarkers are used in conjunction with the clinical picture to try to make the diagnosis of CJD without brain tissue samples, and all of these are reviewed in this article. The current diagnostic criteria are limited; test sensitivity and specificity varies with the genetics of the disease as well as the clinical stage. Physicians may be unsure of all diagnostic testing available, and may order outdated tests or prematurely request a brain biopsy when the diagnostic workup is incomplete. The authors review CJD, discuss the role of brain biopsy in this patient population, provide a diagnostic pathway for the patient presenting with rapidly progressive dementia, and propose newer diagnostic criteria.
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Ogura A, Moriyoshi H, Nakai N, Nishida S, Kitagawa S, Yoshida M, Yasuda T, Ito Y. [A case of amyloid-β-related cerebral angiitis with ApoE ε4/ε2 genotype]. Rinsho Shinkeigaku 2015; 55:561-566. [PMID: 26084230 DOI: 10.5692/clinicalneurol.cn-000685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 53-year-old male with a past medical history of hypertension and bipolar disorder gradually developed gait disturbance and cognitive dysfunction over half a year. His cranial MRI showed an area of hyperintensity in the right occipital lobe on T2 weighted images and the surface of the lesion was enhanced along the sulci. We diagnosed his condition as amyloid-β-related angiitis (ABRA) based on brain biopsy. Repeated, frequent seizures resistant to several antiepileptic drugs (AEDs) occurred after the operation. Steroid therapy was effective and the symptoms, including the intractable seizures and MRI abnormalities dramatically improved. In contrast to the common wild type ε3/ε3 ApoE genotype, a majority of ABRA patients have ε4/ε4. However, in this case the rare ε4/ε2 type was detected. The ε4 allele is considered to promote Aβ deposition on the vessel wall, and ε2 is speculated to trigger vessel ruptures or vascular inflammation. Although seizure is not a common complication of brain biopsy, it occurred repeatedly and responded poorly to AEDs in this case. Surgical stress in this patient with ε2 probably induced the uncontrolled seizures. ApoE genotype may be an effective and low-invasive marker in case of suspected ABRA and in predicting the risks of the complication from brain biopsy.
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Affiliation(s)
- Aya Ogura
- Department of Neurology, Stroke Center, TOYOTA Memorial Hospital
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Magaki S, Gardner T, Khanlou N, Yong WH, Salamon N, Vinters HV. Brain biopsy in neurologic decline of unknown etiology. Hum Pathol 2015; 46:499-506. [PMID: 25661242 PMCID: PMC4380782 DOI: 10.1016/j.humpath.2014.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 12/11/2014] [Accepted: 12/18/2014] [Indexed: 11/21/2022]
Abstract
Brain biopsies have an uncertain role in the diagnosis of patients with dementia or neurologic decline of unknown etiology. They are often performed only after an exhaustive panel of less invasive tests and procedures have failed to provide a definitive diagnosis. The objective of this study was to evaluate the sensitivity of brain biopsies in this patient group through the retrospective analysis of 53 brain biopsies performed for neurologic disease of unknown etiology at a single tertiary care institution between December 2001 and December 2011. Patients with known nonlymphomatous neoplasms thought to be associated with the neurologic symptoms or with immunodeficiency were excluded from the study. Furthermore, the clinical presentation, imaging and laboratory tests were compared between diagnostic groups to identify factors more likely to yield a diagnosis. Sixty percent of the biopsies were diagnostic (32 of 53), with the most common histologic diagnosis of central nervous system lymphoma in 14 of 53 patients (26% of total) followed by infarct in four subjects (7.5%). A few patients were found to have rare and unsuspected diseases such as lymphomatosis cerebri, neurosarcoidosis and neuroaxonal leukodystrophy. Complications from biopsy were uncommon and included hemorrhage and infection with abscess formation at the biopsy site. These results suggest that brain biopsies may be useful in difficult cases in which less invasive measures have been unable to yield a definitive diagnosis.
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Affiliation(s)
- Shino Magaki
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA.
| | - Tracie Gardner
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA
| | - Negar Khanlou
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA
| | - William H Yong
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA
| | - Noriko Salamon
- Department of Radiological Sciences, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA
| | - Harry V Vinters
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA; Department of Neurology, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA; Brain Research Institute, David Geffen School of Medicine at University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA 90095-1732, USA
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Hawasli AH, Buckley RT, Gao F, Limbrick DD, Smyth MD, Leonard JR, Santiago P, Stewart TJ, Park TS, Grubb RL, Dowling JL, Leuthardt EC, Rich KM, Zipfel GJ, Dacey RG, Chicoine MR. Biopsy of the superficial cortex: predictors of effectiveness and outcomes. Neurosurgery 2014; 73:224-31; discussion 231-2; quiz 232. [PMID: 23632761 DOI: 10.1227/01.neu.0000430310.63702.3e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Brain biopsies of superficial cortex are performed for diagnosis of neurological diseases, but preoperative predictors of successful diagnosis and risks are lacking. OBJECTIVE We evaluated effectiveness and outcomes of superficial cortical biopsies and determined preoperative predictors of diagnosis, outcomes, morbidities, and mortality. METHODS A single-institution retrospective analysis of 170 patients who underwent open brain biopsies of superficial cortex was performed. Clinical predictors of effectiveness and outcomes were determined using univariate/multivariate analyses and a system for risk-benefit stratification was created and tested. RESULTS Brain biopsies led to successful diagnosis in 122 of 170 (71.8%) and affected management in 97 of 170 (57.1%) cases. Factors increasing the odds of diagnostic pathology included age older than 45 years (odds ratio [OR]: 2.67, 95% confidence interval [CI]: 1.34-5.27, P < .01), previous cancer diagnosis (OR: 3.64, 95% CI: 1.69-7.85, P < .001), focal (OR: 3.90, 95% CI: 1.91-8.00, P < .001) and enhancing (OR: 5.03, 95% CI: 2.41-10.52, P < .001) lesions on magnetic resonance imaging, biopsy of specific lesions on magnetic resonance imaging (OR: 9.34, 95% CI: 4.29-20.33, P < .001), and use of intraoperative navigation (OR: 6.59, 95% CI: 3.04-14.28, P < .001). Brain biopsies led to symptomatic intracranial hemorrhage, seizures, other significant morbidities, and perioperative mortality in 12.4%, 16.2%, 37.1%, and 8% of cases, respectively. Risk of postoperative intracranial hemorrhage was increased by a history of aspirin use (OR: 2.51, 95% CI: 1.23-5.28, P < .05) and age older than 60 years (OR: 2.66, 95% CI: 1.36-5.18, P < .01). CONCLUSION Effectiveness and risk of morbidity/mortality can be estimated preoperatively for patients undergoing open brain biopsies of the superficial cortex. Older age and specific imaging characteristics increase the odds of diagnostic biopsy. Conversely, older age and aspirin use increases the risk of postoperative complications.
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Affiliation(s)
- Ammar H Hawasli
- Departments of Neurosurgery and Biostatistics, Washington University School of Medicine, St. Louis, Missouri
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Torres-Corzo J, Viñas-Rios JM, Sanchez-Aguilar M, Vecchia RRD, Chalita-Williams JC, Rangel-Castilla L. Transventricular Neuroendoscopic Exploration and Biopsy of the Basal Cisterns in Patients with Basal Meningitis and Hydrocephalus. World Neurosurg 2012; 77:762-71. [DOI: 10.1016/j.wneu.2011.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/07/2011] [Accepted: 08/12/2011] [Indexed: 10/15/2022]
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Gilkes CE, Love S, Hardie RJ, Edwards RJ, Scolding NJ, Rice CM. Brain biopsy in benign neurological disease. J Neurol 2012; 259:995-1000. [DOI: 10.1007/s00415-012-6455-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 01/29/2012] [Accepted: 01/31/2012] [Indexed: 11/29/2022]
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Rice CM, Gilkes CE, Teare E, Hardie RJ, Scolding NJ, Edwards RJ. Brain biopsy in cryptogenic neurological disease. Br J Neurosurg 2011; 25:614-20. [DOI: 10.3109/02688697.2010.551677] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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