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Sheikh TS, Rozenberg A, Merhav G, Shifrin A, Stein P, Shelly S. Primary CNS vasculitis: insights into clinical, neuropathological, and neuroradiological characteristics. Front Neurol 2024; 15:1363985. [PMID: 38651108 PMCID: PMC11034515 DOI: 10.3389/fneur.2024.1363985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 02/26/2024] [Indexed: 04/25/2024] Open
Abstract
Background and objectives Primary CNS vasculitis (PCNSV) is a rare inflammatory disorder that affects the blood vessels of the central nervous system (CNS). We aimed to analyze the neurological presentations, clinical follow-up, and long-term outcomes of patients with primary central nervous system vasculitis. Methods We conducted a retrospective analysis of medical records to assess the neurological presentation, rate of remission, and functional status at the last follow-up in patients with primary central nervous system vasculitis seen in our center in the last 13 years (2010-2023). Results We identified five patients, whose median age at symptom onset was 31 years (range: 15-41 years), including four male individuals (80%) from Muslim Arab (n = 4) and Ashkenazi Jewish (n = 1) backgrounds. Symptoms persisted for a median of 36 weeks (range: 3 weeks to 4 years) before diagnosis, with one case exceeding 3 years. Follow-up lasted a median of 56 months (range: 20-161 months). Clinical symptoms varied, presenting unilateral weaknesses (n = 2), cognitive and gait abnormality (n = 1), headaches (n = 1), and epileptic seizures (n = 1). MRI scans revealed abnormalities in the basal ganglia, corona radiata, parietal, and frontal lobes, showing hemorrhage, vasogenic edema, restricted diffusion, and enhancement post-gadolinium. All patients reported progressive holocephalic headaches and cognitive changes with overall progressive symptoms. Initial neurological examinations revealed abnormalities in all patients and included one or more of the following: cognitive or visual impairment (n = 2), seizures (n = 1), and unilateral UMN signs (n = 2) at the initial neurological examination, all but one patient required walking aids including (cane 2, wheelchair, bedridden 1). Patients were stable (n = 2), deteriorated (n = 1), or improved (n = 2). Following treatment, two patients still required ambulatory aids, with one using a cane and the other using a wheelchair, while the remaining three did not require any ambulatory aids. Discussion The study on PCNSV highlights varied symptoms and diagnostic challenges, including delayed diagnosis and a spectrum of neurological issues from cognitive impairments to seizures. Brain biopsies showed lymphocytic infiltration, thrombi, and necrosis. Immunotherapy significantly improved clinical and radiological outcomes. Over 56 months of follow-up, outcomes varied from stability and deterioration to improvement.
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Affiliation(s)
| | - Ayal Rozenberg
- Department of Neurology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Goni Merhav
- Department of Neuropathology, Rambam Medical Center, Haifa, Israel
| | - Alla Shifrin
- Department of Neurology, Rambam Medical Center, Haifa, Israel
| | - Polina Stein
- Department of Neuropathology, Rambam Medical Center, Haifa, Israel
| | - Shahar Shelly
- Department of Neurology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Institute of Pathology, Rambam Medical Center, Haifa, Israel
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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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Kalashnikova LA, Anufriev PL, Konovalov RN, Dobrynina LA, Shabalina AA. [Pseudotumorous form of primary central nervous system vasculitis]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:141-147. [PMID: 38147394 DOI: 10.17116/jnevro2023123121141] [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: 12/27/2023]
Abstract
A 23-year-old female patient with primary vasculitis of the central nervous system simulating a brain tumor is described. The clinical picture was represented by migraine-like headaches, ataxia, transient numbness of the right leg, the lips, double vision, a slight decrease of cognitive functions. MRI of the brain revealed a tumor-like focus in the cerebellum, intensively accumulating contrast, containing micro-hemorrhages (SWI mode). Small single ischemic foci in the brain hemispheres and brain stem were also found. MR angiography (3T) did not found any pathology. Examination of the cerebrospinal fluid revealed a small cytosis (mainly T-lymphocytes) and a slight increase in protein. The results of the analysis of cerebrospinal fluid for syphilis, tuberculosis and the herpetic group of viruses were negative, type 1 oligoclonal synthesis was found. Blood tests for toxoplasmosis, antibodies to aquaporin, anti-neutrophil antibodies, markers of systemic inflammation were within normal limits. Different diagnoses were assumed: demyelinating disease, encephalitis, multiple encephalomyelitis, lymphoma. The diagnosis was established only by a brain biopsy - lymphocytic vasculitis was revealed. According to the immunohistochemical study, T-helpers predominated in the infiltrates. After pulse therapy with Metylprednisolon (1000 mg intravenously drip №. 5), the patient's condition almost returned to normal. It was recommended to take prednisolone per os (starting dose 60 mg) for 7 months.
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Liu L, Zhang L. Anaplastic pleomorphic xanthoastrocytoma misdiagnosed as cerebral sparganosis-identification of the "mirror image". Quant Imaging Med Surg 2021; 11:4479-4487. [PMID: 34604000 DOI: 10.21037/qims-20-1398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 05/19/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Luji Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lihong Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Suthiphosuwan S, Bharatha A, Hsu CCT, Lin AW, Maloney JA, Munoz DG, Palmer CA, Osborn AG. Tumefactive Primary Central Nervous System Vasculitis: Imaging Findings of a Rare and Underrecognized Neuroinflammatory Disease. AJNR Am J Neuroradiol 2020; 41:2075-2081. [PMID: 32883666 DOI: 10.3174/ajnr.a6736] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022]
Abstract
Primary central nervous system vasculitis (PCNSV) is a poorly understood neuroinflammatory disease of the CNS affecting the intracranial vasculature. Although PCNSV classically manifests as a multifocal beaded narrowing of the intracranial vessels, some patients may not have angiographic abnormalities. A rare subset of patients with PCNSV present with masslike brain lesions mimicking a neoplasm. In this article, we retrospectively review 10 biopsy-confirmed cases of tumefactive PCNSV (t-PCNSV). All cases of t-PCNSV in our series that underwent CTA or MRA were found to have normal large and medium-sized vessels. T-PCNSV had a variable MR imaging appearance with most cases showing cortical/subcortical enhancing masslike lesion (70%), often with microhemorrhages (80%). Diffusion restriction was absent in all lesions. In summary, normal vascular imaging does not exclude the diagnosis of t-PCNSV. Advanced imaging techniques including MR perfusion and MR spectroscopy failed to demonstrate specific findings for t-PCNSV but assisted in excluding neoplasm in the differential diagnosis. Biopsy remains mandatory for definitive diagnosis.
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Affiliation(s)
- S Suthiphosuwan
- From the Department of Medical Imaging (S.S., A.B., CC-T.H., A.W.L.)
| | - A Bharatha
- From the Department of Medical Imaging (S.S., A.B., CC-T.H., A.W.L.)
- Surgery (A.B.)
| | - C C-T Hsu
- From the Department of Medical Imaging (S.S., A.B., CC-T.H., A.W.L.)
- Department of Medical Imaging (CC-T.H.), Gold Coast University Hospital, Queensland, Australia
| | - A W Lin
- From the Department of Medical Imaging (S.S., A.B., CC-T.H., A.W.L.)
| | - J A Maloney
- Department of Radiology (J.A.M.), University of Colorado, Denver, Colorado
| | - D G Munoz
- Laboratory Medicine and Pathobiology (D.G.M.), University of Toronto, Toronto, Canada
| | | | - A G Osborn
- Radiology and Imaging Sciences (A.G.O.), University of Utah, Salt Lake City, Utah
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"When should primary angiitis of the central nervous system (PACNS) be suspected?": literature review and proposal of a preliminary screening algorithm. Neurol Sci 2020; 41:3135-3148. [PMID: 32776287 PMCID: PMC7567723 DOI: 10.1007/s10072-020-04583-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 07/05/2020] [Indexed: 12/03/2022]
Abstract
Background Primary angiitis of the CNS (PACNS) is a process causing variously combined neurological disturbances. Its rarity and kaleidoscopic presentation make it difficult to diagnose and even to suspect. Objective (1) To provide an up-to-date review on PACNS and (2) to create a preliminary screening algorithm based on clinical and radiological first-level data, useful to suspect PACNS and guide further investigations. Methods Review of PUBMED case series on PACNS, published from 2002 to 2017, collection of frequencies of clinical and neuroimaging features and calculation of median values. Classification of features as “major” or “minor” if frequency was higher or lower than median value. Combination of features in sets of criteria represented by all possible combinations of major and minor clinical and neuroradiological features. Application of criteria to published PACNS case reports and selection of the ones best identifying patients with definite PACNS. Results We reviewed 24 case series. “Major” clinical features were headache, stroke, cognitive impairment, focal neurological deficits; “minor” were seizures, altered consciousness, psychiatric disorders. “Major” neuroradiological features were multiple parenchymal lesions, parenchymal/meningeal contrast enhancement, magnetic resonance angiography vessel abnormalities, vessel wall enhancement; “minor” were parenchymal/subarachnoid hemorrhage, single parenchymal lesion. The selected sets of criteria able to identify all PACNS patients were (1) one clinical (major/minor) + one major neuroradiological feature; and (2) Two clinical (≥ 1 major) + one minor neuroradiological feature. Conclusion Our review provides a detailed clinical/neuroradiological picture of PACNS. The proposed algorithm should be regarded as a preliminary screening tool to move the first steps towards PACNS diagnosis that needs validation.
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Jin H, Qu Y, Guo ZN, Cui GZ, Zhang FL, Yang Y. Primary Angiitis of the Central Nervous System Mimicking Glioblastoma: A Case Report and Literature Review. Front Neurol 2019; 10:1208. [PMID: 31798527 PMCID: PMC6863980 DOI: 10.3389/fneur.2019.01208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/30/2019] [Indexed: 01/29/2023] Open
Abstract
Primary angiitis of the central nervous system (PACNS) is a rare disorder resulting in idiopathic inflammation affecting the parenchymal and leptomeningeal vessels confined to the central nervous system (CNS), of which a tumor-like mass lesion is an even rare subtype. We described a case of PACNS initially misdiagnosed as glioblastoma. The patient was a 35 year-old female with right-sided weakness and expressive dysphasia. Brain MRI showed a tumor-like lesion highly suggestive of glioblastoma, therefor surgical removal was done. After a resection and an exhaustive workup, PACNS was ultimately diagnosed. The case illustrates a type of imaging presentation of PACNS that is often misdiagnosed as high-grade glioma. Differentiation between tumor-like PACNS lesions and actual CNS tumors is challenging due to similar MR images. To avoid unnecessary surgical interventions, we summarized previously reported mass-forming PACNS cases in adults from January 1, 2000, to December 31, 2018 and the imaging characteristics of PACNS. Some less commonly used diagnostic methods such as MR spectroscopy may also help clinicians distinguish PACNS from its mimics.
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Affiliation(s)
- Hang Jin
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Yang Qu
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Zhen-Ni Guo
- Department of Neurology, Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
| | - Guo-Zhen Cui
- Department of Hepatology, Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Fu-Liang Zhang
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, Stroke Center, The First Hospital of Jilin University, Changchun, China.,Department of Neurology, Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
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Huang YJ, Zhang L, Mao Y, Nan GX. Ataxia as the main manifestation of tumor-like primary angiitis of the central nervous system: a case report and literature review. BMC Med Imaging 2019; 19:79. [PMID: 31615440 PMCID: PMC6794905 DOI: 10.1186/s12880-019-0382-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary angiitis of the central nervous system (PACNS) is a rare disease, and tumor-like primary angiitis of the central nervous system is even rarer. Histopathology is the gold standard for tumor-mimicking PACNS. However, pathological diagnosis is relatively limited due to fewer biopsy opportunities. CASE PRESENTATION A 68-year-old male presented with ataxia, and was diagnosed with tumor-like primary angiitis of the central nervous system. The patient underwent Intravenous drip glucocorticoid therapy (10 mg of dexamethasone, daily). After 10 days, the symptoms of the patient were completely relieved. Radiology revealed that the low density lesion in the right cerebellar hemisphere obviously narrowed. Cyclophosphamide therapy was not initiated. CONCLUSION It is crucial for clinicians to be aware of changes in radiology that indicate PACNS, since the diagnosis of tumor-like PACNS remains quite challenging. Glucocorticoid therapy is an effective therapy in this condition, and the prognosis can be favorable.
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Affiliation(s)
- Yu-Jing Huang
- Department of Neurology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, 130033, Jilin, China
| | - Li Zhang
- Department of Neurology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, 130033, Jilin, China
| | - Ying Mao
- Department of Neurology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, 130033, Jilin, China
| | - Guang-Xian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, Changchun, 130033, Jilin, China.
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Abstract
Angiitis of the central nervous system (ACNS) is a rather new disease entity that is defined as vascular inflammation limited to the central nervous system and was formally nominated in 1959. Etiologically, it can be divided into primary and secondary ACNS. However, the potential pathogenesis of ACNS remains unclear. The clinical presentation is variable, and there is no consensus concerning its diagnosis and management. Although the incidence is relatively low, ACNS is still a life-threatening condition. It is essential to get a comprehensive and updated understanding of the disease. In this paper, we reviewed the history, definition, classification, pathogenesis, and clinical manifestations of ACNS. In addition, we focused on the latest investigations and viewpoints regarding the diagnosis and treatment of ACNS.
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Affiliation(s)
- Cheng Wan
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Salvarani C, Brown RD, Christianson TJ, Huston J, Morris JM, Giannini C, Hunder GG. Primary central nervous system vasculitis mimicking brain tumor: Comprehensive analysis of 13 cases from a single institutional cohort of 191 cases. J Autoimmun 2019; 97:22-28. [DOI: 10.1016/j.jaut.2018.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
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Ronen JA, Nguyen A, Mueller JN, Lee H. Intracranial Atherosclerosis Versus Primary Angiitis of the Central Nervous System: a Case Report. Cureus 2018; 10:e3031. [PMID: 30254820 PMCID: PMC6150750 DOI: 10.7759/cureus.3031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Primary angiitis of the central nervous system (PACNS) is a rare disease with various clinical presentations. It is the preferred name for vasculitis that is confined to the central nervous system (CNS) and is often considered a diagnosis of exclusion in vascular or inflammatory CNS diseases. This case describes a 46-year-old right-handed female with a past medical history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type two (DM2), obesity, and hemorrhagic stroke who was transferred from an outside facility after a one-month hospitalization to be evaluated for CNS vasculitis. Emergency medical personnel who brought the patient to the receiving hospital endorsed dysarthria and fluctuating level of cognition. Before she was transferred, the patient underwent a series of computed tomography (CT) and magnetic resonance imaging and angiographies (MRI/MRA) as well as four-vessel angiography. The studies revealed multiple bilateral striatal and cortical infarcts, scattered narrowing and occlusion of major cerebral vasculature, as well as other signs initially more suggestive of intracranial atherosclerosis than CNS vasculitis. Before she was transferred, imaging demonstrated a new cortical stroke. Hypercoagulable studies were positive for protein C deficiency although ensuing echocardiograms with normal ejection fractions were negative for a source of cardioembolism. Having undergone extensive rheumatological, radiological, and neurosurgical evaluation in the receiving facility, recommendations were made for the patient to undergo leptomeningeal biopsy to confirm the diagnosis of vasculopathy and to specifically rule out intracranial atherosclerosis and reversible cerebral vasoconstriction syndrome (RCVS).
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Affiliation(s)
- Joshua A Ronen
- Internal Medicine, Texas Tech University Health Sciences Center of the Permian Basin, Odessa, USA
| | - Aileen Nguyen
- Internal Medicine Resident Physician, St. Mary's Medical Center, San Francisco, USA
| | - Jerrica N Mueller
- Internal Medicine Resident Physician, St. Agnes Medical Center, Fresno, USA
| | - Hyonju Lee
- Ross University School of Medicine, California Hospital Medical Center, Los Angeles, USA
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