Cerebral vasculitis in Wegener's granulomatosis

High risk of pulmonary embolism and deep venous thrombosis but not of stroke in granulomatosis with polyangiitis (Wegener's)

OBJECTIVE

To assess the incidence of stroke, pulmonary embolism (PE), and deep venous thrombosis (DVT) in granulomatosis with polyangiitis (Wegener's) (GPA).

METHODS

Patients diagnosed with GPA at a Danish tertiary care center during 1993-2011 were identified (n = 180). Each patient was matched with 19 population controls (n = 3,420). Information on hospitalizations for stroke, PE, and DVT was obtained from the Danish National Hospital Register. The occurrence of vascular events in the GPA cohort was compared with that in the control group by calculation of incidence rate ratios (IRRs).

RESULTS

The median duration of followup was 7.2 years (interquartile range 3.1-11.7 years) in the GPA cohort. Within the first 2 years following the diagnosis of vasculitis, the incidences of PE and DVT were substantially increased among the patients (IRR 25.7 [95% confidence interval (95% CI) 6.9-96] for PE and IRR 20.2 [95% CI 5.1-81] for DVT). The incidence of stroke was not increased during this time interval (IRR 1.4 [95% CI 0.3-5.7]). From 2 years after GPA diagnosis, an increased incidence was found for DVT (IRR 4.5 [95% CI 1.7-11.8]) but not for PE (IRR 1.3 [95% CI 0.2-9.6]) or stroke (IRR 1.4 [95% CI 0.6-3.3]). In the GPA cohort, 70% of the vascular events occurred during phases with active vasculitis.

CONCLUSION

The present study confirms that GPA patients have a markedly increased risk of venous thromboembolism. We did not observe an increased risk of stroke in our cohort. Thus, our observations demonstrate a differential impact of GPA and/or its treatment on the risk of various vascular events.

Wegener Granulomatosis With Massive Intracerebral Hemorrhage

Wegener granulomatosis (WG) is a multisystem necrotizing vasculitis that primarily involves the upper and lower respiratory tract and kidneys but can affect almost any organ, including the central nervous system (CNS). We present a patient with WG whose disease was complicated by a massive intracerebral hemorrhage (ICH) despite standard treatment with prednisone and cyclophosphomide. Although CNS involvement is not uncommon in WG, ICH is a rare complication of WG, and although the majority of patients with WG complicated by a cerebrovascular accident have a fatal outcome, our patient survived this event. The disease subsequently progressed with recurrent pulmonary involvement and renal failure. Our patient either did not tolerate or failed to respond to several immunosuppressive agents, including cyclophosphamide, methotrexate, and mycophenolate mofetil, but achieved remission after treatment with rituximab.

A Patient With Wegener Granulomatosis and Intraventricular Hemorrhage

We report a case of intraventricular hemorrhage (IVH) in a 27-year-old man with Wegener granulomatosis (WG), successfully treated with corticosteroids and cyclophosphamide. Neurologic manifestations occur in 22%-54% of patients with WG, with cerebral vasculitis in less than 5%. Only 2 cases of IVH associated with WG have been reported at autopsy. This is the first reported case of in situ IVH associated with WG in a patient who survived. In patients with WG who present with neurologic manifestations, cerebral vasculitis with secondary intracranial hemorrhage should be considered, as these patients are often resistant to immunosuppressive therapies and may present with normal angiograms.

Central nervous system vasculitis in the intensive care unit

Intensivists are sometimes faced with unexplained neurologic defects in ICU patients. A subacute presentation over weeks or months characterized by headache and mental status change with focal deficits in the absence of evidence of secondary vasculitis or other diseases mentioned in the differential diagnosis should arouse suspicion of PACNS. Delay in diagnosis of this rare condition may lead to additional morbidity and prolong ICU stay. There is also a risk of permanent cognitive dysfunction with untreated PACNS. A reactive CSF picture, ischemic changes on MR imaging, and alterations in vessel caliber on cerebral angiography are not diagnostic but strengthen the evidence for PACNS. A brain biopsy may be required to confirm the diagnosis. High-dose steroid therapy with a prolonged course and gradual taper controls the disease in most cases. Additional immunosuppressive therapy is needed in some patients.

Retinocochleocerebral vasculopathy

We report 10 patients with retinocochleocerebral vasculopathy and review the clinical and diagnostic considerations in previously reported patients with this uncommonly recognized disease. The clinical manifestations include acute and subacute multifocal and diffuse encephalopathic symptoms, hearing loss, and visual loss attributable to microangiopathy affecting the arterioles of the brain, retina, and cochlea. Diagnosis is facilitated by demonstration of retinal arteriolar occlusions without uveitis or keratoconjunctivitis, mid- to low-frequency unilateral or bilateral sensorineural hearing loss, and numerous small foci of increased signal in the white and gray matter on T2 weighted brain magnetic resonance imaging. Because many conditions may produce any combination of strokelike cerebral symptoms, encephalopathy, hearing loss, and visual loss, the differential diagnosis for retinocochleocerebral vasculopathy includes connective tissue disease, demyelinating disease, procoagulant state, infection, neoplasm, and more routine mechanisms of cerebral and retinal ischemia. Brain biopsy specimens demonstrate only minimal nonspecific periarteriolar chronic inflammatory cell infiltration with or without microinfarcts. The demonstration of subclinical arteriolar microangiopathy in muscle biopsy specimens, documented in 3 of our patients may assist in making the diagnosis. The clinical course appears to be monophasic. In addition to corticosteroids, treatment options include immunosuppressant agents (cyclophosphamide or azathioprine) aspirin, calcium channel blockers (nimodipine), intravenous immunoglobulin, and plasmapheresis. The etiology of the disease is unknown, but histopathologic and laboratory evidence suggests that an immune-mediated mechanism may be involved.

Basilar artery occlusion in a young patient with Wegener's granulomatosis

BACKGROUND AND PURPOSE

Stroke is an uncommon sequela of Wegener's granulomatosis, resulting primarily from vasculitic infiltration of small to medium-sized vessels. We describe a young patient with Wegener's granulomatosis and basilar artery occlusion.

CASE DESCRIPTION

A 26-year-old man with histopathologically confirmed Wegener's granulomatosis suffered a brain stem stroke 24 hours after open lung biopsy. Angiography revealed midbasilar artery occlusion.

CONCLUSIONS

Patients with Wegener's granulomatosis may experience premature large cerebral vessel occlusion. Putative etiologies in our patient include vasculitis, postoperative hypercoagulability, and/or intraoperative neck positioning leading to embolization.

Neurological involvement in Wegener's granulomatosis: an analysis of 324 consecutive patients at the Mayo Clinic

Neurological involvement in Wegener's granulomatosis was studied by reviewing the charts of 324 consecutive patients in whom the diagnosis was made at the Mayo Clinic. One hundred nine patients (33.6%) had neurological involvement. Peripheral neuropathy occurred in 53; cranial neuropathy, in 21; external ophthalmoplegia, in 16; cerebrovascular events, in 13; seizures, in 10; cerebritis, in 5; and miscellaneous involvement, in 25. The mean age and sex ratio were similar in the patients with and those without neurological involvement. Among the patients with peripheral neuropathy, 42 had mononeuropathy multiplex; 6, distal symmetrical polyneuropathy; and 5, unclassified peripheral neuropathy. Multiple mononeuropathy was a major presenting symptom in 8 patients. A significantly higher percentage of patients with peripheral neuropathy, compared to those without peripheral neuropathy, had kidney involvement (p < 0.001). The second, sixth, and seventh cranial nerves were most frequently affected. Multiple cranial nerves were affected in 8 patients. Unusual neurological manifestations in the miscellaneous group were spastic paraparesis, temporal arteritis, Horner's syndrome, and papilledema.

Extensive cerebral infarction due to involvement of both anterior cerebral arteries by Wegener's granulomatosis

The central nervous system is often affected in Wegener's granulomatosis (WG), but massive cerebral infarction due to occlusion of branches of the anterior cerebral arteries (ACA) by granulomatous lesions or thrombosis, or both, has seldom been reported. A case is reported here of a 67 year old man with WG complicated by generalised necrotising vasculitis in the lung, kidney, and gastrointestinal tract, and cerebral infarction in the territory of both anterior cerebral arteries, probably caused by thrombosis and a contiguous invasion of granulomatous lesion from the nasal cavity.

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

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