MRI findings in neuro-behçet's disease

[Imaging of non-traumatic and non-tumoral cord lesions]

There is a wide range of spinal cord pathologies (vascular, inflammatory, infectious, metabolic, degenerative). They present clinically as acute partial or complete cord syndromes, or chronic myelopathies (more than 4 weeks in duration). MRI examination should be undertaken with a very strict protocol. Spinal cord lesions should be evaluated with regards to their T1W and T2W signal characteristics, involvement of grey and/or white matter, axial and sagittal extension, cord volume changes, contrast uptake and associated lesions (perimedullary, radicular or brain). The correlation of MR imaging features with clinical and biological data (blood and CSF) should suggest a differential diagnosis.

Subacute longitudinal myelitis associated with Behcet's disease

In neuro-Behcet's disease (NBD), myelitis is a rare clinical form. We report the case of a woman with NBD presenting with unsteady gait and generalized spasticity. Spinal magnetic resonance imaging (MRI) showed multiple and confluent hyperintensities extending throughout the entire spinal cord on a T2-weighted image with some contrast enhancement. High-dose steroid therapy was so effective that the myelitis was markedly improved, as shown in the follow-up MRI. Longitudinal myelitis involving the entire spinal cord, as seen in our patient, has never been described before. This case suggests that NBD could be one of the important differential diagnoses of longitudinal myelitis.

Central tegmental tract lesion in a girl with holoprosencephaly presenting with West syndrome

We described a 16-month-old female patient who developed West syndrome at 3 months of age. MRI revealed a holoprosencephaly with incomplete fusion of the cerebrum, associated with central tegmental tract (CTT) lesions. At 1 year of age, the CTT lesion was still present on T2-weighted MRI. The CTT represents an important projection pathway of the extrapyramidal tract and the CTT lesions have rarely been reported using MRI in patients with neonatal hypoxic-ischemic encephalopathy and several inborn errors of metabolism. Although the exact mechanism remains obscure, we suggest that disturbances in midbrain fibers that connect to the basal ganglia, may have contributed to the etiology of West syndrome in this patient.

Cerebral infarct in pediatric neuro-Behçet's disease

Behçet's disease is a multisystem inflammatory vasculitic disorder with a chronic course for which the etiology is unknown. The central nervous system can be affected in 5% to 30% of all Behçet patients, yet it has been rarely reported in children or in Western countries. We describe a 14-year-old girl with Behçet's disease that presented initially as a cerebral infarct without venous sinus thrombosis.

[Acute meningoencephalitis revealing a Behçet's disease]

We report a 69-year-old man admitted in intensive care unit for aseptic meningoencephalitis. Initially, suspicion of an infectious etiology led to introduce an anti-infectious treatment. Behçet's disease was diagnosed during hospitalization incited to screen for noninfectious etiologies. A high dose steroid therapy was rapidly effective. The diagnosis of neuro-Behçet's disease was entertained.

[Longitudinally extensive spinal cord lesion in a case of Neuro-Behçet disease]

A 56-year-old right-handed man with recurrent orogenital aphtoid ulcers and bilateral uveitis had presented with memory disturbance, dressing apraxia and constructional apraxia at age 53. Neuro-Behçet disease was diagnosed based on pathergy test results and positivity for HLA-B51. Four months after azathioprine was introduced, he presented with subacute spastic paraparesis and urinary retention at age 56. Neurological examination demonstrated hyperreflexia in the lower limbs without pathological reflexes. He also showed memory disturbance, dressing apraxia and constructional apraxia. Spinal cord MRI showed a longitudinally extensive spinal cord lesion (LESCL) from C1 to Th3 with partial gadolinium enhancement from C6 to C8. Brain MRI showed moderate atrophy of the right temporal and parietal lobes without contrast enhanced lesion. There were hyperintense lesions in the pons, bilateral periventricular white matter and right parietal subcortical white matter. Cerebrospinal fluid analysis showed mild lymphocytic pleocytosis. After intravenous methylprednisolone treatment, clinical symptoms largely resolved and the abnormal intensities with contrast enhancement of the cord disappeared. However, higher cortical dysfunctions were not changed. LESCL may reflect inflammatory venous vasculitis with edema extending along the neural fibers since the lesion shows excellent responses to steroid without neurological sequelae. Differential diagnosis of neurological diseases demonstrating LESCL should include Neuro-Behçet disease.

Neuro-Behcet's disease mimicking multiple brain tumors: Diffusion-weighted MR study and literature review

A 47-year-old man with Behcet's disease presented with a five day history of right side weakness and dysarthria. Ten years ago, he was diagnosed as Behcet's disease. Since then, he was treated with low dose steroids. T1-weighted magnetic resonance images with gadolinium injection revealed ring enhancing lesions with internal hypointensities at the left side of the pons and at the left parietal cortex suggesting multiple metastatic tumors. Diffusion-weighted image and ADC map revealed central hyperintensity on diffusion with low ADC values at both lesions. The histopathology of stereotactic biopsy specimen showed frequent perivascular lymphocytic cuffings, focal necrotic lesions and reactive gliosis. The most common neuropathologic findings in neuro-Behcet's disease are focal necrotic lesions, but the location in cerebral cortex has not been reported before. Long term steroid therapy and antibiotics were administered and the patient recovered gradually. Neuro-Behcet's disease could be presented as brain tumor like lesion, and stereotactic biopsy should be considered in such situation.

Manifestations neurologiques de la maladie de Behçet

INTRODUCTION

Neurological involvement is well described in Behçet's Disease (BD), with variable prevalence of 5.3 to 30p.cent. The purpose of this retrospective study was to analyze the clinical patterns of neuro-Behçet (NB) and to compare them with different clinical features of 925 BD registered in the same period and the literature.

METHODS

All patients of NB fulfilled the International Study Group Criteria for the diagnosis of BD. 93 patients with headache, without other neurological symptoms were excluded. The findings were supported by cerebrospinal fluid, computed tomography scan, magnetic resonance imaging and angiography.

RESULTS

NB was present in 16.64p.cent of BD. A sex ratio male/female: 4.31. The mean age of patients with NB was 31.76 years. The average age of onset of NB was 29.83. The mean duration of the NB disease was 3.81 years. The findings were categorised in 2 main types: parenchymal and non-parenchymal involvement. Some patients had features of both types (mixed patterns). 94 patients (61.03p.cent) presented with parenchymal central nervous system (CNS) involvement. The most common findings were pyramidal signs, cranial nerve palsies, pseudobulbar syndrome and cerebellar signs. 27 patients (17.53p.cent) without parenchymal CNS which were divided into: intracranial hypertension in 24 patients (15.58p.cent) presenting headache, vomiting and bilateral papilloedema; cerebro-arterial involvement in 3 cases (one of them had cerebrovascular aneurysms). Mixed patterns were observed in 9 cases. Erythema nodosum and vascular involvement were more frequent in intracranial hypertension than in BD. Other clinical features were reported: pure meningeal pattern in 15 cases, pure peripheral nervous system involvement in 4 cases, isolated cranial nerves in 8 cases, chorea in one patient and pseudotumor of cervical medulla in other patient. 6 cases of juvenile BD and one case of familial Behçet were observed. 133 patients were treated (86.36p.cent). Mean duration of treatment was 7.46 month. We used corticosteroids, immunosuppressive agents (cyclophosphamid, azathioprine, chlorambucil) and anticoagulant in intracranial hypertension. The course of disease was good in only 54.13p.cent of cases, and was bad in 18.79p.cent.

CONCLUSION

NB occurred frequently in men and is more serious especially in parenchymal CNS involvement: 7 deaths (6 from parenchymal CNS).

MRI and the diagnosis of multiple sclerosis: expanding the concept of "no better explanation"

Although the diagnosis of multiple sclerosis relies on the demonstration of disease dissemination in space and time, the exclusion of other neurological disorders is also essential. The limited specificity of abnormalities disclosed by MRI may increase the likelihood of diagnosis of multiple sclerosis in patients affected by other disorders. The available criteria for diagnosis of multiple sclerosis have not taken advantage of the potential of MRI to detect features "not suggestive" of multiple sclerosis. Recognition of such features in the work-up of patients suspected of having multiple sclerosis may reduce the likelihood of a false positive diagnosis of the disorder in some, while suggesting the correct alternative diagnosis in other patients. On the basis of this, a workshop of the European MAGNIMS (Magnetic Resonance Network in Multiple Sclerosis) was held to define a series of MRI red flags in the setting of clinically suspected multiple sclerosis that is derived from evidence-based findings and educated guesses. The presence of such red flags should alert clinicians to reconsider the differential diagnosis more extensively. In this review we will report on the conclusions of this international consensus, which should represent a first step beyond the concept of "no better explanation", and inform future diagnostic criteria for multiple sclerosis.

CNS involvement occurs more frequently in patients with Behçet's disease under cyclosporin A (CSA) than under other medications—results of a retrospective analysis of 117 cases

The aim of this study was to evaluate the incidence of neurological manifestations of Behçet's disease (BD) in patients on cyclosporin A (CSA) compared with those on other medications. The records of 117 patients with BD who visited our hospital between 1990 and 2003 were reviewed with respect to symptoms and medication. All episodes of constant therapy prior to central nervous system (CNS) involvement were counted, and then the associations were analysed by the exact Fisher-Freeman-Halton test and adjusted for multiple tests by the Bonferroni-Holm method. We observed ten new cases of CNS manifestations in our patients with BD being regularly seen and treated in our tertiary care centre. The overall prevalence of neuro-BD in our patient group was 8.5%. In a retrospective analysis, the incidence of new-onset neurological disease (neuro-BD) in all patients with BD who regularly visited our hospital was significantly higher in patients on CSA than in those on other medications (6 of 21 vs 0 of 175 episodes, P<0.0001). This contrasts the obvious efficacy of CSA on extracerebral manifestations of BD, such as severe ocular disease, mucocutaneous lesions or arthritis. CSA exerts differential efficacy on various manifestations of BD. It is very effective for severe ocular and other moderate to severe manifestations of BD, but its efficacy for the prevention of neuro-BD seems to be inferior to that of other medications used in BD, such as azathioprine or interferon-alpha. The reasons for this are unclear, but the potential toxic effects of CSA on the CNS may be a predisposing factor for CNS vasculitis in BD.

Atteintes bilatérales des noyaux gris chez l’adulte

Several diseases may cause non-specific MR signal abnormalities of the bilateral basal ganglia and thalami. As such, diagnosis of the underlying etiology may be difficult to achieve at imaging. In this review, we will present interpretative guidelines based on clinical data (mode of presentation, previous history, clinical symptoms, and evolution) and imaging data (type of signal abnormalities, location of lesions, and associated abnormalities). The main categories of diseases causing MR signal abnormalities of the bilateral basal ganglia and thalami in adults are reviewed: toxic, metabolic, vascular, tumoral, infectious and inflammatory diseases.

Migraine and Cerebral White Matter Lesions

BACKGROUND

Patients with migraine are at an increased risk for white matter lesions, typically multiple, small, punctate hyperintensities in the deep or periventricular white matter, best observed on magnetic resonance imaging utilizing T2-weighted or FLAIR sequences. The underlying pathogenesis of white matter lesions in migraineurs is unknown, and the lesions are usually nonspecific and of unclear clinical significance.

REVIEW SUMMARY

Often the presence of white matter lesions causes uncertainty for physicians and anxiety for patients and may lead to a variety of diagnostic tests and treatments. Occasionally, white matter lesions may represent a secondary cause for headaches such as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). CADASIL is underrecognized and underdiagnosed; it should be suggested by (i) 1 or more of recurrent subcortical ischemic strokes (especially before age 60 and in the absence of vascular risk factors), migraine (especially with aura, including atypical or prolonged auras) and/or early cognitive decline or subcortical dementia; (ii) bilateral, multifocal, T2/FLAIR hyperintensities in the deep white matter and periventricular white matter with lesions involving the anterior temporal pole, external capsule, basal ganglia, and/or pons; and (iii) an autosomal-dominant family history of migraine, early-onset stroke, or dementia. The clinical spectrum of CADASIL is broad, and there is a poor genotype-phenotype correlation. In certain individuals or families, migraine may be the only clinical manifestation.

CONCLUSIONS

While the prevalence of nonspecific white matter lesions in migraineurs is increased, the white matter lesions may occasionally represent a secondary cause for headache such as CADASIL. Greater awareness of the unique clinical, neuroimaging, and pathologic features, as well as the availability of diagnostic genetic testing, should enhance the recognition and diagnosis of this fascinating condition.

Neuro-Behçet's disease--rapidly reversible with early diagnosis and treatment

Behçet's disease is an idiopathic multi-systemic, inflammatory disorder that may affect major organs, including the central nervous system. It is a clinical diagnosis, and a history of recurrent oral and genital ulcers should be elicited, especially in cases of unexplained uveitis with atypical neurological symptoms. We describe the rapid neurological recovery and neuroimaging changes following high-dose systemic corticosteroids in a 44-year-old man with recurrent oral ulcers, panuveitis, and acute neuro-Behçet's, presenting with meningoencephalitis. Early diagnosis with the aid of appropriate neuroimaging and immunosuppressive therapy prevented long-term neurological complications. Appropriate neuroimaging can facilitate early diagnosis and treatment, and provide prognostic information on neuro-Behçet's.

Prevalence and patterns of neurological involvement in Behcet's disease: a prospective study from Iraq

OBJECTIVES

To determine the prevalence of neurological involvement in Behcet's disease in a prospective study, and to describe the clinical patterns of neurological presentation in this disease in patients attending a multidisciplinary clinic in Baghdad.

METHODS

All patients attending the clinic who fulfilled the international study group criteria for the diagnosis of Behcet's disease were studied during a two year period starting in April 1999. Patients were assessed neurologically by a neuro-Behcetologist. All those with clinical neurological manifestations were sent for CSF examination, cranial magnetic resonance imaging, and magnetic resonance venography and were followed up to explore the patterns of neurological relapse.

RESULTS

140 patients with Behcet's disease were studied. Their mean age was 34.2 years (range 16 to 66); 105 (75%) were men and 35 (25%) were women. The mean duration of the disease was 4.2 years (range 0.4 to 26). Twenty patients (14%) had neurological involvement (neuro-Behcet's disease); 14 of these (70%) were men and six (30%) women. The mean age at the first neurological presentation was 34.1 years. The mean duration of follow up of patients with neuro-Behcet's disease was 20.7 months. Ten patients with neuro-Behcet's disease (50%) presented with parenchymal CNS involvement, six (30%) with intracranial hypertension, and four (20%) with a mixed pattern of both parenchymal CNS involvement and intracranial hypertension.

CONCLUSIONS

Careful neurological assessment of patients with Behcet's disease may show a relatively high prevalence of neuro-Behcet features, and though the clinical patterns of presentation are characteristic a mixed pattern may occur.