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Guo A, Zhang Z, Dong GH, Su L, Gao C, Zhang M, Shi X, Wang H, Zhang X, Lu DH, Fu Y, Jing J, Shi FD, Tian DC. Cortical Microhemorrhage Presentation of Small Vessel Primary Angiitis of the Central Nervous System. Ann Neurol 2024; 96:194-203. [PMID: 38661030 DOI: 10.1002/ana.26940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/29/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Primary angiitis of the central nervous system (PACNS) is a rare vasculitis restricted to the brain, spinal cord, and leptomeninges. This study aimed to describe the imaging characteristics of patients with small vessel PACNS (SV-PACNS) using 7 T magnetic resonance imaging (MRI). METHODS This ongoing prospective observational cohort study included patients who met the Calabrese and Mallek criteria and underwent 7 T MRI scan. The MRI protocol includes T1-weighted magnetization-prepared rapid gradient echo imaging, T2 star weighted imaging, and susceptibility-weighted imaging. Two experienced readers independently reviewed the neuroimages. Clinical data were extracted from the electronic patient records. The findings were then applied to a cohort of patients with large vessel central nervous system (CNS) vasculitis. RESULTS We included 21 patients with SV-PACNS from December 2021 to November 2023. Of these, 12 (57.14%) had cerebral cortical microhemorrhages with atrophy. The pattern with microhemorrhages was described in detail based on the gradient echo sequence, leading to the identification of what we have termed the "coral-like sign." The onset age of patients with coral-like sign (33.83 ± 9.93 years) appeared younger than that of patients without coral-like sign (42.11 ± 14.18 years) (P = 0.131). Furthermore, the cerebral lesions in patients with cortical microhemorrhagic SV-PACNS showed greater propensity toward bilateral lesions (P = 0.03). The coral-like sign was not observed in patients with large vessel CNS vasculitis. INTERPRETATION The key characteristics of the coral-like sign represent cerebral cortical diffuse microhemorrhages with atrophy, which may be an important MRI pattern of SV-PACNS. ANN NEUROL 2024;96:194-203.
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Affiliation(s)
- Ai Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhe Zhang
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ge-Hong Dong
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Su
- Department of Neurology, Tianjin General Hospital, Tianjin, China
| | - Chenyang Gao
- Department of Neurology, Tianjin General Hospital, Tianjin, China
| | - Mengting Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Shi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huabing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinghu Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - De-Hong Lu
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Fu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu-Dong Shi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Tianjin General Hospital, Tianjin, China
| | - De-Cai Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Alkabie S, Gray MT, Lau JC, Barra L, Mandzia J, Zhang Q, Budhram A. Teaching NeuroImage: Unilateral Primary Angiitis of the CNS. Neurology 2024; 102:e208018. [PMID: 38175856 PMCID: PMC10834122 DOI: 10.1212/wnl.0000000000208018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/27/2023] [Indexed: 01/06/2024] Open
Abstract
A 48-year-old woman was referred with an 18-year history of focal-onset seizures. She also reported years-long slowly progressive right-sided weakness that was corroborated on examination. Repeated brain MRIs over 15 years showed multifocal left hemispheric T2 fluid-attenuated inversion recovery-hyperintense lesions with patchy enhancement and microhemorrhages, no diffusion restriction, and a left cerebellar infarct (Figure 1, A-F). Only 2 nonspecific white matter lesions were seen contralaterally, indicating largely unihemispheric disease. Differential diagnosis included unilateral primary angiitis of the CNS (PACNS), Rasmussen encephalitis, and myelin oligodendrocyte glycoprotein antibody-associated disease.1 Serum and CSF testing for autoimmune, infectious, and malignant etiologies and whole-body fluorodeoxyglucose-PET, whole-exome genetic sequencing, and MR vessel-wall imaging were nondiagnostic. Brain biopsy revealed vasculitis (Figure 2, A-F), and the patient was diagnosed with unilateral PACNS. Treatment with mycophenolate mofetil has been initiated. Unilateral PACNS is a rare unihemispheric disease characterized by an indolent course and seizures, recognition of which is critical to accurate diagnosis.1,2.
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Affiliation(s)
- Samir Alkabie
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
| | - Madison T Gray
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
| | - Jonathan C Lau
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
| | - Lillian Barra
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
| | - Jennifer Mandzia
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
| | - Qi Zhang
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
| | - Adrian Budhram
- From the Departments of Clinical Neurological Sciences (S.A., J.C.L., J.M., Q.Z., A.B.) and Pathology and Laboratory Medicine (M.T.G., Q.Z., A.B.), Western University, London Health Sciences Centre; and Division of Rheumatology, Department of Medicine (L.B.), Western University, St. Joseph's Health Care, London, Ontario, Canada
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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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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [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] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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