Spinal cord MRI in neuro-Behçet's disease

Treatment of myelitis in Behçet's disease with rituximab

Behçet's disease (BD) is a chronic inflammatory disorder that involves the parenchymal central nervous system (neuro-BD, NBD) approximately in 5-49% of patients, causing lesions rarely located in the spinal cord (SC). We report the first case of NBD-myelitis treated with intravenous rituximab. A 41-year-old man affected by BD presented with mild paraparesis with a miliary involvement and a 'net-like' gadolinium enhancement (Gde) of the SC. After a therapeutic attempt with pulsed cyclophosphamide and intravenous methylprednisolone, the clinical and neuroradiological course worsened. A progressive improvement was observed after rituximab administration associated with low doses of oral prednisone. No disease activity was detected and the patient reported no adverse event. After six rituximab cycles, cervical MRI was normal while thoracic MRI showed a slight T2-weighted hyperintensity of D4-D10 spinal tract without Gde. A combined use of rituximab and oral steroids resulted in a long-term suppression of NBD activity without any safety concern.

Muscular involvement of Behçet's disease: ultrasonography, computed tomography, and magnetic resonance imaging findings

Behçet's disease (BD) is a form of systemic vasculitis with the classic triad of recurrent oral and genital ulcers along with uveitis. In BD, muscular involvement is very rare. We report a case of muscular involvement in BD with characteristic findings using ultrasonography, computed tomography, and magnetic resonance imaging.

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.

Clinical characteristics and course of spinal cord involvement in Behçet's disease

Parenchymal neurological involvement in Behçet's disease (p-NBD) usually presents with a brainstem syndrome; occasionally spinal cord may also be involved. Files of patients with Behçet's disease and spinal cord involvement were reviewed retrospectively, in comparison with other types of p-NBD. Amongst 216 patients with p-NBD, 24 had spinal cord involvement (11%). Most commonly patients presented with sensory-motor symptoms, sphincter and/or sexual dysfunction evolving over days. Four of 10 patients showed single or multiple cervical and/or dorsal lesions on spinal MRI's and one showed dorsal atrophy. Although the clinical picture was variable, it tended to be severe; seven cases had primary progressive course, 11 cases had a secondary progressive course after initial attack(s), four had attacks with severe residual sequela and two had improvement after attacks. After a median follow-up period of 67 months, eight were independent and 14 were dead or dependent, whereas amongst the remaining patients with p-NBD, 113 patients were independent and 56 patients were dead or dependent (P < 0.05). Our study suggests that spinal cord involvement has even worse prognosis compared with other types of p-NBD. Therefore, recognition of spinal cord involvement in Behçet's patients should prompt early vigorous treatment.

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.

MRI findings of myositis in Behçet disease

We report the magnetic resonance imaging findings in a case of localized myositis in a 23-year-old man with long-standing Behçet disease.

Neuroimaging techniques in the diagnostic work-up of patients with the antiphospholipid syndrome

The detection of multisystemic involvement often leads to a correct diagnosis of the antiphospholipid syndrome (APS), even in cases with predominant neurologic manifestations. However, when central nervous system deficits are isolated and have a relapsing-remitting or a progressive course, other conditions must be carefully considered. In this context, the diagnostic accuracy of conventional magnetic resonance imaging (MRI) is hampered by its limited pathologic specificity, which is one of the reasons why no or only modest correlations have been found between the burden of MRI-visible lesions and other clinical or laboratory measures of disease severity in patients with APS. Neuroimaging techniques with a higher pathologic specificity than conventional MRI show promise in achieving diagnostic confidence earlier in the course of APS and in better monitoring the efficacy of therapeutic interventions.

MRI findings in neuro-behçet's disease

AIM

To evaluate the pattern and site of involvement in neuro-Behçet's disease (NBD).

MATERIALS AND METHODS

Twenty-one patients with NBD were evaluated. Using 1.5T magnetic resonance imaging (MRI), T1-weighted axial and sagittal images, gadolinium enhanced axial and coronal images and T2-weighted axial images were obtained.

RESULTS

The brainstem, basal ganglia, cerebral white matter, internal capsule, thalamus and spinal cord were involved in eighteen, nine, nine, seven, six and two patients, respectively. In nine patients with cerebral white matter involvement, four had subcortical involvement and three had periventricular involvement, in addition to two patients with focal deep white matter lesions. Among the brainstem lesions, pons involvement was seen in fourteen patients, all had ventrally located lesions, and nine had tegmental involvement. Midbrain involvement was seen in fourteen patients; the cerebral peduncle was involved in 11 of these. Five patients had brainstem atrophy: two cases were demonstrated at initial MRI, the other three cases were seen on follow-up MRI. Pyramidal signs, the most common neurological signs, were demonstrated in fourteen patients. Follow-up MRI was obtained 10 days to 20 months after the initial MRI in eight cases; all showed changes in size, shape and site of involvement. After gadolinium enhancement, thirteen patients demonstrated mottled non-confluent enhancement in the brainstem (eight patients), posterior limb of the internal capsule (three patients), pachymeninges (two patients) and spinal cord (two patients).

CONCLUSION

NBD manifests a reversible course, but chronic NBD may result in brainstem atrophy. Characteristic involvement along the corticospinal tract is well correlated with neurological signs.

Cervical cord magnetic resonance imaging findings in systemic immune-mediated diseases

Brain magnetic resonance imaging (MRI) findings in patients with systemic immune-mediated diseases (SID) affecting the central nervous system (CNS) are heterogeneous and lack diagnostic specificity. In the present study, we evaluated the potential role of cervical cord MRI for increasing confidence when making a diagnosis of SID. Sagittal, T2-weighted images of the cervical cord were obtained in patients affected by systemic lupus erythematosus (SLE) with (NSLE, n=9) and without clinical CNS involvement (n=15), Behçet disease (BD, n=5), Wegener granulomatosis (WG, n=9), antiphospholipid antibody syndrome (APLAS, n=6) and multiple sclerosis (MS, n=10). Spinal cord hyperintense lesions were found in 9/10 MS patients, while no lesions were visible in the cervical cord of any patient with SID, regardless of the presence or absence of brain abnormalities. Cervical cord MRI can be useful in diagnosing patients suspected of having a SID.

Spinal cord Neurobehçet's disease detected on magnetic resonance imaging

Imaging studies in Neurobehçet's disease have to date focused on the brain, with only four previous case reports of documented spinal cord involvement on MRI being published. A fifth case is documented here, together with a review of the literature.