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Relationship Between Vitamin D Status and Brain Perfusion in Neuropsychiatric Lupus. Nucl Med Mol Imaging 2022; 56:158-168. [DOI: 10.1007/s13139-022-00741-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/20/2022] [Accepted: 02/08/2022] [Indexed: 11/26/2022] Open
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Zhuo Z, Su L, Duan Y, Huang J, Qiu X, Haller S, Li H, Zeng X, Liu Y. Different patterns of cerebral perfusion in SLE patients with and without neuropsychiatric manifestations. Hum Brain Mapp 2019; 41:755-766. [PMID: 31650651 PMCID: PMC7268026 DOI: 10.1002/hbm.24837] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 11/06/2022] Open
Abstract
To investigate brain perfusion patterns in systemic lupus erythematosus (SLE) patients with and without neuropsychiatric systemic lupus erythematosus (NPSLE and non-NPSLE, respectively) and to identify biomarkers for the diagnosis of NPSLE using noninvasive three-dimensional (3D) arterial spin labeling (ASL). Thirty-one NPSLE and 24 non-NPSLE patients and 32 age- and sex-matched normal controls (NCs) were recruited. Three-dimensional ASL-MRI was applied to quantify cerebral perfusion. Whole brain, gray (GM) and white matter (WM), and voxel-based analysis (VBA) were performed to explore perfusion characteristics. Correlation analysis was performed to find the relationship between the perfusion measures, lesion volumes, and clinical variables. Receiver operating characteristic (ROC) analysis and support vector machine (SVM) classification were applied to differentiate NPSLE patients from non-NPSLE patients and healthy controls. Compared to NCs, NPSLE patients showed increased cerebral blood flow (CBF) within WM but decreased CBF within GM, while non-NPSLE patients showed increased CBF within both GM and WM. Compared to non-NPSLE patients, NPSLE patients showed significantly reduced CBF in the frontal gyrus, cerebellum, and corpus callosum. CBF within several brain regions such as cingulate and corpus callosum showed significant correlations with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the Systemic Lupus International Collaborating Clinics (SLICC) damage index scores. ROC analysis showed moderate performance in distinguishing NPSLE from non-NPSLE patients with AUCs > 0.7, while SVM analysis demonstrated that CBF within the corpus callosum achieved an accuracy of 83.6% in distinguishing NPSLE from non-NPSLE patients. Different brain perfusion patterns were observed between NPSLE and non-NPSLE patients. CBF measured by noninvasive 3D ASL could be a useful biomarker for the diagnosis and disease monitoring of NPSLE and non-NPSLE patients.
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Affiliation(s)
- Zhizheng Zhuo
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Li Su
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Huang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolu Qiu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sven Haller
- Department of Imaging and Medical Informatics, University Hospitals of Geneva and Faculty of Medicine of the University of Geneva, Geneva, Switzerland
| | - Haiyun Li
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Miyata M, Kakeda S, Kudo K, Iwata S, Tanaka Y, Wang Y, Korogi Y. Evaluation of oxygen extraction fraction in systemic lupus erythematosus patients using quantitative susceptibility mapping. J Cereb Blood Flow Metab 2019; 39:1648-1658. [PMID: 29547080 PMCID: PMC6681530 DOI: 10.1177/0271678x18764829] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purposes of this study are to assess the oxygen extraction fraction (OEF) changes on MRI-based quantitative susceptibility mapping (QSM) in systemic lupus erythematosus (SLE) patients and to determine whether QSM-OEF is associated with disease activity in SLE. We enrolled 42 SLE patients and 20 healthy subjects (HS) who had no pathologies on conventional brain MRI. Disease activity was assessed using SLE Disease Activity Index (SLEDAI). For the measurement of QSM-OEF, QSM data were analysed using the Perfusion Mismatch Analyzer software program. Spearman's or Pearson's correlation coefficients were calculated, and independent predictors were identified through a multiple linear regression analysis. QSM-OEF was significantly higher in SLE than that in HS (51.3 ± 10.1 vs. 40.5 ± 3.7, p < 0.001). QSM-OEF was positively correlated with SLEDAI and the presence of neuropsychiatric symptom (NPS) scores (ρ = 0.663, p < 0.001 and ρ = 0.340, p = 0.028). At multiple linear regression analysis, SLEDAI and NPS were independently associated with QSM-OEF (standardized β = 0.426, p = 0.016 and standardized β = 6.148, p = 0.029). In the SLE patients, QSM-OEF is associated with disease activity, which might predict an increased risk of stroke in SLE.
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Affiliation(s)
- Mari Miyata
- 1 Department of Radiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shingo Kakeda
- 1 Department of Radiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kohsuke Kudo
- 2 Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Shigeru Iwata
- 3 Department of the First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- 3 Department of the First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yi Wang
- 4 Departments of Biomedical Engineering and Radiology, Cornell University, MedImageMetric LLC, New York, NY, USA
| | - Yukunori Korogi
- 1 Department of Radiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Yoon S, Kang DH, Choi TY. Psychiatric Symptoms in Systemic Lupus Erythematosus: Diagnosis and Treatment. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.2.93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Seoyoung Yoon
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Hun Kang
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Tae Young Choi
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
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Rayes HA, Tani C, Kwan A, Marzouk S, Colosimo K, Medina-Rosas J, Mustafa A, Su J, Lambiris P, Mosca M, Touma Z. What is the prevalence of cognitive impairment in lupus and which instruments are used to measure it? A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 48:240-255. [DOI: 10.1016/j.semarthrit.2018.02.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 01/10/2018] [Accepted: 02/16/2018] [Indexed: 11/30/2022]
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6
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Kozora E, Filley CM, Erkan D, Uluğ AM, Vo A, Ramon G, Burleson A, Zimmerman RD, Lockshin MD. Longitudinal evaluation of diffusion tensor imaging and cognition in systemic lupus erythematosus. Lupus 2018; 27:1810-1818. [DOI: 10.1177/0961203318793215] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective This pilot study aimed to examine longitudinal changes in brain structure and function in patients with systemic lupus erythematosus (SLE) using diffusion tensor imaging (DTI) and neuropsychological testing. Methods Fifteen female SLE patients with no history of major neuropsychiatric (NP) manifestations had brain magnetic resonance imaging (MRI) with DTI at baseline and approximately 1.5 years later. At the same time points, a standardized battery of cognitive tests yielding a global cognitive impairment index (CII) was administered. At baseline, the SLE patients had mean age of 34.0 years (SD = 11.4), mean education of 14.9 years (SD = 2.1), and mean disease duration of 121.5 months (SD = 106.5). The MRI images were acquired with a 3T GE MRI scanner. A DTI sequence with 33 diffusion directions and b-value of 800 s/mm2 was used. Image acquisition time was about 10 minutes. Results No significant change in cognitive dysfunction (from the CII) was detected. Clinically evaluated MRI scans remained essentially unchanged, with 62% considered normal at both times, and the remainder showing white matter (WM) hyperintensities that remained stable or resolved. DTI showed decreased fractional anisotropy (FA) and increased mean diffusivity (MD) in bilateral cerebral WM and gray matter (GM) with no major change in NP status, medical symptoms, or medications over time. Lower FA was found in the following regions: left and right cerebral WM, and in GM areas including the parahippocampal gyrus, thalamus, precentral gyrus, postcentral gyrus, angular gyrus, parietal lobe, and cerebellum. Greater MD was found in the following regions: left and right cerebral WM, frontal cortex, left cerebral cortex, and the putamen. Conclusions This is the first longitudinal study of DTI and cognition in SLE, and results disclosed changes in both WM and GM without cognitive decline over an 18-month period. DTI abnormalities in our participants were not associated with emergent NP activity, medical decline, or medication changes, and the microstructural changes developed in the absence of macrostructural abnormalities on standard MRI. Microstructural changes may relate to ongoing inflammation, and the stability of cognitive function may be explained by medical treatment, the variability of NP progression in SLE, or the impact of cognitive reserve.
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Affiliation(s)
- E Kozora
- Department of Medicine, National Jewish Health, Denver, CO, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - C M Filley
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
- Marcus Institute for Brain Health, University of Colorado, Aurora, CO, USA
| | - D Erkan
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - A M Uluğ
- CorTechs Labs, San Diego, CA, USA
- Institute of Biomedical Engineering, Boğaziçi University, Istanbul, Turkey
| | - A Vo
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - G Ramon
- Hospital for Special Surgery, New York, NY, USA
| | - A Burleson
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL, USA
| | | | - M D Lockshin
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
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Sahebari M, Rezaieyazdi Z, Khodashahi M, Abbasi B, Ayatollahi F. Brain Single Photon Emission Computed Tomography Scan (SPECT) and functional MRI in Systemic Lupus Erythematosus Patients with Cognitive Dysfunction: A Systematic Review. ASIA OCEANIA JOURNAL OF NUCLEAR MEDICINE & BIOLOGY 2018; 6:97-107. [PMID: 29998142 PMCID: PMC6038975 DOI: 10.22038/aojnmb.2018.26381.1184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives Systemic lupus erythematosus (SLE) is an autoimmune disease with a wide range of clinical manifestations. Cognitive dysfunction is one of the manifestations that could present prior to the emergence of any other neuropsychiatric involvements in SLE. Cognitive dysfunction is a subtle condition occurring with a high frequency. However, there is no data on the correlation of cognitive dysfunction with central nervous system (CNS) imaging findings, in particular single-photon emission computed tomography scan (SPECT) and functional MRI. We decided to perform a systematic review of brain SPECT and fMRI in SLE patients with cognitive dysfunction. Methods PubMed, Scopus, and Google Scholar databases were searched until April 2017 with the following keywords: "SLE OR systemic lupus erythematous OR lupus" AND "functional MRI OR functional magnetic resonance imaging OR fMRI OR SPECT or SCAN". A total of 1,767articles were found. Two rheumatologists reviewed the articles and finally 14 articles were selected for the final systematic review. Results The fMRI and SPECT imaging techniques could provide valuable information regarding the SLE patients with cognitive dysfunction at the early stages of the disease. Conclusion Brain SPECT scan and fMRI are used as functional imaging tools in SLE. Both of these diagnostic modalities are sensitive in reflecting the subtle brain damages in SLE patients with cognitive dysfunction. Brain fMRI and SPECT scan could be significantly beneficial in the diagnosis and initial management of cognitive dysfunction in SLE. Nevertheless, prospective studies could be useful in confirming the application of these diagnostic modalities in the clinical setting.
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Affiliation(s)
- Maryam Sahebari
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Rezaieyazdi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mandana Khodashahi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fazlollah Ayatollahi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Hanly JG. Avoiding diagnostic pitfalls in neuropsychiatric lupus: the importance of attribution. Lupus 2017; 26:497-503. [DOI: 10.1177/0961203317690244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neuropsychiatric events in systemic lupus erythematosus patients may present a diagnostic and therapeutic challenge. Common and heterogeneous, their characterization and attribution to systemic lupus erythematosus and non-systemic lupus erythematosus is important and derived from clinical assessment, selection and interpretation of investigations. A standardized approach to assigning attribution has been used in recent studies. The current therapies are largely empiric, based upon known disease mechanisms and treatment of other serious organ disease in systemic lupus erythematosus. Further insight on the immunopathogenetic mechanisms and clinical outcome of neuropsychiatric systemic lupus erythematosus is required to inform the design and execution of therapeutic clinical trials.
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Affiliation(s)
- J G Hanly
- Division of Rheumatology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
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Lupus brain fog: a biologic perspective on cognitive impairment, depression, and fatigue in systemic lupus erythematosus. Immunol Res 2016; 63:26-37. [PMID: 26481913 DOI: 10.1007/s12026-015-8716-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Cognitive disturbances, mood disorders and fatigue are common in SLE patients with substantial adverse effects on function and quality of life. Attribution of these clinical findings to immune-mediated disturbances associated with SLE remains difficult and has compromised research efforts in these areas. Improved understanding of the role of the immune system in neurologic processes essential for cognition including synaptic plasticity, long term potentiation and adult neurogenesis suggests multiple potential mechanisms for altered central nervous system function associated with a chronic inflammatory illness such as SLE. This review will focus on the biology of cognition and neuroinflammation in normal circumstances and potential biologic mechanisms for cognitive impairment, depression and fatigue attributable to SLE.
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Tatsukawa H, Ishii K, Haranaka M, Kumagi M, Hino I, Yoshimatsu H. Evaluation of average amount of cerebral blood flow measured by brain perfusion index in patients with neuropsychiatric systemic lupus erythematosus. Lupus 2016; 14:445-9. [PMID: 16038108 DOI: 10.1191/0961203305lu2127oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We used the brain perfusion index (BPI), an indicator of the average amount of cerebral blood flow (CBF), to evaluate the usefulness of the average amount of CBF for neuropsychiatric systemic lupus erythematosus (NPSLE). Of the seventy three SLE patients examined in this study (total 100 scans), 16 patients (23 scans) had already been diagnosed with NPSLE based on clinical symptoms indicative of central nervous system involvement. In addition, 12 patients (17 scans) exhibited the antiphospholipid antibody syndrome (APS). BPI is significantly influenced by age and we therefore used the BPI ratio (ratio of age predicted BPI to measured BPI value) for each assessment. The mean BPI value of 100 scans was 11.2 + 2.79, and the mean BPI ratio was 0.99 + 0.24 in all SLE patients. The mean BPI ratio among NPSLE (0.84 + 0.19) was significantly lower than that of the non-NPSLE patients (1.04 + 0.24) (P, 0.0005). However, there was no difference in the mean BPI ratio between APS patients (0.98 + 0.24) and non-APS patients (0.99 + 0.25). These results indicate that the mean CBF assessed by the BPI ratio using SPECT is of use in the evaluation of central nervous system involvement in SLE patients.
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Affiliation(s)
- H Tatsukawa
- Department of Internal Medicine I, Faculty of Medicine, Oita University, Oita, Japan.
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Mikdashi JA, Esdaile JM, Alarcón GS, Crofford L, Fessler BJ, Shanberg L, Brunner H, Gall V, Kalden JR, Lockshin MD, Liang MH, Roberts N, Schneider M. Proposed response criteria for neurocognitive impairment in systemic lupus erythematosus clinical trials. Lupus 2016; 16:418-25. [PMID: 17664232 DOI: 10.1177/0961203307079044] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to identify reliable and valid instruments to measure cognitive impairment in systemic lupus erythematosus (SLE), and to define minimally important change of cognitive impairment in SLE for clinical trials. Neurocognitive measures used in randomized clinical trials in SLE were reviewed, and response criteria were developed using consensus expert opinion. The definition of cognitive impairment in the ACR nomenclature for neuropsychiatric lupus syndrome was adopted. Cognitive impairment is a deficit of 2.0 or more standard deviations (SD) below the mean, compared to normative data, in the key domains of attention, memory and psychomotor speed. Cognitive decline is defined as a deficit of 1.5—1.9 SD below the mean. Focal decline is defined if impairment exists in one or more measures within one domain, and multifocal decline if impairment exists on measures spanning two or more domains. The combination of ACR neuropsychological battery and the Cognitive Symptoms Inventory (CSI) is recommended to quantitate cognitive function. A clinically important response is defined as an improvement of ≥ 1.0 SD with an effect size of 1.0 in the key domains of the ACR neuropsychological testing, and an improvement of ≥ 1.0 SD with an effect size of 1.0 in functional performance of the CSI. Lupus (2007) 16, 418—425
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Massardo L, Bravo-Zehnder M, Calderón J, Flores P, Padilla O, Aguirre JM, Scoriels L, González A. Anti-N-methyl-D-aspartate receptor and anti-ribosomal-P autoantibodies contribute to cognitive dysfunction in systemic lupus erythematosus. Lupus 2014; 24:558-68. [DOI: 10.1177/0961203314555538] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 09/23/2014] [Indexed: 12/28/2022]
Abstract
Objective Autoantibodies against N-methyl-D-aspartate receptor (anti-NMDAR) and ribosomal-P (anti-P) antigens are potential pathogenic factors in the frequently observed diffuse brain dysfunctions in patients with systemic lupus erythematosus (SLE). Although studies have been conducted in this area, the role of anti-NMDAR antibodies in SLE cognitive dysfunction remains elusive. Moreover, the specific contribution of anti-P antibodies has not been reported yet. The present study attempts to clarify the contribution of anti-NMDAR and anti-P antibodies to cognitive dysfunction in SLE. Methods The Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to assess a wide range of cognitive function areas in 133 Chilean women with SLE. ANCOVA models included autoantibodies, patient and disease features. Results Cognitive deficit was found in 20%. Higher SLEDAI-2K scores were associated with impairment in spatial memory and learning abilities, whereas both anti-NMDAR and anti-P antibodies contributed to deficits in attention and spatial planning abilities, which reflect fronto-parietal cortex dysfunctions. Conclusions These results reveal an association of active disease together with specific circulating autoantibodies, such as anti-NMDAR and anti-P, with cognitive dysfunction in SLE patients.
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Affiliation(s)
- L Massardo
- Departamento de Inmunología Clínica y Reumatología, Facultad de Medicina
| | - M Bravo-Zehnder
- Departamento de Inmunología Clínica y Reumatología, Facultad de Medicina
- Centro de Envejecimiento y Regeneración, Departamento de Biología Celular y Molecular, Facultad de Ciencias Biológicas
| | | | | | - O Padilla
- Departamento de Salud Pública, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - L Scoriels
- Institute of Biomedical Sciences, Universidade Federal do Rio de Janeiro, Brazil
| | - A González
- Departamento de Inmunología Clínica y Reumatología, Facultad de Medicina
- Centro de Envejecimiento y Regeneración, Departamento de Biología Celular y Molecular, Facultad de Ciencias Biológicas
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Zardi EM, Taccone A, Marigliano B, Margiotta DP, Afeltra A. Neuropsychiatric systemic lupus erythematosus: Tools for the diagnosis. Autoimmun Rev 2014; 13:831-9. [DOI: 10.1016/j.autrev.2014.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/30/2014] [Indexed: 01/18/2023]
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Abstract
Nervous system involvement in systemic lupus erythematosus (SLE) can manifest as a range of neurological and psychiatric features, which are classified using the ACR case definitions for 19 neuropsychiatric syndromes. Approximately one-third of all neuropsychiatric syndromes in patients with SLE are primary manifestations of SLE-related autoimmunity, with seizure disorders, cerebrovascular disease, acute confusional state and neuropathy being the most common. Such primary neuropsychiatric SLE (NPSLE) events are a consequence either of microvasculopathy and thrombosis, or of autoantibodies and inflammatory mediators. Diagnosis of NPSLE requires the exclusion of other causes, and clinical assessment directs the selection of appropriate investigations. These investigations include measurement of autoantibodies, analysis of cerebrospinal fluid, electrophysiological studies, neuropsychological assessment and neuroimaging to evaluate brain structure and function. Treatment involves the management of comorbidities contributing to the neuropsychiatric event, use of symptomatic therapies, and more specific interventions with either anticoagulation or immunosuppressive agents, depending upon the primary immunopathogenetic mechanism. Although the prognosis is variable, studies suggest a more favourable outcome for primary NPSLE manifestations compared with neuropsychiatric events attributable to non-SLE causes.
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Abstract
The location of both autoimmune processes and other causes of brain inflammation is important in determining the impact of inflammation on brain function. This chapter focuses on autoimmune and infectious diseases leading to inflammatory brain disease resulting in cognitive defects with a special focus on systemic lupus erythematosus (SLE). Collectively called neuropsychiatric SLE (NPSLE), NPSLE occurs in 20-95% of pediatric patients with SLE (pSLE). The incidence of cognitive dysfunction is difficult to ascertain in pediatric patients as few studies have been performed. Using formal neurocognitive testing of unselected pediatric SLE patients, the rate of cognitive abnormalities was approximately 50% and impairment was associated with longer disease duration in one study. A second small study showed global depression on performance and academic scores while a larger study using a neuropsychiatric inventory showed a 55% rate of dysfunction. These diverging findings may result from the lack of a standardized cognitive assessment battery. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) group of pediatric rheumatologists proposed a 2 hour 40 minutes battery for assessment of cognitive testing of SLE patients from age 9 to 18 years. Further assessments using this battery should provide a better neurocognitive profile of pSLE.
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Wang PI, Cagnoli PC, McCune WJ, Schmidt-Wilcke T, Lowe SE, Graft CC, Gebarski SS, Chenevert TL, Khalatbari S, Myles JD, Watcharotone K, Cronin P, Sundgren PC. Perfusion-weighted MR imaging in cerebral lupus erythematosus. Acad Radiol 2012; 19:965-70. [PMID: 22608862 DOI: 10.1016/j.acra.2012.03.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 02/27/2012] [Accepted: 03/16/2012] [Indexed: 01/14/2023]
Abstract
RATIONALE AND OBJECTIVE Neuropsychiatric systemic lupus erythematosus (NPSLE) is a diagnostically challenging, severe, and life-threatening condition, which is currently lacking a "gold standard." Our aim with this study is to look for magnetic resonance (MR) perfusion differences in NPSLE, SLE, and healthy control (HC) patients and correlate our findings with clinical parameters. MATERIALS AND METHODS Twenty-four NPSLE patients, 21 SLE patients, and 21 HC underwent dynamic susceptibility contrast enhanced MR perfusion using a 3-T scanner. Nine prospectively selected intracranial regions of interest were placed in white and gray matter and the cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) values were calculated. Subjects underwent clinical evaluation with SLEDAI and serum antibodies. RESULTS The SLE patients had higher CBF and CBV compared to the HC overall (P = .01) and in specific areas (P = .03-.048). SLE patients with signs of active disease (elevated SLEDAI and anti-double-stranded DNA) had significantly elevated CBV, CBF, and MTT in the posterior cingulate gyrus (P = .01-.02). No significant difference was seen in the magnetic resonance perfusion measurements of NPSLE patients compared to SLE and HC, although the NPSLE patients also showed higher CBV variability compared to the SLE (P = .0004) and HC cohort (P < .0001). CONCLUSION SLE patients have increased CBV and CBF compared to healthy controls. The SLE patients with clinical markers for active disease have elevated CBV, CBF, and MTT in the posterior cingulate gyrus. NPSLE patients show increased variability in perfusion measurements, which may explain why susceptibility contrast enhanced MRI has not yet provided a specific target for NPSLE.
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Affiliation(s)
- Page I Wang
- Department of Diagnostic Radiology, University of Michigan Hospital, Ann Arbor, 48109-5030, USA.
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Gasparovic C, Qualls C, Greene ER, Sibbitt WL, Roldan CA. Blood pressure and vascular dysfunction underlie elevated cerebral blood flow in systemic lupus erythematosus. J Rheumatol 2012; 39:752-8. [PMID: 22247349 DOI: 10.3899/jrheum.110538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In previous studies cerebral blood flow (CBF) was found to be altered in patients with systemic lupus erythematosus (SLE) compared to controls. We investigated the relationships between CBF and clinical data from subjects with SLE with the aim of determining the pathologic factors underlying altered CBF in SLE. METHODS A total of 42 SLE subjects and 19 age- and sex-matched healthy control subjects were studied. Dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) was used to measure CBF. Patients and controls underwent complete clinical and laboratory evaluations in close proximity with their MRI studies. RESULTS A higher CBF was present in the SLE group and was independently associated in statistical models with higher systolic blood pressure (SBP; p < 0.01). The intensity of the relationships (slope of curve) between CBF and mean arterial blood pressure, diastolic blood pressure, or blood levels of tissue plasminogen activator in the SLE group was significantly blunted relative to the control group. CONCLUSION These findings are consistent with an underlying cerebral hyperperfusion in SLE induced by elevated but nonhypertensive levels of SBP. The factors underlying this relationship may be functional and/or structural (atherosclerotic, thrombotic, thromboembolic, or vasculitic) cerebrovascular disease.
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Affiliation(s)
- Charles Gasparovic
- Pete and Nancy Domenici Hall, University of New Mexico, 1101 Yale Blvd. NE, Albuquerque, NM 87106, USA.
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Mak A, Ren T, Fu EHY, Cheak AAC, Ho RCM. A prospective functional MRI study for executive function in patients with systemic lupus erythematosus without neuropsychiatric symptoms. Semin Arthritis Rheum 2012; 41:849-58. [PMID: 22221909 DOI: 10.1016/j.semarthrit.2011.11.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 11/21/2011] [Accepted: 11/24/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the functional brain activation signals before and after sufficient disease control in patients with systemic lupus erythematosus (SLE) without clinical neuropsychiatric symptoms. METHODS Blood-oxygen-level-dependent signals during event-related functional magnetic resonance imaging brain were recorded, while 14 new-onset SLE patients and 14 demographically and intelligence quotient matched healthy controls performed the computer-based Wisconsin card sorting test for assessing executive function, which probes strategic planning and goal-directed task performance during feedback evaluation (FE) and response selection (RS), respectively. Composite beta maps were constructed by a general linear model to identify regions of cortical activation. Blood-oxygen-level-dependent functional magnetic resonance imaging signals were compared between (1) new-onset SLE patients and healthy controls and (2) SLE patients before and after sufficient control of their disease activity. RESULTS During RS, SLE patients demonstrated significantly higher activation than healthy controls in both caudate bodies and Brodmann area (BA) 9 to enhance event anticipation, attention, and working memory, respectively, to compensate for the reduced activation during FE in BA6, 13, 24, and 32, which serve complex motor planning and decision-making, sensory integration, error detection, and conflict processing, respectively. Despite significant reduction of SLE activity, BA32 was activated during RS to compensate for reduced activation during FE in BA6, 9, 37, and 23/32, which serve motor planning, response inhibition and attention, color processing and word recognition, error detection, and conflict evaluation, respectively. CONCLUSIONS Even without clinically overt neuropsychiatric symptoms, SLE patients recruited additional pathways to execute goal-directed tasks to compensate for their reduced strategic planning skill despite clinically sufficient disease control.
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Affiliation(s)
- Anselm Mak
- Division of Rheumatology, Department of Medicine, University Medicine Cluster, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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19
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Kozora E, Filley CM, Zhang L, Brown MS, Miller DE, Arciniegas DB, Pelzman JL, West SG. Immune function and brain abnormalities in patients with systemic lupus erythematosus without overt neuropsychiatric manifestations. Lupus 2011; 21:402-11. [DOI: 10.1177/0961203311429116] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: This study examined the relationship between immune, cognitive and neuroimaging assessments in subjects with systemic lupus erythematosus (SLE) without histories of overt neuropsychiatric (NP) disorders. Methods: In total, 84 subjects with nonNPSLE and 37 healthy controls completed neuropsychological testing from the American College of Rheumatology SLE battery. Serum autoantibody and cytokine measures, volumetric magnetic resonance imaging, and magnetic resonance spectroscopy data were collected on a subset of subjects. Results: NonNPSLE subjects had lower scores on measures of visual/complex attention, visuomotor speed and verbal memory compared with controls. No clinically significant differences between nonNPSLE patients and controls were found on serum measures of lupus anticoagulant, anticardiolipin antibodies, beta 2-glycoproteins, or pro-inflammatory cytokines (interleukin (IL)-1, IL-6, interferon alpha (IFN-alpha), and interferon gamma (IFN-gamma)). Higher scores on a global cognitive impairment index and a memory impairment index were correlated with lower IFN-alpha. Few associations between immune functions and neuroimaging parameters were found. Conclusions: Results indicated that nonNPSLE patients demonstrated cognitive impairment but not immune differences compared with controls. In these subjects, who were relatively young and with mild disease, no relationship between cognitive dysfunction, immune parameters, or previously documented neuroimaging abnormalities were noted. Immune measures acquired from cerebrospinal fluid instead of serum may yield stronger associations.
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Affiliation(s)
- E Kozora
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - CM Filley
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - L Zhang
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - MS Brown
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - DE Miller
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - DB Arciniegas
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - JL Pelzman
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
| | - SG West
- National Jewish Health, Denver, Colorado, USA; 2Department of Neurology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 3Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 4Department of Radiology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; 5Department of Rheumatology, University of Colorado Denver School of Medicine, Denver, Colorado, USA; and 6Denver Veterans Affairs Medical Center, Denver, Colorado,
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Greene ER, Yonan KA, Sharrar JM, Sibbitt WL, Roldan CA. Middle cerebral artery resistivity and pulsatility indices in systemic lupus erythematosus: evidence for hyperperfusion. Lupus 2011; 21:380-5. [PMID: 22127458 DOI: 10.1177/0961203311428458] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Systemic lupus erythematosus (SLE) is associated with significant cerebrovascular and neuropsychiatric disease for which multiple pathogeneses have been proposed. Although global cerebral hypoperfusion has been proposed, there are limited data about intracerebral arterial hemodynamics. Transcranial Doppler (TCD) allows portable, high temporal and spatial resolution, noninvasive blood velocity measurements in the middle cerebral arteries, and calculations of standard resistivity (RI) and pulsatility (PI) indices. RI and PI correlate with cerebral hemispheric arteriolar tone, blood flow resistances, and impedances. Accordingly, we hypothesized that there would be significant differences (p < 0.05) in RI and PI between SLE patients and healthy, age and gender matched controls. METHODS TCD was used to measure RI and PI bilaterally on 34 stable SLE patients (35 ± 11 years) and 15 control subjects (34 ± 10 years). Patients and controls had similar, normal blood pressures and were examined in the supine position during normal, resting respiration. RI and PI were determined by a blinded, experienced observer. RESULTS There were no significant differences in RI and PI bilaterally within each cohort. However, SLE patients had significantly lower average RI and PI values compared with controls: 0.45 ± 0.10 versus 0.52 ± 0.05 (p < 0.05); and 0.65 ± 0.19 versus 0.77 ± 0.12, (p < 0.05); respectively. CONCLUSIONS These preliminary data suggest that RI and PI values in the human middle cerebral artery are significantly lower in SLE compared with controls. These indices indicate that middle cerebral arterial resistances and impedances are decreased in SLE. Under normotensive conditions, the results are consistent with hyperperfusion in SLE with increased arteriolar dilation and increased cerebral blood flow.
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Affiliation(s)
- E R Greene
- Department of Computer and Mathematical Sciences, New Mexico Highlands University, Las Vegas, New Mexico, USA.
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21
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Mackay M, Bussa MP, Aranow C, Uluğ AM, Volpe BT, Huerta PT, Argyelan M, Mandel A, Hirsch J, Diamond B, Eidelberg D. Differences in regional brain activation patterns assessed by functional magnetic resonance imaging in patients with systemic lupus erythematosus stratified by disease duration. Mol Med 2011; 17:1349-56. [PMID: 21953419 DOI: 10.2119/molmed.2011.00185] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 09/20/2011] [Indexed: 01/26/2023] Open
Abstract
The mediators of tissue damage in systemic lupus erythematosus (SLE) such as antibodies, cytokines and activated immune cells have direct access to most organs in the body but must penetrate the blood-brain barrier (BBB) to gain access to brain tissue. We hypothesized that compromise of the BBB occurs episodically such that the brain will acquire tissue damage slowly and not at the same rate as other organs. On the basis of these assumptions, we wished to determine if duration of disease correlated with brain injury, as measured with functional magnetic resonance imaging (fMRI), and if this was independent of degree of tissue damage in other organs. We investigated differences in brain activation patterns using fMRI in 13 SLE patients stratified by disease duration of ≤2 years (short-term [ST]) or ≥10 years (long-term [LT]). Two fMRI paradigms were selected to measure working memory and emotional response (fearful faces task). Performance in the working memory task was significantly better in the ST group for one and two shape recall; however, both groups did poorly with three shape recall. Imaging studies demonstrated significantly increased cortical activation in the ST group in regions associated with cognition during the two shape retention phase of the working memory task (P < 0.001) and increased amygdala (P < 0.05) and superior parietal (P < 0.01) activation in response to the fearful faces paradigm. In conclusion, analysis of activation patterns stratified by performance accuracy, differences in co-morbid disease, corticosteroid doses or disease activity suggests that these observed differences are attributable to SLE effects on the central nervous system exclusive of vascular disease or other confounding influences. Our hypothesis is further supported by the lack of correlation between regional brain abnormalities on fMRI and the Systemic Lupus International Collaborating Clinics (SLICC) damage index.
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Affiliation(s)
- Meggan Mackay
- Center for Autoimmune and Musculoskeletal Disease, The Feinstein Institute for Medical Research, Manhasset, New York, United States of America.
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22
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Systemic lupus erythematosus, the brain, and anti-NR2 antibodies. J Neurol 2011; 259:622-9. [DOI: 10.1007/s00415-011-6232-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 08/25/2011] [Indexed: 01/08/2023]
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Vogel A, Bhattacharya S, Larsen JL, Jacobsen S. Do subjective cognitive complaints correlate with cognitive impairment in systemic lupus erythematosus? A Danish outpatient study. Lupus 2011; 20:35-43. [PMID: 21233148 DOI: 10.1177/0961203310382430] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined the prevalence of cognitive impairment and its association with depressive symptoms and self-reported cognitive complaints in Danish outpatients with systemic lupus erythematosus (SLE). Fifty-seven consecutive female SLE-outpatients were examined with a comprehensive neuropsychological test-battery, a 20-item self-administered Perceived Deficits Questionnaire (PDQ) and a self-rated depression scale (Major Depression Inventory). Twenty-two patients (38.5%) were classified as cognitively impaired, mostly with deficits in executive functions and attention. Among cognitively impaired patients only 18.2% had significantly higher PDQ scores than the normal range. PDQ scores were highly correlated to depressive symptoms (r = 0.67, p < 0.001). Only two neuropsychological tests were significantly correlated with subjective cognitive complaints. When these variables and self-rated depression score were entered into a regression model both depression score and Symbol Digit Modalities Test performances were significantly associated with the PDQ score. In conclusion, cognitive impairments were common in this group of (mild) SLE outpatients, but the level of significant subjective cognitive complaints was low even among patients with cognitive impairment. Affective status may influence subjective experience of cognitive functions even more than cognitive functioning itself, and absence of subjective cognitive complaints did not exclude the presence of cognitive impairments.
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Affiliation(s)
- A Vogel
- Memory Disorders Research Group, Department of Neurology, Neuroscience Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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24
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Emmer BJ, van Osch MJ, Wu O, Steup-Beekman GM, Steens SC, Huizinga TW, van Buchem MA, van der Grond J. Perfusion MRI in neuro-psychiatric systemic lupus erthemathosus. J Magn Reson Imaging 2010; 32:283-8. [PMID: 20677252 DOI: 10.1002/jmri.22251] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To use perfusion weighted MR to quantify any perfusion abnormalities and to determine their contribution to neuropsychiatric (NP) involvement in systemic lupus erythematosus (SLE). MATERIALS AND METHODS We applied dynamic susceptibility contrast (DSC) perfusion MRI in 15 active NPSLE, 26 inactive NPSLE patients, and 11 control subjects. Cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) maps were reconstructed and regions of interest were compared between groups. In addition, the effect of SLE criteria, NPSLE syndromes, immunological coagulation disorder, and medication on CBF, CBV, and MTT was investigated. RESULTS No significant differences were found between the groups in CBF, CBV, and MTT. No significant influence of SLE criteria or NPSLE syndromes on CBF, CBV, or MTT was found. No significant influence of anti-cardiolipin antibodies, lupus anti-coagulant, the presence of anti-phospholipid syndrome (APS), or medication on CBF, CBV, or MTT was found. CONCLUSION Our findings suggest CBF, CBV, and MTT in the white and the gray matter in SLE patients is not significantly different from healthy controls or between patients with and without specific symptoms or with and without immunological disorder involving coagulation.
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Affiliation(s)
- Bart J Emmer
- Radiology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands.
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25
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Aranow C, Diamond B, Mackay M. Glutamate receptor biology and its clinical significance in neuropsychiatric systemic lupus erythematosus. Rheum Dis Clin North Am 2010; 36:187-201, x-xi. [PMID: 20202599 DOI: 10.1016/j.rdc.2009.12.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The recent appreciation that a subset of anti-DNA antibodies cross-reacts with the N-methyl-d-aspartate receptor encourages a renewed examination of antibrain reactivity in systemic lupus erythematosus (SLE) autoantibodies. Moreover, investigations of their autospecificity present a paradigm for studies of antibrain reactivity and show that (1) serum antibodies access brain tissue only after a compromise of blood-brain barrier integrity, (2) the same antibodies have differential effects on brain function depending on the region of brain exposed to the antibodies, and (3) insults to the blood-brain barrier are regional rather than diffuse. These studies suggest that an anatomic classification scheme for neuropsychiatric SLE may facilitate research on etiopathogenesis and the design of clinical trials.
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Affiliation(s)
- Cynthia Aranow
- Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
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26
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Gasparovic CM, Roldan CA, Sibbitt WL, Qualls CR, Mullins PG, Sharrar JM, Yamamoto JJ, Bockholt HJ. Elevated cerebral blood flow and volume in systemic lupus measured by dynamic susceptibility contrast magnetic resonance imaging. J Rheumatol 2010; 37:1834-43. [PMID: 20551095 DOI: 10.3899/jrheum.091276] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Studies that have examined abnormalities in cerebral blood flow (CBF) in patients with systemic lupus erythematosus (SLE) reported CBF relative to a region assumed to be normal in the brain. We examined the absolute differences in both regional CBF and cerebral blood volume (CBV) between patients with SLE and healthy controls. METHODS CBF and CBV were measured with dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI), a technique that provides an alternative to radionuclide perfusion studies and permits quantitative anatomic, CBF, and CBV imaging in a single scanning session. CBF and CBV were measured in lesions and in normal-appearing tissue in the major cerebral and subcortical brain regions. Unlike most perfusion studies in SLE, CBF and CBV values were not normalized to a region of the brain assumed to be healthy. RESULTS CBF and CBV within MRI-visible lesions were markedly reduced relative to surrounding normal-appearing white matter. CBF and CBV in normal-appearing tissue were both higher in SLE patient groups, with or without lesions, relative to the control group. CONCLUSION DSC MRI, without normalization to a region presumed to be healthy, revealed that CBF and CBV in normal-appearing tissue in patients with SLE was higher than CBF and CBV in controls. Since this finding was made in subgroups of patients with and without lesions, the higher CBF and CBV appear to precede lesion pathology.
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Affiliation(s)
- Charles M Gasparovic
- Department of Psychology, Divisions of Cardiology and Rheumatology, University of New Mexico, 1101 Yale Blvd. NE, Albuquerque, NM 87106, USA.
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Erkan D, Kozora E, Lockshin MD. Cognitive dysfunction and white matter abnormalities in antiphospholipid syndrome. ACTA ACUST UNITED AC 2010; 18:93-102. [PMID: 20472406 DOI: 10.1016/j.pathophys.2010.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 02/28/2010] [Accepted: 04/19/2010] [Indexed: 12/11/2022]
Abstract
Diagnosis of the antiphospholipid syndrome (APS) requires that a patient have both a clinical event (thrombosis or pregnancy loss) and persistently positive antiphospholipid antibodies (aPL). Although stroke and transient ischemic attack are the most common neurologic manifestations of APS, both cognitive dysfunction and magnetic resonance imaging (MRI) white matter hyperintensities can occur in aPL-positive patients (with or without APS). Relatively little is known about the cognitive pattern in aPL-positive patients; MRI white matter hyperintensities may be related to underlying attentional and executive cognitive impairment. Studies with sophisticated neuroimaging techniques aimed to better understand MRI white matter hyperintensities may eventually facilitate our understanding of cognitive dysfunction in aPL-positive patients.
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Affiliation(s)
- Doruk Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, United States; Hospital for Special Surgery, United States; Weill Medical College of Cornell University, United States
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Bertsias GK, Boumpas DT. Pathogenesis, diagnosis and management of neuropsychiatric SLE manifestations. Nat Rev Rheumatol 2010; 6:358-67. [PMID: 20458332 DOI: 10.1038/nrrheum.2010.62] [Citation(s) in RCA: 173] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neuropsychiatric events are common in patients with systemic lupus erythematosus (SLE), but less than one-third of these events can be directly attributed to SLE. Increased generalized SLE disease activity or damage, previous or concurrent major neuropsychiatric SLE (NPSLE) events, and persistently positive moderate-to-high antiphospholipid antibody titers are established risk factors, and their presence could facilitate proper attribution to the disease itself. Diagnostic evaluation is guided by the presenting manifestation; MRI is used to visualize brain or spinal pathologies. For neuropsychiatric events believed to reflect an immune or inflammatory process, or when these events occur in the context of active generalized disease, evidence (primarily from uncontrolled studies) supports the use of glucocorticoids alone or in combination with immunosuppressive therapy. Antiplatelet and/or anticoagulation therapy is recommended for NPSLE manifestations related to antiphospholipid antibodies, especially for thrombotic cerebrovascular disease. For the future, we anticipate that novel biomarkers and advanced neuroimaging tests will better define the underlying pathologic mechanisms of SLE-related neuropsychiatric disease, and help guide therapeutic decisions.
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Affiliation(s)
- George K Bertsias
- Division of Rheumatology, Clinical Immunology, and Allergy, Department of Internal Medicine, University of Crete School of Medicine, 1 Voutes Street, 71 003 Heraklion, Greece
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Neurocognitive impairment in children and adolescents with systemic lupus erythematosus. ACTA ACUST UNITED AC 2009; 5:106-14. [PMID: 19182817 DOI: 10.1038/ncprheum0988] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 12/04/2008] [Indexed: 11/08/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease, in which neuropsychiatric manifestations are a common cause of significant morbidity. The American College of Rheumatology has identified 19 distinct neuropsychiatric syndromes associated with SLE, although the 1982 American College of Rheumatology classification criteria for SLE recognize only two: seizures and psychosis. Neurocognitive impairment (NCI) is one of the most common and clinically challenging manifestations of SLE, but its pathophysiology remains poorly understood. This Review examines the epidemiology and pathophysiology of NCI in children and adolescents with SLE, as well as the diagnostic and therapeutic approaches that are available for these patients. As few published studies specifically address NCI in pediatric SLE, new directions for research are also discussed.
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Kozora E, Hanly JG, Lapteva L, Filley CM. Cognitive dysfunction in systemic lupus erythematosus: past, present, and future. ACTA ACUST UNITED AC 2009; 58:3286-98. [PMID: 18975345 DOI: 10.1002/art.23991] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Elizabeth Kozora
- National Jewish Medical and Research Center, Denver, Colorado 80206, USA.
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31
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Driver CB, Wallace DJ, Lee JC, Forbess CJ, Pourrabbani S, Minoshima S, Waxman AD, Weisman MH. Clinical validation of the watershed sign as a marker for neuropsychiatric systemic lupus erythematosus. ACTA ACUST UNITED AC 2008; 59:332-7. [PMID: 18311758 DOI: 10.1002/art.23308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To study the relationship between single-photon-emission computed tomography (SPECT) brain imaging and neuropsychiatric signs/symptoms in a cohort of patients with systemic lupus erythematosus (SLE), analyzed using a stereotactic surface projection (SSP) technique. METHODS Thirty-seven SLE patients were referred for 99mTc-ethyl cysteinate dimer SPECT brain imaging because of neuropsychiatric signs/symptoms. Nineteen normal controls were studied with the identical protocol. Reconstructed images were computed and Z scores were calculated using the SSP technique with the 2-sample t-tests comparing normal controls with SLE patients, and patients with mild cognitive dysfunction with those with severe cognitive dysfunction. The clinical characteristics of SLE patients were collected by retrospective chart review and categorized according to American College of Rheumatology case definitions for neuropsychiatric SLE. Cognitive dysfunction was rated by the treating physician on a scale of 0-3. RESULTS Thirty of 37 SLE patients had abnormal SPECT results. SLE patients had reduced perfusion in the watershed areas of the frontal lobes bilaterally compared with controls. Additionally, SLE patients with severe cognitive dysfunction had more severe perfusion deficits than those with mild cognitive dysfunction. In some patients with severe cognitive dysfunction, the watershed areas had Z scores > or =4 SDs below controls. CONCLUSION A convenience sample of patients with SLE and neuropsychiatric signs/symptoms demonstrated reduced perfusion in the watershed areas of the frontal lobes on SPECT scanning analyzed by the SSP technique. The severity of findings correlated with severity of cognitive dysfunction. The area of the brain affected is one that is susceptible to ischemia.
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Yoshida A, Shishido F, Kato K, Watanabe H, Seino O. Evaluation of cerebral perfusion in patients with neuropsychiatric systemic lupus erythematosus using 123I-IMP SPECT. Ann Nucl Med 2007; 21:151-8. [PMID: 17561586 DOI: 10.1007/s12149-006-0006-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In the course of systemic lupus erythematosus (SLE), central nervous system (CNS) complications occur at a high frequency. An accurate diagnosis of CNS lupus, differentiated from secondary CNS involvement, is difficult. CNS lupus is indicative of advancing primary disease and is treated by steroid pulse therapy or increased dosage of steroids. In contrast, if symptoms are caused by secondary CNS complications, it is possible to observe or treat these complications using symptomatic therapy. We examined whether quantitative cerebral blood flow (CBF) measured using cerebral perfusion single photon emission computed tomography (SPECT) can be used to differentiate CNS lupus from secondary CNS involvement. METHODS We divided 18 SLE patients with CNS symptoms into a CNS lupus group and a non-CNS lupus group, and then compared the mean cerebral blood flow (mCBF) of each group of patients. SPECT was performed with N-isopropyl-p-[123I] iodoamphetamine (IMP), with quantitation carried out by table look-up and autoradiographic methods. RESULTS The mCBF of both groups was decreased; however, the mCBF of patients with CNS lupus was significantly lower than that of non-CNS lupus patients. CONCLUSION Quantitative CBF may provide a useful tool to distinguish CNS lupus from non-CNS lupus.
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Affiliation(s)
- Atsuko Yoshida
- Department of Radiology, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima-city, Fukushima 960-1295, Japan.
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Stojanovich L, Zandman-Goddard G, Pavlovich S, Sikanich N. Psychiatric manifestations in systemic lupus erythematosus. Autoimmun Rev 2007; 6:421-6. [PMID: 17537389 DOI: 10.1016/j.autrev.2007.02.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 02/14/2007] [Indexed: 11/24/2022]
Abstract
Psychiatric abnormalities are common in systemic lupus erythematosus (SLE) with a prevalence of 17% to 75%, reflecting different methods of patient selection and assessment, the different professional orientation of clinicians, and lack of an accepted consensus for diagnosing active neuropsychiatric lupus (NPSLE). The psychiatric syndromes included in the ACR Neuropsychiatric Lupus Nomenclature Committee criteria are cognitive dysfunction, acute confusional state (delirium), anxiety disorder, mood disorder, and psychosis. In SLE patients, identification of psychiatric phenomena and the generation of a differential diagnosis are crucial. Possible mechanisms include vascular injury and pathogenic antibodies. Treatment strategies are based on small case studies. The purpose of this review is to discuss clinical manifestations, pathogenesis and the present therapeutic options in psychiatric lupus.
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Affiliation(s)
- Ljudmila Stojanovich
- Department of Internal Medicine, Bezhanijska Kosa University Medical Center, Belgrade University, Serbia and Montenegro.
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34
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Kowal C, Aranow C, Mackay M, Diamond B, Volpe BT. Systemic Lupus Erythematosus: Descriptive Past and Mechanistic Future. Neurobiol Dis 2007. [DOI: 10.1016/b978-012088592-3/50018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Bruns A, Meyer O. Neuropsychiatric manifestations of systemic lupus erythematosus. Joint Bone Spine 2006; 73:639-45. [PMID: 17064944 DOI: 10.1016/j.jbspin.2006.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Accepted: 05/03/2006] [Indexed: 11/15/2022]
Abstract
Central nervous system (CNS) involvement in systemic lupus erythematosus (SLE) can produce a broad range of disease-specific neuropsychiatric manifestations that must be differentiated from infections, metabolic complications, and drug-induced toxicity. Despite the development of classification criteria by the American College of Rheumatology, the prevalence of neuropsychiatric systemic lupus erythematosus (NPSLE) varies widely across studies. Some of the neuropsychiatric manifestations are extremely rare, indicating a need for multicenter studies. Mechanisms that can lead to neuropsychiatric manifestations include intracranial vascular lesions (vasculitis and thrombosis); production of autoantibodies to neuronal antigens, ribosomes, and phospholipids; and inflammation related to local cytokine production. As a rule, no reference standard is available for establishing the diagnosis of NPSLE. Several investigations can be used to assist in the clinical diagnosis and to evaluate severity. Treatment remains largely empirical, given the absence of controlled studies. Variable combinations of corticosteroids, immunosuppressants, and symptomatic drugs are used according to the presumptive main pathogenic mechanism.
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Affiliation(s)
- Alessandra Bruns
- Service de rhumatologie, hôpital Bichat, APHP, 46, rue Henri-Huchard, 75018 Paris, France
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Emori A, Matsushima E, Aihara O, Ohta K, Koike R, Miyasaka N, Kato M. Cognitive dysfunction in systemic lupus erythematosus. Psychiatry Clin Neurosci 2005; 59:584-9. [PMID: 16194262 DOI: 10.1111/j.1440-1819.2005.01418.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune-mediated collagen disease that results in multiorgan failure. It is the collagen disease most frequently associated with neuropsychiatric symptoms, which have been hypothesized to stem from certain types of cognitive dysfunction. Subjects were 21 patients with SLE (one man, 20 women; aged 16-55 years; mean age, 35.1+/-10.7 years) who were undergoing treatment in the rheumatology unit of a general hospital, and 17 healthy control subjects matched to the patient group with respect to age and gender (two men, 15 women; mean age, 35.9+/-6.3 years). They were administered various tests of cognitive function including verbal reasoning, non-verbal reasoning, verbal memory, non-verbal memory, attention and mental flexibility, psychomotor speed and frontal lobe function. In addition, the SLE patients were tested for antiphospholipid antibodies. The SLE patients performed worse than the control group on immediate, delayed and interference of the Rey verbal test and paired associate tests of Wechsler Memory Scale, and their reaction time was slower in Trail A and Trail B tests. Moreover, these findings were more pronounced in the group with major neuropsychiatric symptoms. However, no relationship was apparent between these deficits in cognitive function and the presence or absence of antiphospholipid antibodies. The results suggest that verbal memory and psychomotor speed underlie the neuropsychiatric symptoms seen in SLE patients.
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Affiliation(s)
- Asako Emori
- Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan
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Abstract
Nervous system disease in patients who have systemic lupus erythematosus (SLE) spans a wide spectrum of neurologic (N) and psychiatric (P) features that may be attributed to a primary manifestation of SLE, complications of the disease or its therapy, or a coincidental disease process. The etiology of primary NP disease is multifactorial and includes vascular injury of intracranial vessels, autoantibodies to neuronal antigens, ribosomes and phospholipid-associated proteins, and the intracranial generation of cytokines. In the absence of a diagnostic gold standard for most of the NP-SLE syndromes, a range of investigations are employed to support the clinical diagnosis and determine the severity of NP disease. Treatment remains largely empiric in the absence of controlled studies, and current strategies include the use of immunosuppressive therapies, appropriate symptomatic interventions, and the treatment of non-SLE factors.
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Affiliation(s)
- John G Hanly
- Division of Rheumatology, Arthritis Center of Nova Scotia, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS B3H 4K4, Canada.
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Omdal R, Sjöholm H, Koldingsnes W, Sundsfjord JA, Jacobsen EA, Husby G, Mellgren SI. Fatigue in patients with lupus is not associated with disturbances in cerebral blood flow as detected by SPECT. J Neurol 2005; 252:78-83. [PMID: 15654558 DOI: 10.1007/s00415-005-0610-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2004] [Revised: 07/05/2004] [Accepted: 07/14/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Fatigue is a common complaint in patients with systemic lupus erythematosus (SLE). We investigated whether focal or general disturbances of cerebral blood flow (CBF), as assessed by SPECT, were associated with the presence of fatigue in an unselected group of SLE patients. METHODS Fifty-six patients were included. Mean age was 47.5 years (+/-12.7), mean disease duration 14.7 years (+/-8.9), and disease activity measured by SLE disease activity index (SLEDAI) was 5.7 (+/-5.4). Fatigue was assessed by the Fatigue Severity Scale (FSS) and CBF by Tc-99m-hexamethyl propylamine oxime (HMPAO)-SPECT. The images were read and processed quantitatively by a computer program using the primary visual cortex as reference region and > 15% CBF deviation as definition of abnormality. RESULTS The mean FSS score was 4.6 (+/-1.8). SPECT revealed focal CBF disturbances in 17 patients (30.4 %). Generalized symmetrical CBF reductions were present in 32 patients (57.1 %). There were no significant associations between CBF disturbances in any region of the brain and the degree of fatigue. CONCLUSIONS Fatigue in SLE patients is not related to focal or general CBF disturbances. Therefore, factors that do not influence blood flow seem responsible for the fatigue phenomenon.
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Affiliation(s)
- Roald Omdal
- Clinical Immunology Unit, Department of Medicine, Rogaland Central Hospital, 4068 Stavanger, Norway.
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Abstract
Systemic lupus erythematosus (SLE) is accompanied by several features that can be attributed to involvement of the central or peripheral nervous system. The etiology and pathogenesis of these manifestations are mostly unknown. To which degree these neuropsychiatric conditions can be explained on the basis of chronic illness, or as part of the disease spectrum of SLE, is also a matter of debate. Some of the controversial issues on these matters are discussed in the article.
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Abstract
Neuropsychiatric syndromes associated with systemic lupus erythematosus are common, but diverse in etiology and presentation. Cognitive dysfunction is prevalent among these syndromes, but exhibit a significant degree of heterogeneity both within and between patient variability. Earlier studies of SLE-associated cognitive dysfunction addressed its identification and description. Common associations were repeatedly acknowledged, including concomitant or past neuropsychiatric disease, use of corticosteroids, disease activity, emotional disturbance, and antiphospholipid antibodies. The past several years have focused more on elucidating the relative strengths of various risk associations, patterns of cognitive abnormalities, both cross-sectionally and longitudinally (, clinical course), and novel means to identify cognitive impairment, both functionally and biologically.
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Affiliation(s)
- Melanie J Harrison
- Division of Rheumatology, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Abstract
The correct diagnosis of central and peripheral nervous system manifestations in patients with systemic lupus erythematosus (SLE) can be challenging because of many SLE-related and non-SLE-related processes that can be present in a patient. The American College of Rheumatology (ACR) has published case definitions for 19 neuropsychiatric SLE (NPSLE) syndromes, with careful attention to important exclusion criteria. These criteria were developed for research purposes but can be helpful to clinicians with a patient who has nervous system dysfunction. This report reviews the data regarding the application of the ACR NPSLE criteria and the influence of ethnicity and disease duration on the development of NPSLE syndromes. Cognitive dysfunction and psychiatric disorders are the two most common manifestations. The work-up and treatment of nervous system syndromes are also discussed.
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Affiliation(s)
- David Hermosillo-Romo
- University of Texas Health Science Center at San Antonio, Division of Neurology, Mail Stop #7883, 7703 Floyd Curl Drive, San Antonio, TX 79220-3900, USA
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