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Al-Omoush O, AlBarakat MM, Alasmar D, Al-Khalaileh A, Alzoubi A, Tarakhan H, Shakhatreh Z, Hatamleh Z, Abu-Saleh M, Saleh O, Altiti A, A Hazaymeh W, Alshwayyat S, Hanifa H, Hazaimeh E. Clinical and imaging features of parenchymal and non-parenchymal neuro-Behçet's disease: a systematic review of case reports and series. BMC Neurol 2025; 25:225. [PMID: 40419971 DOI: 10.1186/s12883-025-04250-0] [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] [Received: 01/07/2025] [Accepted: 05/20/2025] [Indexed: 05/28/2025] Open
Abstract
BACKGROUND Neuro-Behçet's Disease (NBD) is a serious neurological complication of Behçet's Disease, but there's still a lack of research on its early-stage symptoms and imaging findings. While previous research highlights MRI abnormalities and cerebrospinal fluid changes, there hasn't been a systematic effort to identify patterns specific to newly diagnosed patients. Our study aimed to investigate the clinical and imaging characteristics of newly diagnosed parenchymal and non-parenchymal NBD based on case reports and case series studies. METHODS We synthesized case reports and case series from MEDLINE, Scopus, EMBASE, PubMed, Web of Science, and Cochrane Library until October 17th,2023. Multiple statistical tests, such as the chi-square and Mann-Whitney tests, were used, with the corresponding 95% confidence interval (CI). The study protocol was registered with PROSPERO (ID: CRD42023472436). We included case reports and case series of adult patients (≥ 18 years) with a confirmed diagnosis of parenchymal or non-parenchymal Neuro-Behçet's disease (NBD), based on neurological symptoms attributed to Behçet's disease. Studies were required to report MRI findings demonstrating central or peripheral nervous system involvement. RESULTS Our analysis of 107 case reports and a case series (n = 174 patients) revealed that parenchymal NBD patients (n = 141; mean age 35.54 ± 13.33 years) frequently presented with ocular manifestations (80.9%), pyramidal signs (57.5%), cranial nerve palsies (50.4%), and headache (32.6%) while non-parenchymal NBD patients (n = 19; mean age 28.68 ± 10.67 years) commonly experienced headache (86.4%), papilledema (47.4%), cranial nerve palsies (42.1%), and nausea (31.6%). For the mixed-type group (n = 14; mean age 27.5 ± 11.57 years), commonly presented with headache (64.3%), pyramidal sign (50%), fever (50%), and diplopia (35.7%). Brainstem involvement for parenchymal NBD predominated in acute and chronic cases. Contrast enhancement was significantly more prevalent in acute NBD compared to chronic progressive NBD. CONCLUSION Neuro-Behçet's disease is an uncommon but serious medical condition with varying symptoms based on its type. Parenchymal and non-parenchymal NBD have unique patterns, with parenchymal cases exhibiting primarily ocular symptoms and pyramidal signs, while non-parenchymal cases present with headache and papilledema. Patients with both types of features were more likely to experience headaches, pyramidal symptoms, fever, and diplopia. Recognizing these patterns can help diagnose and treat the disease earlier.
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Affiliation(s)
- Omar Al-Omoush
- Internal Medicine and Family Medicine Department, The Hashemite University, Zarqa, 13133, Jordan
| | - Majd M AlBarakat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Deya'a Alasmar
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ali Al-Khalaileh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ahmad Alzoubi
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Husam Tarakhan
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Zaid Shakhatreh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Zaid Hatamleh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Othman Saleh
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | | | - Wafa' A Hazaymeh
- The College of Education, Humanities and Social Sciences, Al-Ain University, Al-Ain, United Arab Emirates
| | - Sakhr Alshwayyat
- Research Associate, King Hussein Cancer Center, Amman, Jordan
- Princess Basma Teaching Hospital, Irbid, Jordan
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
| | - Hamdah Hanifa
- Faculty of Medicine, University of Kalamoon, Al-Nabk, Syria.
| | - Ethar Hazaimeh
- Neurology Specialist, Neuropedia for Training and Scientific Research, Amman, Jordan
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Borelli A, Behr J, Ruggeri M, Han M, Zhou Y, Foster CS. Indications for Magnetic Resonance Imaging in Patients With Behcet Uveitis. J Neuroophthalmol 2024; 44:473-477. [PMID: 37847219 DOI: 10.1097/wno.0000000000002018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
BACKGROUND Behcet disease is a systemic vasculitis, which may involve the eyes and central nervous system. The true prevalence of neurological involvement is not precisely known but may be associated with ocular involvement. This study investigates the association between Behcet uveitis and neuro-Behcet disease. METHODS A retrospective single-center analysis was conducted for consecutive patients with Behcet uveitis at the Massachusetts Eye Research and Surgery Institution. Uveitis characteristics, neurological symptoms, fluorescein fundus angiography, and MRI results were recorded. RESULTS Our population included 108 patients with Behcet uveitis, and 26 (24.1%) were found to have neurological involvement associated with Behcet disease. Optic nerve leakage on fundus angiography and neurological symptoms were associated with an increased risk of neurological involvement. Three cases (11.5%) were nonparenchymal, while 23 (88.5%) were parenchymal with lesions in the cortex, subcortical white matter, thalamus, basal ganglia, and brainstem. CONCLUSIONS There is a high comorbidity between ocular and neurological involvement in Behcet disease. Careful assessment of neurological symptoms and baseline fluorescein fundus angiography are recommended for patients with Behcet disease. MRI has a high diagnostic yield and should be pursued if there is concern for progressive or pre-existing neurological involvement.
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Affiliation(s)
- Anna Borelli
- Massachusetts Eye Research and Surgery Institution (AB, JB, MR, MH, YZ, CSF), Waltham, Massachusetts; The Ocular Immunology and Uveitis Foundation (AB, JB, MR, MH, YZ, CSF), Waltham, Massachusetts; and Department of Ophthalmology (CSF), Harvard Medical School, Boston, Massachusetts
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Algahtani H, Shirah B, Almohiy H, AlAlmai A. Neuro-Behcet's disease misdiagnosed and treated as multiple sclerosis: a deceiving masquerader. Int J Neurosci 2024; 134:1134-1138. [PMID: 37548488 DOI: 10.1080/00207454.2023.2246099] [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] [Received: 06/05/2023] [Revised: 07/18/2023] [Accepted: 08/04/2023] [Indexed: 08/08/2023]
Abstract
Behcet's disease is a chronic polysymptomatic systemic vasculitis disorder of unknown etiology characterized by several clinical manifestations in multiple organ systems. Involvement of the nervous system occurs in ∼9% of patients with Behcet's disease (ranging from 3 to 30%). Neuro-Behcet's disease is a great masquerader of multiple sclerosis. Diagnosing this disorder might be challenging, especially in a patient who does not fulfill the criteria of Behcet's disease while having a neurological presentation. We report a case of neuro-Behcet's disease who was misdiagnosed as having multiple sclerosis for many years and started on unnecessary disease-modifying therapy for multiple sclerosis. A thorough history, physical examination, and systematic investigations are mandatory to differentiate between these two conditions. Our case presentation raises awareness of the importance of differentiating between these two conditions since the consequences of misdiagnosis are catastrophic. The main challenges differentiating between multiple sclerosis and neuro-Behcet's are clinical and paraclinical, including neuroimaging.
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Affiliation(s)
- Hussein Algahtani
- Neurology Section, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Hussain Almohiy
- Department of Radiological Science, King Khalid University, Abha, Saudi Arabia
| | - Ahmad AlAlmai
- College of Medicine, King Khalid University, Abha, Saudi Arabia
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Silvagni E, Bortoluzzi A, Maranini B, Govoni M. Neurologic Involvement in Rheumatic Diseases. RARE DISEASES OF THE IMMUNE SYSTEM 2024:313-350. [DOI: 10.1007/978-3-031-60855-1_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Toledano M. Neurologic Manifestations of Rheumatologic Disease. Continuum (Minneap Minn) 2023; 29:734-762. [PMID: 37341329 DOI: 10.1212/con.0000000000001263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article describes the neurologic manifestations of systemic rheumatologic disorders. LATEST DEVELOPMENTS Although most have historically been classified as autoimmune disorders, rheumatologic diseases are increasingly conceptualized as distributed along a spectrum with various contributions of autoimmune (adaptive immune dysregulation) and autoinflammatory (innate immune dysregulation) mechanisms. Our evolving understanding of systemic immune-mediated disorders has been accompanied by an expansion in our differential diagnoses and therapeutic options. ESSENTIAL POINTS Rheumatologic disease involves both autoimmune and autoinflammatory mechanisms. Neurologic symptoms can be the first manifestation of these disorders, and familiarity with the systemic manifestations of specific diseases is essential to establish the correct diagnosis. Conversely, knowledge of the neurologic syndromes that are most likely to be associated with specific systemic disorders can help narrow the differential and increase confidence when attributing a neuropsychiatric symptom to an underlying systemic disorder.
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Branson HM, Longoni G. Clinical Neuroimaging in Pediatric Dysimmune Disorders of the Central Nervous System. Semin Roentgenol 2023; 58:67-87. [PMID: 36732013 DOI: 10.1053/j.ro.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/23/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Helen M Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Department of Medical Imaging, Toronto, Ontario, Canada.
| | - Giulia Longoni
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada; Garry Hurvitz Centre for Brain & Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Department of Paediatrics, Toronto, Ontario, Canada
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Genç B, Aslan K, Bolat N, İncesu L. Quantitative evaluation of cortical thickness in 3T in Behçet’s patients without neurological involvement and parenchymal neuro-Behçet’s disease. J Clin Neurosci 2022; 106:128-134. [DOI: 10.1016/j.jocn.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/08/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
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Jarry VDM, Pereira FV, Dalaqua M, Duarte JÁ, França Junior MC, Reis F. Common and uncommon neuroimaging manifestations of ataxia: an illustrated guide for the trainee radiologist. Part 1 – acquired diseases. Radiol Bras 2022; 55:253-258. [PMID: 35983343 PMCID: PMC9380605 DOI: 10.1590/0100-3984.2021.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/10/2021] [Indexed: 11/22/2022] Open
Abstract
Abstract Ataxia is defined as a lack of coordination of voluntary movement, caused by a variety of factors. Ataxia can be classified by the age at onset and type (chronic or acute). The causative lesions involve the cerebellum and cerebellar connections. The correct, appropriate use of neuroimaging, particularly magnetic resonance imaging, can make the diagnosis relatively accurate and facilitate implementation of the appropriate clinical management. The purpose of this pictorial essay is to describe the imaging findings of ataxia, based on cases obtained from the archives of a tertiary care hospital, with a review of the most important findings. We also review and discuss the imaging aspects of infectious, toxic, vascular, and inflammatory diseases.
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Affiliation(s)
| | | | | | | | | | - Fabiano Reis
- Universidade Estadual de Campinas (Unicamp), Brazil
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Emekli AS, Ersözlü E, Emekli MA, Gündüz T, Kürtüncü M. Lesion distribution pattern of parenchymal Neuro-Behçet's disease using probability mapping. Mult Scler Relat Disord 2021; 58:103457. [PMID: 34929453 DOI: 10.1016/j.msard.2021.103457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/10/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Behçet's disease (BD) is an inflammatory disorder with multisystemic involvement. The most disabling aspect of BD is Neuro-Behçet's disease (NBD). In NBD, parenchymal lesions tend to occur in the mesodiencephalic region and brainstem, as reported in large series of NBD. Our study aimed to generate probability maps of parenchymal lesions to compare patient subgroups with different clinical and laboratory features. METHOD We included 66 non-standardized acute relapse MRIs of 55 patients with parenchymal NBD (p-NBD). We used T2-weighted axial images to digitalize the lesions using the CAD software. Boundaries of lesions were determined as polygons and converted into high-definition raster datasets. Then, digitalized lesion maps were transferred into the ICBM-152 brain template to perform spatial analyses. Finally, we created subtraction maps to compare the patient subgroups. RESULTS We used a total of 66 MRIs of 55 patients to generate the probability maps. The most frequently affected parenchymal structures were the rostral pons, mesencephalon, and diencephalic region. Interestingly, the brainstem was more commonly affected in females than males (p<0.01). In the late-onset disease, lesions were localized in the corticospinal tracts and caudal brainstem (p<0.01). Progressive disease and severe disability at the end of the follow-up period were associated with corticospinal tract lesions during relapses (p<0.01). Patients with positive pathergy tests were more likely to present right hemisphere involvement (p<0.01). Additionally, cyclosporine-induced lesions tend to be in atypical locations such as hemispheric white matter. CONCLUSIONS In the published studies, lesions in NBD were localized according to coarse anatomical regions. Our study uses visual maps to offer accurate lesion localizations using non-standardized brain MRIs, allowing comparisons across different NBD subgroups. By using this technique, we investigated the relationship of the clinical and laboratory features with the lesion locations. We found that the late age of onset was associated with a poor prognosis. Additionally, corticospinal lesions may predict severe and progressive disease course, requiring aggressive treatment. Interestingly, females had more brainstem lesions and lesion lateralization might be influenced by the pathergy test status.
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Affiliation(s)
- Ahmed Serkan Emekli
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ersin Ersözlü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Abstract
PURPOSE This article describes the neurologic manifestations of systemic autoimmune diseases. RECENT FINDINGS Systemic autoimmune diseases can be associated with a wide spectrum of neurologic comorbidities involving the central and peripheral nervous systems. Systemic lupus erythematosus (SLE) can be associated with a number of manifestations predominantly affecting the central nervous system (CNS), whereas peripheral neuropathy is less common. Sjögren syndrome can be associated with peripheral neuropathy in 10% of cases and CNS disease in 2% to 5% of cases. The risk of stroke is increased in SLE, rheumatoid arthritis, temporal arteritis, psoriatic arthritis, and ankylosing spondylitis. Systemic vasculitides present most commonly with mononeuritis multiplex but can also affect the CNS. Cognitive dysfunction is a common symptom among patients with systemic autoimmune diseases, most commonly seen in patients with SLE or Sjögren syndrome. SUMMARY Neurologic manifestations of systemic autoimmune disease are important to recognize, as they may often be the presenting manifestation leading to diagnosis of the systemic disease or may be associated with increased morbidity, other complications, or mortality. Timely diagnosis and institution of appropriate treatment, often requiring multidisciplinary care, is essential to minimize morbidity and decrease the risk of permanent neurologic deficits.
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Partalidou S, Tsiakalou V, Vassilakos I, Kassimos D. Walking Instability in a Patient with Known Neuro-Behçet's Disease. Mediterr J Rheumatol 2020; 31:78-80. [PMID: 32411936 PMCID: PMC7219649 DOI: 10.31138/mjr.31.1.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
A 53-year-old man with known history of Neuro-Behçet›s Disease (NBD) presented to the Emergency Department with numbness on the left side of the body and the face. The patient was admitted to the Neurological Department and after a thorough investigation, the magnetic resonance imaging (MRI)of the brain revealed a lesion on the brainstem (rhombencephalitis). The case is presented due to rarity of the clinical picture and the good outcome. The therapeutic strategy and the modification of his medication is discussed.
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Borhani-Haghighi A, Kardeh B, Banerjee S, Yadollahikhales G, Safari A, Sahraian MA, Shapiro L. Neuro-Behcet's disease: An update on diagnosis, differential diagnoses, and treatment. Mult Scler Relat Disord 2019; 39:101906. [PMID: 31887565 DOI: 10.1016/j.msard.2019.101906] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 02/08/2023]
Abstract
Neuro-Behcet's disease (NBD) is defined as a combination of neurologic symptoms and/or signs in a patient with Behcet's disease (BD). Relevant syndromes include brainstem syndrome, multiple-sclerosis like presentations, movement disorders, meningoencephalitic syndrome, myelopathic syndrome, cerebral venous sinus thrombosis (CVST), and intracranial hypertension. Central nervous involvement falls into parenchymal and non-parenchymal subtypes. The parenchymal type is more prevalent and presents as brainstem, hemispheric, spinal, and meningoencephalitic manifestations. Non-parenchymal type includes CVST and arterial involvement. Perivascular infiltration of polymorphonuclear and mononuclear cells is seen in most histo-pathologic reports. In parenchymal NBD, cerebrospinal fluid (CSF) generally exhibits pleocytosis, increased protein and normal glucose. In NBD and CVST, CSF pressure is increased but content is usually normal. The typical acute NBD lesions in brain magnetic resonance imaging (MRI) are mesodiencephalic lesions. The pattern of extension from thalamus to midbrain provides a cascade sign. Brain MRI in chronic NBD usually shows brain or brainstem atrophy and/or black holes. The spinal MRI in the acute or subacute myelopathies reveals noncontiguous multifocal lesions mostly in cervical and thoracic lesions. In chronic patients, cord atrophy can also be seen. Brain MRI (particularly susceptibility-weighted images), MR venography (MRV) and computerized tomographic venography (CTV) can be used to diagnose CVST. Parenchymal NBD attacks can be treated with glucocorticoids alone or in combination with azathioprine. For patients with relapsing-remitting or progressive courses, shifting to more potent immunosuppressive drugs such as mycophenolate, methotrexate, cyclophosphamide, or targeted therapy is warranted. For NBD and CVST, immunosuppressive drugs with or without anticoagulation are suggested.
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Affiliation(s)
| | - Bahareh Kardeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shubhasree Banerjee
- Division of Rheumatology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anahid Safari
- Stem Cells Technology Research Center, Shiraz University of Medical Sciences Shiraz, Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical sciences, Tehran, Iran
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Abstract
PURPOSE OF REVIEW Pediatric central nervous system demyelinating diseases include multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and acute disseminated encephalomyelitis (ADEM). As diagnostic criteria become more inclusive, the risk of misdiagnosis of atypical demyelinating diseases of rheumatologic, infectious, and autoimmune etiology increases. RECENT FINDINGS We review mimics of multiple sclerosis, neuromyelitis optica spectrum disorder, and acute disseminated encephalomyelitis, including rheumatologic diseases: systemic lupus erythematosus and neuro-Behçet disease; infectious diseases: human immunodeficiency virus, progressive multifocal leukoencephalopathy, and subacute sclerosis panencephalitis; and autoimmune diseases including X-linked Charcot-Marie-Tooth disease, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) and autoimmune glial fibrillary acidic protein (GFAP) encephalopathy. Atypical demyelinating disease may mimic classic neuroinflammatory diseases of the central nervous system. Imaging may meet criteria for a diagnosis of multiple sclerosis, or patients may present with optic neuritis and transverse myelitis consistent with neuromyelitis optica spectrum or myelin oligodendrocyte glycoprotein (MOG) antibody disorders. Through careful history-taking and review of atypical MRI findings, we may avoid misdiagnosis and mistreatment.
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Fisher CA, Bernard C. A Systematic Review of Neurocognitive Functioning in Behçet's Disease. Neuropsychol Rev 2019; 29:498-521. [PMID: 31494834 DOI: 10.1007/s11065-019-09416-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/21/2019] [Indexed: 11/25/2022]
Abstract
Behçet's disease (BD) is a vascular, inflammatory multisystem disorder with neuro-Behçet's (NBD) diagnosed in a subset of patients with neurological manifestations. The objective of this review was to determine whether neurocognitive dysfunction is observed in BD, in which neurocognitive domains, and whether there are differences in rates of dysfunction observed between BD and NBD groups. Studies of any methodology were included that reported results from standardized neurocognitive assessment measures in participants with BD or NBD. Twelve group comparison studies met the criteria for inclusion in the review (totalling 284 BD and 157 NBD participants), as well as 17 case study/series papers (11 BD, 35 NBD). Issues with blinding, incomplete data reporting and selective reporting bias were found across the group and case study/series papers, as well as inadequate statistical adjustment for multiple comparisons in the group studies, and the lack of the use of appropriate norms or adjustment for premorbid ability in the case series/studies papers. These quality issues impacted on the conclusions that could be drawn from the current literature. Neurocognitive dysfunction was found in NBD compared to health controls (HC) in a higher proportion of results across studies, than in comparisons between BD and HC groups. The domains in which neurocognitive attenuation was most often reported were visual spatial ability, working memory and acquired knowledge, with more than 25% of these results showing significantly lower functioning in both the BD and NBD groups compared to HC. More than 25% of the processing speed and long-term memory encoding and retrieval results were also lower for the NBD group, compared to HC. Group comparisons between NBD and multiple sclerosis participants indicated few significant differences in neurocognitive test results. The majority of case study/series participants were found to have some degree of attenuated neurocognitive functioning, as defined by case study/series authors.
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Affiliation(s)
- Caroline A Fisher
- Allied Health - Psychology, Melbourne Health, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, Victoria, 3052, Australia.
- Neuropsychology Service, The Melbourne Clinic, Healthscope, Richmond, Melbourne, Australia.
| | - Coco Bernard
- Allied Health - Psychology, Melbourne Health, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, Victoria, 3052, Australia
- Adult Neuropsychology Service, Rehabilitation and Aged Care Services, Monash Health, Kingston Centre, Cheltenham, Australia
- Adult Neuropsychology Service, Rehabilitation and Aged Care, Monash Health, Caulfield Hospital, Caulfield, Australia
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Magnetic resonance imaging in immune-mediated myelopathies. J Neurol 2019; 267:1233-1244. [PMID: 30694379 DOI: 10.1007/s00415-019-09206-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
Immune-mediated myelopathies are a heterogeneous group of inflammatory spinal cord disorders including autoimmune disorders with known antibodies, e.g. aquaporin-4 IgG channelopathy or anti-myelin oligodendrocyte glycoprotein-associated myelitis, myelopathies in the context of multiple sclerosis and systemic autoimmune disorders with myelopathy, as well as post-infectious and paraneoplastic myelopathies. Although magnetic resonance imaging of the spinal cord is still challenging due to the small dimension of the cord cross-section and frequent movement and susceptibility artifacts, recent methodological advances have led to improved diagnostic evaluation and characterization of immune-mediated myelopathies. Topography, length and width of the lesion, gadolinium enhancement pattern, and changes in morphology over time help in narrowing the broad differential diagnosis. In this review, we give an overview of recent advances in magnetic resonance imaging of immune-mediated myelopathies and its role in the differential diagnosis and monitoring of this heterogeneous group of disorders.
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Kim SW, Kim TG, Oh J, Kim DY, Choi YC, Kim SM, Shin HY, Bang D. Clinical and Radiographic Characteristics of Neuro-Behçet's Disease in South Korea. J Clin Neurol 2019; 15:429-437. [PMID: 31591829 PMCID: PMC6785476 DOI: 10.3988/jcn.2019.15.4.429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 02/05/2023] Open
Abstract
Background and Purpose Neurological involvement in Behçet's disease [neuro-Behçet's disease (NBD)] is uncommon, but it is worth investigating since it can cause substantial disability. However, difficulties exist in understanding the clinical features of NBD due to regional variations and the lack of studies utilizing well-established diagnostic criteria. We therefore analyzed the clinical features of patients with NBD based on the recent international consensus recommendation. Methods We retrospectively searched electronic databases for patients with Behçet's disease (BD) between 2000 and 2017, and reviewed their medical records. Based on the recent international consensus recommendation, patients with definite or probable NBD were included. Results Of 9,817 patients with the diagnosis code for BD, 1,682 (17.1%) visited the neurology clinic and 110 (1.1%) were classified as NBD. Ninety-eight patients exhibited parenchymal NBD and 12 exhibited nonparenchymal NBD. Their age at the onset of NBD was 37.6±10.6 years and the male-to-female ratio was 1.24:1. Brainstem syndrome (43.9%) was the most common condition in the 98 patients with parenchymal NBD, followed by multifocal (32.7%) and spinal cord (12.2%) syndromes. 72.4% exhibited acute NBD and 27.6% exhibited a progressive disease course. Frequent manifestations included pyramidal signs (52.0%), headache (45.9%), dysarthria (42.9%), and fever (31.6%). A frequent pattern in brain MRI was an upper brainstem lesion extending to the thalamus and basal ganglia. Conclusions Approximately 1% of the patients with suspected BD exhibited NBD. Neurologists must understand the clinical characteristics of NBD in order to perform the differential diagnosis and management of these patients.
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Affiliation(s)
- Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Gyun Kim
- Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jongwook Oh
- Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Chul Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
| | - Dongsik Bang
- Department of Dermatoloy, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea.
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Cohen-Aubart F, Psimaras D, Galanaud D, Bielle F, Touitou V, Haroche J, Amoura Z. Cerebral pseudo-tumoral neuro-Behcet: Histological demonstration of an inflammatory and vascular disease. Clin Neurol Neurosurg 2017; 161:48-50. [DOI: 10.1016/j.clineuro.2017.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 10/19/2022]
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Ishido M, Horita N, Takeuchi M, Shibuya E, Yamane T, Kawagoe T, Ishido T, Minegishi K, Yoshimi R, Kirino Y, Hirohata S, Ishigatsubo Y, Takeno M, Kaneko T, Mizuki N. Distinct clinical features between acute and chronic progressive parenchymal neuro-Behçet disease: meta-analysis. Sci Rep 2017; 7:10196. [PMID: 28860590 PMCID: PMC5579041 DOI: 10.1038/s41598-017-09938-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 08/01/2017] [Indexed: 01/18/2023] Open
Abstract
Neuro-Behçet’s disease (NBD) is subcategorized into parenchymal-NBD (P-NBD) and non-parenchymal-NBD types. Recently, P-NBD has been further subdivided into acute P-NBD (A-P-NBD) and chronic progressive P-NBD (CP-P-NBD). Although an increasing number of studies have reported the various clinical features of A-P-NBD and CP-P-NBD over the last two decades, there was a considerable inconsistency. Two investigators systematically searched four electrical databases to detect studies that provided sufficient data to assess the specific characteristics of A-P-NBD and CP-P-NBD. All meta-analysis was carried out by employing the random-model generic inverse variance method. We included 11 reports consisted of 184 A-P-NBD patients and 114 CP-P-NBD patients. While fever (42% for A-P-NBD, 5% for CP-P-NBD, p < 0.001, I2 = 93%) was more frequently observed in A-P-NBD cases; sphincter disturbances (9%, 34%, P = 0.005, I2 = 87%), ataxia (16%, 57%, P < 0.001, I2 = 92%), dementia (7%, 61%, P < 0.001, I2 = 97%), confusion (5%, 18%, P = 0.04, I2 = 76%), brain stem atrophy on MRI (4%, 75%, P < 0.001, I2 = 98%), and abnormal MRI findings in cerebellum (7%, 54%, P = 0.02, I2 = 81%) were more common in CP-P-NBD. Cerebrospinal fluid cell count (94/mm3, 11/mm3, P = 0.009, I2 = 85%) was higher in A-P-NBD cases. We demonstrated that A-P-NBD and CP-P-NBD had clearly different clinical features and believe that these data will help future studies investigating P-NBD.
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Affiliation(s)
- Mizuho Ishido
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Masaki Takeuchi
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Etsuko Shibuya
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takahiro Yamane
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tatsukata Kawagoe
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takehito Ishido
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kaoru Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shunsei Hirohata
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | | | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuhisa Mizuki
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Delayed symptomatic intracerebral hemorrhages in neuro-Behcet's disease. J Neurol 2016; 264:394-396. [PMID: 28000007 PMCID: PMC5306077 DOI: 10.1007/s00415-016-8363-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 01/08/2023]
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Jade J, Chung K, Arendse M, Hussain Z, White D. Neuro-Behçet's disease presenting with tumour-like lesions and responding to rituximab. J Clin Neurosci 2016; 32:139-41. [PMID: 27320374 DOI: 10.1016/j.jocn.2016.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 03/14/2016] [Indexed: 11/29/2022]
Abstract
We describe a patient with neuro-Behçets disease (NBD) that presented with symptoms of raised intracranial pressure including papilloedema. MRI revealed tumour-like lesions which, on biopsy, confirmed an active vasculitis. Treatment was commenced with prednisone and cyclophosphamide which proved unsuccessful with enlargement of the cerebral mass lesions. Infliximab and mycophenolate were trialled also without benefit. The patient required ventriculoperitoneal shunts to relieve the symptoms of hydrocephalus. Rituximab was then commenced with significant symptomatic and imaging improvement. The case is unique, in our experience, in the need for shunting to relieve the symptoms of hydrocephalus related to vasculitis.
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Affiliation(s)
- J Jade
- Waikato DHB, Hamilton 3204, New Zealand
| | - K Chung
- Sydney Adventist Hospital Clinic, Wahroonga, NSW 2076, Australia
| | - M Arendse
- Waikato DHB, Hamilton 3204, New Zealand
| | - Z Hussain
- Waikato DHB, Hamilton 3204, New Zealand
| | - D White
- Waikato DHB, Hamilton 3204, New Zealand; Waikato Clinical School, Waikato Hospital, University of Auckland, Pembroke Street, Private Bag 3200, Hamilton 3240, New Zealand.
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Abstract
Between 5 and 30% of patients with Behçet's disease will present neurological signs during the course of their illness. In order to evaluate the radiological signs on neuro-behçet disease, we studied consecutive patients in whom the diagnosis of this disease was retained, and who referred from January 2004 to December 2011 to the neurology and internal medicine departments in Mohammed VI universitary hospital in Marrakesh. Using 1.5T magnetic resonance imaging (MRI) with axial and coronal T2- weighted, axial Fluid Attenuated Inversion Recovery (FLAIR), pre- and post-contrast axial, coronal and sagittal T1-weighted sequences. The final number of patients in whom the diagnosis criteria of behçet disease were fulfilled and in whom an MRI was performed was 68 cases. Among these patients, 52 had parenchymal form of neuro-behçet with abnormalities in the MRI, 12 had vascular form and 4 patients had normal MRI. The brainstem, cerebral white matter, basal ganglia, internal capsule, thalamus and spinal cord were involved in forty four, thirty one, thirty, twenty nine, seventeen and four patients, respectively. The cerebral peduncle was the brainstem structure mainly involved with thirty cases followed by the pons with, twenty cases. Midbrain involvement interested forty patients. Brainstem atrophy was seen in eighteen cases. Finally, control MRI were obtained in four cases only, and showed changes in lesions size and shape.
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Affiliation(s)
- Chraa Mohamed
- Neurology Department, Mohamed VI university hospital, Marrakesh, Morocco
| | - Kissani Najib
- Neurology Department, Mohamed VI university hospital, Marrakesh, Morocco
| | - Lamia Essaadouni
- Internal medicine department, Mohamed VI university hospital, Marrakesh, Morocco
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Martins W, Schilling L, Neto F, Becker J. Hypertrophic Olivary Degeneration Secondary to Neuro-Behçet’s Disease. Clin Neuroradiol 2015; 26:99-102. [DOI: 10.1007/s00062-015-0384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/04/2015] [Indexed: 11/28/2022]
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Mohamed C, Najib K, Essaadouni L. Radiological findings in Behçet disease. Pan Afr Med J 2015; 20:51. [PMID: 26090009 PMCID: PMC4449986 DOI: 10.11604/pamj.2015.20.51.5928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/08/2015] [Indexed: 11/11/2022] Open
Abstract
Between 5 and 30% of patients with Behçet's disease will present neurological signs during the course of their illness. In order to evaluate the radiological signs on neuro-behçet disease, we studied consecutive patients in whom the diagnosis of this disease was retained, and who referred from January 2004 to December 2011 to the neurology and internal medicine departments in Mohammed VI universitary hospital in Marrakesh. Using 1.5T magnetic resonance imaging (MRI) with axial and coronal T2- weighted, axial Fluid Attenuated Inversion Recovery (FLAIR), pre- and post-contrast axial, coronal and sagittal T1-weighted sequences. The final number of patients in whom the diagnosis criteria of behçet disease were fulfilled and in whom an MRI was performed was 68 cases. Among these patients, 52 had parenchymal form of neuro-behçet with abnormalities in the MRI, 12 had vascular form and 4 patients had normal MRI. The brainstem, cerebral white matter, basal ganglia, internal capsule, thalamus and spinal cord were involved in forty four, thirty one, thirty, twenty nine, seventeen and four patients, respectively. The cerebral peduncle was the brainstem structure mainly involved with thirty cases followed by the pons with, twenty cases. Midbrain involvement interested forty patients. Brainstem atrophy was seen in eighteen cases. Finally, control MRI were obtained in four cases only, and showed changes in lesions size and shape.
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Affiliation(s)
- Chraa Mohamed
- Neurology Department, Mohamed VI university hospital, Marrakesh, Morocco
| | - Kissani Najib
- Neurology Department, Mohamed VI university hospital, Marrakesh, Morocco
| | - Lamia Essaadouni
- Internal medicine department, Mohamed VI university hospital, Marrakesh, Morocco
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Abstract
A variety of neurologic diseases have cutaneous manifestations. These may precede, coincide with, or follow the neurologic findings. An array of autoimmune, genetic, and environmental factors play a role in expression and severity of the neurologic burden in these conditions. This chapter emphasizes congenital and genetic disorders, but we also discuss the pathophysiology and manifestation of various acquired neurocutaneous disorders with an emphasis Behcet's disease, dermatomyositis, Sjögren's syndrome, systemic lupus erythematosus, scleroderma, Parry-Romberg syndrome and Degos disease.
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Affiliation(s)
- Amre Nouh
- Department of Neurology, Hartford Hospital - University of Connecticut, Hartford CT, USA
| | - Jodi Speiser
- Section of Dermatopathology, Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA.
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Nava F, Ghilotti F, Maggi L, Hatemi G, Del Bianco A, Merlo C, Filippini G, Tramacere I, Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group. Biologics, colchicine, corticosteroids, immunosuppressants and interferon-alpha for Neuro-Behçet's Syndrome. Cochrane Database Syst Rev 2014; 2014:CD010729. [PMID: 25521793 PMCID: PMC10594584 DOI: 10.1002/14651858.cd010729.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Neuro-Behçet Syndrome (NBS) is a severe chronic inflammatory vascular disease involving the Central Nervous System (CNS), and it is an invalidating condition with disability and a huge impact on quality of life. Recommendations on treatments for NBS include the use of disease-modifying therapies in general, although they are not supported by a systematic review of the evidence. OBJECTIVES To assess the benefit and harms of available treatments for NBS, including biologics, colchicine, corticosteroids, immunosuppressants and interferon-alpha. SEARCH METHODS We searched the following databases up to 30 September 2014: Trials Specialised Register of The Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group, CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS, ORPHANET, Clinicaltrials.gov and World Health Organization (WHO) International Clinical Trials Registry Portal. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs), prospective and retrospective controlled cohort studies were eligible to assess the benefit. Patients over 13 years of age with a diagnosis of NBS. For assessment of harms, open-label extension (OLE), case-control studies, population-based registries, case-series and case-reports were additionally planned to be evaluated. DATA COLLECTION AND ANALYSIS Selection of studies, data extraction and assessment of risk of bias were planned to be carried out independently by two review authors. Standard methodological procedures expected by The Cochrane Collaboration were followed. We planned to perform standard pair-wise meta-analyses for RCTs, and meta-analyses based on the adjusted estimates using the inverse-variance weighted average method for non-randomised studies (NRSs). We planned to present the main results of the review in a 'Summary of Findings' table using the GRADE approach. MAIN RESULTS No RCTs, CCTs or controlled cohort studies on the benefit of the treatments for NBS met the inclusion criteria of the review. Only one potentially eligible study was identified, but it did not report sufficient details on the patient characteristics. The author of this study did not provide additional data on request, and therefore it was excluded. Hence, no studies were included in the present review. Since no studies were included in the assessment of benefit, no further search was performed in order to collect data on harms. AUTHORS' CONCLUSIONS There is no evidence to support or refute the benefit of biologics, colchicine, corticosteroids, immunosuppressants and interferon-alpha for the treatment of patients with NBS. Thus, well-designed multicentre RCTs are needed in order to inform and guide clinical practice.
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Affiliation(s)
- Francesca Nava
- University of Milano‐BicoccaFaculty of Statistical Sciencevia Bicocca degli Arcimboldi 8MilanItaly20126
| | - Francesca Ghilotti
- University of Milano‐BicoccaFaculty of Statistical Sciencevia Bicocca degli Arcimboldi 8MilanItaly20126
| | - Lorenzo Maggi
- Fondazione I.R.C.C.S. Istituto Neurologico Carlo BestaNeurology IV‐ Neuro‐Immunology and Neuromuscular DiseasesVia Celoria, 11MilanoItaly20133
| | - Gulen Hatemi
- Istanbul University, Cerrahpasa Medical SchoolDepartment of Internal Medicine, Division of RheumatologyCerrahpasa Tip Fakultesi, AksarayIstanbulTurkey34365
| | | | - Chiara Merlo
- Fondazione MarchiOspedale Di Circolo Del PonteVia Del Ponte, 19VareseVareseItaly21040
| | - Graziella Filippini
- Fondazione I.R.C.C.S. Istituto Neurologico Carlo BestaScientific Directionvia Celoria, 11MilanoItaly20133
| | - Irene Tramacere
- Fondazione I.R.C.C.S. Istituto Neurologico Carlo BestaNeuroepidemiology UnitVia Giovanni Celoria, 11MilanoItaly20133
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Abdel Razek AAK, Alvarez H, Bagg S, Refaat S, Castillo M. Imaging Spectrum of CNS Vasculitis. Radiographics 2014; 34:873-894. [DOI: 10.1148/rg.344135028] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Yoon DL, Kim YJ, Koo BS, Kim YG, Lee CK, Yoo B. Neuro-behçet's disease in South Korea: clinical characteristics and treatment response. Int J Rheum Dis 2014; 17:453-8. [PMID: 24506839 DOI: 10.1111/1756-185x.12265] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Neuro-behçet's disease (NBD) is a rare complication of Behçet's disease (BD) but is still important due to its morbidity and mortality. In this study, we sought to identify the characteristics of NBD by examining the clinical characteristics, and whether there were differences in the clinical characteristics or the treatment between relapsed and non-relapsed groups. METHODS We retrospectively reviewed the medical history of all patients diagnosed with BD at the Asan Medical Center in South Korea from January 1996 to May 2012. NBD was defined as neurological symptoms and compatible abnormalities identified by magnetic resononance imaging. RESULTS Among 624 BD patients, 22 were diagnosed with NBD. The common initial neurological symptoms were headache, gait disturbance and dysarthria. The common involved sites were the diencephalon, including internal capsule, the thalamus and basal ganglia, followed by the brainstem. An increased signal intensity on T2-weighted images was the most common finding. All patients had an improved disease state after steroid treatment, regardless of combined treatment with cyclophosphamide. However, eight patients experienced a disease recurrence at 7.3 ± 5.1 months after treatment. There were no significant differences in treatment patterns between the relapsed group and the non-relapsed group. CONCLUSIONS NBD may present with various neurologic manifestations with multifocal diencephalon and brainstem involvement. Most NBD patients had a good clinical outcome after steroid treatment, with or without a cytotoxic agent, but showed a pattern of relapse-remission. Therefore, careful long-term follow-up is needed in most cases of NBD.
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Affiliation(s)
- Da-Lim Yoon
- Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Uygunoglu U, Benbir G, Saip S, Kaynak H, Siva A. A Polysomnographic and Clinical Study of Sleep Disorders in Patients with Behçet and Neuro-Behçet Syndrome. Eur Neurol 2014; 71:115-9. [DOI: 10.1159/000355277] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 08/25/2013] [Indexed: 11/19/2022]
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Abstract
Behçet syndrome (BS) is an idiopathic chronic relapsing multisystem vascular-inflammatory disease of unknown origin. As the disease affects many organs and systems and shows a wide range of clinical manifestations and presentations, it is prefereable to call Behçet's a syndrome (BS) rather than a disease. Nervous system involvement, known as "neuro-BS" (NBS), is seen in about 5-10% of all cases. Clinical and imaging evidence suggests that primary neurologic involvement in BS may be subclassified into two major forms: the first, which is seen in the majority of patients, may be characterized as a vascular-inflammatory central nervous system disease with focal or multifocal parenchymal involvement, mostly presenting with a subacute brainstem syndrome and hemiparesis (intra-axial NBS); the other, which has few symptoms and a better neurologic prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension (extra-axial NBS), occurring in 10-20% of the cases. These two types are rarely seen in the same individual, and their pathogenesis is likely to be different. Isolated behavioral syndromes and peripheral nervous system involvement are rare, whereas a vascular type headache is relatively common and independent from neurologic involvement. Neurologic complications secondary to systemic involvement of BS, as well as neurologic complications related to BS treatments are considered as secondary neurologic involvement of the syndrome. The core histopathologic phenomenon seems to be a vasculitic involvement in some cases, and low-grade chronic nonspecific inflammation in others. As the neurologic involvement in this syndrome is so heterogeneous, it is difficult to predict its course and prognosis, and its response to treatment. Currently, treatment options for NBS are limited to attack therapies with high-dose intravenous methylprednisolone followed by a prolonged oral taper, symptomatic management, and generally the use of azathioprine, cyclophosphamide, interferon-α and anti-TNF agents for long-term preventive treatment, although there no evidence for their efficacy.
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Affiliation(s)
- Sabahattin Saip
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey
| | - Gulsen Akman-Demir
- Department of Neurology, School of Medicine, Istanbul Bilim University, Istanbul, Turkey
| | - Aksel Siva
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey.
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Diagnosis and management of Neuro-Behçet's disease: international consensus recommendations. J Neurol 2013; 261:1662-76. [PMID: 24366648 PMCID: PMC4155170 DOI: 10.1007/s00415-013-7209-3] [Citation(s) in RCA: 214] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/04/2013] [Indexed: 11/16/2022]
Abstract
Neuro-Behçet’s disease (NBD) is one of the more serious manifestations of Behçet’s disease (BD), which is a relapsing inflammatory multisystem disease with an interesting epidemiology. Though NBD is relatively uncommon, being potentially treatable, neurologists need to consider it in the differential diagnosis of inflammatory, infective, or demyelinating CNS disorders. Evidence-based information on key issues of NBD diagnosis and management is scarce, and planning for such studies is challenging. We therefore initiated this project to develop expert consensus recommendations that might be helpful to neurologists and other clinicians, created through an extensive literature review and wide consultations with an international advisory panel, followed by a Delphi exercise. We agreed on consensus criteria for the diagnosis of NBD with two levels of certainty in addition to recommendations on when to consider NBD in a neurological patient, and on the use of various paraclinical tests. The management recommendations included treatment of the parenchymal NBD and cerebral venous thrombosis, the use of disease modifying therapies, prognostic factors, outcome measures, and headache in BD. Future studies are needed to validate the proposed criteria and provide evidence-based treatments.
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Kikuchi H, Takayama M, Hirohata S. Quantitative analysis of brainstem atrophy on magnetic resonance imaging in chronic progressive neuro-Behçet's disease. J Neurol Sci 2013; 337:80-5. [PMID: 24289890 DOI: 10.1016/j.jns.2013.11.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 10/26/2013] [Accepted: 11/13/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To examine whether quantitative analysis of the brainstem areas on magnetic resonance imaging (MRI) scans is useful for diagnosis as well as evaluation of disease activity in chronic progressive neuro-Behçet's disease (CPNB). METHODS MRI scans in patients with acute neuro-Behçet's disease (ANB) (n = 10), CPNB (n = 10), Behçet's disease with neurological manifestations non-attributable to NB (non-NB) (n = 8), and control patients with non-inflammatory neurological diseases (NID) (n = 10) were studied. The areas of midbrain tegmentum and pons were measured on mid-sagittal sections of T1-weighted images of MRI using software NIH Image J ver.1.45. RESULTS The areas of midbrain tegmentum as well as those of pons were significantly decreased in CPNB compared with those in the other three groups. On receiver operating characteristic (ROC) analysis, the sensitivity and specificity of the areas of brainstem combining midbrain tegmentum and pons for diagnosis of CPNB against non-CPNB (ANB+non-NB) were 80.0% and 94.4%, respectively, at cut-off value of 614.9 mm(2). Brainstem atrophy progressed most markedly during the first 2 years during the course of CPNB. Moreover, the progression rate of atrophy was closely correlated with the elevation of cerebrospinal fluid interleukin-6. CONCLUSION These results indicate that quantitative analysis of the brainstem areas on MRI scans is effective for diagnosis as well as for evaluation of the disease activity in CPNB. Moreover, it is suggested that an appropriate therapeutic intervention to reduce CSF IL-6 would be required as early as possible upon diagnosis of CPNB.
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Affiliation(s)
- Hirotoshi Kikuchi
- Department of Microbiology and Immunology, Teikyo University School of Medicine, Japan.
| | - Maki Takayama
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shunsei Hirohata
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Japan
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Mora P, Menozzi C, Orsoni JG, Rubino P, Ruffini L, Carta A. Neuro-Behçet's disease in childhood: a focus on the neuro-ophthalmological features. Orphanet J Rare Dis 2013; 8:18. [PMID: 23360593 PMCID: PMC3567996 DOI: 10.1186/1750-1172-8-18] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/23/2013] [Indexed: 02/01/2023] Open
Abstract
Neuro-Behçet's disease (NBD) involves the central nervous system; peripheral nervous system involvement is not often reported. NBD is quite common in adult patients and occurs rarely during childhood and adolescence. Young patients may share symptoms and signs of NBD with other neuro-ophthalmological disorders (e.g. idiopathic intracranial hypertension); thus, making the differential diagnosis difficult. Neuroimaging is mandatory and necessary for a correct NBD diagnosis but in children radiological examinations are often difficult to perform without sedation. From 1971 to 2011, 130 patients aged ≤16 years have been reported with NBD, according to retrospective surveys, case series, and case reports. The origin of the reported cases met the well-known geographical distribution of Behçet's disease (BD); the mean age at presentation of neurological findings was 11.8 years, with male gender prevalence (ratio, 2.9:1). We considered in detail the neuro-ophthalmological features of the 53 cases whose neuroimaging alterations were described with an assigned radiological pattern of the disease (parenchymal: 14 cases, non-parechymal: 35 cases, and mixed: 4 cases). In 19/53 patients (36%), neuro-ophthalmological symptoms anticipated any pathognomonic sign for a BD diagnosis, or only occasional aphtae were recalled by the patients. Family history was positive in 17% of subjects. Headache was reported in 75% of the patients; in those presenting with cerebral vascular involvement, headache was combined to other symptoms of intracranial hypertension. Papilledema was the most frequently reported ophthalmological finding, followed by posterior uveitis. Treatment consisted of systemic steroids in 93% of patients, often combined with other immunosuppressive drugs (especially colchicine and azathioprine). Clinical recovery or improvement was documented in the large majority of patients. Nine subjects had definitive alterations, and one died. Based on our review and personal experience, a delayed diagnosis, and the consequently delayed immunosuppressive treatment, may favour permanent sequelae, in particular, optic atrophy.
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Affiliation(s)
- Paolo Mora
- Institute of Ophthalmology - Department of Biological, Biotechnological, and Translational Sciences, University of Parma, via Gramsci 14, 43126, Parma, Italy.
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Brain stem and cerebellar atrophy in chronic progressive neuro-Behçet's disease. Eur J Radiol 2013; 82:146-50. [DOI: 10.1016/j.ejrad.2012.04.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 04/27/2012] [Accepted: 04/30/2012] [Indexed: 11/19/2022]
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Rodrigues MI, Loureiro C, Geraldo Couceiro A, Reis Ferreira C, Monteiro-Grillo M. Neuro-Behçet, pseudotumor cerebri and ocular signs: a rare association. GMS OPHTHALMOLOGY CASES 2013; 3:Doc02. [PMID: 27625934 PMCID: PMC5015602 DOI: 10.3205/oc000012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: The central nervous system involvement in Behçet’s disease occurs in 5–30% of cases. The diagnosis of pseudotumor cerebri is even rarer (only 22 cases reported worldwide). Purpose: To emphasize the importance of differential diagnosis in a case of pseudotumor cerebri in the context of ocular inflammation. Methods: V.A.V.R., a 31 year old female, was diagnosed with pan-uveitis on the left eye associated with recurrent bipolar aphthosis. During the etiological investigation, there was an onset of a left hemiparesis and facial palsy. Results: The central nervous system (CNS) neuroradiological investigation revealed a space-occupying lesion within the right hemisphere with intense signal enhancement with gadolinium. It globally reached the nucleo-basal structures and induced deviation of the middle structures (including homolateral ventricle). Cytochemical analysis of cerebrospinal fluid (CSF) was negative for atypical cells. The ophthalmological features regressed with the corticosteroid and immunosuppressive therapy instituted. The final diagnosis was of pseudotumor cerebri in the context of Behçet’s disease. Conclusion: In Behçet’s disease, a cerebral space-occupying lesion should lead to a diagnosis of pseudotumor cerebri. The correct diagnosis will determine an appropriate therapy and may prevent an inappropriate neurosurgical approach. The cortico and immunotherapy allowed a substantial regression of the lesion.
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Affiliation(s)
- Maria Inês Rodrigues
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Cláudia Loureiro
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Ana Geraldo Couceiro
- Neuro-Radiology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Cidalina Reis Ferreira
- Inflammation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Manuel Monteiro-Grillo
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
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Noel N, Hutié M, Wechsler B, Vignes S, Le Thi Huong-Boutin D, Amoura Z, Dormont D, Delcey V, Polivka M, Cacoub P, Saadoun D. Pseudotumoural presentation of neuro-Behcet's disease: case series and review of literature. Rheumatology (Oxford) 2012; 51:1216-25. [PMID: 22337940 DOI: 10.1093/rheumatology/ker449] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To describe the pseudotumoural presentation of neuro-Behçet's disease (NBD). METHODS We report here the main characteristics, treatment and outcome of 23 patients (5 personal cases and 18 patients from the literature) with a pseudotumoural presentation of NBD. Pseudotumoural NBD patients were compared with 69 consecutive patients, with a classical form of NBD. RESULTS The median age was 39 (range 27-48 years) years, with a male predominance (65.2%). Clinical features of the pseudotumoural NBD included hemi- or tetra-pyramidal symptoms (n = 20), headache (n = 17), cerebellar syndrome (n = 3), sphincter impotence (n = 3) and pseudobulbar signs (n = 2). CNS imaging showed pseudotumoural lesions mainly in the capsulo-thalamic area (69.6 vs 11.6% for classical NBD; P < 0.01). Histological analysis revealed necrotic lesions with perivascular inflammatory infiltrate without signs of tumoural or infectious lesions. Patients with pseudotumoural NBD had more severe initial disability status (Rankin's score ≥3 in 65.2 vs 24.7%; P < 0.01) and had a 3 years' longer duration between neurological signs and BD diagnosis (P = 0.01) compared with patients with classical NBD. Treatment consisted of CSs (n = 21, 95.5%) and immunosuppressive agents (n = 10, 35.7%) that led to complete clinical and imaging remission in 60.9% of patients. Two (8.7%) of the 23 patients with pseudotumoural NBD died of bedridden state complications. CONCLUSION The pseudotumoural form of NBD is a rare and life-threatening condition.
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Affiliation(s)
- Nicolas Noel
- Service de Médecine Interne, AP-HP, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris F-75013, France
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Association of amyotrophic lateral sclerosis and Behcet's disease: is there a relationship? A multi-national case series. Clin Rheumatol 2012; 31:733-8. [PMID: 22234492 DOI: 10.1007/s10067-011-1923-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 12/16/2011] [Indexed: 12/11/2022]
Abstract
Neurological involvement may be seen in 5-30% of the patients with Behcet's disease (BD). Occasionally, parenchymal neurological involvement in BD can present as a spinal cord syndrome. However, motor neuron disease-like presentation is extremely uncommon. Here we are reporting five patients (all male; median age, 38) fulfilling both International Study Group criteria for BD and El Escorial criteria for amyotrophic lateral sclerosis (ALS). These patients were identified by a questionnaire sent to the members of the Neuro-Behcet Study Group of the International Study Group for BD. Three out of five patients had only motor presentations. In two patients, sensory and urinary manifestations were present as well. Spinal cord MRIs were normal in all, and brain MRIs were normal in four patients; one patient had nonspecific white matter changes. Two patients passed away 1-3 years after diagnosis of ALS, and two patients were lost to follow-up 3 and 11 years after admission; one patient is still alive 3 years after onset. The patients that are presented here might represent a rare form of neurological involvement in BD as well as sole coincidence. Larger prospective series are needed to further answer this issue.
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Infliximab for patients with neuro-Behcet's disease: case series and literature review. Clin Rheumatol 2011; 30:1007-12. [DOI: 10.1007/s10067-011-1726-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 02/24/2011] [Indexed: 10/18/2022]
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Borhani-Haghighi A, Safari A. Comment on “cerebral venous thrombosis in Behcet’s disease: a systematic review”. J Neurol 2011; 258:910-1. [DOI: 10.1007/s00415-011-5968-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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