Cerebral vasculitis secondary to Wegener's granulomatosis: computed tomography and angiographic findings

Hemorrhagic complications associated with PR3-ANCA crescentic glomerulonephritis

Hemorrhagic complications of anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis are life-threatening conditions. Of these, alveolar hemorrhage is the most common and well-described hemorrhagic complication and is a prominent component of the pulmonary-renal syndrome. The clinical presentation of alveolar hemorrhage is highly variable ranging from mild to serious disease that may require respiratory support. Less attention has been directed at hemorrhagic complications that have been reported in other organs and which may be as severe or more severe with regard to morbidity and mortality. For example, among the most serious non-pulmonary complications are those related to cerebral and gastrointestinal hemorrhage. Cerebral hemorrhage is the clearly the most critical issue with a persistent high mortality rate. The prognosis of gastrointestinal hemorrhage, once an ominous complication has improved with medical and surgical intervention. Not to be dismissed are the consequences of hemorrhagic issues related to skin, soft tissue or muscle involvement. Muscle hematomas, while rare, also accompanied by significant morbidity.

[Sinonasal and cerebral imaging findings in Wegener's granulomatosis]

Sinonasal CT must be studied with both soft tissue and bone algorithms. Sinonasal findings in Wegener's granulomatosis are mucosal thickening, subtotal opacification, air-fluid level, bony destruction (mainly of the nasal septum), and sclerosing osteitis. Orbital MRI helps to define the extent of the disease. Contiguous granulomatous infiltration of the orbit appears dark (hypointense signals) on both T2-weighted-and T1-weighted images, but is enhanced after gadolinium administration. Cerebral MRI findings include diffuse linear dural thickening, enhanced by injection, and local dural thickening contiguous with orbital, nasal and paranasal disease. The remote granulomatous lesions in brain parenchyma are the least common form of central nervous system lesion. The pituitary gland and infundibulum can also be involved in Wegener's granulomatosis. These imaging findings of Wegener's granulomatosis are nonspecific. They should be combined with clinical examination and c-ANCA tests to confirm the diagnosis.

Wegener Granulomatosis With Massive Intracerebral Hemorrhage

Wegener granulomatosis (WG) is a multisystem necrotizing vasculitis that primarily involves the upper and lower respiratory tract and kidneys but can affect almost any organ, including the central nervous system (CNS). We present a patient with WG whose disease was complicated by a massive intracerebral hemorrhage (ICH) despite standard treatment with prednisone and cyclophosphomide. Although CNS involvement is not uncommon in WG, ICH is a rare complication of WG, and although the majority of patients with WG complicated by a cerebrovascular accident have a fatal outcome, our patient survived this event. The disease subsequently progressed with recurrent pulmonary involvement and renal failure. Our patient either did not tolerate or failed to respond to several immunosuppressive agents, including cyclophosphamide, methotrexate, and mycophenolate mofetil, but achieved remission after treatment with rituximab.

A Patient With Wegener Granulomatosis and Intraventricular Hemorrhage

We report a case of intraventricular hemorrhage (IVH) in a 27-year-old man with Wegener granulomatosis (WG), successfully treated with corticosteroids and cyclophosphamide. Neurologic manifestations occur in 22%-54% of patients with WG, with cerebral vasculitis in less than 5%. Only 2 cases of IVH associated with WG have been reported at autopsy. This is the first reported case of in situ IVH associated with WG in a patient who survived. In patients with WG who present with neurologic manifestations, cerebral vasculitis with secondary intracranial hemorrhage should be considered, as these patients are often resistant to immunosuppressive therapies and may present with normal angiograms.

Wegener granulomatosis: MR imaging findings in brain and meninges

PURPOSE

To determine the spectrum of intracranial magnetic resonance (MR) imaging appearances of Wegener granulomatosis.

MATERIALS AND METHODS

MR imaging studies in 19 patients with Wegener granulomatosis and possible central nervous system involvement were reviewed by two neuroradiologists. Intermediate-weighted and T2-weighted fast spin-echo MR images of the brain had been acquired in all patients, and spin-echo T1-weighted nonenhanced and gadolinium-enhanced images had been acquired in 18 patients.

RESULTS

MR imaging findings included diffuse linear dural thickening and enhancement (n = 6); focal dural thickening and enhancement contiguous with orbital, nasal, or paranasal disease (n = 5); infarcts (n = 4); nonspecific white matter areas of high signal intensity on intermediate-weighted and T2-weighted images (n = 10); enlarged pituitary gland with infundibular thickening and enhancement (n = 2); a discrete cerebellar lesion that was probably granulomatous in origin (n = 1); and cerebral (n = 8) and cerebellar atrophy (n = 2).

CONCLUSION

MR imaging demonstrated the wide spectrum of findings of central nervous system involvement in patients with Wegener granulomatosis and was particularly useful for the evaluation of direct intracranial spread from orbital, nasal, or paranasal disease.

Communicating hydrocephalus secondary to diffuse meningeal spread of Wegener's granulomatosis: case report and literature review

OBJECTIVE AND IMPORTANCE

We present a very unusual case of diffuse spread of Wegener's granulomatosis causing hydrocephalus.

CLINICAL PRESENTATION

A 53-year-old man presented in 1985 with bilateral middle ear infections requiring myringotomies. During the next 18 months, he went on to develop a left Bell's palsy. The patient then began to develop recurrent occipital headaches along with left sixth and seventh nerve palsies and a green nasal discharge requiring hospitalization. Workup included magnetic resonance imaging showing pronounced enhancement of the tentorium and meninges in the occipital region with normal ventricle size. An x-ray of the chest showed multiple pulmonary nodules. A regimen of prednisone and cyclophosphamide was initiated. The patient did well for 2 years until he again developed middle ear infections and headache. Serial lumbar punctures showed increased pressures. A circulating antineutrophil cytoplasmic antibody was positive. Cyclophosphamide was administered, with acetazolamide added for treatment of the elevated intracranial pressure. The patient stabilized for another 2 years but then presented in 1994 with recurrent headache, bilateral papilledema, and mild left arm and right leg weakness. A lumbar puncture was performed with an opening pressure of 52 cm H2O. Computed tomography of the head revealed moderate enlargement of the lateral third and fourth ventricles, consistent with communicating hydrocephalus.

INTERVENTION

A right frontal ventriculoperitoneal shunt was placed. A leptomeningeal biopsy performed at the side of catheter placement (far away from any meningeal enhancement revealed by magnetic resonance imaging) showed chronic meningitis and multinucleated giant cells. Cyclophosphamide therapy was begun again. The patient has not experienced recurrence of headache, cranial nerve deficits, or papilledema for more than 3 years.

CONCLUSION

This is the first reported case of diffuse involvement of the meninges from Wegener's granulomatosis. Fortunately, this patient responded well to shunting and sustained medical management. Although rare, Wegener's granulomatosis should be included in the differential diagnosis of chronic aseptic meningitis, communicating hydrocephalus, and papilledema.

Subdural and meaningful involvement related to Wegener's granulomatosis: case report

OBJECTIVE AND IMPORTANCE

The first case of Wegener's granulomatosis associated with subdural empyema is presented.

CLINICAL PRESENTATION

A 37-year-old man was admitted to our hospital for treatment of bilateral subdural masses. Magnetic resonance imaging demonstrated strong bilateral subdural and meningeal enhancement. The patient was treated with subdural drainage, based on the diagnosis of bilateral subdural hematoma or empyema as revealed by magnetic resonance imaging. Even after surgery, he developed systemic symptoms that are typical for Wegener's granulomatosis, including hemosputum, papules, peripheral nervous disorders, hematuria, myalgia, and joint pain. A diagnosis of Wegener's granulomatosis was confirmed by positive circulating antineutrophil cytoplasmic antibodies and histological findings from the skin and nasal mucosa. We diagnosed the subdural masses as Wegener's granulomatosis from the laboratory and neuroimaging studies, retrospectively.

INTERVENTION

Pus-like fluid containing hematoma with negative micro-organism was evacuated by surgery.

CONCLUSION

Wegener's granulomatosis should be suspected in young patients with pulmonary symptoms and subdural hematoma without head injury. This is the first case of Wegener's granulomatosis associated with subdural masses.

Neurological involvement in Wegener's granulomatosis: an analysis of 324 consecutive patients at the Mayo Clinic

Neurological involvement in Wegener's granulomatosis was studied by reviewing the charts of 324 consecutive patients in whom the diagnosis was made at the Mayo Clinic. One hundred nine patients (33.6%) had neurological involvement. Peripheral neuropathy occurred in 53; cranial neuropathy, in 21; external ophthalmoplegia, in 16; cerebrovascular events, in 13; seizures, in 10; cerebritis, in 5; and miscellaneous involvement, in 25. The mean age and sex ratio were similar in the patients with and those without neurological involvement. Among the patients with peripheral neuropathy, 42 had mononeuropathy multiplex; 6, distal symmetrical polyneuropathy; and 5, unclassified peripheral neuropathy. Multiple mononeuropathy was a major presenting symptom in 8 patients. A significantly higher percentage of patients with peripheral neuropathy, compared to those without peripheral neuropathy, had kidney involvement (p < 0.001). The second, sixth, and seventh cranial nerves were most frequently affected. Multiple cranial nerves were affected in 8 patients. Unusual neurological manifestations in the miscellaneous group were spastic paraparesis, temporal arteritis, Horner's syndrome, and papilledema.