Neuroimaging findings in rheumatologic disorders

Cerebrovascular Involvement in Systemic Sclerosis

Systemic sclerosis (SSc) is a chronic autoimmune rheumatic disease characterized by vascular damage, immune system dysregulation and fibrosis. The hallmark features include microvascular alterations and progressive tissue fibrosis, affecting skin, internal organs as well central and peripheral nervous system, adding to the disease's complexity and influencing overall outcomes. Of note, SSc has also been linked to macrovascular and cardiovascular involvement, including cerebrovascular damage as observed in stroke. Indeed, advanced neuroimaging is highly recommended for assessing cerebrovascular status in overt SSc to evaluate the complex interactions between cerebrovascular dysfunction and brain tissue damage and/or inflammation. Cerebral vasospasm detected by angiography, as well as an increase in subclinical cerebrovascular atherosclerosis observed by ultrasonography (carotid intimal medial thickness), are predictive for elevated stroke risk. Furthermore, a significant brain hypoperfusion detected by magnetic resonance imaging, along with white matter focal and/or diffuse signal abnormalities in SSc, have been found associated with concomitant peripheral microvascular damage detectable by "Active" and "Late" nail fold video capillaroscopy scleroderma patterns. Finally, the presence of calcifications in small arteries and arterioles found postmortem in the brain of SSc patients reinforces the hypothesis that SSc is associated with brain vascular remodeling. Furthermore, the current state of art shows an increased risk of cerebrovascular events in the SSc, confirmed by neuroimaging. Given the lack of updated comprehensive reviews on cerebrovascular involvement in SSc, we gathered the most relevant evidence on central nervous system damage, highlighting the underlying mechanisms, clinical implications, and potential advantages that neuroimaging may provide for its early detection.

Neurological involvement in patients with systemic autoimmune rheumatic diseases: a descriptive study in an Egyptian cohort

Background

Neurologic manifestations in the systemic autoimmune rheumatic diseases (SARDs) are protean. They add to the disease burden and could contribute to mortality. Increasing awareness about the neuro-rheumatologic syndromes might help with early diagnosis and effective therapy. Our aim is to survey the clinical and imaging patterns of neurological involvement in Egyptian patients with SARDs.

Results

Neurological involvement is common in Behçet’s disease (BD) (12.7%) and systemic lupus erythematosus (SLE) (6.4%) patients compared with other SARDs. Compared with SLE, neurological involvement in BD tends to develop at an older age (31 ± 7.1 versus 28.3 ± 9.6 years = 0.022) with a greater progression risk (13.8% versus 2.6%, P = 0.003). A higher proportion of SLE patients had abnormal neuroimaging without neurological symptoms (15.7% versus 4.3%, P = 0.026, OR = 4.9, 95%CI 1.1–22.4). SLE patients had a higher frequency of seizures (31.3% versus 6.4%, P < 0.001, OR = 6.7, 95%CI 2.7–16.7) and benign intracranial hypertension (9.6% versus 1.1%, P = 0.009, OR = 9.8, 95%CI 1.2–77.7) but a lower prevalence of quadriplegia due to brain insult (1.7% versus 3.2%, P = 0.045, OR = 0.2, 95%CI 0.04–0.9), dural sinus thrombosis (13% versus 33%, P = 0.001, OR = 0.3, 95%CI 0.2–0.6), brainstem syndrome (0.9% versus 6.4%, P = 0.047, OR = 0.1, 95%CI 0–1.1) and cranial neuropathies (9.6% versus 31.9%, P < 0.001, OR = 0.2, 95%CI 0.1–0.5). Concerning neuroimaging, brain atrophic changes were more common (27.4% versus 9.5%, P = 0.002, OR = 3.6, 95%CI 1.6–8.3) while thrombosis was less prevalent (36.3% versus 53.6%, P = 0.016, OR 0.5, 95%CI = 0.3–0.9) in lupus patients. The cerebral cortex was more commonly affected (20.4 versus 4.8%, P = 0.002, OR = 5.1, 95%CI 1.7–15.4) while dural sinuses (14.2% versus 40.5%, P < 0.001, OR = 0.2, 95%CI 0.1–0.5), basal ganglia (1.8% versus 10.7%, P = 0.010, OR = 0.2, 95%CI 0–0.7), diencephalon (0% versus 13.1%, P < 0.001) and brainstem (1.8% versus 22.6%, P < 0.001, OR = 0.1, 95%CI 0–0.3) were less frequently involved in SLE patients. Concerning other SARDs, cranial neuropathies were the most common neurological presentations. Abnormalities in neuroimaging did not correlate with the patients’ clinical presentations.

Conclusions

Neurological presentations associated with SARDs are protean. Neuroimaging abnormalities should be interpreted within the context of the clinical picture and the results of other investigations.

Extrapulmonary sarcoidosis

Sarcoidosis is a chronic disease of unknown origin that develops when a genetically susceptible host is exposed to an antigen, leading to an exuberant immune response characterized by granulomatous inflammation. Although lung involvement is almost universal as well as the leading cause of morbidity and mortality, virtually any organ can be affected. In particular, sarcoidosis of the heart, nervous system, and eyes can be devastating, leading to death, debilitation and blindness, and a multidisciplinary approach involving expert specialists is required for prompt diagnosis and appropriate treatment. Sarcoidosis of the skin can be disfiguring, thus posing a substantial psychologic and social impact on the patients. The diagnosis is often straightforward in the presence of compatible clinical manifestations in patients with biopsy-proven sarcoidosis, but is challenging when extrapulmonary signs/symptoms occur in isolation. Corticosteroids remain the first line therapy, with immunosuppressive or biologic agents being reserved to patients failing or experiencing side effects from steroids or developing refractory disease.

Central Nervous System Imaging in Rheumatic Diseases

Central nervous system (CNS) involvement is seen across a variety of rheumatic diseases. Common CNS manifestations include cerebrovascular events (such as ischemic and hemorrhagic strokes, cerebral venous sinus thrombosis), seizures, headaches, demyelinating lesions (such as optic neuritis, myelitis, parenchymal lesions), meningeal disease (leptomeningeal and pachymeningeal involvement, meningitis), and others. While most patients have other systemic symptoms of their rheumatic disease at the time of developing neurologic complications, some may present with CNS disease as the first symptom of their rheumatic disease. This review discusses rheumatic diseases with CNS manifestations and provides neuroimaging findings observed among affected individuals.

Central nervous system manifestations in rheumatic diseases

As the role of neurologists in managing patients with rheumatic diseases expands, collaboration between rheumatologists and neurologists becomes increasingly vital. This literature review provides an overview of the central nervous system (CNS) manifestations of major autoimmune rheumatic disorders, which may include parenchymal brain and meningeal disease (stroke, meningoencephalitis, meningitis), myelopathies, psychosis, chorea, seizure disorders, and various forms of cephalea. Novel findings linking specific autoimmune markers to CNS damage reveal a direct, previously underestimated link between systemic inflammation and neural injury. Besides, with the increasing use of biological therapies, it is crucial to recognize when neurological manifestations are related to adverse events of therapy, as this may significantly influence treatment decisions. Neurologists play a key role in this assessment, working closely with rheumatologists. Overall, addressing CNS involvement in rheumatic diseases is important for improving patient outcomes and advancing medical knowledge in this complex field. A thorough understanding of the neurologic aspects of rheumatic diseases is essential for optimal patient care, necessitating a multidisciplinary approach to management.

Cardiac sarcoidosis and neurosarcoidosis - multidisciplinary approach for diagnosis

PURPOSE OF REVIEW

The current review aims to highlight the role of multidisciplinary approach in the diagnosis of patients with cardiac and neurosarcoidosis. Multidisciplinary approach integrates the available clinical information, imaging and histopathological results aiming to reach a definite or at least provisional diagnosis and allow appropriate management. Multidisciplinary approach is the reference standard for diagnosis of interstitial lung disease and should be strongly considered in complex clinical conditions such as cardiac sarcoidosis (CS) and neurosarcoidosis.

RECENT FINDINGS

Histopathological confirmation of noncaseating granulomatous inflammation provides a definite diagnosis of sarcoidosis involving any organ. However, a provisional high confidence or even definite clinical diagnosis can be reached using multidisciplinary evaluation of all available evidence. The diagnosis of cardiac sarcoidosis and neurosarcoidosis requires the integration of different expertise based on the current diagnostic criteria sets. Identifying typical or at least compatible patterns on advanced imaging modalities (CMR and Fluro-Deoxy-Glucose Positron Emission Tomography (FDG-PET)) seems key for the diagnosis of CS, while a confident diagnosis of extra-cardiac disease supports an at least provisional diagnosis. Similarly, in neurosarcoidosis integrating compatible MRI appearances and cerebrospinal fluid results in patients with systemic sarcoidosis allows an at least provisional diagnosis. Exclusion of alternative differential diagnoses is crucial and requires high clinical suspicion, imaging review expertise and appropriate tests performance.

SUMMARY

There have been considerable advances in the diagnostic approach of patients with cardiac and neurosarcoidosis. Multidisciplinary approach for both diagnosis and management is required to reach a confident clinical diagnosis and should be applied when possible.

Imaging of Vasculitis Associated with Systemic Disease

Vasculitides are characterized by inflammation of the vessel wall, with their categorization relying on clinical and paraclinical manifestations, vessel type, size, distribution, histological attributes, and associated conditions. This review delves into the salient neuroimaging hallmarks of central nervous system vasculitis associated with the most prevalent systemic diseases and highlightings potential pitfalls and diagnostic confounders.

Insights into Magnetic Resonance Imaging Findings in Central Nervous System Paracoccidioidomycosis: A Comprehensive Review

Paracoccidioidomycosis (PCM) is a infection caused by the thermodimorphic fungus Paracoccidioides spp. (P. lutzii and, mainly, P. brasiliensis). This infection predominantly affects rural male workers aged between 30 and 50 years old who deal with soil on daily activities. Clinically, the disease is classified as acute/subacute phase, which evolves rapidly, secondary to dissemination of the fungus through to the phagocytic-mononuclear system, leading to fever, weight loss, and anorexia, associated with hepatosplenomegaly and lymphadenopathy, which can be complicated with suppuration and fistulization; and chronic phase, which corresponds to 74% to 95% of symptomatic cases, with a common pulmonary involvement. Central nervous system involvement is almost always a characteristic of the chronic form. Inhalation is the most common route of primary infection, usually affecting the lungs, forming the primary complex. From the primary complex, hematogenic dissemination can occur to any organ, including the brain and spinal cord. Although PCM of the central nervous system diagnosis is usually based on histopathological analysis and the imaging features are not specific for PCM, computed tomography and magnetic resonance imaging can demonstrate evidences of granuloma, abscess, meningitis, or a combination of these lesions, contributing to a preoperative diagnosis, especially when considered in conjunction with epidemiology. In this article, we review the pathophysiology, clinical manifestations and imaging aspects of neuro-PCM.

Neurosarcoidosis: Diagnostic Challenges and Mimics A Review

PURPOSE OF REVIEW

Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis.

RECENT FINDINGS

Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.

Non-traumatic Acute Subdural Hematoma in a Patient With Scleroderma Complicated by Pulmonary Arterial Hypertension: A Case Report

Non-traumatic acute subdural hematoma (SDH) in patients with scleroderma is infrequently described in literature reviewing the neurologic disorders in scleroderma. We report a case of a patient with scleroderma complicated by severe pulmonary arterial hypertension (PAH), and a history of pulmonary embolism on warfarin who developed an SDH, requiring hemicraniectomy after initiating therapy with IV epoprostenol. The proposed mechanisms for SDH development and management strategy are discussed.

Imaging of Central Nervous System Autoimmune, Paraneoplastic, and Neuro-rheumatologic Disorders

OBJECTIVE

This article provides an overview of the imaging modalities used in the evaluation of central nervous system (CNS) autoimmune, paraneoplastic, and neuro-rheumatologic disorders. An approach is outlined for interpreting imaging findings in this context, synthesizing a differential diagnosis based on certain imaging patterns, and choosing further imaging for specific diseases.

LATEST DEVELOPMENTS

The rapid discovery of new neuronal and glial autoantibodies has revolutionized the autoimmune neurology field and has elucidated imaging patterns characteristic of certain antibody-associated diseases. Many CNS inflammatory diseases, however, lack a definitive biomarker. Clinicians should recognize neuroimaging patterns suggestive of inflammatory disorders, as well as the limitations of imaging. CT, MRI, and positron emission tomography (PET) modalities all play a role in diagnosing autoimmune, paraneoplastic, and neuro-rheumatologic disorders. Additional imaging modalities such as conventional angiography and ultrasonography can be helpful for further evaluation in select situations.

ESSENTIAL POINTS

Knowledge of imaging modalities, both structural and functional, is critical in identifying CNS inflammatory diseases quickly and can help avoid invasive testing such as brain biopsy in certain clinical scenarios. Recognizing imaging patterns suggestive of CNS inflammatory diseases can also facilitate the early initiation of appropriate treatments to diminish morbidity and future disability.

Association of intracranial abnormalities with the development of epilepsy and drug-resistant epilepsy in patients with Parry-Romberg syndrome

BACKGROUND

Epilepsy represents an essential component of Parry Romberg syndrome (PRS). This study aimed to identify clinical factors that influence the development of epilepsy and drug-resistant epilepsy (DRE) in PRS.

METHODS

We retrospectively reviewed the medical records of eighty patients with PRS. Data including the age of onset for PRS, history of seizures, use and timing of immunotherapy, antiseizure medication use, and EEG and brain imaging findings were reviewed. For comparison with the patients with epilepsy (PRSe+) group, we selected 18 age and sex-matched controls from the patient without epilepsy (PRSe-) cohort using propensity score matching.

RESULTS

Eighteen (22.5%) had epilepsy: 12 were female, and the median age was 14.5 years (range = 6-48 years). Eleven patients developed DRE. The median latency between the onset of cutaneous manifestations and diagnosis and timing and use of immunotherapy was similar between the PRSe + and PRSe- groups. Intracranial abnormalities were commonly seen in the PRSe + group (16 vs. 2, p < 0.01). White matter disease and ipsilateral atrophy were common among the PRSe + group. Timing and use of immunotherapy, epileptiform discharges, and brain imaging abnormalities did not differ between those with DRE and without.

CONCLUSIONS

The presence and degree of severity of ipsilateral brain abnormalities are risk factors for the development of epilepsy in PRS but not factors in predicting drug resistance. The timing of immunotherapy did not influence the development of PRSe + or DRE. Prospective studies are needed to identify biomarkers for epilepsy and assess the role of immunotherapy on seizure outcomes in PRSe + .

A Rare Case of Neurosarcoidosis Overlapped with Sjogren’s Syndrome

The coexisting of sarcoidosis and Sjögren’s syndrome (SS) has long been neglected since sarcoidosis is considered as an exclusion criterion for SS. We described a 55-year-old woman, who was diagnosed with coexisting neurosarcoidosis and Sjögren’s syndrome for 16 years. She presented with erythema nodosum, progressive sensory and motor impairment of the extremities, dry mouth, and dry eyes. High-resolution computed tomography (HRCT) of the chest showed symmetrical pulmonary micronodules, interstitial changes, and enlarged mediastinal lymph nodes. Spine magnetic resonance imaging (MRI) showed syringomyelia and thickening of the T3-9 spinal cord. She was with positive ANA and anti-SSA antibodies, impaired function of the lacrimal, salivary gland and renal tubules. Biopsy of skin and lung nodules revealed non-caseous granuloma. Salivary gland biopsy showed focal lymphocyte infiltration. Classification criteria for sarcoidosis and Sjogren’s syndrome were fulfilled in this patient based on clinical and laboratory features. This case extends our understanding of overlapped Sjogren’s syndrome with sarcoidosis and provides a referential value for clinical diagnosis.