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Kidd DP, Adams A. Cerebral infarction in Behçet's syndrome caused by obliterative focal arteritis. Neurol Sci 2024; 45:745-748. [PMID: 37851295 DOI: 10.1007/s10072-023-07135-7] [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: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 10/19/2023]
Abstract
We present a case in which cerebral infarction was seen and Behcet's syndrome was diagnosed. Following investigation and monitoring, we identified that the cause was a progressive obliterative focal arteritis of the middle cerebral artery. Such an entity has not previously been reported, although similar cases are described which explain the pathophysiology of the disorder.
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Affiliation(s)
- D P Kidd
- Behçet's Syndrome Centre of Excellence, Royal London Hospital, Whitechapel, London, E1 1BB, UK.
| | - A Adams
- Department of Neuroradiology, Royal London Hospital, Whitechapel, London, E1 1BB, UK
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2
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Kidd DP. Neurological involvement by Behçet's syndrome: clinical features, diagnosis, treatment and outcome. Pract Neurol 2023; 23:386-400. [PMID: 37775123 DOI: 10.1136/pn-2023-003875] [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] [Accepted: 08/11/2023] [Indexed: 10/01/2023]
Abstract
Neurological involvement in Behçet's syndrome arises predominately through an inflammatory meningoencephalitis characterised by perivenular inflammation due to activation of Th-17 immunological pathways. The brainstem is involved in 50% of cases, the diencephalon and other areas of the brain in 30%, and the spinal cord in 10%. Movement disorders and epilepsy may occur. Psychiatric syndromes may arise with brain and brainstem involvement, and cognitive disorders relate to the brain disease, to circulating inflammatory factors, and to fatigue and despondency. Eighty per cent of cases begin with a relapsing disease course, of whom 70% have only one attack, and 30% have a progressive disease course either from onset or following an initially relapsing course. Venous thrombosis leading to intracranial hypertension and cerebral venous infarction is less common and caused by inflammation in affected veins and a circulating prothrombotic state. Arterial involvement is rare and relates to an arteritis affecting large-sized and medium-sized vessels within the brain leading to infarction, subarachnoid and parenchymal haemorrhage, aneurysm formation and arterial dissection. There is a newly recognised disorder of cerebral cortical hypoperfusion. Cranial neuropathy, peripheral neuropathy and myositis are rare. There has been significant progress in understanding the pathophysiology and treatment of the systemic disease, leading to improved outcomes, but there has been no randomised trial of treatment in the neurological disorder.
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3
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Renson T, Hamiwka L, Benseler S. Central nervous system manifestations of monogenic autoinflammatory disorders and the neurotropic features of SARS-CoV-2: Drawing the parallels. Front Pediatr 2022; 10:931179. [PMID: 36034552 PMCID: PMC9399631 DOI: 10.3389/fped.2022.931179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/20/2022] [Indexed: 11/18/2022] Open
Abstract
Central nervous system (CNS) involvement in monogenic autoinflammatory disorders (AID) is increasingly recognized and can be life threatening. Therefore, a low threshold to consider CNS disease should be maintained in patients with systemic inflammation. Hyperinflammation is also a key feature of severe acute COVID-19 and post COVID-19 entities such as multisystem inflammatory syndrome in children. Like AID, COVID-19 patients can present with severe CNS involvement. The impact of COVID-19 on AID and CNS involvement in particular is still obscure, nevertheless dreaded. In the current review, we synthesize the spectrum of CNS manifestations in monogenic AID. We explore common pathophysiological and clinical features of AID and COVID-19. Moreover, we assess the impact of immune dysregulation associated with SARS-CoV-2 infections and post COVID-19 hyperinflammation in AID. The striking commonalities found between both disease entities warrant caution in the management of AID patients during the current pandemic.
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Affiliation(s)
- Thomas Renson
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Lorraine Hamiwka
- Division of Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Susanne Benseler
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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4
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Hamid M, Adan K, Satte A, Bourazza A. Chorea in Neuro-Behçet's Disease. Cureus 2021; 13:e19039. [PMID: 34853756 PMCID: PMC8608035 DOI: 10.7759/cureus.19039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 12/05/2022] Open
Abstract
Behçet’s disease (BD) was described as a multisystemic recurrent inflammatory disorder of unknown cause comprising uveitis, skin lesions, recurrent genital, and oral ulcers. Involvement of the central nervous system in BD is about 10-25%. Chorea is defined as a hyperkinetic movement disorder, which can be caused by different etiologies. It was rarely mentioned in the literature as a manifestation of neuro-Behçet’s disease (NB). Radiological lesions are predominant in basal ganglia and periventricular white matter. The evolution of chorea in NB is variable in literature studies. We present a rare case of parenchymal NB with chorea.
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Affiliation(s)
- Mohamed Hamid
- Department of Neurology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
| | - Kadira Adan
- Department of Neurology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
| | - Amal Satte
- Department of Neurophysiology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
| | - Ahmed Bourazza
- Department of Neurology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
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Sabiry S, Abdulhakeem Z, Bellakhdar S, El Moutawakil B, Rafai MA, El Otmani H. Posterior cerebral arteritis revealing Behçet disease in an adolescent. JOURNAL DE MEDECINE VASCULAIRE 2020; 45:298-299. [PMID: 32862989 DOI: 10.1016/j.jdmv.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/07/2020] [Indexed: 06/11/2023]
Affiliation(s)
- S Sabiry
- Department of neurology and Clinical neurophysiology, Hassan II University of Casablanca, IBN ROCHD University Hospital, 1, rue des Hôpitaux, Casablanca, Morocco.
| | - Z Abdulhakeem
- Department of neurology and Clinical neurophysiology, Hassan II University of Casablanca, IBN ROCHD University Hospital, 1, rue des Hôpitaux, Casablanca, Morocco
| | - S Bellakhdar
- Department of neurology and Clinical neurophysiology, Hassan II University of Casablanca, IBN ROCHD University Hospital, 1, rue des Hôpitaux, Casablanca, Morocco
| | - B El Moutawakil
- Department of neurology and Clinical neurophysiology, Hassan II University of Casablanca, IBN ROCHD University Hospital, 1, rue des Hôpitaux, Casablanca, Morocco
| | - M A Rafai
- Department of neurology and Clinical neurophysiology, Hassan II University of Casablanca, IBN ROCHD University Hospital, 1, rue des Hôpitaux, Casablanca, Morocco
| | - H El Otmani
- Department of neurology and Clinical neurophysiology, Hassan II University of Casablanca, IBN ROCHD University Hospital, 1, rue des Hôpitaux, Casablanca, Morocco
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Yin H, Song Y, Zheng M, Han J, Tang J. Behcet's Disease With Cerebral Artery Infarction Caused by Cerebral Arteritis as an Early Symptom Only With Elevated Interleukin-8. Front Neurol 2019; 10:1102. [PMID: 31695669 PMCID: PMC6817676 DOI: 10.3389/fneur.2019.01102] [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: 06/04/2019] [Accepted: 10/01/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Behcet's disease (BD) is multi-systemic vasculitis, which generally is repeated oral and genital ulcerations as well as ocular and skin lesions. Today, the pathogenesis of BD remains mostly unknown. It is also suggested that the disease is probably related to autoinflammatory and autoimmune disorders, and innate immunity damages were perceived as key in its pathologic process. Only 5% of BD patients have neurological involvement, and it usually occurs in 4–6 years after the initial symptoms. Early onset of neurological impairment makes it difficult to diagnose and treat definitely. Case Presentation: A 38-year-old man was admitted to our hospital with numbness and weakness of the left extremities. Diffusion magnetic resonance imaging (MRI) revealed focal infarction in the posterior limb of the internal capsule. Skin pathology suggested small vessel vasculitis, and high-resolution MRI revealed intracranial arteritis. The patient had a negative skin pathery test and then developed a scar at the venous puncture site at the early stage of disease. Laboratory examination showed that interleukin 8 (IL-8) increased. The patient was treated with an immunosuppressive agent including mycophenolate mofetil, hydroxychloroquine, and colchicine. All symptoms were alleviated after half a year's treatment. There was neither stroke nor recurrence of oral ulcer thereafter. Conclusion: This case demonstrates that neurological involvement might be an early symptom of BD. IL-8 could act as a novel target for the treatment of BD theoretically and probably play a key role in disease recovery.
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Affiliation(s)
- Hao Yin
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yun Song
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Meimei Zheng
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Ju Han
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jiyou Tang
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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Brenière C, Blanc C, Devilliers H, Samson M, Delpont B, Bielefeld P, Besancenot JF, Giroud M, Béjot Y. Associated arterial and venous cerebral manifestations in Behçet's disease. Rev Neurol (Paris) 2018; 174:337-341. [PMID: 29704959 DOI: 10.1016/j.neurol.2017.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 06/23/2017] [Accepted: 06/27/2017] [Indexed: 10/17/2022]
Abstract
Behçet's disease is a rare multisystemic vasculitis with an etiology that is still unknown. Neurological manifestations may be seen in approximately 5-15% of patients, and both parenchymal and extraparenchymal neurological involvement has been described. When cerebral venous thrombosis (CVT) is the main extraparenchymal manifestation of Behçet's disease, the condition is then dubbed "angio-Behçet's syndrome". However, arterial involvement is extremely rare, with only one reported case of vasculo-neuro-Behçet's disease, characterized by both venous and intracranial arterial involvement - until now. This report is of two patients diagnosed with Behçet's disease characterized by the concomitant presence of both cerebral arterial manifestations and CVT.
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Affiliation(s)
- C Brenière
- Dijon Stroke Registry, EA7460, department of neurology, university hospital and medical school of Dijon, university of Burgundy, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - C Blanc
- Dijon Stroke Registry, EA7460, department of neurology, university hospital and medical school of Dijon, university of Burgundy, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - H Devilliers
- Department of internal medicine, university hospital of Dijon, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - M Samson
- Department of internal medicine, university hospital of Dijon, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - B Delpont
- Dijon Stroke Registry, EA7460, department of neurology, university hospital and medical school of Dijon, university of Burgundy, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - P Bielefeld
- Department of internal medicine, university hospital of Dijon, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - J-F Besancenot
- Department of internal medicine, university hospital of Dijon, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - M Giroud
- Dijon Stroke Registry, EA7460, department of neurology, university hospital and medical school of Dijon, university of Burgundy, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - Y Béjot
- Dijon Stroke Registry, EA7460, department of neurology, university hospital and medical school of Dijon, university of Burgundy, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France.
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Abstract
OPINION STATEMENT Management of neuro-Behçet's disease can be divided into two stages: treatment of acute attacks and prevention of relapses. Treatment of acute attacks is accomplished by high-dose intravenous corticosteroids followed by maintenance treatment with oral steroids for 6-12 months depending on the type and severity of the neurological involvement. Relapses can be prevented by using immunosuppressants. Oral immunosuppressants such as azathioprine and mycophenolate are the most widely utilized agents for this purpose. Patients who are refractory or who cannot tolerate these medications can be managed by cyclophosphamide, interferon alpha, or anti-TNF-α monoclonal antibodies such as infliximab, etanercept, and adalimumab. Recent reports showed that newer agents such as tocilizumab, canakinumab, and anakinra, which exert their biological activity through IL-1 and IL-6 pathways, are also promising treatment alternatives for progressive or relapsing patients.
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Affiliation(s)
- Murat Kürtüncü
- Istanbul Faculty of Medicine, Department of Neurology, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Institute of Experimental Medicine and Research, Department of Neuroscience, Istanbul University, Istanbul, Turkey
| | - Gulsen Akman-Demir
- School of Medicine, Department of Neurology, Istanbul Bilim (Science) University, Istanbul, Turkey.
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Yoshimura S, Ago T, Koga M, Kamouchi M, Kitazono T. Cerebral Small-Vessel Disease in Neuro-Behçet Disease. J Stroke Cerebrovasc Dis 2015; 24:e237-9. [PMID: 26123875 DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/05/2015] [Accepted: 05/11/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Involvement of central nervous system is very common in Behçet disease, known as neuro-Behçet disease (NBD). However, there have been few reports which evaluated stroke-like cerebral small-vessel disease associated with Behçet disease. OBJECTIVE We evaluated cerebral small-vessel lesions by using magnetic resonance imaging in 2 patients with NBD. CLINICAL CASES In a 41-year-old woman case, who developed dysarthria and left hemiparesis, diffusion-weighted images (DWI) showed small high-intensity areas in the bilateral internal capsule. The right lesion had a low apparent diffusion coefficient (ADC) value, whereas the left one had a high value. In a 59-year-old woman case, who developed dysarthria and left hemihypesthesia, DWI showed high-intensity areas in the right side of the pons and in the right peduncle of the midbrain. The lesion in the pons had a low ADC value, whereas the lesion in the midbrain had a high value. ADC map may be useful to identify symptomatic lesions in the brain, because only the lesions with low ADC values were symptomatic. CONCLUSIONS NBD should be considered in those who had not had any risk factors for ischemic stroke but experienced cerebral small-vessel disease.
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Affiliation(s)
- Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Tetsuro Ago
- Department of Nephrology, Hypertension, and Strokology, Kyushu University Hospital, Fukuoka, Japan; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatoshi Koga
- Division of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masahiro Kamouchi
- Department of Nephrology, Hypertension, and Strokology, Kyushu University Hospital, Fukuoka, Japan; Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Nephrology, Hypertension, and Strokology, Kyushu University Hospital, Fukuoka, Japan; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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10
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Koike Y, Sakai N, Umeda Y, Umeda M, Oyake M, Fujita N. [A case of Behçet disease developing recurrent ischemic stroke with fever and scrotal ulcers]. Rinsho Shinkeigaku 2015; 55:428-31. [PMID: 26103818 DOI: 10.5692/clinicalneurol.cn-000682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 30-year-old man, who was diagnosed with Behçet disease at 10 years of age, was hospitalized because of transient right hemiparesis after presenting with high fever and scrotal ulcers. Brain MRI revealed ischemic lesions in the area supplied by the anterior cerebral arteries. Analysis of cerebrospinal fluid (CSF) showed pleocytosis and a high interleukin-6 (IL-6) concentration (668 pg/ml). The patient was diagnosed with acute ischemic stroke associated with exacerbation of Behçet disease. After initiation of corticosteroid therapy, his clinical symptoms improved, and the CSF IL-6 concentration decreased. One year later, the patient developed high fever and scrotal ulcers after the onset of transient left upper limb plegia. Brain MRI showed an acute ischemic lesion in the right putamen, and CSF analysis showed an elevated IL-6 concentration (287 pg/ml). Brain CT angiography revealed stenosis of the left anterior cerebral artery and occlusion of the right anterior cerebral artery, which had been well visualized one year previously. Involvement of the intracranial cerebral arteries in Behçet disease is extremely rare. To the best of our knowledge, this is the first case report of a patient with recurrent symptomatic ischemic stroke associated with high fever and scrotal ulcers, which suggests exacerbation of Behçet disease.
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Affiliation(s)
- Yuka Koike
- Department of Neurology, Nagaoka Red Cross Hospital
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11
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Mazzoccoli G, Matarangolo A, Rubino R, Inglese M, De Cata A. Behçet syndrome: from pathogenesis to novel therapies. Clin Exp Med 2014; 16:1-12. [PMID: 25447032 DOI: 10.1007/s10238-014-0328-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 11/22/2014] [Indexed: 12/11/2022]
Abstract
Behçet syndrome is a chronic disease hallmarked by inflammation of the blood vessels that is related to an autoimmune reaction caused by inherited susceptibility due to specific genes and environmental factors, probably components of infectious microorganisms, which turn on or get going the disease in genetically susceptible subjects. The more common clinical expression of the disease is represented by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis, sometimes associated with inflammatory arthritis, phlebitis, iritis, as well as inflammation of the digestive tract, brain, and spinal cord. The treatment strategies used to manage the manifestations of Behçet syndrome have gradually progressed, and a number of new therapeutic resources have been implemented in recent years, allowing better control of pathogenic mechanisms, reducing symptoms and suffering, and ameliorating patient's outcome.
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Affiliation(s)
- Gianluigi Mazzoccoli
- Division of Internal Medicine and Chronobiology Unit, Department of Medical Sciences, IRCCS Scientific Institute and Regional General Hospital "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy.
| | - Angela Matarangolo
- Division of Internal Medicine and Rheumatology Unit, Department of Medical Sciences, IRCCS Scientific Institute and Regional General Hospital "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - Rosa Rubino
- Division of Internal Medicine and Chronobiology Unit, Department of Medical Sciences, IRCCS Scientific Institute and Regional General Hospital "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - Michele Inglese
- Division of Internal Medicine and Rheumatology Unit, Department of Medical Sciences, IRCCS Scientific Institute and Regional General Hospital "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy
| | - Angelo De Cata
- Division of Internal Medicine and Rheumatology Unit, Department of Medical Sciences, IRCCS Scientific Institute and Regional General Hospital "Casa Sollievo della Sofferenza", San Giovanni Rotondo, FG, Italy.
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12
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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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13
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Noel N, Drier A, Wechsler B, Piette JC, De Paz R, Dormont D, Cacoub P, Saadoun D. [Neurological manifestations of Behçet's disease]. Rev Med Interne 2013; 35:112-20. [PMID: 24290030 DOI: 10.1016/j.revmed.2013.10.332] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/12/2013] [Indexed: 11/17/2022]
Abstract
Neurological manifestations of Behçet's disease (BD) occur in 5.3 to more than 50% of patients. They are divided into two major forms: "parenchymal" lesions, which include mainly meningoencephalitis as opposed to "extra-parenchymal" lesions (i.e. cerebral venous thrombosis and arterial aneurysms). Myelitis or peripheral neuropathy is exceptional. The neuro-Behçet syndrome (NBS) should be considered in the setting of neurological manifestations, particularly headache and pyramidal signs, in a young man diagnosed with BD. However, its recognition may be difficult when neurological manifestations are the presenting features of BD (one third of cases), and requires a thorough knowledge of clinical manifestations and morphological lesions. Thus, parenchymal NB lesions classically exhibit inflammatory characteristics on MRI and are located at the meso-diencephalic junction and in the brainstem, rarely with a supratentorial extension. Meningitis is not systematically associated, and may be absent in about 30% of cases. The pathogenesis of these lesions is incompletely understood, but inflammatory infiltrates include mainly neutrophils and activated T cells (mainly Th17). Differential diagnoses include infectious diseases (herpes, listeria, tuberculosis), and inflammatory diseases (i.e. multiple sclerosis and sarcoidosis). A prompt recognition of NBS should lead to initiate adequate therapies in order to limit the risk of sequelae, relapses or death.
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Affiliation(s)
- N Noel
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - A Drier
- Service de neuroradiologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - B Wechsler
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - J-C Piette
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France
| | - R De Paz
- Service de neurologie, groupe hospitalier Pitié-Salpétrière, AP-HP, 75013 Paris, France
| | - D Dormont
- Service de neuroradiologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France
| | - P Cacoub
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France
| | - D Saadoun
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France.
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14
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Tascilar NF, Akman-Demir G, Demiryurek BE, Tokgoz O, Akgun N, Ozen Barut B. An unusual case of neuro-Behçet's disease presenting with co-occurence of cerebral venous sinus thrombosis with basilar artery occlusion. Neurol Sci 2012; 34:785-8. [PMID: 22661102 DOI: 10.1007/s10072-012-1122-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/21/2012] [Indexed: 11/28/2022]
Abstract
Non-parenchymal neuro-Behçet disease generally affects cerebral venous sinuses, whereas intracranial intracerebral arterial involvement has been rarely reported. But co-involvement of both intracranial intracerebral artery and venous vascular systems in a patient at the same time has not been mentioned before. To the best of our knowledge, this case involving a 25-year-old male with a 7-year history of Behçet disease is the first reported of this type of involvement. He developed occlusion of the basilar artery together with thrombosis of the left sigmoid sinus, distal internal jugular vein, and straight sinus. He was successfully treated with a combination of high-dose steroid and cyclophosphamide. Cranial magnetic resonance angiography demonstrated the resolution of these abnormalities.
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Alkan A, Goktan A, Karincaoglu Y, Kamisli S, Dogan M, Oztanir N, Turan N, Kocakoc E. Brain perfusion MRI findings in patients with Behcet's disease. ScientificWorldJournal 2012; 2012:261502. [PMID: 22654579 PMCID: PMC3361152 DOI: 10.1100/2012/261502] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 12/08/2011] [Indexed: 11/17/2022] Open
Abstract
Objective. To search brain perfusion MRI (pMRI) changes in Behcet's disease (BD) with or without neurological involvement. Materials and Method. The pMRI were performed in 34 patients with BD and 16 healthy controls. Based on neurologic examination and post-contrast MRI, 12 patients were classified as Neuro-Behcet (group 1, NBD) and 22 patients as BD without neurological involvement (group 2). Mean transit time (MTT), time to peak (TTP), relative cerebral blood volume (rCBV), and relative cerebral blood flow (rCBF) were obtained and compared to those of healthy control group (group 3). Results. There was a significant difference in the MTT and rCBF within the pons and parietal cortex in groups 1 and 2. rCBV increased in cerebral pedicle in group 1 compared with groups 2 and 3. In the temporal lobe white matter, prolonged MTT and decreased rCBF were found in groups 1 and 2. In the corpus striatum, internal capsule, and periventricular white matter, rCBF increased in group 1 compared with group 3 and decreased in groups 1 and 2. Conclusion. Brain pMRI is a very sensitive method to detect brain involvement in patients with BD and aids the clinical diagnosis of NBD, especially in patients with negative MRI findings.
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Affiliation(s)
- Alpay Alkan
- Department of Radiology, School of Medicine, Bezmialem Vakif University, İstanbul, Turkey. alpay
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Abstract
PURPOSE OF REVIEW To review the current literature of childhood central nervous system vasculitis, and to discuss a tailored approach to diagnosis and treatment based on recent evidence. RECENT FINDINGS Primary angiitis of the central nervous system in children (cPACNS) is an increasingly recognized inflammatory brain disease with potentially devastating neurological consequences. The diagnostic approach should be tailored to the clinical presentation of the child with suspected cPACNS and should address the expanding spectrum of inflammatory and noninflammatory brain diseases with overlapping clinical features. New evidence has confirmed that elective brain biopsies in children have a higher diagnostic yield than in adults and improve our ability to diagnose angiography-negative cPACNS. Finally, observational studies have shown that early diagnosis and aggressive treatment lead to improved neurological outcomes and lower mortality rates in patients with cPACNS. SUMMARY This review summarizes the recent data on diagnosis, classification, treatment, and outcomes in cPACNS. Our improved understanding of cPACNS facilitates a tailored diagnostic approach that results in earlier diagnosis and initiation of therapy for this potentially reversible condition.
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Abstract
Neurological manifestations of Behçet's disease (neuro-Behçet's disease) present in 5-30% of cases. They are classified into parenchymal and nonparenchymal categories. Poor prognostic factors include multifocal involvement, spinal presentations, more than two attacks per year, progressive course and increased cerebrospinal fluid cell count and protein content at the time of neurologic manifestations. For patients with parenchymal neuro-Behçet's disease without any poor prognostic factor, azathioprine or methotrexate and corticosteroids are recommended as the first-line treatment. For high-risk patients, intravenous cyclophosphamide and corticosteroids are recommended. If these regimens failed, TNF-alpha-blocking drugs, such as infliximab or etanercept, should be added. Alternating IFN-alpha and then chlorambucil or experimental treatments are the last resorts for most refractory patients. Treatment of venous sinus thrombosis is achieved by using anticoagulation and short-term corticosteroids with or without immunosuppressants.
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Affiliation(s)
- Afshin Borhani Haghighi
- Associate Professor of Neurology, Nemazee Hospital, Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran.
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Siva A, Saip S. The spectrum of nervous system involvement in Behçet's syndrome and its differential diagnosis. J Neurol 2009; 256:513-29. [PMID: 19444529 DOI: 10.1007/s00415-009-0145-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 08/25/2008] [Indexed: 01/30/2023]
Abstract
Behçet's Syndrome (BS) is a multi-system, vascular-inflammatory disease of unknown origin, involving the nervous system in a subgroup of patients. The growing clinical and imaging evidence suggests that primary neurological involvement in BS may be subclassified into two major forms: the first one, which is seen in the majority of patients, may be characterized as a vascular-inflammatory central nervous system (CNS) disease, with focal or multifocal parenchymal involvement mostly presenting with a subacute brainstem syndrome and hemiparesis; the other, which has few symptoms and a better neurological prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension. These two types rarely occur in the same individual, and their pathogenesis is likely to be different. Isolated behavioral syndromes and peripheral nervous system involvement are rare, whereas a nonstructural vascular type headache is relatively common and independent from neurological involvement. Neurologic complications secondary to systemic involvement of BS such as cerebral emboli from cardiac complications of BS and increased intracranial pressure due to superior vena cava syndrome, as well as neurologic complications related to BS treatments such as CNS neurotoxicity with cyclosporine and peripheral neuropathy with the use of thalidomide or colchisin are considered as secondary neurological complications of this syndrome. As the neurological involvement in this syndrome is so heterogeneous, it is difficult to predict its course and prognosis, and response to treatment. Currently, treatment options are limited to attack and symptomatic therapies with no evidence for the efficacy of any long term preventive treatment.
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Affiliation(s)
- Aksel Siva
- Haci Emin Sok.No:20/7 Nisantasi, 34365, Istanbul, Turkey.
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Cerebrovascular manifestations of Behçet’s disease. J Clin Neurosci 2009; 16:576-8. [DOI: 10.1016/j.jocn.2008.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 01/21/2008] [Accepted: 05/06/2008] [Indexed: 11/18/2022]
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Cerebral venous thrombosis in Behçet’s disease compared to those associated with other etiologies. J Neurol 2009; 256:1134-42. [DOI: 10.1007/s00415-009-5088-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Revised: 01/08/2009] [Accepted: 01/28/2009] [Indexed: 11/27/2022]
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Abstract
Central nervous system (CNS) vasculitis is an increasingly recognized, often devastating inflammatory brain disease of children and adults. In primary or isolated CNS vasculitis/angiitis of childhood (cPACNS), the vascular inflammation is limited to the brain and spinal cord. Secondary CNS vasculitis occurs in a variety of conditions including infections, collagen vascular diseases, systemic vasculidities, and malignancies. Mimics of CNS vasculitis in children include dissections and noninflammatory vasculopathies. Diagnosis of primary CNS vasculitis in both adults and children is based on the Calabrese criteria. This review summarizes recent data on CNS vasculitis in children; reviews the clinical spectrum at presentation and the role of laboratory tests, neuroimaging, and brain biopsy; and discusses treatment strategies, outcome data, and overlapping conditions of cPACNS.
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Affiliation(s)
- Susanne M Benseler
- Division of Pediatric Emergency Medicine and Rheumatology, Population Health Sciences Program, Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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Abstract
PURPOSE OF REVIEW Behçet's syndrome (BS) is a multi-system, vascular-inflammatory disease of unknown origin, involving the nervous system in a subgroup of patients. The syndrome is rare, but as patients with BS are young and frequently present with an acute or subacute brainstem syndrome or hemiparesis, as well as with other various neurological manifestations, the syndrome is often included in the differential diagnosis of multiple sclerosis, stroke of the young adult, and another wide range of neurological disorders. The present review summarizes the neurological involvement in BS, and emphasizes recent clinical concepts and ethiopathogenetic findings. RECENT FINDINGS Over the last years the growing clinical and imaging evidence had suggested that neurological involvement in BS may be subclassified into two major forms: one, which is seen in the majority of patients, may be characterized as a vascular-inflammatory CNS disease, with focal or multifocal parenchymal involvement; the other, which has few symptoms and a better neurological prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension. These two types rarely occur in the same individual, and their pathogenesis is likely to be different. A nonstructural vascular type headache is relatively common, whereas isolated behavioral syndromes and peripheral nervous system involvement are rare. SUMMARY The involvement of the nervous system in BS is heterogeneous as clinical and imaging data reveal. Currently it is unknown which factors determine or have a role in the development of neurological involvement, but some progress has been achieved in understanding the neurological spectrum of the syndrome, which may lead to a better management of these patients.
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Affiliation(s)
- Aksel Siva
- Department of Neurology, Clinical Neuroimmunology Division, Cerrahpaşa School of Medicine, University of Istanbul, Cerrahpaşa 34303, Istanbul, Turkey.
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Abstract
PURPOSE OF THE REVIEW To summarize the current literature on central nervous system vasculitis in childhood because this condition remains a diagnostic and therapeutic challenge. RECENT FINDINGS Central nervous system vasculitis in childhood may be primary or secondary to a variety of conditions including infections, collagen vascular diseases, systemic vasculitides, and malignancies. Conditions that result in vasospasm or are associated with noninflammatory vasculopathies may mimic the features of central nervous system vasculitis. Recent studies have described the clinical spectrum of CNS vasculitis in childhood. The most common presenting features are headaches and focal neurologic deficits. The diagnosis of central nervous system vasculitis remains particularly difficult because the available investigative modalities have limited sensitivities and specificities. The most helpful diagnostic tests include cerebrospinal fluid analysis, MRI of the brain, and angiography. However, brain biopsy may be required to diagnose small vessel vasculitis. SUMMARY This review summarizes recent data on primary central nervous system vasculitis and some of the secondary CNS vasculitides in children. Awareness of the presenting clinical features of CNS vasculitis should lead to consideration of the diagnosis. Awareness of the sensitivity and specificity of the various diagnostic tests should lead to the more prudent use of invasive diagnostic tests including angiography and brain biopsy.
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Affiliation(s)
- Susanne Benseler
- Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Ontario, Canada M5G1X8
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Cakirer S. Isolated Spinal Neurobehcet Disease Mr Imaging Findings. A case report. Acta Radiol 2003. [DOI: 10.1034/j.1600-0455.2003.00117.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Stroke has enormous clinical, social, and economic implications, and demands a significant effort from both basic and clinical science in the search for successful therapies. Atherosclerosis, the pathologic process underlying most coronary artery disease and the majority of ischemic stroke in humans, is an inflammatory process. Complex interactions occur between the classic risk factors for atherosclerosis and its clinical consequences. These interactions appear to involve inflammatory mechanisms both in the periphery and in the CNS. Central nervous system inflammation is important in the pathophysiologic processes occurring after the onset of cerebral ischemia in ischemic stroke, subarachnoid hemorrhage, and head injury. In addition, inflammation in the CNS or in the periphery may be a risk factor for the initial development of cerebral ischemia. Peripheral infection and inflammatory processes are likely to be important in this respect. Thus, it appears that inflammation may be important both before, in predisposing to a stroke, and afterwards, where it is important in the mechanisms of cerebral injury and repair. Inflammation is mediated by both molecular components, including cytokines, and cellular components, such as leukocytes and microglia, many of which possess pro- and/or antiinflammatory properties, with harmful or beneficial effects. Classic acute-phase reactants and body temperature are also modified in stroke, and may be useful in the prediction of events, outcome, and as therapeutic targets. New imaging techniques are important clinically because they facilitate dynamic evaluation of tissue damage in relation to outcome. Inflammatory conditions such as giant cell arteritis and systemic lupus erythematosus predispose to stroke, as do a range of acute and chronic infections, principally respiratory. Diverse mechanisms have been proposed to account for inflammation and infection-associated stroke, ranging from classic risk factors to disturbances of the immune and coagulation systems. Considerable opportunities therefore exist for the development of novel therapies. It seems likely that drugs currently used in the treatment of stroke, such as aspirin, statins, and modulators of the renin-angiotensin-aldosterone system, act at least partly via antiinflammatory mechanisms. Newer approaches have included antimicrobial and antileukocyte strategies. One of the most promising avenues may be the use of cytokine antagonism, for example, interleukin-1 receptor antagonist.
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Affiliation(s)
- Hedley C A Emsley
- University of Manchester and Stroke Services, Clinical Sciences Building, Hope Hospital, Eccles Old Road, Salford, M6 8HD, U.K.
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