Noninvasive cerebrovascular assessment of Takayasu arteritis

Transcranial Doppler ultrasonography to evaluate cerebral hemodynamic changes in neurocysticercosis

BACKGROUND

 Arteritis is a complication of neurocysticercosis (NCC), which is not well known and could trigger strokes. The transcranial Doppler ultrasound (TCD) is a noninvasive method for detecting, staging, and monitoring cerebrovascular diseases. Nonetheless, the utility of TCD to evaluate cerebral hemodynamic changes, suggesting vasculitis associated with NCC remains uncertain.

OBJECTIVE

 To evaluate cerebral hemodynamic changes using TCD in patients with subarachnoid and parenchymal NCC.

METHODS

 There were 53 patients with NCC evaluated at a reference hospital for neurological diseases included (29 with subarachnoid and 24 with parenchymal). Participants underwent a clinical interview and serology for cysticercosis and underwent TCD performed within 2 weeks of enrollment. Mean flow velocity, peak systolic velocity, end diastolic velocity, and pulsatility index were recorded.

RESULTS

 Among the participants, there were 23 (43.4%) women, with a median age of 37 years (IQR: 29-48). Cerebral hemodynamic changes suggesting vasculitis were detected in 12 patients (22.64%); the most compromised vessel was the middle cerebral artery in 11 (91.67%) patients. There were more females in the group with sonographic signs of vasculitis (10/12, 83.33% vs. 13/41, 31.71%; p = 0.002), and this was more frequent in the subarachnoid NCC group (9/29, 31.03% vs. 3/24, 12.5%; p = 0.187), although this difference did not reach statistical significance.

CONCLUSION

 Cerebral hemodynamic changes suggestive of vasculitis are frequent in patients with NCC and can be evaluated using TCD.

Affected Microcirculation and Vascular Hemodynamics in Takayasu Arteritis

Introduction: Takayasu arteritis (TAK) is a rare inflammatory disease affecting aorta and its major branches. Ultrasound (US) can detect inflammatory features in the arterial wall, but less is known regarding skin microcirculation and vascular hemodynamics. The aim was to study if assessment of these variables could add valuable information regarding vascular affection in TAK.

Methods: 17 patients diagnosed with TAK and 17 age- and sex-matched healthy controls were included. Microcirculatory peak oxygen saturation (OxyP) in the skin after induced ischemia was evaluated with laser Doppler flowmetry/diffuse reflectance spectroscopy. Cerebrovascular reserve capacity (CVR) in the brain was assessed with transcranial Doppler (TCD). Pulse waves were recorded in the radial artery by the aid of applanation tonometry, for calculation of central augmentation index (AIx75). Intima-media thickness (IMT) and stenosis/occlusions were evaluated using US in carotid and central arteries.

Results: Reduced OxyP (79 ± 8% vs. 87 ± 4%, p < 0.001) was seen in patients with TAK regardless of significant arterial stenosis/occlusion or not. Increased AIx75 (22.3 ± 13.6 vs. 9.2 ± 16.3, p = 0.01) was seen in TAK patients without significant stenosis/occlusions. No differences were found in CVR, regardless of proximal stenosis. However, signs of a more high-resistance flow profile were seen in arteria cerebri media.

Conclusion: Regardless of arterial stenosis or not, impaired microcirculation of the skin and preserved CVR in the brain were found in subjects with TAK. Signs of increased arterial stiffness in the brain and central arteries were observed. The value of these findings for prediction of future cardiovascular events needs to be clarified in further studies.

Carotid intima-media thickness/diameter ratio and peak systolic velocity as risk factors for neurological severe ischemic events in Takayasu's arteritis

Objective

To characterize Takayasu arteritis (TAK) with supra-aortic involvement and determine the associations between clinical features, carotid ultrasonographic (US) parameters, and neurological severe ischemic events (SIE).

Methods

Patients with supra-aortic involvement including brachiocephalic trunk, bilateral common carotid artery and internal carotid artery, and bilateral subclavian and vertebral artery and baseline carotid US examination were enrolled from the East China Takayasu arteritis cohort. Bilateral carotid diameter, intima-media thickness (IMT), and peak systolic velocity (PSV) were measured by US. Then, IMT/diameter ratio (IDR) was calculated. Risk factors associated with neurological SIE were analyzed by multivariate logistic regression.

Results

Totally, 295 patients were included, of whom 260 (88.14%) were female, and 93 (31.53%) experienced neurological SIE. Involved supra-aortic artery distribution (p=0.04) and number (p<0.01) differed between neurologic and non-neurologic SIE subjects, showing higher prevalence of common carotid and vertebral artery involvement after Bonferroni correction and 56.99% patients having more than four involved arteries in neurological SIE group. The bilateral IDR (p<0.01) differed between patients with and without neurological SIE. The carotid IDR (left: cut-off value ≥0.55, odds ratio [OR] 2.75, 95% confidence interval [CI] 1.24-6.07, p=0.01; right: ≥0.58, OR 2.70, 95% CI 1.21-6.02, p=0.01) and left carotid PSV (≤76.00 cm/s, OR 3.09; 95% CI 1.53-6.27; p<0.01) as well as involved supra-aortic artery number (≥4, OR 2.33, 95% CI 1.15-4.72, p =0.02) were independently associated with neurological SIE.

Conclusion

The carotid IDR and PSV might be performed as valuable markers for recognizing neurological SIE in TAK patients with supra-aortic lesions.

Intracranial Involvement in Takayasu's Arteritis

Takayasu’s arteritis (TAK) is a large-vessel vasculitis that targets the aorta and its major branches. Although extracranial vascular involvement is uniformly present in this disease, the frequency of intracranial involvement in TAK has not been well studied. We retrospectively reviewed the clinical and imaging records of patients diagnosed with TAK at a single Canadian university medical centre to determine the prevalence of intracranial vascular involvement. Intracranial vascular and non-vascular findings were described, and a review of the literature was performed. Of 20 patients with TAK, 12 had vascular neuroimaging completed. Intracranial vascular lesions were identified in 4 patients (33.3% of those with imaging available, 20% of all patients). The frequency of intracranial vessel involvement in TAK may be more common than appreciated. Imaging of both the intra- and extra-cranial vessels should be considered in these young patients.

Application progress of multiple imaging modalities in Takayasu arteritis

Takayasu arteritis (TA) is a chronic, idiopathic, granulomatous large vessel vasculitis of unknown etiology. The clinical manifestations of TA are incredibly variable, mainly depending on the location of the lesions. In the light of its insidious progress and the diversity of clinical manifestations, a substantial proportion of patients might experience a considerable delay in diagnosis, which leads to irreversible malignant complications, highlighting the importance of early diagnosis. There has been accumulating evidence that early identification of disease is pivotal to initiate timely therapy and ameliorate the prognosis. Therefore, this review discusses and summarizes the latest evidence on the application progress of multiple imaging modalities.

Usefulness of carotid ultrasonography and treatment of carotid disease

Carotid stenosis is an important etiology of ischemic stroke. Most of the strokes associated with carotid stenosis are caused by artery-to-artery embolism. The risk of embolism highly depends on the stenosis degree and the vulnerability of the carotid plaque. Carotid ultrasonography is useful for evaluating the characteristics of carotid plaque. This review aims to provide information on performing and interpreting the result of carotid ultrasonography and the treatment of carotid artery disease based on the current guidelines. The degree of stenosis can be measured by the diameter reduction and flow velocity criteria. The risk of embolism is highest when the stenosis degree is around 70% to 80%. A heterogeneous echolucent plaque with an irregular surface or an ulcer shows a high risk of embolism. Appropriate treatment is important for the patients with carotid stenosis. In symptomatic patients, a potent antiplatelet treatment, especially during the acute stage, is beneficial. Patients with asymptomatic stenosis over 50% can also be considered for antiplatelet treatments. The associated risk factors should be managed according to the targets. Medically intractable cases or patients with high risk of embolism may receive carotid endarterectomy or carotid artery stenting depending on the concomitant disease and the degree of carotid stenosis. Considering the safety of ultrasound imaging, treatment may be followed-up by carotid ultrasonography.

[Takayasu's arteritis and atherosclerosis]

INTRODUCTION

Chronic inflammatory diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), are accompanied by high cardiovascular morbidity and mortality secondary to accelerated and premature atherosclerosis. Atherosclerosis is correlated with chronic systemic inflammation independently of the factors for cardiovascular risk. Vasculitis of large arteries such as Takayasu's disease, are characterized both by chronic systemic inflammation and local parietal vascular inflammation.

METHODS

We prospectively analyzed in a case-control study, a group of 64 carriers of Takayasu's arteritis patients with a mean age of 41 years [±11.94], a group of 50 RA female patients aged 45 years [±10.27], and a control group with an average age of 44 years [±12.63]. We recorded classic cardiovascular risk factors and used the Framingham equation to calculate the risk. We measured the intima-media thickness (IMT) in the carotids and noted the presence of carotid, aortic and femoral atheroma.

RESULTS

The mean calculated cardiovascular risk was 3.5 % in the Takayasu's group. It was 4.4 % in the RA group, and 4.5 % in controls with no significant difference between the three groups (P=0.153). Subclinical atherosclerosis defined by IMT> 0.70mm and/or the presence of atheroma plaque was found in 87 % of Takayasu's patients versus 76 % of RA patients, (P=0.088) and 48 % of controls (P<0.001). Most atherosclerotic plaques were found in the Takayasu group. Compared to the control group the carotid intima-media thickness was significantly higher in the Takayasu group. The average IMT in the Takayasu group was 0.91mm [±0.368], 0.76mm [±0.151] for the PR group, and 0.71mm [±0.141] for controls.

DISCUSSION

Atherosclerosis observed in Takayasu's disease was accelerated and premature, occurring in young patients with a low overall cardiovascular risk. Recent data support the central role of inflammation in all stages of atherogenesis from endothelial dysfunction to plaque rupture. Systemic inflammation associated with local parietal inflammation observed in Takayasu's arteritis, appears to be responsible for accelerated and premature atherosclerosis. The results of our study and the literature review favor an active strategy for cardiovascular prevention in Takayasu's disease.

Genetic Basis of Vasculitides with Neurologic Involvement

"Vasculitides are a heterogeneous group of inflammatory diseases of blood vessels in which genetic variation plays an important role in their susceptibility and clinical spectrum. Because of the use of novel technologies and the increase of the sample size of the study cohorts, the knowledge of the genetic background of vasculitides has considerably expanded during the last years. However, few insights have been obtained regarding the genetics underlying severe clinical phenotypes, such as those related to the nervous system. In this review the authors provide an updated overview of the genetic landscape behind vasculitis predisposition and development of neurologic manifestations."

Transcranial Doppler Evaluation in Takayasu Arteritis With Oculo-Cerebrovascular Complications

INTRODUCTION

Takayasu arteritis is a large-vessel vasculitis that may cause oculo-cerebral ischemia. We report a patient with visual loss as initial manifestation, and discuss transcranial Doppler (TCD) findings before and after surgical revascularization.

CASE DESCRIPTION

A 19-year-old female developed episodes of transient positional right vision loss, progressing to permanent right vision loss and bright light-induced left amaurosis. Examination demonstrated subclavian bruits, palpable epigastrium aortic pulsation, faint radial pulses, right retinal pallor, arteriolar narrowing, and bilateral boxcarring. Head and neck computed tomography angiogram demonstrated left subclavian origin and right common carotid artery occlusion, and severe innominate and left common carotid artery stenosis. TCD demonstrated right ophthalmic artery flow reversal and nonpulsatile waveforms with dampened spectra in the right anterior circulation. Corticosteroids, methotrexate, infliximab, and dual-antiplatelet therapy were initiated. Eleven weeks later, the patient underwent ascending aortic aneurysm repair and bilateral carotid artery bypass with an aortic graft. Pathology was consistent with chronic active Takayasu arteritis. Two weeks postoperatively, left eye visual symptoms resolved; right visual loss persisted. Postoperative TCD showed marked improvement in cerebral perfusion.

CONCLUSIONS

Retinal ischemia in young women should prompt emergent inflammatory and systemic vascular evaluation. In our subject, prolonged right retinal ischemia had dismal prognosis despite carotid-aortic revascularization, whereas left retinal boxcarring reversed. Surgical revascularization is recommended for severely symptomatic oculo-cerebrovascular disease, once inflammation is better controlled with immunosuppressive therapy. TCD documented the presence and monitored the subsequent resolution of blood flow changes causing retinal and brain hypoxia.

Definitions and reliability assessment of elementary ultrasound lesions in giant cell arteritis: a study from the OMERACT Large Vessel Vasculitis Ultrasound Working Group

Objectives

To define the elementary ultrasound (US) lesions in giant cell arteritis (GCA) and to evaluate the reliability of the assessment of US lesions according to these definitions in a web-based reliability exercise.

Methods

Potential definitions of normal and abnormal US findings of temporal and extracranial large arteries were retrieved by a systematic literature review. As a subsequent step, a structured Delphi exercise was conducted involving an expert panel of the Outcome Measures in Rheumatology (OMERACT) US Large Vessel Vasculitis Group to agree definitions of normal US appearance and key elementary US lesions of vasculitis of temporal and extracranial large arteries. The reliability of these definitions on normal and abnormal blood vessels was tested on 150 still images and videos in a web-based reliability exercise.

Results

Twenty-four experts participated in both Delphi rounds. From originally 25 statements, nine definitions were obtained for normal appearance, vasculitis and arteriosclerosis of cranial and extracranial vessels. The ‘halo’ and ‘compression’ signs were the key US lesions in GCA. The reliability of the definitions for normal temporal and axillary arteries, the ‘halo’ sign and the ‘compression’ sign was excellent with inter-rater agreements of 91–99% and mean kappa values of 0.83–0.98 for both inter-rater and intra-rater reliabilities of all 25 experts.

Conclusions

The ‘halo’ and the ‘compression’ signs are regarded as the most important US abnormalities for GCA. The inter-rater and intra-rater agreement of the new OMERACT definitions for US lesions in GCA was excellent.

Takayasu Arteritis

Takayasu arteritis is an idiopathic granulomatous vasculitis of the aorta and its main branches and it constitutes one of the more common vasculitides in children. Inflammation and intimal proliferation lead to wall thickening, stenotic or occlusive lesions, and thrombosis, while destruction of the elastica and muscularis layers originates aneurysms and dissection. Carotid artery tenderness, claudication, ocular disturbances, central nervous system abnormalities, and weakening of pulses are the most frequent clinical features. The diagnosis is usually confirmed by the observation of large vessel wall abnormalities: stenosis, aneurysms, occlusion, and evidence of increased collateral circulation in angiography, MRA or CTA imaging. The purpose of this revision is to address the current knowledge on pathogenesis, investigations, classification, outcome measures and management, and to emphasize the need for timely diagnosis, effective therapeutic intervention, and close monitoring of this severe condition.

Intracranial and Extracranial Neurovascular Manifestations of Takayasu Arteritis

BACKGROUND AND PURPOSE

Takayasu arteritis is a rare, large-vessel vasculitis that presents with symptoms related to end-organ ischemia. While the extracranial neurovascular manifestations of Takayasu arteritis are well-established, little is known regarding the intracranial manifestations. In this study, we characterize the intracranial and cervical neurovascular radiologic findings in patients with Takayasu arteritis.

MATERIALS AND METHODS

Patients with Takayasu arteritis who presented to our institution between 2001 and 2016 with intracranial and/or cervical vascular imaging were included in this study. Images were evaluated for the presence of vascular abnormalities, including intracranial or extracranial stenosis, vessel-wall thickening, dissection, subclavian steal, aneurysms, infarcts, and hemorrhages. Descriptive analyses are reported.

RESULTS

Seventy-nine patients with Takayasu arteritis met the criteria for inclusion in this study. The most common presenting neurologic symptoms were headache (32.9%) and dizziness (15.2%). Intracranial and extracranial vascular imaging was performed in 84.8% and 89.9% of patients, respectively. Among patients with intracranial vascular imaging, 3 (3.9%) had intracranial aneurysms, 3 (3.9%) had acute large-vessel occlusion, 6 (7.6%) had intracranial vasculitis, and 1 (1.3%) had reversible cerebrovascular constriction syndrome. Among patients with cervical vascular imaging, 42 (53.1%) had some degree of narrowing of the common carotid artery and 18 (22.8%) had narrowing of the ICAs. Seventeen patients (23.6%) had subclavian steal.

CONCLUSIONS

Intracranial vascular abnormalities in patients with Takayasu arteritis presenting with neurologic symptoms are not rare, with cerebral vasculitis seen in 7.8% of patients, and stroke secondary to large-vessel occlusion, in 3.9% of patients. Cervical vascular manifestations of Takayasu arteritis were present in most patients in our study.

Clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis - A single centre experience

OBJECTIVE

Aim of the study was to evaluate clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis.

BACKGROUND

Takayasu's arteritis is a chronic inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations.

METHODS

In this prospective study a total of 50 consecutive patients who were reported as having Takayasu's arteritis between January 2010 and April 2016 were evaluated. Detailed clinical presentation and angiograms of all patients were analysed.

RESULTS

50 patients were analysed during study period. Among 50 patients, 43(86%) were female and 7 (14%) were male. Average age of presentation was 26.92years. Most common clinical presentation was claudication (74%) followed by, musculoskeletal symptoms (48%), fatigue (46%), weight loss (22%), headache (22%), visual disturbances (16%), syncope (10%), dyspnoea (20%). Most common features were absent/diminished pulses (80%), difference in blood pressure (80%), followed by bruit (70%)hypertension (64%), cerebrovascular accident (8%),heart failure (8%) and aortic regurgitation (4%). According to the new angiographic classification, angiographic type I (40%) was encountered most frequently, followed by type III (30%), type V (16%), type IIb (8%), type IIa (2%), and type IV is (4%). Angioplasty was the main stay of treatment in 66% of the patients, remaining 34% of them were treated medically either with corticosteroids or methotrexate.

CONCLUSION

Takayasu's arteritis is a rare disease, affects mainly women, manifestations range from asymptomatic disease, found as a result of impalpable pulses or bruits, to catastrophic neurological impairment. Takayasu's arteritis is the common cause of renovascular hypertension. Angiography remains the gold standard for diagnosis. Angiographic evaluation and percutaneous transluminal angioplasty with stenting is useful in selected cases.

An unusual case of Takayasu's arteritis: Evaluation by CT angiography

Takayasu's arteritis is a chronic, idiopathic, medium and large vessel vasculitis involving aorta and its main branches. Frequent neurological manifestations include postural syncope, seizures, and blindness. Stroke, as presenting feature of Takayasu's arteritis, is unusual. CT angiography reveals characteristic involvement of aortic arch and its branches. Involvement of intracranial vasculature is rather unusual. We are describing an unusual patient of Takayasu's arteritis who presented with recurrent disabling syncopal attacks and had extensive involvement of intracranial vasculature. CT angiography revealed severe involvement of aortic arch. There was near complete occlusion at origins of both subclavian arteries, distal flow was maintained by collateral vessels along the chest wall. There was near total occlusion (at origin) of right common carotid with normal flow in distal part. The left common carotid was more severely involved showing greater than 80% narrowing in proximal half of the vessel. CT angiography also revealed involvement of left internal carotid artery, narrowing of left middle cerebral artery and involvement of cortical vessels. Patient was treated with oral corticosteroids. She improved remarkably after two and half months of follow up.

Symptomatic intracranial arterial disease: incidence, natural history, diagnosis, and management

Symptomatic intracranial arterial disease is associated with a high rate of recurrent ischemic events. The management of this condition is controversial, with some advocating medical therapy as a sole means of treatment and others recommending endovascular therapy in addition to best medical management. In rare cases, surgical intervention is considered. A thorough review of the available literature was performed, and treatment recommendations based on these data are provided.

Cerebral Embolic Activity in a Patient during Acute Crisis of Takayasu's Arteritis

Takayasu's arteritis is a disease that affects large vessels and may cause neurological symptoms either by stenoses/occlusions or embolisms from vessels with an inflammatory process. Transcranial Doppler (TCD) ultrasound can provide useful information for diagnosis and monitoring during the active phase of the disease. Cerebral embolic signals can be detected by TCD and have been considered a risk factor for vascular events. We report a patient in whom TCD ultrasound was used to monitor cerebral embolic signals during the active phase of the disease. This case report suggests that embolic activity in Takayasu's arteritis may represent disease activity, and its monitoring may be useful for evaluating the response to therapy.

Cardiovascular co-morbidity in patients with rheumatic diseases

During recent years atherosclerosis, the major cause of cardiovascular disease (CVD), has been recognised as a chronic inflammatory condition in which rupture of atherosclerotic lesions appears to play a major role. The risk of CVD is raised in many rheumatic diseases. This risk is high in systemic lupus erythematosus - as much as a 50-times increase among middle-aged women has been reported. Studies on CVD and atherosclerosis in rheumatic disease could thus provide interesting information about CVD and atherosclerosis in addition to being an important clinical problem. A combination of traditional and nontraditional risk factors accounts for the increased risk of CVD and atherosclerosis in rheumatic disease. One interesting possibility is that atherosclerotic lesions in rheumatic disease are more prone to rupture than normal atherosclerotic lesions. It is also likely that increased risk of thrombosis may play an important role, not least in systemic lupus erythematosus. Further, it is not clear whether an increased risk of CVD is a general feature of rheumatic disease, or whether this only occurs among subgroups of patients. It should be emphasised that there is an apparent lack of treatment studies where CVD in rheumatic disease is the end point. Control of disease activity and of traditional risk factors, however, appears to be well founded in relation to CVD in rheumatic disease. Further studies are needed to determine the exact role of lipid-lowering drugs as statins. Hopefully novel therapies can be developed that target the causes of the inflammation in atherosclerotic lesions both in rheumatic patients and in the general population.

Whole-body MR angiography: initial experience in imaging pediatric vasculopathy

Radiological assessment of vasculopathy in children is typically undertaken with ultrasonography, echocardiography, conventional angiography, computed tomography and, more recently, positron emission tomography. Drawbacks of these modalities include radiation exposure or, in the case of ultrasonography, the dependence on operator skills and sufficient acoustic windows. With advancements in MR technology, which have improved sensitivity and shortened scan times, whole-body magnetic resonance angiography (WB-MRA) lends itself as a potential "one-stop shop" for vascular imaging. Currently, WB-MRA is primarily used in adult patients with atherosclerosis or multifocal regional vasculopathy. WB-MRA has not been employed in the routine assessment of pediatric vascular disease. The purpose of this article is to describe and illustrate our WB-MRA imaging technique for evaluation of pediatric vasculopathy.

Clinical utility of quantitative magnetic resonance angiography in the assessment of the underlying pathophysiology in a variety of cerebrovascular disorders

BACKGROUND

Quantitative MRA (qMRA) is a relatively new technique that uses traditional time-of-flight and phase-contrast MRI to visualize extracranial and intracranial vascular anatomy and measure volumetric blood flow. We aimed to assess the clinical utility of qMRA in assessing the hypothesized pathophysiology (HP) in a range of cerebrovascular diseases. Moreover, we postulated that evaluation of the arterial waveforms, can improve the evaluation of the hypothesized pathophysiology by qMRA.

METHODS

We reviewed studies from 10 patients who underwent qMRA examinations before and after their treatments. Two reviewers assessed the anatomy, volumetric flow rates and arterial waveforms for each vessel sampled and reached a consensus as to whether the above parameters supported the clinical diagnosis/hypothesized pathophysiology and the subsequent management.

FINDINGS

All 20 qMRA studies were technically adequate. qMRA supported the HP in all 10 patients as determined by abnormal volumetric flow values in the affected vessels before treatment and by the correction of these abnormal values in the patients whose treatment was successful. Each of our five patients with occlusive disease/vasoconstriction demonstrated evidence of dampening of the arterial waveforms distally to the narrowed artery (parvus-tardus phenomenon). The parvus-tardus effect disappeared after treatment.

CONCLUSION

qMRA is unique in combining time-of-flight MRA in a complementary manner with phase-contrast MRA to obtain volumetric flow values and potentially important physiologic information from arterial waveform analysis in patients with a range of cerebrovascular diseases during the course of a single MR examination.

Takayasu arteritis with intracranial involvement mimicking epilepsy: case report and review of the literature

The symptoms of Takayasu arteritis (TA) are related to end organ ischemia. Here we present a patient with convulsions and intracranial involvement. A 15-year-old young woman was admitted with the complaint of convulsions since one and a half months previously. Her physical examination showed absent pulses and unobtainable blood pressure in both arms. Electroencephalography was normal. An arcus aorto-abdominal aortography, performed for TA prediagnosis, revealed that the subclavian artery ended as a stump at its origin on the right and was occluded by tapering on the left. Arcus aorta was normal. The right renal artery was occluded up to 80-90%. Magnetic resonance imaging of the brain revealed abnormal signal intensity in the deep white matter bilaterally. Cerebral catheter angiography showed focal stenosis of cerebral vessels; it was classified as type V according to the classification of the Takayasu Conference of 1994. A diagnosis of TA was made and 1 mg/kg steroid was given, and after a month methotrexate (15 mg/week) was added. On the tenth treatment day her pulse could be revealed. During the control period she had no convulsion. In young patients TA should be kept in mind as a rare cause in convulsion etiology. Intracranial involvement of TA must be evaluated especially if there is a headache and convulsion.

Risk factors and treatment outcomes of childhood stroke

Stroke is an important cause of childhood mortality and morbidity. The risk factors and pathophysiological processes of stroke in children are very different than those in adults. The range of risk factors is very wide, with over 100 presumptive risk factors described. There are a number of clinical guidelines, but despite recent increases in research, the evidence base underpinning these guidelines is sparse. Therefore, treatment is largely based upon expert consensus and extrapolation from adult data. Mortality from childhood stroke is relatively high and at least two-thirds of survivors have neurological impairments. Stroke can affect a wide range of neurocognitive domains and a high proportion of children require additional educational support and have a reduced quality of life.

Takayasu arteritis in children and adolescents

Takayasu arteritis is a devastating vasculitis of the aorta and its major branches. The clinical manifestations in paediatric patients are less specific than in adults: in children the disease presents with fever, arthralgias and hypertension. Intramural inflammation results in narrowing of the blood vessel lumen and therefore hypoperfusion of the parenchyma. Conventional angiography is the gold standard diagnostic procedure. Corticosteroids, cyclophosphamide, MTX and biological therapies such as TNF-α blocking agents are treatment options.

The clinical spectrum of the neurological involvement in vasculitides

Both the central nervous system (CNS) and the peripheral nervous system (PNS) are major target organs in primary vasculitides. They may either be affected in the setting of systemic vasculitis, potentially involving any other organ, or they may be the sole site of the inflammatory process. In both cases, the clinical pattern of PNS involvement is essentially uniform, presenting as sensory axonal polyneuropathy or mononeuritis multiplex. The damage is related to the ischemic occlusion of the vasanervorum due to small-vessel vasculitis. On the contrary, the range of manifestations of CNS vasculitis is much wider and several pathogenetic mechanisms are implicated, including angiitis of the hemispheres and spinal cord, thrombosis of dural sinuses, stenosis and aneurysms of medium and large arteries, granulomatous meningeal involvement and direct cytokine damage presenting with encephalopathy. Besides, even extracranial noninflammatory vascular disease may induce CNS symptoms, as is the case of carotid stenosis, vena cava syndrome and renovascular hypertension. In this paper we will review the broad spectrum of clinical manifestations of CNS and PNS neuropathy as they occur in primary systemic and non systemic vasculitides.

Arterial ischemic stroke in children--recent advances

Childhood stroke syndromes are an important cause of mortality and morbidity. This paper focuses on the recent advances in arterial ischaemic stroke beyond the neonatal period. Vascular risk factors are identified in the majority of children and guide both acute and longer term treatments, as well as determining prognosis. Contrary to popular belief many children have residual impairments encompassing a wide range of domains. National and international collaborations are facilitating an increase in the understanding of childhood stroke and have the eventual aim of conducting trials of potential therapeutic interventions.

F-18-fluorodeoxyglucose positron emission tomography-computed tomography for the diagnosis of Takayasu's arteritis in stroke: a case report

INTRODUCTION

Diagnosis of Takayasu's arteritis as the cause of stroke is often delayed because of non-specific clinical presentation. F-18-fluorodeoxyglucose positron emission tomography-computed tomography may help to accurately diagnose and monitor Takayasu's arteritis in stroke patients.

CASE PRESENTATION

We report the case of a left middle cerebral artery stroke in a 39-year-old man. Laboratory data were consistent with an inflammatory reaction. While abdominal contrast-enhanced computed tomography showed an aneurysm of the infrarenal aorta, only F-18-fluorodeoxyglucose positron emission tomography-computed tomography revealed pathology (that is, intense F-18-fluorodeoxyglucose accumulation) in the carotid arteries, ascending aorta and the abdominal aorta cranial to the aneurysm. After treatment with high-dose prednisone followed by cyclophosphamide, the signs of systemic inflammation decreased and F-18-fluorodeoxyglucose uptake was reduced as compared with the initial scan.

CONCLUSION

F-18-fluorodeoxyglucose positron emission tomography-computed tomography showed inflammatory activity in the aorta and carotid arteries, suggestive of Takayasu's arteritis in a young stroke patient, and follow-up under immunosuppressive therapy indicated reduced F-18-fluorodeoxyglucose uptake. F-18-fluorodeoxyglucose positron emission tomography-computed tomography appears to be useful in detecting and quantifying the extent of vascular wall activity in systemic large-vessel vasculitis.

Takayasu's disease: a review

Takayasu's disease is a rare chronic vasculitis of unknown aetiology. Initial symptoms and signs are non-specific, and a high index of suspicion is needed to make the correct diagnosis. The disease is associated with a high incidence of morbidity, and a significant risk of premature death. Serological tests have proved unreliable in distinguishing active from quiescent disease, with non-invasive imaging currently offering the best option for early diagnosis, and monitoring the response to treatment. In this review, we detail the epidemiology, pathophysiology, clinical features, imaging characteristics, and currently available treatments.

[Imaging procedures in rheumatology: imaging in vasculitis]

In small vessel vasculitides, imaging studies aid in determining disease extent and activity, localization for biopsy, and for disease monitoring. They do not directly delineate the vasculitic lesion. Imaging studies focus on the upper and lower respiratory tract. Cranial magnetic resonance imaging (MRI) shows upper respiratory and retrobulbar granuloma in Wegener's granulomatosis. Furthermore, MRI depicts both mastoiditis and mucosal inflammation of the ear, nose, and throat. It is sensitive but not specific for the detection of cerebral vasculitis. Computed tomography (CT) reliably detects osseous facial lesions. Chest radiography in two planes remains the standard method of investigation for the lower respiratory tract. High-resolution CT aids in detecting further interstitial pathologies. Medium-sized vasculitides frequently occur with aneurysms. The classification criteria for polyarteritis nodosa involve the angiographic detection of visceral aneurysms. Patients with Kawasaki disease may develop coronary aneurysms that may be described by echocardiography or angiography according to diagnostic criteria. In large-vessel vasculitides such as temporal arteritis (giant cell arteritis) and Takayasu arteritis, MRI, MR-angiography, CT, CT-angiography, and duplex sonography delineate characteristic homogenous wall thickening with or without stenoses in the aorta and other arteries. There is a high correlation with angiography and positron emission tomography. Duplex sonography of the temporal arteries has a high sensitivity and specificity for the diagnosis. Data on temporal artery MRI in giant cell arteritis have recently been published.

[Ischemic stroke caused by Takayasu's arteritis]

Takayasu's disease is a non specific, chronic, inflammatory panarteritis. It affects the aorta, its chief collaterals and the pulmonary arteries. Clinical manifestations depend on the site and the severity of the occlusive vascular lesion. We report a case observed in a young woman who presented ischemic stroke as the inaugural sign of Takayasu's disease.

Maladie de Takayasu

Takayasu arteritis is an inflammatory arteritis affecting large vessels, predominantly the aorta and its main branches. Thickening of the vessel wall is an early hallmark of the disease and leads to stenosis, thrombosis, and sometimes aneurysm formation. Reported incidence ranges from 1.2 to 2.6/million/year. Women aged 20 to 40 are most likely to suffer from the disease than men. Manifestations are very polymorphous, with presentations ranging from asymptomatic to neurologic catastrophes. Prognosis depends essentially on complications (retinopathy, hypertension, aneurysm, aortic insufficiency) and initial disease aggressivity. Diagnosis is based on imaging methods. Doppler ultrasound, computed tomography, and magnetic resonance imaging are fast and reliable methods for assessing vessel anatomy and luminal status. Positron emission tomography with fluorodeoxyglucose appears to be a highly sensitive and effective method for detecting disease activity, especially since standard inflammatory markers seem ineffective. Until now, corticosteroids have been the treatment of choice. If remission does not occur, methotrexate is added. Percutaneous transluminal angioplasty and sometimes vascular surgery is necessary in cases of critical ischemia or threatening aneurysm. Duration of treatment, choice of second-line treatment, and protocol for tapering medication currently depend more on experience than on evidence-based medicine. Multicenter studies are needed to guide future practice.

Evaluation of cerebral hypoperfusion by nuclear medicine imaging in a patient with Takayasu's arteritis

In patients with Takayasu's arteritis presenting with cerebrovascular insufficiency, deciding whether and how to perform surgical intervention is difficult. We report successful extra-anatomical cerebrovascular reconstruction in a patient with Takayasu's arteritis involving the aortic arch. A 27-year-old woman was diagnosed with Takayasu's arteritis with occlusion of all three branches of the aortic arch. Single-photon emission computed tomography and positron emission tomography of the brain were useful in assessing the indication and effect of surgical treatment. Right common ilioaxillary artery bypass grafting was performed, and at 18-month follow-up the patient remained symptom-free. Extra-anatomical bypass can be a therapeutic option for surgical management of Takayasu's arteritis with aortic arch involvement.

What is the best approach to diagnosing large-vessel vasculitis?

Temporal arteritis, including large-vessel giant cell arteritis, and Takayasu's arteritis are the two primary large-vessel vasculitides. Patients with temporal arteritis often present with headache, swollen temporal arteries, impairment of vision or symptoms of polymyalgia rheumatica. Clinical examination includes palpation of the temporal arteries and radial pulses, auscultation of the subclavian and axillary region, and fundoscopy. The presence of jaw claudication, diplopia and temporal artery abnormalities correlates with a high probability of positive histology. Duplex ultrasonography of the temporal arteries delineates a characteristic hypoechoic, oedematous wall swelling, stenoses and occlusions. It detects the same pathologies in the axillary arteries and other arteries in large-vessel giant cell arteritis. Angiography, magnetic resonance imaging, magnetic resonance angiography, electron beam computed tomography, computed tomography angiography and positron emission tomography show characteristic changes in the aorta and its primary branches in large-vessel giant cell arteritis and Takayasu's arteritis. Takayasu's arteritis often begins with diffuse symptoms such as low-grade fever, arthralgia, fatigue and weight loss. Clinical examination is important to detect bruits, pulse reduction and blood pressure differences. Profound experience exists with angiography. Other imaging methods are interesting alternatives as they are less invasive and may depict the inflammatory wall swelling.

New developments in imaging for diagnosis and therapy monitoring in rheumatic diseases

The availability of therapeutic modalities that are able to stop inflammatory joint damage has also markedly influenced recent developments in muskuloskeletal imaging. One focus of interest is the detection of joint pathology as early as possible in order to prevent erosive bony changes. Ultrasonography and magnetic resonance imaging are the most valuable technologies in this respect. Another focus is on the exact assessment and documentation of joint damage using scoring systems not only in therapeutic trials, but also in clinical practice. In addition to these recent advances in peripheral and axial joint imaging, this chapter also discusses advances in vascular imaging and scintigraphy in rheumatoid diseases as well as interventional procedures guided by imaging technologies.

Doppler sonography in rheumatology

The importance of ultrasonography in rheumatology has increased dramatically within the last few years both with regard to clinical practice and to research. High-resolution colour Doppler ultrasound equipment is, to date, widely available. Colour and power Doppler studies of intra-articular and peritendinous blood flow allow an estimation of the inflammatory activity and aid in distinguishing anatomical structures. Contrast agent increases the ability of ultrasonography to detect even minor perfusion. These findings have a practical clinical impact on the management of inflammatory rheumatic diseases. The resolution of ultrasonography is superior to that of magnetic resonance imaging (MRI) and computed tomography (CT) with regard to superficial anatomical structures. Furthermore, ultrasonography can depict the artery wall in contrast to angiography. In temporal arteritis and Takayasu's arteritis, ultrasonography depicts characteristic, homogenous wall thickening, stenoses and acute occlusions. These pathologies resolve quickly with treatment in the temporal arteries and much more slowly in larger arteries.

Use of imaging studies in the diagnosis of vasculitis

Imaging studies are necessary to determine disease extension and disease activity in the small-vessel vasculitides. Computed tomography (CT) and magnetic resonance imaging (MRI) increase the number of pathologic findings compared with conventional radiography. MRI delineates mucosal inflammation and granulomas in the paranasal sinuses, whereas CT provides information about osseous lesions. CT is superior to MRI for the detection of pulmonary lesions. Radiograph angiography has been the gold standard for medium- and large-vessel vasculitides for decades. Echocardiography and MRI correspond well with conventional angiography to assess cardiac involvement in Kawasaki disease. MRI, CT, and CT angiography are alternative noninvasive techniques to delineate vasculitic lesions in polyarteritis nodosa, Takayasu's arteritis, and large-vessel giant cell arteritis. Duplex ultrasonography has the greatest resolution. It delineates typical artery wall swelling in temporal arteritis and Takayasu's arteritis. Positron emission tomography can assess inflammatory activity of large arteries.

Diagnostic imaging in Takayasu arteritis

PURPOSE OF REVIEW

New imaging modalities may help accurately diagnose and monitor Takayasu arteritis (TAK). Examination of the published literature on arterial imaging studies other than conventional angiography will help guide appropriate use of these studies in TAK. MRI, magnetic resonance angiography (MRA), Doppler ultrasound, CT, and positron emission tomography (PET) are all potentially useful for evaluation of TAK.

RECENT FINDINGS

MRI/A avoids the risks of arterial puncture, iodinated contrast load, and radiation exposure, while providing information on arterial wall anatomy and obtaining a generalized arterial survey in TAK. Ultrasound can be helpful in detecting sub-millimeter changes in wall thickness of the carotid arteries and in differentiating TAK from atherosclerotic disease based on minimal plaque content, concentric and long segmental involvement, and location of lesion. Like MRI, CT angiography can be used to detect areas of aortic wall thickening and obtain a generalized survey of the aorta and its proximal branches for areas of stenosis and without the risks associated with arterial puncture. However, CT provides less detailed resolution than ultrasound and incurs the risks of contrast administration. Finally, PET scanning may provide valuable information about cellular activity within an inflamed arterial wall before morphologic changes on other imaging studies.

SUMMARY

Although it is still unclear how often early arterial wall changes lead to stenotic lesions, use of these modalities in combination, for both routine monitoring and evaluation of new symptoms, may facilitate the detection of TAK disease activity at a more treatable stage.