Middle cerebral artery resistivity and pulsatility indices in systemic lupus erythematosus: evidence for hyperperfusion

Cerebral microvascular and microstructural integrity is regionally altered in patients with systemic lupus erythematosus

Background

To measure regional brain microvascular and microstructural changes in childhood-onset SLE (cSLE) using diffusion-weighted imaging (DWI) at multiple b values and investigate relationships of those measures with neurocognitive function and disease activity.

Methods

In this cross-sectional, case-control study, vascular volume fraction, effective diffusion, parenchymal diffusion, and blood flow parameters were regionally compared in cSLE patients and matched healthy controls. These markers of microvascular and microstructural integrity were derived by diffusion-weighted brain MRI and intravoxel incoherent motion (IVIM) modeling. Formal neurocognitive testing was completed focused on the domains of attention, visuoconstructional ability, working memory, and psychomotor speed. Test scores and measures of disease severity were regressed against regional microvascular integrity parameters among cSLE patients.

Results

Formal cognitive testing confirmed normal cognitive ability among all cSLE patients included in the analysis (n = 11). Nevertheless, reduction in blood volume fraction coincided with increased effective diffusion and flow parameters in cSLE patients vs. controls in posterior brain regions including the cuneus and precuneus. Regional microvascular measures correlated (|r| = 0.54–0.66) with neuropsychiatric scores and disease activity among cSLE patients.

Conclusions

There is imaging evidence, using IVIM, of degraded microvascular integrity in cSLE patients with normal cognitive ability. The observed regional changes correspond with posterior vascular border zones. These outcomes appear consistent with regional gray matter volume loss previously observed in cSLE patients with overt neurocognitive deficits, supporting the notion that adverse vascular changes precede loss of cognitive ability in cSLE. Longitudinal studies are needed to confirm the findings of this initial study.

Speckle tracking echocardiography as a new diagnostic tool for an assessment of cardiovascular disease in rheumatic patients

Chronic inflammation represents the cornerstone of the raised cardiovascular (CV) risk in patients with inflammatory rheumatic diseases (IRD). Standardized mortality ratios are increased in these patients compared to the general population, which can be explained by premature mortality associated with early atherosclerotic events. Thus, IRD patients need appropriate CV risk management in view of this CV disease (CVD) burden. Currently, optimal CV risk management is still lacking in usual care, and early diagnosis of silent and subclinical CVD involvement is mandatory to improve the long-term prognosis of those patients. Although CV involvement in such patients is highly heterogeneous and may affect various structures of the heart, it can now be diagnosed earlier and promptly treated. CV imaging provides valuable information as a reliable diagnostic tool. Currently, different techniques are employed to evaluate CV risk, including transthoracic or trans-esophageal echocardiography, magnetic resonance imaging, or computed tomography, to investigate valve abnormalities, pericardial disease, and ventricular wall motion defects. All the above methods are reliable in investigating CV involvement, but more recently, Speckle Tracking Echocardiography (STE) has been suggested to be diagnostically more accurate. In recent years, the role of left ventricular ejection fraction (LVEF) as the gold standard parameter for the evaluation of systolic function has been debated, and many efforts have been focused on the clinical validation of new non-invasive tools for the study of myocardial contractility as well as to characterize the subclinical alterations of the myocardial function. Improvement in the accuracy of STE has resulted in a large amount of research showing the ability of STE to overcome LVEF limitations in the majority of primary and secondary heart diseases. This review summarizes the additional value that STE measurement can provide in the setting of IRD, with a focus in the different clinical stages.

Inter-patient variations in flow boundary conditions at middle cerebral artery from 7T PC-MRI and influence on Computational Fluid Dynamics of intracranial aneurysms

BACKGROUND

Computational fluid dynamics(CFD) of intracranial aneurysms requires flow boundary conditions(BCs) as inputs. Patient-specific BCs are usually unavailable and substituted by literature-derived generic BCs. Therefore, we investigated inter-patient BC variations and their influence on middle cerebral artery aneurysmal hemodynamics.

METHOD

We retrospectively collected CT angiography and 7-T Phase-Contrast(PC)-MRI data from eight middle-cerebral-artery bifurcation aneurysms to reconstruct the geometry and measure the arterial flowrates, respectively. The coefficient of variation(CoV) was calculated for the inlet flowrate and the pulsatility index(PI). The outflow split estimated by Murray's law was compared with PC-MRI measurements. For each aneurysm, we performed seven simulations: "baseline" using PC-MRI-derived BCs and the other six with changing BCs to explore the influence of BC variations on hemodynamics.

RESULTS

From PC-MRI, the inlet flowrate was 1.94 ± 0.71 cm³/s(CoV = 36%) and PI was 0.37 ± 0.13(CoV = 34%). The outflow split estimated by Murray's law deviated by 15.3% compared to PC-MRI. Comparing to "baseline" models, ±36% variations in inlet flowrate caused -61% to +89% changes in time-averaged wall shear stress(WSS), -37% to +32% in normalized WSS(NWSS; by parent-artery), and -42% to +126% in oscillatory shear index(OSI). The ±34% variations in PI caused, -46% to +67% in OSI. Applying ±15% variations in outflow split led to inflow jet deflection and -41% to +52% changes in WSS, -41% to +47% in NWSS, and -44% to +144% in OSI.

CONCLUSION

Inflow rate and outflow split have a drastic impact on hemodynamics of intracranial aneurysms. Inlet waveform has a negligible impact on WSS and NWSS but major impact on OSI. CFD-based models need to consider such sensitivity.

Neurosonological and cognitive screening for evaluation of systemic sclerosis patients

OBJECTIVE

Assessment of cerebrovascular hemodynamics, third ventricle diameter (as a proxy of brain atrophy) by transcranial sonography (TCS), and screening of cognitive performance by the Symbol Digit Modalities Test (SDMT) in systemic sclerosis (SSc) patients.

METHODS

A total of 38 SSc patients recruited from the outpatient clinic of the Rheumatology Department, Kasr Alainy Hospital, Cairo University, and 51, age- and sex-matched, healthy controls were included in the study. TCS was used to assess the mean flow velocity (MFV), pulsatility index (PI) of the anterior, middle, and posterior cerebral arteries bilaterally, and to measure the third ventricle diameter as a proxy of brain atrophy. Cognitive impairment was screened using the SDMT. p values < 0.05 were considered statistically significant.

RESULTS

There was no significant difference between SSc patients and controls regarding either PI or MFV of the anterior, middle, and posterior cerebral arteries; also, there was no difference regarding the third ventricle diameter; however, limited SSc patients showed a significant increase in the PI of PCA and MFV of ACA as compared with diffuse SSc patients (p = 0.005, 0.004). There was a significant difference between SSc patients and controls regarding the SDMT (p = 0.016).

CONCLUSION

There is an evidence of increased cerebral vascular tone and resistance in limited SSc patients compared with diffuse SSc subgroup, without evidence of cerebral atrophy, suggesting early cerebrovascular affection even in asymptomatic limited SSc patients. There was also an evidence of cognitive impairment in SSc patients.

Intracranial hemodynamic changes in primary Sjögren syndrome: a transcranial Doppler case-control study

The aim of this case-control study is to evaluate the cerebral hemodynamic parameters in primary Sjögren syndrome patients by means of transcranial Doppler and the possible relationship with neuroimaging structural alteration, immunological markers and subclinical neurological involvement. 87 consecutive treatment-naïve outpatients with primary Sjögren syndrome and 86 age- and sex-matched healthy controls underwent transcranial Doppler for bilateral measurement of mean flow velocities, pulsatility index and systolic-diastolic ratio, brain magnetic resonance imaging, clinical evaluation with neuropsychological test and serological assessment. 28 patients and 4 controls (32 vs. 4 %, p .001) had executive function disorders at neuropsychological tests. Mean pulsatility index and systolic-diastolic ratio were significantly higher in both mean cerebral arteries of the patients than in controls (1.3 ± 0.6 vs. 0.9 ± 0.6, p .01 and 3.4 ± 1.7 vs. 1.6 ± 0.7, p .001, respectively). White matter hyperintensities were present in 21 patients and 18 controls. Only age was significantly associated with WMHs in both groups (p < .0001). The increase in systolic-diastolic ratio significantly correlates with neuropsychological impairment. Anti-SSA autoantibodies positively correlate with impaired systolic-diastolic ratio and with neuropsychiatric symptoms. The correlation between haemodynamic changes and anti-SSA autoantibodies suggests a role for the autoimmune response in determining early cerebral hemodynamic dysfunctions. The functional impairment of the endothelium may play a pivotal role in vasomotor dysfunction before any organic damage. The subsequent structural damage of the arterial wall may be responsible for the increase in resistances in small cerebral arteries and sustained hypoperfusion.

Subclinical right ventricle systolic dysfunction in childhood-onset systemic lupus erythematosus: insights from two-dimensional speckle-tracking echocardiography

Objective

The objective of this article is to evaluate right ventricle strain imaging by two-dimensional speckle-tracking (2DST) in childhood-onset systemic lupus erythematosus (c-SLE).

Methods

Thirty-five c-SLE patients with no signs or symptoms of heart failure and 33 healthy volunteers were evaluated by standard echocardiogram and 2DST. Conventional parameters included tricuspid annular plane systolic excursion (TAPSE), RV tissue-Doppler-derived Tei index and systolic pulmonary artery pressure. Global peak longitudinal systolic strain (PLSS) and strain rate (PLSSR) of RV were obtained by 2DST. Demographic/clinical features, SLEDAI-2K/SLICC/ACR-DI and treatment were also assessed.

Results

The median current age was similar in patients and controls (14.75 vs. 14.88 years, p = 0.62). RV PLSS was significantly reduced in c-SLE (−24.5 ± 5.09 vs. −27.62 ± 3.02%, p = 0.003). Similar findings were observed after excluding patients with pulmonary hypertension (−24.62 ± 4.87% vs. −27.62 ± 3.02%, p = 0.0041). RV PLSS was positively correlated with TAPSE ( r = +0.49, p = 0.0027) and negatively correlated with Tei index ( r = −0.34, p = 0.04) in c-SLE. RV PLSSR was not different comparing patients and controls (−0.65 s−1 ± 0.47 vs. −1.87 ± 0.49 s−1, p = 0.07). Further analysis of c-SLE patients revealed higher frequencies of neuropsychiatric manifestations (39% vs. 0%, p = 0.007) and antiphospholipid antibodies (55% vs. 18%, p = 0.035) in those with RV PLSS ≤ −23.7% vs >−23.7%. No differences were evidenced in demographic data, disease activity/damage or treatments ( p > 0.05).

Conclusions

The present study, using a new and more sensitive technique, revealed subclinical RV systolic dysfunction in c-SLE patients that may have future prognostic implications. The novel association of asymptomatic RV dysfunction with neuropsychiatric manifestations and antiphospholipid antibodies may suggest common physiopathological pathways.

Physical therapy combined with corticosteroid intervention for systemic lupus erythematosus with central nervous system involvement: a case report

[Purpose] Systemic lupus erythematosus (SLE) is a chronic, immune-mediated disease, affecting 0.1% of the general population. To date, few studies have investigated the efficacy of physical therapy for SLE patients with CNS involvement. The aim of this study was to report whether the combined use of corticosteroids and physical therapy, consisting of reflex inhibition and functional training, was beneficial to functional recovery. [Subjects and Methods] A 22-year-old male SLE patient with CNS involvement requested physical therapy due to strong spasticity of the trunk and limbs in a bedridden state. Corticosteroid intervention and physical therapy were undertaken for 16 days. [Result] After 16 days of the interventions, the patient demonstrated stabilized and alleviated neurological symptoms and an improved functional level. [Conclusion] The present case indicates that physical therapy combined with corticosteroids might be a possible treatment and rehabilitation method to effectively recover motor function for SLE patients who have strong spasticity due to CNS involvement.