Ataxia as the main manifestation of tumor-like primary angiitis of the central nervous system: a case report and literature review

Primary angiitis of the CNS and ANCA-associated vasculitis: from pathology to treatment

Vasculitis of the central nervous system can be a localized process, such as primary angiitis of the central nervous system (PACNS), or systemic vasculitis, such as ANCA-associated vasculitis (AAV). Since both conditions share neurological manifestations, the following review will discuss the neurological aspects of both. This review aims to provide a comprehensive comparison of the pathogenesis, clinical manifestation and assessment, diagnostic workup, and treatment protocol for both PACNS and AAV with central nervous system involvement. To provide a comprehensive comparison and update, a literature review was conducted using PubMed and Ovid databases (Embase and Medline). Then, the references were retrieved, screened, and selected according to the inclusion and exclusion criteria. PACNS and AAV share similarities in clinical presentation and neurological symptoms, especially in terms of headache, focal deficits, and cognitive impairment. Additionally, both conditions may exhibit similarities in laboratory and radiological findings, making brain biopsy the gold standard for differentiation between the two conditions. Moreover, the treatment protocols for PACNS and AAV are nearly identical. Comparing PACNS and AAV with CNS involvement highlights the similarities in clinical presentation, radiological findings, and treatment protocols between the two conditions. Further research should focus on establishing a practical diagnostic protocol.

[Pseudotumorous form of primary central nervous system vasculitis]

A 23-year-old female patient with primary vasculitis of the central nervous system simulating a brain tumor is described. The clinical picture was represented by migraine-like headaches, ataxia, transient numbness of the right leg, the lips, double vision, a slight decrease of cognitive functions. MRI of the brain revealed a tumor-like focus in the cerebellum, intensively accumulating contrast, containing micro-hemorrhages (SWI mode). Small single ischemic foci in the brain hemispheres and brain stem were also found. MR angiography (3T) did not found any pathology. Examination of the cerebrospinal fluid revealed a small cytosis (mainly T-lymphocytes) and a slight increase in protein. The results of the analysis of cerebrospinal fluid for syphilis, tuberculosis and the herpetic group of viruses were negative, type 1 oligoclonal synthesis was found. Blood tests for toxoplasmosis, antibodies to aquaporin, anti-neutrophil antibodies, markers of systemic inflammation were within normal limits. Different diagnoses were assumed: demyelinating disease, encephalitis, multiple encephalomyelitis, lymphoma. The diagnosis was established only by a brain biopsy - lymphocytic vasculitis was revealed. According to the immunohistochemical study, T-helpers predominated in the infiltrates. After pulse therapy with Metylprednisolon (1000 mg intravenously drip №. 5), the patient's condition almost returned to normal. It was recommended to take prednisolone per os (starting dose 60 mg) for 7 months.

Retrospective Analysis of 28 Cases Confirmed for Primary Angiitis of the Central Nervous System by Biopsy

OBJECTIVE

The present study aimed to summarize the clinical characteristics, therapeutic effects, and long-term prognosis of cases confirmed with primary angiitis of the central nervous system (PACNS) by biopsy, analyze the risk factors, and provide clinical guidance for the diagnosis and treatment of the disease.

METHODS

Retrospective analysis was performed on 28 cases of PACNS confirmed by biopsy, and the age, gender, pathological results, course of the disease, imaging manifestations, treatment, and prognosis of the patients were analyzed and summarized.

RESULTS

The cohort (age 16-60 years) comprised of 16 males. The average time from the visit to diagnosis was 6 months. The first symptom was chronic headache in 18 patients. The pathological results were accompanied by demyelination in 10 cases and glial hyperplasia in 6 cases. A total of 27 patients received treatments including glucocorticoid+cyclophosphamide; of these, 3 cases of craniotomy were improved. Among the 28 patients, 15 patients improved after the treatment, 12 patients had no significant improvement, and 1 patient was deceased. Patients with a long course of the disease before diagnosis, a Karnofsky performance status (KPS) score <60 at the time of diagnosis, a behavioral, cognitive abnormality before treatment, and a short-term relapse (0.3-1 month) have a poor outcome.

CONCLUSIONS

PACNS patients are prone to misdiagnosis and mistreatment, with unknown etiology and poor prognosis due to delayed treatment. Therefore, early biopsy, pathological diagnosis, and timely treatment with glucocorticoid shock are recommended, and patients with obvious mass effect should be treated by surgical resection.