Amyloid-β related angiitis presenting as eosinophilic meningitis: a case report

Amyloid β-related Angiitis Presenting with Subarachnoid Hemorrhage Diagnosed by Brain Biopsy: A Case Report

Cerebral amyloid angiopathy is a vascular disorder characterized by amyloid β deposition in leptomeningeal and cortical blood vessels. Rarely, amyloid β accumulation induces inflammatory responses, classified as cerebral amyloid angiopathy-related inflammation or amyloid β-related angiitis, with the latter being extremely rare. We report a case of a 74-year-old woman presenting with visual field disturbance, occipital pain, speech impairment, agraphia, and acalculia. Imaging revealed subarachnoid hemorrhage without an identifiable source on cerebral angiography. Magnetic resonance imaging demonstrated abnormal enhancement in the dura and pia mater of the left temporal and parietal lobes. Brain biopsy confirmed amyloid β-related angiitis, showing histopathological findings of amyloid deposition with granulomatous inflammation. Steroid pulse therapy led to marked clinical and radiological improvement. This case highlights the importance of considering amyloid β-related angiitis in the differential diagnosis of angiographically negative subarachnoid hemorrhage. Early recognition and immunosuppressive therapy are essential to reduce neurological deficits, with brain biopsy providing a definitive diagnosis.

Primary Angiitis of the Central Nervous System with Pathological Findings of Eosinophilic Granulomatosis with Polyangiitis

A 79-year-old woman presented with difficulty walking and disturbance of consciousness. Magnetic resonance imaging revealed diffuse white matter lesions and abnormal signals along the surface of the brain and sulci. A brain biopsy revealed granulomatous vasculitis with eosinophil infiltration. There was no peripheral blood eosinophilia or evidence of angiitis in other organs, and primary angiitis of the central nervous system (PACNS) with pathological findings of eosinophilic granulomatosis with polyangiitis (EGPA) was diagnosed. Steroids and other immunosuppressant therapies showed only limited effects. PACNS with pathological findings of EGPA is extremely rare, and a prompt brain biopsy is necessary for a diagnosis.

Primary Angiitis of the Central Nervous System in Adults: A Comprehensive Review of 76 Biopsy-Proven Case Reports

Purpose

Primary angiitis of the adult central nervous system (PACNS) is an increasingly recognized but limited disease. Using previous case reports, we sought to summarize the clinical symptoms, imaging manifestations, treatment, and prognosis of patients with biopsy-confirmed PACNS to guide clinical diagnosis and management.

Methods

We searched the Web of Science database for studies published from January 2000 to April 2023, with the language set to English and the document type limited to [Article or Review or Letter or Editorial Material]. A systematic review of all case reports met the inclusion and exclusion criteria was performed. These patients' clinical, pathological, and imaging characteristics were analyzed, and treatment and prognostic data were summarized.

Results

We analyzed 69 articles, including 76 patients with biopsy-confirmed PACNS. And 57.9% of the patients were male, the median age at presentation was 47.0 years, and focal neurological deficits were the most common symptom in patients (78.9%), followed by headache (52.6%). The median duration of biopsy was 1.1 months, of which 49 (64.5%) patients were lymphocytic, 13 (17.1%) were granulomatous, 11 (14.5%) were amyloidotic, and 3 (3.9%) were necrotizing PACNS. Relapse events occurred in 41 (53.9%) patients, including 34 (44.2%) relapses and 8 (10.5%) deaths. Univariate logistic regression analysis revealed that symptomatic epilepsy, prolonged biopsy time window, and CD20 expression in pathological tissues might be independent risk factors for recurrent events in patients (HR=4.69, 95% CI: 1.51-14.54, p=0.007; HR=1.11, 95% CI: 1.00-1.22, p=0.043; HR=5.33, 95% CI: 1.07-26.61, p=0.041).

Conclusion

Adult PACNS is associated with frequent relapses and high mortality. Symptomatic epilepsy, prolonged biopsy time window, and CD20 expression in pathological tissue may be associated with recurrent events.