Imaging of Non-atherosclerotic Vasculopathies

Ischemic stroke as a presenting feature of neurosyphilis in an immunocompetent adult and attained complete recovery following treatment: a case report and review of the literature

BACKGROUND

Neurosyphilis typically presents with nonspecific symptoms such as behavioral changes or cognitive impairment, rather than an initial stroke.

CASE PRESENTATION

This case report describes a Black African man in his thirties who experienced sudden weakness on the left side of his body. Computed tomography suggested a nucleo-capsular ischemic lesion. However, given his young age and lack of traditional stroke risk factors, further investigations were pursued. Laboratory tests revealed positive results for syphilis in both blood and cerebrospinal fluid. Additional imaging (head and neck angiography) indicated intracranial vasculitis with widespread and acute ischemia in the right hemisphere. Treatment with ceftriaxone and aspirin was initiated. Through ongoing monitoring and care, the patient's neurological condition improved.

CONCLUSION

The case underscores the critical need for prompt diagnosis and comprehensive assessment in patients experiencing stroke-like symptoms, especially in younger individuals. By recognizing neurosyphilis as a potential cause, healthcare providers can initiate timely treatment and improve patient outcomes.

Neurovascular management of intracranial internal carotid artery dissection post-carotid endarterectomy: A case report of an innovative approach

Carotid endarterectomy (CEA) is an established method of stroke prevention in patients with severe carotid artery stenosis, especially in those with symptomatic disease. Complications of CEA include perioperative stroke, cranial nerve palsy, hemorrhage, and vascular dissection. We present an unusual case of a 66-year-old man who presented for elective right CEA for symptomatic 70% right internal carotid artery (ICA) stenosis due to ulcerated plaque. Following surgery, the patient developed fluctuating neurological deficits consistent with involvement of the right middle cerebral artery territory. Imaging revealed possible mild clamp-induced ICA dissection limited to the ICA in the neck. Despite initial successful anticoagulation management in the neurointensive care unit, the patient returned 2 days later with stroke symptoms, necessitating urgent endovascular intervention. Neurovascular interventions involved aspiration thrombectomy and multiple stenting extending distally into intracranial ICA, which successfully restored cerebral arterial perfusion and normal neurological function. This case highlights the first reported instance of extensive intracranial ICA dissection managed with full-length stenting. This article offers an effective endovascular procedure for preventing a devastating stroke from a complication of a procedure that was performed to prevent it.

Imaging Review of Pediatric Monogenic CNS Vasculopathy with Genetic Correlation

Monogenic cerebral vasculopathy is a rare but progressively recognizable cause of pediatric cerebral vasculopathy manifesting as early as fetal life. These monogenic cerebral vasculopathies can be silent or manifest variably as fetal or neonatal distress, neurologic deficit, developmental delay, cerebral palsy, seizures, or stroke. The radiologic findings can be nonspecific, but the presence of disease-specific cerebral and extracerebral imaging features can point to a diagnosis and guide genetic testing, allowing targeted treatment. The authors review the existing literature describing the frequently encountered and rare monogenic cerebral vascular disorders affecting young patients and describe the relevant pathogenesis, with an attempt to categorize them based on the defective step in vascular homeostasis and/or signaling pathways and characteristic cerebrovascular imaging findings. The authors also highlight the role of imaging and a dedicated imaging protocol in identification of distinct cerebral and extracerebral findings crucial in the diagnostic algorithm and selection of genetic testing. Early and precise recognition of these entities allows timely intervention, preventing or delaying complications and thereby improving quality of life. It is also imperative to identify the specific pathogenic variant and pattern of inheritance for satisfactory genetic counseling and care of at-risk family members. Last, the authors present an image-based approach to these young-onset monogenic cerebral vasculopathies that is guided by the size and predominant radiologic characteristics of the affected vessel with reasonable overlap. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Stroke risk in rheumatoid arthritis patients: exploring connections and implications for patient care

Rheumatoid arthritis (RA) can independently increase the risk of stroke, affecting both young and adult RA patients. Recent attention has been drawn to the association between stroke and RA, supported by mounting evidence. Given that stroke is a significant and an urgent public health concern, this review aims to highlight the relationship between stroke and RA, covering mechanisms, underlying risk factors, early detection tools, and treatment implications. By uncovering the connection that links RA to stroke, we can pave the way for targeted healthcare practices and the development of preventive strategies for individuals with RA. Therefore, further research is imperative to deepen our understanding of this association and, ideally, guide treatment decisions for individuals at risk of both RA and stroke.

Childhood Cerebral Vasculitis : A Multidisciplinary Approach

Cerebral vasculitis is increasingly recognized as a common cause of pediatric arterial stroke. It can present with focal neurological deficits, psychiatric manifestations, seizures, and encephalopathy. The etiopathogenesis of childhood cerebral vasculitis (CCV) is multifactorial, making an inclusive classification challenging. In this review, we describe the common and uncommon CCV with a comprehensive discussion of etiopathogenesis, the role of various imaging modalities, and advanced techniques in diagnosing CCV. We also highlight the implications of relevant clinical, laboratory, and genetic findings to reach the final diagnosis. Based on the clinicoradiological findings, a stepwise diagnostic approach is proposed to facilitate CCV diagnosis and rule out potential mimics. Identification of key clinical manifestations, pertinent blood and cerebrospinal fluid results, and evaluation of central nervous system vessels for common and disease-specific findings will be emphasized. We discuss the role of magnetic resonance imaging, MR angiography, and vessel wall imaging as the imaging investigation of choice, and reservation of catheter angiography as a problem-solving tool. We emphasize the utility of brain and leptomeningeal biopsy for diagnosis and exclusion of imitators and masqueraders.

Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology

Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short- and long-term outcomes in many cases. Because of a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describes advantages and disadvantages of different imaging modalities, highlights disorders that predispose children to infarct or hemorrhage, and presents an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.

The emerging role of positron emission tomography (PET) in the management of photon radiotherapy-induced vasculitis in head and neck cancer patients

Purpose

While radiotherapy (RT) for head and neck cancer (HNC) has made recent strides, RT-induced vasculitis continues to adversely affect long-term patient outcomes. Guidelines for managing this complication remain scarce, supporting the need for a sensitive imaging modality in post-treatment evaluations. In this review, we discuss the current literature regarding 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and 18F-sodium fluoride (NaF-PET) in evaluating RT-induced vasculitis in HNC patients, highlighting several arenas of evolving clinical significance: (1) early recognition and standardized evaluation of RT-induced vasculitis, and (2) potential for a multifaceted diagnostic tool to stratify cardiovascular risk in HNC patients.

Methods

Numerous databases, including, but not limited to, Google Scholar and PubMed, were utilized to compile a body of literature regarding PET imaging of RT-induced vasculitis in HNC and related malignancies.

Results

Multiple studies have established the clinical capabilities of FDG-PET/computed tomography (FDG-PET/CT) for detection and management of RT-induced vasculitis in HNC patients, while NaF-PET/CT remains under investigation. Inflammatory vascular stages may be best analyzed by FDG-PET/CT, while vascular microcalcification and atherosclerotic disease may be supplementally assessed by the unique properties of NaF-PET/CT. With these modalities detecting primary stages of more detrimental vascular complications, PET imaging may carry several advantages over conventional, structural techniques.

Conclusion

FDG-PET/CT and NaF-PET/CT hold significant potential as preliminary diagnostic tools in monitoring early inflammation and atherosclerotic plaque development, warranting further research and attention. Applying these techniques in this context may foster proactive and consistent assessments of RT-induced vasculitis in HNC patients, mitigating potential cardiovascular risks through better-informed treatment decisions.