Multiple cerebral infarctions from nonbacterial thrombotic endocarditis mimicking cerebral vasculitis

Quadravalvular Noninfectious Endocarditis

Nonbacterial thrombotic endocarditis is characterized by sterile thrombi on cardiac valves. This report describes the case of nonbacterial endocarditis without pathologic findings of fibrin or platelet deposition. Quadrivalvular endocarditis was found to be due to immunoglobulin M heavy chain deposition. This was a case of nonbacterial, nonthrombotic quadrivalvular endocarditis, which was termed noninfective endocarditis. (Level of Difficulty: Intermediate.)

Central nervous system vasculitis: still more questions than answers

The central nervous system (CNS) may be involved by a variety of inflammatory diseases of blood vessels. These include primary angiitis of the central nervous system (PACNS), a rare disorder specifically targeting the CNS vasculature, and the systemic vasculitides which may affect the CNS among other organs and systems. Both situations are severe and convey a guarded prognosis. PACNS usually presents with headache and cognitive impairment. Focal symptoms are infrequent at disease onset but are common in more advanced stages. The diagnosis of PACNS is difficult because, although magnetic resonance imaging is almost invariably abnormal, findings are non specific. Angiography has limited sensitivity and specificity. Brain and leptomeningeal biopsy may provide a definitive diagnosis when disclosing blood vessel inflammation and are also useful to exclude other conditions presenting with similar findings. However, since lesions are segmental, a normal biopsy does not completely exclude PACNS. Secondary CNS involvement by systemic vasculitis occurs in less than one fifth of patients but may be devastating. A prompt recognition and aggressive treatment is crucial to avoid permanent damage and dysfunction. Glucocorticoids and cyclophosphamide are recommended for patients with PACNS and for patients with secondary CNS involvement by small-medium-sized systemic vasculitis. CNS involvement in large-vessel vasculitis is usually managed with high-dose glucocorticoids (giant-cell arteritis) or glucocorticoids and immunosuppressive agents (Takayasu's disease). However, in large vessel vasculitis, where CNS symptoms are usually due to involvement of extracranial arteries (Takayasu's disease) or proximal portions of intracranial arteries (giant-cell arteritis), revascularization procedures may also have an important role.

Gliomatosis cerebri angiographically mimicking central nervous system angiitis: case report

OBJECTIVE

The diagnosis of isolated central nervous system angiitis often requires both cerebral angiography and biopsy for diagnosis.

CLINICAL PRESENTATION

We present a case of gliomatosis cerebri with demonstrated angiographic changes suggestive of a central nervous system vasculitis.

INTERVENTION

A 47-year-old woman presented with a 2-week history of worsening headache and progressive drowsiness. Magnetic resonance imaging scans revealed confluent nonenhancing T2-weighted hyperintensity involving the frontal white matter bilaterally, hypothalamus, and both thalami. A four-vessel angiogram revealed diffuse arterial beading with stenoses of a right frontal middle cerebral artery branch and the distal posterior cerebral artery and anterior cerebral artery branches, bilaterally. The biopsy revealed a Grade 2 fibrillary astrocytoma consistent with gliomatosis cerebri.

CONCLUSION

Gliomatosis cerebri can mimic central nervous system vasculitis angiographically. Perivascular infiltration by tumor cells may be responsible for these changes.

Nonbacterial thrombotic endocarditis after lung transplantation

Bacteria-free verrucae has been recognized as a condition associated with several clinical conditions such as bone marrow transplantation, malignant tumors, autoimmune disorders, and acquired immunodeficiency syndrome, but it has not been reported in relation to lung transplantation. We report the case of a patient who underwent bilateral lung transplant and died 3 days later. Histologic examination revealed, among other lesions, the presence of nonbacterial thrombotic endocarditis in the right atrium and mitral and tricuspid valves that was not present in the preoperative echocardiographic studies. Even with transesophageal echocardiography, a reliable detection of vegetations may not be possible. Hypoxigenic pulmonary states developed in the course of lung transplant could be the factor that triggers the interaction between the coagulation system, platelets, and endothelial cells that induce the formation of bacteria-free verrucae.

Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study

BACKGROUND AND PURPOSE

Although infective endocarditis (IE) and nonbacterial thrombotic endocarditis (NBTE) are associated with cardioembolic stroke, differences in the nature of these conditions may result in differences in associated stroke patterns. We compared patterns of acute and recurrent ischemic stroke in IE and NBTE, using diffusion-weighted MRI (DWI).

METHODS

Using ICD-9 diagnostic codes and medical record review, we identified 362 patients (387 episodes) with IE and 14 patients with NBTE. Thirty-five patients (with 27 episodes of IE, 9 NBTE) who underwent 36 initial and 29 follow-up DWI scans were selected for this study. DWI lesion size, number, and location were compared between groups and correlated with stroke syndromes and endocarditis features.

RESULTS

DWI was abnormal in all but 2 patients. Four acute stroke patterns were identified: (1) single lesion, (2) territorial infarction, (3) disseminated punctate lesions, and (4) numerous small (<10 mm) and medium (10 to 30 mm) or large (>30 mm) lesions in multiple territories. All patients with NBTE exhibited pattern 4, whereas those with IE exhibited patterns 1, 2, 3, and 4 (6, 2, 8 and 9 episodes, respectively). Seventy-five percent of patients with pattern 3 exhibited the clinical syndrome of embolic encephalopathy. Vegetation size, valve, and organisms had no correlation with stroke patterns.

CONCLUSION

DWI has utility in differentiating between IE and NBTE. Patients with NBTE uniformly have multiple, widely distributed, small and large strokes, whereas patients with IE exhibit a panoply of stroke patterns.

Intracranial vasculitis and multiple abscesses in a pregnant woman

Cerebral vasculitis is an unusual disorder with many causes. Infectious causes of cerebral vasculitis are predominantly bacterial or viral in nature. Purulent bacterial vasculitis is most often a complication of severe bacterial meningitis. The patient is a 25-year-old African American female, 25 weeks pregnant, who presented to the neurology service after a consult and referral from an outside hospital. She had a 1-month history of right sixth nerve palsy. Initial workup included a negative lumber puncture and a noninfused magnetic resonance imaging (MRI). Three days later, the patient developed right-sided migraine headaches and right third nerve palsy. The angiogram revealed diffuse irregularity and narrowing of the petrous, cavernous, and supraclinoid portions of the internal carotid and right middle cerebral arteries. Shortly thereafter, an MRI examination revealed diffuse leptomeningeal enhancement and abscess and a right parietal subdural empyema. Infectious vasculitis secondary to purulent meningitis has a rapidly progressive course and presents with cranial nerve palsy with involvement of the cavernous sinus. Although the association of this disease with pregnancy has not been established, it should be recognized that the early imaging studies may be negative or discordant and follow-up imaging might be necessary.

Vasculitis of the central nervous system

Central nervous system (CNS) vasculitis occurs in a variety of clinical settings. Some exhibit a distinct age preference; others a tissue tropism. Most frequently encountered are giant cell arteritis (temporal arteritis) and vasculitis secondary to infections. The CNS may be involved in the systemic vasculitides, and neurologic abnormalities occasionally appear as a presenting manifestation of disease. Isolated angiitis of the CNS, a rare form of vasculitis restricted to the CNS, must be distinguished from other causes of CNS inflammation and from noninflammatory vascular disease. We are learning a great deal about the cellular mechanisms of vascular inflammation in the brain. Some manifestations of the clinical disease result from histologic features of the infiltrate and the size of affected vessel. However, the local consequences of inflammation such as increased coagulation and altered vasomotor tone, as well as the systemic consequences such as activation of the central noradrenergic systems, trigeminovascular system, and hypothalamic pituitary adrenal axis contribute to both pathogenesis of disease and recovery. Two central issues that confront us now are improving the accuracy of the diagnosis (including identifying any underlying infectious causes) and limiting the long-term damage both from disease and its therapies.

Systemic and Central Nervous System Vasculitides

The vasculitides are a collection of diseases sharing the central feature of tissue injury due to inflammation of blood vessels. Although some occur frequently, many are encountered uncommonly or rarely. Nonetheless, because peripheral or central nervous system abnormalities may be a prominent part of these disorders, neurologists should know or be able to refer to studies on the classification, pathophysiology, treatments, and long-term complications of vasculitis. Two central issues that confront us now are 1) improving the accuracy of diagnosis, including identifying any underlying infectious causes, and 2) limiting the long-term damage from both the disease and its therapies.