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Year : 2005  |  Volume : 15  |  Issue : 4  |  Page : 419-420
CNS Vasculitis : Not an uncommon entity


Rangaraya Medical College/Govt. General Hospital, Kakinada. Andhra Pradesh.India. Pin: 533001, India

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How to cite this article:
Desai SB. CNS Vasculitis : Not an uncommon entity. Indian J Radiol Imaging 2005;15:419-20

How to cite this URL:
Desai SB. CNS Vasculitis : Not an uncommon entity. Indian J Radiol Imaging [serial online] 2005 [cited 2020 Aug 9];15:419-20. Available from: http://www.ijri.org/text.asp?2005/15/4/419/28762
CNS vasculitis is a rare inflammatory disease associated with many causes that involve the small vessels of cerebral parenchyma and meninges. This may be the result of either primary angitis or associated with variety of conditions including infection, cocaine use, radiation, malignancy or autoimmune disease.

Today we suspect this disease almost daily, though, it is a comparatively rare disease.

CNS vasculitis is a serious disorder, hence, prompt diagnosis and early therapy are essential for positive outcome. The diagnosis of vasculitis is challenging because of lack of uniform diagnostic criterias and difficulty in obtaining pathological specimens from the brain. The diagnosis of CNS vasculitis usually is clinically suspected based on neurology presentation and presence of or rather lack of definitive signs of other disorders. The presence of an inflammatory process and fibrinoid necrosis in the walls of small veins and arterioles remains the gold standard for the diagnosis of primary angitis of CNS. LP is of little help.

MR imaging is considered to be an excellent tool for CNS vasculitis because of its reportedly high sensitivity. Greenan TJ et.al, Harris KG et.al reported almost 100% sensitivity of MR in detecting vasculitic lesions. MR typically reveals multi focal, white and gray matter lesions caused by ischemia, infarction or both. Large number of lesions are usually seen in MCA territory [Figure - 1]. It is not uncommon for involvement of corpus callosum, brainstem or other regions in vasculitic lesions. The lesions can be symmetric or asymmetric in distribution. We have seen cases with bilateral symmetrical parieto-occipital subcortical involvement [Figure - 2]. The lesions usually are multiple. Solitary lesion is a rare finding in vasculitis. We have, however, come across a very unusual case of solitary right posterior deep parietal vasculitic lesion in an immunosupressed patient [Figure - 3]. The lesion mimicked and was suspected to be a low-grade infective pathology, the only clue being decreased ADC values and restricted diffusion observed within the lesion. Vasculitic lesions appear hyperintense on T2 W1 and FLAIR images.

Perfusion imaging is of great help to detect hypoperfusion in these lesions, which appears to be hallmark of the disease. Diffusion images will be of help in the acute setting, showing restricted diffusion with decreased ADC values. We tried Magnetisation Transfer MR and MR spectroscopy for evaluation of these lesions and found them of no great help. MR angiography some times reveals associated arterial abnormalities like segmental narrowings, occlusions, beading etc., Standard DSA, however, reveals the arterial abnormalities better, as the disease involves the smaller vessels. Usually a negative MR would be against the diagnosis of vasculitis and preclude the necessity of invasive angiography. Vanderzant et al. have reported a single case of biopsy proven CNS vasculitis with normal MRI, however, this was challenged later. Imbesi and Alhalabi and Moore have reported a single case of drug induced CNS vasculitis in a patient with normal MR and abnormal cerebral angiogram. Though most of the lesions seen on MR are infarctions, hemorrhagic lesions also have been reported in vasculitis. Both intraparenchymal and subarachnoid hemorrhages have been seen, though rarely, in CNS vasculitis. To summarize multiple subcortical infarctions are classical MR findings in CNS vasculitis, though appreciable variation in number, size and location of the lesions may occur.

In approaching patient with possible CNS vasculitis radiologist has to address few basic issues and questions

a. Does MR images with normal findings exclude the diagnosis of CNS vasculitis?

b. Are there typical MRI findings in CNS vasculitis ?

c. Is there any need of further angiogram.?

I hope with our present knowledge and understanding of this difficult but not so uncommon clinical entity, radiologists should be in a position to answer these questions.

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Correspondence Address:
Shrinivas B Desai
Dept. of Radio Diagnosis, Govt. General Hospital, Kakinada. Andhra Pradesh 533001.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.28762

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[Figure - 1], [Figure - 2], [Figure - 3]

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