We report the rare case of a primary angiitis of the CNS (PACNS) with isolated spinal cord manifestation. This 44-year-old female presented diffuse dysesthesia with moderate progressive weakness of the lower limbs. There were no cerebral symptoms; cMRI was normal. The diagnosis of PACNS was made by a spinal cord biopsy demonstrating granulomatous vasculitis. The patient was successfully treated with steroids and methotrexate. During a 2 year follow-up our patient did not show any brain or other organ involvement.
Anzeige
The 44-year-old female presented with moderate progressive weakness of both legs and burning sensory symptoms of all limbs and the trunk. In addition to moderate paraparesis, the physical examination revealed a moderate pallhypesthesia of the legs with reduced vibratory sense and a diffuse hyp- and dysesthesia below the level of CD5. The family history was unremarkable for neurological diseases.
The MRI of the cervical spine showed a gadolinium-enhancing lesion in the posterior part of the myelon with intramedullary edema. This lesion extended from cervical vertebral bodies 2–7 (Fig. 1a).
×
The cerebral MRI and visual evoked potentials were entirely normal, the examination of the CSF revealed a slight pleocytosis (12 cells/mm3), cytological examination showed regular cells. Oligoclonal bands were absent which makes multiple sclerosis highly improbable.
Laboratory examinations did not reveal any evidence for either metabolic (vitamin-B12, folate), autoimmune or infectious disorder. We found no aquaporin-4-antibodies. With normal VEP, we had no evidence for neuromyelitis optica.
Anzeige
We started with intravenous high dose methylprednisolone therapy (1 g for 5 days), but symptoms relapsed after 3 months of disease freedom.
Before introduction of another immunosuppressive therapy, and to exclude a spinal lymphoma, a biopsy of the spinal lesion was taken. The neuropathological examination revealed a granulomatous vasculitis with transmural inflammation consisting of lymphocytes, epitheloid cells and giant cells (Fig. 2a–h). There was no evidence for systemic organ involvement assessed by thoracic and abdominal computer tomography.
×
Treatment was started with methotrexate (20 mg/week) combined with prednisolone (tapered from 80 to 10 mg/d within 6 weeks).
Neurological examination at 3 month intervals revealed normal findings except a slight dysesthesia in the legs.
A follow-up MRI after 24 months of treatment demonstrated an obvious regression of the signal intensities within the cervical cord (Fig. 1b), whereas the cMRI remained normal.
Spinal symptoms are a rare presentation of primary CNS vasculitis [1]. The previously reported cases with spinal cord involvement also showed progressive paraparesis and dysesthesia as the most common clinical symptoms [2]. However, usually these symptoms occur in the course of the disease and not at disease onset as in our case. A review of the literature showed only eight cases with initially pure spinal cord involvement [3]; half of these cases developed brain lesions later on [1, 4].
The stereotactic biopsy remains the gold standard to assure the diagnosis of a CNS vasculitis [5], but the diagnosis in daily clinical routine is often only based on clinical and imaging findings as well as the response to treatment. This might be a potential reason for overdiagnosing PACNS in clinical routine. As illustrated by our case, histological verification is crucial for the diagnosis.
The standard therapy for PACNS consists of corticosteroids (1 mg/kg prednisolone) and pulsed cyclophosphamide (0.5 mg/kg). The treatment with cyclophosphamide can have severe side effects [6]. Monotherapy with steroids leads to higher recurrence rates [7]. Since methotrexate has been successfully used in systemic vasculitis [8], we started treatment with a combination of steroids and methotrexate. Our patient reached remission within 3 months and remains stable now more than 2 years later. In biopsy-proven PACNS of the spinal cord, methotrexate seems to be an effective and less toxic alternative to cyclophosphamide.
Anzeige
Open Access This is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License (
https://creativecommons.org/licenses/by-nc/2.0
), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Mit e.Med Neurologie & Psychiatrie erhalten Sie Zugang zu CME-Fortbildungen der Fachgebiete, den Premium-Inhalten der dazugehörigen Fachzeitschriften, inklusive einer gedruckten Zeitschrift Ihrer Wahl.
Mit e.Med Neurologie erhalten Sie Zugang zu CME-Fortbildungen des Fachgebietes, den Premium-Inhalten der neurologischen Fachzeitschriften, inklusive einer gedruckten Neurologie-Zeitschrift Ihrer Wahl.
Ein hohes soziales Niveau ist mit die beste Versicherung gegen eine Demenz. Noch geringer ist das Demenzrisiko für Menschen, die sozial aufsteigen: Sie gewinnen fast zwei demenzfreie Lebensjahre. Umgekehrt steigt die Demenzgefahr beim sozialen Abstieg.
Kommt es zu einer nichttraumatischen Hirnblutung, spielt es keine große Rolle, ob die Betroffenen zuvor direkt wirksame orale Antikoagulanzien oder Marcumar bekommen haben: Die Prognose ist ähnlich schlecht.
Eine Studie zum Nutzen der druckentlastenden Kraniektomie nach schwerer tiefer supratentorieller Hirnblutung deutet einen Nutzen der Operation an. Für überlebende Patienten ist das dennoch nur eine bedingt gute Nachricht.
Auch ein sehr ausgedehnter ischämischer Schlaganfall scheint an sich kein Grund zu sein, von einer mechanischen Thrombektomie abzusehen. Dafür spricht die LASTE-Studie, an der Patienten und Patientinnen mit einem ASPECTS von maximal 5 beteiligt waren.
Update Neurologie
Bestellen Sie unseren Fach-Newsletterund bleiben Sie gut informiert.