20-28: Primary Angiitis of the Central Nervous System

Primary angiitis of the CNS is a syndrome with several possible causes that produces small- and medium-sized vasculitis limited to the brain and spinal cord. Biopsy-proved cases have predominated in men who have a history of weeks to months of headaches, encephalopathy, and multifocal strokes. Systemic symptoms and signs are absent, and routine laboratory tests, including ESR and CRP, may be normal. MRI of the brain is almost always abnormal, and the spinal fluid often reveals a mild lymphocytosis and a modest increase in protein level. Angiograms classically reveal a “string of beads” pattern produced by alternating segments of arterial narrowing and dilation. However, neither the MRI nor the angiogram appearance is specific for vasculitis. Indeed, in one study, none of the patients who had biopsy-proved CNS vasculitis had an angiogram showing “the string of beads,” and none of the patients with the classic angiographic findings had a positive brain biopsy for vasculitis. Review of many studies suggests that the sensitivity of angiography varies greatly (from 40% to 90%) and the specificity is only approximately 30%. Several conditions, including vasospasm, can produce the same angiographic pattern as vasculitis. Definitive diagnosis requires a compatible clinical picture with exclusion of infection (including subacute bacterial endocarditis), neoplasm (especially intravascular lymphoma), or drug exposure (eg, cocaine) that can mimic primary angiitis of the CNS and a positive brain biopsy. In contrast to biopsy-proved cases, patients with angiographically defined CNS vasculopathy are chiefly women who have had an abrupt onset of headaches and stroke (often in the absence of encephalopathy) with normal spinal fluid findings. Many patients who fit this clinical profile may have reversible cerebral vasoconstriction rather than true vasculitis. Such cases are best treated with calcium channel blockers (such as nimodipine or verapamil) and possibly a short course of corticosteroids. Biopsy-proved cases usually improve with prednisone therapy and often require cyclophosphamide. Treatment response correlates with the size of arteries involved: vasculitis of small cortical and leptomeningeal vessels is associated with a better response and outcome than vasculitis of larger arteries. Cases of CNS vasculitis associated with cerebral amyloid angiopathy often respond well to corticosteroids, albeit the long-term natural history remains poorly defined.