V. Cuvinciuc

Isolated Acute Nontraumatic Cortical Subarachnoid Hemorrhage

SUMMARY: Our aim was to review the etiologic background of isolated acute nontraumatic cSAH. While SAH located in the basal cisterns originates from a ruptured aneurysm in approximately 85% of cases, a broad spectrum of vascular and even nonvascular pathologies can cause acute nontraumatic SAH along the convexity. Arteriovenous malformations or fistulas, cortical venous and/or dural sinus thrombosis, and distal and proximal arteriopathies (RCVS, vasculitides, mycotic aneurysms, Moyamoya, or severe atherosclerotic carotid disease) should be sought by noninvasive imaging methods or/and conventional angiography. Additionally, PRES may also be a source of acute cSAH. In elderly patients, cSAH might be attributed to CAA if numerous hemorrhages are demonstrated by GRE T2 images. Finally, cSAH is rarely observed in nonvascular disorders, such as abscess and primitive or secondary brain tumors.

Cortical subarachnoid haemorrhage in the elderly: a recurrent event probably related to cerebral amyloid angiopathy.

Objective:  Isolated, non‐traumatic, cortical subarachnoid haemorrhage (cSAH) is a rare type of cerebrovascular disease caused by various disorders. In a few cases, especially in the elderly, no apparent cause can be identified. We report a case series of patients without apparent cause of cSAH. We aimed to determine whether cerebral amyloid angiopathy (CAA) could be a common cause of cSAH.

In situ evidence of JC virus control by CD8+ T cells in PML-IRIS during HIV infection

Objective: To determine the pathophysiologic features of progressive multifocal leukoencephalopathy (PML) associated with immune reconstitution inflammatory syndrome (PML-IRIS) in HIV-infected patients. Methods: In a cross-sectional study, we retrospectively analyzed 11 HIV-infected patients with a firm diagnosis of PML-IRIS. Brain biopsies were collected from 5 patients and their histopathologic features were compared to those of 4 HIV-infected patients with classic PML. Results: PML-IRIS developed soon after initiation of antiretroviral therapy in late-presenting HIV-infected patients. The lesions from the 5 biopsied PML-IRIS patients were characterized by a reduction in the density of JC virus (JCV)–infected cells when compared to the 4 patients with PML (11.1 ± 3.2/mm2 vs 51.2 ± 4.3/mm2, p = 0.01). Comparing the 5 patients with PML-IRIS vs the 4 patients with PML, this correlated with an increased accumulation of CD8+ T cells (818.2 ± 192.8/mm2 vs 52.5 ± 10.6/mm2, p = 0.01), CD20+ B cells (33.4 ± 13.5/mm2 vs 0.5 ± 0.5/mm2, p = 0.01), and CD138+ plasma cells (177 ± 84.1/mm2 vs 0.25 ± 0.25/mm2, p = 0.01), while the number of CD68+ macrophages/microglia did not differ. The ratio between CD8+ T cells and JCV-infected cells was 70 times higher in the 5 patients with PML-IRIS. These findings indicate a clear relationship between an enhanced recruitment of CD8+ T cells and the associated control of the JCV infection. Conclusions: Our data provide in situ evidence that PML-IRIS brain lesions are enriched in cytotoxic CD8+ T cells that engage JCV-infected oligodendrocytes. This leads to a better control of JCV dissemination, but at the cost of oligodendrocyte cell death and demyelination.

Toxoplasmic encephalitis IRIS in HIV-infected patients: a case series and review of the literature

Background Toxoplasmic encephalitis associated with immune reconstitution inflammatory syndrome (TE-IRIS) is rarely described. Methods To identify TE-IRIS cases, the authors performed a retrospective study of all HIV-infected patients diagnosed as having TE in our unit between January 2000 and June 2009, and a review of published cases. Results Three patients out of 65 toxoplasmic encephalitis (TE) cases, together with six from the literature, fulfilled the unmasking TE-IRIS definition. None fulfilled the paradoxical TE-IRIS definition. TE occurred within a median time of 48.5 days (IQ25–75 21–56) after starting antiretroviral therapy. Cases did not have distinctive clinical or neuroimaging features from TE occurring without immune reconstitution. However: (1) cases occurred at a median CD4 lymphocytes count of 222/μl (IQ25–75 160–280); (2) TE occurred in five patients who were supposed to take an effective chemoprophylaxis; (3) two patients had a brain biopsy showing an intense angiocentric inflammatory infiltrating with predominantly CD8 lymphocytes; (4) in one patient, the abnormal length of evolution under treatment might be due to the heightened immune response. Conclusion Although rare, unmasking TE-IRIS exists and might occur despite effective prophylaxis and an unusually high CD4 lymphocyte count. Immune reconstitution inflammatory syndrome does not modify TE diagnosis and treatment but might extend its clinical course.

Proton MR Spectroscopy of Progressive Multifocal Leukoencephalopathy−Immune Reconstitution Inflammatory Syndrome

We read with great interest the article by Bag et al[1][1] entitled “JC Virus Infection of the Brain.” In this work, the authors dedicated a significant section to the inflammatory forms of progressive multifocal leukoencephalopathy (PML), referred to as PML-immune reconstitution inflammatory

MR perfusion of intracranial Rosai-Dorfman disease mimicking meningioma.

Journal of Neuroradiology - In Press.Proof corrected by the author Available online since jeudi 19 aout 2010

Arterial embolization with Onyx of head and neck paragangliomas

Object To report the morbidity and long term results in the treatment of paragangliomas by transarterial embolization with ethylene vinyl alcohol (Onyx), either as preoperative or palliative treatment. Methods Between September 2005 and 2012, 18 jugulotympanic, 7 vagal, and 4 carotid body paragangliomas (CBPs) underwent Onyx embolization, accordingly to our head and neck multidisciplinary teams decision. CBPs were embolized preoperatively. Jugulotympanic and vagal paragangliomas underwent surgery when feasible, otherwise palliative embolization was carried out alone, or in combination with radiotherapy or tympanic surgery in the case of skull base or tympanic extension. Treatment results, and clinical and MRI follow-up data were recorded. Results In all cases, devascularization of at least 60% of the initial tumor blush was obtained; 6 patients underwent two embolizations. Post-embolization, 8 patients presented with cranial nerve palsy, with partial or complete regression at follow-up (mean 31 months, range 3–86 months), except for 2 vagal and 1 hypoglossal palsy. 10 patients were embolized preoperatively; 70% were cured after surgery and 30% showed residual tumor. 19 patients received palliative embolization, of whom 5 underwent radiotherapy and 3 received tympanic surgery post-embolization. Long term follow-up of palliative embolization resulted in tumor volume stability (75%) or extension in intracranial or tympanic compartments. Onyx embolization of CBPs resulted in more difficult surgical dissection in 2 of 4 cases. Conclusions Onyx embolization is a valuable alternative to surgery in the treatment of jugulotympanic and vagal paragangliomas; tympanic surgery or radiosurgery of the skull base should be considered in selected cases. Preoperative Onyx embolization of CBPs is not recommended.