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Diagnostic Work-Up Necessary in Young Stroke Patients With Inflammatory Findings: Presented at ANA

By Paula Moyer

SAN FRANCISCO, CA -- November 3, 2003 -- Physicians need to rule out other causes in the face of suspected central nervous system (CNS) vasculitis when treating young stroke patients with inflammatory findings, according to findings presented here October 20^th at the 128^th Annual Meeting of the American Neurological Association.

"If you have a young stroke patient, there will often be signs of inflammation in the blood or cerebrospinal fluid [CSF], or other inflammatory markers such as more than one lesion detected on magnetic resonance imaging [MRI]," said principal investigator Peter D. Berlit, MD. "When these are present, it is crucial to determine the cause of the inflammation, and particularly to exclude bacterial or viral infection."

Dr. Berlit, the chair of the neurology department at Alfred Krupp Hospital in Essen, Germany, pointed out that the conventional treatment when inflammatory factors are present consists of immunosuppressive therapy, typically a combination of corticosteroids and cyclophosphatase. However, such treatment would be quite deleterious if the patient had an underlying infection, he said.

He and co-investigators reviewed the records of 35 stroke patients aged 20 to 45 years who had had suspected CNS vasculitis within a five-year period. The patients' median age was 37 years. In 24 cases, patients had multiple lesions as detected by MRI.

Inflammatory findings were present in the serum of 20 patients and in the CSF of five patients. In eight patients, a vasculitic pattern was present on digital subtraction angiography (DSA). Among these patients, the treating physicians made a definitive diagnosis of either CNS involvement in systemic vasculitis or collagen vascular disease in five patients. Four patients had systemic lupus erythematosus, and one had Takayasu's disease.

Among the overall group of patients, eight had premature atherosclerosis, seven had coagulopathies, and five had noninflammatory vasculopathies, including moyamoya, Sneddon's disease, and cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy (CADA-SIL). The investigators identified tumours in two patients, and the following conditions were present in one patient each: brainstem encephalitis, paraneoplastic disorder, mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes, and migraine-associated stroke.

These findings led the investigators to conclude that CNS vasculitis is rare in young stroke patients, even if inflammatory findings are present in laboratory analyses and neuroimaging studies. Therefore, they urged that treating physicians identify the underlying aetiology rather than treating such patients empirically with immunosuppressive agents.

Dr. Berlit said that if CNS vasculitis is suspected, the treating physician should order laboratory specimens that screen for coagulopathy, such as abnormal levels of antiphosphilopidase, and a DSA. If the findings from such studies are unclear, a leptomeningeal biopsy should be performed to exclude bacterial or viral infections. Such studies are necessary in 20% of patients with suspected CNS vasculitis, according to the researchers.


[Study title: Suspected Central Nervous System Vasculitis in Young Stroke Patients. Abstract 16]

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