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Isolated angiitis of the CNS in children

From the Department of Pediatrics, Divisions of Neurology (Drs. Lanthier and deVeber) and Rheumatology (Dr. Laxer), and Department of Pathology (Dr. Jay), The Hospital for Sick Children and University of Toronto; the Département de Médecine, Service de Neurologie, Centre Hospitalier de l’Université de Montréal (Dr. Lanthier) and Département de Pédiatrie, Service de Neurologie, Hôpital Sainte-Justine (Dr. Lortie), and Université de Montréal; and the Department of Pathology (Dr. Michaud), Children’s Hospital of Eastern Ontario and University of Ottawa, Canada.

Address correspondence and reprint requests to Dr. Gabrielle deVeber, Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8; e-mail: deveber{at}sickkids.on.ca

OBJECTIVE: To clarify the clinical features and pathologic manifestations of isolated angiitis of the CNS (IACNS) in children.

METHODS: The authors report two new cases and summarize the literature of childhood IACNS confirmed by pathology.

RESULTS: IACNS affecting small vessels (n = 5)—Neurologic manifestations included headaches, focal seizures, and progressive, behavioral, or multifocal neurologic impairment. MRI showed multifocal, T2-hyperintense, cerebral lesions without mass effect or tumor-like lesions. CSF, erythrocyte sedimentation rate, and cerebral angiograms were often normal. CNS biopsy disclosed a nongranulomatous vasculitis. Children were treated with prednisone alone or combined with cyclophosphamide. One child died. Four children had a favorable outcome. IACNS affecting large and medium arteries (n = 5)—Three children presented with acute ischemic stroke or TIA. Brain CT showed ischemic infarcts. Two children presented with subarachnoid hemorrhage. In this group, CSF, erythrocyte sedimentation rate, and angiograms were often abnormal. No patient received immunosuppressive therapy. Five children died. Autopsy showed granulomatous IACNS (n = 5)

CONCLUSIONS: Clinical and radiologic features correlate with the size of affected vessels. Prognosis differs between groups. Potential markers of poor outcome are acute stroke presentation secondary to large and medium-sized artery involvement, granulomatous angiitis, and delayed institution of immunosuppressive therapy.

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