Magnetic Resonance Imaging In Young Patients With Neuro - Psychiatric SLE : A Case Series Dr. Vivek Gupta Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh INDIA

Introduction Neurological involvement is a frequent occurrence in SLE. Associated with increase in morbidity and mortality. About 50% of SLE patients have neuropsychiatric phenomena at some time during their illness.

Introduction NPSLE extremely difficult to diagnose - wide variety of neuropsychiatric symptoms of the disease Neuro-imaging has become important in the evaluation of SLE patients with neurologic symptoms.

AIMS & OBJECTIVES: To describe the MR imaging pattern in children and young adults with neuro psychiatric involvement in systemic lupus erythematosus (NPSLE).

Materials and methods Design: –Retrospective case analysis. Methodology: –Patients of systemic lupus erythematosus who presented with neuro-psychiatric symptoms. –Detailed history & clinical examination done in all patients. –All patients fulfilled the criteria of 1999 consensus document of ACR that defines the neurologic and psychiatric manifestations of SLE.

Materials and methods MRI brain performed on 1.5 Tesla system. Axial Tl-weighted images ( TR: 570 ms; TE: 14 ms; four excitations ), Axial proton density and T2-weighted images (TR 2735/2500 ms; TE 102 ms; two excitations). Coronal FLAIR sequences (TR: 8000ms TE :110ms) Diffusion imaging (TR 5700 ms TE139ms) MR scans were read by two neuroradiologists who were blinded for the clinical information.

RESULTS Total patients = 14. Mean age = years (Range: 7-25 years). Male: female = 5:9. Mean duration of onset of illness: 2.4 yrs.

Clinical featuresNo. of patients Seizures 4 (28.5%) Chorea 2 (14.2%) Altered sensorium 5 (35.7%) Visual loss2 (14.2%) Hemiparesis 2 (14.2%) Mononeuritis multiplex1 (7.14%) Cranial neuropathy1 (7.14%) RESULTS

MRI findingsNo. of patients White matter hyperintensities 11 Non hemorrhagic Infarcts 5 Hemorrhagic infarcts 1 Myelitis1 Subarachnoid hemorrhage 1 B/L subdural effusion1 PRES1 Cerebral atrophy 1 RESULTS

LocationNo. of patient Cerebral hemispheres 10 Spinal cord 1 Cerebellum1 Combination2 RESULTS

Typical imaging findings RESULTS

White matter hyperintensities RESULTS

White matter hyperintensities

Micro Infarcts

Infarction with hemorrrhage

Hemorrrhagic infarcts

RESULTS Atypical imaging findings

ISOLATED BRAIN STEM INVOLVMENT

PRES

SUB ARACHNOID HEMORRHAGE

Discussion Incidence : 14% to 75 % Manifestations can range from mild to severe NPSLE events occur at the disease onset or within 1-2 years after SLE diagnosis

Primary NPSLE directly attributed to active disease < 40 % Secondary NPSLE cause unrelated to SLE

ACR 19 NP Syndromes in SLE ( 1999) Acute confusional state Cognitive dysfunction Psychosis Mood disorder Anxiety disorder Headache Cerebrovascular disease Myelopathy Movement disorder Demyelinating syndrome Seizure disorders Aseptic meningitis Cranial neuropathy Polyneuropathy Plexopathy Mononeuropathy,single/ multiplex Demyelinating polyradiculopathy Autonomic disorder Myasthenia gravis

Discussion Vasculopathy Infarction Haemorrhage White mater damage Infection

Summary Findings in young and children similar to adults. Supratentorial involvement more common. Average time of onset of NPSLE 2 yrs. Atypical findings must be kept in mind to avoid misinterpretation.

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