Incidence, clinical spectrum, and immunotherapy of non-ischemic cerebral enhancing lesions after endovascular therapy

 So you described a problem, but did nothing to solve it. USELESS!

Incidence, clinical spectrum, and immunotherapy of non-ischemic cerebral enhancing lesions after endovascular therapy

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Antonios Bayas*, Monika Christ*, Ansgar Berlis, ...

First Published January 31, 2022 Research Article 

https://doi.org/10.1177/17562864211072372

Article information

Abstract

Background:

Symptomatic and asymptomatic delayed non-ischemic cerebral enhancing (NICE) lesions in magnetic resonance imaging (MRI) have been reported as a rare complication after endovascular therapy (EVT) in recent years with incidence rates between 0.05% and 0.9% in most studies. Information on long-term clinical course and immunotherapies is scarce or has not been reported in detail in the literature.

Objective:

Aims of our study were to assess the incidence of NICE lesions in patients after cerebral EVT over a period of more than 12 years, describe clinical and EVT characteristics, and immunotherapies applied.

Methods:

A retrospective chart review of all patients treated by endovascular therapy for symptomatic or asymptomatic aneurysms at the University Hospital of Augsburg from May 1, 2008 to December 31, 2020 was performed. Patients were identified retrospectively and followed-up prospectively where appropriate. In addition, one case treated at another institution was included.

Results:

Five out of 746 patients, 0.67%, developed NICE lesions after EVT, all with non-ruptured aneurysms and all symptomatic upon detection of NICE lesions by MRI. In total, the disease course of 6 female patients is reported. Symptoms occurred after a mean time of 15 days (±13.42, SD) after EVT with headache (6/6 patients), focal neurological signs (6/6 patients), epileptic seizures (2/6 patients) and cognitive deficits (3/6 patients). All 6 patients received glucocorticosteroids (GCS), 1/6 azathioprine (AZA), 4/6 mycophenolate mofetil (MMF), 1/6 methotrexate (MTX), 1/6 rituximab (RTX), 2/6 cyclophosphamide (CYC) and 3/6 tocilizumab (TCZ). A treatment response could be observed for GCS, TCZ and MMF (in two of four cases), RTX and AZA did not result in disease stabilization.

Conclusions:

Delayed NICE lesions are a rare complication after EVT, requiring immunotherapies in all patients reported here. Physicians should be aware(What good does being aware do if there is no solution to the problem? Oh you have this problem, but I know nothing about treating it.) of this disorder in case of new symptoms or contrast enhancing lesions after EVT.

Keywords

aneurysm, endovascular therapy, MRI, NICE, non-ischemic cerebral enhancing lesions

Introduction

Standard of care for treatment of cerebral aneurysms has been dominated by endovascular therapy (EVT) in recent years. Main complications of endovascular coiling are procedural aneurysm perforations and thromboembolic events.¹ Delayed non-ischemic cerebral enhancing (NICE) lesions in magnetic resonance imaging (MRI) have rarely been reported as a complication after EVT.^2–8 Punctate, nodular or annular foci of leptomeningeal, cortical, and subcortical enhancements and perilesional edema⁸ in the territory of the endovascular access of EVT represent characteristics of NICE lesions. The disorder has also been termed as delayed cerebral hypersensitivity,⁴ leukoencephalopathy⁹ or descriptively as reversible intracranial parenchymal changes.⁷ Incidence rates after EVT are reported to be as high as 0.05%¹⁰ to 0.9%,¹¹ except for one study reporting a higher incidence rate of 2.3%.¹² Several studies have been published on the pathogenesis of NICE lesions: Besides foreign body emboli, in some patients identified as hydrophilic polymer coating emboli, and subsequent granulomatous reactions,^{2,3,5,6,8,13,14} cerebral metallic hypersensitivity and nickel allergy^4,7,15 have been reported. Successful treatment with glucocorticosteroids (GCS) has been described in many cases, other immunosuppressants like mycophenolate mofetil (MMF) or azathioprine (AZA) in few cases only.^13,16,17 However, data on long-term follow-up and response to long-term treatments are scarce and have not been reported in detail in many cases.

Main aims of our study were (a) to compute the incidence of NICE lesions in patients undergoing cerebral EVT over 12 years and 8 months, (b) describe clinical and EVT characteristics of patients affected, and (c) immunotherapies used, including long-term follow-up.

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