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| T1 axial post gad | T2 axial | FIR axial |
Diagnosis: Multiple infarcts secondary to CNS vasculitis
Possible causes of CNS vasculitis include idiopathic, infectious, autoimmune, or drug induced. Patients often present with waxing and waning focal neurologic deficits. Infarcts of varying sizes may be present in multiple vascular territories. Cerebral angiography may demonstrate multiple foci of concentric narrowing and occlusion with downstream dilatation as in this case. Treatment usually consists of steroids and therapy for the underlying etiology. Atherosclerotic vascular disease may be difficult to tell from vasculitis. Athero tends to produce a non-concentric narrowing. Also, it does not typically produce dilatation after a focus of narrowing. Another way to suggest athero versus vasculitis is to see disease involving the siphon or carotid bifurcation. Vasculitis does not usually effect these areas. Other etiologies to consider for multiple infarctions include arterial embolism or venous occlusion. This patient had a pheochromocytoma which was resected leading to resolution of the angiographic findings. It was postulated that the vasculitis was due to the release of norepinephrine with resulting vasoconstriction. Cocaine is known to produce CNS vasculitis through a similar mechanism by acting as a sympathomimetic. Other considerations in the differential of multiple enhancing lesions in general are metastases, multifocal astrocytoma, demyelination, lymphoma and infection. Related Cases
