Elsevier

Magnetic Resonance Imaging

Volume 21, Issue 9, November 2003, Pages 1033-1037
Magnetic Resonance Imaging

Magnetic resonance imaging
In vivo proton magnetic resonance spectroscopy (MRS) and single photon emission computerized tomography (SPECT) in systemic lupus erythematosus (SLE)

https://doi.org/10.1016/S0730-725X(03)00200-5Get rights and content

Abstract

Neuropsychiatric involvement in SLE (NP-SLE) may not be picked up by routine neuroimaging procedures like computerized tomography (CT) or magnetic resonance imaging (MRI). We prospectively studied the role of single photon emission computerized tomography (SPECT) and magnetic resonance spectroscopy (MRS) in detection of NP-SLE in 20 patients with lupus (10 with clinical NP involvement and 10 without) and 9 healthy controls. MRI abnormalities were seen in 5/10 patients with NP-SLE while the MRI was normal in all the lupus patients without clinical NP involvement. Perfusion defects on SPECT were seen in as many as 8/10 patients with NP-SLE while only 1/10 lupus patients without clinical NP involvement and none of the healthy controls demonstrated perfusion defects. MRS revealed abnormal metabolite ratios in all patients with NP-SLE and as many as 8 lupus patients without clinical NP features. Normal metabolite ratios were observed in healthy controls. SPECT and MRS can help detect changes not evident on MRI and may serve as useful supplements to existing neuroimaging techniques in the diagnosis of NP-SLE. The precise significance of alterations in regional cerebral blood flow on SPECT and neurometabolite ratios on MRS needs larger, longitudinal studies.

Introduction

SLE is a common connective tissue disease that involves almost all organ systems. Neuropsychiatric involvement (NP-SLE) is seen in as many as 11-60% of SLE patients [1]. NP-SLE may cause transient neurologic deficits or chronic brain injury with mortality rate ranging from 7-40% [2]. The diagnosis of NP-SLE is difficult because of several reasons, namely, protean manifestations, need to differentiate NP-SLE from secondary causes of neurologic involvement like central nervous system (CNS) infections, metabolic encephalopathy etc., and last but not the least, confusion over nomenclature. In addition, the lack of reliable surrogate serum markers and an ideal imaging modality compound the problem. Magnetic resonance imaging (MRI) is the currently preferred anatomic imaging modality [3]. MRI is more likely to show abnormalities if there are focal neurologic deficits, seizures, chronic cognitive dysfunction, or the antiphospholipid syndrome (APS). However, in many patients with obvious NP-SLE, the MRI may not exhibit any changes especially patients with affective disorders, confusional states or headache [3], [4]. Another drawback of MRI is the difficulty in differentiating lesions of active NP-SLE from old lesions [5], [6]. Neuroimaging frequently (25-50% cases) reveals chronic lesions in patients even without active disease. The frequency of these lesions increases with age, disease severity and past history of NP-SLE [3], [6].

In this setting of a lack of gold standard imaging modality in NP-SLE, techniques to detect functional brain abnormalities can serve as useful adjuncts. Regional cerebral blood flow (rCBF) abnormalities detected by SPECT and non-invasive assessment of tissue metabolites in vivo by MRS can supplement information provided by MRI in patients with NP-SLE. We undertook a prospective study to evaluate the role of MRS and SPECT in picking up neuropsychiatric involvement in patients with SLE.

Section snippets

Patients

Twenty patients of SLE, 10 with clinical evidence of neuropsychiatric involvement (cases) and 10 without any neuropsychiatric features (disease controls) were prospectively recruited into the study after informed consent. All patients with SLE fulfilled the American College of Rheumatology (formerly American Rheumatism Association) criteria for SLE [7]. NP-SLE was diagnosed when SLE patients manifested definite neurologic &/or psychiatric events currently or in the past provided other causes

Results

The 20 lupus patients included in our study included 10 with NP-SLE (female 9, male 1; mean age 27.3 ± 10.07 years) and 10 disease controls without clinical neuropsychiatric involvement-(female 9, male 1; mean age 26.9 ± 8.19 years) with disease duration ranging from 4 months to 9 years. The spectrum of NP-SLE included seizures, peripheral neuropathy, movement disorder, stroke, depression psychosis, anxiety disorder and headache.

MRI was abnormal in 5 out of 10 NP-SLE patients while all the 10

Discussion

The diagnosis of NP-SLE continues to be a major clinical problem. It is mandatory to exclude central nervous system infections, drug effects (e.g., due to corticosteroids and chloroquine), and metabolic alterations before attributing neurologic or psychiatric events to SLE. Apart from a wide list of differential diagnoses, the other difficulty is that there is no single confirmatory diagnostic test. Anti ribosomal and anti neuronal antibodies are neither sufficiently specific nor sensitive to

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