Antwort zum Leserbrief: Rare Presentation of a Relapsing Remitting Central Nervous System Vasculitis: A Case Report

Dear Prof Freund,

We would like to thank you for your letter regarding our case. We are extremely pleased that this article has caught your attention.

First of all, we welcome your comments re the MR imaging. For the sake of integrity, we presented the report as given by the specialist in neuroradiology. Your findings would definitely enhance the readers’ understanding of the imaging published. As described in the report, the signs were indeed of an ischaemic nature, and we agree with your further, more detailed elaboration.

Undoubtedly, FAST is just a screening tool. Indeed, the patient received a full diagnostic workup from a variety of specialties, including a very thorough neurological examination. We agree that the signs presented could indeed be attributed to the posterior cerebral artery lesion.

As you rightly pointed out, however, this does not necessitate a diagnosis of an ischemic stroke. There are three substantial arguments for the CNS vasculitis as a more probable finding.

(1) A relapsing-remitting nature would be very unusual for a stroke, especially in a young person without any risk factors or indeed any demonstrable origin of possible thrombi.

(2) The MR findings were only demonstrated on the occasion published. There were at least 5 other MR scans that we are aware of, and these were unremarkable. We agree that there may have been changes too subtle for the neuroradiologist to appreciate. However, it is not unfeasible to postulate that the present findings are of an ischemic nature and are indeed caused by a neuroinflammatory process.

(3) During the publication of the report, the patient was started on prednisolone and subsequent remission of all symptoms was observed (within 2 weeks). After the medication was withdrawn, and an acute presentation of symptoms followed. Again, the immunosuppression palliated the symptoms (within five days). We are pleased to report that the patient is now doing well. We believe that a dose-dependent symptomatology, first statin (to a smaller extent) and now steroid-associated could be more convincing than a coincidental onset and remission of multiple strokes.

Overall, we appreciate your important input into the diagnostic process. We believe that your remarks regarding the MR findings are an invaluable addition to a better understanding of the case.

Whilst we enjoy the academic discussion about the aetiology of the syndrome, we think we can agree that this cannot obstruct our view of the patients’ needs.

Common things are, indeed, common, and the differential diagnosis of an ischaemic stroke, along with the appropriate acute interventions and secondary prevention still takes priority.

Our report, now enhanced by your comments, proposes a diagnostic option for a rare presentation, which may be entertained by a neurologist seeing a young patient with unusual stroke features.

We would like to thank you again for your time reviewing our paper.

Yours sincerely,

On behalf of the authors

Max Brzezicki