Value of brain MRI in the evaluation of systemic lupus erythematosus patients with and without overt neuropsychiatric manifestations: correlation with clinical findings and cerebrospinal fluid autoantibodies

ABSTRACT

To evaluate morphological abnormalities by conventional cerebral Magnetic Resonance Imaging [MRI] in a series of systemic lupus erythematosus [SLE] patients with and without overt neurologic/neuropsychiatric [NP] manifestations and to detect possible relationships with clinical parameters and a large panel of autoantibodies in CSF to provide insight into whether they participate in the pathogenesis of NPSLE. Twenty five Saudi SLE patients [11 with and 14 without NP symptoms] and 14 controls [8 healthy subjects and 6 patients with neuropsychiatric disease unrelated to SLE] of comparable age and sex were studied. The American College of Rheumatology's classification for neuropsychiatric manifestations was employed. A full medical history, rheumatological, neurological and psychiatric examination were administered to all patients. Disease activity was scored using the SLEDAI. Laboratory and serologic tests, cerebral MRI and CSF examination for autoantibodies [anti-double stranded DNA [anti-ds DNA], anti-cardiolipin [aCL] IgG, anti-beta2 glycoprotein I [anti-beta2GPI] IgG, anti-PC22 [antibodies directed against the C-terminal 22-amino acid sequences of ribosomal P protein] and anti-N-methyl-D-aspartate [anti-NMDAR or anti-NR2] antibodies] were also carried out. Out of the 11 patients with NP symptoms, 7 had diffuse, 2 had focal and 2 had complex syndromes. SLE patients had significantly higher frequency of T2-weighted punctate areas of increased signal [PAIS] and cerebral atrophy on MRI, anti- PC22 and anti-NMDAR antibodies in CSF compared with the control group [44%, 20%, 24% and 20% Vs 14.2%, 0%, 0% and 0%, respectively]. Anti-dsDNA, aCL and anti-beta2GPI antibodies were found each in one of NPSLE patients. The frequency of PAIS, cerebral atrophy, CSF anti-PC22 and anti-NMDAR antibodies in NPSLE patients [54.6%, 36.4% 36.4% and 36.4%, respectively] was insignificantly higher than in non-NPSLE patients [35.7%, 7.1%, 14.3% and 7.1%, respectively]. MRI abnormalities are significantly more common in patients with SLE and are related to specific NP manifestations but their specificity seems limited as they are also detected in neurologically asymptomatic patients. CSF anti-NMDAR and to less extent anti-P antibodies might play a role in the pathogenesis of diffuse neuropsychiatric lupus. Combined clinical presentation, CSF autoantibodies testing and neuroimaging techniques might help to support the diagnosis of cerebral lupus or to predict development of CNS disease in non-NPSLE patients