Most Cerebrovascular Events in Lupus Patients are Caused by Disease Itself, Study Shows

Cerebrovascular events are the fourth most frequent neuropsychiatric event in systemic lupus erythematosus (SLE) patients and mostly are due to SLE rather than other causes, a new multi-national study shows.

Stroke and transient ischemia were the most common cerebrovascular events in these patients.

The research, “Cerebrovascular Events in Systemic Lupus Erythematosus,” appeared in the journal Arthritis Care & Research.

Neuropsychiatric events often are observed in SLE patients and reduce their health-related quality of life. Approximately one-third of neuropsychiatric manifestations in SLE are directly attributed to the disease. However, clinicians find significant challenges when assigning individual events to an SLE or non-SLE cause.

Clinical improvement in SLE requires correct identification and treatment of neuropsychiatric events. In this regard, studies with well-documented groups of SLE patients with neuropsychiatric events are particularly helpful.

Potential causes for cerebrovascular events in SLE include clotting factors and conditions that promote atherosclerosis, such as hypertension or SLE itself. However, thorough investigation of these factors and of the clinical outcome of cerebrovascular events in SLE is still lacking.

The investigators used a large, multi-ethnic/racial, international group of 1,826 SLE patients (approximately 89% women, 49% Caucasian, with a mean age 35 years) to assess the clinical outcomes and mechanisms of cerebrovascular events in SLE.

Patients were evaluated annually. There was a total of 19 neuropsychiatric manifestations, including five cerebrovascular events: stroke, transient ischemia (insufficient blood supply), chronic multifocal ischemia (occurring in more than brain area), intracranial hemorrhage, and sinus thrombosis (a blood clot in the brain’s venous sinuses, or channels). Disease activity and lupus damage scores also were analyzed.

After a median follow-up of 6.6 years, cerebrovascular events were the fourth most common neuropsychiatric events, with a total of 82 patients (4.5%) exhibiting 109 events. Of these, 103 (94.5%) were attributed to SLE. The main events were stroke and transient ischemia – seen in 55% and 25.7% of cases, respectively.

“As most of the events occurred early in the disease course, it is possible that [cerebrovascular events] occurring later in the disease may be more frequently attributed to atherosclerosis, but further follow-up is required to confirm this,” the researchers wrote.

In addition, cerebrovascular events correlated with African ancestry and organ damage.

Researchers also found that lupus anticoagulant elevated the risk of first stroke, sinus thrombosis, and transient ischemic attack.

For physicians, the outcomes of cerebrovascular events were generally favorable. However, patients self-reported sustained reduction in their quality of life after these events.

One of the possible causes for this discrepancy is different health concerns in patients and physicians. Research indicated that the main concerns of patents are fatigue and function, while physicians primarily focus on SLE-related factors, the team observed.

Among the study’s limitations, the investigators indicate the absence of a control population and of frequent neuroimaging examinations, as well as the short follow-up period that precluded evaluation of atherosclerosis.

Overall, the study highlights important features of cerebrovascular events in SLE. “This includes their predilection for presenting early in the disease course, their association with clinical and serological variables and their short and long-term impact on [health-related quality of life],” the researchers concluded.