Effectiveness of Infliximab for Refractory Nonischemic Cerebral Enhancing Foreign-Body Granulomatous Lesions After Endovascular Therapy.

OBJECTIVES: Nonischemic cerebral enhancing (NICE) foreign-body granulomatous lesions are an immune-mediated complication of endovascular therapy (EVT). No single immunotherapy has demonstrated consistent effectiveness. We highlight the novel use of tumor necrosis factor (TNF)-α inhibition in treating refractory NICE lesions. METHODS: This multicenter case series describes 3 patients with refractory NICE lesions (recurrent seizures, persistent MRI enhancement, and/or steroid dependence with failure of ≥1 maintenance immunotherapy) treated with infliximab. Their clinical course, evaluation, and outcomes are detailed. RESULTS: Patients were women (median age 57 years [range 56-58]), presenting with headache and seizures within 6 months of EVT for intracranial aneurysm (n = 2) or carotid stenosis (n = 1). MRI (n = 3) revealed unilateral nodular enhancement with vasogenic edema, and brain biopsy (n = 2) revealed foreign-body granulomatous inflammation. All patients developed refractory disease and steroid dependence despite ≥1 immunotherapy including mycophenolate (n = 3), rituximab (n = 1), and/or cyclophosphamide (n = 1). Infliximab treatment resulted in significant clinical and radiologic improvement in all 3 patients. DISCUSSION: TNF-α inhibition may be an effective targeted treatment strategy for NICE foreign-body granulomatous lesions, expanding treatment options for patients with refractory disease. Larger prospective studies are needed to establish treatment guidelines aimed at improving outcomes in individuals with refractory disease. CLASSIFICATION OF EVIDENCE: This article provides Class IV evidence that infliximab may offer potential benefit in patients with NICE lesions after EVT.