To highlight the novel use of tumor necrosis factor (TNF)-α inhibition in treating refractory non-ischemic cerebral enhancing (NICE) lesions.

This multi-center case series describes three 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.

Patients were female (median age 57 years [range 56-58]), presenting with headache and seizures within six 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 radiological improvement in all three patients.

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.