Neuromyelitis optica in France: a multicenter study of 125 patients

BACKGROUND

There have been few epidemiologic studies on neuromyelitis optica (NMO) and none used the recent 2006 diagnostic criteria. Here we describe the clinical, laboratory, MRI, and disability course of NMO in a French cohort of 125 patients.

METHODS

We performed an observational, retrospective, multicenter study. Data were collected from September 2007 through August 2008, corresponding to the endpoint of the study. We identified 125 patients fulfilling the 2006 NMO criteria. Selection was made using hospital files and a specific clinical questionnaire for NMO.

RESULTS

Mean age at onset was 34.5 years (range 4-66) with a mean disease duration of 10 +/- 7.8 years at the endpoint. The patients were mainly (87%) Caucasian, with a female:male ratio of 3:1. In 90% of cases, the association of optic neuritis, longitudinal extensive myelitis, and a Paty-negative initial brain MRI was sufficient to fulfill the supportive criteria. Eighty-eight percent of patients were treated with immunosuppressive therapies. Median delay from onset to Expanded Disability Status Scale (EDSS) score 4 was 7 years; score 6, 10 years; and score 7, 21 years. The first episode of myelitis was immediately followed by an EDSS score > or = 4 in 37.3% of cases, and a severe residual visual loss was observed in 22% of patients after the first episode of optic neuritis. Multivariate analysis did not reveal any predictors of a poor evolution other than a high number of MRI brain lesions at diagnosis, which were predictive of a residual visual acuity < or = 1/10.

CONCLUSIONS

Our demographic data provide new data on disability in patients with neuromyelitis optica, most of whom were receiving treatment.

GQ1b ganglioside antibody-related disorders: a case with a complex phenotype

We described an overlap syndrome associating Miller Fisher syndrome (MFS) and acute inflammatory demyelinating polyradiculoneuropathy (AIDP). Furthermore, the patient presented unusual neurological manifestations including headache, T10 sensory level, urinary urgency, and gadolinium enhancement of the spinal roots. One year follow-up was characterized by clinical recovery and persistent high rates of anti-GQ1b, -GD1b and -GT1b antibodies. Our case suggests broad phenotype of persistent antigangliosides antibodies.

[Recurrent inflammatory optic neuropathy]

PURPOSE

To analyze clinical and paraclinical characteristics of recurrent isolated optic neuropathy.

PATIENTS

and method: In three university hospitals (Montpellier, Nimes, and Strasbourg), between October 2005 and September 2006, the charts of patients with corticosensitive recurrent isolated optic neuropathy and normal cerebral magnetic resonance imaging included prospectively were reviewed. The following parameters were analyzed: date of the first relapse, age at onset, duration at the time of inclusion, recurrence after steroid withdrawal, unilateral or bilateral involvement, number of relapses, visual acuity, retinal nerve fiber layer thickness, diagnostic workup, and long-term treatment with immunosuppressive or immunomodulatory drugs.

RESULTS

During the predefined period, 13 patients (11 women, 2 men; age, 17-54 years at onset) matched the inclusion criteria. Between two and six relapses of optic neuropathy were observed. The median duration was 4 years. In untreated patients (n=7), a significant (Spearman p=0.0156) inverse correlation was observed between visual acuity and duration of the disease; this correlation was not found in the group of patients (n=6) with long-term treatment (Spearman p=0.1032).

CONCLUSION

The progressive loss of vision over time in this retrospective study of recurrent isolated optic neuropathy could be related to axonal loss. A prospective cohort study is necessary to confirm this hypothesis and to evaluate the benefit of long-term treatment on this progression.

[Retinal atrophy using optical coherence tomography (OCT) in 15 patients with multiple sclerosis and comparison with healthy subjects]

INTRODUCTION

Multiple sclerosis is a common disabling progressive neurological disorder. Axonal loss is thought to be a likely cause of persistent disability after a multiple sclerosis relapse. Retinal nerve fiber layer (RNFL) imaging by optical coherence tomography (OCT) seems to be a non-invasive way of detecting optical axonal loss following optic neuritis.

OBJECTIVE

To determine whether multiple sclerosis affects retinal nerve fiber layer measurements obtained with optical coherence tomography (OCT3-Carl Zeiss Meditec, Dublin, California, USA).

MATERIAL AND METHODS

Diagnosis of MS was based on the MacDonald criteria. The cohort was divided into two groups based on their clinical course (multiple sclerosis with [n=8; 16 eyes] or without [n=7; 14 eyes] optic neuritis antecedents). The disease-free controls were matched for age and gender (n=15; 30 eyes). Retinal nerve fiber layer thickness was measured using optical coherence tomography (OCT; fastRNFL and RNFL thickness software protocol). Visual acuity, visual field, color vision were also noted.

RESULTS

There were highly significant reductions (p<0.001) of retinal nerve fiber layer thickness in affected patients (with or without optic neuritis antecedents) compared with control eyes (fastRNFL and RNFL procedures). Visual acuity, visual field and color vision were globally less altered than OCT. There were no significant relationships among RNFL thickness and visual acuity, visual field, or color vision.

CONCLUSION

This study has demonstrated the anatomic changes of the retinal nerve fiber layer of patients with multiple sclerosis with optic neuritis antecedents. Thus axonal loss following optic neuritis can be detected with OCT. But the retinal nerve fiber layer of patients without optic neuritis is also thinner than disease-free controls so that chronic optic axonal loss can be frequent in multiple sclerosis. Additionally, OCT was more sensitive than the common ophthalmological explorations to detect optical nerve impairment during multiple sclerosis. Finally, we demonstrated that two procedures fastRNFL and RNFL could be used to detect optic nerve impairment.

[Devic disease associated with isolated spinal cord atrophy]

Devic disease is a rare entity characterized by bilateral optic neuritis and transverse myelitis. Recently, recognition of antibody activity (Anti NMO) led to broaden the clinical and MR phenotype spectrum of this disease. This report is about a patient with spinal cord atrophy and bilateral optic neuritis, occurring more than 8 years after symptom onset.

[Adult leukoencephalopathy caused by alpha-mannosidosis deficiency]

Adult leukoencephalopathy caused by alpha-mannosidosis deficiency (MIM248500) is a recessive inherited lysosomal storage disease associated with decreased activity of alpha-mannosidase. This enzyme degrades oligosaccharides and glycoproteins in neural and visceral tissues. There are two different disease phenotypes, type-I or severe infantile phenotype and type 2, which progresses more slowly and is compatible with survival into adulthood. We report the case of a 51-year-old man with gait disorders beginning at the age of 40 years associated with leukoencephalopathy due to alpha-mannosidosis deficiency.

Une crampe de l’écrivain associée à une ataxie spinocérébelleuse de type 7

Spinocerebellar ataxia type 7 (SCA 7) is a rare autosomal dominant neurodegenerative disorder (ADCA) caused by expansion of a highly unstable CAG repeat. Clinical features including progressive cerebellar, retinal degeneration and pyramidal signs. We report a patient with SCA 7 diagnosis revealed by progressive cerebellar ataxia and writer's cramp.

Influence des poussées sur la survenue d’un handicap au long cours dans la sclérose en plaques de forme rémittente : étude observationnelle de 99 patients

INTRODUCTION

Rate of relapse occurring during the first 5 years of MS-RR is a prognosis factor of occurrence of disability or secondary progressive (SP) phase. Progressive phase, related to chronic axonal loss, is mainly considered as the principal factor of disability progression. Influence of acute relapses during the relapsing-remitting phase on disability development is not known as a prognosis factor.

OBJECTIVES

To determine the influence of the exacerbations among patients with RR-MS after the second clinical event on the disability occurrence.

METHODS

Diagnosis of multiple sclerosis was established according to Poser's classification. Disability measurement was made with the use of the Expanded Disability Status Scale (EDSS). The patients included in the study were classified as clinically definite RR-MS, with an EDSS score<or=3.5. The progressive phase was defined as the steady worsening of symptoms and signs for at least 6 months (Schumacher et al., 1965; Lublin and Reingold, 1996). The exacerbations were quoted and evaluated by a neurologist and the residual disability lasting at least 6 months after an acute event was measured with the EDSS. A score of 4.0 corresponds to limited walking ability, but without aid or rest for>500 m. The study began at the time of the second clinical event and ended when an EDSS score of 4.0 was reached or when a SP phase was beginning or at the last follow-up visit date if these two stages were not reached. The primary outcome measure was the comparison of the risk and the average time to reach an EDSS>or=4.0 or a SP form according to the annual exacerbation rate (AER) using Kaplan-Meier survival curve.

RESULTS

Among the 238 ms patients of the database, 136 patients were classified as having a definite RR-MS. Among these 136 patients, 99 patients could be included in the study according to the inclusion criteria. The median follow up of the patients since the first clinical event was 9.8 years (range 4 to 44). The average EDSS score was 0.7 at the beginning of the study and 2.3 at the end. 20.2p.cent of patients (n=20) reached an EDSS score of 4.0 or a SP-MS. The median AER was 0.4 and the average 0.62 (range 0 to 6.1). The time to reach the primary end point for 25p.cent of the population was 17.8 years in group with an AER<0.4 (group A) and 6.9 years in group with an AER>0.4 (group B) (logrank; p<0.0001). The relative risk for patients of the group B compared to group A to reach an EDSS of 4.0 or a SP form was 8.01 (IC-95p.cent: 2.74-23.46; p=0.0001).

CONCLUSIONS

In spite of a limited number of patients, this study gives evidence that a high rate of acute exacerbations in RR-MS patients after the second clinical event may be an independent predictive factor of long-term residual disability progression. High relapse rate leads to a more frequent and faster SP or EDSS>4.0 occurrence.

[Camptocormia disclosing Parkinson's disease]

Camptocormia is characterised as an extreme bent-forward posture of the trunk that disappears in the recumbent position. On X-ray, trunk flexion appears without vertebral rotation as in scoliosis. The condition is a well-known complication of Parkinson's disease (PD) at the late stage. The authors present the case of a 77-year-old woman affected by severe camptocormia, which appeared and worsened in less than 6 months and hindered gait. Despite no signs of PD, neuro-imaging (DAT-Scan) showed an L-Dopa transducer decrease in putamens. A few weeks later, bradykinesia appeared and the clinical diagnosis of PD became more obvious. L-Dopa improved bradykinesia but did not change the bent-spine posture. A 1-year follow-up showed no other signs of PD other than bradykinesia, but the camptocormia was unchanged.

[Assessment of idiopathic Parkinson's disease in physical medicine and rehabilitation]

Parkinson's disease (PD) is a chronic disease associated with motor impairments (bradykinesia, rigidity, tremor and postural disorders), cognitive disorders and dysautonomia. Most symptoms are greatly improved by dopatherapy during the first stages, then signs of treatment ineffectiveness or intolerance occur that signal the beginning of motor and cognitive decline. This evolution signified the need to develop an effective tool to measure the effectiveness of drugs or surgery in PD and has had the Movement Disorder Society to propose 20 years ago a tool to assess such patients: the Unified Parkinson's Disease Rating Scale (UPDRS). This scale has a good internal consistency and a good interrater reliability. Yet, some impairments, especially of cognitive origin, are evaluated too succinctly and need complementary scales. As well, other disorders such as bladder disorders are not included, nor is quality of life studied despite the impact of PD on daily life. Specific scales have been proposed. UPDRS may be well-adapted to PD follow-up in the physical medicine and rehabilitation context by measuring treatment effectiveness, detecting Dopa ineffectiveness or complications and assessing patients' handicap in daily activities. The evolution of UPDRS will improve the qualities of the scale and contribute to better determining the various stages of the disease.

Thrombus endoluminal de l’artère carotide sans lésion sous-jacente

Strokes are rarely secondary to spontaneous carotid artery thrombosis. The objectives of this retrospective analysis were to define characteristic features and the clinical course. The study population included eight patients (6 females/2 males) seen at six university neurological centers. Age of onset was 46.5 years (range 38-52). Half of the patients had no vascular risk factor. Symptoms were TIA (n=1), strokes (n=7). Echotomography revealed intraluminal thrombus, with occlusion in 2 cases. Thrombi were found in common carotid artery (n=3), carotid bifurcation (n=2) and internal carotid artery (n=3). The thrombus was mobile in 4 cases. Seven patients were treated by anticoagulation therapy, one by surgery because of recurrent TIA. Further echotomographic exams revealed total resolution (3 cases) or decrease of the thrombus (3 cases). Occlusion was definitive in one patient. A cause was identified in six patients: acute leukemia (n=1), thrombocytopenic purpura (n=1), iron deficiency anemia (n=4).