[Nerve conduction blocks and peripheral neuropathies]

A motor nerve conduction block is defined as a reduction of either amplitude or area of the compound motor action potential elicited by proximal vs. distal motor nerve stimulation. The pathophysiological mechanisms leading to a figure of conduction block include segmental demyelination, recent axonal interruption, or various axonal excitability abnormalities due to ion channel dysfunction or membrane potential changes. These processes can be related to compressive, ischemic or dysimmune inflammatory causes. The etiologic diagnosis is established on the combination of clinical, electrophysiological, and biological data. Among the neuropathies that feature nerve conduction blocks, there is a group of particular dysimmune multifocal neuropathies characterized by long-term persistent conduction blocks, including pure motor forms and sensori-motor forms. The clinical, electrophysiological, biological, and therapeutic specificities of these two types of neuropathy will be discussed.

Myelin regeneration in demyelinating disorders: new developments in biology and clinical pathology

PURPOSE OF REVIEW

The following article reviews recent advances in remyelination biology and its presentation in demyelinating diseases such as multiple sclerosis. It is based primarily on articles published during 2006.

RECENT FINDINGS

The principal themes are the identity and properties of remyelinating cells; the role of inflammation in remyelination; and the complexity of and redundancy within the signalling environment regulating remyelination.

SUMMARY

Central nervous system remyelination is mainly mediated by oligodendrocyte precursor cells, although subventricular zone-derived cells contribute to the repair of periventricular lesions. Oligodendrocyte precursor cells may differentiate into astrocytes and Schwann cells following injury and exhibit more stem cell-like features than previously recognized. A complex matrix of environmental factors, including cytokines, chemokines and growth factors, act upon oligodendrocyte precursor cells, causing their activation and eventual differentiation into remyelinating oligodendrocytes. Inflammatory cells contribute by providing components of the signalling matrix and by the phagocytic removal of myelin debris. Many factors within the signalling environment have redundant functions - a feature of regeneration with implications for developing remyelination therapies. Advances in remyelination biology have been accompanied by more detailed analyses of remyelination in multiple sclerosis and important translational developments, including the ability to identify myelin by positron emission tomography.

Stellenwert der Uveitis im Rahmen demyelinisierender Erkrankungen des Zentralnervensystems

An involvement of the visual system can be found in many neurologic diseases. Especially demyelinating processes of the central nervous system (CNS) and multiple sclerosis (MS) in particular present with a variety of ophthalmological abnormalities. While optic neuritis (ON) is known to be a positive predictor for the development of MS and can be considered a symptom of the disease, the high frequency of uveitis observed in MS patients seems to occur rather in the context of a general predisposition for autoimmune disorders. However, MS-associated uveitis can precede the onset of neurological symptoms by many years and shows response to treatment with steroids and interferons, suggesting the presence of similar underlying pathogenic mechanisms. Therefore, further studies are warranted in order to reveal whether administration of early immunomodulatory therapy can delay or even prevent the clinical manifestation of MS in a distinct subgroup of patients presenting with uveitis.

Double Filtration Plasmapheresis Can Decrease Factor XIII Activity

Factor XIII (FXIII) produces cross-linkages among fibrin molecules within fibrin clots. Its deficiency is related with bleeding diathesis or retardation of wound healing. We report the possibility that intense double filtration plasmapheresis (DFPP) is associated with decreased FXIII activity. Five patients with various primary diagnoses were treated with DFPP and their FXIII activity was measured. Coagulation test results remained almost normal, but FXIII activities declined to less than 20% of their initial value before starting DFPP and 10% after DFPP in most cases. The cases that received intense DFPP therapy exhibited profoundly decreased FXIII activity. The clinical course demonstrated that DFPP caused the FXIII decrease. Fortunately, with careful observation, none of the patients experienced fatal bleeding. Only one case required fresh frozen plasma and an open hemostatic procedure because of prolonged postoperative bleeding. In general, DFPP most efficiently removes substances with the following characteristics: adequate molecular weight; long half-life; and small extravascular distribution volume. The FXIII properties meet all these characteristics. Consequently, we should devote much attention to FXIII activity during DFPP because it cannot be estimated from the usual coagulation tests. Patients who receive DFPP therapy, especially intensified therapy, should have FXIII measured during the course of therapy. Results show that DFPP can decrease FXIII activity. For this reason we recommend the measurement of FXIII when patients receive intense DFPP therapy with albumin replacement.

Glial progenitor-based repair of demyelinating neurological diseases

Demyelinating diseases of the brain and spinal cord affect more than one-quarter million of Americans, with numbers reaching more than two million across the world. These patients experience not only the vascular, traumatic, and inflammatory demyelinations of adulthood but the congenital and childhood dysmyelinating syndromes of the pediatric leukodystrophies. Several disease-modifying strategies have been developed that slow disease progression, especially in the inflammatory demyelinations and in multiple sclerosis in particular. Yet, currently available disease modifiers typically influence the immune system and are neither intended to nor competent to reverse the structural neurologic damage attending acquired demyelination. Fortunately, however, the disorders of myelin lend themselves well to attempts at structural repair, because central oligodendrocytes are the primary, and often sole, victims of the underlying disease process. Given the relative availability and homogeneity of human oligodendrocyte progenitor cells, the disorders of myelin formation and maintenance may be especially compelling targets for cell-based neurologic therapy.

Chronic inflammatory demyelinating polyradiculopathy: an atypical pediatric case complicated with phrenic nerve palsy

An atypical form of chronic inflammatory demyelinating polyneuropathy (CIDP) complicated with phrenic nerve palsy is presented with clinical and electrophysiologic features. A seven-year-old girl had initial presentation mimicking Guillain-Barré syndrome based on electrophysiologic characteristics. Between 7-11 years of age, she had five recurrences of subacute onset of weakness which usually developed over at least 2-4 months and progressed to loss of ambulation and to respiratory insufficiency. Radiologic examinations revealed unilateral phrenic nerve palsy associated with CIDP. Our patient demonstrated the rare association of CIDP and phrenic nerve palsy, resulting in diaphragmatic paralysis and respiratory failure.

Demyelinating diseases and potential repair strategies

Demyelination is associated with a number of neurological disorders including multiple sclerosis (MS), spinal cord injury and nerve compression. MS lesions often show axon loss and therefore reparative therapeutic goals include remyelination and neuroprotection of vulnerable axons. Experimental cellular transplantation has proven successful in a number of demyelination and injury models to remyelinate and improve functional outcome. Here we discuss the remyelination and neuroprotective potential of several myelin-forming cells types and their behavior in different demyelination and injury models. Better understanding of these models and current cell-based strategies for remyelination and neuroprotection offer exciting opportunities to develop strategies for clinical studies.

Haplotype matching is not an essential requirement to achieve remyelination of demyelinating CNS lesions

Transplantation of oligodendrocyte precursor cells (OPCs) results in efficient remyelination in animal models of demyelination. However, the experiments so far undertaken have not addressed the need for tissue-type matching to achieve graft-mediated remyelination. Examination of MHC expression (main determinant of allograft rejection) by OPCs showed nondetectable levels under standard culture conditions and upregulation of MHC Class I expression only upon exposure to interferon gamma. We therefore hypothesized that MHC matching of OPC grafts may not be crucial to achieve transplant-mediated remyelination. Transplant experiments performed using a nonself repairing toxin-induced demyelination model showed that, similarly to allogeneic neurons, survival of allogeneic oligodendrocyte lineage cells is influenced by donor-host haplotype combination and graft composition. Transplantation of allogeneic mixed glial cell cultures resulted in remyelination failure by 1 month postengraftment due to a rejection response targeting both myelinating oligodendrocytes and OPCs, suggesting that inflammation-induced upregulation of OPC MHC I expression results in susceptibility to cytotoxic T cell attack. In contrast, remyelination persisted for at least 2 months following transplantation of OPC-enriched cultures whose overall MHC expression level was significantly decreased. While OPC-enriched preparations elicited delayed type hypersensitivity responses in hosts sensitized to alloantigens, allografting of such preparations into a central nervous system demyelinating lesion did not result in recipient priming. We conclude that while allografted oligodendrocyte lineage cells become targets of a graft rejection response once this response has been initiated, transplantation of OPC-enriched preparations can evade priming against alloantigens and graft rejection. This finding indicates that close tissue matching may not be an essential requirement for successful transplant-mediated remyelination.

Anti-CCL2 treatment inhibits Theiler's murine encephalomyelitis virus-induced demyelinating disease

Theiler's murine encephalomyelitis virus induces a demyelinating disease (TMEV-IDD) of the central nervous system (CNS) in susceptible mouse strains with accompanying histopathology characterized by mononuclear cell infiltrates. In susceptible strains of mice such as SJL, virus establishes a persistent infection in macrophages, induces a CNS infiltration by macrophages, T cells, and B cells, which results in chronic-progressive paralysis. In the present report the authors have investigated the functional role of CCL2 (monocyte chemotactic protein-1) in the induction and progression of demyelinating disease. Treatment of infected mice at day 0, 14, or 28 with anti-CCL2 resulted in a significant decrease in the clinical disease progression. Further analysis of anti-CCL2-treated mice revealed decreased CNS inflammation and mononuclear cell infiltration with an accompanying change in inflammatory cytokine responses. There was an overall decrease in the absolute numbers of CNS-infiltrating CD4+ T cells, macrophages, and B cells. Finally, anti-CCL2 treatment resulted in decreased viral load in the CNS. These data directly demonstrate a role for CCL2 in the pathogenesis of TMEV-IDD.

Adult stem cell therapy: Dream or reality?

Adult stem cells may be an invaluable source of plastic cells for tissue regeneration. The bone marrow contains different subpopulations of adult stem cells easily accessible for transplantation. However the therapeutic value of adult stem cell is a question of debate in the scientific community. We have investigated the potential benefits of adult hematopoietic stem cell transplantation in animal models of demyelinating and motor neuron diseases. Our results suggest that transplantation of HSC have direct and indirect neuroregenerative and neuroprotective effects.

Endogenous stem and precursor cells for demyelinating diseases: an alternative for transplantation?

Remyelination can be very effective in human. However, this process ultimately fails in multiple sclerosis (MS). In this paper, we discuss the possibility of stimulating endogenous oligodendrocyte precursors to participate in remyelination in experimental models (rat and primate Callithrix jacchus) of MS through thyroid hormone (TH) administration. TH is in fact known to be a key signal in brain development, oligodendrocyte development and myelin protein gene expression regulation.

Idiopathic inflammatory demyelinating disorders after acute transverse myelitis

Acute transverse myelitis (ATM) is commonly para-infectious. Recurrent ATM occurs in connective tissue diseases (CTD), infective myelitis and idiopathic inflammatory demyelinating disorders (IIDD) including multiple sclerosis (MS) and neuromyelitis optica (NMO). Previous studies might include NMO and idiopathic recurrent transverse myelitis (IRTM) as MS. The aim was to study the outcome of patients after a first attack of idiopathic ATM. Idiopathic ATM patients over a 6-year period were retrospectively studied. Known causes of myelopathy were excluded. Among 32 patients studied, 20 (63%) had single ATM attack upon follow up for 39-93 months, three developed recurrent ATM related to CTD (two systemic lupus erythematosus and one anti-Ro antibody positive) and nine (28.1%) developed recurrent neuroinflammation compatible with IIDD. Among IIDD patients, three had NMO, two restricted variant of NMO, three IRTM and one classical MS. NMO, its variant and IRTM had mean spinal MRI abnormality of 3.7, 2.1 and 3.9 vertebral segments respectively while non-recurrent ATM had 1.6 vertebral segments. Four (80%) of the five patients with NMO or its variant had poor neurological prognosis versus only one (5%) of non-recurrent ATM patients. IRTM patients had advanced mean onset age, 62 years vs. 43 years for non-recurrent ATM patients. In IIDD patients presenting with ATM as first attack of neuroinflammation, NMO and its variant (56%) were most frequent, then IRTM (33%), with classical MS (11%) the rarest. As long-term treatments for NMO are different from MS, early recognition of NMO and its variant is important for prevention of serious neurological deficits.

European Federation of Neurological Societies/Peripheral Nerve Society guideline on management of paraproteinaemic demyelinating neuropathies: report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society*

BACKGROUND

Paraprotein-associated neuropathies have heterogeneous clinical, neurophysiological, neuropathological and haematological features. Objectives. To prepare evidence-based and consensus guidelines on the clinical management of patients with both a demyelinating neuropathy and a paraprotein (paraproteinaemic demyelinating neuropathy, PDN).

METHODS

Search of MEDLINE and the Cochrane library, review of evidence and consensus agreement of an expert panel.

RECOMMENDATIONS

In the absence of adequate data, evidence based recommendations were not possible but the panel agreed the following good practice points: (1) Patients with PDN should be investigated for a malignant plasma cell dyscrasia. (2) The paraprotein is more likely to be causing the neuropathy if the paraprotein is immunoglobulin (Ig)M, antibodies are present in serum or on biopsy, or the clinical phenotype is chronic distal sensory neuropathy. (3) Patients with IgM PDN usually have predominantly distal and sensory impairment, with prolonged distal motor latencies, and often anti-myelin associated glycoprotein antibodies. (4) IgM PDN sometimes responds to immune therapies. Their potential benefit should be balanced against their possible side-effects and the usually slow disease progression. (5) IgG and IgA PDN may be indistinguishable from chronic inflammatory demyelinating polyradiculoneuropathy, clinically, electrophysiologically, and in response to treatment. (6) For POEMS syndrome, local irradiation or resection of an isolated plasmacytoma, or melphalan with or without corticosteroids, should be considered, with haemato-oncology advice.

Olig gene function in CNS development and disease

Olig1 and Olig2 encode basic helix-loop-helix (bHLH) transcription factors that are expressed in both the developing and mature vertebrate central nervous system. While numerous studies have established critical functions for Olig genes during the formation of motor neurons and oligodendrocytes of the ventral neural tube, their roles at later stages of development and in adulthood have remained relatively obscure. Recent studies, however, reveal that in the fetal dorsal spinal cord and neural progenitor cells of the adult brain, Olig expression continues to mark, and may regulate, the formation of oligodendroglia. Studies of Olig expression in human brain tumors and repair of demyelinating lesions suggest the possibility of additional functions in a variety of neurological diseases.

Skin-derived precursors generate myelinating Schwann cells for the injured and dysmyelinated nervous system

Although neural stem cells hold considerable promise for treatment of the injured or degenerating nervous system, their current human sources are embryonic stem cells and fetally derived neural tissue. Here, we asked whether rodent and human skin-derived precursors (SKPs), neural crest-related precursors found in neonatal dermis, represent a source of functional, myelinating Schwann cells. Specifically, cultured SKPs responded to neural crest cues such as neuregulins to generate Schwann cells, and these Schwann cells proliferated and induced myelin proteins when in contact with sensory neuron axons in culture. Similar results were obtained in vivo; 6 weeks after transplantation of naive SKPs or SKP-derived Schwann cells into the injured peripheral nerve of wild-type or shiverer mutant mice (which are genetically deficient in myelin basic protein), the majority of SKP-derived cells had associated with and myelinated axons. Naive rodent or human SKPs also generated Schwann cells that myelinated CNS axons when transplanted into the dysmyelinated brain of neonatal shiverer mice. Thus, neonatal SKPs generate functional neural progeny in response to appropriate neural crest cues and, in so doing, provide a highly accessible source of myelinating cells for treatment of nervous system injury, congenital leukodystrophies, and dysmyelinating disorders.

Transcranial magnetic stimulation shows impaired transcallosal inhibition in Marchiafava-Bignami syndrome

A case of Marchiafava-Bignami (MB) syndrome with selective callosal involvement was evaluated by clinical examination and magnetic resonance imaging (MRI) in the acute phase and 6 months after the onset of symptoms; at the same time, the corticospinally and transcallosally mediated effects elicited by transcranial magnetic stimulation (TMS) were investigated. The first MRI study showed the presence of extensive abnormal signal intensity throughout the entire corpus callosum. After high-dose corticosteroid administration her symptoms rapidly resolved, in parallel with the reversion of MRI changes, except for severe cognitive impairment. Follow-up TMS examination revealed persistent transcallosal inhibition (TI) abnormalities. This report indicates that the measurement of TI during the course of MB syndrome is useful for evaluating functional changes to the corpus callosum, including their evaluation with time and after treatment and for elucidating the pathophysiology of MB syndrome.

Infection-associated encephalopathies: their investigation, diagnosis, and treatment

Reduced level of consciousness is a common clinical finding in acutely sick patients. In the majority of cases a cause for the encephalopathy is readily identifiable,whilst in a minority the aetiology is more difficult to ascertain. Frequently the onset of encephalopathy is associated with, or follows, infection. The mechanisms through which infection leads to encephalopathy are diverse. They range from direct microbial invasion of the brain or its supporting structures, to remote, infection-triggered mechanisms such as acute disseminated encephalomyelitis. Most common however, is the encephalopathy caused through a remote effect of systemic sepsis-septic encephalopathy. This article discusses the clinical presentation and underlying pathogeneses of the acute encephalopathies associated with infection, aiming to aid both their recognition and treatment.

Stem cells in inflammatory demyelinating disorders: a dual role for immunosuppression and neuroprotection

In recent years much excitement has been generated over the possibility that adult stem cells may attempt repair of the injured central nervous system (CNS), thus setting the stage for their utilisation in the treatment of neurodegenerative disorders. Recent studies have shown that some subsets of stem cells can also modulate the (auto)immune response, thus providing a rationale for their use as therapy for experimental autoimmune encephalomyelitis (EAE), an animal model for multiple sclerosis (MS). This article reviews the scientific evidence supporting the possible use of neural stem cells (NSCs) and mesenchymal stem cells (MSCs) for the treatment of MS. In addition, possible mechanisms sustaining the beneficial mode of action of haematopoietic stem cells (HSCs) following transplantation in MS individuals are discussed. Overall, it is proposed that limited subsets of adult stem cells may have a dual function that may be effective for the treatment of MS, an autoimmune disease of the CNS where degeneration of neural cells follows inflammation.

Demyelinating disorders: Update on transverse myelitis

Transverse myelitis (TM) is a focal inflammatory disorder of the spinal cord. Perivascular monocytic and lymphocytic infiltration, demyelination, and axonal injury are prominent histopathogic features of TM. The clinical manifestations of TM are consequent to dysfunction of motor, sensory, and autonomic pathways. At peak deficit, 50% of patients with TM are completely paraplegic (with no volitional movements of legs), virtually all have some degree of bladder dysfunction, and 80% to 94% have numbness, paresthesias, or band-like dysesthesias. Longitudinal case series of TM reveal that approximately one third of patients recover with little to no sequelae, one third are left with a moderate degree of permanent disability, and one third have severe disability. Recent studies have shown that the cytokine interleukin-6 may be a useful biomarker, as the levels of interleukin-6 in the cerebrospinal fluid of acute TM patients strongly correlate with and are highly predictive of disability. Clinical trials testing the efficacy of promising axonoprotective agents in combination with intravenous steroids in the treatment of TM are currently underway.

Immunotherapy for IgM anti-myelin-associated glycoprotein paraprotein-associated peripheral neuropathies

BACKGROUND

Serum monoclonal anti-myelin associated glycoprotein antibodies may be pathogenic in some people with IgM paraprotein and demyelinating neuropathy. Immunotherapies aimed at reducing the level of these antibodies might be expected to be beneficial.

OBJECTIVES

To examine the efficacy of any form of immunotherapy in reducing disability and impairment resulting from IgM anti-myelin associated glycoprotein paraprotein-associated demyelinating peripheral neuropathy.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Register (March 2005), MEDLINE (January 1966 to March 2005) and EMBASE (January 1980 to March 2005) for controlled trials. We also checked bibliographies and contacted authors and experts in the field.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials of participants of any age treated with any type of immunotherapy for anti-myelin-associated glycoprotein antibody associated demyelinating peripheral neuropathy with monoclonal gammopathy of undetermined significance of any severity. Our primary outcome measure was change in the Neuropathy Impairment Scale or Modified Rankin Scale at six months after randomisationSecondary outcome measures were: Neuropathy Impairment Scale or the Modified Rankin Score at 12 months after randomisation; ten-metre walk time, subjective clinical scores and electrophysiological parameters at six and 12 months after randomisation; IgM paraprotein levels and anti-myelin associated glycoprotein antibody titres at six months after randomisation and adverse effects of treatments.

DATA COLLECTION AND ANALYSIS

We identified eight possible trials. Of these, five randomised controlled trials were included after discussion between the authors. One author extracted and the other checked the data. No missing data could be obtained from trial authors.

MAIN RESULTS

The five eligible trials (97 participants) tested intravenous immunoglobulin, interferon-alpha or plasma exchange. Only two, of intravenous immunoglobulin, had comparable interventions and outcomes but both were short-term. There were no significant benefits of the treatments used in the outcomes predefined for this review, but not all the predefined outcomes were used in every included trial. Intravenous immunoglobulin showed benefits in terms of improvement in Modified Rankin Scale at two weeks and 10-metre walk time at four weeks. Serious adverse effects of intravenous immunoglobulin are known to occur from observational studies but none were encountered in these trials.

AUTHORS' CONCLUSIONS

There is inadequate reliable evidence from trials of immunotherapies in anti-myelin associated glycoprotein paraproteinaemic neuropathy to recommend any particular immunotherapy treatment. Intravenous immunoglobulin is relatively safe and may produce some short-term benefit. Large well-designed randomised trials of at least six to 12 months duration are required to assess existing or novel therapies.

Remyelination of dorsal column axons by endogenous Schwann cells restores the normal pattern of Nav1.6 and Kv1.2 at nodes of Ranvier

Demyelination of CNS axons occurs in a number of pathological conditions, including multiple sclerosis and contusion-type spinal cord injury. The demyelination can be repaired by remyelination in both humans and rodents, and even within the CNS remyelination can be achieved by endogenous and/or exogenous Schwann cells, the myelinating cells of the PNS. Remyelinated axons can often conduct impulses securely, but the organization of ion channels at long-term remyelinated nodes is not known. In the present study, the expression of voltage-gated sodium (Na(v)) and potassium (K(v)) channels along central axons remyelinated by endogenous Schwann cells has been studied in lesions induced more than 1 year previously by the intraspinal injection of ethidium bromide (EB). The expression of the channels at long-term nodes formed by Schwann cell remyelination has been compared with that present in nascent nodes formed in the adult at 18 and 23 days post-EB injection. Immunohistochemical studies revealed that long-term nodes formed by Schwann cell remyelination exhibit a clustering of Na(v)1.6 sodium channels within the nodal membrane, with the Shaker-type potassium channel K(v)1.2 segregated within the juxtaparanodal region, similar to the arrangement at normal mature CNS nodes. Na(v)1.2 was not detected at nodes formed by Schwann cells at any stage of their development. Moreover, Na(v)1.6, but not Na(v)1.2, was clustered at nascent nodes formed by remyelinating Schwann cells 18 and 23 days following EB injection. These observations show that endogenous Schwann cells can establish and maintain nodes of Ranvier on central axons for over one year, and that the nodes exhibit an apparently normal distribution of sodium and potassium channels, with Na(v)1.6 the predominant subtype of sodium channel present at such nodes at all stages of their development.

Glial grafting for demyelinating disease

Remyelination of demyelinated central nervous system (CNS) axons is considered as a potential treatment for multiple sclerosis, and it has been achieved in experimental models of demyelination by transplantation of pro-myelinating cells. However, the experiments undertaken have not addressed the need for tissue-type matching in order to achieve graft-mediated remyelination since they were performed in conditions in which the chance for graft rejection was minimized. This article focuses on the factors determining survival of allogeneic oligodendrocyte lineage cells and their contribution to the remyelination of demyelinating CNS lesions. The immune status of the CNS as well as the suitability of different models of demyelination for graft rejection studies are discussed, and ways of enhancing allogeneic oligodendrocyte-mediated remyelination are presented. Finally, the effects of glial graft rejection on host remyelination are described, highlighting the potential benefits of the acute CNS inflammatory response for myelin repair.

Chronic progressive sensory ataxic neuropathy associated with limited systemic sclerosis

We report the case of a 33-year-old woman with limited systemic sclerosis and chronic progressive sensory ataxic neuropathy. Sural nerve biopsy showed loss of myelinated fibers mostly those of large diameter, axonal degeneration and infiltration of macrophages, but no signs of vasculitis. Physical examination, laboratory testing, neurophysiological and neuroradiological examinations suggested that the dorsal root was primarily affected in this patient. Cytokine analysis by multiplex bead array assay revealed that IL-1beta and GM-CSF were increased both in serum and CSF. Although her symptoms did not respond to corticosteroid therapy, intravenous immunoglobulin (IVIg) therapy resulted in marked improvement. IVIg could be effective in case of immune-mediated reversible neuronal dysfunction associated with collagen disease without vasculitis.

Multiple sclerosis: pathologic, clinical, and imaging updates

Highlights of the 21st Congress of the European Committee for Treatment and Research in Multiple Sclerosis, September 28-October 1, 2005, Thessaloniki, Greece.