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Abstract
Brain has been considered as an immune-privileged site for centuries owing to the presence of blood-brain barrier, absent lymphatic drainage, and antigen-presenting cells. However, the present prevailing concept is of immune surveillance where brain is continuously surveyed by immune cells. However, the presence of immune cells in central nervous system (CNS) brings the risk of inflammation and autoimmunity involving both T and B cell mediated pathways. These mechanisms form the underlying pathology in a wide spectrum of pediatric CNS diseases manifesting as acquired neurological deficits. Overlapping, heterogenous, and ambiguous clinical features often delays the diagnosis. Although not always pathognomonic, magnetic resonance imaging can be an important biomarker leading to early diagnosis, prognostication, and systematic follow-up pf these diseases. This review describes the spectrum of different pediatric inflammatory disorders and their pertinent imaging features illustrated with clinical examples.
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Affiliation(s)
| | - Karthik Muthusamy
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manohar Shroff
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
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Dale GH, Svendsen KB, Gjelstrup MC, Christensen T, Houen G, Nielsen E, Bek T, Petersen T. Incidence of neuromyelitis optica spectrum disorder in the Central Denmark Region. Acta Neurol Scand 2018; 137:582-588. [PMID: 29359475 DOI: 10.1111/ane.12903] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Neuromyelitis optica (NMO)/NMO spectrum disorder (NMOSD) may be misdiagnosed as multiple sclerosis. The aim of this study was to (i) to measure AQP4-IgG in patients who fulfilled the clinical and radiological criteria of NMOSD in the Central Denmark Region and (ii) to estimate the incidence of NMOSD in the region, according to both the 2006 Wingerchuk criteria and the 2015 International Panel for NMO Diagnosis criteria. MATERIALS AND METHODS Medical records of all patients diagnosed with a demyelinating disorder in the region from 1 January 2012 to 31 December 2013 were reviewed. Patients were classified as having (i) "NMO" if the 2006 criteria were met, (ii) "NMOSD with AQP4-IgG" or (iii) "NMOSD without/unknown AQP-IgG" if the new 2015 NMOSD criteria were met. Patients with core symptoms were invited to provide a blood sample for AQP4-IgG analysis with an enzyme-linked immunosorbent assay and a cell-based indirect immunofluorescence assay. RESULTS In 191 patients with core symptoms, one met the 2015 NMOSD with AQP4-IgG criteria. Two patients met the 2006 NMO and 2015 NMOSD without/unknown AQP4-IgG criteria. Among 108 patients providing a blood sample, all were seronegative. The estimated incidence of NMO (2006 criteria) and NMOSD (2015 criteria) was 0.08 and 0.12 per 100 000 person-years, respectively. CONCLUSION NMO/NMOSD is a rare disease in the Central Denmark Region, with a considerably lower incidence rate than previously estimated in a neighbouring region.
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Affiliation(s)
- G. H. Dale
- Department of Neurology; Aarhus University Hospital; Aarhus Denmark
- Department of Biomedicine; Aarhus University; Aarhus Denmark
| | - K. B. Svendsen
- Department of Neurology; Aarhus University Hospital; Aarhus Denmark
| | - M. C. Gjelstrup
- Department of Biomedicine; Aarhus University; Aarhus Denmark
| | - T. Christensen
- Department of Biomedicine; Aarhus University; Aarhus Denmark
| | - G. Houen
- Department of Autoimmunology and Biomarkers; Statens Serum Institut; Copenhagen Denmark
| | - E. Nielsen
- Department of Neuroradiology; Aarhus University Hospital; Aarhus Denmark
| | - T. Bek
- Department of Ophthalmology; Aarhus University Hospital; Aarhus Denmark
| | - T. Petersen
- Department of Neurology; Aarhus University Hospital; Aarhus Denmark
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Urtiaga S, Terrero R, Malumbres M, Pinel A. Mielopatía por déficit de cobre: la gran simuladora. Neurologia 2018; 33:278-281. [DOI: 10.1016/j.nrl.2017.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 01/18/2017] [Accepted: 02/04/2017] [Indexed: 10/19/2022] Open
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Urtiaga S, Terrero R, Malumbres M, Pinel A. Myelopathy secondary to copper deficiency: The great imitator. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2017.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Chee CG, Park KS, Lee JW, Ahn HW, Lee E, Kang Y, Kang HS. MRI Features of Aquaporin-4 Antibody-Positive Longitudinally Extensive Transverse Myelitis: Insights into the Diagnosis of Neuromyelitis Optica Spectrum Disorders. AJNR Am J Neuroradiol 2018; 39:782-787. [PMID: 29449281 DOI: 10.3174/ajnr.a5551] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/29/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE Longitudinally extensive transverse myelitis is a well-documented spinal manifestation of neuromyelitis optica spectrum disorders, however, other forms of nontumorous myelopathy can also manifest as longitudinally extensive transverse myelitis. Our aim was to evaluate the MR imaging features of aquaporin-4 antibody-positive longitudinally extensive transverse myelitis, which is strongly associated with neuromyelitis optica spectrum disorders. MATERIALS AND METHODS We evaluated cervicomedullary junction involvement, cord expansion ratios, bright spotty lesions, the number of involved segments, skipped lesions, enhancement patterns, and axial distribution patterns using spinal MR imaging of 41 patients with longitudinally extensive transverse myelitis who underwent aquaporin-4 antibody testing. Univariate logistic regression analysis was performed to identify factors associated with aquaporin-4 antibody seropositivity, which were then used to develop a scoring system for diagnosing aquaporin-4 antibody-positive longitudinally extensive transverse myelitis. Interrater reliability for cord expansion ratio measurement and bright spotty lesions was determined using intraclass correlation coefficients and κ values, respectively. RESULTS Fifteen patients with longitudinally extensive transverse myelitis were aquaporin-4 antibody-positive. Sex (female), cervicomedullary junction involvement, a cord expansion ratio of >1.4, and bright spotty lesions were significantly associated with aquaporin-4 antibody seropositivity. The sensitivity and specificity of the scoring system were 73.3% and 96.2%, respectively. The interclass correlation value for the cord expansion ratio was 0.78, and the κ value for bright spotty lesions was 0.61. CONCLUSIONS Our scoring system, based on cervicomedullary junction involvement, higher cord expansion ratio, bright spotty lesions, and female sex, can facilitate the timely diagnosis of neuromyelitis optica spectrum disorders.
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Affiliation(s)
- C G Chee
- From the Departments of Radiology (C.G.C., J.W.L., H.W.A., E.L., Y.K., H.S.K.)
| | - K S Park
- Neurology (K.S.P.), Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - J W Lee
- From the Departments of Radiology (C.G.C., J.W.L., H.W.A., E.L., Y.K., H.S.K.)
| | - H W Ahn
- From the Departments of Radiology (C.G.C., J.W.L., H.W.A., E.L., Y.K., H.S.K.)
| | - E Lee
- From the Departments of Radiology (C.G.C., J.W.L., H.W.A., E.L., Y.K., H.S.K.)
| | - Y Kang
- From the Departments of Radiology (C.G.C., J.W.L., H.W.A., E.L., Y.K., H.S.K.)
| | - H S Kang
- From the Departments of Radiology (C.G.C., J.W.L., H.W.A., E.L., Y.K., H.S.K.)
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Malik S, Saran S, Dubey A, Punj A. Longitudinally extensive transverse myelitis following dengue virus infection: A rare entity. Ann Afr Med 2018. [PMID: 29536963 PMCID: PMC5875125 DOI: 10.4103/aam.aam_30_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Association of dengue fever with longitudinally extensive transverse myelitis in pediatric age group is a rare entity. We describe a case of 15 year old adolescent male who presented with dengue fever and in whom symptoms of transverse myelitis developed 4 weeks after fever (post-infectious stage). Magnetic resonance imaging confirmed the diagnosis of longitudinally extensive transverse myelitis involving dorso-lumbar cord. Patient recovered almost completely with minimal residual neurological deficit after a six weeks course of corticosteroids and supportive management including physiotherapy.
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Affiliation(s)
- Sunil Malik
- Department of Pediatrics, Subharti Medical College, Meerut, Uttar Pradesh, India
| | - Sonal Saran
- Department of Radiology, Subharti Medical College, Meerut, Uttar Pradesh, India
| | - Archana Dubey
- Department of Pediatrics, Subharti Medical College, Meerut, Uttar Pradesh, India
| | - Ajay Punj
- Department of Pediatrics, Subharti Medical College, Meerut, Uttar Pradesh, India
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Geraldes R, Ciccarelli O, Barkhof F, De Stefano N, Enzinger C, Filippi M, Hofer M, Paul F, Preziosa P, Rovira A, DeLuca GC, Kappos L, Yousry T, Fazekas F, Frederiksen J, Gasperini C, Sastre-Garriga J, Evangelou N, Palace J. The current role of MRI in differentiating multiple sclerosis from its imaging mimics. Nat Rev Neurol 2018. [DOI: 10.1038/nrneurol.2018.14] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
PURPOSE OF REVIEW The discovery of aquaporin-4 (AQP4) antibodies with high specificity for neuromyelitis optica spectrum disorder (NMOSD) has induced tremendous changes in the approach and management of central nervous system (CNS) neuroinflammatory disorders. Owing to the increasing availability of the AQP4 antibody assay and evolution of diagnostic criteria for multiple sclerosis and NMOSD, recent studies have reevaluated CNS neuroinflammatory disorders. This review describes recent advances in the understanding of CNS neuroinflammatory disorders in Asian/Pacific regions. RECENT FINDINGS Although multiple sclerosis prevalence is lower in Asian countries than in Western countries, the overall clinical features of multiple sclerosis are comparable between these countries. Hospital-based studies have reported that the frequency of NMOSD is higher in Asian populations (22-42%) than in white populations (2-26%). Despite improvements in the AQP4 antibody assay, AQP4 antibodies are not detected in certain patients with NMOSD. Recently, myelin oligodendrocyte glycoprotein (MOG) antibodies have been identified in AQP4 antibody-negative patients with the NMOSD phenotype, and the clinical features differ slightly between MOG antibody-positive patients and AQP4 antibody-positive patients. SUMMARY The understanding of CNS neuroinflammatory disorders in Asian/Pacific regions continues to evolve owing to the discovery of new biological markers and recognition of broader clinical phenotypes.
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Zhang Y, Zhu M, Wang L, Shi M, Deng H. Longitudinally extensive transverse myelitis with pulmonary tuberculosis: Two case reports. Medicine (Baltimore) 2018; 97:e9676. [PMID: 29505015 PMCID: PMC5779784 DOI: 10.1097/md.0000000000009676] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous inflammatory lesions of spinal cord extending to ≥3 vertebral segments. The etiology of LETM is complicated, including various infection, autoimmune disease, and so on. Neuromyelitis optic spectrum disorder (NMOSD) is the most common cause of LETM. Several case reports have suggested the associations between NMOSD and pulmonary tuberculosis (PTB). PATIENT CONCERNS Patient 1, a 20-year-old woman who had a past history of PTB, presented with weakness, numbness, and pain in the limbs. The serum anti-aquaporin-4 antibody (AQP4-Ab) was strongly positive, and the magnetic resonance imaging (MRI) scan of cervical and thoracic spinal cord after admission to the hospital revealed hyperintensity lesions extending from C3 to T8 on T2-weighted (T2W) image, T1-weighted (T1W) image, and fluid-attenuated inversion recovery (FLAIR) image. Patient 2, a 21-year-old woman who had a past medical history of PTB without receiving any treatment, presented for numbness in bilateral lower limbs and in the chest. The anti-AQP4-Ab was negative both in the serum and in the cerebral spinal fluid (CSF) of the patient. The MRI scan during hospitalization of cervical and thoracic spinal cord revealed diffuse hyperintense signal extending C3 to T11 on T2W and FLAIR images and hypointense signal on T1W image. DIAGNOSIS The first patient was diagnosed with anti-AQP4-Ab positive NMOSD, while the second case was an anti-AQP4-Ab negative LETM patient. INTERVENTIONS Both of the patients received a combination of corticosteroid and anti-tuberculosis (isonicotinyl hydrazide 0.3 g/d, rifampin 0.45 g/d, pyrazinamide 1 g/d, and ethambutol 1 g/d) treatment. OUTCOMES The patients were followed up for up to 1 year. The Expanded Disability Status Scale (EDSS) of both patients were decreased and the lesion size in the spinal cord was significantly reduced at the time point of the follow-up. LESSONS Combination of anti-tuberculosis and corticosteroid treatment may have better prognosis for patient of LETM with PTB.
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Rana DS, Rohatgi A, Patel S, Dave N, Agarwal R, Gupta P. Longitudinally Extensive Transverse Myelitis as Presenting Manifestation of Lung Adenocarcinoma. Indian J Med Paediatr Oncol 2018. [DOI: 10.4103/ijmpo.ijmpo_55_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractLongitudinally extensive transverse myelitis (LETM) is an unusual manifestation of systemic malignancy. It has been mainly reported with lung cancers and lymphoproliferative malignancy. LETM in systemic malignancy can be caused by either intramedullary metastases or paraneoplastic syndrome. Occurrence of LETM as the first manifestation of malignancy has been rarely reported. We present clinical, laboratory, and imaging findings of a 66-year-old man with nonsmall-cell lung (adeno) carcinoma, who presented with LETM without having any cardinal manifestations of lung malignancy. The rarity of the disease and especially such a presentation can cause considerable delay in the diagnosis and treatment.
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Affiliation(s)
| | - Anshu Rohatgi
- Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
| | - Samir Patel
- Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
| | - Nikhil Dave
- Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
| | - Rajat Agarwal
- Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
| | - Pooja Gupta
- Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
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Sireesha Y, Uppin MS, Bohra K, Alugolu R, Neeharika ML, Kanikannan A. Longitudinally Extensive Transverse Myelitis Due to Toxoplasma: An Autopsy Study. Ann Indian Acad Neurol 2018; 21:161-163. [PMID: 30122845 PMCID: PMC6073972 DOI: 10.4103/aian.aian_387_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Toxoplasma is an obligate intracellular parasite that remains asymptomatic in humans but, at times, can cause devastating disease. Here, we describe an autopsy study of a young immunocompetent gentleman with no comorbidities whose presentation was acute transverse myelitis. Magnetic resonance imaging spine showed longitudinally extensive spinal cord lesion (LESCL) that mimicked neuromyelitis optica with normal brain imaging at presentation. Investigations showed albuminocytological dissociation which prompted a course of parenteral steroid. However, the lesion relentlessly progressed to involve the brain stem and cerebrum leading to toxoplasmic encephalitis that terminated fatally. This report highlights that toxoplasma can present as LESCL and needs to be considered in the differential diagnosis of atypical myelitis.
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Affiliation(s)
- Yareeda Sireesha
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Komal Bohra
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rajesh Alugolu
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | | | - Angamuthu Kanikannan
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Patterson SL, Jafri K, Narvid JA, Margaretten M. A Young Woman With Sudden Urinary Retention and Sensory Deficits. Arthritis Care Res (Hoboken) 2017; 70:635-642. [PMID: 29125903 DOI: 10.1002/acr.23473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 11/07/2017] [Indexed: 12/27/2022]
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63
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Jafri K, Patterson SL, Lanata C. Central Nervous System Manifestations of Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2017; 43:531-545. [DOI: 10.1016/j.rdc.2017.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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64
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Elavarasi A, Dash D, Warrier AR, Bhatia R, Kumar L, Jain D, Tripathi M. Spinal cord involvement in primary CNS lymphoma. J Clin Neurosci 2017; 47:145-148. [PMID: 29110994 DOI: 10.1016/j.jocn.2017.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/09/2017] [Indexed: 11/20/2022]
Abstract
LETM is a common syndrome and the diagnosis of CNS lymphoma is not usually considered in the list of differentials. Primary CNS lymphoma can present as longitudinally extensive transverse myelopathy. Failure to suspect and evaluate leads to delay in diagnosis and treatment. PCNSL may be non contrast enhancing on gadolinium enhanced MRI. CSF analysis should be done preferably before starting corticosteroids as it is usual practice in treatment of transverse myelitis, as steroids may lead to transient improvement and mask the correct diagnosis. Repeated CSF examinations may be needed to clinch the diagnosis.
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Affiliation(s)
| | - Deepa Dash
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Anand R Warrier
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
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65
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Abstract
Neuromyelitis optica (NMO) and neuromyelitis optica spectrum disorders (NMOSD), previously known as Devic's syndrome, are a group of inflammatory disorders of the central nervous system (CNS) characterized by severe, immune-mediated demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord typically associated with a disease-specific serum NMO-IgG antibody that selectively binds aquaporin-4 (AQP4). The classic and best-defined features of NMOSD include acute attacks of bilateral or rapidly sequential optic neuritis (leading to visual loss) or transverse myelitis (often causing limb weakness and bladder dysfunction) or both with a typically relapsing course. The diagnosis of NMO/NMOSD requires a consistent history and examination with typical clinical presentations, findings on spinal cord neuroimaging with MRI, cerebrospinal fluid analysis along with determination of AQP4-IgG serum autoantibody status, and exclusion of other disorders. Two major advances in this field has been the development of diagnostic criteria and treatment recommendations. Consensus diagnostic criteria have been established and were recently revised and published in 2015, enhancing the ability to make a diagnosis and appropriately evaluate these disorders. Expert recommendations and uncontrolled trials form the basis of treatment guidelines. All patients with suspected NMOSD should be treated for acute attacks as soon as possible with high-dose intravenous methylprednisolone -1 gram daily for three to five consecutive days and in some cases, plasma exchange should be used. It is recommended that every patient with NMOSD be started on an immunosuppressive agent, such as, azathioprine, methotrexate, or mycophenolate and in some cases, rituximab, soon after the acute attack and usually be treated for about 5 years after the attack. These advances have helped improve the prognosis and outcome in these disorders.
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Affiliation(s)
- Teresa M Crout
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS, 39216, USA.
| | - Laura P Parks
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Vikas Majithia
- Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS, 39216, USA
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Abstract
Neuromyelitis optica (NMO), formerly known as Devic disease, is an autoimmune astrocytopathic disease characterized by transverse myelitis and optic neuritis. Most patients demonstrate a relapsing course with incomplete recovery between attacks, resulting in progressive disability. The pathogenesis involves production of aquaporin-4 antibodies (AQP4-IgG) by plasmablasts in peripheral circulation, disruption of the blood-brain barrier, complement-mediated astrocyte injury, and secondary demyelination. The diagnosis relies on characteristic clinical manifestations in the presence of serum AQP4-IgG positivity or specific neuroimaging findings, and exclusion of alternative etiologies. Current treatment involves aggressive immunosuppression with pulse-dose steroids during acute attacks and long-term immunosuppression for attack prevention.
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Affiliation(s)
- Sarah L Patterson
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Sarah E Goglin
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
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Magnetic Resonance Imaging and Clinical Features in Acute and Subacute Myelopathies. Clin Neuroradiol 2017; 27:417-433. [PMID: 28667382 DOI: 10.1007/s00062-017-0604-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/07/2017] [Indexed: 12/22/2022]
Abstract
Differential diagnosis of acute and subacute transverse myelopathy includes inflammatory, infectious, vascular, metabolic and paraneoplastic etiologies. Information on the diagnostic approach to transverse myelopathy with regard to daily clinical practice is provided. The differentiation between five lesion patterns on magnetic resonance imaging (MRI) in myelitis may be helpful: (1) longitudinal extensive transverse myelitis, (2) short segment ovoid or peripherally located, (3) "polio-like", (4) granulomatous and (5) segmental with rash. A correlation with these imaging features is supported if the clinical course and neurological symptoms are known. Although the mean interval from onset to nadir of symptoms in spinal cord infarction is 1 h, an overlap with a fulminant course of myelitis is possible, and impaired diffusion may also occur in acute inflammatory processes. As a result, laboratory testing, including aquaporin-4 antibodies and cerebrospinal fluid analysis, is crucial for the correct interpretation of imaging findings. Moreover, the discrimination of acute complete and acute partial transverse myelitis is advantageous in order to identify diverse entities, the latter often being a precursor to multiple sclerosis. Additional brain imaging is mandatory in suspected demyelinating, infectious, neoplastic and systemic autoimmune disease. A symmetrical lesion pattern restricted to individual tracts or dorsal columns indicates subacute combined degeneration of the spinal cord and, in addition to deficiency syndromes, a paraneoplastic etiology should be considered.
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68
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Flanagan EP, Weinshenker BG. Myelitis in neuromyelitis optica spectrum disorder: The long and the short of it. Mult Scler 2017; 23:360-361. [PMID: 28260418 DOI: 10.1177/1352458517692888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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69
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Carnero Contentti E, Hryb J, Leguizamón F, Di Pace J, Celso J, Knorre E, Perassolo M. Differential diagnosis and prognosis for longitudinally extensive myelitis in Buenos Aires, Argentina. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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70
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Carnero Contentti E, Hryb J, Leguizamón F, Di Pace J, Celso J, Knorre E, Perassolo M. Diagnósticos diferenciales y pronóstico de las mielitis longitudinales extensas en Buenos Aires, Argentina. Neurologia 2017; 32:99-105. [DOI: 10.1016/j.nrl.2015.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/12/2015] [Accepted: 06/23/2015] [Indexed: 12/18/2022] Open
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Han J, Yang MG, Zhu J, Jin T. Complexity and wide range of neuromyelitis optica spectrum disorders: more than typical manifestations. Neuropsychiatr Dis Treat 2017; 13:2653-2660. [PMID: 29118581 PMCID: PMC5659226 DOI: 10.2147/ndt.s147360] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Neuromyelitis optica (NMO), considered to be mediated by autoantibodies, often cause severely disabling disorders of the central nervous system, and predominantly cause optic nerve damage and longitudinally extensive transverse myelitis. Remarkable progress has been made in deciphering NMO pathogenesis during the past decade. In 2015, the International Panel for NMO Diagnosis proposed the unifying term "NMO spectrum disorders" (NMOSD) and the updated NMOSD criteria reflects a wide range of disease and maintains reasonable specificity. Moreover, cumulative findings have indicated that NMOSD are frequently associated with multiple autoimmune diseases, thereby presenting complex clinical symptoms that make this disease more difficult to recognize. Notably, most neurologists do not heed these symptoms or comorbid conditions in patients with NMOSD. Whereas previous reviews have focused on pathogenesis, treatment, and prognosis in NMOSD, we summarize the present knowledge with particular emphasis on atypical manifestations and autoimmune comorbidities in patients with NMOSD. Furthermore, we emphasized the identification of these atypical characteristics to enable a broader and better understanding of NMOSD, and improve early accurate diagnosis and therapeutic decision making.
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Affiliation(s)
- Jinming Han
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Meng-Ge Yang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Jie Zhu
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Tao Jin
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
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Park SJ, Jeong IH, Kong BS, Lee JE, Kim KH, Lee DY, Kim HJ. Disease Type- and Status-Specific Alteration of CSF Metabolome Coordinated with Clinical Parameters in Inflammatory Demyelinating Diseases of CNS. PLoS One 2016; 11:e0166277. [PMID: 27855220 PMCID: PMC5113962 DOI: 10.1371/journal.pone.0166277] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/25/2016] [Indexed: 01/15/2023] Open
Abstract
Central nervous system (CNS) inflammatory demyelinating diseases (IDDs) are a group of disorders with different aetiologies, characterized by inflammatory lesions. These disorders include multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and idiopathic transverse myelitis (ITM). Differential diagnosis of the CNS IDDs still remains challenging due to frequent overlap of clinical and radiological manifestation, leading to increased demands for new biomarker discovery. Since cerebrospinal fluid (CSF) metabolites may reflect the status of CNS tissues and provide an interfacial linkage between blood and CNS tissues, we explored multi-component biomarker for different IDDs from CSF samples using gas chromatography mass spectrometry-based metabolite profiling coupled to multiplex bioinformatics approach. We successfully constructed the single model with multiple metabolite variables in coordinated regression with clinical characteristics, expanded disability status scale, oligoclonal bands, and protein levels. The multi-composite biomarker simultaneously discriminated four different immune statuses (a total of 145 samples; 54 MS, 49 NMOSD, 30 ITM, and 12 normal controls). Furthermore, systematic characterization of transitional metabolic modulation identified relapse-associated metabolites and proposed insights into the disease network underlying type-specific metabolic dysfunctionality. The comparative analysis revealed the lipids, 1-monopalmitin and 1-monostearin were common indicative for MS, NMOSD, and ITM whereas fatty acids were specific for the relapse identified in all types of IDDs.
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Affiliation(s)
- Soo Jin Park
- The Department of Bio and Fermentation Convergence Technology, BK21 PLUS project, Kookmin University, Seoul, Korea
| | - In Hye Jeong
- The Department of Neurology, Research Institute and Hospital of the National Cancer Center, Goyang, Korea
| | - Byung Soo Kong
- The Department of Neurology, Research Institute and Hospital of the National Cancer Center, Goyang, Korea
| | - Jung-Eun Lee
- The Department of Bio and Fermentation Convergence Technology, BK21 PLUS project, Kookmin University, Seoul, Korea
| | - Kyoung Heon Kim
- The Department of Biotechnology, Graduate School, Korea University, Seoul, Korea
| | - Do Yup Lee
- The Department of Bio and Fermentation Convergence Technology, BK21 PLUS project, Kookmin University, Seoul, Korea
- * E-mail: (HJK); (DYL)
| | - Ho Jin Kim
- The Department of Neurology, Research Institute and Hospital of the National Cancer Center, Goyang, Korea
- * E-mail: (HJK); (DYL)
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73
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Bianchi A, Bartolini E, Melani F, Guerrini R, Mascalchi M. Isolated recurrent myelitis in a 7-year-old child with serum aquaporin-4 IgG antibodies. J Neurol 2016; 264:179-181. [PMID: 27844163 DOI: 10.1007/s00415-016-8332-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Andrea Bianchi
- Neuroradiology Unit, Meyer Children's Hospital Florence, Florence, Italy
| | - Emanuele Bartolini
- Neurology Unit and Laboratories, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Federico Melani
- Neurology Unit and Laboratories, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Renzo Guerrini
- Neurology Unit and Laboratories, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Mario Mascalchi
- Neuroradiology Unit, Meyer Children's Hospital Florence, Florence, Italy. .,"Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
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74
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Rain S, Udding J, Broere D. Acute Clinical Worsening after Steroid Administration in Cervical Myelitis May Reveal a Subdural Arteriovenous Fistula. Case Rep Neurol 2016; 8:234-242. [PMID: 27920716 PMCID: PMC5126604 DOI: 10.1159/000452830] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/25/2016] [Indexed: 01/01/2023] Open
Abstract
Subdural arteriovenous fistula (SDAVF) is a rare condition characterized by clinical manifestations ranging from mild bilateral sensory deficits to quadriplegia. The diagnosis is often delayed due to unspecific neurological symptoms, initially diagnosed as polyneuropathy or myelopathy. The diagnosis can be delayed for as long as 1–15 years. The following report describes a cervical SDAVF case initially misdiagnosed as myelitis transversa and treated with intravenous steroids. A 56-year-old male presented with sensory deficits and mild leg and right arm weakness. Cervical MRI showed a central medullary hyperintense lesion with contrast enhancement. After metabolic, infectious, and malignant causes were excluded, myelitis transversa was presumed and the patient was treated intravenously with methylprednisolone. Shortly after that, he developed quadriplegia. Cervical MRI imaging showed engorged cervical perimedullary vessels, which were not visible on the initial MRI. The diagnosis was revised and a SDAVF identified. Prompt surgical treatment led to a complete recovery. The effect of intravenous steroids in SDAVF is controversial. Acute clinical worsening after steroid administration is previously reported in several publications; however, due to the paucity of clinical studies on SDAVF, this effect remains mostly overlooked or unknown. The findings in this patient support the causative relation between SDAVF clinical worsening and steroid administration. We propose that acute clinical worsening under steroids in patients initially diagnosed with myelitis should raise suspicion of an SDAVF.
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Affiliation(s)
- Silvia Rain
- Department of Neurology, Westfriesgasthuis Hospital, Hoorn, The Netherlands
| | - Jan Udding
- Department of Radiology, Westfriesgasthuis Hospital, Hoorn, The Netherlands
| | - Daniel Broere
- Department of Neurology, Westfriesgasthuis Hospital, Hoorn, The Netherlands
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75
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Specific MRI findings help distinguish acute transverse myelitis of Neuromyelitis Optica from spinal cord infarction. Mult Scler Relat Disord 2016; 9:62-7. [DOI: 10.1016/j.msard.2016.04.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/26/2016] [Accepted: 04/11/2016] [Indexed: 01/23/2023]
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76
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Etiological, clinical, and radiological features of longitudinally extensive myelopathy in Chinese patients. J Clin Neurosci 2016; 32:61-6. [PMID: 27526974 DOI: 10.1016/j.jocn.2015.12.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/21/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022]
Abstract
Longitudinally extensive myelopathy (LEM) is a rare spinal syndrome, and was mostly assessed in western populations. In order to investigate the etiological, clinical, and radiological features of LEM in Chinese patients, we retrospectively analyzed eighty-nine (40 men and 49 women, median age 45.9±15.7years) patients with LEM hospitalized in China-Japan Friendship Hospital. LEM comprised autoimmune inflammatory myelitis (n=53), metabolic and compressive disorders (n=13), vascular diseases (n=10), neoplastic diseases (n=7), infectious diseases (n=4), and syringomyelia (n=2). Neuromyelitis optica spectrum disorders (NMOSD) was the most common cause of transverse myelopathy identified in LEM (38/89 [42.7%]) characterized by intractable vomiting and hiccups and painful tonic spasms. Subacute combined degeneration and anterior spinal artery syndrome accounted for the largest non-transverse LEM, which selectively affected the spinal dorsal and/or lateral columns and the spinal anterior region, respectively. Radicular pain was common in anterior spinal artery syndrome. Postrema (n=15, 39.5%) and cervical (n=31, 81.6%) lesions were significantly increased in NMOSD versus non-NMOSD (n=7, 13.7% and n=34, 66.7%, respectively, p<0.05]. Axial T2-weighted MRI indicated that 46 (51.7%) patients exhibited complete lesions; 43 (48.3%) patients exhibited non-transverse lesions, mainly unilateral or symmetrical tract lesions. Twenty-four (51.1%) LEM patients exhibited distinct gadolinium contrast enhancement. In this Chinese cohort, LEM was primarily attributed to NMOSD. While the etiological distribution in the non-NMOSD group was different from western populations, clinical and imaging features may facilitate a differential diagnosis.
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77
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Young V, Quaghebeur G. Transverse Myelitis and Neuromyelitis Optica Spectrum Disorders. Semin Ultrasound CT MR 2016; 37:384-95. [PMID: 27616312 DOI: 10.1053/j.sult.2016.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Transverse myelitis is defined as inflammation of the spinal cord, named because of its typical clinical presentation with bandlike symptoms of altered sensation or pain in a horizontal fashion-at a specific dermatome level. Radiographic patterns might vary but the idiopathic form is more frequent to present as involvement of 3-4 vertebral segments and both sides of the cord. It is now recognized that there are numerous other causes as well as the idiopathic type, with often atypical features and geographic variation. There is also increasing recognition of other forms of myelitis, particularly the longitudinally extensive manifestation with involvement of 3 or more vertebral segments. Neuromyelitis optica, one of these subtypes can be diagnosed by means of an antibody assessment. The picture is more complicated with the expansion of the description to involve neuromyelitis optica spectrum disorders, new antibodies such as myelin oligodendrocyte glycoprotein and the inclusion of an antibody-negative variant. This article describes the different entities of transverse myelitis, with a particular focus on neuromyelitis optica spectrum disorders.
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Affiliation(s)
- Victoria Young
- Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gerardine Quaghebeur
- Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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78
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Flanagan EP, Kaufmann TJ, Krecke KN, Aksamit AJ, Pittock SJ, Keegan BM, Giannini C, Weinshenker BG. Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol 2016; 79:437-47. [PMID: 26677112 DOI: 10.1002/ana.24582] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 12/01/2015] [Accepted: 12/13/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare longitudinally extensive myelitis in neuromyelitis optica spectrum disorders (NMOSD) and spinal cord sarcoidosis (SCS). METHODS We identified adult patients evaluated between 1996 and 2015 with SCS or NMOSD whose first myelitis episode was accompanied by a spinal cord lesion spanning ≥3 vertebral segments. All NMOSD patients were positive for aquaporin-4-immunoglobulin G, and all sarcoidosis cases were pathologically confirmed. Clinical characteristics were evaluated. Spine magnetic resonance imaging was reviewed by 2 neuroradiologists. RESULTS We studied 71 patients (NMOSD, 37; SCS, 34). Sixteen (47%) SCS cases were initially diagnosed as NMOSD or idiopathic transverse myelitis. Median delay to diagnosis was longer for SCS than NMOSD (5 vs 1.5 months, p < 0.01). NMOSD myelitis patients were more commonly women, had concurrent or prior optic neuritis or intractable vomiting episodes more frequently, had shorter time to maximum deficit, and had systemic autoimmunity more often than SCS (p < 0.05). SCS patients had constitutional symptoms, cerebrospinal fluid (CSF) pleocytosis, and hilar adenopathy more frequently than NMOSD (p < 0.05); CSF hypoglycorrhachia (11%, p = 0.25) and elevated angiotensin-converting enzyme (18%, p = 0.30) were exclusive to SCS. Dorsal cord subpial gadolinium enhancement extending ≥2 vertebral segments and persistent enhancement >2 months favored SCS, and ringlike enhancement favored NMOSD (p < 0.05). Maximum disability was similar in both disorders. INTERPRETATION SCS is an under-recognized cause of longitudinally extensive myelitis that commonly mimics NMOSD. We identified clinical, laboratory, systemic, and radiologic features that, taken together, help discriminate SCS from NMOSD.
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Affiliation(s)
| | | | | | | | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN.,Laboratory Medicine, Mayo Clinic, Rochester, MN
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79
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Zhang W, Jiao Y, Cui L, Jiao J. Differentiation of neuromyelitis optica spectrum disorders from ultra-longitudinally extensive transverse myelitis in a cohort of Chinese patients. J Neuroimmunol 2016; 291:96-100. [DOI: 10.1016/j.jneuroim.2016.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/04/2016] [Accepted: 01/06/2016] [Indexed: 11/27/2022]
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80
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Yeo TR, Wong CF, Lee JJX, Ng VZY, Tan K. Primary spinal oligoastrocytoma mimicking longitudinally extensive transverse myelitis. Mult Scler Relat Disord 2015; 4:590-3. [PMID: 26590667 DOI: 10.1016/j.msard.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/16/2015] [Accepted: 09/20/2015] [Indexed: 11/25/2022]
Abstract
Longitudinally extensive transverse myelitis (LETM) is most commonly associated with neuromyelitis optica spectrum disorders (NMOSD). However, a wide range of etiologies may produce longitudinally extensive spinal cord lesions (LESCLs) on imaging. We highlight the case of a patient with a spinal cord tumor whose imaging showed LESCL and was diagnosed with LETM. He did not respond to immunosuppression and subsequently developed a progressive and protracted clinical course. Thoracic cord biopsy performed 6 years after symptom onset showed primary spinal oligoastrocytoma. We discuss the features that should raise suspicion of a neoplasm in the context of LESCL and serve a reminder that not all LESCLs are inflammatory.
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Affiliation(s)
- T R Yeo
- Department of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433 Singapore, Singapore.
| | - C F Wong
- Department of Pathology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433 Singapore, Singapore.
| | - J J X Lee
- Department of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore, Singapore.
| | - V Z Y Ng
- Department of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433 Singapore, Singapore.
| | - K Tan
- Department of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433 Singapore, Singapore.
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81
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Juryńczyk M, Weinshenker B, Akman-Demir G, Asgari N, Barnes D, Boggild M, Chaudhuri A, D'hooghe M, Evangelou N, Geraldes R, Illes Z, Jacob A, Kim HJ, Kleiter I, Levy M, Marignier R, McGuigan C, Murray K, Nakashima I, Pandit L, Paul F, Pittock S, Selmaj K, de Sèze J, Siva A, Tanasescu R, Vukusic S, Wingerchuk D, Wren D, Leite I, Palace J. Status of diagnostic approaches to AQP4-IgG seronegative NMO and NMO/MS overlap syndromes. J Neurol 2015; 263:140-9. [PMID: 26530512 DOI: 10.1007/s00415-015-7952-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/21/2022]
Abstract
Distinguishing aquaporin-4 IgG(AQP4-IgG)-negative neuromyelitis optica spectrum disorders (NMOSD) from opticospinal predominant multiple sclerosis (MS) is a clinical challenge with important treatment implications. The objective of the study was to examine whether expert clinicians diagnose and treat NMO/MS overlapping patients in a similar way. 12 AQP4-IgG-negative patients were selected to cover the range of clinical scenarios encountered in an NMO clinic. 27 NMO and MS experts reviewed their clinical vignettes, including relevant imaging and laboratory tests. Diagnoses were categorized into four groups (NMO, MS, indeterminate, other) and management into three groups (MS drugs, immunosuppression, no treatment). The mean proportion of agreement for the diagnosis was low (p o = 0.51) and ranged from 0.25 to 0.73 for individual patients. The majority opinion was divided between NMOSD versus: MS (nine cases), monophasic longitudinally extensive transverse myelitis (LETM) (1), acute disseminated encephalomyelitis (ADEM) (1) and recurrent isolated optic neuritis (RION) (1). Typical NMO features (e.g., LETM) influenced the diagnosis more than features more consistent with MS (e.g., short TM). Agreement on the treatment of patients was higher (p o = 0.64) than that on the diagnosis with immunosuppression being the most common choice not only in patients with the diagnosis of NMO (98 %) but also in those indeterminate between NMO and MS (74 %). The diagnosis in AQP4-IgG-negative NMO/MS overlap syndromes is challenging and diverse. The classification of such patients currently requires new diagnostic categories, which incorporate lesser degrees of diagnostic confidence. Long-term follow-up may identify early features or biomarkers, which can more accurately distinguish the underlying disorder.
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Affiliation(s)
- Maciej Juryńczyk
- Nuffield Department of Clinical Neurosciences, Level 3, West Wing, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford, OX3 9DU, UK. .,Department of Neurology, Medical University of Lodz, Lodz, Poland.
| | - Brian Weinshenker
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, 55905, MN, USA
| | - Gulsen Akman-Demir
- Department of Neurology, School of Medicine, Istanbul Bilim University, Istanbul, Turkey
| | - Nasrin Asgari
- Department of Neurology, Vejle Hospital and Neurobiology, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - David Barnes
- Department of Neurology, Atkinson Morley's Wing, St George's Hospital, London, UK
| | - Mike Boggild
- The Townsville Hospital, 100 Angus Smith Drive, Douglas Qld 4814, Douglas, Townsville, Australia
| | - Abhijit Chaudhuri
- Department of Neurology, Queens Hospital Rom Valley Way, Romford, RM7 0AG, UK
| | - Marie D'hooghe
- Department of Neurology, University Hospital Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nikos Evangelou
- Division of Clinical Neuroscience, Queens Medical Center, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK
| | - Ruth Geraldes
- Neuroscience Department, Santa Maria Hospital, University of Lisbon, Lisbon, Portugal
| | - Zsolt Illes
- Department of Neurology, Institute of Clinical Research, Odense, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Anu Jacob
- NMO Clinical Service, The Walton Centre, Liverpool, UK
| | - Ho Jin Kim
- Department of Neurology, National Cancer Center, Seoul, South Korea
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael Levy
- Neuromyelitis Optica Clinic, John Hopkins University, 1800 E. Orleans St., Baltimore, MD, 21287, USA
| | - Romain Marignier
- Service de Neurologie A, Hopital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677, Lyon, France
| | - Christopher McGuigan
- University College Dublin, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - Ichiro Nakashima
- Department of Neurology, Tohoku University School of Medicine, Sendai, 980-8574, Japan
| | - Lekha Pandit
- Nitte University, Mangalore, 575018, Karnataka, India
| | - Friedemann Paul
- Department of Neurology, NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sean Pittock
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Krzysztof Selmaj
- Department of Neurology, Medical University of Lodz, Lodz, Poland
| | - Jérôme de Sèze
- Neurology Service, University Hospital of Strasbourg, Strasbourg, France
| | - Aksel Siva
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey
| | - Radu Tanasescu
- Division of Clinical Neuroscience, Queens Medical Center, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.,Department of Neurology, Neurosurgery and Psychiatry, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Sandra Vukusic
- Service de Neurologie A, Hopital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677, Lyon, France
| | - Dean Wingerchuk
- Mayo Clinic Division of Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, 13400 E Shea BLVD, Scottsdale, 85259, AZ, USA
| | - Damian Wren
- Department of Neurology, Atkinson Morley's Wing, St George's Hospital, London, UK
| | - Isabel Leite
- Nuffield Department of Clinical Neurosciences, Level 3, West Wing, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, Level 3, West Wing, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford, OX3 9DU, UK.
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82
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Rigney L, Cappelen-Smith C, Sebire D, Beran RG, Cordato D. Nontraumatic spinal cord ischaemic syndrome. J Clin Neurosci 2015; 22:1544-9. [PMID: 26154150 DOI: 10.1016/j.jocn.2015.03.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 02/04/2015] [Accepted: 03/03/2015] [Indexed: 02/08/2023]
Abstract
This study presents the clinical features and functional outcomes of eight consecutive patients who were admitted to our institution between 2012 and 2014 with nontraumatic spinal cord infarction (SCI), a rare and devastating condition. We also present a literature review of aetiologies and prognostic factors relevant to our case series. The mean age of our cohort was 64 years and five patients were female. Aortic disease was causative in three, including one patient with biopsy confirmed giant cell arteritis. Fibrocartilaginous embolism was a possible aetiology in two others, anterior spinal artery aneurysm in one, and the cause was undetermined in two patients. American Spinal Injury Association impairment scale (ASIA) scores at nadir (time of maximum severity of signs) were B in three, C in three and D in two patients (all were wheelchair dependent). At last follow-up, ASIA scores were C in one, D in five and E in one patient. One patient died, two remained wheelchair dependent, four required a walking aid or frame and one was mobilising independently. A literature review of 11 patient series of nontraumatic SCI found that prognosis is primarily determined by the severity of motor or sensory involvement, in particular, initial and nadir ASIA A/B scores which strongly correlate with poor outcome. In the majority of series, 40-60% of patients had initial ASIA A/B scores with a similar proportion remaining wheelchair dependent on follow-up. Most patients in our cohort had nadir ASIA C/D scores, which may explain their better outcomes.
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Affiliation(s)
- Louise Rigney
- Department of Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Dale Sebire
- Department of Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Roy G Beran
- Department of Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Griffith University, Southport, QLD, Australia
| | - Dennis Cordato
- Department of Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
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83
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Jain RS, Kumar S, Tejwani S. A rare association of tuberculous longitudinally extensive transverse myelitis (LETM) with brain tuberculoma. SPRINGERPLUS 2015; 4:476. [PMID: 26361577 PMCID: PMC4559554 DOI: 10.1186/s40064-015-1232-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/10/2015] [Indexed: 11/18/2022]
Abstract
Background Longitudinally extensive transverse myelitis is characterized by contiguous inflammatory lesion of spinal cord involving three or more spinal segments. It is a well-recognized but rare presentation of Mycobacterium tuberculosis infection. Case description We report a case of young boy diagnosed with multiple brain tuberculomas. He was on antitubercular drugs therapy for 2 months and became asymptomatic. On 2-month followup visit, the patient complained of acute onset progressive sensorimotor, spastic paraparesis with bladder dysfunction. Magnetic resonance imaging of spine showed longitudinally extensive transverse myelitis extending from thoracic spinal segment T2 to T10 level. He was treated with high dose intravenous methylprednisolone therapy and continued on combination of first line four antitubercular drugs. At 6-month followup, patient was able to walk with support. In our patient, clinical features, previous history of brain tuberculoma and spinal neuroimaging confirmed the diagnosis of tuberculous myelitis. The new onset longitudinally extensive transverse myelitis in our patient was may be related to paradoxical response to antitubercular therapy. Conclusions Our case highlights that tubercular infection might be an important but overlooked cause of longitudinally extensive transverse myelitis. Therefore, clinicians should have a high index of suspicion to diagnose this potentially treatable cause especially in high-risk conditions like tuberculosis endemic areas, associated brain tuberculosis and HIV infection. Our case is unique because of paradoxical presentation of longitudinally extensive transverse myelitis in cranial tuberculomas, already on antitubercular treatment.
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Affiliation(s)
- Rajendra Singh Jain
- Department of Neurology, Sawai Man Singh Medical College, Jaipur, Rajasthan India
| | - Sunil Kumar
- Department of Neurology, Sawai Man Singh Medical College, Jaipur, Rajasthan India
| | - Shankar Tejwani
- Department of Radiology, Sawai Man Singh Medical College, Jaipur, Rajasthan India
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84
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Pekcevik Y, Mitchell CH, Mealy MA, Orman G, Lee IH, Newsome SD, Thompson CB, Pardo CA, Calabresi PA, Levy M, Izbudak I. Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging. Mult Scler 2015. [PMID: 26209588 DOI: 10.1177/1352458515591069] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although spinal magnetic resonance imaging (MRI) findings of neuromyelitis optica (NMO) have been described, there is limited data available that help differentiate NMO from other causes of longitudinally extensive transverse myelitis (LETM). OBJECTIVE To investigate the spinal MRI findings of LETM that help differentiate NMO at the acute stage from multiple sclerosis (MS) and other causes of LETM. METHODS We enrolled 94 patients with LETM into our study. Bright spotty lesions (BSL), the lesion distribution and location were evaluated on axial T2-weighted images. Brainstem extension, cord expansion, T1 darkness and lesion enhancement were noted. We also reviewed the brain MRI of the patients during LETM. RESULTS Patients with NMO had a greater amount of BSL and T1 dark lesions (p < 0.001 and 0.003, respectively). The lesions in NMO patients were more likely to involve greater than one-half of the spinal cord's cross-sectional area; to enhance and be centrally-located, or both centrally- and peripherally-located in the cord. Of the 62 available brain MRIs, 14 of the 27 whom were NMO patients had findings that may be specific to NMO. CONCLUSIONS Certain spinal cord MRI features are more commonly seen in NMO patients and so obtaining brain MRI during LETM may support diagnosis.
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Affiliation(s)
- Yeliz Pekcevik
- Russell H Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Charles H Mitchell
- Russell H Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Maureen A Mealy
- Johns Hopkins Transverse Myelitis and Multiple Sclerosis Centers, Baltimore, MD, USA
| | - Gunes Orman
- Russell H Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - In H Lee
- Russell H Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA/Department of Radiology, Chungnam National University Hospital, Daejeon, Korea
| | - Scott D Newsome
- Division of Neuroimmunology and Neuroinfectious Diseases, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Carol B Thompson
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins, Baltimore, MD, USA
| | - Carlos A Pardo
- Division of Neuroimmunology and Neuroinfectious Diseases, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Michael Levy
- Department of Neurology, Johns Hopkins Hospital, Neuromyelitis Optica Clinic Baltimore, MD, USA
| | - Izlem Izbudak
- Russell H Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
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85
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Ringelstein M, Aktas O, Harmel J, Prayer D, Jarius S, Wildemann B, Hartung HP, Salhofer-Polanyi S, Leutmezer F, Rommer PS. [Contribution of spinal cord biopsy to the differential diagnosis of longitudinal extensive transverse myelitis]. DER NERVENARZT 2015; 85:1298-303. [PMID: 25148869 DOI: 10.1007/s00115-014-4137-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorders (NMOSD) are characterized by recurrent optic neuritis (ON) and longitudinally extensive transverse myelitis (LETM) as well as the serological detection of antibodies to aquaporin-4 (AQP4-ab). However, longitudinal extensive spinal cord lesions are not pathognomonic for NMOSD as they can also occur in systemic autoimmune diseases or mimic spinal cord tumors. OBJECTIVES/METHODS We report a female patient who initially presented with a subacute spinal syndrome and a longitudinal spinal cord lesion on magnetic resonance imaging (MRI). As the brain MRI showed only unspecific white matter lesions and the cerebrospinal fluid was normal, a spinal cord biopsy was performed to exclude malignancies and revealed inflammatory demyelinating changes. In addition, after several deep vein thromboses and the detection of antiphospholipid antibodies, an antiphospholipid syndrome (APS) was diagnosed. Many years after the spinal cord biopsy, AQP4-ab were tested and found to be positive. We discuss the important differential diagnoses of LETM, give an overview of previously reported NMOSD cases in which a spinal cord biopsy was performed and highlight the crucial role of AQP4-ab testing for the differential diagnosis of longitudinal spinal cord lesions. RESULTS/CONCLUSIONS Considering possible serious sequelae of spinal biopsy procedures, testing for AQP4-ab is mandatory in patients with unclear longitudinally extensive spinal cord lesions and should be performed preoperatively in all cases. In light of the heterogeneity of available assays, different detection methods should be used in doubtful cases. The relationship between NMO and APS needs further clarification; however, AQP4 IgG testing is recommended in patients presenting with APS and myelitis, optic neuritis or brainstem encephalitis.
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Affiliation(s)
- M Ringelstein
- Neurologische Klinik, Medizinische Fakultät, Heinrich-Heine-Universität, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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86
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Differential Diagnosis of Acute Myelopathies: An Update. Clin Neuroradiol 2015; 25 Suppl 2:183-7. [PMID: 26031429 DOI: 10.1007/s00062-015-0401-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/27/2015] [Indexed: 12/25/2022]
Abstract
Appropriate description may lead to adequate diagnostic and therapeutic measures, and therefore, a simple scheme to categorize and term the imaging findings of acute myelopathy is suggested based on current literature. Assigning imaging findings to five groups, that is (a) "segmental with rash," (b) "poliolike," (c) "granulomatous-nodular," (d) "longitudinally extensive transverse myelitis," (e) "short-segment ovoid or peripherally located," provides a rationale to lessen differential diagnoses. The key for understanding, proper description and differential diagnosis is the correlation of two time points: When did the first symptoms appear and when did imaging take place? Early infarction within the first 24 h will show neither swelling nor enhancement.
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87
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Sorte DE, Poretti A, Newsome SD, Boltshauser E, Huisman TAGM, Izbudak I. Longitudinally extensive myelopathy in children. Pediatr Radiol 2015; 45:244-57; quiz 241-3. [PMID: 25636706 DOI: 10.1007/s00247-014-3225-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 08/09/2014] [Accepted: 10/27/2014] [Indexed: 12/13/2022]
Abstract
When children present with acute myelopathy manifested by sensory, motor, or bowel and bladder symptoms, MRI of the neuraxis with contrast agent is the most important imaging study to obtain. Although occasionally normal, MRI often demonstrates signal abnormality within the spinal cord. Classically, longitudinally extensive transverse myelitis (≥3 vertebral bodies in length) has been described with neuromyelitis optica (NMO), but alternative diagnoses should be considered. This pictorial essay reviews the differential diagnoses that may present with longitudinally extensive spinal cord signal abnormalities. Multiple inflammatory, infectious, vascular, metabolic and neurodegenerative etiologies can present with a myelopathy. Thus, radiologists can assist in the diagnosis by familiarizing themselves with the spectrum of diseases in childhood that result in longitudinally extensive signal abnormalities in the absence of trauma.
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Affiliation(s)
- Danielle Eckart Sorte
- Division of Interventional Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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88
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Juryńczyk M, Craner M, Palace J. Overlapping CNS inflammatory diseases: differentiating features of NMO and MS. J Neurol Neurosurg Psychiatry 2015; 86:20-5. [PMID: 25248365 DOI: 10.1136/jnnp-2014-308984] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neuromyelitis optica (NMO) has long been considered as a variant of multiple sclerosis (MS) rather than a distinct disease. This concept changed with the discovery of serum antibodies (Ab) against aquaporin-4 (AQP4), which unequivocally differentiate NMO from MS. Patients who test positive for AQP4-Abs and present with optic neuritis (ON) and transverse myelitis (TM) are diagnosed with NMO and those who show an incomplete phenotype with isolated ON or longitudinally extensive TM (LETM) or less commonly brain/brainstem disease are referred to as NMO spectrum disorders (NMOSD). However, many patients, who have overlapping features of both NMO and MS, test negative for AQP4-Abs and may be difficult to definitively diagnose. This raises important practical issues, since NMO and MS respond differently to immunomodulatory treatment and have different prognoses. Here we review distinct features of AQP4-positive NMO and MS, which might then be useful in the diagnosis of antibody-negative overlap syndromes. We identify discriminators, which are related to demographic data (non-white origin, very late onset), clinical features (limited recovery from ON, bilateral ON, intractable nausea, progressive course of disability), laboratory results (cerebrospinal fluid (CSF) pleocytosis with eosinophils and/or neutrophils, oligoclonal bands, glial fibrillary acidic protein in the CSF) and imaging (LETM, LETM with T1 hypointensity, periependymal brainstem lesions, perivenous white matter lesions, Dawson's fingers, curved or S-shaped U-fibre juxtacortical lesions). We review the value of these discriminators and discuss the compelling need for new diagnostic markers in these two autoimmune demyelinating diseases of the central nervous system.
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Affiliation(s)
- Maciej Juryńczyk
- Department of Neurology, Oxford University Hospitals National Health Service Trust, Oxford, UK
| | - Matthew Craner
- Department of Neurology, Oxford University Hospitals National Health Service Trust, Oxford, UK
| | - Jacqueline Palace
- Department of Neurology, Oxford University Hospitals National Health Service Trust, Oxford, UK
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89
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Hyun JW, Kim SH, Huh SY, Kim W, Yun J, Joung A, Sato DK, Fujihara K, Kim HJ. Idiopathic aquaporin-4 antibody negative longitudinally extensive transverse myelitis. Mult Scler 2014; 21:710-7. [DOI: 10.1177/1352458514551454] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/13/2014] [Indexed: 12/27/2022]
Abstract
Background: Longitudinally extensive transverse myelitis (LETM) is a characteristic manifestation of neuromyelitis optica (NMO). However, not all patients with LETM are positive for aquaporin-4 (AQP4) antibodies. We evaluated the characteristics of idiopathic isolated LETM negative for AQP4 antibodies. Methods: From the National Cancer Center registry of inflammatory diseases of the central nervous system, patients with LETM as an initial manifestation and follow-up for at least two years were enrolled. Their medical records and MRIs were reviewed retrospectively. AQP4 antibody was confirmed by three different validated methods at least three times. Cerebrospinal fluid (CSF) glial fibrillary acidic protein (GFAP) levels were measured to investigate astrocyte damage. Results: Among 108 patients with first-ever LETM, 55 were positive for AQP4 antibodies (P-LETM) and 53 were consistently negative. Of them, seven were later diagnosed with seronegative NMO, and four were positive for MOG antibodies. The remaining 42 patients (N-LETM) showed several features distinct from P-LETM: male predominance, older age of onset, milder clinical presentation, spinal cord confinement and absence of combined autoimmunity. CSF GFAP levels were not increased in N-LETM but were markedly elevated in P-LETM. Conclusions: Idiopathic isolated N-LETM is not that rare among first-ever LETM, and has many features distinct from P-LETM where astrocytic damage is evident.
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Affiliation(s)
- Jae-Won Hyun
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Su-Hyun Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - So-Young Huh
- Kosin University School of Medicine, Busan, Korea
| | - Woojun Kim
- Catholic University School of Medicine, Seoul, Korea
| | - Junglim Yun
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - AeRan Joung
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Douglas Kazutoshi Sato
- Department of Neurology and Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuo Fujihara
- Department of Neurology and Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
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90
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Jarius S, Wildemann B, Paul F. Neuromyelitis optica: clinical features, immunopathogenesis and treatment. Clin Exp Immunol 2014; 176:149-64. [PMID: 24666204 DOI: 10.1111/cei.12271] [Citation(s) in RCA: 240] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2014] [Indexed: 12/11/2022] Open
Abstract
The term 'neuromyelitis optica' ('Devic's syndrome', NMO) refers to a syndrome characterized by optic neuritis and myelitis. In recent years, the condition has raised enormous interest among scientists and clinical neurologists, fuelled by the detection of a specific serum immunoglobulin (Ig)G reactivity (NMO-IgG) in up to 80% of patients with NMO. These autoantibodies were later shown to target aquaporin-4 (AQP4), the most abundant water channel in the central nervous system (CNS). Here we give an up-to-date overview of the clinical and paraclinical features, immunopathogenesis and treatment of NMO. We discuss the widening clinical spectrum of AQP4-related autoimmunity, the role of magnetic resonance imaging (MRI) and new diagnostic means such as optical coherence tomography in the diagnosis of NMO, the role of NMO-IgG, T cells and granulocytes in the pathophysiology of NMO, and outline prospects for new and emerging therapies for this rare, but often devastating condition.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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91
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Cobo-Calvo Á, Alentorn A, Mañé Martínez MA, Bau L, Matas E, Bruna J, Romero-Pinel L, Martínez-Yélamos S. Etiologic spectrum and prognosis of longitudinally extensive transverse myelopathies. Eur Neurol 2014; 72:86-94. [PMID: 24942967 DOI: 10.1159/000358512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/08/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with a first episode of longitudinal extensive transverse myelopathy (LETM) were reviewed with two objectives: to evaluate the clinical spectrum of LETM and to analyze the related clinical and laboratory variables that can be used as functional prognostic markers. METHODS A retrospective review was conducted of clinical, radiologic and biochemical data of patients admitted for LETM between 1993 and 2011. RESULTS Our cohort included 72 patients [median age 41 years, interquartile range (IQR) 29-61.5]. Median follow-up was 34 months (IQR 17.2-63). The modified Rankin Scale (mRS) score was ≥2 at the end of follow-up in 72.2%. The final diagnosis was idiopathic LETM in 22 patients, multiple sclerosis in 18, parainfectious disease in 11, systemic disease in 9, spinal cord infarction and neuromyelitis optica spectrum disorders in 3 patients each, and acute demyelinating encephalomyelitis, dural fistula, and tumor-related LETM in 2 patients each. Unfavorable outcome was associated with mRS ≥2 at admission [odds ratio (OR) 1.39, 95% confidence interval (CI) 1.16-1.66] and older age (OR 1.06, 95% CI 1.01-1.11). CONCLUSION Idiopathic LETM was the most frequent diagnosis at the end of follow-up. Older age and clinically severe disease at onset were independent prognostic factors of poorer functional recovery.
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Affiliation(s)
- Álvaro Cobo-Calvo
- Multiple Sclerosis Unit, Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Spain
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92
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Sato DK, Callegaro D, Lana-Peixoto MA, Nakashima I, Fujihara K. Seronegative Neuromyelitis Optica Spectrum - The challenges on disease definition and pathogenesis. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:445-50. [DOI: 10.1590/0004-282x20140032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/19/2014] [Indexed: 12/12/2022]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are characterized by severe optic neuritis and/or longitudinally extensive transverse myelitis, and some brain lesions are also unique to NMOSD. Serum autoantibodies against aquaporin-4 (AQP4) are detected in most cases of NMOSD. However, some patients with NMOSD remain seronegative despite repetitive testing during attacks with highly sensitive cell-based assays. The differential diagnosis of NMOSD is not restricted to multiple sclerosis and it includes many diseases that can produce longitudinally extensive myelitis and/or optic neuritis. We review the clinical features, imaging, and laboratory findings that can be helpful on the diagnostic work-up, discuss the differences between AQP4 antibody positive and negative patients with NMOSD, including features of NMOSD with antibodies against myelin oligodendrocyte glycoprotein.
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93
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Tackley G, Kuker W, Palace J. Magnetic resonance imaging in neuromyelitis optica. Mult Scler 2014; 20:1153-64. [DOI: 10.1177/1352458514531087] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/16/2014] [Indexed: 12/18/2022]
Abstract
Neuromyelitis optica (NMO), or Devic’s disease, is a rare demyelinating disorder of the central nervous system that has a predilection for the optic nerve and spinal cord. Magnetic resonance imaging (MRI) is required to diagnose NMO. Longitudinally extensive transverse myelitis is NMO’s imaging hallmark and the presence of a brain MRI that is not diagnostic of multiple sclerosis (MS) also remains part of the diagnostic criteria. It is increasingly recognised that MS and NMO brain imaging can, however, have similar appearances but differences do exist: hypothalamic, periaqueductal grey and area postrema lesions implicate NMO whilst cortical, U-fibre or Dawson’s finger lesions are suggestive of MS. The timing of image acquisition, age, ethnicity and aquaporin-4 antibody status are all likely to alter the findings at MRI. This review therefore aims to overview and update the reader on NMO imaging, to provide clinically relevant guidance for diagnosing NMO and differentiating it from MS in order to guide management, and to highlight recent research insights.
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94
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Matthews LA, Palace JA. The role of imaging in diagnosing neuromyelitis optica spectrum disorder. Mult Scler Relat Disord 2014; 3:284-93. [DOI: 10.1016/j.msard.2013.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 10/31/2013] [Accepted: 11/14/2013] [Indexed: 12/16/2022]
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95
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Kimbrough DJ, Mealy MA, Simpson A, Levy M. Predictors of recurrence following an initial episode of transverse myelitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2014; 1:e4. [PMID: 25340060 PMCID: PMC4202674 DOI: 10.1212/nxi.0000000000000004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 03/17/2014] [Indexed: 12/02/2022]
Abstract
Objective: This study sought to identify factors that increased the risk of recurrence after an initial transverse myelitis (TM) presentation. Methods: Retrospective cohort study of 192 patients initially presenting with TM of unknown etiology. Patients diagnosed with multiple sclerosis during the first myelitis episode were excluded. Demographic and laboratory data were analyzed for associations with recurrence. Results: One hundred ten of 192 patients (57%) eventually developed recurrent symptoms: 69 (63%) neuromyelitis optica (NMO) or NMO spectrum disorder, 34 (31%) non-NMO recurrent TM, and 7 (6%) systemic autoimmune disease. Multiple independent risk factors for recurrence were identified: African American race (risk ratio 1.60, p < 0.001, 95% confidence interval 1.26–2.03; similarly noted hereafter), female sex (1.88, p = 0.007, 1.19–2.98), longitudinally extensive myelitis at onset (1.34, p = 0.036, 1.01–1.78), Sjogren syndrome antigen A (1.89, p = 0.003, 1.44–2.48), vitamin D insufficiency (4.00, p < 0.001, 1.60–10.0), antinuclear antibody titer ≥1:160 (1.69, p = 0.006, 1.23–2.32), and the presence of inflammatory markers (e.g., immunoglobulin G index) in the CSF (2.14, p < 0.001, 1.44–3.17). Conclusions: Sex, race, and serologic biomarkers warrant consideration when assessing risk of TM recurrence. Male sex and Caucasian American race were independently associated with risk of monophasic idiopathic TM. Recurrence risk in female and African American patients appears driven by a greater likelihood of developing NMO or NMO spectrum disorder.
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Affiliation(s)
| | - Maureen A Mealy
- Department of Neurology, Johns Hopkins University, Baltimore, MD
| | | | - Michael Levy
- Department of Neurology, Johns Hopkins University, Baltimore, MD
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96
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97
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Wingerchuk DM, Weinshenker BG. Acute disseminated encephalomyelitis, transverse myelitis, and neuromyelitis optica. Continuum (Minneap Minn) 2014; 19:944-67. [PMID: 23917095 DOI: 10.1212/01.con.0000433289.38339.a2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW This review defines current clinical criteria for diagnosis, differential diagnosis, and clinical evaluation of acute disseminated encephalomyelitis, transverse myelitis, and neuromyelitis optica, and summarizes principles of treatment. RECENT FINDINGS Consensus criteria for transverse myelitis and acute disseminated encephalomyelitis have been proposed. A specific biomarker, aquaporin-4 autoantibody, has been discovered for neuromyelitis optica that allows for early and accurate diagnosis even in the absence of cardinal findings of optic neuritis and myelitis. The antibody is pathogenic and is facilitating an understanding of the pathophysiology of neuromyelitis optica and development of antigen-specific treatments. SUMMARY Clinical and radiologic findings combined with serologic findings may permit classification of syndromes of transverse myelitis and acute disseminated encephalomyelitis in ways that may predict risk of relapse, type of relapse, and prognosis. Treatment, especially to prevent relapse, is dependent on the specific disease context in which syndromes such as transverse myelitis occur.
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Affiliation(s)
- Dean M Wingerchuk
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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98
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Luigetti M, Lo Monaco M, Evoli A, Mirabella M, Damato V, Iorio R. Lower motor neuron involvement in longitudinally extensive transverse myelitis with and without aquaporin-4 antibodies. Clin Neurophysiol 2014; 125:1925-6. [PMID: 24525092 DOI: 10.1016/j.clinph.2013.12.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 12/09/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Marco Luigetti
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy.
| | - Mauro Lo Monaco
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy
| | - Amelia Evoli
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy
| | | | - Valentina Damato
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy
| | - Raffaele Iorio
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy.
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99
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Affiliation(s)
- Pavan Bhargava
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield
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100
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Ringelstein M, Metz I, Ruprecht K, Koch A, Rappold J, Ingwersen J, Mathys C, Jarius S, Brück W, Hartung HP, Paul F, Aktas O. Contribution of spinal cord biopsy to diagnosis of aquaporin-4 antibody positive neuromyelitis optica spectrum disorder. Mult Scler 2013; 20:882-8. [PMID: 24192218 DOI: 10.1177/1352458513510981] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 10/03/2013] [Indexed: 01/04/2023]
Abstract
Longitudinally extensive transverse myelitis is characteristic but not pathognomonic for neuromyelitis optica spectrum disorders (NMOSDs) and may mimic local tumors. In this retrospective study based on a cohort of 175 NMOSD patients we identified seven patients who initially presented with a longitudinally extensive spinal cord lesion and underwent spinal cord biopsy due to magnetic resonance imaging (MRI)-suspected malignancies. Remarkably, routine neuropathology was inconclusive and did not guide the diagnostic process to anti-aquaporin-4 (AQP4)-seropositive NMOSD. Serious postoperative complications occurred in 5/7 patients and persisted during follow-up in 2/7 patients (29%). Considering these sequelae, AQP4-antibody testing should be mandatory in patients with inconclusive longitudinally extensive spinal cord lesions prior to biopsy.
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Affiliation(s)
- M Ringelstein
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - I Metz
- Department of Neuropathology, University Hospital Göttingen, Germany
| | - K Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany
| | - A Koch
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Germany
| | - J Rappold
- Department of Neurology, Landesklinikum Thermenregion Hochegg, Austria
| | - J Ingwersen
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - C Mathys
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - S Jarius
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Germany
| | - W Brück
- Department of Neuropathology, University Hospital Göttingen, Germany
| | - H-P Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Germany
| | - O Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
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