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Branch retinal artery occlusion with visual field and multifocal erg in Susac syndrome: a case report. Doc Ophthalmol 2010; 121:223-9. [DOI: 10.1007/s10633-010-9244-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/10/2010] [Indexed: 10/19/2022]
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152
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Susac's syndrome, a rare, potentially severe or lethal neurological disease. J Neurol Sci 2010; 297:71-3. [PMID: 20723912 DOI: 10.1016/j.jns.2010.07.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 07/20/2010] [Accepted: 07/26/2010] [Indexed: 11/22/2022]
Abstract
Susac's syndrome (SS) is a rare, immune-mediated endotheliopathy affecting the microvasculature of the brain, the inner ear and the retina. Clinical presentation is characterised by a triad: encephalopathy, hearing loss and branch retinal artery occlusion (BRAO). Given the rarity of this disease, its natural history still remains partially unknown, but lethal cases appear to be extremely rare since there has never been, to our knowledge, a report of SS leading to death. We report 2 cases of SS illustrating the multiplicity of neurological symptomatology and its unpredictable course. One case is particularly unusual due to its severe neurological evolution, leading to death despite treatments. This report presents clinical and paraclinical findings contributory to SS diagnosis and offers an innovative perspective on disease management. These cases represent the potential severity of this disease. Early, aggressive treatment strategies may be warranted for SS in order to avoid neurological deterioration and lethal evolution.
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Kale N, Agaoglu J, Yazici I, Tanik O. Susac Syndrome, a Retino-Cochleo-Cerebellar Vasculitis: A Case-Series and Literature Review. Neuroophthalmology 2010. [DOI: 10.3109/01658107.2010.483755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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154
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Allmendinger AM, Spektor V, Destian S. CT and MR imaging of Susac syndrome in a young male presenting with acute disorientation. Clin Imaging 2010; 34:138-42. [DOI: 10.1016/j.clinimag.2009.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Accepted: 05/06/2009] [Indexed: 11/16/2022]
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155
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Liu GT, Volpe NJ, Galetta SL. Vision loss. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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156
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Encephalopathy, visual disturbance and hearing loss—recognizing the symptoms of Susac syndrome. Nat Rev Neurol 2009; 5:683-8. [DOI: 10.1038/nrneurol.2009.176] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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157
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Klein M, Illies T, Georgi S, Rosenkranz T, Terborg C. Aggressive Immuntherapie beim Susac-Syndrom. DER NERVENARZT 2009; 80:1502-5. [DOI: 10.1007/s00115-009-2866-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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158
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159
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Serial retinal fluorescein angiography and immune therapy in Susac's Syndrome. J Neurol Sci 2009; 285:230-4. [DOI: 10.1016/j.jns.2009.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 05/23/2009] [Accepted: 06/02/2009] [Indexed: 11/18/2022]
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160
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Jarius S, Neumayer B, Wandinger KP, Hartmann M, Wildemann B. Anti-endothelial serum antibodies in a patient with Susac's syndrome. J Neurol Sci 2009; 285:259-61. [PMID: 19643446 DOI: 10.1016/j.jns.2009.07.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 06/28/2009] [Accepted: 07/01/2009] [Indexed: 12/01/2022]
Abstract
BACKGROUND Susac's syndrome (SS) is a rare arteriopathy affecting the microvasculature of the brain, retina, and inner ear, resulting in encephalopathy, branch retinal artery occlusion and hearing loss. Anecdotal reports exist on SS being associated with a humoral immune response against endothelial cells. However, no original data has ever been published. OBJECTIVE To analyze serum and CSF from a patient with SS for the presence of CNS auto-antibodies and, if present, to further characterize such antibodies immunologically. METHODS Serum and CSF samples were examined by indirect immunofluorescence on adult mouse cerebrum, cerebellum, brain stem, and inner ear tissue sections, and IgG subclasses were determined. RESULTS Anti-endothelial antibodies were found at a titre of 1:960 in serum but not CSF. Antibodies belonged to the complement activating IgG1 subclass. Glucocorticoid treatment resulted in a decrease of titres (1:480), though the antibodies remained clearly detectable. CONCLUSION Our finding of anti-endothelial cell antibodies in a patient with SS is important in the light of previous pathological data suggesting that SS is associated with endothelial damage. Larger serological studies are now warranted to assess systematically the frequency and relevance of auto-antibodies in SS.
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Affiliation(s)
- S Jarius
- Division of Molecular Neuroimmunology, Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
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161
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Maillart E, Deschamps R, Moulignier A, Vignal-Clermont C, Obadia M, Le Mer Y, Laloum L, Gout O. Syndrome de Susac : étude de cinq cas. Rev Neurol (Paris) 2009; 165:575-82. [DOI: 10.1016/j.neurol.2008.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 07/01/2008] [Accepted: 10/08/2008] [Indexed: 11/29/2022]
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162
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163
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Blecic S. Rare causes of stroke. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:955-968. [PMID: 18804688 DOI: 10.1016/s0072-9752(08)93047-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Serge Blecic
- Hôpital Erasme, Service de Neurologie, Brussels, Belgium.
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164
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Susac Syndrome-A Report of Cochlear Implantation and Review of Otologic Manifestations in Twenty-Three Patients. Otol Neurotol 2009; 30:34-40. [DOI: 10.1097/mao.0b013e31818b6ac2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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165
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Petzold A, Plant GT. Central and Paracentral Visual Field Defects and Driving Abilities. Ophthalmologica 2008; 219:191-201. [PMID: 16088237 DOI: 10.1159/000085727] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2004] [Accepted: 08/19/2004] [Indexed: 12/29/2022]
Abstract
The effect of central and paracentral visual field defects on driving abilities has until now received little attention. To date studies and surveys have concentrated on visual acuity and peripheral field loss. Here we summarise for the first time those diseases causing central visual field defects likely to be associated with binocular visual acuity adequate for driving.
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Affiliation(s)
- A Petzold
- Department of Neuroimmunology, Institute of Neurology, London, UK.
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166
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Abstract
PURPOSE Susac syndrome is a rare microangiopathy of the brain, retina, and cochlea that mainly affects young women. We studied the management of this disease using retinal fluorescein and indocyanine green angiographies. METHODS Retrospective, observational case series of seven patients with Susac syndrome identified in ophthalmology and internal medicine departments. We reviewed medical, ophthalmologic, and angiographic records at study enrollment and during long-term treatment. Mean follow-up was 37 months. Best-corrected visual acuity, intraocular inflammation score, ophthalmoscopy data, automated perimetry score, and fluorescein and indocyanine green angiographic features were analyzed with the results of cerebral magnetic resonance imaging and spinal fluid analysis and ENT signs. RESULTS Retinal fluorescein angiography showed focal nonperfused retinal arterioles with hyperfluorescent walls in all cases. Indocyanine green angiography showed normal choroidal circulation. Retinal vasculitis was uncontrolled in a patient treated with steroids. Improvement of retinal arteriole perfusion occurred during immunosuppressive treatment with cyclophosphamide. CONCLUSION Absence of intraocular inflammation and focal, labile nonperfused retinal arterioles with integrity of choroidal circulation are monomorphic ophthalmologic features that could immediately suggest the diagnosis of Susac syndrome. Early ophthalmologic examination aided by retinal fluorescein angiography could be useful for managing cases of unexplained neurologic symptoms in women.
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167
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Susac syndrome and vestibular-evoked myogenic potentials. Otolaryngol Head Neck Surg 2008; 138:542-3. [DOI: 10.1016/j.otohns.2007.10.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 10/23/2007] [Accepted: 10/29/2007] [Indexed: 11/18/2022]
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168
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Winkler DT, Lyrer P, Probst A, Devys D, Haufschild T, Haller S, Willi N, Mihatsch MJ, Steck AJ, Tolnay M. Hereditary systemic angiopathy (HSA) with cerebral calcifications, retinopathy, progressive nephropathy, and hepatopathy. J Neurol 2008; 255:77-88. [PMID: 18204807 DOI: 10.1007/s00415-008-0675-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 05/14/2007] [Accepted: 06/06/2007] [Indexed: 11/26/2022]
Abstract
Several hereditary conditions affecting cerebral, retinal and systemic microvessels have recently been described. They include CADASIL, CRV, and HERNS. We here report on a variant form of a hereditary systemic angiopathy (HSA) affecting two generations of a Caucasian family. Clinical symptoms of HSA appear in the mid-forties and are characterized by visual impairment, migraine-like headache, skin rash, epileptic seizures, progressive motor paresis and cognitive decline. Late symptoms include hepatic and renal failure. Retinal capillary microaneurysms and arteriolar tortuosity are associated with marked optic disc atrophy. Radiological hallmarks consist of multiple cerebral calcifications and tumor-like subcortical white matter lesions. Brain, peripheral nerve, muscle, kidney and colon biopsies have revealed a multi organ small vessel involvement with partly altered endothelium, perivascular inflammation and thrombotic microangiopathy. No curative therapeutic options are known for hereditary cerebral vasculopathies. The use of cyclophosphamide, azathioprine and methotrexate was of no benefit in our cases of HSA. Early diagnosis of hereditary systemic angiopathies is important in order to prevent patients from repetitive invasive diagnostic measures and to avoid the use of inappropriate and potentially harmful drugs.
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Affiliation(s)
- D T Winkler
- Department of Neurology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
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170
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171
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Saliba M, Pelosse B, Momtchilova M, Laroche L. Syndrome de Susac et atteinte ophtalmologique chez l’enfant. J Fr Ophtalmol 2007; 30:1017-22. [DOI: 10.1016/s0181-5512(07)79280-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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172
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Eluvathingal Muttikkal TJ, Vattoth S, Keluth Chavan VN. Susac syndrome in a young child. Pediatr Radiol 2007; 37:710-3. [PMID: 17476496 DOI: 10.1007/s00247-007-0492-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 03/26/2007] [Accepted: 03/31/2007] [Indexed: 10/23/2022]
Abstract
Susac syndrome is a microangiopathy of unknown origin affecting the brain, retina and inner ear. This rare entity is often misdiagnosed as a demyelinating condition such as multiple sclerosis or acute disseminated encephalomyelitis. A high index of suspicion must be present as the majority of patients do not have the complete clinical triad at the time of onset of symptoms. The radiologist plays an important role when the disease is suspected and helps orient the investigations. The syndrome has characteristic imaging features on MRI that include multifocal white matter and occasional grey matter lesions, the corpus callosum being always involved. The predominant central callosal lesions, especially with rapid cystic transformation (central callosal holes) can be considered pathognomonic of this condition in the appropriate clinical setting. This disease is extremely rare in children. We report a case of Susac syndrome in a 9-year-old girl to increase the awareness among paediatric radiologists of this entity, which is usually not considered as a differential diagnosis of multifocal white matter involvement in this age group.
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173
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Susac JO, Egan RA, Rennebohm RM, Lubow M. Susac's syndrome: 1975–2005 microangiopathy/autoimmune endotheliopathy. J Neurol Sci 2007; 257:270-2. [PMID: 17331544 DOI: 10.1016/j.jns.2007.01.036] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Susac's syndrome (SS) consists of the clinical triad of encephalopathy, branch retinal artery occlusions (BRAO) and hearing loss. It is due to a microangiopathy affecting the precapillary arterioles of the brain, retina, and inner ear (cochlea and semicircular canals). Women are more commonly affected than men (3:1); the age of onset ranges from 9 to 58 years; but young women between the ages of 20 and 40 are most vulnerable. The encephalopathy is almost always accompanied by headache which may be the presenting feature. Multifocal neurological signs and symptoms, psychiatric disturbances, cognitive changes, memory loss, and confusion may rapidly progress to dementia. The MRI shows a distinctive white matter disturbance that always affects the corpus callosum. The central callosal fibers are particularly vulnerable and central callosal holes develop as the active lesions resolve. Linear defects (spokes) and rather large round lesions (snowballs) sometime dominate the MRI findings, which include cortical, deep gray (70%) and leptomeningeal involvement (33%). Frequently, the lesions enhance and may be evident on diffusion weighted imaging (DWI). The BRAO are best evaluated with fluorescein angiography, which may show the pathognomonic multifocal fluorescence. Gass plaques are frequently present and reflect endothelial damage. Brain biopsy shows microinfarction to be the basic pathology, but more recent pathological studies have shown endothelial changes that are typical for an antiendothelial cell injury syndrome. Elevated levels of Factor VIII and von Willebrand Factor Antigen reflect the endothelial perturbation. Despite extensive evaluations, a procoagulant state has never been demonstrated. SS is an autoimmune endotheliopathy that requires treatment with immunosuppressants: steroids, cyclophosphamide, and intravenous immunoglobulin, usually in combination. Aspirin is a useful adjunct.
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Affiliation(s)
- John O Susac
- Neurology and Neurosurgery Associates, P.A., 50 2nd Street S.E., Winter Haven, FL 33880 USA.
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174
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Differentialdiagnose und Therapie retinaler Gefäßverschlüsse. SPEKTRUM DER AUGENHEILKUNDE 2007. [DOI: 10.1007/s00717-007-0197-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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175
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Mike A, Gaál V, Németh A, Kövér F, Komoly S, Illés Z. Susac’s syndrome: clinical characteristics of a Hungarian case. Orv Hetil 2007; 148:897-905. [PMID: 17478405 DOI: 10.1556/oh.2007.28099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A Susac-szindróma ritka, többszörös szervi érintettséggel járó kórkép, melyet encephalopathiából, a retinát ellátó artéria ágainak okklúziójából és halláscsökkenésből álló triász jellemez. Ritka előfordulása, fluktuáló lefolyása és a hosszabb-rövidebb ideig inkomplett klinikai kép miatt sokszor nem ismerik fel, pedig az időben megkezdett kezelés a prognózist kedvezően befolyásolja.
Módszer:
Közleményünkben egy beteg esetét ismertetjük, és összefoglaljuk a kórkép legfontosabb ismérveit, diagnosztikai és terápiás lehetőségeit.
Eredmények:
A 30 éves nőbeteg ismeretlen eredetű encephalopathia, napok alatt kialakuló személyiségváltozás, meglassult gondolkodás, indítékhiány miatt került a pszichiátriai, majd a neurológiai klinikánkra. A koponya MR-vizsgálata multiplex fehérállományi laesiókat, liquorvizsgálata emelkedett összfehérjét mutatott. Az anamnézisben szereplő ismétlődő kétoldali látászavar, halláscsökkenés és migrénes fejfájás az encephalopathiával együtt a fiatal nőbeteg esetében Susac-szindróma lehetőségét vetette fel. Az immunszerológiai vizsgálatok szisztémás kötőszöveti betegséget nem jeleztek, a thrombophilia irányában végzett vizsgálatok negatívak voltak. A fundoszkópia és a fluoreszcens angiográfia a retinaerek többszörös okklúzióját, az audiogram kétoldali típusos halláscsökkenést mutatott. A liquor vizsgálata a szindrómára jellemző összfehérje-emelkedést jelezte. A krónikus szteroidterápia a tünetek regresszióját eredményezte.
Következtetések:
Egy magyar eset ismertetésével célunk ráirányítani a figyelmet egy olyan ritka kórképre, melynél az interdiszciplináris gondolkodás a klinikai diagnózis alapvető része.
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Affiliation(s)
- Andrea Mike
- Pécsi Tudományegyetem, Altalános Orvostudományi Kar Neurológiai Klinika, Pécs
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176
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Abstract
A 38-year-old woman seropositive for hepatitis C developed headache, sensorineural hearing loss, encephalopathy, and retinal arteriolar occlusions. Brain MRI showed signal abnormalities in the basal ganglia and corpus callosum. These features are consistent with Susac syndrome, a multifocal central nervous system disorder of uncertain etiology. This is the first reported case of Susac syndrome in a patient with hepatitis C.
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Affiliation(s)
- Anand Chawla
- Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerly, Liverpool, United Kingdom.
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177
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Aubart-Cohen F, Klein I, Alexandra JF, Bodaghi B, Doan S, Fardeau C, Lavallée P, Piette JC, Hoang PL, Papo T. Long-term outcome in Susac syndrome. Medicine (Baltimore) 2007; 86:93-102. [PMID: 17435589 DOI: 10.1097/md.0b013e3180404c99] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Susac syndrome is characterized by the clinical triad of encephalopathy, hearing loss, and retinal artery branch occlusions, mostly in young women. To our knowledge, long-term outcome and impact of pregnancy have not been specifically addressed. We report a series of 9 patients (7 female, 2 male) followed at the same institution, with special emphasis on clinical outcome including pregnancy and long-term sequelae. Clinical, brain magnetic resonance imaging (MRI), funduscopy, retinal angiography, and audiogram data were recorded every 3-12 months. We also analyzed the 92 previously reported cases of Susac syndrome. Mean follow-up was 6.4 years. Age at onset was 30.4 years. The first symptom occurred between April and September in 7 of 9 patients in the current study, and in 68% of all patients. The complete triad at onset was clinically obvious in only 1 of 9 patients. Brain involvement was heralded by headache and symptoms of encephalopathy. Cerebrospinal fluid was abnormal in 5 patients showing pleocytosis (mean, 24.6; range, 6-85 cells/mL) and elevated protein level (mean, 210; range, 113-365 mg/dL). Over time, quantitative brain MRI analysis showed that the number of lesions diminished and did not parallel clinical flares, and MRI never normalized. At the end of follow-up, no patient had severe impairment, and all but 1 returned to work. Inner ear involvement was present at onset in 2 patients and occurred in others with a mean delay of 11 months. Initially unilateral in 3, it became bilateral in all. Mean hearing loss was 34 dB (range, 15-70 dB). Hearing loss never improved, either spontaneously or under treatment. The eye was involved at onset in 8 patients, and after 3 years in 1. All had multiple bilateral retinal artery branch occlusions and/or dye leakage with hyperfluorescence of the arterial wall on fluorescein angiography. Over time, angiography normalized in 3 patients. In others, it was still abnormal at the end of follow-up (range, 1.5-10 yr). On late findings, fluorescein leakage was more frequent than true arterial occlusion. Eye involvement was mostly asymptomatic, unilateral, peripheral, and resumed spontaneously to remit in other sites over time. Corticosteroids were efficient to treat encephalopathy, with relapses occurring when the dosage was tapered. Steroid treatment did not improve hearing loss or prevent new retinal arteriolar occlusions. Anticoagulation had a role in treating encephalopathy and retinal arteriolar occlusions. Three patients had 4 pregnancies. Two pregnancies needed induced abortion. One pregnancy was uneventful. One pregnancy was complicated with Susac disease flare in the early postpartum period. In conclusion, at the end of follow-up, most patients had returned to work and none had severe impairment. Pregnancy may affect the course of Susac syndrome, with relapse of encephalopathy postpartum. Our main finding was that the course of Susac syndrome is not self-limited as previously thought, since isolated retinal arteriolar involvement may occur as a very late manifestation.
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Affiliation(s)
- Fleur Aubart-Cohen
- From Internal Medicine (FA-C, J-FA, TP), Radiology (IK), Ophthalmology (SD), and Neurology (PL) Departments, Bichat Hospital, Paris; and Ophthalmology (BB, CF, PLH) and Internal Medicine (J-CP) Departments, Pitié-Salpétrière Hospital, Paris, France
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178
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Abstract
Susac's syndrome (SS) is an immune-mediated endotheliopathy that affects the microvasculature of the brain, retina, and inner ear. SS responds well to immunosuppressive therapies when treatment is prompt, aggressive, and sustained. Striking similarities exist between SS and dermatomyositis (DM), regarding immunopathogenesis, natural history, and treatment needs. We apply lessons learned from study of DM to SS, and offer our current treatment protocol for SS. Since these treatment guidelines are based mainly on anecdotal evidence, they represent only preliminary recommendations.
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Affiliation(s)
- Robert M Rennebohm
- Clinical Pediatrics, Division of Pediatric Rheumatology, Ohio State University, College of Medicine and Public Health, Columbus Children's Hospital, 700 Children's Drive, Columbus, OH 43205, United States.
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179
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Kleffner I, Ringelstein EB, Stupp N, Niederstadt TU, Young P. Neurological picture. Susac's syndrome: effective combination of immunosuppression and antiplatelet treatment. J Neurol Neurosurg Psychiatry 2006; 77:1335. [PMID: 17110748 PMCID: PMC2077432 DOI: 10.1136/jnnp.2006.095596] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- I Kleffner
- Department of Neurology, University of Muenster, Albert-Schweitzer-Str. 33, 48129 Muenster, Germany.
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180
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Erer S, Boz M, Taskapilioglu O, Hakyemez B, Kaderli B, Zarifoglu M. The first Susac's syndrome case in Turkey. J Neurol Sci 2006; 251:134-7. [PMID: 17109892 DOI: 10.1016/j.jns.2006.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Revised: 09/18/2006] [Accepted: 09/19/2006] [Indexed: 11/28/2022]
Abstract
Susac's syndrome is a vasospastic disease resulting from bilateral microangiopathy of the brain, cochlea and retina. It is characterized by encephalopathy, bilateral sensorineural fluctuating hearing loss and visual loss. It is very uncommon and usually affects women during young adulthood. Since all three symptoms of the triad may not be present, the clinical diagnosis is difficult. Therefore, neuroimaging, particularly magnetic resonance imaging, has an important role in establishing the diagnosis. In this case report, we present a young woman who had all the symptoms of Susac's syndrome. This is the first Susac's syndrome case reported in Turkey.
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Affiliation(s)
- Sevda Erer
- Uludag University Medical Faculty Department of Neurology, Gorukle / Nilufer 16059, Bursa, Turkey.
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181
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Abstract
PURPOSE To report the clinical and imaging features in four male patients presenting with Susac syndrome, a microangiopathy affecting the brain, the retina, and the cochlea. METHODS Retrospective review of clinical data, fluorescein angiograms, and magnetic resonance imaging findings in these four cases. RESULTS All four patients were young men (range, 20-35 years). The axiomatic triad of ocular, cochlear, and neurologic involvement was present in three patients. Neurologic symptoms were absent in the fourth one. Fluorescein angiography showed arteriolar wall hyperfluorescence in all four patients. Magnetic resonance images showed in three patients multifocal hyperintense lesions in the white matter and the corpus callosum with typical involvement of the central fibers. Therapeutic modalities and clinical course are described. Three patients had a follow-up of 3, 5, and 13 years with complete remission of the disease within 1 year in all three cases. One patient had severe neuropsychological sequelae. CONCLUSION Susac syndrome seems to be less unusual in men than previously reported. Though presenting as a self-limited monophasic course disease in most cases, it may result in severe neuropsychological sequelae. Early diagnosis of the syndrome is enabled by the combination of the ophthalmologic, audiometric, and brain magnetic resonance features.
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Affiliation(s)
- Bernadette Snyers
- Department of Ophthalmology, Saint-Luc University Hospital, Brussels, Belgium.
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Gruhn N, Pedersen LK, Nielsen NV. Susac's syndrome: the first case report in a Nordic country, with an 8-year follow-up. ACTA ACUST UNITED AC 2006; 83:757-8. [PMID: 16396658 DOI: 10.1111/j.1600-0420.2005.00558.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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183
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Abstract
PURPOSE OF REVIEW Cerebral small vessel diseases are responsible for 20-30% of ischemic strokes as well as for a considerable proportion of cerebral hemorrhages and encephalopathies. Less known than the manifestations in old age are those in young women comprising posterior encephalopathy and Susac's syndrome. RECENT FINDINGS Magnetic resonance imaging has allowed us to identify posterior encephalopathy, characterized by headache, seizures, visual disturbances and hypertension, as a frequent complication of preeclampsia/eclampsia syndrome in the perinatal and postpartum period. Magnetic resonance findings are pathognomonic with bilateral cortical-subcortical lesions in the posterior hemispheres typically sparing the calcarine fissure. Conversely, white matter lesions on magnetic resonance imaging particularly involving the corpus callosum, and a (subclinical) sensorineural hearing loss are diagnostic of the retinocochleocerebral vasculopathy called Susac's syndrome. SUMMARY Posterior encephalopathy can also follow from a broad spectrum of endotheliotoxic conditions like chemotherapy, immunosuppression and sepsis. Early recognition of the disorder is decisive for a benign outcome since therapy consists of removal of precipitating factors, lowering of blood pressure and treatment with magnesium sulfate. The retinocochleocerebral vasculopathy appears to be underdiagnosed. An autoimmune-mediated arteriolopathy is presumed and the disease is nearly always monophasic. A variety of therapeutic approaches have been recommended, none of which, however, is based on anything other than anecdotal evidence.
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184
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Bodaghi B, Wechsler B, Adam R, Galanaud D, Fardeau C, Papo T, LeHoang P, Piette JC. Baisse visuelle sévère liée à une occlusion artérielle rétinienne au cours du syndrome de Susac : à propos d’un cas. Rev Neurol (Paris) 2005; 161:1221-4. [PMID: 16340918 DOI: 10.1016/s0035-3787(05)85196-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Susac's syndrome consists of the clinical triad of cerebral microangiopathy, branch retinal artery occlusions, and hearing loss. The pathogenesis of the disease remains unknown. The severity of retinal vasculopathy remains variable. CASE REPORT A 57-year-old Caucasian woman presented in 1999 for the diagnostic and therapeutic management of a severe and complete form of the disease. Fluorescein angiography and cerebral MRI were contributive in this case and confirmed the diagnosis. A severe unilateral visual loss occurred one month after the initiation of systemic corticosteroids. Funduscopy disclosed a temporal retinal artery occlusion with major ischemia. Therefore, cyclophosphamide and anticoagulants were added to corticosteroids and total visual recovery was achieved within 2 weeks without any relapse after a follow-up period of 54 months. CONCLUSION Therapeutic management of Susac's syndrome is still controversial. Major immunosuppressive regimens are mandatory in the face of severe visual loss associated with central or branch retinal artery occlusions. The final prognosis of the disease seems favorable in the absence of prolonged and symptomatic retinal ischemia.
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Affiliation(s)
- B Bodaghi
- Service d'Ophtalmologie, CHU Pitié-Salpêtrière, Paris.
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185
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Abstract
PURPOSE OF REVIEW Small vessel diseases of the brain are still clinically underrecognized whereas their burden is increasing steeply. The most frequent is acquired degenerative small vessel disease. Many hereditary or idiopathic small vessel diseases have also been identified, of which cerebral autosomal-dominant arteriopathy with stroke and ischaemic leukoencephalopathy (CADASIL) is the most prominent. In this review, we will highlight current evidence on pathophysiology and genetics, new imaging tools, and treatment options. RECENT FINDINGS Recent imaging studies have stressed the disruption of white matter connections in the pathogenesis of cognitive impairment in acquired small vessel disease. Clinical trials suggest a therapeutic benefit of acetylcholinesterase inhibitors. CADASIL is caused by mutations in the Notch3 gene. Current basic research has identified Notch genes to be important for endothelial and smooth muscle cells to form arteries and veins. Diagnosis can now be made reliably by magnetic resonance brain imaging, skin biopsy, or genetic testing. The so-called retinocerebral vasculopathies share the involvement of both retinal, cerebral and cochlear arterioles (e.g. Susac's syndrome). Cerebral amyloid angiopathy, occurring either sporadically or as a cause of various gene mutations, predisposes to lobar haemorrhages caused by rupture of affected small cortical vessels. Other rare cerebral microangiopathies, such as mitochondrial cytopathies, Fabry's disease and toxemic vasculopathy, offer established or new therapeutic options. SUMMARY Cerebral small vessel diseases are highly variable in their aetiopathogenesis and clinical course. Current pathophysiological insights will help develop better treatment modalities; new imaging tools will provide surrogate markers for monitoring disease progression and treatment effects.
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186
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Abstract
UNLABELLED PURPOSE OF VIEW: We review recent developments in the clinical course and imaging modalities for Susac's syndrome, a clinical triad consisting of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. RECENT FINDINGS Susac's syndrome has variable clinical presentations; recently described presentations include epileptic seizures and transient inverted vision. Advances in neuroradiology suggest that magnetic resonance imaging demonstrates distinctive patterns in the white and grey matter and in the leptomeninges. Reports have verified that Susac's syndrome is under-diagnosed because of its multisystem involvement and confusion with other imitating disorders (such as multiple sclerosis), and because of the fact that neuroradiologists are not acquainted with this syndrome. SUMMARY The precise aetiology of Susac's syndrome is still unknown and many areas have not yet been explored. Magnetic resonance imaging is the neuroimaging study of choice. Findings include multiple small hyperintense foci on T2-weighted images and contrast enhancement in white and grey matter of both supratentorial and infratentorial structures, corpus callosum and, occasionally, leptomeninges. Callosal lesions typically involve the central fibres and are probably pathognomonic for Susac's syndrome. When assessing patients with unexplained encephalopathy involving white and grey matter, leptomeninges and corpus callosum, the findings of sensorinueral hearing loss or visual disturbances may yield important clues regarding the possibility of Susac's syndrome.
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Affiliation(s)
- Menachem Gross
- Department of Otolaryngology/Head and Neck Surgery, The Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel.
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187
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Abstract
OBJECTIVE The objective of this study was to describe the clinical manifestations; radiographic, audiometric, and retinal fluorescein angiography findings; pathogenesis and treatment of Susac syndrome with review of the literature. STUDY DESIGN We conducted a retrospective case review. SETTING This study was conducted at a tertiary referral center. PATIENT A 50-year-old woman presented with recurrent episodes of neurologic symptoms, bilateral sensorineural hearing loss, and silent retinal artery occlusion. INTERVENTIONS The patient underwent complete evaluation, including magnetic resonance image studies, audiometric tests, and retinal fluorescein angiography. She was treated initially with corticosteroids and later with other immunosuppressive agents. RESULTS The patient was initially diagnosed with left sudden sensorineural hearing loss. Despite comprehensive clinical and laboratory studies that did not reveal systemic disease, 3 weeks later, the patient developed vertigo, sensorineural hearing loss, and tinnitus in the opposite ear. The neurologic involvement and the bilateral audiologic manifestations raised the possibility of Susac syndrome. CONCLUSION Susac syndrome is a rare disorder of unknown origin characterized by the triad of encephalopathy, fluctuating hearing loss, and visual loss resulting from microangiopathy of the brain, cochlea, and retina. The multiple organ involvement seen in Susac syndrome raises a differential diagnosis ranging from autoimmune disease, through systemic vasculitis, to multiple sclerosis. Otolaryngologists should be aware of this syndrome as a result of the vestibulocochlear manifestations and the multidisciplinary evaluation that is required.
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Affiliation(s)
- Menachem Gross
- Department of Otolaryngology/Head & Neck Surgery, Hadassah-Hebrew University Hospital, Jerusalem, Israel.
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188
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Plummer C, Rattray K, Donnan GA, Basilli S. An unusual disease presenting at an unusual age: Susac’s syndrome. J Clin Neurosci 2005; 12:99-100. [PMID: 15639427 DOI: 10.1016/j.jocn.2004.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2004] [Accepted: 07/07/2004] [Indexed: 12/01/2022]
Abstract
Susac's syndrome is a rare disease of unknown aetiology affecting the small vessels of the retina, brain, and cochlea. We present the case of a 55-year-old female, the oldest patient yet described with the condition, and highlight the syndrome's clinical features.
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Affiliation(s)
- C Plummer
- Austin and Repatriation Medical Centre, Studley Road, Heidelberg, Australia.
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189
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Bucciarelli S, Cervera R, Martínez M, Latorre X, Font J. Susac's syndrome or catastrophic antiphospholipid syndrome? Lupus 2004; 13:607-8. [PMID: 15462492 DOI: 10.1191/0961203304lu1046cr] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Susac's syndrome is a microangiopathic disorder of unknown pathogenesis presenting with encephalopathy, hearing loss and branch retinal artery occlusions. The term 'catastrophic' antiphospholipid syndrome (APS) is used to define a subset of the APS characterized by thrombotic microangiopathy with clinical evidence of three or more organ involvement developed in a short period of time. We describe a patient with typical features of Susac's syndrome, that appeared in less than a week, in whom aPL were detected, thus fulfilling criteria for 'probable' catastrophic APS.
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Affiliation(s)
- S Bucciarelli
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
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190
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Xu MS, Tan CB, Umapathi T, Lim CCT. Susac syndrome: serial diffusion-weighted MR imaging. Magn Reson Imaging 2004; 22:1295-8. [PMID: 15607101 DOI: 10.1016/j.mri.2004.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2004] [Accepted: 08/01/2004] [Indexed: 10/26/2022]
Abstract
Susac syndrome (SS) is a clinical triad of hearing loss, retinal artery occlusion and encephalopathy. The typical MR imaging findings of multiple focal lesions in the corpus callosum and subcortical white matter can be easily misdiagnosed as multiple sclerosis. On diffusion-weighted (DW) MR imaging, new lesions were hyperintense, with reduced apparent diffusion coefficient (ADC). These lesions later became less prominent or hypointense on subsequent DW MR imaging. Serial DW imaging and ADC maps may be useful in differentiating SS from demyelinating diseases.
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Affiliation(s)
- Mao Sheng Xu
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
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191
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Síndrome de Susac. Diagnóstico diferencial. Med Clin (Barc) 2004. [DOI: 10.1016/s0025-7753(04)74595-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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192
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Hahn JS, Lannin WC, Sarwal MM. Microangiopathy of brain, retina, and inner ear (Susac's syndrome) in an adolescent female presenting as acute disseminated encephalomyelitis. Pediatrics 2004; 114:276-81. [PMID: 15231946 DOI: 10.1542/peds.114.1.276] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Susac's syndrome is a rare disorder that consists of microangiopathy of the brain, retina, and inner ear and usually affects young women in young adulthood. The triad of clinical manifestations consists of acute encephalopathy with neurologic signs, branch retinal artery occlusion (BRAO), and sensorineural hearing loss. We present a case of an adolescent female who presented at age 16 years with clinical and neuroimaging features of acute disseminated encephalomyelitis (ADEM). The full triad did not develop until 2.5 years after the initial neurologic presentation.
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Affiliation(s)
- Jin S Hahn
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA.
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193
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Abstract
The retinal arteries and veins may be involved in isolation or as the result of a systemic vasculitis. This article emphasizes neurologic diseases in which the ocular vasculature is affected.
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Affiliation(s)
- Judith E A Warner
- Department of Ophthalmology and Visual Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah 84132, USA.
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194
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Adatia FA, Sheidow TG. Central retinal artery occlusion as the initial ophthalmic presentation of Susac's syndrome. Can J Ophthalmol 2004; 39:288-91. [PMID: 15180149 DOI: 10.1016/s0008-4182(04)80129-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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195
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Collagen Vascular and Infectious Diseases. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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196
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Egan RA, Ha Nguyen T, Gass JDM, Rizzo JF, Tivnan J, Susac JO. Retinal arterial wall plaques in Susac syndrome. Am J Ophthalmol 2003; 135:483-6. [PMID: 12654364 DOI: 10.1016/s0002-9394(02)02085-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To demonstrate retinal arterial wall plaques (RAWPs) in patients with Susac syndrome, a disorder that consists of the triad of branch retinal artery occlusion, encephalopathy, and hearing loss. The clinician may misinterpret these RAWPs as emboli. DESIGN Observational case series. METHODS Four patients (one man and three women, aged 21-38 years) were examined and followed. RESULTS Four patients with Susac syndrome had RAWPs in association with branch retinal artery occlusions. They were present in six of eight eyes. The plaques were yellow to yellow-white and located usually away from retinal bifurcations. Retinal arterial wall plaques occur at the midarteriolar segments, whereas Hollenhorst plaques occur at vascular bifurcations. Four of six eyes had resolution of the plaques. CONCLUSIONS Retinal arterial wall plaques may occur with branch retinal artery occlusions in Susac syndrome. This finding should help the clinician who is struggling to make a diagnosis in a patient with an enigmatic encephalopathy and/or hearing loss. These plaques may resolve over time.
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Affiliation(s)
- Robert A Egan
- Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon, USA.
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197
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Fialho D, Holmes P, Riordan-Eva P, Silber E. A Blinding Headache Falling on Deaf Ears (Susac’s Syndrome). Pract Neurol 2002. [DOI: 10.1046/j.1474-7766.2002.00097.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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198
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Cubillana Herrero JD, Soler Valcárcel A, Albaladejo Devis I, Rodríguez González-Herrero B, Minguez Merlos N, Jiménez Cervantes-Nicolás JA. [Susac syndrome as a cause of sensorineural hearing loss]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2002; 53:379-83. [PMID: 12185873 DOI: 10.1016/s0001-6519(02)78323-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Susac's syndrome is an extremely rare clinical manifestation characterized by the triad of fluctuating sensorineural hearing loss, sudden visual loss and encephalopathy. Probably underdiagnosed, it affects young women who start the clinical history with headache, visual and hearing disturbances, with neurological findings in MRI. With unknown aetiology, pathogenesis is based on arteriolar microinfarcts in retina, cochlea, and grey and white matter in the brain. Treatment is, as stated in the bibliography and our experience, intravenous high doses of steroids followed by oral steroids together with hyperbaric oxygen to minimize ischaemic lesions. Aspirin associate to nimodipine has been useful to date in the treatment of our patient. We present a case and review the existing literature.
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Affiliation(s)
- J D Cubillana Herrero
- Servicio ORL, Hospital Virgen de la Arrixaca, Carretera Madrid-Cartagena, s/n. 30120 El Palmar, Murcia.
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199
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Petty GW, Matteson EL, Younge BR, McDonald TJ, Wood CP. Recurrence of Susac syndrome (retinocochleocerebral vasculopathy) after remission of 18 years. Mayo Clin Proc 2001; 76:958-60. [PMID: 11560310 DOI: 10.4065/76.9.958] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Susac syndrome (retinocochleocerebral vasculopathy) is a syndrome of unknown pathogenesis. The triad of multifocal encephalopathy, visual loss, and hearing loss is caused by microangiopathy of the brain, retina, and cochlea. The illness tends to be monophasic, and to our knowledge, recurrence after years of remission has not been reported. We describe a 51-year-old woman with symptoms, signs, and brain magnetic resonance imaging findings consistent with recurrence of Susac syndrome 18 years after remission. Clinicians should be aware of the possibility of late recurrence of Susac syndrome when evaluating patients with a distant history of the syndrome who present with complaints referable to the brain, retina, and cochlea.
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Affiliation(s)
- G W Petty
- Division of Cerebrovascular Diseases, Mayo Clinic, Rochester, Minn 55905, USA
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200
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Sbaï A, Wechsler B, Papo T, Godeau P, Piette JC. [Aphthous ulcers have their secrets....]. Rev Med Interne 2001; 22 Suppl 2:227s-229s. [PMID: 11433577 DOI: 10.1016/s0248-8663(01)83655-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A Sbaï
- Service de médecine interne, hôpital Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
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