1
|
Hearn SL, Stino AM, Howard IM, Malhotra G, Robinson L. Serial electrodiagnostic testing: Utility and indications in adult neurological disorders. Muscle Nerve 2024; 69:670-681. [PMID: 38549195 DOI: 10.1002/mus.28083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 05/08/2024]
Abstract
Although existing guidelines address electrodiagnostic (EDX) testing in identifying neuromuscular conditions, guidance regarding the uses and limitations of serial (or repeat) EDX testing is limited. By assessing neurophysiological change longitudinally across time, serial electrodiagnosis can clarify a diagnosis and potentially provide valuable prognostic information. This monograph presents four broad indications for serial electrodiagnosis in adult peripheral neurological disorders. First, where clinical change has raised suspicion for a new or ongoing lesion, EDX reassessment for spatial spread of abnormality, involvement of previously normal muscle or nerve, and/or evolving pathophysiology can clarify a diagnosis. Second, where diagnosis of a progressive neuromuscular condition is uncertain, electrophysiological data from a second time point can confirm or refute suspicion. Third, to establish prognosis after a static nerve injury, a repeat study can assess the presence and extent of reinnervation. Finally, faced with a limited initial study (as when complicated by patient or environmental factors), a repeat EDX study can supplement missing or limited data to provide needed clarity. Repeat EDX studies carry certain limitations, however, such as with prognostication in the setting of remote or chronic lesions, sensory predominant fascicular injury, or mild axonal injury. Nevertheless, serial electrodiagnosis remains a valuable and underused tool in the diagnostic and prognostic evaluation of neuromuscular conditions.
Collapse
Affiliation(s)
- Sandra L Hearn
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amro Maher Stino
- Division of Neuromuscular Medicine, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ileana M Howard
- Department of Rehabilitation Medicine, University of Washington, Washington, USA
| | - Gautam Malhotra
- Altair Health, Morristown, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lawrence Robinson
- Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Dalakas MC, Latov N, Kuitwaard K. Intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): mechanisms of action and clinical and genetic considerations. Expert Rev Neurother 2022; 22:953-962. [PMID: 36645654 DOI: 10.1080/14737175.2022.2169134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune peripheral nerve disorder that is characterized by subacute onset, progressive or relapsing weakness, and sensory deficits. Proven treatments include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. This review focuses on the mechanisms of action, pharmacodynamics, genetic variations, and disease characteristics that can affect the efficacy of IVIg. AREAS COVERED The proposed mechanisms of action of IVIg that can mediate its therapeutic effects are reviewed. These include anti-idiotypic interactions, inhibition of neonatal Fc receptors (FcRn), anti-complement activity, upregulation of inhibitory FcγRIIB receptors, and downregulation of macrophage activation or co-stimulatory and adhesion molecules. Clinical and genetic factors that can affect the therapeutic response include misdiagnosis, degree of axonal damage, pharmacokinetic variability, and genetic variations. EXPERT OPINION The mechanisms of action of IVIg in CIDP and their relative contribution to its efficacy are subject of ongoing investigation. Studies in other autoimmune neurological conditions, in addition, highlight the role of key immunopathological pathways and factors that are likely to be affected. Further investigation into the pathogenesis of CIDP and the mechanisms of action of IVIg may lead to the development of improved diagnostics, better utilization of IVIg, and more targeted and effective therapies.
Collapse
Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson Neuroimmunology Unit, Philadelphia, PA and National and Department of Pathophysiology, Kapodistrian University of Athens, Greece
| | - Norman Latov
- Neuroimmunology Unit, Weill Cornell Medical College, New York, NY, USA
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| |
Collapse
|
3
|
Fisse AL, Motte J, Grüter T, Kohle F, Kronlage C, Stahl JH, Winter N, Seeliger T, Gingele S, Stascheit F, Hotter B, Klehmet J, Kummer K, Enax-Krumova EK, Sturm D, Skripuletz T, Schmidt J, Yoon MS, Pitarokoili K, Lehmann HC, Grimm A. Versorgungssituation von CIDP-Patienten in neun deutschen Zentren des Neuritis Netzes. DER NERVENARZT 2022; 94:320-326. [PMID: 35997784 PMCID: PMC10104951 DOI: 10.1007/s00115-022-01377-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 11/26/2022]
Abstract
Zusammenfassung
Hintergrund
Die Diagnose und Behandlung von Patienten mit immunvermittelten Polyneuropathien ist aufgrund der Heterogenität der Erkrankungen herausfordernd.
Ziel der Arbeit
Ein aktueller epidemiologischer Überblick über die Versorgungssituation von Patienten mit immunvermittelten Polyneuropathien innerhalb des deutschen Neuritis-Netzwerks „Neuritis Netz“.
Material und Methoden
Es erfolgte eine Umfrage in neun deutschen neurologischen Zentren, die auf die Betreuung von Patienten mit Immunneuropathie spezialisiert sind. Wir erfassten Diagnose, Vorgehen in der Diagnostik und Nachsorge, typische Symptome bei Manifestation und im Krankheitsverlauf sowie Therapiedaten.
Ergebnisse
Die Erhebung umfasst Daten von 1529 jährlich behandelten Patienten mit Immunneuropathien, 1320 davon mit chronisch inflammatorisch demyelinisierender Polyneuropathie (CIDP). Die Diagnostik umfasste fast immer Lumbalpunktionen sowie Elektroneuro- und -myografien entsprechend den aktuellen Leitlinien. Der Einsatz von Ultraschall, Biopsie und MRT war unterschiedlich. Wichtigster klinischer Parameter zum Therapiemonitoring in allen Zentren war die motorische Funktion in den klinischen Nachuntersuchungen. Zur Erhaltungstherapie wurde bei rund 15 % der Patienten ein breites Spektrum unterschiedlicher Immunsuppressiva eingesetzt.
Diskussion
Die Studie liefert wichtige epidemiologische Daten zur aktuellen Versorgungsituation von Patienten mit Immunneuropathien in Deutschland. Die Weiterentwicklung spezifischer Empfehlungen zur Therapie und Nachverfolgung von CIDP-Patienten ist notwendig, um einen einheitlichen Standard der Patientenversorgung zu gewährleisten. Dieses wird durch die strukturierte Zusammenarbeit von Exzellenzzentren wie dem deutschen Neuritis Netz erheblich unterstützt.
Collapse
Affiliation(s)
- Anna Lena Fisse
- Klinik für Neurologie des St. Josef-Hospitals, Katholisches Klinikum Bochum, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland.
| | - Jeremias Motte
- Klinik für Neurologie des St. Josef-Hospitals, Katholisches Klinikum Bochum, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - Thomas Grüter
- Klinik für Neurologie des St. Josef-Hospitals, Katholisches Klinikum Bochum, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - Felix Kohle
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Köln, Köln, Deutschland
| | - Cornelius Kronlage
- Klinik für Neurologie mit Schwerpunkt Epileptologie, Hertie-Institut für klinische Hirnforschung, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
| | - Jan-Hendrik Stahl
- Klinik für Neurologie mit Schwerpunkt Epileptologie, Hertie-Institut für klinische Hirnforschung, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
| | - Natalie Winter
- Klinik für Neurologie mit Schwerpunkt Epileptologie, Hertie-Institut für klinische Hirnforschung, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
| | - Tabea Seeliger
- Klinik für Neurologie mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stefan Gingele
- Klinik für Neurologie mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Frauke Stascheit
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Benjamin Hotter
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Juliane Klehmet
- Klinik für Neurologie, Jüdisches Krankenhaus, Berlin, Deutschland
| | - Karsten Kummer
- Klinik für Neurologie, Neuromuskuläres Zentrum, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Elena K Enax-Krumova
- Neurologische Universitätsklinik und Poliklinik, BG Universitätsklinikum Bergmannsheil gGmbH Bochum, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Dietrich Sturm
- Klinik für Neurologie, Agaplesion Bethesda Krankenhaus Wuppertal, Wuppertal, Deutschland
| | - Thomas Skripuletz
- Klinik für Neurologie mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Jens Schmidt
- Klinik für Neurologie, Neuromuskuläres Zentrum, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Abteilung Neurologie und Schmerztherapie, Immanuel Klinik Rüdersdorf, Universitätsklinikum der Medizinischen Hochschule Brandenburg Theodor Fontane, Rüdersdorf bei Berlin, Deutschland
- Fakultät für Gesundheitswissenschaften Brandenburg, Medizinische Hochschule Brandenburg Theodor Fontane, Rüdersdorf bei Berlin, Deutschland
| | - Min-Suk Yoon
- Klinik für Neurologie, Evangelisches Krankenhaus Hattingen, Hattingen, Deutschland
| | - Kalliopi Pitarokoili
- Klinik für Neurologie des St. Josef-Hospitals, Katholisches Klinikum Bochum, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - Helmar C Lehmann
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Köln, Köln, Deutschland
| | - Alexander Grimm
- Klinik für Neurologie mit Schwerpunkt Epileptologie, Hertie-Institut für klinische Hirnforschung, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
| |
Collapse
|
4
|
Niu J, Zhang L, Fan J, Liu J, Ding Q, Guan Y, Wu S, Cui L, Liu M. Nerve ultrasound may help predicting response to immune treatment in chronic inflammatory demyelinating polyradiculoneuropathy. Neurol Sci 2022; 43:3929-3937. [DOI: 10.1007/s10072-022-05882-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022]
|
5
|
Okhovat AA, Advani S, Ziaadini B, Panahi A, Salehizadeh S, Nafissi S, Haghi Ashtiani B, Rajabally YA, Fatehi F. The value of MUNIX as an objective electrophysiological biomarker of disease progression in CIDP. Muscle Nerve 2022; 65:433-439. [PMID: 35040150 DOI: 10.1002/mus.27498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/31/2021] [Accepted: 01/09/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Objective outcome measures to monitor treatment response and guide treatment are lacking in chronic inflammatory demyelinating polyneuropathy (CIDP). We aimed to evaluate the motor unit number index (MUNIX) as an outcome measurement in patients with CIDP and investigate the correlation of MUNIX with functional and standard electrodiagnostic tests in a single follow-up study. METHODS We evaluated MUNIX of the abductor pollicis brevis (APB), abductor digiti minimi (ADM), and tibialis anterior (TA) muslces bilaterally. Muscle force was assessed by Medical Research Council sumscores (MRCSS). Functional measures used were the Overall Neuropathy Limitation Score (ONLS) and the Rasch-built Overall Disability Scale (R-ODS) at baseline and after six months of treatment. Standard electrophysiology was evaluated by the Nerve Conduction Study Score (NCSS). RESULTS Twenty patients were included at baseline, and 16 completed the follow-up study. Significant correlations were found between the MUNIX sumscore and both MRCSS and NCSS at baseline, between both the pinch strength and grip and upper limb MUNIX at baseline and follow-up, and between MUNIX of TA and both lower limb MRCSS with lower limb ONLS at baseline and follow-up. Significant correlations also were found between MUNIX sumscore change and MRCSS change, R-ODS change, and ONLS change. DISCUSSION MUNIX changes correlated with strength and electrophysiological improvements in CIDP patients. This suggests that MUNIX may represent a useful objective biomarker for patient follow-up.
Collapse
Affiliation(s)
- Ali Asghar Okhovat
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroor Advani
- Neurology Department, Shohada Tajrish Hospital, Shahid-Beheshti University of Medical Sciences, Tehran, Iran
| | - Bentolhoda Ziaadini
- Neurology Research center, Kerman University of Medical Sciences, Kerman, Iran
| | - Akram Panahi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeideh Salehizadeh
- Neurologist, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran
| | - Shahriar Nafissi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Haghi Ashtiani
- Neurology Department, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Farzad Fatehi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
7
|
Allen JA, Eftimov F, Querol L. Outcome measures and biomarkers in chronic inflammatory demyelinating polyradiculoneuropathy: from research to clinical practice. Expert Rev Neurother 2021; 21:805-816. [PMID: 34130574 DOI: 10.1080/14737175.2021.1944104] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated syndrome characterized clinically by weakness and/or numbness that evolves over 2 months or more. The heterogeneity of clinical features necessitates an individualized approach to disease monitoring that takes lessons learned from clinical trials and applies them to clinical practice.Areas covered: This review discusses the importance of clinimetrics and biomarkers in CIDP diagnosis and disease monitoring. Highlighted are the challenges of defining responses to immunotherapy, the usefulness, and limitations of utilizing evidence-based clinical outcome measures during routine clinical care, and the evolving understanding of how diagnostic and disease activity biomarkers may reshape our treatment and disease monitoring paradigms.Expert opinion: Although disability and impairment outcome measures are commonly used in CIDP to indicate disease status, the nonspecific nature of these metrics limits the ability to attribute a change in any given metric to a change in CIDP. This interpretive challenge may be magnified by inconsistencies in the direction of change as well as a strong placebo effect. There is a need to improve our understanding of minimally important changes in existing outcome measures as a means to personalize treatment and to better assess disease activity status with biomarker discovery.
Collapse
Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Luis Querol
- Neuromuscular Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| |
Collapse
|
8
|
Alcantara M, Hartung HP, Lawo JP, Durn BL, Mielke O, Bril V. Electrophysiological predictors of response to subcutaneous immunoglobulin therapy in chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol 2021; 132:2184-2190. [PMID: 34293528 DOI: 10.1016/j.clinph.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/19/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess axonal function prior to subcutaneous immunoglobulin (SCIG) therapy or placebo in relation to relapse in chronic inflammatory demyelinating polyneuropathy (CIDP) to determine whether axonal damage can predict therapy response. METHODS Relapse rates in patients from the Polyneuropathy and Treatment with Hizentra (PATH) study, where patients were treated with placebo or SCIG (IgPro20), were analyzed by baseline (post-intravenous immunoglobulin stabilization) axonal damage (≤1 mV peroneal compound muscle action potential) status. RESULTS In patients with non-axonal damage, relapses were significantly higher with placebo (73.0%) than IgPro20 (0.2 g/kg: 39.1%, 0.4 g/kg: 19.2%). In patients with axonal damage, IgPro20 had no effect on relapse (placebo: 25.0%, IgPro20: 0.2 g/kg: 30.0%, 0.4 g/kg: 19.4%). Patients with axonal damage relapsed significantly less on placebo versus non-axonal damage, but they also demonstrated higher baseline disability. CONCLUSION Axonal damage may correspond to relapse upon treatment withdrawal; patients with axonal damage relapse less, possibly reflecting poor response to immunoglobulin therapy, while non-axonal damage patients may experience more relapse, perhaps indicating better treatment response. SIGNIFICANCE In CIDP patients with axonal loss, immunoglobulin therapy may not be as effective. Assessing axonal damage could help guide therapy, with immunoglobulins ideally used before substantial axonal damage arises.
Collapse
Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Brain and Mind Centre, University of Sydney, Australia; Medical University of Vienna, Austria
| | | | | | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.
| |
Collapse
|
9
|
Early axonal loss predicts long-term disability in chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol 2021; 132:1000-1007. [DOI: 10.1016/j.clinph.2020.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022]
|
10
|
Allen JA, Merkies ISJ, Lewis RA. Monitoring Clinical Course and Treatment Response in Chronic Inflammatory Demyelinating Polyneuropathy During Routine Care: A Review of Clinical and Laboratory Assessment Measures. JAMA Neurol 2021; 77:1159-1166. [PMID: 32338716 DOI: 10.1001/jamaneurol.2020.0781] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Identifying clinical change in many neurologic diseases, including chronic inflammatory demyelinating polyneuropathy (CIDP), can be challenging. At the same time, how change is defined heavily influences a patient's diagnostic and treatment pathway. It can be especially problematic when equivocal subjective observations are interpreted as clinically meaningful and then used to make diagnostic and treatment decisions. Change in clinical trials is strictly defined by a preselected metric, but there is a perception that formal outcomes collection during routine clinical care is neither feasible nor necessary. Given the importance placed on how change is interpreted, there is a need to select assessments that can be applied to routine care that are representative of the neurologic disease state. Observations For an outcome measure to be useful during clinical trials, it must have good reliability, validity, be responsive to change, and have clinical meaning. To be useful during routine clinical care, the assessment must additionally be easy to collect without the need for extensive training or equipment and should provide an immediately available result that can be rapidly quantified and interpreted. Chronic inflammatory demyelinating polyneuropathy is clinically heterogeneous and so is best evaluated with a diverse group of assessment tools. Assessing strength impairment, disability, and quality of life is ideally suited for everyday practice when caring for patients with CIDP. While electrophysiologic studies, imaging, cerebrospinal fluid, and nodal/paranodal antibodies can provide diagnostic data, they are less practical and helpful longitudinal assessment tools. Conclusions and Relevance Sound clinimetric outcome measures in CIDP are widely available and have the potential to help clinicians objectify treatment response and disease progression. Such data are critically important when justifying the need for ongoing or periodic immunotherapy, documenting relapse or deterioration, or providing reassurance of disease improvement, stability, or remission.
Collapse
Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands.,Department of Neurology, St Elisabeth Hospital, Willemstad, Curaçao
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
11
|
Okhovat AA, Advani S, Moradi K, Ziaadini B, Panahi A, Nafissi S, Haghi Ashtiani B, Fatehi F. Application of CMAP scan for the evaluation of patients with chronic inflammatory demyelinating polyneuropathy: a prospective study. Neurophysiol Clin 2021; 51:175-181. [PMID: 33423829 DOI: 10.1016/j.neucli.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/26/2020] [Accepted: 12/26/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS We aimed to assess the compound muscle action potential (CMAP) scan in the follow-up of chronic inflammatory demyelinating polyneuropathy (CIDP) patients and investigate the correlation of CMAP scan parameters with functional and standard electrodiagnostic tests. METHODS We evaluated four parameters of abductor pollicis brevis (APB) CMAP scan (i.e., step numbers, step percentage, S10, S90), functional measures (e.g., Medical Research Council Sum Scores), and electrodiagnostic tests, including nerve conduction study (NCS) and motor NCS of the median nerve in the baseline and after six months of treatment. RESULTS Twenty patients completed baseline clinical and electrodiagnostic studies. However, sixteen patients completed the follow-up study. The median of step numbers at baseline was 3.5 (2-4.2), which decreased to 2.5 (0-3) (p = 0.005). After the treatment, step percentage reduced from 28.6 (23.9-38.7) to 13.4 (0-23.6) (p = 0.001). The scores obtained from the clinical scales showed significant recovery of most of the functions, while the alterations of NCSS and NCS of the median nerve were not significant. CONCLUSIONS We found a significant reduction in step number and step percentage after follow-up. This alteration was not reflected in standard electrodiagnostic values. The improvement of functional scales alongside the CMAP scan parameters suggests that the CMAP scan could be considered an appropriate outcome measurement in research and clinical fields.
Collapse
Affiliation(s)
- Ali Asghar Okhovat
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroor Advani
- Neurology Department, Shohada Tajrish Hospital, Shahid-Beheshti University of Medical Sciences, Tehran, Iran
| | - Kamyar Moradi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bentolhoda Ziaadini
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Panahi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahriar Nafissi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Haghi Ashtiani
- Neurology Department, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farzad Fatehi
- Neurology Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
12
|
Bril V, Hartung HP, Lawo JP, Durn BL, Mielke O. Electrophysiological testing in chronic inflammatory demyelinating polyneuropathy patients treated with subcutaneous immunoglobulin: The Polyneuropathy And Treatment with Hizentra (PATH) study. Clin Neurophysiol 2020; 132:226-231. [PMID: 33039291 DOI: 10.1016/j.clinph.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/12/2020] [Accepted: 09/07/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess electrophysiology parameters that can reflect patients' clinical status and show changes in nerve function with treatment, in a study of subcutaneous immunoglobulin in chronic inflammatory demyelinating polyneuropathy. METHODS Nerve conduction studies (latency, conduction velocity, conduction block and compound muscle action potential [CMAP] on upper limb median, ulnar, and lower limb peroneal motor nerves) were conducted in the placebo-controlled PATH (Polyneuropathy And Treatment with Hizentra) study of two doses of maintenance subcutaneous immunoglobulin (SCIG) IgPro20 in CIDP. RESULTS Averaged proximal latency substantially increased with placebo (+1.1 ms) indicating electrophysiologic deterioration but remained stable with IgPro20 (0.2 g/kg bodyweight [bw]: +0.1 ms; 0.4 g/kg bw: -0.1 ms). Distal latencies were also more prolonged with placebo versus IgPro20. Averaged motor nerve conduction velocity substantially decreased with placebo (-1.6 m/s) versus increasing in both IgPro20 groups (+0.2 m/s and +1.0 m/s, respectively). Conduction block and CMAP amplitudes did not change substantially. CONCLUSION These findings support the effectiveness of maintenance IgPro20, as nerve function changed in the direction of increasing nerve dysfunction with placebo but remained stable with ongoing IgPro20 therapy. SIGNIFICANCE Electrophysiology testing can support assessment of clinical status in CIDP to determine treatment efficacy.
Collapse
Affiliation(s)
- Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | | | | |
Collapse
|
13
|
Khomand P, Katzberg H, Ngo M, Bril V. Electrophysiological Responsiveness to Long-Term Therapy in Chronic Inflammatory Demyelinating Polyneuropathy: Case Report. Case Rep Neurol 2020; 12:40-44. [PMID: 32095131 PMCID: PMC7011741 DOI: 10.1159/000505234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 11/30/2019] [Indexed: 12/14/2022] Open
Abstract
Electrophysiological studies are essential for the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP), but the utility of nerve conduction studies in monitoring outcomes in individual CIDP patients is controversial. Electrophysiological improvements after short-term treatment have been described in large cohorts of CIDP patients, but the magnitude of the changes is small and might be obscured in individual patients due to the variation inherent in nerve conduction testing. We present the case of a CIDP patient treated successfully with immunosuppression and followed for 31 years with serial standardized clinical and electrophysiological evaluations. Improvement in electrophysiological parameters lagged clinical changes for up to 2 years, but all motor parameters improved (distal motor and F wave latencies, conduction velocities, and compound muscle action potential amplitudes) even with evidence of initial axonal damage. Worsening of electrophysiological parameters, specifically increasing F wave latencies, heralded clinical relapse by as much as a year. Electrophysiological parameters do improve with treatment in CIDP patients, although the changes can take up to 2 years, and also worsening electrophysiological parameters can herald clinical relapse and might help guide therapeutic decisions.
Collapse
Affiliation(s)
- Payam Khomand
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hans Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mylan Ngo
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
14
|
Lawley A, Seri S, Rajabally YA. Motor unit number index (MUNIX) in chronic inflammatory demyelinating polyneuropathy: A potential role in monitoring response to intravenous immunoglobulins. Clin Neurophysiol 2019; 130:1743-1749. [DOI: 10.1016/j.clinph.2019.06.231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/30/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023]
|
15
|
Khoo A, Frasca J, Schultz D. Measuring disease activity and predicting response to intravenous immunoglobulin in chronic inflammatory demyelinating polyneuropathy. Biomark Res 2019; 7:3. [PMID: 30805188 PMCID: PMC6373155 DOI: 10.1186/s40364-019-0154-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 12/13/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterised by significant clinical heterogeneity and as such reliable biomarkers are required to measure disease activity and assess treatment response. Recent advances in our understanding of disease pathogenesis and the discovery of novel serum-based, electrophysiologic and imaging biomarkers allow clinicians to make more informed decisions regarding individualised treatment regimes. As a chronic immune-mediated process typified by relapse following withdrawal of immunomodulatory therapy, a substantial proportion of patients with CIDP require long term treatment with intravenous immunoglobulin (IVIg), a scarce and expensive donor-derived resource. The required duration and intensity of immunoglobulin treatment vary widely between individuals, highlighting both the heterogeneous nature of the underlying disease process as well as the variable pharmacologic properties of IVIg. This review outlines the use of multimodal biomarkers in the longitudinal evaluation of nerve injury and how recent developments have impacted our ability to predict both response to immunoglobulin administration and its withdrawal.
Collapse
Affiliation(s)
- Anthony Khoo
- 1Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042 Australia.,2College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| | - Joseph Frasca
- 1Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042 Australia.,2College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| | - David Schultz
- 1Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042 Australia.,2College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| |
Collapse
|
16
|
Härtig F, Ross M, Dammeier NM, Fedtke N, Heiling B, Axer H, Décard BF, Auffenberg E, Koch M, Rattay TW, Krumbholz M, Bornemann A, Lerche H, Winter N, Grimm A. Nerve Ultrasound Predicts Treatment Response in Chronic Inflammatory Demyelinating Polyradiculoneuropathy-a Prospective Follow-Up. Neurotherapeutics 2018; 15:439-451. [PMID: 29435815 PMCID: PMC5935640 DOI: 10.1007/s13311-018-0609-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
As reliable biomarkers of disease activity are lacking, monitoring of therapeutic response in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) remains a challenge. We sought to determine whether nerve ultrasound and electrophysiology scoring could close this gap. In CIDP patients (fulfilling EFNS/PNS criteria), we performed high-resolution nerve ultrasound to determine ultrasound pattern sum scores (UPSS) and predominant echotexture nerve conduction study scores (NCSS) as well as Medical Research Council sum scores (MRCSS) and inflammatory neuropathy cause and treatment disability scores (INCAT) at baseline and after 12 months of standard treatment. We retrospectively correlated ultrasound morphology with nerve histology when available. 72/80 CIDP patients featured multifocal nerve enlargement, and 35/80 were therapy-naïve. At baseline, clinical scores correlated with NCSS (r2 = 0.397 and r2 = 0.443, p < 0.01), but not or hardly with UPSS (Medical Research Council sum scores MRCSS r2 = 0.013, p = 0.332; inflammatory neuropathy cause and treatment disability scores INCAT r2 = 0.053, p = 0.048). Longitudinal changes in clinical scores, however, correlated significantly with changes in both UPSS and NCSS (r2 = 0.272-0.414, p < 0.0001). Combining nerve/fascicle size with echointensity and histology at baseline, we noted 3 distinct classes: 1) hypoechoic enlargement, reflecting active inflammation and onion bulbs; 2) nerve enlargement with additional hyperechogenic fascicles/perifascicular tissue in > 50% of measured segments, possibly reflecting axonal degeneration; and 3) almost no enlargement, reflecting "burned-out" or "cured" disease without active inflammation. Clinical improvement after 12 months was best in patients with pattern 1 (up to 75% vs up to 43% in pattern 2/3, Fisher's exact test p < 0.05). Nerve ultrasound has additional value not only for diagnosis, but also for classification of disease state and may predict treatment response.
Collapse
Affiliation(s)
- Florian Härtig
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Marlene Ross
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
| | - Nele Maria Dammeier
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Nadin Fedtke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
| | - Bianka Heiling
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, 07747, Germany
| | - Bernhard F Décard
- Department of Neurology, Basel University Hospital, Basel, 4031, Switzerland
| | - Eva Auffenberg
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Marilin Koch
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Tim W Rattay
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Markus Krumbholz
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Antje Bornemann
- Institute of Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Holger Lerche
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Natalie Winter
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany
| | - Alexander Grimm
- Department of Neurology, Tübingen University Hospital, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tubingen, Germany.
- Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076, Tubingen, Germany.
| |
Collapse
|
17
|
Décard BF, Pham M, Grimm A. Ultrasound and MRI of nerves for monitoring disease activity and treatment effects in chronic dysimmune neuropathies – Current concepts and future directions. Clin Neurophysiol 2018; 129:155-167. [DOI: 10.1016/j.clinph.2017.10.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023]
|
18
|
Katzberg HD, Latov N, Walker FO. Measuring disease activity and clinical response during maintenance therapy in CIDP: from ICE trial outcome measures to future clinical biomarkers. Neurodegener Dis Manag 2017; 7:147-156. [DOI: 10.2217/nmt-2016-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Some patients with chronic inflammatory demyelinating polyradiculoneuropathy who respond to initial intravenous immunoglobulin require repeated courses over prolonged periods of time; however, evidence to guide dosage and interval of intravenous immunoglobulin during maintenance therapy is limited. Optimizing treatment requires assessment of underlying disease activity and clinical outcome. Electrophysiological measures of demyelination, and clinical measures using handgrip strength and walking velocity promise to be particularly informative. Major advances in resolution and image processing have expanded clinical applications for ultrasound to include the study of peripheral nerves. Ultrasonography shows promise in diagnosing chronic inflammatory demyelinating polyradiculoneuropathy and distinguishing it from other conditions, providing first ever insight into gross pathology of peripheral nerves. Ultrasonography may also have a role in monitoring disease activity and treatment response.
Collapse
Affiliation(s)
- Hans D Katzberg
- University of Toronto, Toronto General Hospital/UHN, Toronto, ON, Canada
| | | | - Francis O Walker
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
19
|
Bril V, Blanchette CM, Noone JM, Runken MC, Gelinas D, Russell JW. The dilemma of diabetes in chronic inflammatory demyelinating polyneuropathy. J Diabetes Complications 2016; 30:1401-7. [PMID: 27389526 PMCID: PMC5528142 DOI: 10.1016/j.jdiacomp.2016.05.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 05/03/2016] [Accepted: 05/06/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE We reviewed the literature on chronic inflammatory demyelinating polyneuropathy (CIDP) in diabetes mellitus (DM) and explored real-world data on the prevalence and treatment of CIDP within DM. METHODS A literature search of Scopus was performed for the terms chronic inflammatory demyelinating polyradiculoneuropathy, chronic inflammatory demyelinating polyneuropathy, CIDP, and prevalence, incidence, epidemiology, or diabetes; peripheral neuropathy and prevalence or diabetes. We also searched through the reference lists of the resulting publications for additional findings that may have been missed. Additional publications on guidelines for the diagnosis of CIDP and diabetic neuropathy were also included. A descriptive analysis of the 2009-2013 PharMetrics Plus™ Database was performed to estimate the prevalence and treatment of CIDP within the DM population. RESULTS There is an increasing body of literature suggesting that the prevalence of CIDP tends to be higher in diabetic patients, especially in those of older age. Our real-world data seem to support published findings from the literature. For the total cohort (N=101,321,694), the percent prevalence of CIDP (n=8,173) was 0.008%; DM (n=4,026,740) was 4%. The percent prevalence of CIDP without DM (n=5,986) was 0.006%; CIDP with DM (n=2,187) was 9-fold higher at 0.054%. For patients >50years old, there was a significantly higher percentage of CIDP with DM than CIDP without DM. Approximately 50% of CIDP patients were treated with IVIg, 23%-24% with steroids, 1%-2% with PE, and 20%-23% received no treatment. CONCLUSIONS In addition to the growing evidence of higher prevalence of CIDP in DM, our findings reinforce the need for heightened awareness of the association of CIDP and DM.
Collapse
Affiliation(s)
- Vera Bril
- Division of Neurology, University of Toronto, 200 Elizabeth St, 5EC-309, TGH, Toronto, ON, M5G 2C4, Canada
| | - Christopher M Blanchette
- Department of Public Health Sciences, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA
| | - Joshua M Noone
- Department of Public Health Sciences, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA
| | - M Chris Runken
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg 4101 Research Commons, Research Triangle Park, NC 27709, USA
| | - Deborah Gelinas
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg 4101 Research Commons, Research Triangle Park, NC 27709, USA
| | - James W Russell
- Department of Neurology, University of Maryland School of Medicine, and VA Maryland Health Care System, 110S Paca Street, 3S-129, Baltimore, MD, 21201, USA.
| |
Collapse
|