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Zhao Z, Pan C, Chen J, Wu R, Xu Z, Huang H. Symptom progression in neuromyelitis optica spectrum disorder from ataxia through syncope to neuropathic pain: A case report. Medicine (Baltimore) 2024; 103:e38966. [PMID: 39029081 PMCID: PMC11398810 DOI: 10.1097/md.0000000000038966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
RATIONALE Neuromyelitis optica spectrum disorder (NMOSD) involves autoimmune and inflammatory responses in the central nervous system, primarily affecting the optic nerves and spinal cord. Atypical presentations such as ataxia and syncope complicate the diagnosis, and lesions in the medulla are easily mistaken for cerebral infarction. This case report emphasizes the need to recognize such manifestations to avoid misdiagnosis and ensure timely treatment. PATIENT CONCERNS This case report presents an NMOSD female patient who experienced ataxia, syncope, and neuropathic pain during her illness. DIAGNOSIS NMOSD. INTERVENTIONS The patient managed her blood sugar with insulin, controlled neuropathic pain with pregabalin, and underwent 5 plasma exchanges. OUTCOMES Significant improvement was noted 1 week post-plasma exchange, with complete resolution of neuropathic pain and no symptom recurrence reported at 6-month follow-up. LESSONS Atypical manifestations of NMOSD, such as ataxia, syncope, and trigeminal neuralgia, increase diagnostic difficulty. Recognizing these symptoms is crucial to avoid misdiagnosis and ensure timely and appropriate treatment for patients.
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Affiliation(s)
- Ziyi Zhao
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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Afsharzadeh M, Mirmosayyeb O, Vaheb S, Shaygannejad A, Maracy M, Shaygannejad V. Dysphagia in neuromyelitis optica spectrum disorder and multiple sclerosis: A comparison of frequency, severity, and effects on quality of life. Mult Scler Relat Disord 2024; 87:105640. [PMID: 38692153 DOI: 10.1016/j.msard.2024.105640] [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: 11/20/2023] [Revised: 03/27/2024] [Accepted: 04/20/2024] [Indexed: 05/03/2024]
Abstract
OVERVIEW Dysphagia has been previously discussed as a potential life-threatening condition secondary to chronic neurological diseases such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). However, its impact on the quality of life (QoL) of patients with NMOSD has never been studied before. This study aims to determine the frequency of dysphagia and its impact on QoL in NMOSD patients in comparison with MS people and healthy individuals. METHODS Seventy-five MS and sixty-five NMOSD patients with an expanded disability status scale (EDSS) score ≥ 3.5 in addition to 106 healthy controls were enrolled in this cross-sectional study. All the participants completed the self-report dysphagia in MS (DYMUS) and 36-item short-form health survey (SF-36) questionnaires. In case of positive answers to at least one of the questions in DYMUS, they were asked to fill out the dysphagia handicap index (DHI) questionnaire. RESULTS The frequency of dysphagia in NMOSD, MS, and control groups was 61.54 %, 72.97 %, and 27 %, respectively. Patients with swallowing problems had reduced scores across different swallowing-related QoL domains compared to non-dysphagic patients (p < 0.05). NMOSD (1, IQR [0-3.5]) and MS patients (2, IQR [0-4]) had a significantly higher median total DYMUS score than control (0, IQR [0-1]) (p < 0.01). However, there was no discernible difference between the two patient groups. NMOSD had the highest mean total DHI score (21.22 ± 21), followed by MS (15.25 ± 18.94) and control (7.08 ± 5.12). A significant correlation was seen in the NMOSD group between the DHI total score and the SF-36 total score (r = 0.62, p < 0.05). The DHI and SF-36 subscales showed a strong association as well. The overall SF-36 scores in both the control and MS groups was not significantly correlated with DHI. The generalized linear model analysis showed that the NMOSD group's age (p-value = 0.005), EDSS (p-value < 0.001), and total DYMUS score (p-value = 0.018) significantly affected overall health status. CONCLUSION The presence of dysphagia significantly impacts the QoL in NMOSD patients, particularly in aspects related to swallowing. These findings underscore the critical need for diligent dysphagia screening and emphasize the importance of educating both caregivers and NMOSD patients about managing this challenging symptom.
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Affiliation(s)
- Mahshad Afsharzadeh
- Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Mirmosayyeb
- Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Vaheb
- Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Aysa Shaygannejad
- Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Maracy
- Department of Epidemiology and Biostatistics School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Vahid Shaygannejad
- Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Li Z, Yang M, Pan Y, Fang Q. Neuromyelitis optica spectrum disorder with acute brainstem manifestations as initial symptoms. Heliyon 2024; 10:e32539. [PMID: 38988536 PMCID: PMC11233896 DOI: 10.1016/j.heliyon.2024.e32539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 07/12/2024] Open
Abstract
Objective To explore the clinical features and prognosis of patients with neuromyelitis optica spectrum disorder (NMOSD) initially presenting with acute brainstem symptoms. Methods The clinical data of NMOSD patients admitted to two medical centers were collected. The clinical characteristics, laboratory data, neuroimaging features and prognoses of patients with NMOSD with acute brainstem manifestations as initial symptoms (NMOSD-BSMIS) were analyzed. The clinical features and prognosis of patients with NMOSD-BSMIS and patients with NMOSD with other manifestations as initial symptoms (NMOSD-OMIS) were compared. Results Fifty-two patients (18.37 %, 52/283) initially presented with acute brainstem symptoms. Intractable nausea, vomiting or hiccups, diplopia, vertigo, headache, and facial hypoesthesia were the initial symptoms in most of the patients. The percentage of patients who were positive for serum aquaporin 4 (AQP4)-IgG antibodies was 81.63 % (40/49). MRI revealed that the lesions were usually located in the postrema, dorsal medulla oblongata, pons and other areas around the fourth ventricle. The early-stage misdiagnosis rate was 46.15 %. Compared with those in the non-misdiagnosed group, the age of onset of patients in the NMOSD-BSMIS group was older, and the proportion of patients admitted to the neurology department as the first department was lower in the misdiagnosed group. The annual relapse rate of patients who underwent NMOSD-BSMIS was significantly greater than that of patients who underwent NMOSD-OMIS (P < 0.01). Conclusions NMOSD patients can initially present with different brainstem symptoms. The early misdiagnosis rate of NMOSD-BSMIS is high. Moreover, if patients are older or initially admitted to nonneurological departments, they are more likely to be misdiagnosed. Moreover, the annual recurrence rate of NMOSD-BSMIS is greater in the early stage.
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Affiliation(s)
- Zhen Li
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Minggang Yang
- Department of Neurology, Xuyi People's Hospital, Xuyi, 211700, China
| | - Yang Pan
- Department of Geriatric Neurology, Affiliated Brain Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
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Zhou J, Lu Y, Shen S, Fang L, Chen C, Wang X, Li C, Zou Y, Liu Z, Zhou H, Quan C, Qiu W, Zhong X. Predictors for acute respiratory failure in AQP4-IgG-positive neuromyelitis optica spectrum disorders patients with medullary lesions. J Clin Neurosci 2023; 114:131-136. [PMID: 37392560 DOI: 10.1016/j.jocn.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Jing Zhou
- Department of Neurology, Foshan First People's Hospital, Foshan, China
| | - Yaxin Lu
- Department of Clinical Data Center, The Third Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
| | - Shishi Shen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ling Fang
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Chen Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xia Wang
- Department of Neurology, Huizhou Sixth People's Hospital, Huizhou, China
| | - Cong Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yan Zou
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zifeng Liu
- Department of Clinical Data Center, The Third Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chao Quan
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Xiaonan Zhong
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Worldwide prevalence of neuromyelitis optica spectrum disorder (NMOSD) and neuromyelitis optica (NMO): a systematic review and meta-analysis. Neurol Sci 2023; 44:1905-1915. [PMID: 36745300 DOI: 10.1007/s10072-023-06617-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is a progressive demyelinating disease of the central nervous system that has overlapping symptoms with multiple sclerosis (MS) but differs from it in a variety of ways. Previous studies have reported conflicting results trying to estimate the number of individuals affected by them which is why we designed this systematic review and meta-analysis to estimate the worldwide prevalence and incidence of NMOSD/NMO based on current evidence. METHODS We searched PubMed, Scopus, EMBASE, Web of Science, and gray literature including references from the identified studies, review studies, and conference abstracts which were published up to February 1, 2022. We used all MeSH terms pertaining to "NMOSD," "NMO," and all the terms on "prevalence," "incidence," and "epidemiology" to identify the search components. Pooled effect sizes were measured using random-effect model by DerSimonian-Laird. RESULTS The prevalence and incidence rates of NMOSD/NMO ranged from 0.07 to 10 and 0.029 to 0.880 per 100,000 population, respectively. The overall pooled prevalence of NMO per 100,000 population was 1.54 (I2: 98.4%, 95% CI: 1.13-1.96, P< 0.001) based on the 2006 criteria, 1.51 (I2: 99.4%, 95% CI: 1.21-1.81, P < 0.001) based on the 2015 criteria and 2.16 (I2: 89.4%, 95% CI: 1.46-2.86, P < 0.001) based on the 2006/2015 criteria. The overall annual incidence of NMO per 100,000 population was 0.155 (I2: 95%, 95% CI: 0.115-0.195, P < 0.001) based on the 2006 criteria and 0.278 (I2: 100%, 95% CI: 0.135-0.420, P < 0.001) based on the 2015 criteria. The prevalence rates were highest in French West Indies and South Korea, and lowest in Cuba and Australia, based on the 2006 and 2015 criteria, respectively. Also, the highest annual incidence rates were obtained for Sweden and Slovak republic and the lowest for Cuba and Australia based on the 2006 and 2015 criteria, respectively. All estimated rates were higher among females compared to males. CONCLUSION Although rare, NMOSD/NMO impact affected individuals in devastating ways. Several large-scale prospective studies are required to reach a comprehension of the epidemiological aspects of these notorious demyelinating conditions.
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Krasnov VS, Prakhova LN, Totolyan NA. Current view on the diagnosis and treatment of neuromyelitis optica spectrum disorders exacerbations. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2022. [DOI: 10.14412/2074-2711-2022-5-69-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Irreversible neurological deficit and disability in neuromyelitis optica spectrum disorders (NOSD) are formed as a result of exacerbations, which are often life-threatening. Timely diagnosis and treatment of exacerbations is a key task in the management of this category of patients. A unified structured approach to the diagnosis and treatment of NOSD exacerbations has not been developed. The purpose of this article is to analyze the scientific literature data on this issue in order to optimize the diagnostics and treatment of NOSD exacerbations in everyday clinical practice.
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Affiliation(s)
- V. S. Krasnov
- Acad. I.P. Pavlov First Saint Petersburg State Medical University of Ministry of Health of Russia
| | - L. N. Prakhova
- N.P. Bekhtereva Human Brain Institute, Russian Academy of Sciences
| | - N. A. Totolyan
- Acad. I.P. Pavlov First Saint Petersburg State Medical University of Ministry of Health of Russia
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Abstract
PURPOSE OF REVIEW This article reviews the cardinal clinical features, distinct immunopathology, current diagnostic criteria, relapse-related risk factors, emerging biomarkers, and evolving treatment strategies pertaining to neuromyelitis optica spectrum disorders (NMOSD). RECENT FINDINGS The discovery of the pathogenic aquaporin-4 (AQP4)-IgG autoantibody and characterization of NMOSD as an autoimmune astrocytopathy have spearheaded the identification of key immunologic therapeutic targets in this disease, including but not limited to the complement system, the interleukin 6 (IL-6) receptor, and B cells. Accordingly, four recent randomized controlled trials have demonstrated the efficacy of three new NMOSD therapies, namely eculizumab, satralizumab, and inebilizumab. SUMMARY Currently, NMOSD poses both diagnostic and treatment challenges. It is debated whether individuals who are seropositive for myelin oligodendrocyte glycoprotein (MOG)-IgG belong within the neuromyelitis optica spectrum. This discussion is fueled by disparities in treatment responses between patients who are AQP4-IgG seropositive and seronegative, suggesting different immunopathologic mechanisms may govern these conditions. As our understanding regarding the immune pathophysiology of NMOSD expands, emerging biomarkers, including serum neurofilament light chain and glial fibrillary acidic protein (GFAP), may facilitate earlier relapse detection and inform long-term treatment decisions. Future research focal points should include strategies to optimize relapse management, restorative treatments that augment neurologic recovery, and practical solutions that promote equitable access to approved therapies for all patients with NMOSD.
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He Z, Zhao F, Shan Y, Dou Z, Wen H. Botulinum toxin injection combined with traditional swallowing rehabilitation improved cricopharyngeal dysfunction in neuromyelitis optica spectrum disorder: A case report. Front Neurol 2022; 13:939443. [PMID: 35968297 PMCID: PMC9366393 DOI: 10.3389/fneur.2022.939443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune diseases of the central nervous system, and often influence optic nerve and medulla oblongata. Previous studies found out that brain abnormalities were not rare in these patients. Medulla oblongata (MO) was commonly involved and usually located at dorsal part. Patients who diagnosed NMOSD with MO lesions were more likely to have dysphagia. Previous reports indicated that the symptoms and signs of NMOSD patients could be controlled after immunosuppressive therapy. This patient was a 49-year-old Asian woman presented with recurrent vomiting and diagnosed NMOSD with MO involvement. However, after immunotherapy in other hospital, she still suffered from dysphagia. She then came to our department and completed videofluoroscopic swallowing study (VFSS) and high-resolution pharyngeal manometry (HRPM). Her UES was not opening with aspiration and the UES residue pressure was higher than normal range, we figured that she had cricopharyngeal (CP) dysfunction. Then the SLP gave her traditional treatment, including catheter balloon dilation. But she failed improvement after treatment for 2 weeks. Then the clinicians decided to inject botulinum toxin (BTX) into her CP muscles, which needed specific location and appropriate dosage. Her UES residue pressure decreased after three times BTX injection. During this time, her SLP adjusted the treatment strategies based on her VFSS and HRM results. Combined BTX injection with traditional treatment, she can now eat food orally without restrictions. This case report we presented can provide treatment strategies for similar patients with dysphagia.
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Clinical and prognostic aspects of patients with the Neuromyelitis Optica Spectrum Disorder (NMOSD) from a cohort in Northeast Brazil. BMC Neurol 2022; 22:95. [PMID: 35296261 PMCID: PMC8925163 DOI: 10.1186/s12883-022-02621-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction Neuromyelitis optica spectrum disorders (NMOSD) is a rare inflammatory and demyelinating disease of the central nervous system (CNS) more frequent in women and Afro-descendants. No previous epidemiological or prognostic study has been conducted in the region of the state of Bahia, Brazilian Northeast. Objective To evaluate clinical and prognostic aspects in patients with NMOSD from a cohort in northeastern Brazil. Material and methods A single-center retrospective study was conducted with consecutive patients diagnosed with NMOSD. Clinical and epidemiological characteristics were described. The degree of disability was expressed by the Expanded Disability Status Scale (EDSS). Worsening disability were analyzed through negative binomial regression adjusted for disease duration. Results Ninety-one patients were included, 72 (79.1%) female and 67 (73.6%) afro descendants. Mean age at onset was 36 (± 14) years and 73.3% were anti-aquaporin-4 antibody positive. Isolated transverse myelitis (32.9%) and isolated optic neuritis (22.4%) were the most frequent initial clinical syndromes. After multivariate analysis, optic neuritis (RR = 0.45; 95% CI = 0.23 – 0.88; p = 0.020) and dyslipidemia (RR = 0.40; 95% CI = 0.20 – 0.83; p = 0.014) were associated with slower disease progression. Area postrema involvement (RR = 6.70; 95% CI = 3.31 – 13.54; p < 0.001) and age at onset (RR = 1.03; 95% CI = 1.01 – 1.05; p = 0.003) were associated with faster disease progression. Conclusions In the first clinical and prognostic study in northeastern Brazil, we identified area postrema involvement, age at onset, optic neuritis at fist syndrome and dyslipidemia as the main prognostic factors associated with disease progression. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02621-5. • Isolated transverse myelitis was the most frequent initial clinical syndrome. • Optic neuritis as first clinical syndrome was independently associated with better prognostic. • Age at onset were associated with faster disease progression. • Hashimoto's thyroiditis was the most frequent autoimmune disease in NMOSD.
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Huo L, Wang H, Yuan Y, Gao J, Liu X. Positive antithyroid antibody predicts severity of neuromyelitis optica spectrum disorder in children. Mult Scler Relat Disord 2021; 57:103425. [PMID: 34906814 DOI: 10.1016/j.msard.2021.103425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/19/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disease (NMOSD) is a rare autoimmune disease, which can coexist with autoimmune thyroid diseases (AITDS). There has been no report on the clinical characteristics of NMOSD in children with positive anti-thyroid antibodies (ATAbs). The aim of this study is to evaluate thyroid function and detect the difference between ATAbs seropositive and seronegative NMOSD children. METHODS 108 children with a confirmed diagnosis of NMOSD who were admitted to Shengjing Hospital of China Medical University from January 2015 to September 2020 were enrolled and their thyroid functions were evaluated. They were divided into two groups by ATAbs abnormalities. Their demographic characteristics, clinical symptoms, laboratory and MRI scan results of the brain and spinal cord were assessed. RESULTS ATAbs positive rate was higher in children with NMOSD when compared with healthy controls (P < 0.05). Most NMOSD children with positive ATAbs were female (P < 0.01). The expanded disability status scale (EDSS) score was significantly higher in the ATAbs positive group (P < 0.01). There were statistically significant differences for the incidence of bulbar area postrema symptoms, spinal cord symptoms, and fever of unknown origin of the first onset between the ATAbs positive and negative group (P < 0.05). The ANA and MOG antibody positive rate, longitudinally extensive transverse myelitis (LETM), and electroencephalogram (EEG) were significantly higher in ATAbs positive group (P < 0.05). CONCLUSION MOG antibody-positive is a unique marker of aggravation of neurological dysfunction in ATAbs-positive NMOSD children. Monitoring ATAbs may play an important role in predicting the prognosis of NMOSD.
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Affiliation(s)
- Liang Huo
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, China.
| | - Hua Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yujun Yuan
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, China; Department of Neurological Function, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Jian Gao
- Department of Radiology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Xueyan Liu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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Abstract
Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.
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Chen H, Lian Z, Liu J, Shi Z, Du Q, Feng H, Zhang Q, Yang M, Wu X, Zhou H. Brain changes correlate with neuropathic pain in patients with neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 2021; 53:103048. [PMID: 34090129 DOI: 10.1016/j.msard.2021.103048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/23/2021] [Accepted: 05/17/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neuropathic pain (NP) is a highly disturbing sensory experience in patients with neuromyelitis optica spectrum disorders (NMOSD). However, the brain changes in NMOSD patients with NP have rarely been studied. OBJECTIVE The aim of the cross-sectional and follow-up longitudinal study was to investigate the brain changes in NMOSD patients with NP. METHODS In the cross-sectional study, comparisons were performed between groups with NP (W-NP) and without NP (Wo-NP), and age, sex and years of education were adjusted. We compared the voxel-wise whole-brain gray matter (GM) volume, cortical thickness (CT), cortical surface area (CSA) and local gyrification index (LGI). Probabilistic tractography started from regions with significant between-group differences in GM volume, CT, CSA and LGI. We also compared fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD) of the white matter (WM) skeleton using Tract-Based Spatial Statistics (TBSS). In the longitudinal study, the patients were followed for 2.0±0.0 years and underwent the same imaging scanning as the cross-sectional study. Changes of the CT, CSA, LGI and WM were obtained. RESULTS Patients in the W-NP group were older than those in the Wo-NP group and showed significantly reduced LGI of the left temporal lobe and adjacent regions(regions of interest, ROIs), which participated in neuropathic pain processing, possibly by emotion and attention control. Probabilistic tractography started from ROIs, and the generated WM tracts showed decreased MD and RD in the W-NP group compared to the Wo-NP group. Using TBSS, both MD and RD decreased in extensive WM skeleton in the right hemisphere of the patients in the W-NP group. Additionally, in the follow-up longitudinal study, compared with patients in the Wo-NP group, patients in the W-NP group showed lower mean reduction rates of LGI of ROIs, and less increase of FA and more increases of MD, AD and RD in the extensive WM skeleton. CONCLUSIONS These findings support the hypothesis that brain changes might correlate with NP in NMOSD patients and predict the changes related to NP over time.
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Affiliation(s)
- Hongxi Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhiyun Lian
- Department of Neurology, Chongqing City Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Ju Liu
- Department of Neurology, the first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ziyan Shi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qin Du
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huiru Feng
- Department of Internal Medicine, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, Sichuan, China
| | - Qin Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mu Yang
- Sichuan Cancer Hospital and research Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xi Wu
- Department of Computer Science, Chengdu University of Information Technology.
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Pawlitzki M, Ahring S, Rolfes L, Dziewas R, Warnecke T, Suntrup-Krueger S, Wiendl H, Klotz L, Meuth SG, Labeit B. Dysphagia in neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody disease as a surrogate of brain involvement? Eur J Neurol 2021; 28:1765-1770. [PMID: 33338309 DOI: 10.1111/ene.14691] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are demyelinating disorders that typically affect the optic nerves and the spinal cord. However, recent studies have demonstrated various forms of brain involvement indicating encephalitic syndromes, which consequently are included in the diagnostic criteria for both. Swallowing is processed in a distributed brain network and is therefore disturbed in many neurological diseases. The aim of this study was to investigate the occurrence of oropharyngeal dysphagia in NMOSD and MOGAD using flexible endoscopic evaluation of swallowing (FEES) as a surrogate parameter of brain involvement. METHODS Thirteen patients with NMOSD and MOGAD (mean age 54.2 ± 18.6 years, six men) who received FEES during clinical routine were retrospectively reviewed. Their extent of oropharyngeal dysphagia was rated using an ordinal dysphagia severity scale. FEES results were compared to a control group of healthy individuals. Dysphagia severity was correlated with the presence of clinical and radiological signs of brain involvement, the Expanded Disability Status Scale (EDSS) and the occurrence of pneumonia. RESULTS Oropharyngeal dysphagia was present in 8/13 patients, including six patients without other clinical indication of brain involvement. Clinical or subclinical swallowing impairment was significantly more severe in patients with NMOSD and MOGAD compared to the healthy individuals (p = 0.009) and correlated with clinical signs of brain involvement (p = 0.038), higher EDSS (p = 0.006) and pneumonia (p = 0.038). CONCLUSION Oropharyngeal dysphagia can occur in NMOSD and MOGAD and might be associated with pneumonia and disability. FEES may help to detect subclinical brain involvement.
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Affiliation(s)
- Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Sigrid Ahring
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Rainer Dziewas
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Tobias Warnecke
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Sonja Suntrup-Krueger
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany.,Institute for Biomagnetism and Biosignal Analysis, University of Muenster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Bendix Labeit
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany.,Institute for Biomagnetism and Biosignal Analysis, University of Muenster, Muenster, Germany
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14
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Paroxysmal symptoms in neuromyelitis optica spectrum disorder: Results from an online patient survey. Mult Scler Relat Disord 2020; 46:102578. [DOI: 10.1016/j.msard.2020.102578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 11/16/2022]
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15
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Ma X, Kermode AG, Hu X, Qiu W. Risk of relapse in patients with neuromyelitis optica spectrum disorder: Recognition and preventive strategy. Mult Scler Relat Disord 2020; 46:102522. [PMID: 33007726 DOI: 10.1016/j.msard.2020.102522] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/09/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune inflammatory disorder of the central nervous system (CNS) that is mainly associated with serum autoantibodies against aquaporin-4 (AQP4) in astrocytes. The relapsing clinical course of NMOSD, which can be blinding and disabling due to severe visual impairment, spinal cord lesions and a group of brain syndromes, suggests the importance of accurately evaluating the likelihood and severity of relapse at an early stage of the disease. To date, many risk factors have been revealed in association with relapse, and only some of them are supported by substantial evidence. Furthermore, while the clinical use of conventional immunosuppressants is mostly empirical, an increasing number of emerging therapies for monoclonal antibodies have been confirmed by several randomized placebo-controlled trials to be effective and safe for relapse prevention. In this review, we summarize the reported risk factors that may influence the frequency, symptoms, severity and prognosis of relapse in NMOSD, as well as the efficacy and safety of emerging therapies for relapse prevention. All of these results enable us to better recognize patients who are at higher risk of relapse and suggest more effective monoclonal antibody therapies for use in these patients.
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Affiliation(s)
- Xiaoyu Ma
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, China
| | - Allan G Kermode
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, China; Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Perth, WA, Australia; Institute of Immunology and Infectious Diseases, Murdoch University, Perth, WA, Australia
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, China.
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16
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Ma X, Kermode AG, Hu X, Qiu W. NMOSD acute attack: Understanding, treatment and innovative treatment prospect. J Neuroimmunol 2020; 348:577387. [PMID: 32987231 DOI: 10.1016/j.jneuroim.2020.577387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/25/2020] [Accepted: 09/05/2020] [Indexed: 01/09/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a group of severe inflammatory demyelinating disorders of the central nervous system that involves the optic nerve and spinal cord. Currently the therapeutic options for an acute attack in NMOSD are limited and rarely characterized in clinical studies. This review discussed the overall characteristics of acute attack of NMOSD, related risk factor, prognosis and management. Considering the huge unmet needs and the emergence of new therapeutic targets, we also reviewed innovative treatments that might alleviate attack damage, along with the challenges to evaluate new drug for acute attack in NMOSD.
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Affiliation(s)
- Xiaoyu Ma
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Allan G Kermode
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Perth, WA, Australia; Institute of Immunology and Infectious Diseases, Murdoch University, Perth, WA, Australia
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Asseyer S, Cooper G, Paul F. Pain in NMOSD and MOGAD: A Systematic Literature Review of Pathophysiology, Symptoms, and Current Treatment Strategies. Front Neurol 2020; 11:778. [PMID: 33473247 PMCID: PMC7812141 DOI: 10.3389/fneur.2020.00778] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022] Open
Abstract
Neuromyelitis optica spectrum disorders (NMOSDs) and myelin oligodendrocyte glycoprotein-antibody-associated disease (MOGAD) are autoimmune inflammatory disorders of the central nervous system (CNS). Pain is highly prevalent and debilitating in NMOSD and MOGAD with a severe impact on quality of life, and there is a critical need for further studies to successfully treat and manage pain in these rare disorders. In NMOSD, pain has a prevalence of over 80%, and pain syndromes include neuropathic, nociceptive, and mixed pain, which can emerge in acute relapse or become chronic during the disease course. The impact of pain in MOGAD has only recently received increased attention, with an estimated prevalence of over 70%. These patients typically experience not only severe headache, retrobulbar pain, and/or pain on eye movement in optic neuritis but also neuropathic and nociceptive pain. Given the high relevance of pain in MOGAD and NMOSD, this article provides a systematic review of the current literature pertaining to pain in both disorders, focusing on the etiology of their respective pain syndromes and their pathophysiological background. Acknowledging the challenge and complexity of diagnosing pain, we also provide a mechanism-based classification of NMOSD- and MOGAD-related pain syndromes and summarize current treatment strategies.
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Affiliation(s)
- Susanna Asseyer
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
| | - Graham Cooper
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
- Einstein Center for Neurosciences, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
- Einstein Center for Neurosciences, Berlin, Germany
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt—Universität zu Berlin, Berlin, Germany
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Li XL, Han J, Zhao HT, Long YM, Zhang BW, Wang HY. Autoimmune glial fibrillary acidic protein astrocytopathy with lesions distributed predominantly in the entire spinal cord. Ther Adv Neurol Disord 2020; 13:1756286420909973. [PMID: 32547640 PMCID: PMC7270931 DOI: 10.1177/1756286420909973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/27/2020] [Indexed: 11/17/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy has been considered a novel central nervous system autoimmune disease characterized by relapse and responsiveness to corticosteroid with a specific GFAP-Immunoglobulin G (IgG) being noted in cerebrospinal fluid. We report the case of a 21-year-old girl presenting with dysuria and weariness, who subsequently developed blurry vision, slight dysphagia, slurred speech, and sensory abnormality. GFAP-IgG was detected in her cerebrospinal fluid. Magnetic resonance imaging using both T2-weighted and contrast-enhanced T1-weighted images revealed a rare finding of lesions distributed mainly in the entire spinal cord rather than typical brain lesions. After treating with corticosteroids, her clinical symptoms were alleviated, and the spinal cord lesion enhancement was reduced. Our observations extend the clinical spectrum of autoimmune GFAP astrocytopathy. We suggest that rare distributed lesions in the entire spinal cord in patients with autoimmune GFAP astrocytopathy cannot be ignored by neurologists. The identification of potential atypical lesions broadens the understanding of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Xue-Lin Li
- Department of Intensive Care Unit, Jining No. 1 People's Hospital, Jining, China
| | - Jinming Han
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hao-Tian Zhao
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| | - You-Ming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bing-Wei Zhang
- Department of Neurology and Psychiatry, The First Affiliate Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian, Liaoning Province 116011, China
| | - Hai-Yang Wang
- Department of Neurology, Jining No. 1 People's Hospital, No. 6, Jiankang Road, Jining, Shandong Province, 272011, China
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19
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Intractable Hiccups: A Pearl in Demyelinating Disease. Can J Neurol Sci 2019; 46:623-624. [DOI: 10.1017/cjn.2019.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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20
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Mealy MA, Mossburg SE, Kim SH, Messina S, Borisow N, Lopez-Gonzalez R, Ospina JP, Scheel M, Yeshokumar AK, Awad A, Leite MI, Arango JJ, Paul F, Palace J, Kim HJ, Levy M. Long-term disability in neuromyelitis optica spectrum disorder with a history of myelitis is associated with age at onset, delay in diagnosis/preventive treatment, MRI lesion length and presence of symptomatic brain lesions. Mult Scler Relat Disord 2018; 28:64-68. [PMID: 30554040 DOI: 10.1016/j.msard.2018.12.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/05/2018] [Accepted: 12/09/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disease of the central nervous system (CNS) that preferentially targets the spinal cord and optic nerves. Increasing disability is accrued with each inflammatory attack. Disability has been shown to be an independent predictor of poor quality of life in those with NMOSD. Factors associated with increasing disability need further systematic investigation. METHODS We performed a multi-center retrospective chart analysis of aquaporin-4 (AQP4) seropositive NMOSD patients with a history of myelitis seen at five large referral centers for patients with NMOSD worldwide for whom thorough records including relapse history and corresponding imaging were available. Potential contributors to long-term disability were extracted including demographics, radiographic findings, and clinical characteristics. Multivariable regression modeling was conducted to determine correlates of disability in patients with NMOSD, as measured by the Expanded Disability Status Scale (EDSS). RESULTS One hundred eighty-two AQP4 seropositive patients (88% female) were included in this analysis. Multiple regression modeling revealed that older age at disease onset, delay in diagnosis/preventive treatment, length of longest acute myelitis lesion and presence of symptomatic brain/brainstem lesions were associated with increased disability when holding other variables constant. CONCLUSION While age at onset is a factor that cannot be controlled in NMOSD, we can reduce the delay in diagnosis/preventive treatment and reduce future relapses in the brain/brainstem and spinal cord. Delay in diagnosis/preventive treatment and imaging variables that contributed to increased disability support the need for improved measures for early, accurate diagnosis and management of NMOSD, and aggressive treatment of acute relapses.
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Affiliation(s)
- Maureen A Mealy
- Johns Hopkins University, School of Medicine, Department of Neurology, Baltimore, MD, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA.
| | | | - Su-Hyun Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Silvia Messina
- Nuffield Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Nadja Borisow
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center and Department of Neurology, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | | | - Juan Pablo Ospina
- Johns Hopkins University, School of Medicine, Department of Neurology, Baltimore, MD, USA
| | - Michael Scheel
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center and Department of Neurology, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Anusha K Yeshokumar
- Johns Hopkins University, School of Medicine, Department of Neurology, Baltimore, MD, USA; Icahn School of Medicine at Mount Sinai, Department of Neurology, New York, NY
| | - Amine Awad
- Nuffield Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - JorgeA Jimenez Arango
- University of Antioquia, Department of Neurology, Neuroclinica, Medellín, CO, Colombia
| | - Friedemann Paul
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center and Department of Neurology, Berlin, Germany; Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Michael Levy
- Johns Hopkins University, School of Medicine, Department of Neurology, Baltimore, MD, USA
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Camara-Lemarroy CR, Burton JM. Area postrema syndrome: A short history of a pearl in demyelinating diseases. Mult Scler 2018; 25:325-329. [DOI: 10.1177/1352458518813105] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In this topical review, we discuss the history of the area postrema syndrome, with special attention given to early studies aimed at identifying the area postrema and its function, possible early cases of the syndrome and its current relevance in neuroimmunology and demyelinating diseases. In 1896, Retzius named a structure in the posterior medulla oblongata as the area postrema. The work of Borison in the middle of the 20th century led to the elucidation of its function as a “vomiting center.” The historical medical literature is filled with excellent examples that could be described as “area postrema syndrome.” While severe and bilateral optic neuritis and transverse myelitis still constitute the classic components of neuromyelitis optica spectrum disorder (NMOSD), intractable vomiting and hiccups due to area postrema involvement is now recognized as essentially pathognomonic, indeed a shiny pearl in neuroimmunology and demyelinating diseases.
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Affiliation(s)
- Carlos R Camara-Lemarroy
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada/ The Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada/ Department of Clinical Neurosciences, Cumming School of Medicine, MS Clinic and Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Jodie M Burton
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Zabad RK, Stewart R, Healey KM. Pattern Recognition of the Multiple Sclerosis Syndrome. Brain Sci 2017; 7:brainsci7100138. [PMID: 29064441 PMCID: PMC5664065 DOI: 10.3390/brainsci7100138] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 09/29/2017] [Accepted: 10/17/2017] [Indexed: 12/13/2022] Open
Abstract
During recent decades, the autoimmune disease neuromyelitis optica spectrum disorder (NMOSD), once broadly classified under the umbrella of multiple sclerosis (MS), has been extended to include autoimmune inflammatory conditions of the central nervous system (CNS), which are now diagnosable with serum serological tests. These antibody-mediated inflammatory diseases of the CNS share a clinical presentation to MS. A number of practical learning points emerge in this review, which is geared toward the pattern recognition of optic neuritis, transverse myelitis, brainstem/cerebellar and hemispheric tumefactive demyelinating lesion (TDL)-associated MS, aquaporin-4-antibody and myelin oligodendrocyte glycoprotein (MOG)-antibody NMOSD, overlap syndrome, and some yet-to-be-defined/classified demyelinating disease, all unspecifically labeled under MS syndrome. The goal of this review is to increase clinicians’ awareness of the clinical nuances of the autoimmune conditions for MS and NMSOD, and to highlight highly suggestive patterns of clinical, paraclinical or imaging presentations in order to improve differentiation. With overlay in clinical manifestations between MS and NMOSD, magnetic resonance imaging (MRI) of the brain, orbits and spinal cord, serology, and most importantly, high index of suspicion based on pattern recognition, will help lead to the final diagnosis.
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Affiliation(s)
- Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center College of Medicine, Omaha, NE 68198-8440, USA.
| | - Renee Stewart
- University of Nebraska Medical Center College of Nursing, Omaha, NE 68198-5330, USA.
| | - Kathleen M Healey
- Department of Neurological Sciences, University of Nebraska Medical Center College of Medicine, Omaha, NE 68198-8440, USA.
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Lee CY, Mak HKF, Chiu PW, Chang HC, Barkhof F, Chan KH. Differential brainstem atrophy patterns in multiple sclerosis and neuromyelitis optica spectrum disorders. J Magn Reson Imaging 2017; 47:1601-1609. [PMID: 28990252 DOI: 10.1002/jmri.25866] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are central nervous system (CNS) inflammatory demyelinating disorders. It is clinically important to distinguish MS from NMOSD, as treatment and prognosis differ. Brainstem involvement is common in both disorders. PURPOSE To investigate whether the patterns of brainstem atrophy on volumetric analysis in MS and NMOSD were different and correlated with clinical disability. STUDY TYPE Case-control cross-sectional study. SUBJECTS In all, 17 MS, 13 NMOSD, and 18 healthy control (HC) subjects were studied. FIELD STRENGTH/SEQUENCE T1 -weighted and T2 w spin-echo images were acquired with a 3T scanner. ASSESSMENT Semiautomated segmentation and volumetric measurement of brainstem regions were performed. Anatomical information was obtained from whole brain T1 w images using a 3D magnetization-prepared rapid gradient-echo (MPRAGE) imaging sequence (TR/TE/T: 7.0/3.2/800 msec, voxel size: 1 × 1 × 1 mm3 , scan time: 10 min 41 sec). STATISTICAL TESTS Independent samples t-test, Mann-Whitney U-test, partial correlation, and multiple regression analysis. RESULTS Baseline characteristics were similar across the three groups, without significant difference in disease duration (P = 0.354) and EDSS score (P = 0.159) between MS and NMOSD subjects. Compared to HC, MS subjects had significantly smaller normalized whole brainstem (-5.2%, P = 0.027), midbrain (-8.3%, P = 0.0001), and pons volumes (-5.9%, P = 0.048), while only the normalized medulla volume was significantly smaller in NMOSD subjects compared to HC (-8.5% vs. HC, P = 0.024). Normalized midbrain volume was significantly smaller in MS compared to NMOSD subjects (-5.0%, P = 0.014), whereas normalized medulla volume was significantly smaller in NMOSD compared to MS subjects (-8.1%, P = 0.032). Partial correlations and multiple regression analysis revealed that smaller normalized whole brainstem, pons, and medulla oblongata volumes were associated with greater disability on the Expanded Disability Status Scale (EDSS), Functional System Score (FSS)-brainstem and FSS-cerebellar in NMOSD subjects. DATA CONCLUSION Differential patterns of brainstem atrophy were observed, with the midbrain being most severely affected followed by pons in MS, whereas only the medulla oblongata was affected in NMOSD. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1601-1609.
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Affiliation(s)
- Chi-Yan Lee
- Department of Medicine, University of Hong Kong, Hong Kong
| | - Henry Ka-Fung Mak
- Department of Diagnostic Radiology, University of Hong Kong, Hong Kong
| | - Pui-Wai Chiu
- Department of Diagnostic Radiology, University of Hong Kong, Hong Kong
| | - Hing-Chiu Chang
- Department of Diagnostic Radiology, University of Hong Kong, Hong Kong
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, VU University Medical Centre, Amsterdam, the Netherlands.,Institutes of Neurology and Healthcare Engineering, University College London, London, UK
| | - Koon-Ho Chan
- Department of Medicine, University of Hong Kong, Hong Kong
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López-Chiriboga AS, Huang JF, Flanagan EP, Cheshire WP. Paroxysmal sneezing in NMOSD: Further evidence of the localization of the human sneeze center. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 4:e303. [PMID: 27844040 PMCID: PMC5087252 DOI: 10.1212/nxi.0000000000000303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/21/2016] [Indexed: 12/18/2022]
Affiliation(s)
- A Sebastian López-Chiriboga
- Department of Neurology (S.L.-C., J.F.H., W.P.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (E.P.F.), Mayo Clinic, Rochester, MN
| | - Josephine F Huang
- Department of Neurology (S.L.-C., J.F.H., W.P.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (E.P.F.), Mayo Clinic, Rochester, MN
| | - Eoin P Flanagan
- Department of Neurology (S.L.-C., J.F.H., W.P.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (E.P.F.), Mayo Clinic, Rochester, MN
| | - William P Cheshire
- Department of Neurology (S.L.-C., J.F.H., W.P.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (E.P.F.), Mayo Clinic, Rochester, MN
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Cheng C, Jiang Y, Lu X, Gu F, Kang Z, Dai Y, Lu Z, Hu X. The role of anti-aquaporin 4 antibody in the conversion of acute brainstem syndrome to neuromyelitis optica. BMC Neurol 2016; 16:203. [PMID: 27769253 PMCID: PMC5073440 DOI: 10.1186/s12883-016-0721-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 10/15/2016] [Indexed: 12/20/2022] Open
Abstract
Background Acute brainstem syndrome (ABS) may herald multiple sclerosis (MS), neuromyelitis optica (NMO), or occur as an isolated syndrome. The aquaporin 4 (AQP4)-specific serum autoantibody, NMO-IgG, is a biomarker for NMO. However, the role of anti-AQP4 antibody in the conversion of ABS to NMO is unclear. Methods Thirty-one patients with first-event ABS were divided into two groups according to the presence of anti-AQP4 antibodies, their clinical features and outcomes were retrospectively analyzed. Results Fourteen of 31 patients (45.16 %) were seropositive for NMO-IgG. The 71.43 % of anti-AQP4 (+) ABS patients converted to NMO, while only 11.76 % of anti-AQP4 (-) ABS patients progressed to NMO. Anti-AQP4 (+) ABS patients demonstrated a higher IgG index (0.68 ± 0.43 vs 0.42 ± 0.13, p < 0.01) and Kurtzke Expanded Disability Status Scale (4.64 ± 0.93 vs 2.56 ± 0.81, p < 0.01) than anti-AQP4 (-) ABS patients. Area postrema clinical brainstem symptoms occurred more frequently in anti-AQP4 (+) ABS patients than those in anti-AQP4 (-) ABS patients (71.43 % vs 17.65 %, p = 0.004). In examination of magnetic resonance imaging (MRI), the 78.57 % of anti-AQP4 (+) ABS patients had medulla-predominant involvements in the sagittal view and dorsal-predominant involvements in the axial view. Conclusions ABS represents an inaugural or limited form of NMO in a high proportion of anti-AQP4 (+) patients.
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Affiliation(s)
- Chen Cheng
- Department of Neurology, The Affiliated Hospital, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, Zhejiang, 310015, People's Republic of China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China.
| | - Xiaodong Lu
- Department of Neurology, The Affiliated Hospital, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, Zhejiang, 310015, People's Republic of China
| | - Fu Gu
- Department of Chemical and Environmental Engineering, University of Nottingham, 199 Taikang East Road, Ningbo, Zhejiang, 315100, People's Republic of China
| | - Zhuang Kang
- Department of Radiology, the Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yongqiang Dai
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Zhengqi Lu
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China.
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Wang Y, Wang Y, Tan S, Lu Z. Spinal cord atrophy in neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 2016; 8:9-10. [DOI: 10.1016/j.msard.2016.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/08/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
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Neuromyelitis optica shorter lesion can cause important pyramidal deficits. J Neurol Sci 2015; 355:189-92. [PMID: 26076879 DOI: 10.1016/j.jns.2015.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Evaluate the correlation between spinal cord lesion length and pyramidal function system score in a cohort of patients with NMO. METHODOLOGY Retrospective retrieval of all exams performed in our center from January 2004 to December 2012 for patients with NMO. The exams were evaluated for lesion length, contrast enhancement and T1 hypointensity; these variables were correlated with the functional system score from the EDSS, performed no more than three months from the scan. RESULTS 41 patients were included. Although patients with lesion extension ≥2 vertebral segments did not present worse pyramidal scores in a direct comparison, the influence of lesion length was not so strong when patients were separated in 3 groups (≥2, ≥3 or ≥4 vertebral segments) and evaluated with a receiving operating characteristics (ROC) curves. Gadolinium enhancement also contributed to more severe pyramidal system scores, but T1 hypointensity did not. CONCLUSION Although patients with spinal cord lesion extending ≥3 vertebral segments had more pyramidal disability, its difference was not so strong when compared to patients with ≥2 or ≥4 vertebral segments. This suggests that lesion extension might not be the most important factor in favoring a worse prognosis in spinal cord lesions in NMO.
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Li Y, Jiang B, Chen B, Zhao M, Zhou C, Wang S, Li J, Wang R. Neuromyelitis optica spectrum disorders with multiple brainstem manifestations: a case report. Neurol Sci 2015; 37:309-13. [PMID: 25837714 DOI: 10.1007/s10072-015-2196-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/24/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Multiple brainstem manifestations have been rarely reported during the same attack in neuromyelitis optica spectrum disorders (NMOSD). CASE PRESENTATION We describe a 39-year-old Asian woman presenting multiple brainstem manifestations including intractable nausea and vomiting, vertigo, diplopia, facial palsy, hypogeusia, ophthalmoplegia, hemiplegia, dysphagia and tonic spasm during the same attack. Hypogeusia was transient and recovered without any immunotherapy. The brain MRIs showed progressive multiple lesions in the brainstem. NMO-IgG (aquaporin4-antibody, AQP4-Ab) were positive in both serum and cerebral spinal fluid. The symptoms and signs were controlled after immunosuppressive therapy. No relapse happened during the 15-month follow-up. CONCLUSION This report emphasizes multiple brainstem manifestations during the same attack in NMOSD and the most characteristic symptom was reversible hypogeusia.
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Affiliation(s)
- Yao Li
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Bin Jiang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Bin Chen
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Mingxia Zhao
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Chunlai Zhou
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Shuhui Wang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Jimei Li
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China.
| | - Ruijin Wang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
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Wang Y, Wu A, Chen X, Zhang L, Lin Y, Sun S, Cai W, Zhang B, Kang Z, Qiu W, Hu X, Lu Z. Comparison of clinical characteristics between neuromyelitis optica spectrum disorders with and without spinal cord atrophy. BMC Neurol 2014; 14:246. [PMID: 25526927 PMCID: PMC4302083 DOI: 10.1186/s12883-014-0246-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 12/11/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Spinal cord lesions is one of the predominant characteristics in patients with neuromyelitis optica spectrum disorders (NMOSD). Interestingly, mounting evidence indicates that spinal cord atrophy (SCA) is one of common clinical features in multiple sclerosis (MS) patients, and correlates closely with the neurological disability. However, Clinical studies related to the SCA aspects of NMOSD are still scarce. METHODS We retrospectively analyzed 185 patients with NMOSD, including 23 patients with SCA and 162 patients without SCA. Data were collected regarding clinical characteristics, laboratory tests, and magnetic resonance imaging findings. RESULTS 12.4% of patients had SCA in NMOSD. Patients with SCA had a longer disease duration and higher EDSS at clinical onset and last visit. More importantly, SCA patients were more prone to reach disability milestones (EDSS ≥ 6.0). Bowel or bladder dysfunction, movement disorders, and sensory disturbances symptoms were more common in patients with SCA. ESR and CRP were significantly higher in patients with SCA than those without SCA. Patients with SCA were more frequently complicated with cervical cord lesions. However, the ARR, progression index, seropositive rate of NMO-IgG and OCB were similar in the two groups. Futhermore, LETM did not differ significantly between patients with SCA and without SCA in NMOSD patients. CONCLUSIONS Patients with SCA might have longer disease duration, more severe clinical disability, and more frequently complicated with cervical spinal cord lesions. SCA might be predictive of the more severe neurologic dysfunction and worse prognosis in NMOSD. Inflammation contributes to the development of SCA in NMOSD.
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Affiliation(s)
- Yanqiang Wang
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Aimin Wu
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Xiaoyu Chen
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Lei Zhang
- Department of Neurology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China.
| | - Yinyao Lin
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Shaoyang Sun
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Wei Cai
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Bingjun Zhang
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Zhuang Kang
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Wei Qiu
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Xueqiang Hu
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
| | - Zhengqi Lu
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, No 600 Tianhe Road, Guangzhou, Guangdong, 510630, China.
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