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Czeisler BM. Emergent Management of Central Nervous System Demyelinating Disorders. Continuum (Minneap Minn) 2024; 30:781-817. [PMID: 38830071 DOI: 10.1212/con.0000000000001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the various conditions that can present with acute and severe central nervous system demyelination, the broad differential diagnosis of these conditions, the most appropriate diagnostic workup, and the acute treatment regimens to be administered to help achieve the best possible patient outcomes. LATEST DEVELOPMENTS The discovery of anti-aquaporin 4 (AQP4) antibodies and anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in the past two decades has revolutionized our understanding of acute demyelinating disorders, their evaluation, and their management. ESSENTIAL POINTS Demyelinating disorders comprise a large category of neurologic disorders seen by practicing neurologists. In the majority of cases, patients with these conditions do not require care in an intensive care unit. However, certain disorders may cause severe demyelination that necessitates intensive care unit admission because of numerous simultaneous multifocal lesions, tumefactive lesions, or lesions in certain brain locations that lead to acute severe neurologic dysfunction. Intensive care may be necessary for the management and prevention of complications for patients who have severely altered mental status, rapidly progressive neurologic worsening, elevated intracranial pressure, severe cerebral edema, status epilepticus, or respiratory failure.
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Nguyen L, Miles DK, Harder L, Singh S, Whittemore BA, Greenberg BM, Wang CX. Increased Intracranial Pressure in Pediatric Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200174. [PMID: 37918972 PMCID: PMC10621892 DOI: 10.1212/nxi.0000000000200174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/28/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Elevated intracranial pressure (ICP) in myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) has been largely unexplored. The objectives of this study were to determine the frequency of increased ICP in MOGAD and its association with disease course and outcomes and to highlight cases requiring medical and/or surgical management of increased ICP. METHODS In this retrospective, single-center cohort study, we examined the clinical and paraclinical data from the initial presentation and follow-up data of children diagnosed with MOGAD. In those with opening pressure (OP) measurements, univariate analyses were used to evaluate factors associated with increased ICP, which was defined as OP > 28 cm H2O. We also present a case series of patients with or without OP measurement who required medical and/or surgical management of increased ICP. RESULTS Of 86 children with MOGAD, 43 (50.0%) had an OP recorded and 7 (8.1%) required ICP management. In those with OP recorded, the median (interquartile range) OP for the different MOGAD phenotypes were: 30.0 (22.8-41.6) (acute disseminated encephalomyelitis, ADEM), 20.5 (16.1-23.6) (optic neuritis), 17.0 (17.0-22.5) (myelitis), and 19.5 (16.5-29.3) (other) cm H20. Overall, 20.9% had increased ICP based on an OP > 28 cm H2O, of whom 77.8% presented with ADEM. In a subgroup analysis of those presenting with ADEM, those with an elevated ICP had longer hospital stay (p = 0.007) and neurologic disability (defined as modified Rankin Scale >1) (p = 0.049). In those with or without OP recorded, 7 (6 with ADEM, one with cerebral cortical encephalitis) required ICP-directed therapies. Findings on brain MRI in these 7 children revealed extensive disease burden with bilateral cerebral involvement and evidence of restricted diffusion. While neuropsychological data in this small subset revealed significant variability, all sustained identifiable deficits after discharge, including attention-deficit hyperactivity disorders and language and learning disorders. DISCUSSION In pediatric MOGAD, increased OP and ADEM at initial presentation were associated with longer hospital stays and greater long-term morbidity. Although invasive ICP monitoring has not been specifically advocated in the management of MOGAD, it is important to recognize signs and symptoms of increased ICP in these patients and consider ICP monitoring and management strategies based on clinical and radiologic findings, especially in those presenting with ADEM and with OP > 28 cm H2O.
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Affiliation(s)
- Linda Nguyen
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas.
| | - Darryl K Miles
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Lana Harder
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Sumit Singh
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Brett A Whittemore
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Benjamin M Greenberg
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
| | - Cynthia X Wang
- From the Department of Neurology (L.N., L.H., B.M.G., C.X.W.); Department of Pediatrics (D.K.M., B.M.G., C.X.W.); Department of Psychiatry (L.H.); Department of Radiology (S.S.); and Department of Neurological Surgery (B.A.W.), University of Texas Southwestern Medical Center, Dallas
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Nathani HR, Deodhe NP, Zade RJ, Ratnani GR. Implementation of Multimodal Stimulation and Physical Therapy in Improving the Level of Consciousness and Recovery in Acute Disseminated Encephalomyelitis. Cureus 2023; 15:e51217. [PMID: 38288205 PMCID: PMC10823210 DOI: 10.7759/cureus.51217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024] Open
Abstract
This case report aims to explore the use of multimodal sensory stimulation and physical therapy in rehabilitating a 30-year-old female patient with severe acute disseminated encephalomyelitis (ADEM). ADEM, characterized by autoimmune demyelination in the central nervous system, presents challenges in clinical management, particularly in cases with severe motor deficits and coordination issues. The patient's progress was measured using the Glasgow Coma Scale (GCS), Extended Glasgow Outcome Scale (GOS-E), and Coma Recovery Scale-Revised (CRS-R). The patient showed significant improvement in consciousness levels, functional status, and cognitive and neurological function. The study concludes that a collaborative approach involving both therapeutic modalities and active family participation contributed positively to the patient's recovery.
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Affiliation(s)
- Harsh R Nathani
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nishigandha P Deodhe
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ruchika J Zade
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Grisha R Ratnani
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hardy D. Monophasic Acquired Demyelinating Syndromes of the Central Nervous System in Children. Semin Pediatr Neurol 2023; 46:101050. [PMID: 37451746 DOI: 10.1016/j.spen.2023.101050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/23/2023] [Indexed: 07/18/2023]
Abstract
Acquired demyelinating syndromes of the central nervous system are immune-mediated demyelinating disorders that can affect the brain, optic nerves, and spinal cord. These disorders have become increasingly recognized in children due to advances in imaging techniques, improvements in diagnostic testing, extensive research into understanding the pathophysiology underlying these disorders, and collaborative multi-institutional efforts to raise awareness of these disorders in children. Moreover, developments in the field of neuroimmunology have allowed us to identify autoantibodies that have presumed causal roles in acquired demyelinating syndromes. Identification of these autoantibodies helps determine clinical course (ie, monophasic vs relapsing course), prognosis, and treatment approach. Acquired demyelinating disorders can affect both children and adults. However, the clinical features, disease course, and treatments are often unique in the pediatric population. Thus, it is important to understand the spectrum of these disorders in children to help provide a timely diagnosis and prompt treatment to achieve optimal outcomes. In this article, the epidemiology, clinical features, diagnosis, treatment, and outcomes of the most common monophasic acquired demyelinating syndromes in children will be reviewed.
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Affiliation(s)
- Duriel Hardy
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX.
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Vova JA, Howarth RA. Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children. Pediatr Clin North Am 2023; 70:429-444. [PMID: 37121635 DOI: 10.1016/j.pcl.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.
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Affiliation(s)
- Joshua A Vova
- Department of Physical Medicine and Rehabilitation, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road Northeast, Atlanta, GA 30342, USA; Department of Neuropsychology, Children's Healthcare of Atlanta, 5461 Meridian Mark Road NE, Atlanta, GA 30342, USA; Department of Pediatrics, Division of Neurology, Emory University School of Medicine.
| | - Robyn A Howarth
- Department of Neuropsychology, Children's Healthcare of Atlanta, 5461 Meridian Mark Road NE, Atlanta, GA 30342, USA; Department of Pediatrics, Division of Neurology, Emory University School of Medicine
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Campbell D, Wong GS, Park H, McLeod G. An Adult Case of Adenovirus-Associated Acute Disseminated Encephalomyelitis. Case Rep Infect Dis 2023; 2023:5528198. [PMID: 37261248 PMCID: PMC10228215 DOI: 10.1155/2023/5528198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/26/2023] [Accepted: 05/05/2023] [Indexed: 06/02/2023] Open
Abstract
Acute disseminated encephalomyelitis (ADEM) is an autoimmune neurological disease that predominately affects pediatric population. Only a single fatal adult case of adenovirus-associated ADEM has previously been published by Qamar et al. in 2021. Here, we present an adult case of adenovirus-associated ADEM, which was diagnosed early in her clinical course. The patient was treated with the prompt initiation of steroids, intravenous immune globulin (IVIG), and plasmapheresis (PLEX), and the patient recovered fully. This case highlights the importance of early accurate diagnosis for other clinicians to treat adenovirus-associated ADEM in a timely fashion to prevent a potentially fatal outcome.
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Affiliation(s)
- Dewayne Campbell
- Department of Internal Medicine, Yale New Haven Health, Greenwich Hospital, Greenwich, CT, USA
| | - Gordon S. Wong
- Department of Internal Medicine, Yale New Haven Health, Greenwich Hospital, Greenwich, CT, USA
| | - Hyun Park
- Department of Internal Medicine, Yale New Haven Health, Greenwich Hospital, Greenwich, CT, USA
| | - Gavin McLeod
- Department of Internal Medicine, Yale New Haven Health, Greenwich Hospital, Greenwich, CT, USA
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Shah CC, Dudek CJ, Viorritto EN, Sarandria JJ. Clinically Isolated Syndrome and Frontal Lobe Arteriovenous Malformation Presenting With Behavior Issues. J Med Cases 2023; 14:1-6. [PMID: 36755998 PMCID: PMC9881484 DOI: 10.14740/jmc4005] [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: 09/06/2022] [Accepted: 10/21/2022] [Indexed: 01/20/2023] Open
Abstract
Prevalence of brain arteriovenous malformation ranges from 0.14% to 0.6% according to various estimates. A large number of these patients remain asymptomatic. The most common presentation is due to brain hemorrhage. A 14-year-old girl presented to the pediatrician with erratic behavior issues and hallucinations. She was diagnosed by the pediatrician and mental health facility as having schizophrenia and bipolar disorder. Once she was transferred to our children's hospital, evaluation by a pediatric neurologist, computed tomography scan, magnetic resonance imaging, and laboratory workup including lumbar puncture confirmed a clinically isolated syndrome and frontal lobe arteriovenous malformation. Frontal lobe lesions including arteriovenous malformation in the frontal lobe can cause psychological symptoms and behavioral issues. We also discuss the differential diagnosis of acute demyelinating syndromes.
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Affiliation(s)
- Chetan C. Shah
- Department of Radiology, Nemours Children’s Health, Jacksonville, FL, USA,Corresponding Author: Chetan C. Shah, Department of Radiology, Nemours Children’s Health, Jacksonville, FL 32207, USA.
| | | | | | - John J. Sarandria
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, FL, USA
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Bunyan RF, AlAbdulSalam AM, Albarakati RG, Al Harbi AA, Alissa DA, Al-Jedai AH, AlKhawajah NM, Al Malik YM, Almejally MA, Al-Mudaiheem HY, AlNajashi HA, AlShehri AA, Althubaiti IA, AlYafeai RH, Babakkor MA, Cupler EJ, Ka MH, Saeedi JA, Shosha E, Al Jumah MA. Saudi consensus recommendations on the management of multiple sclerosis: MS management in children and adolescents. Mult Scler Relat Disord 2022; 66:104061. [PMID: 35908447 DOI: 10.1016/j.msard.2022.104061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/26/2022] [Accepted: 07/15/2022] [Indexed: 12/01/2022]
Abstract
Multiple sclerosis (MS) most commonly presents in young adults, although 3-5% of patients develop MS prior to the age of 18 years. The new and comprehensive consensus for the management of MS in Saudi Arabia includes recommendations for the management of MS and other CNS inflammatory demyelinating disorders in pediatric and adolescent patients. This article summarizes the key recommendations for the diagnosis and management of these disorders in young patients. Pediatric and adult populations with MS differ in their presentation and clinical course. Careful differential diagnosis is important to exclude alternative diagnoses such as acute disseminated encephalomyelitis (ADEM) or neuromyelitis optica spectrum disorders (NMOSD). The diagnosis of MS in a pediatric/adolescent patient is based on the 2017 McDonald diagnostic criteria, as in adults, once the possibility of ADEM or NMOSD has been ruled out. Few data are available from randomized trials to support the use of a specific disease-modifying therapy (DMT) in this population. Interferons and glatiramer acetate are preferred initial choices for DMTs based on observational evidence, with the requirement of a switch to a more effective DMT if breakthrough MS activity occurs.
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Affiliation(s)
- Reem F Bunyan
- Department of Neurology, King Fahad Specialist Hospital Dammam, Eastern Region, Saudi Arabia
| | | | - Rayan G Albarakati
- Department of Obstetrics and Gynecology, Majmaah University, Al-Majmaah, Saudi Arabia
| | - Awad A Al Harbi
- Department of Neuroscience, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Dema A Alissa
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Ahmed H Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Nuha M AlKhawajah
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Neurology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yaser M Al Malik
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Division of Neurology, King Abdulaziz Medical City (National Guard Health Affairs), Riyadh, Saudi Arabia
| | | | | | - Hind A AlNajashi
- Department of Medicine, Division of Neurology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amani A AlShehri
- Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ibtisam A Althubaiti
- Department of Neurology, King Fahad Military Medical Complex Dhahran, Eastern Region, Saudi Arabia
| | - Rumaiza H AlYafeai
- Department of Psychiatry and Psychology, My Clinic International Medical Co., Jeddah, Saudi Arabia
| | - Mohammed A Babakkor
- Neurology Department, Neuroscience Center, King Abdullah Medical City, Ministry of Health, Makkah Al-Mukarramah, Saudi Arabia
| | - Edward J Cupler
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mamdouh H Ka
- Department of Neurology, Al Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Jameelah A Saeedi
- Department of Neuroscience, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Eslam Shosha
- Department of Medicine, Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Mohammed A Al Jumah
- Department of Neurology, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia.
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Nikolaus M, Kühne F, Tietze A, Thumfart J, Kempf C, Gratopp A, Knierim E, Bittigau P, Kaindl AM. Modified Zipper Method, a Promising Treatment Option in Severe Pediatric Immune-Mediated Neurologic Disorders. J Child Neurol 2022; 37:505-516. [PMID: 35435761 PMCID: PMC9160959 DOI: 10.1177/08830738221089476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To introduce and evaluate a modified version of the "zipper method"-a treatment strategy alternating intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) first reported for 9 pediatric cases of Guillain-Barré syndrome in 2018-for treatment of severe immune-mediated neurologic disorders in children. METHODS The modified zipper method comprised longer intervals between PLEX-IVIG cycles (48 hours instead of 24 hours), more cycles (7-10 instead of 5), a consistent plasma volume exchange (instead of the original multistep approach), and variable infusion times for IVIGs (4-8 hours). The modified zipper method was applied as an individual treatment approach once standard therapy failed. The follow-up ranged from 6 months to 2 years. Cases were analyzed retrospectively. Disease severity was mainly quantified by the Guillain-Barré syndrome disability score. RESULTS Four children (9-15 years) with (1) Miller-Fisher syndrome, (2) Bickerstaff brainstem encephalitis, (3) common Guillain-Barré syndrome, and (4) severe acute disseminated encephalomyelitis were treated by the modified zipper method. Results for duration of mechanical ventilation (median of 12 days, interquartile range [IQR] 8-16), hospital stay (median of 23 days, IQR 22-24), and time to unaided walking (median of 22 days, IQR 21-37) outperformed previous studies with IVIG/PLEX alone or IVIG + PLEX combinations unlike the zipper method. CONCLUSION The modified zipper method is associated with a low mortality, a short mechanical ventilation time, a short hospital stay, and an excellent outcome in children with severe Guillain-Barré syndrome or acute disseminated encephalomyelitis. Our regimen is streamlined for applicability. Results emphasize its robust effectiveness as an option for therapy escalation in severe neuroimmunologic diseases. Now, multicenter trials are needed to evaluate this novel treatment strategy.
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Affiliation(s)
- Marc Nikolaus
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany,Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabienne Kühne
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany,Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Tietze
- Institute of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Caroline Kempf
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ellen Knierim
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany,Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Bittigau
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany,Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany,Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany,Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany,Angela M. Kaindl, MD, Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Takahashi Y, Hayakawa I, Abe Y. Diagnostic odyssey of acute disseminated encephalomyelitis in children. Sci Rep 2021; 11:21954. [PMID: 34754056 PMCID: PMC8578490 DOI: 10.1038/s41598-021-01519-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022] Open
Abstract
We aimed to determine whether acute disseminated encephalomyelitis (ADEM) diagnosis in children is delayed, and if so, to identify the clinical risk factors of delayed diagnosis. Standardised data were collected from children with ADEM from 2003 to 2020. Overall diagnostic delay (time between symptom onset and ADEM diagnosis), physicians’ delay (between the first medical visit and ADEM diagnosis), and patients’ delay (between symptom onset and the first medical visit) were analysed. Thirty ADEM patients were identified, including 16 (54%) with neurological deficits at discharge. Overall, physicians’, and patients’ delays were 9 (interquartile range [IQR] 6–20.5), 5.5 (IQR 3–14), and 4 (IQR 2–8) days, respectively. Overall delay was significantly associated with physicians’ delay, but not with patients’ delay. There were 61 misdiagnoses among 25 (83%) patients, while 5 (17%) were diagnosed correctly at the first visit. The misdiagnoses of common respiratory and gastrointestinal infection and aseptic meningitis were associated with overall and/or physicians’ delay. Later onset of specific neurological features suggestive of ADEM was associated with all three diagnostic delays. A unique diagnostic odyssey exists in ADEM. Several clinical risk factors were associated with the diagnostic delay.
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Affiliation(s)
- Yoko Takahashi
- Division of Neurology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, Postal Code 157-8535, Japan.,Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Itaru Hayakawa
- Division of Neurology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, Postal Code 157-8535, Japan.
| | - Yuichi Abe
- Division of Neurology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, Postal Code 157-8535, Japan
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Acute disseminated encephalomyelitis: A retrospective study of 20 children in a pediatrics department in Tunisia. Arch Pediatr 2021; 28:638-646. [PMID: 34690025 DOI: 10.1016/j.arcped.2021.09.027] [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: 11/22/2017] [Revised: 08/03/2021] [Accepted: 09/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disorder of the central nervous system. Little information is available about the clinical and neuroradiological profile or the follow-up of this disease in Tunisian children. AIM To determine the clinical, laboratory, and radiological features and the outcome of ADEM in children admitted to the pediatrics department of a university hospital in Tunisia. METHODS All children ≤ 18 years old presenting with ADEM and admitted to the tertiary referral center for pediatrics at Sahloul University Hospital from January 2000 to December 2020 were included in the study. The diagnosis of ADEM was confirmed according to the international pediatric multiple sclerosis study group criteria. RESULTS A total of 20 patients (13 girls and 7 boys) fulfilled the diagnostic criteria for ADEM. The mean age at diagnosis was 5.6 years. The clinical presentation included polyfocal neurological signs such as cranial hypertension (45%), seizures (35%), and motor weaknesses (55%). Pyramidal tract signs and cranial nerve palsies were noted in 55% of cases. Brain magnetic resonance imaging showed particular features, namely, a relapsing tumor-like form in one case, and optic neuritis and demyelinating lesions of the white matter in the brain and the spinal cord with gadolinium cerebral ring-like enhancement in another case. The treatment consisted of intravenous immunoglobulin in 16 cases (80%) and corticosteroid in 19 cases (95%). Plasmapheresis was used for one patient. Complete recovery was observed in 12 patients (60%); 19 patients (95%) had a monophasic course of the disease while only one patient developed multiphasic ADEM. CONCLUSIONS ADEM remains a difficult diagnosis in children. Nevertheless, after prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with restitutio ad integrum.
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Update on Acute Disseminated Encephalomyelitis in Children and Adolescents. CHILDREN-BASEL 2021; 8:children8040280. [PMID: 33917395 PMCID: PMC8067441 DOI: 10.3390/children8040280] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an immune-mediated, inflammatory demyelinating disease of the central nervous system (CNS) that usually affects children and young adults after an infection or vaccination. The presence of several conditions mimicking ADEM, added to the lack of specific biomarkers, makes diagnosis potentially hard. Prompt diagnosis is necessary to start adequate treatment to improve the clinical course and long-term outcome. Because of its heterogeneity in both clinical presentation and course, challenges remain in establishing the most appropriate therapeutic approach in each patient. The aim of this review is to provide an update on management of this disease with a focus on acute treatment and to give suggestions for future research. We showed that there are currently no guidelines that help clinicians manage ADEM and therapeutic decisions are often made on a case-by-case basis. Further studies are necessary to identify clinical, laboratory, and instrumental criteria that could be correlated with outcomes and guide clinicians in choosing when and what treatment should be given in each case.
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Paolilo RB, Deiva K, Neuteboom R, Rostásy K, Lim M. Acute Disseminated Encephalomyelitis: Current Perspectives. CHILDREN-BASEL 2020; 7:children7110210. [PMID: 33153097 PMCID: PMC7692206 DOI: 10.3390/children7110210] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 12/14/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an immune-mediated central nervous system (CNS) disorder, characterized by polyfocal symptoms, encephalopathy and typical magnetic resonance imaging (MRI) findings, that especially affects young children. Advances in understanding CNS neuroimmune disorders as well as the association of myelin oligodendrocyte glycoprotein antibody (MOG-Ab) with both monophasic and recurrent forms of ADEM have led to new insights into its definition, management and outcome. In this review, we aim to provide an update based on current epidemiologic, clinical, radiological and immunopathological aspects and clinical outcome of ADEM.
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Affiliation(s)
- Renata Barbosa Paolilo
- Department of Neurology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo (HCFMUSP), São Paulo 05508-060, Brazil;
| | - Kumaran Deiva
- Department of Pediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Bicêtre Hospital, 72, Rue G Leclerc, 94270 Le Kremlin Bicêtre, France;
- National Reference Centre for Rare Inflammatory Brain and Spinal Diseases, 72, Rue G Leclerc, 94270 Le Kremlin Bicêtre, France
- Inserm UMR 1184, Immunology of Viral Infections and Autoimmune Diseases, 63, R G Péri, 94270 Le Kremlin Bicêtre, France
| | - Rinze Neuteboom
- Department of Neurology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Kevin Rostásy
- Department of Pediatric Neurology, Vestische Kinder und Jugendklinik, Witten/Herdecke University, 45711 Datteln, Germany;
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
- King’s Health Partners Academic Health Science Centre, London SE1 9RT, UK
- Faculty of Life Sciences and Medicine, King’s College Hospital, London SE5 9RS, UK
- Correspondence: ; Tel.: +44-020-7188-7188
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Algahtani H, Shirah B, Alassiri A, Algahtani S. Decompressive craniectomy as a lifesaving intervention for acute disseminated encephalomyelitis (ADEM). Mult Scler Relat Disord 2020; 47:102612. [PMID: 33161197 DOI: 10.1016/j.msard.2020.102612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 11/17/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM), is an immune-mediated demyelinating disease of the central nervous system that commonly affects children and young adults of both sexes. Hyperacute variants of ADEM represent 2% of cases and are associated with rapid progression of symptoms, malignant brain edema, and high mortality rates. We report a case of a young woman presenting with a hyperacute storming course of few days who was managed with pulse steroid therapy and emergency craniectomy with an excellent outcome. We believe that our patient's acute clinical deterioration and findings on neuroimaging warranted prompt neurosurgery. Although treatment with immunomodulatory medications was commenced, the severity of her condition indicated that only surgical intervention was likely to be lifesaving. We recommend immediate neurosurgical consultation to consider prompt decompressive craniectomy in hyperacute variants with significant brain swelling. Multidisciplinary care including neurologist, neuroradiologist, neurosurgeon, neuropathologist, and neurointensivist is the only way to achieve success and improve survival in patients presenting with hyperacute ADEM.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City / King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
| | - Bader Shirah
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ali Alassiri
- King Abdulaziz Medical City / King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Lapides DA, McDonald MM. Inflammatory Manifestations of Systemic Diseases in the Central Nervous System. Curr Treat Options Neurol 2020; 22:26. [PMID: 32834714 PMCID: PMC7387810 DOI: 10.1007/s11940-020-00636-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review presents the current recommended therapeutic interventions for inflammatory disease in the central nervous system (CNS) secondary to systemic diseases of immune dysregulation. Treatment recommendations for CNS inflammation associated with rheumatologic conditions, immune-related adverse effects from immune checkpoint inhibitors (ICIs), and demyelinating disease from tumor necrosis factor-α (anti-TNFs) are explored. Additional therapeutic options for inflammation related to postviral syndromes and genetic immunodeficiencies are also discussed. RECENT FINDINGS In addition to treatment of mild, moderate, and severe CNS rheumatologic disease as guided by the European League Against Rheumatism (EULAR), early consideration of rituximab for severe IgG4-related disease and induction with anti-TNF therapy for severe neurosarcoidosis should be considered. Although often not first line, treatment options for CNS inflammatory diseases based on disease mechanism are emerging, including tocilizumab for Behcet's disease, natalizumab for ICI associated autoimmune encephalitis, and abatacept for treatment of infiltrative disease secondary to CTLA-4 deficiency. Hematopoietic stem cell treatments represent highly efficacious but risky options for autoimmunity related to genetic immunodeficiency. SUMMARY While early high dose steroids remains first line therapy for most CNS inflammatory conditions, a rapidly expanding arsenal of immune targeted therapies offers clinicians tailored disease specific options for treatment.
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Affiliation(s)
- David A. Lapides
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
| | - Mark M. McDonald
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
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Elkhayat HA, El-Rashidy OF, Elagouza IA, Zaitoun R, Abbas YAA. Childhood acute disseminated encephalomyelitis: an Egyptian pilot study. Acta Neurol Belg 2020; 120:549-555. [PMID: 29222716 DOI: 10.1007/s13760-017-0869-5] [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: 06/30/2017] [Accepted: 12/01/2017] [Indexed: 11/29/2022]
Abstract
Describing the variable clinical features, laboratory findings, neuroimaging findings, and treatments given to children who presented with ADEM and following them up both clinically and radiologically. 21 patients were recruited: 14 new cases, and 7 old ones presenting over the preceding 5 years (retrospective review of existing data). 11 males and 10 females, with a mean age of 4.4 years ± 2.7 SD, were included. All new patients were subject to full history, examination and a panel of investigations including MRI of the brain. Treatment was given in the form of pulsed methyl prednisolone or intravenous immunoglobulin (IVIG), followed by clinical and radiological follow-up every 3 months as needed. 11 cases occurred in spring, 8 post vaccine, of which 5 were after oral polio vaccine (OPV). MRI was done for all 21 patients and was abnormal in all of them, CT was done in only 10 patients as was normal in 9. Hyponatremia was seen in 11 patients. All patients who received corticosteroids showed prompt improvement. 6 out of 10 patients who received IVIG first failed treatment. Of the 17 treated patients, 10 had no sequelae and 10 had total lesion resolution on MRI at 3 months, versus 1 and 0 patients, respectively, in the untreated group. We found a disproportionately large number of post vaccination cases, especially after OPV. The association of ADEM with hyponatremia needs further study. MRI is central to diagnosis. Outcome is much better with treatment with steroids being far superior to IVIG. Excess use of IVIG should be discouraged.
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Affiliation(s)
| | | | - Iman Ali Elagouza
- Faculty of Medicine, Paediatrics Department, Ain Shams University, Cairo, Egypt.
| | - Raghda Zaitoun
- Faculty of Medicine, Paediatrics Department, Ain Shams University, Cairo, Egypt
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Marrodan M, Gaitán MI, Correale J. Spinal Cord Involvement in MS and Other Demyelinating Diseases. Biomedicines 2020; 8:E130. [PMID: 32455910 PMCID: PMC7277673 DOI: 10.3390/biomedicines8050130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Diagnostic accuracy is poor in demyelinating myelopathies, and therefore a challenge for neurologists in daily practice, mainly because of the multiple underlying pathophysiologic mechanisms involved in each subtype. A systematic diagnostic approach combining data from the clinical setting and presentation with magnetic resonance imaging (MRI) lesion patterns, cerebrospinal fluid (CSF) findings, and autoantibody markers can help to better distinguish between subtypes. In this review, we describe spinal cord involvement, and summarize clinical findings, MRI and diagnostic characteristics, as well as treatment options and prognostic implications in different demyelinating disorders including: multiple sclerosis (MS), neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, anti-myelin oligodendrocyte glycoprotein antibody-associated disease, and glial fibrillary acidic protein IgG-associated disease. Thorough understanding of individual case etiology is crucial, not only to provide valuable prognostic information on whether the disorder is likely to relapse, but also to make therapeutic decision-making easier and reduce treatment failures which may lead to new relapses and long-term disability. Identifying patients with monophasic disease who may only require acute management, symptomatic treatment, and subsequent rehabilitation, rather than immunosuppression, is also important.
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Affiliation(s)
| | | | - Jorge Correale
- Neurology Department, Fleni, C1428AQK Buenos Aires, Argentina; (M.M.); (M.I.G.)
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Ashfaq MA, Javed I, Arshad M, Yaseen MR. Role of Methyl Prednisolone in Longitudinal Extensive Transverse Myelitis (LETM) in Children. Pak J Med Sci 2020; 36:451-455. [PMID: 32292451 PMCID: PMC7150395 DOI: 10.12669/pjms.36.3.1232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective: The role of methyl prednisolone in longitudinal extensive transverse myelitis in children is not completely discovered in developing country like Pakistan. So this is the first study which aimed to evaluate the efficacy of methyl prednisolone in longitudinal extensive transverse myelitis in children. Methods: This is quasi experimental hospital based descriptive prospective study. The data was collected from 34 children admitted in Paediatric Neurology department through Outpatient/emergency department in Children’s Hospital and the Institute of Child Health, Lahore for period of one year from January 2018 to December 2018. The children full filling the inclusion criteria were observed before and after giving injection methyl prednisolone 30mg/kg/dose (maximum dose one Gram irrespective of the body weight) once daily for five days in the form of intravenous infusion. Results: Complete recovery was seen in 41.2% while 58.8% showed partial recovery. The correlation of response to treatment (recovery) with gender, area of spinal cord involvement, muscle power and autonomic dysfunction is found at significance level of five percent according to Chi square test. Conclusion: Early consideration and administration of methyl prednisolone in longitudinally extensive transverse myelitis in children can be beneficial and can help to reduce the morbidity.
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Affiliation(s)
- Muhammad Azeem Ashfaq
- Dr. Muhammad Azeem Ashfaq, MBBS, FCPS. Senior Registrar, Department of Paediatric Neurology, The Children's Hospital & the Institute of Child Health, Lahore, Pakistan
| | - Iram Javed
- Dr. Iram Javed, MBBS, FCPS. Assistant Professor, Department of Paediatric Neurology, The Children's Hospital Faisalabad, Pakistan
| | - Muhammad Arshad
- Dr. Muhammad Arshad, MBBS, FCPS Associate Professor, Sargodha Medical College, Sargodha, Pakistan
| | - Muhammad Rizwan Yaseen
- Muhammad Rizwan Yaseen, Assistant Professor, Department of Economics, Government College University, Faisalabad, Pakistan
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Abstract
Acute disseminated encephalomyelitis (ADEM) is an autoimmune demyelinating disease of central nervous system (CNS). ADEM is most commonly seen in children, although adults can also be affected. The disease typically starts with an abrupt onset within day to weeks after a viral infection or immunization. Presenting features include an acute encephalopathy with multifocal neurologic signs and fever. ADEM generally has a monophasic course, although recurrent ADEM has also been described and is defined as multiphasic ADEM. MRI shows widespread lesions located in both brain and spinal cord. An involvement of basal ganglia and thalami has also been described. Analysis of cerebrospinal fluid (CSF) may reveal mild lymphocytic pleocytosis and increased proteins, whereas oligoclonal bands are usually negative. In the absence of specific biologic markers, ADEM remains a diagnosis of exclusion and it is still based on clinical manifestations, imaging, and laboratory features. Therapy is based on steroid administration and the prognosis is usually favorable.
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Wright SK, Wood AG. Neurodevelopmental outcomes in paediatric immune-mediated and autoimmune epileptic encephalopathy. Eur J Paediatr Neurol 2020; 24:53-57. [PMID: 31879225 DOI: 10.1016/j.ejpn.2019.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/06/2019] [Indexed: 12/23/2022]
Abstract
Recognition of paediatric autoimmune/immune-mediated encephalitis and epileptic encephalopathy (e.g. NMDAR-Ab encephalitis) has rapidly increased over the last ten years. While we are succeeding in the diagnosis and identification and even early treatment of these encephalitidies, with studies describing >80% are making a "good" recovery, we are now recognising that a "good" medical outcome does not cover the cognitive, social and behavioural sequelae that can occur, particularly in paediatric patients. Basic measures of medical outcome, for example the modified Rankin Scale (MRS) or the Paediatric Cerebral Performance Category (PCPC), offer the advantage of being quick to use, but do not reveal the more complex difficulties that can impact the future of affected children. This article reviews the current literature on neurodevelopmental outcomes in children affected with autoimmune and immune-mediated encephalitis/epileptic encephalopathy and provides guidance on post-onset surveillance aimed at identifying those most likely to experience ongoing long-term difficulties.
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Affiliation(s)
- Sukhvir K Wright
- School of Life and Health Sciences & Aston Neuroscience Institute, Aston University, Birmingham, UK; Department of Neurology, Birmingham Children's Hospital, Birmingham, UK.
| | - Amanda G Wood
- School of Life and Health Sciences & Aston Neuroscience Institute, Aston University, Birmingham, UK; School of Psychology, Faculty of Health, Melbourne Burwood Campus, Deakin University, Geelong, Victoria, Australia
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Savransky A, Rubstein A, Rios MH, Vergel SL, Velasquez MC, Sierra SP, Marcarian G, Alba R, Pugliese AM, Tenembaum S. Prognostic indicators of improvement with therapeutic plasma exchange in pediatric demyelination. Neurology 2019; 93:e2065-e2073. [PMID: 31645471 DOI: 10.1212/wnl.0000000000008551] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine the safety and clinical benefit of therapeutic plasma exchange (TPE) as rescue therapy in children with acute inflammatory demyelinating CNS syndromes and to identify baseline prognostic indicators of treatment improvement. METHODS This single-center retrospective pediatric cohort included all consecutive patients admitted to our hospital over the period from 2003 to 2017 because of a steroid-refractory acute CNS event presumed to be inflammatory who required TPE. Functional status assessment to identify improvement included the following performance category scales: visual outcome, bladder control, gait, and Expanded Disability Status Scale (EDSS). These assessments were performed before and after TPE in every patient. RESULTS Sixty-five children requiring TPE to treat 78 CNS attacks were included for analysis. Median age at TPE was 10.5 years (1.9-18 years); 45% were girls. Seropositivity (aquaporin-4 water channel-immunoglobulin G [IgG] or myelin oligodendrocyte glycoprotein-IgG) was found in 20 of 42 (48%) patients. Attack phenotypes leading to TPE were optic neuritis (ON) in 42%, longitudinally extensive transverse myelitis (LETM) in 31%, ON + LETM in 15%, and other combined syndromes in 11%. Overall, moderate to marked neurologic improvement was observed in 72% of children at the end of TPE and in 88.5% at 6 months of follow-up. Lower baseline scores on the EDSS, visual outcome, and gait scales were found to be independent prognostic indicators of treatment benefit. Sex, age at onset and at TPE, attack phenotype, disease duration, and time from attack onset to TPE initiation were not significantly associated with treatment outcome. Adverse events were observed in 31 of 524 (5.9%) procedures, being severe in 4. CONCLUSIONS TPE was an effective rescue therapy associated with functional improvement. No therapeutic window for TPE initiation was identified in this pediatric cohort. Overall frequency of adverse events was low; however, serious events should be anticipated and avoided. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for children with acute inflammatory demyelinating CNS syndromes, TPE leads to functional improvement.
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Affiliation(s)
- Andrea Savransky
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Adrian Rubstein
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Marina Huaman Rios
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Silvana L Vergel
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Mabel Castro Velasquez
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Sara Perez Sierra
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Gabriela Marcarian
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Romina Alba
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Ana M Pugliese
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Silvia Tenembaum
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina.
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Santoro JD, Chitnis T. Diagnostic Considerations in Acute Disseminated Encephalomyelitis and the Interface with MOG Antibody. Neuropediatrics 2019; 50:273-279. [PMID: 31340401 PMCID: PMC7117081 DOI: 10.1055/s-0039-1693152] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute disseminated encephalomyelitis (ADEM) is a common yet clinically heterogenous syndrome characterized by encephalopathy, focal neurologic findings, and abnormal neuroimaging. Differentiating ADEM from other demyelinating disorders of childhood can be difficult and appropriate interpretation of the historical, clinical, and neurodiagnostic components of a patient's presentation is critical. Myelin oligodendrocyte glycoprotein (MOG) antibody-associated diseases are a recently recognized set of disorders, which include ADEM presentations, among other phenotypes. This review article discusses the clinical diagnosis, differential diagnosis, interpretation of data, and treatment/prognosis of this unique syndrome with distinctive review of the spectrum of MOG antibodies.
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Affiliation(s)
- Jonathan D. Santoro
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States,Department of Neurology, Harvard Medical School, Boston, Massachusetts, United States,Department of Neurology, Children’s Hospital of Los Angeles, Los Angeles, California, United States,Keck School of Medicine, University of Southern California, Los Angeles, California, United States,Address for correspondence Jonathan D. Santoro, MD Department of Neurology, Massachusetts General Hospital55 Fruit Street, ACC 708, Boston, MA 02114United States
| | - Tanuja Chitnis
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States,Department of Neurology, Harvard Medical School, Boston, Massachusetts, United States
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Vitturi BK, Rosemberg S, Arita FN, da Rocha AJ, Forte WCN, Tilbery CP. Multiphasic disseminated encephalomyelitis associated with herpes virus infection in a patient with TLR3 deficiency. Mult Scler Relat Disord 2019; 36:101379. [PMID: 31479858 DOI: 10.1016/j.msard.2019.101379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/31/2019] [Accepted: 08/28/2019] [Indexed: 11/16/2022]
Abstract
We report a case of a 14-year-old girl that presented headache, amaurosis, drowsiness, fever, vomiting and diffuse reduction of muscle strength. She had been diagnosed with ADEM one year before and had a previous diagnosis of Toll-Like 3 receptor deficiency. Cerebrospinal fluid analysis revealed pleocytosis (28/mm3, 12/mm3 red blood cells, 70% lymphocytes cells, 2% monocytes cells, 28% neutrophils), normal total protein (38 pg/mL) and normal glucose level (53/mm3). Studies for CSF oligoclonal bands and serum anti-MOG were negative but polymerase chain reaction (PCR) testing was positive for herpes virus 1. In the first ADEM episode, PCR for herpes virus was also positive. Magnetic resonance imaging (MRI) of the brain revealed disseminated hyperintense lesions on T2-weighted and FLAIR images in the white matter of frontal, parietal and temporal lobes, corresponding to extensive asymmetric areas of demyelination that produced mass effect and gadolinium enhancement. Electroencephalography demonstrated irregular diffuse and generalized slow-wave activity with predominance in frontal region. The diagnosis of multiphasic disseminated encephalomyelitis (MDEM) triggered by herpes simplex virus was made. Herpes virus is a neurotropic virus that can cause a wide variety of neurological infection-triggered autoimmune disorders and that is particularly damaging to the central nervous system in situations of impaired immune system. TLR3 is expressed in astrocytes and dendritic cells of the central nervous system and is essential for natural immunity to herpes simplex. TLR3-deficient patients have already been described with herpes simplex encephalitis. TLR3 deficiency may predispose and explain autoimmune and demyelinating manifestations induced by herpes virus. The association of multiphasic disseminated encephalomyelitis triggered by herpes virus in a patient with TLR3 deficiency has not been previously reported in the literature.
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Affiliation(s)
- Bruno Kusznir Vitturi
- Department of Neurology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.
| | - Sérgio Rosemberg
- Department of Pediatric Neurology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Fernando Norio Arita
- Department of Pediatric Neurology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Antônio José da Rocha
- Department of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | | | - Charles Peter Tilbery
- Department of Neurology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
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Bakulin IS, Korzhova YE, Kozlova AO, Konovalov RN, Vasil'ev AV, Askarova LS, Zakharova MN. [Clinical characteristics and diagnosis of disseminated encephalomyelitis in adults]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:36-41. [PMID: 31156239 DOI: 10.17116/jnevro20191192236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze clinical, neuroimaging and laboratory characteristics of acute disseminated encephalomyelitis (ODEM) in adults with an analysis of the frequency of diagnostic errors at the initial examination stage. MATERIAL AND METHODS The study included 23 patients hospitalized with a diagnosis of ODEM. The analysis of clinical characteristics, MRI results and cerebrospinal fluid (CSF) was performed. The diagnosis of the disease in each case was specified after a full examination and dynamic observation. RESULTS The diagnosis of ODEM was confirmed only in 16 cases. In 6 cases, the final diagnosis of multiple sclerosis (MS) was made, and one case of Susak syndrome, primary CNS lymphoma and levamisole-associated multifocal inflammatory leukoencephalopathy was also detected. It has been shown that ODEM in adults is characterized by the acute development of multifocal brain lesions in combination with clinical manifestations of encephalopathy, which in half of cases is preceded by an infectious disease. There were no specific clinical, neuroimaging and laboratory features, which could allow differentiation of ODEM from onset of MS. CONCLUSION To make a correct diagnosis in the first episode of acute multifocal brain lesion, a dynamic observation, including repeated MRI, is needed. The development of specific biomarkers may be of great importance for the early differential diagnosis of demyelinating diseases.
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Affiliation(s)
- I S Bakulin
- Research Center of Neurology, Moscow, Russia
| | | | - A O Kozlova
- Lomonosov Moscow State University, Moscow, Russia
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Slinger C, Mehdi SB, Milan SJ, Dodd S, Matthews J, Vyas A, Marsden PA. Speech and language therapy for management of chronic cough. Cochrane Database Syst Rev 2019; 7:CD013067. [PMID: 31335963 PMCID: PMC6649889 DOI: 10.1002/14651858.cd013067.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far-reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non-pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context. OBJECTIVES To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough. SEARCH METHODS We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019. SELECTION CRITERIA We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health-related quality of life (HRQoL) and serious adverse events (SAEs). MAIN RESULTS We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60-minute session and three 45-minute sessions to four 30-minute sessions. The control interventions were healthy lifestyle advice in both studies.One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between-group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low.Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: -9.72, 95% CI -20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study. AUTHORS' CONCLUSIONS The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies.The improvements in HRQoL (LCQ) and reduction in 24-hour cough frequency seen with the PSALTI intervention were statistically significant but short-lived, with the between-group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events.Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high-quality research, with comparable endpoints to inform robust conclusions.
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Affiliation(s)
- Claire Slinger
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | - Syed B Mehdi
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | | | - Steven Dodd
- Lancaster UniversityFaculty of Health and MedicineLancasterUK
| | - Jessica Matthews
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | - Aashish Vyas
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | - Paul A Marsden
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
- Wythenshawe Hospital, Manchester University NHS Foundation TrustNorth West Lung CentreManchesterUK
- School of Biological Sciences, University of ManchesterDivision of Infection, Immunity and Respiratory MedicineManchesterUK
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Golub D, Williams F, Wong T, Iyengar N, Jolley H, Sabadiah S, Rhee D, Gold-von Simson G. A Longitudinally Extensive Spinal Cord Lesion Restricted to Gray Matter in an Adolescent Male. Front Neurol 2019; 10:270. [PMID: 30949125 PMCID: PMC6435483 DOI: 10.3389/fneur.2019.00270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/28/2019] [Indexed: 01/19/2023] Open
Abstract
Longitudinally extensive spinal cord lesions (LECL) restricted to gray matter are poorly understood as are their neurodevelopmental repercussions in children. We herein report the critical case of a 13-year-old male presenting with progressive quadriparesis found to have cervical LECL restricted to the anterior horns. Challenged with a rare diagnostic dilemma, the clinical team systematically worked through potential vascular, genetic, infectious, rheumatologic, and paraneoplastic diagnoses before assigning a working diagnosis of acute inflammatory myelopathy. Nuanced consideration of and workup for both potential ischemic causes (arterial dissection, fibrocartilaginous embolism, vascular malformation) and specific inflammatory conditions including Transverse Myelitis, Neuromyelitis Optica Spectrum Disorders (NMOSD), Multiple Sclerosis (MS), Acute Disseminated Encephalomyelitis (ADEM), and Acute Flaccid Myelitis (AFM) is explained in the context of a comprehensive systematic review of the literature on previous reports of gray matter-restricted longitudinally extensive cord lesions in children. Treatment strategy was ultimately based on additional literature review of treatment-refractory acute inflammatory neurological syndromes in children. A combination of high-dose steroids and plasmapheresis was employed with significant improvement in functional outcome, suggesting a potential benefit of combination immune-modulatory treatment in these patients. This case furthermore highlights quality clinical reasoning with respect to the elusive nature of diagnosis, nuances in neuroimaging, and multifocal treatment strategies in pediatric LECL.
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Affiliation(s)
- Danielle Golub
- New York University School of Medicine, New York, NY, United States
| | - Faith Williams
- School of Medicine, Washington University School of Medicine, Saint Louis, MO, United States
| | - Taylor Wong
- New York University School of Medicine, New York, NY, United States
| | - Nishanth Iyengar
- New York University School of Medicine, New York, NY, United States
| | - Hannah Jolley
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Sakinah Sabadiah
- Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - David Rhee
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Gabrielle Gold-von Simson
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States.,Health and Hospitals, Clinical Translational Science Institute, New York University, New York, NY, United States
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Galetta KM, Bhattacharyya S. Multiple Sclerosis and Autoimmune Neurology of the Central Nervous System. Med Clin North Am 2019; 103:325-336. [PMID: 30704684 DOI: 10.1016/j.mcna.2018.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Autoimmune disorders of the central nervous system are common and often affect people in the most productive years of their lives. Among primary autoimmune diseases of the central nervous system, multiple sclerosis is most prevalent in the United States. Many other autoantibody-mediated neurologic syndromes have been identified within the past 2 to 3 decades, including neuromyelitis optica and anti-N-methyl-D aspartate receptor encephalitis. Finally, the central nervous system can also be affected by systemic autoimmune diseases such as sarcoidosis. Many of these diseases are treatable when detected early.
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Affiliation(s)
- Kristin M Galetta
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shamik Bhattacharyya
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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28
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Jiang Y, Tian X, Gu Y, Li F, Wang X. Application of Plasma Exchange in Steroid-Responsive Encephalopathy. Front Immunol 2019; 10:324. [PMID: 30873174 PMCID: PMC6400967 DOI: 10.3389/fimmu.2019.00324] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/07/2019] [Indexed: 12/18/2022] Open
Abstract
Plasma exchange has been widely used in autoimmune neurological diseases and is the standard treatment for myasthenia gravis crisis and Guillain-Barre syndrome. A growing body of research suggests that, in the clinical application of steroid-responsive encephalopathy, such as for Hashimoto's encephalopathy, limbic encephalitis, systemic lupus erythematosus encephalopathy, ANCA-associated vasculitis encephalopathy, and acute disseminated encephalomyelitis, plasma exchange is a safe, and effective option when steroids or other immunosuppressive therapies are ineffective in the short term or when contraindications are present. Additionally, plasma exchange can also be used alone or in combination with steroids, immunoglobulins, or other immunosuppressive agents to treat steroid-responsive encephalopathy. This paper reviews the clinical application of plasma exchange in steroid-responsive encephalopathy, including its indications, onset time, course, curative effects, and side effects.
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Affiliation(s)
- Yuting Jiang
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Tian
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yixue Gu
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Li
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuefeng Wang
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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29
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Matricardi S, Farello G, Savasta S, Verrotti A. Understanding Childhood Neuroimmune Diseases of the Central Nervous System. Front Pediatr 2019; 7:511. [PMID: 31921724 PMCID: PMC6930888 DOI: 10.3389/fped.2019.00511] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Immune-mediated diseases of the central nervous system (CNS) in childhood are a heterogeneous group of rare conditions sharing the inflammatory involvement of the CNS. This review highlights the growing knowledge of childhood neuroimmune diseases that primarily affect the CNS, outlining the clinical and diagnostic features, the pathobiological mechanisms and genetics, current treatment options, and emerging challenges. The clinical spectrum of these conditions is increasingly expanded, and the underlying mechanisms of dysregulation of the immune system could vary widely. Cell-mediated and antibody-mediated disorders, infection-triggered and paraneoplastic conditions, and genetically defined mechanisms can occur in previously healthy children and can contribute to different stages of the disease. The careful evaluation of the clinical presentation and temporal course of symptoms, the specific neuroimaging and immunological findings, and the exclusion of alternative causes are mandatory in clinical practice for the syndromic diagnosis. A common feature of these conditions is that immunotherapeutic agents could modulate the clinical course and outcomes of the disease. Furthermore, specific symptomatic treatments and comprehensive multidisciplinary care are needed in the overall management. We focus on recent advances on immune-mediated demyelinating CNS disorders, autoimmune encephalitis, interferonopathies, and possible neuroimmune disorders as Rasmussen encephalitis. Better knowledge of these conditions could allow prompt diagnosis and targeted immunotherapy, to decrease morbidity and mortality as well as to improve clinical outcomes, reducing the burden of the disease due to possible long-term neuropsychiatric sequelae. Persisting controversies remain in the rigorous characterization of each specific clinical entity because of the relative rarity in children; moreover, in a large proportion of suspected neuroimmune diseases, the immune "signature" remains unidentified; treatment guidelines are mostly based on retrospective cohort studies and expert opinions; then advances in specific molecular therapies are required. In the future, a better characterization of specific immunological biomarkers may provide a useful understanding of the underlying pathobiological mechanisms of these conditions in order to individualize more tailored therapeutic options and paradigms. Multicenter collaborative research on homogeneous groups of patients who may undergo immunological studies and therapeutic trials could improve the characterization of the underlying mechanisms, the specific phenotypes, and tailored management.
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Affiliation(s)
- Sara Matricardi
- Department of Neuropsychiatry, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Ancona, Italy
| | - Giovanni Farello
- Pediatric Clinic, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Salvatore Savasta
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
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30
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French CD, Willoughby RE, Pan A, Wong SJ, Foley JF, Wheat LJ, Fernandez J, Encarnacion R, Ondrush JM, Fatteh N, Paez A, David D, Javaid W, Amzuta IG, Neilan AM, Robbins GK, Brunner AM, Hu WT, Mishchuk DO, Slupsky CM. NMR metabolomics of cerebrospinal fluid differentiates inflammatory diseases of the central nervous system. PLoS Negl Trop Dis 2018; 12:e0007045. [PMID: 30557317 PMCID: PMC6312347 DOI: 10.1371/journal.pntd.0007045] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/31/2018] [Accepted: 12/02/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Myriad infectious and noninfectious causes of encephalomyelitis (EM) have similar clinical manifestations, presenting serious challenges to diagnosis and treatment. Metabolomics of cerebrospinal fluid (CSF) was explored as a method of differentiating among neurological diseases causing EM using a single CSF sample. METHODOLOGY/PRINCIPAL FINDINGS 1H NMR metabolomics was applied to CSF samples from 27 patients with a laboratory-confirmed disease, including Lyme disease or West Nile Virus meningoencephalitis, multiple sclerosis, rabies, or Histoplasma meningitis, and 25 controls. Cluster analyses distinguished samples by infection status and moderately by pathogen, with shared and differentiating metabolite patterns observed among diseases. CART analysis predicted infection status with 100% sensitivity and 93% specificity. CONCLUSIONS/SIGNIFICANCE These preliminary results suggest the potential utility of CSF metabolomics as a rapid screening test to enhance diagnostic accuracies and improve patient outcomes.
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Affiliation(s)
- Caitlin D. French
- Department of Nutrition, University of California, Davis, California, United States of America
| | - Rodney E. Willoughby
- Department of Pediatrics, Division of Infectious Disease, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- * E-mail: (REW); (CMS)
| | - Amy Pan
- Department of Pediatrics, Division of Infectious Disease, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Susan J. Wong
- Wadsworth Center Diagnostic Immunology Laboratory, New York State Department of Health, Albany, New York, United States of America
| | - John F. Foley
- Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - L. Joseph Wheat
- Department of Medicine, Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Josefina Fernandez
- Hospital Infantil Robert Reid Cabral, Santo Domingo, Distrito Nacional, República Dominicana
| | - Rafael Encarnacion
- Hospital Infantil Robert Reid Cabral, Santo Domingo, Distrito Nacional, República Dominicana
| | | | - Naaz Fatteh
- Inova Fairfax Hospital, Fairfax, Virginia, United States of America
| | - Andres Paez
- Departamento de Ciencias Basicas, Universidad de la Salle, Bogotá, Colombia
| | - Dan David
- Rabies Lab, Kimron Veterinary Institute, Beit Dagan, Israel
| | - Waleed Javaid
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, United States of America
| | - Ioana G. Amzuta
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, United States of America
| | - Anne M. Neilan
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Gregory K. Robbins
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrew M. Brunner
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - William T. Hu
- Mayo Clinic, Rochester, Minnesota, United States of America
| | - Darya O. Mishchuk
- Department of Food Science and Technology, University of California, Davis, California, United States of America
| | - Carolyn M. Slupsky
- Department of Nutrition, University of California, Davis, California, United States of America
- Department of Food Science and Technology, University of California, Davis, California, United States of America
- * E-mail: (REW); (CMS)
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Eyre M, Hacohen Y, Barton C, Hemingway C, Lim M. Therapeutic plasma exchange in paediatric neurology: a critical review and proposed treatment algorithm. Dev Med Child Neurol 2018; 60:765-779. [PMID: 29856068 DOI: 10.1111/dmcn.13925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
UNLABELLED Therapeutic plasma exchange (TPE) has been a key immunotherapeutic strategy in numerous neurological syndromes, predominantly during the acute phase of illness. This paper reviews the indications, strength of evidence, and safety of TPE in children with neurological conditions. The rarity of these immune conditions in children, alongside an often incomplete understanding of their pathobiology, has limited the development of a robust scientific rationale for TPE therapy and the feasibility of conducting larger controlled trials. TPE continues to be used, but is a costly therapy with common adverse effects. Uncertainty remains over how to compare the different TPE methods, the optimal dosage of therapy, and monitoring and integration of TPE with other immunotherapies. Further studies are also required to define the indications and benefits of TPE and assess evolving technologies such as immunoadsorption. WHAT THIS PAPER ADDS Studies investigating therapeutic plasma exchange (TPE) are small and mainly uncontrolled. They provide evidence for the efficacy of TPE in childhood neuro-inflammatory conditions. TPE is generally well tolerated provided key adverse effects are anticipated and avoided. Systematic dosing and objective assessment of treatment effect should be priorities for future research.
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Affiliation(s)
- Michael Eyre
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Carmen Barton
- Children's Kidney Service, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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Zhang X, Guo X, Zhang N, Cai H, Sun J, Wang Q, Qi Y, Zhang L, Yang L, Shi FD, Yu C. Cerebral Blood Flow Changes in Multiple Sclerosis and Neuromyelitis Optica and Their Correlations With Clinical Disability. Front Neurol 2018; 9:305. [PMID: 29780351 PMCID: PMC5946009 DOI: 10.3389/fneur.2018.00305] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 04/18/2018] [Indexed: 11/13/2022] Open
Abstract
Distinguishing relapsing-remitting multiple sclerosis (RRMS) and neuromyelitis optica (NMO) is clinically important because they differ in prognosis and treatment. This study aimed to identify perfusion abnormalities in RRMS and NMO and their correlations with gray matter volume (GMV) atrophy and clinical parameters. Structural and arterial spin labeling MRI scans were performed in 39 RRMS patients, 62 NMO patients, and 73 healthy controls. The gray matter cerebral blood flow (CBF) values were voxel-wisely compared among the three groups with and without GMV correction. The regional CBF changes were correlated with the Expanded Disability Status Scale scores in the corresponding patient groups. Although multiple brain regions showed CBF differences among the three groups without GMV correction, only three of these regions remained significant after GMV correction. Specifically, both the RRMS and NMO groups showed reduced CBF in the occipital cortex and increased CBF in the right putamen compared to the control group. The RRMS group had increased CBF only in the medial prefrontal cortex compared to the other two groups. The occipital CBF was negatively correlated with clinical disability in the NMO group; however, the CBF in the right putamen was positively correlated with clinical disability in both patient groups. These findings suggest that there are perfusion alterations independent of GMV atrophy in RRMS and NMO patients. The regional CBF in the occipital cortex and putamen could be used as imaging features to objectively assess clinical disability in these patients.
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Affiliation(s)
- Xue Zhang
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging, Tianjin, China
| | - Xi Guo
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging, Tianjin, China
| | - Ningnannan Zhang
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging, Tianjin, China
| | - Huanhuan Cai
- Laboratory of Digital Medical Imaging, Medical Imaging Center, The First Affiliated Hospital, Anhui University of Chinese Medicine, Hefei, China
| | - Jie Sun
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging, Tianjin, China
| | - Qiuhui Wang
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging, Tianjin, China
| | - Yuan Qi
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Linjie Zhang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Li Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chunshui Yu
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging, Tianjin, China
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Kheiri B, Abu Sitta E, Salih A, Al Qasmi M, Bachuwa G. Acute disseminated encephalomyelitis following Influenza A pneumonia. Clin Case Rep 2017; 6:436-438. [PMID: 29445493 PMCID: PMC5799639 DOI: 10.1002/ccr3.1353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/19/2017] [Accepted: 12/06/2017] [Indexed: 11/10/2022] Open
Abstract
Acute disseminated encephalomyelitis (ADEM) is an autoimmune demyelinating disorder of the central nervous system and can present following influenza A infections as multifocal neurological deficits. ADEM remains a challenging diagnosis, and high clinical suspicious coupled with laboratory investigations and neuroimaging is required to exclude other primary and secondary demyelinating disorders.
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Affiliation(s)
- Babikir Kheiri
- Internal Medicine Department Hurley Medical Center/Michigan State University Two Hurley Plaza, Ste 212 Flint Michigan 48503
| | - Emad Abu Sitta
- Internal Medicine Department Hurley Medical Center/Michigan State University Two Hurley Plaza, Ste 212 Flint Michigan 48503
| | - Anas Salih
- Internal Medicine Department Hurley Medical Center/Michigan State University Two Hurley Plaza, Ste 212 Flint Michigan 48503
| | - Mohammed Al Qasmi
- Internal Medicine Department Hurley Medical Center/Michigan State University Two Hurley Plaza, Ste 212 Flint Michigan 48503
| | - Ghassan Bachuwa
- Internal Medicine Department Hurley Medical Center/Michigan State University Two Hurley Plaza, Ste 212 Flint Michigan 48503
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35
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Altered mental status after seasonal influenza vaccination. J Clin Neurosci 2017. [DOI: 10.1016/j.jocn.2017.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wan Sulaiman WA, Inche Mat LN, Hashim HZ, Hoo FK, Ching SM, Vasudevan R, Mohamed MH, Basri H. Acute disseminated encephalomyelitis in dengue viral infection. J Clin Neurosci 2017. [PMID: 28625589 DOI: 10.1016/j.jocn.2017.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dengue is the most common arboviral disease affecting many countries worldwide. An RNA virus from the flaviviridae family, dengue has four antigenically distinct serotypes (DEN-1-DEN-4). Neurological involvement in dengue can be classified into dengue encephalopathy immune-mediated syndromes, encephalitis, neuromuscular or dengue muscle dysfunction and neuro-ophthalmic involvement. Acute disseminated encephalomyelitis (ADEM) is an immune mediated acute demyelinating disorder of the central nervous system following recent infection or vaccination. This monophasic illness is characterised by multifocal white matter involvement. Many dengue studies and case reports have linked ADEM with dengue virus infection but the association is still not clear. Therefore, this article is to review and discuss concerning ADEM in dengue as an immune-medicated neurological complication; and the management strategy required based on recent literature.
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Affiliation(s)
- Wan Aliaa Wan Sulaiman
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.
| | - Liyana Najwa Inche Mat
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Hasnur Zaman Hashim
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| | - Fan Kee Hoo
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Siew Mooi Ching
- Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia; Institute of Gerontology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | | | - Mohd Hazmi Mohamed
- Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| | - Hamidon Basri
- Department of Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
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Collongues N, Kremer S, de Sèze J. Mielopatie acute. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)83854-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
Pediatric autoimmune epileptic encephalopathies are predominantly characterized by the presence of autoantibodies to the surface of neuronal proteins, for example, N-methyl-d-aspartate (NMDA) receptor antibodies, but also include diseases with non-cell surface antibodies (eg, anti-Hu, glutamic-acid decarboxylase antibodies). In some cases with distinct clinical and para-clinical features, an autoimmune epileptic encephalopathy can be diagnosed without the presence of an antibody and will also respond favorably to immunotherapy. In this review, we summarize the common presentations of pediatric autoimmune epileptic encephalopathies, treatments, and outcomes, and report recent findings in the field of epilepsy, encephalopathy, and the immune system.
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Affiliation(s)
- Sukhvir Wright
- 1 Department of Pediatric Neurology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Angela Vincent
- 2 Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, Oxford, United Kingdom
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 371] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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Abstract
Acute disseminated encephalomyelitis is a primarily pediatric, immune-mediated disease characterized by demyelination and polyfocal neurologic symptoms that typically occur after a preceding viral infection or recent immunization. This article presents the pathophysiology, diagnostic criteria, and magnetic resonance imaging characteristics of acute disseminated encephalomyelitis. We also present evaluation and management strategies.
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Bai HX, Zou Y, Lee AM, Lancaster E, Yang L. Diagnostic Value and Safety of Brain Biopsy in Patients With Cryptogenic Neurological Disease: A Systematic Review and Meta-analysis of 831 Cases. Neurosurgery 2016; 77:283-95; discussion 295. [PMID: 25856111 DOI: 10.1227/neu.0000000000000756] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The role of brain biopsy in patients with cryptogenic neurological disease is uncertain. OBJECTIVE To determine the risks and benefits of diagnostic brain biopsy for nonneoplastic indications in immunocompetent patients. METHODS Appropriate studies were identified by searching electronic databases. RESULTS We screened 3645 abstracts and included 20 studies with a total of 831 patients. Indications for biopsy were: (1a) severe neurological disease of unknown etiology in adults (n = 7) and (1b) in children (n = 2); (2) suspected primary angiitis of the central nervous system (PACNS) (n = 3); (3) chronic meningitis of unknown cause (n = 3); (4) atypical dementia (n = 4); and (5) nonneoplastic disease (n = 1). Diagnostic success rates calculated for subgroups were 51.3% (34.5-68.1) for 1a, 53.8% (42.9-64.5) for 1b, 74.7% (64.0-84.1) for 2, 30.3% (17.2-45.4) for 3, and 60.8% (41.2-78.8) for 4. Clinical impact rates were 30.5% (13.6-50.6) for 1a (n = 6), 67.1% (42.8-87.3) for 1b (n = 2), 8.3% (2.3-20.0) for 3 (n = 1), and 14.2% (6.5-24.3) for 4 (n = 2). Lymphoma (n = 32) and Creutzfeldt-Jakob disease (n = 30) were the most common diagnoses on the final histopathology reports of positive brain biopsies in 1a. In 1b, encephalitis (n = 7), PACNS (n = 6), and demyelination (n = 6) were the most common. The odds ratio for achieving a diagnostic biopsy when there was a radiological target was 3.70 (P = .014, 95% confidence interval, 1.31-10.42). CONCLUSION Brain biopsy in cryptogenic neurological disease was associated with the highest diagnostic yield in patients with suspected PACNS. The greatest clinical impact was seen in children with cryptogenic neurological disease. The presence of a radiological target was associated with a higher diagnostic yield.
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Affiliation(s)
- Harrison Xiao Bai
- ‡Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; §Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia; ¶Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Berzero G, Cortese A, Ravaglia S, Marchioni E. Diagnosis and therapy of acute disseminated encephalomyelitis and its variants. Expert Rev Neurother 2015; 16:83-101. [DOI: 10.1586/14737175.2015.1126510] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Ben Achour N, Ben Waddey O, Kraoua I, Benrhouma H, Klaa H, Rouissi A, Ben Youssef-Turki I. [Acute disseminated encephalomyelitis in Tunisia: Report of a pediatric cohort]. Rev Neurol (Paris) 2015; 171:882-90. [PMID: 26573333 DOI: 10.1016/j.neurol.2015.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/20/2015] [Accepted: 09/09/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Acute disseminated encephalomyelitis (ADEM) is an inflammatory, demyelinating disorder of the central nervous system whose clinical features, management and outcome are incompletely understood in Tunisian population. OBJECTIVE To describe clinical, neuroimaging and laboratory features; treatment and outcome in a cohort of Tunisian children with ADEM. METHODS We conducted a retrospective review of the medical records of all children attending the Department of Child and Adolescent Neurology (Tunis) with ADEM between 2005 and 2015. Clinical, neuroimaging and laboratory features, therapeutic data and outcome were analyzed. RESULTS There were 15 children (7 males and 8 females). The mean age at onset was 6.9 years. Thirteen (86.6%) patients had a prodromal event. The onset of neurological symptoms occurred within 17.6 days (4-30). Limb weakness was the most common presenting symptom (53.3%). Extrapyramidal syndrome was noticed in 6 patients (40%). Initial MRI showed a deep gray matter involvement in 7 cases (46.6%). Gadolinium enhancement at acute stage was observed in only 2 patients (13%). Cerebrospinal fluid findings did not show intrathecal oligoclonal bands. The use of high-dose IV methylprednisolone followed by oral steroid taper was associated with rapid recovery. Additional treatment with intravenous immunoglobulin was necessary in 2 patients. Complete recovery was obtained in 11 patients (73.3%). A monophasic course was noticed in 14 cases. Only one patient (5%) developed multiple sclerosis. CONCLUSION The high frequency of prodromal events and extrapyramidal syndrome in addition to the low rate of gadolinium enhancement at acute stage seem to be the main features in our patients. Larger ADEM multicenter cohort studies in Tunisia and North Africa could provide more detailed information about this entity.
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Affiliation(s)
- N Ben Achour
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie.
| | - O Ben Waddey
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie
| | - I Kraoua
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie
| | - H Benrhouma
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie
| | - H Klaa
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie
| | - A Rouissi
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie
| | - I Ben Youssef-Turki
- UR12SP24 et service de neurologie de l'enfant et de l'adolescent, Institut national Mongi Ben Hmida de neurologie, La Rabta, 1007 Tunis, Tunisie
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Peng XZ, Hua LH, Qiang SZ, Qiang W. A case of tumor-like inflammatory demyelinating disease with progressive brain and spinal cord involvement. SAO PAULO MED J 2015; 133:445-9. [PMID: 26648435 PMCID: PMC10871805 DOI: 10.1590/1516-3180.2014.7832407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 07/11/2014] [Accepted: 07/21/2014] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Tumor-like inflammatory demyelinating disease (TIDD) usually occurs in the brain and rarely occurs in the spinal cord. TIDD appears to be very similar to tumors such as gliomas on imaging, which may lead to incorrect or delayed diagnosis and treatment. CASE REPORT Because of headache and incoherent speech, a 24-year-old Chinese male presented to our hospital with a two-week history of respiratory infections. After dexamethasone treatment, his symptoms still got worse and surgery was performed for diagnostic purposes. Histological examination revealed that the lesion was inflammatory. Further lesions appeared in the spine (T3 and T4 levels) after two months and in the right occipital lobe after three months. After intravenous immunoglobulin (IVIG) and methylprednisolone treatment, his symptoms improved. CONCLUSION Progressive lesions may damage the brain and spinal cord, and long-term prednisolone and IVIG therapy are beneficial in TIDD patients.
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Affiliation(s)
- Xu Zhi Peng
- MD, MSc. Attending Physician, Department of Neurology, Wuhan General Hospital of Guangzhou Command, Wuhan, China
| | - Li Hong Hua
- MD, PhD. Professor, Department of Neurology, Wuhan General Hospital of Guangzhou Command, Wuhan, China
| | - Sun Zhi Qiang
- MD, MSc. Attending Physician, Department of Radiology, Wuhan General Hospital of Guangzhou Command, Wuhan, China
| | - Wu Qiang
- MD, PhD. Professor, Department of Neurology, Wuhan General Hospital of Guangzhou Command, Wuhan, China
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Bale JF. Virus and Immune-Mediated Encephalitides: Epidemiology, Diagnosis, Treatment, and Prevention. Pediatr Neurol 2015; 53:3-12. [PMID: 25957806 DOI: 10.1016/j.pediatrneurol.2015.03.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/09/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
Abstract
Virus encephalitis remains a major cause of acute neurological dysfunction and permanent disability among children worldwide. Although some disorders, such as measles encephalomyelitis, subacute sclerosing panencephalitis, and varicella-zoster virus-associated neurological conditions, have largely disappeared in resource-rich regions because of widespread immunization programs, other disorders, such as herpes simplex virus encephalitis, West Nile virus-associated neuroinvasive disease, and nonpolio enterovirus-induced disorders of the nervous system, cannot be prevented. Moreover, emerging viral disorders pose new, potential threats to the child's nervous system. This review summarizes current information regarding the epidemiology of virus encephalitis, the diagnostic methods available to detect central nervous system infection and identify viral pathogens, and the available treatments. The review also describes immune-mediated disorders, including acute disseminated encephalomyelitis and N-methyl-D-aspartate receptor antibody encephalitis, conditions that mimic virus encephalitis and account for a substantial proportion of childhood encephalitis.
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Affiliation(s)
- James F Bale
- Division of Pediatric Neurology, Departments of Pediatrics and Neurology, University of Utah School of Medicine, Salt Lake City, Utah.
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Esposito S, Di Pietro GM, Madini B, Mastrolia MV, Rigante D. A spectrum of inflammation and demyelination in acute disseminated encephalomyelitis (ADEM) of children. Autoimmun Rev 2015; 14:923-9. [PMID: 26079482 PMCID: PMC7105213 DOI: 10.1016/j.autrev.2015.06.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 11/15/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that involves multifocal areas of the white matter, rarely the gray matter and spinal cord, mainly affecting children and mostly occurring 1-2weeks after infections or more rarely after vaccinations. Though a specific etiologic agent is not constantly identified, to evaluate carefully patient's clinical history and obtain adequate samples for the search of a potential ADEM causal agent is crucial. In the case of a prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with full recovery, but in the case of diagnostic delays or inappropriate treatment some patients might display neurological sequelae and persistent deficits or even show an evolution to multiple sclerosis. The suspicion of ADEM rises on a clinical basis and derives from systemic and neurologic signs combined with magnetic resonance imaging of the central nervous system. Other advanced imaging techniques may help an appropriate differential diagnosis and definition of exact disease extension. Although there is no standardized protocol or management for ADEM, corticosteroids, intravenous immunoglobulin, and plasmapheresis have been successfully used. There is no marker that permits to identify the subset of children with worse prognosis and future studies should try to detect any biological clue for prevision of neurologic damage as well as should optimize treatment strategies using an approach based on the effective risk of negative evolution.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giada Maria Di Pietro
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Madini
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Vincenza Mastrolia
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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Bigi S, Banwell B, Yeh EA. Outcomes after early administration of plasma exchange in pediatric central nervous system inflammatory demyelination. J Child Neurol 2015; 30:874-80. [PMID: 25246301 DOI: 10.1177/0883073814545883] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 07/01/2014] [Indexed: 12/20/2022]
Abstract
The use of plasma exchange has been described in steroid-refractory central nervous system inflammatory demyelination in adults, but less has been published regarding its use in children and adolescents. We describe 12 children treated with plasma exchange for acute severe central nervous system inflammatory demyelination. The clinical attack leading to plasma exchange included symptomatic spinal cord lesions in 10 and symptomatic brainstem lesions in 2 children. Diagnosis was acute transverse myelitis in 6, relapsing-remitting multiple sclerosis in 5, and acute disseminated encephalomyelitis in 1 child. Adverse events related to plasma exchange necessitating intervention were observed in 3 children. Median Expanded Disability Status Scale score at plasma exchange start was 7.5 (range 4-9.5). At 3 months, 7 children were ambulatory without aid (Expanded Disability Status Scale score of ≤4). This retrospective study suggests that plasma exchange can be effective in ameliorating symptoms in severe pediatric central nervous system inflammatory demyelination, although lack of randomization or control group limits the ability to attribute this outcome entirely to plasma exchange.
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Affiliation(s)
- Sandra Bigi
- The Hospital for Sick Children, Division of Neurology, Toronto, Ontario, Canada
| | - Brenda Banwell
- The Hospital for Sick Children, Division of Neurology, Toronto, Ontario, Canada The Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA
| | - E Ann Yeh
- The Hospital for Sick Children, Division of Neurology, Toronto, Ontario, Canada
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48
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Acute disseminated encephalomyelitis: current controversies in diagnosis and outcome. J Neurol 2015; 262:2013-24. [DOI: 10.1007/s00415-015-7694-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/06/2015] [Accepted: 02/08/2015] [Indexed: 10/23/2022]
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49
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Abstract
OPINION STATEMENT Decompressive craniectomy (DC) involves the removal of a portion of the skull in the setting of life threatening brain edema or potentially uncontrollable intracranial pressures. Often performed on an emergent basis, evaluation and arrangement for DC should be swift and decisive. However, the evidence base for DC in the wide range of conditions for which it is currently performed is still developing. The procedure is associated with a number of complications and ethical considerations; thus, its place in contemporary practice remains controversial. While randomized trials conducted in the last decade have provided valuable data on the indications, eligibility criteria, and outcomes for DC in the treatment of traumatic brain injury and malignant middle cerebral artery infarction, important outstanding issues continue to complicate the decision to pursue DC on an individual case basis and in the number of other clinical settings presenting with brain edema and intracranial hypertension. In this review, we present the existing evidence and remaining questions regarding DC in various neurologic conditions including traumatic brain injury, ischemic stroke, subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, encephalitis, and others. We also discuss perioperative considerations and ethical issues likely to be encountered by clinicians caring for patients and families who are considering or have undergone DC.
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50
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Sannagowdara K, Willoughby R, Whelan H. Proton Nuclear Magnetic Resonance (NMR) Metabolomics: Future in Etiological Diagnosis of Encephalomyelitis. ACTA ACUST UNITED AC 2015; 6. [PMID: 26339656 DOI: 10.4172/2314-7326.1000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kumar Sannagowdara
- Department of Pediatric Neurology, Medical College of Wisconsin, Milwaukee WI, USA
| | - Rodney Willoughby
- Department of Pediatric Infectious Diseases, Medical College of Wisconsin, Milwaukee WI, USA
| | - Harry Whelan
- Department of Pediatric Neurology, Medical College of Wisconsin, Milwaukee WI, USA
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