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Abbatemarco JR, Vedeler CA, Greenlee JE. Paraneoplastic cerebellar and brainstem disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:173-191. [PMID: 38494276 DOI: 10.1016/b978-0-12-823912-4.00030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic cerebellar and brainstem disorders are a heterogeneous group that requires prompt recognition and treatment to help prevent irreversible neurologic injury. Paraneoplastic cerebellar degeneration is best characterized by Yo antibodies in patients with breast or ovarian cancer. Tr (DNER) antibodies in patients with Hodgkin lymphoma can also present with a pure cerebellar syndrome and is one of the few paraneoplastic syndromes found with hematological malignancy. Opsoclonus-myoclonus-ataxia syndrome presents in both pediatric and adult patients with characteristic clinical findings. Other paraneoplastic brainstem syndromes are associated with Ma2 and Hu antibodies, which can cause widespread neurologic dysfunction. The differential for these disorders is broad and also includes pharmacological side effects, infection or postinfectious processes, and neurodegenerative diseases. Although these immune-mediated disorders have been known for many years, mechanisms of pathogenesis are still unclear, and optimal treatment has not been established.
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Affiliation(s)
- Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States.
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States; Department of Neurology, University of Utah, Salt Lake City, UT, United States
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2
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Grossman SN, Rucker JC. Opsoclonus and ocular flutter: evaluation and management. Curr Opin Ophthalmol 2023; 34:465-469. [PMID: 37603546 DOI: 10.1097/icu.0000000000000998] [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: 08/23/2023]
Abstract
PURPOSE OF REVIEW Opsoclonus and ocular flutter are saccadic intrusions characterized by spontaneous, back-to-back, fast eye movements (saccades) that oscillate about the midline of central visual fixation without intervening inter-saccadic intervals. When this type of movement occurs exclusively in the horizontal plane, it is called ocular flutter. When it occurs in multiple planes (i.e. horizontal, vertical, and torsional) it is called opsoclonus. The most common etiologic categories are parainfectious and paraneoplastic diseases. Less common are toxic-metabolic, traumatic, or idiopathic origins. The mechanism of these movements relates to dysfunction of brainstem and cerebellar machinery involved in the generation of saccades. In this review, we discuss the characteristics of opsoclonus and ocular flutter, describe approaches to clinical evaluation and management of the patient with opsoclonus and ocular flutter, and review approaches to therapeutic intervention. RECENT FINDINGS Recent publications demonstrated eye position-dependent opsoclonus present only in left gaze, which may be related to dysfunction of frontal eye fields or structures in the cerebellar vermis. SUMMARY Opsoclonus and ocular flutter originate from a broad array of neuropathologies and have value from both a neuroanatomic and etiologic perspective.
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Affiliation(s)
| | - Janet C Rucker
- Department of Neurology
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, New York, USA
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3
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Kanekar S, Zacharia T, Agarwal A. Neoplastic Meningitis and Paraneoplastic Syndromes. Radiol Clin North Am 2021; 59:409-423. [PMID: 33926686 DOI: 10.1016/j.rcl.2021.01.007] [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] [Indexed: 11/18/2022]
Abstract
Neoplastic meningitis (NM) and paraneoplastic syndromes (PNSs) are a rare group of disorders present in patients with cancer. Clinical diagnosis of these conditions is challenging, and imaging and laboratory analysis play a significant role in diagnosing. Diagnosis of NM largely depends on documenting circulating tumor cells in the cerebrospinal fluid (CSF) and/or leptomeningeal and nodular enhancement on contrast-enhanced MR imaging of the brain or axial spine. PNSs encompass a variety of symptoms or syndromes. Paraneoplastic neuronal disorder diagnosis requires a multidimensional approach, high clinical suspicion, CSF and serum examination, and imaging. Neuroimaging is an integral part in the evaluation.
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Affiliation(s)
- Sangam Kanekar
- Department of Radiology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA; Department of Neurology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA.
| | - Thomas Zacharia
- Department of Radiology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA
| | - Amit Agarwal
- Department of Radiology, UT Southwestern Medical School and Parkland Hospital, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Sotoudeh H, Razaei A, Saadatpour Z, Gaddamanugu S, Choudhary G, Shafaat O, Singhal A. Brainstem Encephalitis. The Role of Imaging in Diagnosis. Curr Probl Diagn Radiol 2020; 50:946-960. [PMID: 33032853 DOI: 10.1067/j.cpradiol.2020.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 01/19/2023]
Abstract
Encephalitis is a relatively challenging rare condition caused by a diverse group of etiologies. Brainstem encephalitis/Rhombencephalitis (BE), which affects the cerebellum, pons, and medulla, is even less common and more challenging for diagnosis and treatment. At this time, there is scattered data about BE in the literature, mainly in the form of case reports and case series. In this manuscript, the imaging presentation of BE is reviewed with the help of case examples. Many imaging presentations are not pathognomonic for BE; however, in many cases, clinical presentation, the spatial distribution of lesions, and other associated radiological lesions can provide the radiologists and clinician the clues to an accurate diagnosis.
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Affiliation(s)
| | - Ali Razaei
- Department of Neuroradiology, University of Alabama at Birmingham (UAB), Birmingham, AL
| | - Zahra Saadatpour
- Department of Neuroradiology, University of Alabama at Birmingham (UAB), Birmingham, AL
| | | | | | - Omid Shafaat
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aparna Singhal
- University of Alabama at Birmingham (UAB), Birmingham, AL
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Abstract
Paraneoplastic neurological syndromes are nonmetastatic complications of malignancy secondary to immune-mediated neuronal dysfunction or death. Pathogenesis may occur from cell surface binding of antineuronal antibodies leading to dysfunction of the target protein, or from antibodies binding against intracellular antigens which ultimately leads to cell death. There are several classical neurological paraneoplastic phenotypes including subacute cerebellar degeneration, limbic encephalitis, encephalomyelitis, and dorsal sensory neuropathy. The patient’s clinical presentations may be suggestive to the treating clinician as to the specific underlying paraneoplastic antibody. Specific antibodies often correlate with the specific underlying tumor type, and malignancy screening is essential in all patients with paraneoplastic neurological disease. Prompt initiation of immunotherapy is essential in the treatment of patients with paraneoplastic neurological disease, often more effective in cell surface antibodies in comparison to intracellular antibodies, as is removal of the underlying tumor.
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Affiliation(s)
- Jonathan Galli
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA.,2. George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - John Greenlee
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA
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Zidan A, Fein A, Zuchowski K. The use, misuse and abuse of paraneoplastic panels in neurological disorders. A retrospective study. Clin Neurol Neurosurg 2019; 186:105545. [PMID: 31622896 DOI: 10.1016/j.clineuro.2019.105545] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/22/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The field of paraneoplastic neurological syndromes PNS has grown exponentially with the increased identification of associated antibodies. Testing for these antibodies is commonly done in "panels" to increase sensitivity, and these panels have become a routine test on CSF samples obtained for a variety of clinical indications. Excessive testing has raised concerns about the correct utilization of these panels. Our study investigates the appropriateness of use of paraneoplastic panel in an academic, tertiary-care medical center. PATIENTS AND METHODS We retrospectively reviewed charts of all patients who had autoimmune paraneoplastic panel testing in one year period. We collected date on demographics, clinical presentations and ancillary testings on all reviewed charts. Then, we devised an algorithm based on available data to define cases where testing had been unnecessary or likely unnecessary. RESULTS We collected 60 cases that had undergone autoimmune paraneoplastic testing serum and/or CSF. Testing was unnecessary in 10 cases (16%), in which presentations had a definitive confirmatory tests. Testing was unlikely necessary in 11 cases (18%), in which all ancillary testing was normal in 6 cases, and presentation was not compatible with any known syndrome in 5 cases. Collectively, paraneoplastic panel testing was of extremely low yield on more than one third of the cases where where w testing was done. CONCLUSION Our results adds to the growing concerns about the utilization of paraneoplastic panels, and the urgent need for enhanced screening and establishing a framework that can guide neurologists on when testing can have a sufficient yield to warrant it. Such framework should be built using diagnostic algorithms based on risk, clinical manifestations, characterization of autoantibodies and their associations.
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Malek N, Damian M. Trismus caused by paraneoplastic brainstem encephalitis. Pract Neurol 2018; 18:146-150. [PMID: 29440480 DOI: 10.1136/practneurol-2017-001819] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2017] [Indexed: 11/04/2022]
Abstract
We discuss the assessment and differential diagnoses of a middle-aged man who presented with trismus, double vision and behavioural problems. MRI scan of the brain was initially normal, but a month later showed high signal in the hippocampal region on fluid attenuated inversion recovery sequence (FLAIR) imaging. We suspected a paraneoplastic brainstem encephalitis because of his smoking history, rapidly progressive symptoms and abnormal brainstem signs. A positron emission tomography-CT scan identified abnormal subcarinal nodes, shown on biopsy to be metastatic small cell lung cancer. He is currently undergoing treatment with chemotherapy and radiotherapy.
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Affiliation(s)
- Naveed Malek
- Department of Neurology, Ipswich Hospital NHS Trust, Ipswich, UK
| | - Maxwell Damian
- Department of Neurology, Ipswich Hospital NHS Trust, Ipswich, UK
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9
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Bentea G, Sculier C, Grigoriu B, Meert AP, Durieux V, Berghmans T, Sculier JP. Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 3: Neurological paraneoplastic syndromes, involving the central nervous system. Lung Cancer 2017; 106:83-92. [PMID: 28285700 DOI: 10.1016/j.lungcan.2017.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The development of new immune treatment in oncology and particularly for lung cancer may induce new complications, particularly activation or reactivation of auto-immune diseases. In this context, a systematic review on the auto-immune paraneoplastic syndromes that can complicate lung cancer appears useful. This article is the third of a series of five and deals mainly with neurological paraneoplastic syndromes involving the central nervous system.
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Affiliation(s)
- Georgiana Bentea
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Claudine Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Bogdan Grigoriu
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Anne-Pascale Meert
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Thierry Berghmans
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Jean-Paul Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium.
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Albadareen R, Gronseth G, Goeden M, Sharrock M, Lechtenberg C, Wang Y. Paraneoplastic autoantibody panels: sensitivity and specificity, a retrospective cohort. Int J Neurosci 2016; 127:531-538. [PMID: 27356679 DOI: 10.1080/00207454.2016.1207644] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Experts in the autoimmune paraneoplastic field recommend autoantibody testing as "panels" to improve the poor sensitivity of individual autoantibodies in detecting paraneoplastic neurological syndromes (PNS). The sensitivity of those panels was not reported to date in a fashion devoid of incorporation bias. We aimed to assess the collective sensitivity and specificity of one of the commonly used panels in detecting PNS. METHODS A single-centered retrospective cohort of all patients tested for paraneoplastic evaluation panel (PAVAL; test ID: 83380) over one year for the suspicion of PNS. Case adjudication was based on newly proposed diagnostic criteria in line with previously published literature, but modified to exclude serological status to avoid incorporation bias. Measures of diagnostic accuracy were subsequently calculated. Cases that failed to show association with malignancy within the follow-up time studied, reflecting a possibly pure autoimmune process was considered paraneoplastic-like syndromes. RESULTS Out of 321 patients tested, 51 patients tested positive. Thirty-two patients met diagnostic criteria for paraneoplastic/paraneoplastic-like syndromes. The calculated collective sensitivity was 34% (95% CI: 17-53), specificity was 86% (95% CI: 81-90), Youden's index 0.2 and a positive clinical utility index 0.07 suggesting poor utility for case-detection. CONCLUSION This is the first reported diagnostic accuracy measures of paraneoplastic panels without incorporation bias. Despite recommended panel testing to improve detection of PNS, sensitivity remains low with poor utility for case-detection. The high-calculated specificity suggests a possible role in confirming the condition in difficult cases suspicious for PNS, when enough supportive evidence is lacking on ancillary testing.
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Affiliation(s)
- Rawan Albadareen
- a Department of Neurology , University of Kansas Medical Center , Kansas City , KS , USA
| | - Gary Gronseth
- a Department of Neurology , University of Kansas Medical Center , Kansas City , KS , USA
| | - Marcie Goeden
- b Division of Neurology , Children's Mercy Hospital , Kansas City , MO , USA
| | - Matthew Sharrock
- a Department of Neurology , University of Kansas Medical Center , Kansas City , KS , USA
| | - Colleen Lechtenberg
- a Department of Neurology , University of Kansas Medical Center , Kansas City , KS , USA
| | - Yunxia Wang
- a Department of Neurology , University of Kansas Medical Center , Kansas City , KS , USA
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Yoon JE, Lee KB, Kim JS, Ahn MY, Roh H. Paraneoplastic Brainstem Encephalitis Associated with Anti-Hu Antibody. JOURNAL OF NEUROCRITICAL CARE 2015. [DOI: 10.18700/jnc.2015.8.2.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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12
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Dudesek A, Rimmele F, Tesar S, Kolbaske S, Rommer PS, Benecke R, Zettl UK. CLIPPERS: chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. Review of an increasingly recognized entity within the spectrum of inflammatory central nervous system disorders. Clin Exp Immunol 2014; 175:385-96. [PMID: 24028073 DOI: 10.1111/cei.12204] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 01/16/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently defined inflammatory central nervous system (CNS) disorder, prominently involving the brainstem and in particular the pons. The condition features a combination of clinical symptoms essentially referable to brainstem pathology and a characteristic magnetic resonance imaging (MRI) appearance with punctate and curvilinear gadolinium enhancement 'peppering' the pons. The radiological distribution is focused in the pons and adjacent rhombencephalic structures such as the cerebellar peduncles, cerebellum, medulla and the midbrain. While the lesion burden with a perivascular pattern is typically most dense in these pontine and peripontine regions, enhancing lesions may additionally extend into the spinal cord and supratentorial structures such as the thalamus, basal ganglia, capsula interna, corpus callosum and the cerebral white matter. Another core feature is clinical and radiological responsiveness to glucocorticosteroid (GCS)-based immunosuppression. As withdrawal of GCS treatment results commonly in disease exacerbation, long-term immunosuppressive therapy appears to be mandatory for sustained improvement. Diagnosis of CLIPPERS is challenging, and requires careful exclusion of alternative diagnoses. A specific serum or cerebrospinal fluid (CSF) biomarker for the disorder is currently not known. Pathogenesis of CLIPPERS remains poorly understood, and the nosological position of CLIPPERS has still to be established. Whether CLIPPERS represents an independent, actual new disorder or a syndrome that includes aetiologically heterogeneous diseases and/or their prestages remains a debated and not finally clarified issue. Clinicians and radiologists should be aware of this condition and its differential diagnoses, given that CLIPPERS constitutes a treatable condition and that patients may benefit from an early introduction of GCS ensued by long-term immunosuppression. Based on previous reports in literature - currently encompassing more than 50 reported cases of CLIPPERS - this review addresses clinical features, diagnostic criteria, differential diagnoses and therapeutic management of this peculiar disorder.
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Affiliation(s)
- A Dudesek
- Department of Neurology, University of Rostock, Rostock, Germany
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Sioka C, Fotopoulos A, Kyritsis AP. Paraneoplastic immune-mediated neurological effects of systemic cancers. Expert Rev Clin Immunol 2014; 10:621-30. [PMID: 24665890 DOI: 10.1586/1744666x.2014.901151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cancer patients may develop paraneoplastic neurological conditions associated with autoantibodies directed against neural or neuromuscular tissues. These syndromes are frequently manifested in advance of the cancer presentation by several months or years necessitating a detailed and expensive investigation to search for the presence of a malignancy. In such cases additional assistance may be obtained by the early employment of whole body 18F flurodeoxyglucose positron emission tomography as a cancer screening imaging procedure for early cancer diagnosis and potential therapy. Effective therapy of the primary cancer consists the best current therapy for a given paraneoplastic syndrome. However, other forms of immune modulation, such as plasma exchange, intravenous gamma globulin, other immune therapies and symptomatic treatment for certain PNS may have additional benefit.
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Affiliation(s)
- Chrissa Sioka
- Neurosurgical Research Institute, University of Ioannina, Ioannina, Greece
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