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Benbrahim FZ, Belkouchi L, Allali N, El Haddad S, Chat L. Susac syndrome: A rare pediatric case. Radiol Case Rep 2024; 19:5191-5195. [PMID: 39263516 PMCID: PMC11387525 DOI: 10.1016/j.radcr.2024.07.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/13/2024] Open
Abstract
Susac syndrome is a rare microangiopathy of unclear etiology, likely autoimmune, characterized by a characteristic clinical triad of encephalopathy, retinopathy, and hypoacusis. The majority of cases reported in the literature involve adult patients, with its occurrence in the pediatric population being extremely rare. Magnetic resonance imaging (MRI) is essential for diagnosis and patient monitoring, revealing nearly pathognomonic features, particularly valuable given the typically incomplete clinical triad and the consistent presence of encephalopathy, often as the initial symptom. We report the case of an 11-year-old child diagnosed with Susac syndrome, highlighting the importance of considering this diagnosis in cases of childhood encephalopathy and initiating treatment as early as possible to prevent irreversible sequelae.
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Affiliation(s)
- Fatima Zohra Benbrahim
- Department of Radiology, Children hospital of Rabat, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Lina Belkouchi
- Department of Radiology, Children hospital of Rabat, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Nazik Allali
- Department of Radiology, Children hospital of Rabat, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Siham El Haddad
- Department of Radiology, Children hospital of Rabat, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Latifa Chat
- Department of Radiology, Children hospital of Rabat, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
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2
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Storp JJ, Englmaier VA, Zimmermann JA, Eter N, Lahme L, Alnawaiseh M. [Effects of Susac syndrome on the central vascular structure of the retina-An optical coherence tomography angiography study]. DIE OPHTHALMOLOGIE 2024; 121:487-493. [PMID: 38634948 DOI: 10.1007/s00347-024-02029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Susac syndrome (SS) describes an endotheliopathy of vessels in the central nervous system. Retinal involvement plays a central role in the manifestation of the disease. OBJECTIVE This case-control study investigated the macular microvasculature in patients with chronic SS compared to controls using optical coherence tomography angiography (OCTA). MATERIAL AND METHODS 12 eyes of 12 patients with SS were compared with age-matched healthy control subjects with regard to their OCT angiographic parameters. The flow density (FD) of different macular layers, foveal avascular zone (FAZ) parameters and central retinal thickness and volume values were compared between the two groups. RESULTS The FD of the choriocapillaris was reduced in Susac patients compared to healthy controls. The FD values of the superficial and deep capillary plexus of the inner retina, parameters of the FAZ as well as central retinal thickness and volume showed no significant differences between the two groups. DISCUSSION Treated chronic SS does not appear to significantly affect the vascular and structural composition of the central inner retina; however, differences in the choriocapillaris indicate changes in deeper, highly vascularized capillary layers.
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Affiliation(s)
- Jens Julian Storp
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude D15, 48149, Münster, Deutschland.
| | - Verena Anna Englmaier
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude D15, 48149, Münster, Deutschland
| | - Julian Alexander Zimmermann
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude D15, 48149, Münster, Deutschland
| | - Nicole Eter
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude D15, 48149, Münster, Deutschland
| | - Larissa Lahme
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude D15, 48149, Münster, Deutschland
| | - Maged Alnawaiseh
- Klinik für Augenheilkunde, Klinikum Bielefeld, 33604, Bielefeld, Deutschland
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3
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Van Vrekhem T, Miatton M, Hemelsoet D, Van Hijfte L, Dekeyser C, De Zaeytijd J, Van Driessche V, Van Hoecke H, Maes L, Laureys G. Cognitive outcomes in Susac syndrome: A 2-year neuropsychological follow-up study. Eur J Neurol 2024; 31:e16186. [PMID: 38308420 PMCID: PMC11235908 DOI: 10.1111/ene.16186] [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: 09/19/2023] [Revised: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND AND PURPOSE Susac syndrome (SuS) is a rare, autoimmune, neurological disease characterized by a clinical triad of branch retinal artery occlusion, sensorineural hearing loss and encephalopathy. Neuropsychological functioning in SuS is little researched and the prevalence, nature, and evolution over time of cognitive deficits in SuS remain unclear. This study aimed to better understand the long-term neuropsychological outcomes of patients with SuS. METHODS Thirteen patients with SuS (mean [SD] age 39.5 [11.1] years) were enrolled at the Ghent University Hospital by their treating neurologist. The cognitive functioning and emotional well-being of each patient was evaluated by means of a thorough neuropsychological test battery at baseline and after 2 years. Follow-up testing after 2 years was performed in 11 patients (mean [SD] age 42.2 [11.5] years). RESULTS Patients showed normal neuropsychological test results at a group level, both at baseline and follow-up testing. Significant improvements over time were found for information processing speed, verbal recognition, and semantic and phonological fluency. Individual test results showed interindividual variability at baseline, with most impairments being in attention, executive functioning and language, which improved after a 2-year period. In addition, patients reported significantly lower mental and physical well-being, both at baseline and follow-up testing. CONCLUSIONS Our results suggest that neuropsychological dysfunction in SuS is limited at a group level and improves over time. Nonetheless, individual test results reveal interindividual variability, making cognitive screening essential. Furthermore, a high psycho-emotional burden of the disease was reported, for which screening and follow-up are necessary.
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Affiliation(s)
| | - Marijke Miatton
- Department of NeurologyGhent University HospitalGhentBelgium
| | | | | | | | | | | | - Helen Van Hoecke
- Department of OtorhinolaryngologyGhent University HospitalGhentBelgium
| | - Leen Maes
- Department of OtorhinolaryngologyGhent University HospitalGhentBelgium
- Department of Rehabilitation SciencesGhent UniversityGhentBelgium
| | - Guy Laureys
- Department of NeurologyGhent University HospitalGhentBelgium
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4
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Cviková M, Štefela J, Všianský V, Dufek M, Doležalová I, Vinklárek J, Herzig R, Zemanová M, Červeňák V, Brichta J, Bárková V, Kouřil D, Aulický P, Filip P, Weiss V. Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature. Front Neurol 2024; 15:1339438. [PMID: 38434197 PMCID: PMC10904644 DOI: 10.3389/fneur.2024.1339438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.
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Affiliation(s)
- Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jakub Štefela
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vít Všianský
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Michal Dufek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Irena Doležalová
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jan Vinklárek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czechia
| | - Markéta Zemanová
- Department of Ophthalmology and Optometry, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vladimír Červeňák
- Department of Medical Imaging, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jaroslav Brichta
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Veronika Bárková
- Department of Clinical Pharmacology, St. Anne's University Hospital, Brno, Czechia
| | - David Kouřil
- Department of Neurology, Blansko Hospital, Blansko, Czechia
| | - Petr Aulický
- Department of Anesthesiology, Hospital of the Brothers of Charity Brno, Brno, Czechia
| | - Pavel Filip
- Department of Neurology, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czechia
- Center for Magnetic Resonance Research (CMRR), University of Minnesota, Minneapolis, MN, United States
| | - Viktor Weiss
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
- Department of Neurology, Charles University Faculty of Medicine, Hradec Králové, Czechia
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5
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Jiang F, Ma Z, Chen Z, Yang M, Huang H, Chen L, He C. Susac syndrome can be diagnosed by examination and cured by comprehensive therapy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 171:329-337. [PMID: 37783562 DOI: 10.1016/bs.irn.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
- Feifei Jiang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang, P.R. China.
| | - Zhiming Ma
- Department of Neurosurgery, Urumqi General Hospital of Lanzhou Military Region, Urumqi, Xinjiang, P.R. China
| | - Zhizhi Chen
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang, P.R. China
| | - Ming Yang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang, P.R. China
| | - Hongyun Huang
- Beijing Hongtianji Neuroscience Academy, Beijing, P.R. China
| | - Lin Chen
- Department of Neurosurgery, Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing, P.R. China
| | - Chao He
- Department of Neurosurgery, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji, Zhejiang, P.R. China.
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6
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Masjuan M, Ivanovski T, Sarasibar Ezcurra H, Rigo Oliver E. Behavioral Impairment and Amnesia at the Onset of Susac Syndrome. Cureus 2023; 15:e38089. [PMID: 37252530 PMCID: PMC10209653 DOI: 10.7759/cureus.38089] [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] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Susac syndrome (SS) is an autoimmune microangiopathy that affects the brain, retina, and inner ear, causing a wide range of clinical manifestations. The triad of encephalopathy, visual disturbances, and hearing loss constitute the classic disease presentation. We describe an original clinical case of a young male with a definitive diagnosis of SS, who presented with disordered behavior and amnesia, initially manifested as a dissociative or anxiety disorder but with a fulminant evolution toward severe encephalopathy associated with retinal infarcts and sensorineural hearing loss. After the diagnosis of SS, aggressive immunosuppressive treatment was started with significant neurological improvement and favorable evolution during the follow-up period. SS is a rare but potentially devastating disease that can cause great disability if not properly diagnosed and treated. The onset of SS with behavioral or psychiatric manifestation can be misleading, causing a diagnostic delay.
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Affiliation(s)
- Marc Masjuan
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | - Trajche Ivanovski
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | | | - Elena Rigo Oliver
- Ophthalmology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
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7
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Suman NS, Poovaiah PP, Rangarajan A, Tiwari R, Nashi S, Yuvraj P, Rajasekaran AK. Cervical and Ocular Vestibular Evoked Myogenic Potential Recovery in Susac Syndrome: A Case Report. Am J Audiol 2022; 31:1059-1066. [DOI: 10.1044/2022_aja-22-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose:
Susac syndrome (SS) is a rare autoimmune disorder that affects the brain and the retina and causes unilateral or bilateral sensorineural hearing loss. Although vestibular dysfunction is reported in SS, limited information is available underlying the vestibular pathophysiology.
Method:
The diagnosis of SS was established based on symptoms and diagnostic tools such as magnetic resonance imaging and fundus fluorescein angiography. The audiovestibular evaluation was done on the seventh day of admission (Session 1) into the emergency unit, whereas the second and third evaluations were done at 3-month (Session 2) and 8-month (Session 3) follow-ups after discharge, respectively. The audiovestibular test battery consisted of routine audiological tests, auditory brainstem response, and vestibular evoked myogenic potentials (VEMPs; both cervical and ocular).
Results:
We found unilateral sensorineural hearing loss and absent cervical VEMPs(cVEMPs) when testing the left ear during Session 1. In the following sessions, the unilateral hearing loss did not recover; however, cVEMPs were present bilaterally. The ocular VEMPs showed an increase in amplitude during Sessions 2 and 3.
Conclusions:
SS can selectively disrupt auditory and vestibular structures. It may present with unique findings of audiovestibular tests. A detailed audiovestibular evaluation may be essential in patients with SS.
Supplemental Material:
https://doi.org/10.23641/asha.21513843
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Affiliation(s)
- Narayana Swamy Suman
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Prashasti P. Poovaiah
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Anush Rangarajan
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Ravindu Tiwari
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Saraswati Nashi
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Pradeep Yuvraj
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Aravind Kumar Rajasekaran
- Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Bangalore, India
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8
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Susac Syndrome: Description of a Single-Centre Case Series. J Clin Med 2022; 11:jcm11216549. [PMID: 36362776 PMCID: PMC9656090 DOI: 10.3390/jcm11216549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
This study describes the clinical characteristics, diagnostic results, treatment regimens, and clinical course of a cohort of patients with Susac syndrome (SS). It is a retrospective observational study of all patients with the diagnosis of SS evaluated at the Hospital Clinic (Barcelona, Spain) between March 2006 and November 2020. Nine patients were diagnosed with SS. The median time from the onset of the symptoms to diagnosis was five months (IQR 9.0), and the median follow-up time was 44 months (IQR 63.5). There was no clear predominance of sex, and mean age of symptoms onset was 36 years (range 19–59). Six patients (67%) presented with incomplete classical clinical triad, but this eventually developed in six patients during the disease course. Encephalopathy, focal neurological signs, visual disturbances, and hearing loss were the most frequent manifestations. Brain magnetic resonance imaging showed callosal lesions in all patients. Most were in remission within two years. Only four patients met the proposed criteria for definite SS. When SS is suspected, a detailed diagnostic workup should be performed and repeated over time to identify the clinical manifestations that will lead to a definite diagnosis.
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9
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Characteristics and management of Susac syndrome in an emergent country: a multi-center case series from Brazil. Neurol Sci 2022; 43:6449-6460. [DOI: 10.1007/s10072-022-06320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/31/2022] [Indexed: 10/15/2022]
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10
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Alshaqi O, Moodie T, Alchaki A. Involuntary crying episodes with Susac's syndrome-a rare presentation of a rare disease: a case report. BMC Neurol 2022; 22:155. [PMID: 35468771 PMCID: PMC9036746 DOI: 10.1186/s12883-022-02639-9] [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: 06/30/2021] [Accepted: 03/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this case, we reported the pseudobulbar affect (PBA) in a patient with Susac's syndrome-a rare condition that was caused by a rare syndrome. Previous case reports of Susac syndrome described psychiatric symptoms such as emotional disturbances or personality changes. Only a few case reports have reported psychiatric disorders in patients with Susac's syndrome. There were no reported cases of Susac syndrome with PBA as an initial presentation. CASE PRESENTATION Our patient was 56 years old and presented with involuntary crying, left-sided headache, left-sided hearing loss, and tinnitus. Brain MRI showed numerous areas of restricted diffusion and enhancement involving the corpus callosum, bilateral hemispheres, and brainstem. Ophthalmological evaluation showed bilateral branch retinal artery occlusion. She was diagnosed with Susac's syndrome and PBA. She was treated with cyclophosphamide and dextromethorphan hydrobromide/quinidine sulfate with excellent recovery. This is a 2-year clinical course. DISCUSSION AND CONCLUSIONS Recognition of the clinical presentation of Susac's syndrome and PBA with early diagnosis and treatment are the keys to preventing further disability and impact on patients and their families.
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Affiliation(s)
- O Alshaqi
- Damascus University, Damascus, Syria
| | - T Moodie
- University of South Dakota, Vermillion, USA
| | - A Alchaki
- University of South Dakota, Vermillion, USA.
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11
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Susac syndrome: A scoping review. Autoimmun Rev 2022; 21:103097. [DOI: 10.1016/j.autrev.2022.103097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/21/2022]
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12
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Susac syndrome with cognitive impairment - case report of 31-year-old woman. CURRENT PROBLEMS OF PSYCHIATRY 2021. [DOI: 10.2478/cpp-2021-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Susac syndrome (SuS) is a rare immune-mediated disease caused by occlusions of microvessels in the brain, retina and inner ear. It is characterized by the clinical triad of encephalopathy, visual disturbances and hearing loss. The diagnosis of SuS is based mainly on the clinical symptoms and the supporting tests in which characteristic changes occur in the MRI.
Case report: Here, we present a case of a patient with possible SuS with psychiatric symptoms. A 31-year-old woman was admitted to the Department of Psychiatry due to deteriorating mental health for several weeks manifested as a negative mood and suicidal thoughts. During hospitalization, a neurological consultation was conducted, in which the patient was identified as conscious, psychomotor sluggish, with impaired verbal contact and persistent hearing and vision impairment. Cross-sectional assessment of cognitive functions revealed that the patient had a generalized syndrome of neuropsychological deficits, which confirms the diagnosis of dementia.
Discussion: This case summary provides an example of a woman diagnosed with SuS manifested as a cognitive impairment with associated vision and hearing deterioration. It is worth emphasizing the fact that such presentation of the triad of at disease onset is rare. The characteristics of the organic changes in the brain described in the MRI probably explain the symptoms described in that case. The prognosis of SuS depends on early diagnosis and treatment.
Conclusions: A diagnosis of SuS should always be considered in the presence of nonspecific neuropsychiatric symptoms and progressive multifocal neurological symptoms, hearing loss, and visual impairment. An important fact is that the typical triad of SuS symptoms in most cases does not occur simultaneously, which makes the diagnostic process very difficult and may lead to misdiagnosis.
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13
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Ahmed A, Kok ZQ, Coles A, Scoffings DJ, Crisp SJ. Susac's syndrome as an autoimmune complication of alemtuzumab-associated immune reconstitution. J Neurol 2021; 269:1695-1697. [PMID: 34586449 DOI: 10.1007/s00415-021-10802-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/09/2021] [Accepted: 09/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Amir Ahmed
- School of Clinical Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Zi Qi Kok
- School of Clinical Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Daniel J Scoffings
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sarah J Crisp
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
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14
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Hamann T, Wiest M, Innes W, Zweifel S. A Novel Quantitative Assessment Method of Disease Activity in Susac's Syndrome Based on Ultra-Wide Field Imaging. Curr Eye Res 2021; 47:262-268. [PMID: 34375542 DOI: 10.1080/02713683.2021.1967402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Susac's syndrome (ScS) is a rare, potentially life-threatening auto-immune disease. Ophthalmic imaging can depict characteristic branch retinal arteriolar occlusions (BRAO) and arterial wall hyperfluorescences that form one of the three diagnostic pillars of this condition. We aim to demonstrate that ophthalmological ultrawide-field (UWF) imaging allows for a qualitative and quantitative assessment in ScS, with application in diagnostics, monitoring of treatment response, and titration of therapy. METHODS In seven ScS patients (♀:♂ = 2:5), with a median age of 36 years, range 18 to 57 years, serial ultrawide-field fluoresceine angiography (UWF-FA) studies were performed, with adjunctive wide-field optical coherence tomography angiography analyses (WF-OCTA) in five patients. Mean follow-up was 12.5 months, range 1 to 46 months. RESULTS In all seven patients, BRAO and arterial wall hyperfluorescences were present in UWF-FA and calculated as a quantitative score of disease activity in fluorescein angiography (DA-FA) during follow-up visits. Treatment response was accessible in follow-up imaging as partial reperfusion of retinal vessels, resolution of arterial wall hyperfluorescences and consequently, in reduction of DA-FA score. While qualitative analysis of WF-OCTA provided further information about retinal micro-perfusion, quantitative analysis did not demonstrate a vectored treatment response as it was accessible in FA. CONCLUSION DA-FA score, as a comprehensive disease activity parameter in ScS has potential to facilitate optimal communication between subspecialties and thereby treatment success.
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Affiliation(s)
- T Hamann
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - M Wiest
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - W Innes
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Newcastle upon Tyne Hospitals, Newcastle University, NHS, Newcastle upon Tyne, UK
| | - S Zweifel
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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15
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Yalçınkaya BÇ, Ertürk Çetin Ö, Kılıç H, Demirci O, Çokyaman T, Uygunoğlu U. A rare presentation of Susac syndrome: Report of three pediatric cases. Mult Scler Relat Disord 2021; 53:103074. [PMID: 34139460 DOI: 10.1016/j.msard.2021.103074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 11/25/2022]
Abstract
Susac syndrome is a rare disorder that is clinically characterized by encephalopathy, retinopathy and hearing loss. Most of the reported cases in the literature are adult patients, pediatric presentation is extremely rare. Here we present three pediatric patients aged between 10-15; diagnosed as Susac syndrome. They all had thalamic involvement in addition to typical callosal lesions. All of the three patients had a monophasic course and good treatment response.
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Affiliation(s)
| | - Özdem Ertürk Çetin
- University of Health Sciences, Sancaktepe Sehit Prof.Dr.Ilhan Varank Training and Research Hospital, Department of Neurology, Istanbul, Turkey.
| | - Hüseyin Kılıç
- Istanbul University-Cerrahpasa; Department of Pediatrics, Division of Pediatric Neurology, Istanbul, Turkey.
| | - Onat Demirci
- Vehbi Koc Foundation, American Hospital, Department of Neurology, Sisli, Turkey.
| | - Turgay Çokyaman
- Canakkale Onsekiz Mart University, Faculty of Medicine, Deparment of Pediatrics, Division of Pediatric Neurology.
| | - Uğur Uygunoğlu
- Istanbul University-Cerrahpasa; Department of Neurology, Istanbul, Turkey.
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Pérez PL, McCall AA, Hirsch BE. Scoping review of cochlear implantation in Susac's syndrome. World J Otorhinolaryngol Head Neck Surg 2021; 7:126-132. [PMID: 33997722 PMCID: PMC8103525 DOI: 10.1016/j.wjorl.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac’s Syndrome(SS) who have undergone cochlear implantation (CI). Data sources All published studies of CI in SS and contribution of two of our own patients who have not been reported previously. Methods A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac’s Syndrome, Cochlear Implantation. Results Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19–46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation. Conclusion Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.
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Affiliation(s)
- Philip L Pérez
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Andrew A McCall
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Barry E Hirsch
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Pereira S, Vieira B, Maio T, Moreira J, Sampaio F. Susac's Syndrome: An Updated Review. Neuroophthalmology 2021; 44:355-360. [PMID: 33408428 DOI: 10.1080/01658107.2020.1748062] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Susac's syndrome is a rare immune-mediated endotheliopathy that mainly affects young women. It is characterised by the presence of encephalopathy, retinal vaso-occlusive disease and hearing loss. Diagnosis is based on the clinical presentation, brain magnetic resonance imaging, retinal fluorescein angiography, and audiometry. Treatment consists of immunosuppressive therapy. This review focuses on recent developments in the diagnosis and management of the condition.
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Affiliation(s)
- Sara Pereira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Bruna Vieira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Tiago Maio
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Jorge Moreira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipa Sampaio
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
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18
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Suárez-Pérez L, Herrero Suárez SE, Peña Suárez J, Caminal-Montero L. Confusional syndrome and retinal vasculitis. REUMATOLOGIA CLINICA 2021; 17:52-54. [PMID: 31405588 DOI: 10.1016/j.reuma.2019.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/09/2019] [Accepted: 05/24/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Lucía Suárez-Pérez
- Unidad de Enfermedades Autoinmunes Sistémicas, Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Central de Asturias, Oviedo, Asturias, España.
| | - Sara E Herrero Suárez
- Servicio de Neurología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Jorge Peña Suárez
- Servicio de Radiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Luis Caminal-Montero
- Unidad de Enfermedades Autoinmunes Sistémicas, Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
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Wilf-Yarkoni A, Elkayam O, Aizenstein O, Oron Y, Furer V, Zur D, Goldstein M, Barequet D, Hallevi H, Karni A, Habot-Wilner Z, Regev K. Increased incidence of Susac syndrome: a case series study. BMC Neurol 2020; 20:332. [PMID: 32878610 PMCID: PMC7465403 DOI: 10.1186/s12883-020-01892-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines. METHODS This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study. RESULTS Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability. CONCLUSIONS We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.
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Affiliation(s)
- A Wilf-Yarkoni
- Neuro-Immunology Service and Department of Neurology Rabin Medical Center, 4941492, Petach Tikva, Israel.
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Aizenstein
- Neuroradiology unit, Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Y Oron
- Department of ENT, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Zur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - M Goldstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Barequet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Hallevi
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Karni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience Tel Aviv University, Tel Aviv, Israel
| | - Z Habot-Wilner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - K Regev
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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20
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Abstract
BACKGROUND Susac syndrome (SS) classically presents with the clinical triad of retinal artery occlusion, sensorineural hearing loss, and encephalopathy and the neuroimaging triad of white matter lesions, deep gray matter lesions, and leptomeningeal disease. However, patients can present with an incomplete clinical or neuroimaging triads making diagnosis difficult in certain situations. A standard treatment paradigm also is lacking in this illness. It is important for neuro-ophthalmologists to recognize clinical and radiographic findings that are pathognomonic for this syndrome and have a basic understanding of the available treatment options. EVIDENCE ACQUISITION Review of medical literature. RESULTS A definite diagnosis of SS is made when the clinical triad or the neuroimaging triad is present. There are numerous reports of 2 other imaging findings in this condition: arteriolar wall hyperfluorescence (AWH) on fluorescein angiography in retinal arterioles remote from retinal ischemia and central callosal lesions on MRI. Both of these imaging findings are diagnostic of SS. Gass plaques in retinal arterioles are almost always seen in the acute phase of the illness but are not pathognomonic for SS. The most common medications used in this syndrome are corticosteroids and intravenous immunoglobulin. A number of other medications have been used including mycopheolate, rituximab, azathioprine, and cyclophosphamide. CONCLUSIONS In the absence of the clinical triad or magnetic resonance imaging triad for SS, AWH remote from retinal vascular injury and central callosal lesions are confirmatory of the diagnosis because they have never been described in any other condition. The presence of Gass plaques in retinal arterioles should strongly suggest the diagnosis. Despite the lack of clinical trial data, patients with SS must be treated promptly and aggressively. In more fulminant cases, addition of mycophenolate mofetil or rituximab is required, followed by cyclophosphamide when disease is refractory to other medications.
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21
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Ba F, Ba EHM, Guèye MM, Sène MSD, Diagne M. Susac syndrome: about two cases. Pan Afr Med J 2019; 33:145. [PMID: 31558942 PMCID: PMC6754840 DOI: 10.11604/pamj.2019.33.145.17954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/12/2019] [Indexed: 11/11/2022] Open
Abstract
Susac syndrome is an autoimmune endothelopathy that affects precapillary arterioles of the brain, retina and inner ear. We report for the first time observations of two patients with Susac syndrome in Senegal.
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Affiliation(s)
- Fatoumata Ba
- Health Sciences Unit, University Gaston Berger, Saint-Louis, Senegal
| | | | | | | | - Massar Diagne
- Neurology Unit, Fann National Teaching Hospital, Saint-Louis, Senegal
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22
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Russo FY, Ralli M, De Seta D, Mancini P, Lambiase A, Artico M, de Vincentiis M, Greco A. Autoimmune vertigo: an update on vestibular disorders associated with autoimmune mechanisms. Immunol Res 2019; 66:675-685. [PMID: 30270399 DOI: 10.1007/s12026-018-9023-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The role of the immune system in mediating cochleovestibular pathologies has received increasing attention in recent years. Autoimmune vertigo may be an invalidating condition and may worsen the quality of life of affected patients, especially in the cases of delayed diagnosis. Since the etiopathogenesis is still not clear, also the treatment is not yet completely delineated. According to the clinical presentation, autoimmune vertigo can present as an isolated disorder or in association with systemic autoimmune diseases. The main feature in autoimmune vertigo is the presence of an abnormal immune response, in either absence or presence of systemic autoimmune disease, directed against delicate components of the inner ear. This may determine a functional or anatomical alteration, with an inflammatory reaction often devastating for hearing and balance. Being the exact pathogenesis unknown, the diagnosis of autoimmune vertigo is based either on clinical criteria or on a positive response to steroids. The earlier the diagnosis is made, the sooner the therapy can be installed, giving a chance to the recovery of inner ear damages. Corticosteroids represent the most effective and universally accepted treatment, even if other immunomodulatory drugs are now having a more extensive use. HIGHLIGHTS: Vertigo is relatively frequent in autoimmune diseases; however, it is often misdiagnosed or attributed to central nervous system alterations rather to specific inner ear involvement. Vertigo and other audiovestibular symptoms may be the first manifestation of an autoimmune disease and if correctly addressed could significantly contribute to early diagnosis of the underlying autoimmune disease. Early diagnosis of immune-related vertigo can lead to prompt initiation of targeted therapy with elevate chances of preventing irreversible damages to the inner ear. The presence of alternating phases of well-being and disabling symptoms in patients with vertigo should always been considered, as they could suggest an underlying autoimmune condition.
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Affiliation(s)
- Francesca Yoshie Russo
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daniele De Seta
- Department of Oral and Maxillo-facial Surgery, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy.
| | - Patrizia Mancini
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillo-facial Surgery, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
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23
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Heng LZ, Bailey C, Lee R, Dick A, Ross A. A review and update on the ophthalmic implications of Susac syndrome. Surv Ophthalmol 2019; 64:477-485. [DOI: 10.1016/j.survophthal.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/26/2022]
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24
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Onat Demirci N, Hacımustafaoğlu AM, Kenangil G, Cevher AZ, Demir MK. Susac's syndrome as a rare arterial stroke mimic. Neuroradiol J 2019; 32:200-202. [PMID: 30839238 PMCID: PMC6512207 DOI: 10.1177/1971400919835493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Susac's syndrome is an uncommon autoimmune microangiopathy characterised mainly by encephalopathy, hearing loss and branch retinal artery occlusions. We present here a case of Susac's syndrome with initial isolated arterial stroke symptoms which are not an uncommon feature of the disease.
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Affiliation(s)
- Nuri Onat Demirci
- Department of Neurology, Bahçeşehir
University School of Medicine, Istanbul, Turkey
| | | | - Gülay Kenangil
- Department of Neurology, Bahçeşehir
University School of Medicine, Istanbul, Turkey
| | - Ayse Zeynep Cevher
- Third class medical student, Yeditepe
University School of Medicine, Istanbul, Turkey
| | - Mustafa Kemal Demir
- Department of Radiology, Bahçeşehir
University School of Medicine, Istanbul, Turkey
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25
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Marrodan M, Laffue A, Fiol MP, Correale J, Gualtieri F. Video head impulse test contributes to Susac syndrome diagnosis. J Neurol 2019; 266:2070-2072. [PMID: 31065784 DOI: 10.1007/s00415-019-09357-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Affiliation(s)
- M Marrodan
- Department of Neurology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Montañeses 2325, 1428, Buenos Aires, Argentina.
| | - A Laffue
- Department of Neuro-Otology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Buenos Aires, Argentina
| | - M P Fiol
- Department of Neurology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Montañeses 2325, 1428, Buenos Aires, Argentina
| | - J Correale
- Department of Neurology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Montañeses 2325, 1428, Buenos Aires, Argentina
| | - F Gualtieri
- Department of Neuro-Otology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Buenos Aires, Argentina
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26
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Vergunova IY, Malkova NA, Korobko DS. Susac syndrome, review and clinical case. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:52-57. [DOI: 10.17116/jnevro20191192252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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27
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Audiovestibular Symptoms in Systemic Autoimmune Diseases. J Immunol Res 2018; 2018:5798103. [PMID: 30211232 PMCID: PMC6120292 DOI: 10.1155/2018/5798103] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 06/11/2018] [Accepted: 07/04/2018] [Indexed: 12/16/2022] Open
Abstract
Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.
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28
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Beuker C, Schmidt A, Strunk D, Sporns PB, Wiendl H, Meuth SG, Minnerup J. Primary angiitis of the central nervous system: diagnosis and treatment. Ther Adv Neurol Disord 2018; 11:1756286418785071. [PMID: 30034536 PMCID: PMC6048610 DOI: 10.1177/1756286418785071] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
Primary angiitis of the central nervous system (PACNS) represents a rare
inflammatory disease affecting the brain and spinal cord. Stroke,
encephalopathy, headache and seizures are major clinical manifestations. The
diagnosis of PACNS is based on the combination of clinical presentation, imaging
findings (magnetic resonance imaging and angiography), brain biopsy, and
laboratory and cerebral spinal fluid (CSF) values. PACNS can either be confirmed
by magnetic resonance angiography (MRA)/conventional angiography or tissue
biopsy showing the presence of typical histopathological patterns.
Identification of PACNS mimics is often challenging in clinical practice, but
crucial to avoid far-reaching treatment decisions. In view of the severity of
the disease, with considerable morbidity and mortality, early recognition and
treatment initiation is necessary. Due to the rareness and heterogeneity of the
disease, there is a lack of randomized data on treatment strategies.
Retrospective studies suggest the combined administration of cyclophosphamide
and glucocorticoids as induction therapy. Immunosuppressants such as
azathioprine, methotrexate or mycophenolate mofetil are often applied for
maintenance therapy. In addition, the beneficial effects of two biological
agents (anti-CD20 monoclonal antibody rituximab and tumour necrosis factor-α
blocker) have been reported. Nevertheless, diagnosis and treatment is still a
clinical challenge, and further insights into the immunopathogenesis of PACNS
are required to improve the diagnosis and management of patients. The present
review provides a comprehensive overview of diagnostics, differential diagnoses,
and therapeutic approaches of adult PACNS.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, D-48149, Germany
| | - Antje Schmidt
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Daniel Strunk
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Peter B Sporns
- Department of Clinical Radiology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
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Yang YS, Zhang L, Asdaghi N, Henry CR, Davis JL. ACUTE MACULAR NEURORETINOPATHY IN SUSAC SYNDROME: A NEW ASSOCIATION. Retin Cases Brief Rep 2018; 14:310-314. [PMID: 29596114 DOI: 10.1097/icb.0000000000000738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report a case of acute macular neuroretinopathy in a patient with Susac syndrome. METHODS Case report. RESULTS A 39-year-old male patient presented with severe headache, photopsias, and a sudden onset of hearing loss in the right ear. Fluorescein angiography of the right eye revealed multiple branch retinal artery occlusions. Clinical presentation of encephalopathy, hearing loss, and branch retinal artery occlusions, along with characteristic magnetic resonance imaging findings, led to a diagnosis of Susac syndrome. Despite aggressive immunosuppression for four months, the patient later presented with acute macular neuroretinopathy in the left eye. CONCLUSION Acute macular neuroretinopathy and Susac is a new association of two well-defined disorders. The concurrence of both disorders supports retinal ischemia as the proximate cause of acute macular neuroretinopathy and inflammation as a potential etiology.
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Affiliation(s)
- Yong-Sheng Yang
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
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30
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Sánchez-Vicente JL, Molina-Sócola FE, Medina-Tapia A, Moruno-Rodríguez A, Gálvez-Carvajal S, López-Herrero F. Retinal and optic disc vasculitis in Susac's syndrome. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2017; 93:246-250. [PMID: 29279239 DOI: 10.1016/j.oftal.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/01/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
Abstract
CASE REPORT The case is presented of 42 year-old woman with no significant medical history, with severe headaches, nausea and vomiting, hearing loss, and alteration of mental status with disorientation and confusion. Ophthalmic examination showed optic disc hyperaemia in right eye, and focal areas of arteriolar occlusion in both eyes. Audiometry demonstrated bilateral neurosensory hypoacusis. Magnetic Resonance Imaging showed multiple small round hyperintense lesions located in the splenium, corpus callosum, basal ganglia, and white matter. DISCUSSION Besides branch retinal arteriolar occlusion, the angiopathy in Susac's syndrome may affect the optic disc vessels.
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Affiliation(s)
- J L Sánchez-Vicente
- Servicio de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - F E Molina-Sócola
- Servicio de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - A Medina-Tapia
- Servicio de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - A Moruno-Rodríguez
- Servicio de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - S Gálvez-Carvajal
- Servicio de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - F López-Herrero
- Servicio de Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, España
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31
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Alves GS, de Carvalho LDA, Sudo FK, Briand L, Laks J, Engelhardt E. A panel of clinical and neuropathological features of cerebrovascular disease through the novel neuroimaging methods. Dement Neuropsychol 2017; 11:343-355. [PMID: 29354214 PMCID: PMC5769992 DOI: 10.1590/1980-57642016dn11-040003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
UNLABELLED The last decade has witnessed substantial progress in acquiring diagnostic biomarkers for the diagnostic workup of cerebrovascular disease (CVD). Advanced neuroimaging methods not only provide a strategic contribution for the differential diagnosis of vascular dementia (VaD) and vascular cognitive impairment (VCI), but also help elucidate the pathophysiological mechanisms ultimately leading to small vessel disease (SVD) throughout its course. OBJECTIVE In this review, the novel imaging methods, both structural and metabolic, were summarized and their impact on the diagnostic workup of age-related CVD was analysed. Methods: An electronic search between January 2010 and 2017 was carried out on PubMed/MEDLINE, Institute for Scientific Information Web of Knowledge and EMBASE. RESULTS The use of full functional multimodality in simultaneous Magnetic Resonance (MR)/Positron emission tomography (PET) may potentially improve the clinical characterization of VCI-VaD; for structural imaging, MRI at 3.0 T enables higher-resolution scanning with greater imaging matrices, thinner slices and more detail on the anatomical structure of vascular lesions. CONCLUSION Although the importance of most of these techniques in the clinical setting has yet to be recognized, there is great expectancy in achieving earlier and more refined therapeutic interventions for the effective management of VCI-VaD.
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Affiliation(s)
| | | | - Felipe Kenji Sudo
- Departamento de Psicologia, Pontifícia Universidade Católica do Rio de Janeiro, RJ, Brazil
- Instituto D'Or de Ensino e Pesquisa, Rio de Janeiro, RJ, Brazil
| | - Lucas Briand
- Departamento de Medicina Interna, Universidade Federal do Ceará, CE, Brazil
| | - Jerson Laks
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, RJ, Brazil
- Programa de Pós-Graduação em Biomedicina Translacional (BIOTRANS), Unigranrio, Duque de Caxias, RJ, Brazil
| | - Eliasz Engelhardt
- Setor de Neurologia Cognitiva e do Comportamento, Instituto de Neurologia Deolindo Couto (INDC-CDA/IPUB), Rio de Janeiro, RJ, Brazil
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Betend R, Humm AM, Medlin F. Delirium as presentation of late-onset and relapsing Susac syndrome. BMJ Case Rep 2017; 2017:bcr-2017-220494. [PMID: 28784886 DOI: 10.1136/bcr-2017-220494] [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] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old patient, only known for bilateral presbycusis, presented with subacute onset of delirium. Clinical examination showed multifocal neurological deficits, all together suggesting subcortical frontal dysfunction together with cerebellar and corpus callosum involvement.Cerebral MRI demonstrated supratentorial and infratentorial subcortical and periventricular T2-hyperintense lesions with cerebellar gadolinium enhancement and multiple central lesions of the corpus callosum (snowball lesions). The diagnosis of Susac syndrome was made and the patient treated with intravenous methylprednisolone, followed by a prednisone maintenance dose over 8 weeks. After a clinical improvement, a relapse was noticed during corticosteroid tapering. The patient was again treated with intravenous methylprednisolone followed by a prednisone maintenance therapy with simultaneous introduction of mycophenolate mofetil acid and one cycle of intravenous rituximab. The patient recovered rapidly. At 11-month follow-up, only mild executive dysfunction and persistent right postural tremor was noted, MRI showed partial regression of subcortical and juxtacortical lesions.
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Affiliation(s)
- Romain Betend
- Department of Internal Medicine, Unit of Neurology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland
| | - Andrea M Humm
- Department of Internal Medicine, Unit of Neurology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland.,Department of Neurology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Friedrich Medlin
- Department of Internal Medicine, Unit of Neurology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland.,Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Oldham M. Autoimmune Encephalopathy for Psychiatrists: When to Suspect Autoimmunity and What to Do Next. PSYCHOSOMATICS 2017; 58:228-244. [DOI: 10.1016/j.psym.2017.02.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/22/2017] [Accepted: 02/22/2017] [Indexed: 12/18/2022]
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Kola M, Erdöl H, Ertuğrul Atasoy S, Türk A. Evaluation of Retinal Changes Using Optical Coherence Tomography in a Pediatric Case of Susac Syndrome. Turk J Ophthalmol 2017; 47:59-62. [PMID: 28182173 PMCID: PMC5282545 DOI: 10.4274/tjo.27482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/15/2015] [Indexed: 12/01/2022] Open
Abstract
Susac syndrome is a rare occlusive vasculopathy affecting the retina, inner ear and brain. The cause is unknown, although it generally affects young women. This syndrome can be difficult to diagnose because its signs can only be revealed by detailed examination. These signs are not always concomitant, but may appear at different times. This report describes a pediatric case who was diagnosed with Susac syndrome when retinal lesions were identified in the inactive period with the help of optical coherence tomography (OCT). The purpose of this case report is to emphasize the importance of OCT in clarifying undefined retinal changes in Susac syndrome.
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Affiliation(s)
- Mehmet Kola
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
| | - Hidayet Erdöl
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
| | - Sevil Ertuğrul Atasoy
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
| | - Adem Türk
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
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Dutra LA, de Souza AWS, Grinberg-Dias G, Barsottini OGP, Appenzeller S. Central nervous system vasculitis in adults: An update. Autoimmun Rev 2017; 16:123-131. [PMID: 28087351 DOI: 10.1016/j.autrev.2016.12.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 09/08/2016] [Indexed: 11/27/2022]
Abstract
Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis includes reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show that data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.
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Affiliation(s)
- Lívia Almeida Dutra
- General Neurology Division, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Simone Appenzeller
- Rheumatology Division, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil.
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Characteristics of headache in relation to the manifestation of Susac syndrome. Medicina (B Aires) 2017; 53:420-425. [DOI: 10.1016/j.medici.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 12/12/2022] Open
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Hung J, Leuillette F, Stekelorom T, Devos P, Moritz F. Syndrome de Susac typique. J Fr Ophtalmol 2017; 40:e15-e17. [DOI: 10.1016/j.jfo.2015.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 11/22/2015] [Accepted: 12/18/2015] [Indexed: 11/26/2022]
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Kowacs F, Ferreira Gomes M, Pigozzo T, Rodrigues Palmeira AL, Muratt Carpenedo C, Castro Ribeiro M. Migraine-Like Headache as Presentation Symptom in Susac Syndrome. Headache 2016; 56:1667-1669. [DOI: 10.1111/head.12991] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/04/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Fernando Kowacs
- Depto. de Clínica Médica/Neurologia; Universidade Federal de Ciências da Saúde de Porto Alegre; Porto Alegre RS Brazil
| | - Matheus Ferreira Gomes
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Medicina; Porto Alegre RS Brazil
| | - Taiane Pigozzo
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Programa de Residência Médica em Neurologia; Porto Alegre RS Brazil
| | - André Luiz Rodrigues Palmeira
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Programa de Residência Médica em Neurologia; Porto Alegre RS Brazil
| | - Camila Muratt Carpenedo
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Programa de Residência Médica em Neurologia; Porto Alegre RS Brazil
| | - Marlise Castro Ribeiro
- Depto. de Clínica Médica/Neurologia; Universidade Federal de Ciências da Saúde de Porto Alegre; Porto Alegre RS Brazil
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Gertner E, Rosenbloom MH. Susac syndrome with prominent dermatological findings and a prompt response to intravenous immunoglobulin, steroids, and rituximab: a case report. J Med Case Rep 2016; 10:137. [PMID: 27234436 PMCID: PMC4884366 DOI: 10.1186/s13256-016-0917-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/27/2016] [Indexed: 12/04/2022] Open
Abstract
Background Susac syndrome (retinocochleocerebral vasculopathy) is an autoimmune endotheliopathy affecting the precapillary arterioles of the brain, retina, and inner ear. It presents with encephalopathy, branch retinal artery occlusions, and hearing loss. The condition is often under recognized because the clinical symptoms may present at different times and physicians may be unfamiliar with the syndrome. Peripheral findings would be helpful in early diagnosis. There are numerous treatment regimens proposed with varying effectiveness. Case presentation We report the case of a 22-year-old Caucasian man in whom there were prominent skin findings, including livedo reticularis and a micropapular eruption which responded promptly to treatment suggesting that skin involvement may facilitate earlier diagnosis. Rituximab has occasionally been used in more refractory disease. We observed a prompt response to the combination of intravenous immunoglobulin, corticosteroids, and rituximab instituted immediately after diagnosis. Conclusions A careful search for dermatological manifestations may help with earlier diagnosis. Skin findings may be another marker of endothelial cell involvement. Early use of rituximab as part of the therapeutic regimen may be warranted.
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Affiliation(s)
- Elie Gertner
- Section of Rheumatology, Regions Hospital, 640 Jackson Street, St. Paul, MN, 55101, USA.
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Abstract
INTRODUCTION Toxic leukoencephalopathy is a possible but rare complication of chronic cocaine abuse. The role of adulterants, mainly levamisole, is still debated. CASE REPORT We describe an atypical case of fatal leukoencephalopathy mimicking Susac syndrome in a 22-year-old man who was chronically abusing cannabis and cocaine. Exposure to levamisole as adulterant to cocaine was proven by hair analysis. Despite cessation of exposure to cocaine and aggressive immunosuppressive therapy, the patient remained in a minimally conscious state until death. DISCUSSION Susac syndrome is a rare entity, and its etiology is not yet fully elucidated. The toxic etiologies have been poorly investigated to date. Further observations are required to determine if cocaine and/or adulterants might play a significant role.
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Seghers A, Van Calster J, Wilms G, Dubois B. Characteristic callosal involvement in Susac's syndrome. Acta Neurol Belg 2015; 115:395-6. [PMID: 25088022 DOI: 10.1007/s13760-014-0337-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 07/14/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Seghers
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium,
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Francis AW, Kiernan CL, Huvard MJ, Vargas A, Zeidman LA, Moss HE. Clinical Reasoning: An unusual diagnostic triad. Susac syndrome, or retinocochleocerebral vasculopathy. Neurology 2015. [PMID: 26195240 DOI: 10.1212/wnl.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrew W Francis
- From the Departments of Ophthalmology and Visual Sciences (A.W.F., M.J.H., H.E.M.) and Neurology and Rehabilitation (A.V., L.A.Z., H.E.M.), University of Illinois at Chicago; and Rush Medical College (C.L.K.), Chicago, IL
| | - Claire L Kiernan
- From the Departments of Ophthalmology and Visual Sciences (A.W.F., M.J.H., H.E.M.) and Neurology and Rehabilitation (A.V., L.A.Z., H.E.M.), University of Illinois at Chicago; and Rush Medical College (C.L.K.), Chicago, IL
| | - Michael J Huvard
- From the Departments of Ophthalmology and Visual Sciences (A.W.F., M.J.H., H.E.M.) and Neurology and Rehabilitation (A.V., L.A.Z., H.E.M.), University of Illinois at Chicago; and Rush Medical College (C.L.K.), Chicago, IL
| | - Alejandro Vargas
- From the Departments of Ophthalmology and Visual Sciences (A.W.F., M.J.H., H.E.M.) and Neurology and Rehabilitation (A.V., L.A.Z., H.E.M.), University of Illinois at Chicago; and Rush Medical College (C.L.K.), Chicago, IL
| | - Lawrence A Zeidman
- From the Departments of Ophthalmology and Visual Sciences (A.W.F., M.J.H., H.E.M.) and Neurology and Rehabilitation (A.V., L.A.Z., H.E.M.), University of Illinois at Chicago; and Rush Medical College (C.L.K.), Chicago, IL
| | - Heather E Moss
- From the Departments of Ophthalmology and Visual Sciences (A.W.F., M.J.H., H.E.M.) and Neurology and Rehabilitation (A.V., L.A.Z., H.E.M.), University of Illinois at Chicago; and Rush Medical College (C.L.K.), Chicago, IL.
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Granata G, Greco A, Iannella G, Granata M, Manno A, Savastano E, Magliulo G. Posterior reversible encephalopathy syndrome--Insight into pathogenesis, clinical variants and treatment approaches. Autoimmun Rev 2015; 14:830-6. [PMID: 25999210 DOI: 10.1016/j.autrev.2015.05.006] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/12/2015] [Indexed: 01/20/2023]
Abstract
Posterior reversible encephalopathy syndrome is a rare clinicoradiological entity characterized by typical MRI findings located in the occipital and parietal lobes, caused by subcortical vasogenic edema. It was first described as a distinctive syndrome by Hinchey in 1996. Etiopathogenesis is not clear, although it is known that it is an endotheliopathy of the posterior cerebral vasculature leading to failed cerebral autoregulation, posterior edema and encephalopathy. A possible pathological activation of the immune system has been recently hypothesized in its pathogenesis. At clinical onset, the most common manifestations are seizures, headache and visual changes. Besides, tinnitus and acute vertigo have been frequently reported. Symptoms can be reversible but cerebral hemorrhage or ischemia may occur. Diagnosis is based on magnetic resonance imaging, in the presence of acute development of clinical neurologic symptoms and signs and arterial hypertension and/or toxic associated conditions with possible endotheliotoxic effects. Mainstay on the treatment is removal of the underlying cause. Further investigation and developments in endothelial cell function and in neuroimaging of cerebral blood flow are needed and will help to increase our understanding of pathophysiology, possibly suggesting novel therapies.
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Affiliation(s)
- Guido Granata
- Department of Clinical Immunology, Sapienza University of Rome, Viale dell'Università, 37, 00161 Rome, Italy.
| | - Antonio Greco
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Giannicola Iannella
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Massimo Granata
- Department of Clinical Immunology, Sapienza University of Rome, Viale dell'Università, 37, 00161 Rome, Italy.
| | - Alessandra Manno
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Ersilia Savastano
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Giuseppe Magliulo
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
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Affiliation(s)
- Jonathan L Zande
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Muhammad U Farooq
- Division of Stroke and Vascular Neurology, Hauenstein Neuroscience Center, Saint Mary's Health Care, Grand Rapids, MI, USA
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Beaujeux P, Cloché V, Tréchot F, Conart JB, Angioi-Duprez K. Mise au point sur le syndrome de Susac. À propos d’un cas pédiatrique. J Fr Ophtalmol 2014; 37:804-11. [DOI: 10.1016/j.jfo.2014.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/11/2014] [Indexed: 10/24/2022]
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Greco A, De Virgilio A, Gallo A, Fusconi M, Ruoppolo G, Turchetta R, Pagliuca G, de Vincentiis M. Idiopathic bilateral vestibulopathy: an autoimmune disease? Autoimmun Rev 2014; 13:1042-7. [PMID: 25173622 DOI: 10.1016/j.autrev.2014.08.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 06/20/2014] [Indexed: 12/28/2022]
Abstract
Bilateral vestibulopathy (BV) is the loss of function of both peripheral labyrinths or of the eighth nerves. Its etiology remains obscure in approximately 20% to 50% of cases (so-called idiopathic bilateral vestibulopathy, IBV). Alternatively, the cause could be viral or vascular; to date, causative gene mutations have not been identified. Other potential disease mechanisms include autoimmune disorders. Antibodies have been detected against inner ear tissue (primarily against vestibular membranous labyrinth). The data suggest that the bulk of anti-labyrinthine autoantibodies may be an epiphenomenon, but a small subgroup of organ-specific autoantibodies may synergize with a cellular response to develop vestibular lesions. The two key symptoms of BV are the following: 1. unsteadiness of gait, particularly in the dark or on uneven ground, and 2. oscillopsia associated with head movements. Episodes of vertigo are reported by patients with IBV, particularly early in the development of vestibular loss. Associated hearing loss seldom occurs in the idiopathic type of this condition. Post-mortem examinations revealed a remarkably selective loss of vestibular hair cells in the vestibular end organs but normal hair cells in the cochlea. The diagnosis is made with a simple bedside test for defective vestibular function. The diagnosis can be confirmed by bithermal caloric testing and pendular body rotation. The therapy is based on steroid treatment, and the early initiation of immunosuppression appears to be essential for therapeutic success.
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Affiliation(s)
- Antonio Greco
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Rome, Italy.
| | - Armando De Virgilio
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Rome, Italy.
| | - Andrea Gallo
- Department of Medico-Surgical Sciences and Biotechnologies, Otorhinolaryngology Section "Sapienza" University of Rome, Corso della Repubblica, 79, 04100 Latina (LT), Italy.
| | - Massimo Fusconi
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Rome, Italy.
| | - Giovanni Ruoppolo
- Department Organs of Sense, Audiology Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Rome, Italy.
| | - Rosaria Turchetta
- Department Organs of Sense, Audiology Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Rome, Italy.
| | - Giulio Pagliuca
- Department of Medico-Surgical Sciences and Biotechnologies, Otorhinolaryngology Section "Sapienza" University of Rome, Corso della Repubblica, 79, 04100 Latina (LT), Italy.
| | - Marco de Vincentiis
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Rome, Italy.
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Susac-like syndrome in a chronic cocaine abuser: could levamisole play a role? JOURNAL OF MEDICAL TOXICOLOGY : OFFICIAL JOURNAL OF THE AMERICAN COLLEGE OF MEDICAL TOXICOLOGY 2014. [PMID: 25142038 DOI: 10.1007/s13181-014-0422-3"] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
INTRODUCTION Toxic leukoencephalopathy is a possible but rare complication of chronic cocaine abuse. The role of adulterants, mainly levamisole, is still debated. CASE REPORT We describe an atypical case of fatal leukoencephalopathy mimicking Susac syndrome in a 22-year-old man who was chronically abusing cannabis and cocaine. Exposure to levamisole as adulterant to cocaine was proven by hair analysis. Despite cessation of exposure to cocaine and aggressive immunosuppressive therapy, the patient remained in a minimally conscious state until death. DISCUSSION Susac syndrome is a rare entity, and its etiology is not yet fully elucidated. The toxic etiologies have been poorly investigated to date. Further observations are required to determine if cocaine and/or adulterants might play a significant role.
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49
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Greco A, De Virgilio A, Gallo A, Fusconi M, Turchetta R, Tombolini M, Rizzo MI, de Vincentiis M. Susac's syndrome--pathogenesis, clinical variants and treatment approaches. Autoimmun Rev 2014; 13:814-21. [PMID: 24727151 DOI: 10.1016/j.autrev.2014.04.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/30/2014] [Indexed: 01/03/2023]
Abstract
Susac's syndrome is a rare disease that is characterised by the clinical triad of encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss. It was first described as a distinctive syndrome by Susac in 1979. There have been 304 reported individual patients with Susac's syndrome. Etiopathogenesis is not clear, although it is now thought that it is an immune-mediated endotheliopathy that affects the microvasculature of the brain, retina, and inner ear. Antiendothelial cell antibodies (AECAs) play an important role in mediating the endothelial cell injury with consequent deposition of thrombotic material in the lumen of the small vessel. In biopsies of the brain, microinfarcts with atrophy of the white and grey matter could be detected. These microinfarcts are caused by a microangiopathic process with arteriolar wall proliferation, lymphocytic infiltration and basal lamina thickening. At clinical onset, the most common manifestation was central nervous system symptoms, followed by visual symptoms and hearing disturbances. Diagnosis is based on Magnetic Resonance Imaging (MRI), retinal fluorescein angiography, and audiometry; these are considered crucial tests to enable diagnosis. Antiendothelial cell antibodies (AECAs) are also of diagnostic relevance. Based on the hypothesis of being an autoimmune disease, treatment has to be immunosuppressive. In addition, anticoagulation measures, antiplatelet agents and antivasospastic agents should be considered. The majority of patients did not initially present with the complete triad of symptoms. An appropriate approach would be to perform a search for absent components of the triad if the clinical presentation is suggestive of Susac's syndrome. Improved understanding of the presentation of Susac's syndrome will prevent misdiagnosis and ensure that patients receive the best possible care.
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Affiliation(s)
- Antonio Greco
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Armando De Virgilio
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Andrea Gallo
- Department of Medico-Surgical Sciences and Biotechnologies, Otorhinolaryngology Section, University of Rome "La Sapienza", Corso della Repubblica 79, 04100 Latina, LT, Italy.
| | - Massimo Fusconi
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Rosaria Turchetta
- Department Organs of Sense, Audiology Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Mario Tombolini
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Maria Ida Rizzo
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Marco de Vincentiis
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
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