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Clinical and Imaging Characteristics of Non-Neoplastic Spinal Lesions: A Comparative Study with Intramedullary Tumors. Diagnostics (Basel) 2022; 12:diagnostics12122969. [PMID: 36552976 PMCID: PMC9777410 DOI: 10.3390/diagnostics12122969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
The features of non-neoplastic lesions are often similar to those of intramedullary tumors, and a differential diagnosis is challenging to obtain in some cases. A surgical biopsy, which is performed on highly invasive tumors, should be avoided in cases of non-neoplastic lesions. Therefore, an accurate diagnosis is important prior to treatment. We evaluated 43 patients suspected of having spinal cord tumors and, finally, were diagnosed with non-neoplastic intramedullary lesions via magnetic resonance imaging. The patients commonly presented with myelitis. The patients with non-neoplastic neurological diseases had a significantly shorter symptom duration than those with intramedullary astrocytomas. The proportion of patients with non-neoplastic neurological diseases who presented with lesions at the cervical spinal level and focal lesions on axial imaging but without a spinal cord enlargement was significantly higher than that of patients with intramedullary astrocytomas. The current study aimed to distinguish spinal cord tumors from non-neoplastic intramedullary lesions based on their distinct features.
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Vegezzi E, Ravaglia S, Buongarzone G, Bini P, Diamanti L, Gastaldi M, Prunetti P, Rognone E, Marchioni E. Acute myelitis and ChAdOx1 nCoV-19 vaccine: Casual or causal association? J Neuroimmunol 2021; 359:577686. [PMID: 34392078 PMCID: PMC8325554 DOI: 10.1016/j.jneuroim.2021.577686] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/18/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022]
Abstract
A 44-year-old previously healthy woman developed acute myelitis in close temporal relationship with ChAdOx1 nCoV-19 vaccine first-dose administration. The neurological involvement was mainly sensory with neuroimaging showing two mono-metameric lesions involving the posterior and lateral cord at dorsal level. Significant improvement was promptly recorded with high-dose intravenous steroids, with complete recovery within one month. The strict temporal relationship between vaccination and myelitis, together with the absence of clues pointing to alternative diagnoses, might suggest a conceivable role for anti-SARS-CoV-2 vaccine as immunological trigger, although a causal relationship has yet to be established and our preliminary observation suggests caution.
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Affiliation(s)
- Elisa Vegezzi
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
| | - Sabrina Ravaglia
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | | | - Paola Bini
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | - Luca Diamanti
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | - Matteo Gastaldi
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy; Neuroimmunology Research Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | - Paolo Prunetti
- Clinical Neurophysiology Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | - Elisa Rognone
- Neuroradiology Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | - Enrico Marchioni
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy.
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Martinelli-Boneschi F, Currò R, Santoro S, Berzero G, Sorosina M, Ferrè L, Mascia E, Peroni S, Comi G, Gugliemi A, Vegezzi E, Callegari I, Filippi M, Cortese A, Esposito F, Clarelli F, Marchioni E. Impact of multiple sclerosis risk loci in postinfectious neurological syndromes. Mult Scler Relat Disord 2020; 44:102326. [PMID: 32615529 DOI: 10.1016/j.msard.2020.102326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/22/2020] [Accepted: 06/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The genetic component of multiple sclerosis (MS) is now set to 200 autosomal common variants. However, it is unclear how genetic knowledge be clinically used in the differential diagnosis between MS and other inflammatory conditions like adult-onset postinfectious neurological syndromes (PINS). The aim of this study was to investigate whether PINS and MS have a shared genetic background using an updated polygenic risk scores. METHODS Eighty-eight PINS patients have been consecutively recruited between 1996 and 2016 at Mondino Foundation of Pavia, diagnosed according to clinical, MRI and CSF findings and followed-up for several years. Patients were typed using Illumina array, and genotypes imputed using the 1000 Genomes Project reference panel. A weighted genetic risk score (wGRS) has been calculated based on autosomal MS risk loci derived from large-scale studies, and an HLA genetic burden (HLAGB) was also calculated on loci associated to MS. RESULTS PINS occurred as an episode of myelitis in 44% of patients, encephalomyelitis in 44%, and encephalitis in remaining cases, with an involvement of peripheral nervous system in 41% of patients. Mean age of onset was 50.1 years, and female:male ratio was 1.4. Patients were followed-up for a mean of 7.2 years, and at last visit 55% had a low disability grade (mRS 0-1). Disease was monophasic in 67% of patients, relapsing in 18% and chronic-progressive in 15%. The wGRS of PINS cases was comparable to 370 healthy controls, while significantly lower compared to 907 bout-onset MS (BOMS) cases (wGRS= 20.9 vs 21.2; p<0.0001). The difference was even larger for PINS with peripheral nervous system involvement (wGRS=20.6) vs BOMS. CONCLUSION The distinction between MS and PINS is not easy to make in clinical practice. However, our study shows that the new set of MS risk alleles does not confer increased susceptibility to PINS. These data support the importance to discriminate these cases from MS with pathophysiological and therapeutic implications.
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Affiliation(s)
- Filippo Martinelli-Boneschi
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy; Neurology Unit and MS Centre, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy.
| | - Riccardo Currò
- Department of Brain and Behavioral Sciences, University of Pavia, via Forlanini 6, 27100 Pavia, Italy; Fondazione Istituto Neurologico Nazionale IRCCS Mondino, via Mondino 2, 27100 Pavia, Italy
| | - Silvia Santoro
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Giulia Berzero
- Department of Brain and Behavioral Sciences, University of Pavia, via Forlanini 6, 27100 Pavia, Italy; Fondazione Istituto Neurologico Nazionale IRCCS Mondino, via Mondino 2, 27100 Pavia, Italy
| | - Melissa Sorosina
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Laura Ferrè
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy; Neurology Unit, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Elisabetta Mascia
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Silvia Peroni
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Giancarlo Comi
- Neurology Unit, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Angelo Gugliemi
- Department of Surgical, Pediatric, and Diagnostic Sciences, University of Pavia, Viale Brambilla 74, 27100 Pavia, Italy; UOC Anestesia e Rianimazione, IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Elisa Vegezzi
- Department of Brain and Behavioral Sciences, University of Pavia, via Forlanini 6, 27100 Pavia, Italy; Fondazione Istituto Neurologico Nazionale IRCCS Mondino, via Mondino 2, 27100 Pavia, Italy
| | - Ilaria Callegari
- Department of Brain and Behavioral Sciences, University of Pavia, via Forlanini 6, 27100 Pavia, Italy; Fondazione Istituto Neurologico Nazionale IRCCS Mondino, via Mondino 2, 27100 Pavia, Italy
| | - Massimo Filippi
- Neurology Unit, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 48 - 20132 Milan, Italy; Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy; Neurophisiology Unit, IRCCS San Raffaele Scientific Institute, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Andrea Cortese
- Department of Brain and Behavioral Sciences, University of Pavia, via Forlanini 6, 27100 Pavia, Italy; Fondazione Istituto Neurologico Nazionale IRCCS Mondino, via Mondino 2, 27100 Pavia, Italy
| | - Federica Esposito
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy; Neurology Unit, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Ferdinando Clarelli
- Laboratory of Human Genetics of Neurological Disorders, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48 - 20132 Milan, Italy
| | - Enrico Marchioni
- Fondazione Istituto Neurologico Nazionale IRCCS Mondino, via Mondino 2, 27100 Pavia, Italy
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Abstract
Diagnosis of multiple sclerosis (MS) is based on the demonstration of dissemination of lesions in space (DIS) and in time (DIT), as well as on the exclusion of an alternative neurologic disorder. As a paraclinical tool brain and/or spinal cord magnetic resonance imaging (MRI), showing typical lesion morphology, characteristic distribution of lesions, or involvement or specific anatomic structures, can support the diagnosis of MS. But from an imaging perspective a considerable amount of inherited and acquired disorders may manifest with radiologic evidence of DIT, DIS, or both. Hypoxic-ischemic vasculopathy, specially small-vessel disease, inflammatory disorders, vasculitis, and non-MS idiopathic inflammatory disorders, as well as some toxic, metabolic, and infectious disorders, may present mimicking MS on MR examinations and should be included in the differential diagnosis of MS-like lesions. Careful evaluation of associated findings on MRI, the so-called MRI red flags, such as the presence of infarcts, microbleeds, meningeal enhancement, and calcifications among others, are very helpful in suggesting a diagnosis other than MS. Complement MRI findings to patient's history, demographics, and serologic findings are crucial to achieve the correct diagnosis. We will review the most frequent radiologic appearance and differential features from the most frequent MS mimickers.
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Affiliation(s)
- Esther Sánchez Aliaga
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
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Williams T, Thorpe J. Post-infective transverse myelitis following Streptococcus pneumoniae meningitis with radiological features of acute disseminated encephalomyelitis: a case report. J Med Case Rep 2012; 6:313. [PMID: 22992300 PMCID: PMC3469354 DOI: 10.1186/1752-1947-6-313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 07/19/2012] [Indexed: 12/05/2022] Open
Abstract
Introduction Post-infectious autoimmune demyelination of the central nervous system is a rare neurological disorder typically associated with exanthematous viral infections. We report an unusual presentation of the condition and a previously undocumented association with Streptococcus pneumonia meningitis. Case presentation A 50-year-old Caucasian woman presented to our facility with an acute myelopathy three days after discharge following acute Streptococcus pneumoniae meningitis. Imaging studies of the spine ruled out an infective focus and no other lesions were seen within the cord. Diffuse, bilateral white matter lesions were seen within the cerebral hemispheres, and our patient was diagnosed as having a post-infective demyelination syndrome that met the diagnostic criteria for an acute transverse myelitis. Our patient clinically and radiologically improved following treatment with steroids. Conclusions The novel association of a Streptococcus pneumoniae infection with post-infectious autoimmune central nervous system demyelination should alert the reader to the potentially causative role of this common organism, and gives insights into the pathogenesis. The unusual dissociation between the clinical presentation and the location of the radiological lesions should also highlight the potential for the condition to mimic the presentation of others, and stimulates debate on the definitions of acute transverse myelitis and acute disseminated encephalomyelitis, and their potential overlap.
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Affiliation(s)
- Thomas Williams
- Addenbrooke's Hospital, University of Cambridge School of Clinical Medicine, Box 111, Hills Road, Cambridge, CB2 0SP, UK.
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García Domínguez J, Martínez Ginés M, Martín-Barriga M, Guzmán-de-Villoria J, Muñoz Blanco J, de Andrés Frutos C. Recurrent acute rhombencephalomyelitis in an adult or neuromyelitis optica? Presentation of a case. NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2012.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Role of NMO-IgG in Distinguishing the Type of Optic Neuritis. Optom Vis Sci 2012; 89:234-37. [DOI: 10.1097/opx.0b013e31823ac6a8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Eckstein C, Saidha S, Levy M. A differential diagnosis of central nervous system demyelination: beyond multiple sclerosis. J Neurol 2011; 259:801-16. [DOI: 10.1007/s00415-011-6240-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/28/2011] [Accepted: 08/30/2011] [Indexed: 12/12/2022]
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García Domínguez JM, Martínez Ginés ML, Martín-Barriga ML, Guzmán-de-Villoria J, Muñoz Blanco JL, de Andrés Frutos C. [Recurrent acute rhombencephalomyelitis in an adult or neuromyelitis optica? Presentation of a case]. Neurologia 2011; 27:154-60. [PMID: 21652118 DOI: 10.1016/j.nrl.2011.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 04/08/2011] [Accepted: 04/11/2011] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The lack of accepted homogeneous criteria for the definition of some demyelinating diseases makes diagnostic characterization difficult and limits data interpretation and therapeutic recommendations. Recurrent encephalomyelitis (ADE-R) along with borderline cases of neuromyelitis optica (NMO) are especially controversial. OBJECTIVE To describe the clinical and radiological evolution of an adult-onset ADE-R versus NMO case throughout 9 years of follow-up. PATIENT AND METHODS Our patient presented with severe symptoms of rhombencephalomyelitis and the cranial and spinal magnetic resonance imaging (MRI) showed large lesions, with gadolinium enhancement in brainstem and spinal cord, correlating with the clinical picture. Infectious aetiology was excluded, IgG index was normal and NMO antibodies were negative. After treatment with intravenous corticosteroids and plasmapheresis, there was excellent recovery in the acute phase. During follow-up, seven relapses have occurred, mainly in the spinal cord, with good recovery and the same symptomatology, albeit with different severity. Immunosuppressive treatment was introduced since the beginning. CONCLUSIONS Our case shares common features of both ADE-R and NMO, illustrating that diagnostic characterization is not easy in spite of current criteria.
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Affiliation(s)
- J M García Domínguez
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España.
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Young NP, Weinshenker BG, Parisi JE, Scheithauer B, Giannini C, Roemer SF, Thomsen KM, Mandrekar JN, Erickson BJ, Lucchinetti CF. Perivenous demyelination: association with clinically defined acute disseminated encephalomyelitis and comparison with pathologically confirmed multiple sclerosis. Brain 2010; 133:333-48. [PMID: 20129932 DOI: 10.1093/brain/awp321] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Distinction between acute disseminated encephalomyelitis and acute multiple sclerosis is often clinically difficult. Perivenous demyelination is the pathological hallmark of acute disseminated encephalomyelitis, whereas confluent demyelination is the hallmark of acute multiple sclerosis. We investigated whether perivenous demyelination versus confluent demyelination distinguishes acute disseminated encephalomyelitis from multiple sclerosis. Patients with perivenous demyelination (n = 13; median age 43 years, range 5-67) on brain biopsy and/or autopsy, ascertained retrospectively, were compared with a cohort with confluent demyelination only (n = 91; 84% multiple sclerosis, 16% isolated syndrome at follow-up; median age 39 years, range 10-69). Clinical presentation, course and the International Paediatric Multiple Sclerosis Study Group clinical criteria for acute disseminated encephalomyelitis were assessed in both cohorts. Among the perivenous demyelination cohort, 10 patients had only perivenous demyelination and three also had confluent demyelination. All but one patient with perivenous demyelination only had a monophasic course, whereas two of three with both types had a relapsing course. The perivenous demyelination cohort was more likely than the confluent demyelination cohort to present with encephalopathy (P < 0.001), depressed level of consciousness (P < 0.001), headache (P < 0.001), meningismus (P = 0.04), cerebrospinal fluid pleocytosis (P = 0.04) or multifocal enhancing magnetic resonance imaging lesions (P < 0.001). A distinct pattern of cortical microglial activation and aggregation without associated cortical demyelination was found among six perivenous demyelination patients, all of whom had encephalopathy and four of whom had depressed level of consciousness. This pattern of cortical pathology was not observed in the confluent demyelination cohort, even in one patient with depressed level of consciousness. Clinical criteria were 80% sensitive and 91% specific for pathologically defined acute disseminated encephalomyelitis (perivenous demyelination), but misdiagnosed acute disseminated encephalomyelitis among 9% of patients with confluent demyelination and multiple sclerosis diagnosis at last follow-up. Perivenous demyelination is associated with meningoencephalopathic presentations and a monophasic course. Depressed level of consciousness is a more specific clinical criterion for pathologically confirmed acute disseminated encephalomyelitis than encephalopathy, which over-diagnosed acute disseminated encephalomyelitis among multiple sclerosis patients. A distinct pattern of cortical microglial activation without cortical demyelination may be the pathological correlate of depressed level of consciousness in acute disseminated encephalomyelitis. Although pathological evidence of perivenous demyelination may be superior to clinical criteria for diagnosing acute disseminated encephalomyelitis, the co-occurrence of perivenous and confluent demyelination in some individuals suggests pathogenic overlap between acute disseminated encephalomyelitis and multiple sclerosis and misclassification even with biopsy.
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Affiliation(s)
- Nathan P Young
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Brinar VV, Poser CM. Disseminated encephalomyelitis in adults. Clin Neurol Neurosurg 2008; 110:913-8. [DOI: 10.1016/j.clineuro.2008.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 06/12/2008] [Indexed: 11/24/2022]
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Brinar VV, Habek M, Zadro I, Barun B, Ozretić D, Vranješ D. Current concepts in the diagnosis of transverse myelopathies. Clin Neurol Neurosurg 2008; 110:919-27. [DOI: 10.1016/j.clineuro.2008.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 07/01/2008] [Accepted: 07/02/2008] [Indexed: 10/21/2022]
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Miller DH, Weinshenker BG, Filippi M, Banwell BL, Cohen JA, Freedman MS, Galetta SL, Hutchinson M, Johnson RT, Kappos L, Kira J, Lublin FD, McFarland HF, Montalban X, Panitch H, Richert JR, Reingold SC, Polman CH. Differential diagnosis of suspected multiple sclerosis: a consensus approach. Mult Scler 2008; 14:1157-74. [PMID: 18805839 PMCID: PMC2850590 DOI: 10.1177/1352458508096878] [Citation(s) in RCA: 458] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Diagnosis of multiple sclerosis (MS) requires exclusion of diseases that could better explain the clinical and paraclinical findings. A systematic process for exclusion of alternative diagnoses has not been defined. An International Panel of MS experts developed consensus perspectives on MS differential diagnosis. METHODS Using available literature and consensus, we developed guidelines for MS differential diagnosis, focusing on exclusion of potential MS mimics, diagnosis of common initial isolated clinical syndromes, and differentiating between MS and non-MS idiopathic inflammatory demyelinating diseases. RESULTS We present recommendations for 1) clinical and paraclinical red flags suggesting alternative diagnoses to MS; 2) more precise definition of "clinically isolated syndromes" (CIS), often the first presentations of MS or its alternatives; 3) algorithms for diagnosis of three common CISs related to MS in the optic nerves, brainstem, and spinal cord; and 4) a classification scheme and diagnosis criteria for idiopathic inflammatory demyelinating disorders of the central nervous system. CONCLUSIONS Differential diagnosis leading to MS or alternatives is complex and a strong evidence base is lacking. Consensus-determined guidelines provide a practical path for diagnosis and will be useful for the non-MS specialist neurologist. Recommendations are made for future research to validate and support these guidelines. Guidance on the differential diagnosis process when MS is under consideration will enhance diagnostic accuracy and precision.
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Affiliation(s)
- D H Miller
- Department of Inflammation, Institute of Neurology, NMR Research Unit, University College London, UK
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Is there sentinel demyelination before development of primary CNS lymphoma? J Clin Neurosci 2008; 15:1069-70; author reply 1071. [DOI: 10.1016/j.jocn.2007.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 12/30/2007] [Indexed: 11/21/2022]
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Poser CM, Brinar VV. Disseminated encephalomyelitis and multiple sclerosis: two different diseases - a critical review. Acta Neurol Scand 2007; 116:201-6. [PMID: 17824894 DOI: 10.1111/j.1600-0404.2007.00902.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The practice of initiating immunomodulatory treatment immediately after a clinically isolated syndrome (CIS) suggestive of multiple sclerosis (MS) emphasizes the need to distinguish between disseminated encephalomyelitis (DEM) and MS. Their clinical, genetic, imaging, and histopathological characteristics establish that they are distinct disease entities. Acute and recurrent DEM are more common in children, but also occur in adults. DEM is polysymptomatic and includes signs and symptoms rarely encountered in MS, such as fever, alterations of the state of consciousness, cognitive and aphasic symptoms, and meningism. Cerebrospinal oligoclonal bands are rare. Magnetic resonance imaging (MRI) is the best means of distinguishing between DEM and MS. In the former, the lesion load is heavy, thalamus or basal ganglia are often affected, and early in the disease most of the lesions are usually larger than those of MS and enhance with gadolinium. The MRI spinal cord lesions are longer than three vertebral segments, and define neuromyelitis optica (NMO). Antibodies against aquaporin-4 are present in some NMO, but are also found in cases of MS and DEM. Most NMO are forms of DEM, not MS, and are identical with the 'Oriental' or 'optico-spinal' form of MS.
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Affiliation(s)
- C M Poser
- Department of Neurology, Harvard Medical School, Boston, MA, USA.
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Mowry EM, Woo JH, Ances BM. Baló's concentric sclerosis presenting as a stroke-like syndrome. ACTA ACUST UNITED AC 2007; 3:349-54. [PMID: 17549061 DOI: 10.1038/ncpneuro0522] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/23/2007] [Indexed: 01/09/2023]
Abstract
BACKGROUND A 37-year-old woman without important previous medical history presented to an emergency room with acute onset of left-sided weakness and numbness. Examination revealed left-sided hemiparesis (in the arm greater than in the leg) and hypoesthesia. INVESTIGATIONS Routine laboratory testing, lumbar puncture, dynamic susceptibility contrast perfusion study, longitudinal brain MRI, and magnetic resonance spectroscopy were performed. DIAGNOSIS Balós concentric sclerosis. MANAGEMENT Intravenous methylprednisolone followed by oral steroid taper.
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Affiliation(s)
- Ellen M Mowry
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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Mowry EM, Woo JH, Ances BM. Technology insight: can neuroimaging provide insights into the role of ischemia in Baló's concentric sclerosis? ACTA ACUST UNITED AC 2007; 3:341-8. [PMID: 17549060 DOI: 10.1038/ncpneuro0519] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 03/22/2007] [Indexed: 12/21/2022]
Abstract
Baló's concentric sclerosis (BCS) has long been considered to be a variant of multiple sclerosis. Although BCS was initially described over 100 years ago, relatively few antemortem cases have been identified, and the exact pathogenesis remains unknown. Inflammatory protective ischemic preconditioning has recently been suggested as a mechanism by which the typical concentric rings of the BCS lesion are formed. Advanced neuroimaging can provide important in vivo markers of disease progression that can assist in the diagnosis and management of patients with BCS. In this Review, we discuss evidence from longitudinal neuroimaging studies that supports the role of ischemic preconditioning in BCS.
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Affiliation(s)
- Ellen M Mowry
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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Ordonez L, Skromne E, Ontaneda D, Rivera VM. Multiphasic disseminated encephalomyelitis, systemic lupus erythematosus and antiphospholipid syndrome. Clin Neurol Neurosurg 2007; 109:102-5. [PMID: 16624483 DOI: 10.1016/j.clineuro.2006.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 03/13/2006] [Accepted: 03/15/2006] [Indexed: 11/20/2022]
Abstract
We report a case of multiphasic disseminated encephalomyelitis (MDEM) associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome. The initial presentation was suggestive of multiple sclerosis. Further clinical attacks, MRI imaging, and CSF findings led to a diagnosis of disseminated encephalomyelitis (DEM). Multiple episodes of neurological dysfunction, which differed in clinical presentation, further categorized the diagnosis as multiphasic DEM. The co-occurrence SLE and antiphospholipid syndrome is unusual and provided an additional diagnostic challenge.
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Affiliation(s)
- Laura Ordonez
- Maxine Mesinger MS Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA.
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