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Hagbohm C, Ouellette R, Flanagan EP, Jonsson DI, Piehl F, Banwell B, Wickström R, Iacobaeus E, Granberg T, Ineichen BV. Clinical and neuroimaging phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy: A systematic review and meta-analysis. Eur J Neurol 2024; 31:e16284. [PMID: 38506182 DOI: 10.1111/ene.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE This study was undertaken to provide a comprehensive review of neuroimaging characteristics and corresponding clinical phenotypes of autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A), a rare but severe neuroinflammatory disorder, to facilitate early diagnosis and appropriate treatment. METHODS A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis)-conforming systematic review and meta-analysis was performed on all available data from January 2016 to June 2023. Clinical and neuroimaging phenotypes were extracted for both adult and paediatric forms. RESULTS A total of 93 studies with 681 cases (55% males; median age = 46, range = 1-103 years) were included. Of these, 13 studies with a total of 535 cases were eligible for the meta-analysis. Clinically, GFAP-A was often preceded by a viral prodromal state (45% of cases) and manifested as meningitis, encephalitis, and/or myelitis. The most common symptoms were headache, fever, and movement disturbances. Coexisting autoantibodies (45%) and neoplasms (18%) were relatively frequent. Corticosteroid treatment resulted in partial/complete remission in a majority of cases (83%). Neuroimaging often revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities (74%) as well as perivascular (45%) and/or leptomeningeal (30%) enhancement. Spinal cord abnormalities were also frequent (49%), most commonly manifesting as longitudinally extensive myelitis. There were 88 paediatric cases; they had less prominent neuroimaging findings with lower frequencies of both T2/FLAIR hyperintensities (38%) and contrast enhancement (19%). CONCLUSIONS This systematic review and meta-analysis provide high-level evidence for clinical and imaging phenotypes of GFAP-A, which will benefit the identification and clinical workup of suspected cases. Differential diagnostic cues to distinguish GFAP-A from common clinical and imaging mimics are provided as well as suitable magnetic resonance imaging protocol recommendations.
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Affiliation(s)
- Caroline Hagbohm
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Russell Ouellette
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eoin P Flanagan
- Department of Neurology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dagur I Jonsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Neurology, Academic Specialist Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Department of Neurology and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin V Ineichen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Reproducible Science, University of Zürich, Zürich, Switzerland
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Greco G, Masciocchi S, Diamanti L, Bini P, Vegezzi E, Marchioni E, Colombo E, Rigoni E, Businaro P, Ferraro OE, Bianchi Marzoli S, Bergamaschi R, Franciotta D, Gastaldi M. Visual System Involvement in Glial Fibrillary Acidic Protein Astrocytopathy: Two Case Reports and a Systematic Literature Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200146. [PMID: 37582612 PMCID: PMC10427126 DOI: 10.1212/nxi.0000000000200146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Glial fibrillary acidic protein (GFAP) antibodies can associate with an astrocytopathy often presenting as a meningoencephalitis. Visual involvement has been reported but scarcely defined. We describe 2 cases of GFAP astrocytopathy with predominant visual symptoms and present a systematic review of the literature. METHODS We describe 2 patients with GFAP astrocytopathy from our neurology department. We performed a systematic review of the literature according to PRISMA guidelines, including all patients with this disease and available clinical data, focusing on visual involvement. RESULTS Patient 1 presented with bilateral optic disc edema and severe sudden bilateral loss of vision poorly responsive to therapy. Patient 2 showed bilateral optic disc edema, headache, and mild visual loss with complete recovery after steroids. We screened 275 records and included 84 articles (62 case reports and 22 case series) for a total of 592 patients. Visual involvement was reported in 149/592 (25%), with either clinical symptoms or paraclinical test-restricted abnormalities. Bilateral optic disc edema was found in 80/159 (50%) of patients investigated with fundoscopy, among which 49/80 (61%) were asymptomatic. One hundred (100/592, 17%) reported visual symptoms, often described as blurred vision or transient visual obscurations. Optic neuritis was rare and diagnosed in only 6% of all patients with GFAP astrocytopathy, often without consistent clinical and paraclinical evidence to support the diagnosis. Four patients (including patient 1) manifested a severe, bilateral optic neuritis with poor treatment response. In patients with follow-up information, a relapsing disease course was more frequently observed in those with vs without visual involvement (35% vs 11%, p = 0.0035, OR 3.6 [CI 1.44-8.88]). DISCUSSION Visual system involvement in GFAP astrocytopathy is common and heterogeneous, ranging from asymptomatic bilateral optic disc edema to severe bilateral loss of vision, but optic neuritis is rare. GFAP CSF antibody testing should be considered in patients with encephalitis/meningoencephalitis or myelitis and bilateral optic disc edema, even without visual symptoms, and in patients with severe bilateral optic neuritis, especially when AQP4 antibodies are negative. Visual symptoms might associate with a higher relapse risk and help to identify patients who may require chronic immunosuppression.
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Affiliation(s)
- Giacomo Greco
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefano Masciocchi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Luca Diamanti
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Paola Bini
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elisa Vegezzi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Enrico Marchioni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Elena Colombo
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Eleonora Rigoni
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Pietro Businaro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Ottavia E Ferraro
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Stefania Bianchi Marzoli
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Roberto Bergamaschi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Diego Franciotta
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy
| | - Matteo Gastaldi
- From the Department of Brain and Behavioural Sciences (G.G., S.M., E.V., P. Businaro), University of Pavia; IRCCS Mondino Foundation (G.G., S.M., L.D., P. Bini, E.V., E.M., E.C., E.R., R.B., D.F., M.G.), National Neurological Institute; Unit of Biostatistics and Clinical Epidemiology (O.E.F.), Department of Public Health, Experimental and Forensic Medicine, University of Pavia; and Neuro-Ophthalmology Center and Ocular Electrophysiology Laboratory (S.B.M.), Istituto Auxologico Italiano IRCCS Capitanio Hospital, Milan, Italy.
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Lanza G, Fisicaro F, Dubbioso R, Ranieri F, Chistyakov AV, Cantone M, Pennisi M, Grasso AA, Bella R, Di Lazzaro V. A comprehensive review of transcranial magnetic stimulation in secondary dementia. Front Aging Neurosci 2022; 14:995000. [PMID: 36225892 PMCID: PMC9549917 DOI: 10.3389/fnagi.2022.995000] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Although primary degenerative diseases are the main cause of dementia, a non-negligible proportion of patients is affected by a secondary and potentially treatable cognitive disorder. Therefore, diagnostic tools able to early identify and monitor them and to predict the response to treatment are needed. Transcranial magnetic stimulation (TMS) is a non-invasive neurophysiological technique capable of evaluating in vivo and in “real time” the motor areas, the cortico-spinal tract, and the neurotransmission pathways in several neurological and neuropsychiatric disorders, including cognitive impairment and dementia. While consistent evidence has been accumulated for Alzheimer’s disease, other degenerative cognitive disorders, and vascular dementia, to date a comprehensive review of TMS studies available in other secondary dementias is lacking. These conditions include, among others, normal-pressure hydrocephalus, multiple sclerosis, celiac disease and other immunologically mediated diseases, as well as a number of inflammatory, infective, metabolic, toxic, nutritional, endocrine, sleep-related, and rare genetic disorders. Overall, we observed that, while in degenerative dementia neurophysiological alterations might mirror specific, and possibly primary, neuropathological changes (and hence be used as early biomarkers), this pathogenic link appears to be weaker for most secondary forms of dementia, in which neurotransmitter dysfunction is more likely related to a systemic or diffuse neural damage. In these cases, therefore, an effort toward the understanding of pathological mechanisms of cognitive impairment should be made, also by investigating the relationship between functional alterations of brain circuits and the specific mechanisms of neuronal damage triggered by the causative disease. Neurophysiologically, although no distinctive TMS pattern can be identified that might be used to predict the occurrence or progression of cognitive decline in a specific condition, some TMS-associated measures of cortical function and plasticity (such as the short-latency afferent inhibition, the short-interval intracortical inhibition, and the cortical silent period) might add useful information in most of secondary dementia, especially in combination with suggestive clinical features and other diagnostic tests. The possibility to detect dysfunctional cortical circuits, to monitor the disease course, to probe the response to treatment, and to design novel neuromodulatory interventions in secondary dementia still represents a gap in the literature that needs to be explored.
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Affiliation(s)
- Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Troina, Italy
- *Correspondence: Giuseppe Lanza,
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Raffaele Dubbioso
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy
| | - Federico Ranieri
- Unit of Neurology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | | | - Mariagiovanna Cantone
- Neurology Unit, Policlinico University Hospital “G. Rodolico – San Marco”, Catania, Italy
- Neurology Unit, Sant’Elia Hospital, ASP Caltanissetta, Caltanissetta, Italy
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Alfio Antonio Grasso
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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