8
|
Mustafa R, Passe TJ, Lopez-Chiriboga AS, Weinshenker BG, Krecke KN, Zalewski NL, Diehn FE, Sechi E, Mandrekar J, Kaufmann TJ, Morris PP, Pittock SJ, Toledano M, Lanzino G, Aksamit AJ, Kumar N, Lucchinetti CF, Flanagan EP. Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions. Neurol Clin Pract 2021; 11:e601-e611. [PMID: 34824894 PMCID: PMC8610516 DOI: 10.1212/cpj.0000000000001036] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/02/2020] [Indexed: 01/21/2023]
Abstract
Objective To determine whether MRI gadolinium enhancement patterns in myelopathies with longitudinally extensive T2 lesions can be reliably distinguished and assist in diagnosis. Methods We retrospectively identified 74 Mayo Clinic patients (January 1, 1996–December 31, 2019) fulfilling the following criteria: (1) clinical myelopathy; (2) MRI spine available; (3) longitudinally extensive T2 hyperintensity (≥3 vertebral segments); and (4) characteristic gadolinium enhancement pattern associated with a specific myelopathy etiology. Thirty-nine cases with alternative myelopathy etiologies, without previously described enhancement patterns, were included as controls. Two independent readers, educated on enhancement patterns, reviewed T2-weighted and postgadolinium T1-weighted images and selected the diagnosis based on this knowledge. These were compared with the true diagnoses, and agreement was measured with Kappa coefficient. Results Among all cases and controls (n = 113), there was excellent agreement for diagnosis using postgadolinium images (kappa, 0.76) but poor agreement with T2-weighted characteristics alone (kappa, 0.25). A correct diagnosis was more likely when assessing postgadolinium image characteristics than with T2-weighted images alone (rater 1: 100/113 [88%] vs 61/113 [54%] correct, p < 0.0001; rater 2: 95/113 [84%] vs 68/113 [60%] correct, p < 0.0001). Of the 74 with characteristic enhancement patterns, 55 (74%) were assigned an alternative incorrect or nonspecific diagnosis when originally evaluated in clinical practice, 12 (16%) received immunotherapy for noninflammatory myelopathies, and 2 (3%) underwent unnecessary spinal cord biopsy. Conclusions Misdiagnosis of myelopathies is common. The gadolinium enhancement patterns characteristic of specific diagnoses can be identified with excellent agreement between raters educated on this topic. This study highlights the potential diagnostic utility of enhancement patterns in myelopathies with longitudinally extensive T2 lesions.
Collapse
Affiliation(s)
- Rafid Mustafa
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Theodore J Passe
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Alfonso S Lopez-Chiriboga
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Brian G Weinshenker
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Karl N Krecke
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Nicholas L Zalewski
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Felix E Diehn
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Elia Sechi
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Jay Mandrekar
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Timothy J Kaufmann
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Padraig P Morris
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Sean J Pittock
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Michel Toledano
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Giuseppe Lanzino
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Allen J Aksamit
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Neeraj Kumar
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Claudia F Lucchinetti
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Eoin P Flanagan
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| |
Collapse
|
13
|
Vogrig A, Muñiz-Castrillo S, Desestret V, Joubert B, Honnorat J. Pathophysiology of paraneoplastic and autoimmune encephalitis: genes, infections, and checkpoint inhibitors. Ther Adv Neurol Disord 2020; 13:1756286420932797. [PMID: 32636932 PMCID: PMC7318829 DOI: 10.1177/1756286420932797] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/17/2020] [Indexed: 12/14/2022] Open
Abstract
Paraneoplastic neurological syndromes (PNSs) are rare complications of systemic cancers that can affect all parts of the central and/or peripheral nervous system. A body of experimental and clinical data has demonstrated that the pathogenesis of PNSs is immune-mediated. Nevertheless, the mechanisms leading to immune tolerance breakdown in these conditions remain to be elucidated. Despite their rarity, PNSs offer a unique perspective to understand the complex interplay between cancer immunity, effect of immune checkpoint inhibitors (ICIs), and mechanisms underlying the attack of neurons in antibody-mediated neurological disorders, with potentially relevant therapeutic implications. In particular, it is reported that ICI treatment can unleash PNSs and that the immunopathological features of PNS-related tumors are distinctive, showing prominent tumor-infiltrating lymphocytes and germinal center reactions. Intriguingly, similar pathological substrates have gained further attention as potential biomarkers of ICI-sensitivity and oncological prognosis. Moreover, the genetic analysis of PNS-associated tumors has revealed specific molecular signatures and mutations in genes encoding onconeural proteins, leading to the production of highly immunogenic neoantigens. Other than PNSs, autoimmune encephalitides (AEs) comprise a recently described group of disorders characterized by prominent neuropsychiatric symptoms, diverse antibody spectrum, and less tight association with cancer. Other triggering factors seem to be involved in AEs. Recent data have shed light on the importance of preceding infections (in particular, herpes simplex virus encephalitis) in inducing neurological autoimmune disorders in susceptible individuals (those with a selective deficiency in the innate immune system). In addition, in some AEs (e.g. LGI1-antibody encephalitis) an association with specific host-related factors [e.g., human leukocyte antigen (HLA)] was clearly demonstrated. We provide herein a comprehensive review of the most recent findings in the field of PNSs and AEs, with particular focus on their triggering factors and immunopathogenesis.
Collapse
Affiliation(s)
- Alberto Vogrig
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Sergio Muñiz-Castrillo
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Virginie Desestret
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Bastien Joubert
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Jérôme Honnorat
- Centre de Référence National pour les Syndromes Neurologiques Paranéoplasiques, Hôpital Neurologique, 59 Boulevard Pinel, Bron Cedex, 69677, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| |
Collapse
|