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Strunk D, Sinnecker T, Kleffner I, Doerr J, Ringelstein M, Gross CC, Deuschl C, Maderwald S, Quick HH, Yamac E, Wrede KH, Kraemer M. Central intra-lesional iron deposits as a possible novel imaging marker at 7 Tesla MRI in Susac Syndrome - an exploratory study. BMC Med Imaging 2024; 24:4. [PMID: 38166655 PMCID: PMC10759674 DOI: 10.1186/s12880-023-01171-7] [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: 06/18/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare autoimmune disease that leads to hearing impairment, visual field deficits, and encephalopathy due to an occlusion of precapillary arterioles in the brain, retina, and inner ear. Given the potentially disastrous outcome and difficulties in distinguishing SuS from its differential diagnoses, such as multiple sclerosis (MS), our exploratory study aimed at identifying potential new SuS-specific neuroimaging markers. METHODS Seven patients with a definite diagnosis of SuS underwent magnetic resonance imaging (MRI) at 7 Tesla (7T), including T2* weighted and quantitative susceptibility mapping (QSM) sequences. T2 weighted hyperintense lesions were analyzed with regard to number, volume, localization, central vein sign, T1 hypointensity, and focal iron deposits in the center of SuS lesions ("iron dots"). Seven T MRI datasets from the same institute, comprising 75 patients with, among others, MS, served as controls. RESULTS The "iron dot" sign was present in 71.4% (5/7) of the SuS patients, compared to 0% in our control cohort. Thus, sensitivity was 71.4% and specificity 100%. A central vein sign was only incidentally detected. CONCLUSION We are the first to demonstrate this type of "iron dot" lesions on highly resolving 7T T2*w and QSM images in vivo as a promising neuroimaging marker of SuS, corroborating previous histopathological ex vivo findings.
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Affiliation(s)
- Daniel Strunk
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Tim Sinnecker
- Medical Image Analysis Center (MIAC AG), Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Ilka Kleffner
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Jan Doerr
- Department of Neurology, Oberhavel Kliniken, Hennigsdorf, Germany
- Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Westfälische Wilhelms University of Münster, Münster, Germany
| | - Cornelius Deuschl
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Stefan Maderwald
- Erwin L. Hahn Institute for Magnetic Resonance ImagingEssen, Germany & High Field and Hybrid MR Imaging, University Duisburg-EssenUniversity Hospital Essen, Essen, Germany
| | - Harald H Quick
- Erwin L. Hahn Institute for Magnetic Resonance ImagingEssen, Germany & High Field and Hybrid MR Imaging, University Duisburg-EssenUniversity Hospital Essen, Essen, Germany
| | - Elif Yamac
- Department of Intracranial Endovascular Therapy, Alfried Krupp Hospital, Essen, Germany
| | - Karsten H Wrede
- Erwin L. Hahn Institute for Magnetic Resonance ImagingEssen, Germany & High Field and Hybrid MR Imaging, University Duisburg-EssenUniversity Hospital Essen, Essen, Germany
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany.
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
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Bose S, Papathanasiou A, Karkhanis S, Appleton JP, King D, Batra R, Mollan SP, Jacob S. Susac syndrome: neurological update (clinical features, long-term observational follow-up and management of sixteen patients). J Neurol 2023; 270:6193-6206. [PMID: 37608221 PMCID: PMC10632257 DOI: 10.1007/s00415-023-11891-z] [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: 02/09/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/24/2023]
Abstract
Susac syndrome is a likely autoimmune microangiopathy affecting the brain, retina and inner ear. Due to the rarity of this condition, diagnosis and treatment can be challenging. Diagnosis is based on the presence of the clinical triad of central nervous system dysfunction, branch retinal artery occlusions and sensorineural hearing loss. Typical MRI findings of callosal and peri-callosal lesions may assist in diagnosis. Clinical course can be monophasic, polycyclic or chronic continuous. It is important to look out for red flags to attain an accurate diagnosis and follow a therapeutic algorithm based on severity of the disease and response to treatment. Patients are treated with steroids and immunosuppressive agents with a variable response. Early aggressive treatment especially in severe cases, may help in preventing relapses and morbidity/disability. This study highlights important diagnostic features and proposes a treatment algorithm based on clinical experience from management of 16 patients from 2 neuroscience centres in the UK since 2007, who were followed up over a long period of 3-15 years.
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Affiliation(s)
- Smriti Bose
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | | | - Sameep Karkhanis
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Jason P Appleton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, Birmingham, UK
| | - Dominic King
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Ruchika Batra
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Johnson P, Chan JK, Vavasour IM, Abel S, Lee LE, Yong H, Laule C, Li DKB, Tam R, Traboulsee A, Carruthers RL, Kolind SH. Quantitative MRI findings indicate diffuse white matter damage in Susac Syndrome. Mult Scler J Exp Transl Clin 2022; 8:20552173221078834. [PMID: 35186315 PMCID: PMC8851927 DOI: 10.1177/20552173221078834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Susac Syndrome (SuS) is an autoimmune endotheliopathy impacting the brain, retina and cochlea that can clinically mimic multiple sclerosis (MS). Objective To evaluate non-lesional white matter demyelination changes in SuS compared to MS and healthy controls (HC) using quantitative MRI. Methods 3T MRI including myelin water imaging and diffusion basis spectrum imaging were acquired for 7 SuS, 10 MS and 10 HC participants. Non-lesional white matter was analyzed in the corpus callosum (CC) and normal appearing white matter (NAWM). Groups were compared using ANCOVA with Tukey correction. Results SuS CC myelin water fraction (mean 0.092) was lower than MS(0.11, p = 0.01) and HC(0.11, p = 0.04). Another myelin marker, radial diffusivity, was increased in SuS CC(0.27μm2/ms) compared to HC(0.21μm2/ms, p = 0.008) and MS(0.23μm2/ms, p = 0.05). Fractional anisotropy was lower in SuS CC(0.82) than HC(0.86, p = 0.04). Fiber fraction (reflecting axons) did not differ from HC or MS. In NAWM, radial diffusivity and apparent diffusion coefficient were significantly increased in SuS compared to HC(p < 0.001 for both measures) and MS(p = 0.003, p < 0.001 respectively). Conclusions Our results provided evidence of myelin damage in SuS, particularly in the CC, and more extensive microstructural injury in NAWM, supporting the hypothesis that there are widespread microstructural changes in SuS syndrome including diffuse demyelination.
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Affiliation(s)
| | - JK Chan
- Department of Medicine (Neurology), University of British Columbia, Canada
| | - IM Vavasour
- Department of Radiology, University of British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD)
| | | | | | - H Yong
- Department of Medicine (Neurology), University of British Columbia, Canada
| | - C Laule
- Department of Radiology, University of British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD)
- Department of Pathology and Laboratory Medicine, University of British Columbia, Canada
- Department of Physics and Astronomy, University of British Columbia, Canada
| | - DKB Li
- Department of Medicine (Neurology), University of British Columbia, Canada
- Department of Radiology, University of British Columbia, Canada
| | - R Tam
- Department of Radiology, University of British Columbia, Canada
- School of Biomedical Engineering, University of British Columbia, Canada
| | | | - RL Carruthers
- Department of Medicine (Neurology), University of British Columbia, Canada
| | - SH Kolind
- Department of Medicine (Neurology), University of British Columbia, Canada
- Department of Radiology, University of British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD)
- Department of Physics and Astronomy, University of British Columbia, Canada
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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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Gross CC, Meyer C, Bhatia U, Yshii L, Kleffner I, Bauer J, Tröscher AR, Schulte-Mecklenbeck A, Herich S, Schneider-Hohendorf T, Plate H, Kuhlmann T, Schwaninger M, Brück W, Pawlitzki M, Laplaud DA, Loussouarn D, Parratt J, Barnett M, Buckland ME, Hardy TA, Reddel SW, Ringelstein M, Dörr J, Wildemann B, Kraemer M, Lassmann H, Höftberger R, Beltrán E, Dornmair K, Schwab N, Klotz L, Meuth SG, Martin-Blondel G, Wiendl H, Liblau R. CD8 + T cell-mediated endotheliopathy is a targetable mechanism of neuro-inflammation in Susac syndrome. Nat Commun 2019; 10:5779. [PMID: 31852955 PMCID: PMC6920411 DOI: 10.1038/s41467-019-13593-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/11/2019] [Indexed: 12/19/2022] Open
Abstract
Neuroinflammation is often associated with blood-brain-barrier dysfunction, which contributes to neurological tissue damage. Here, we reveal the pathophysiology of Susac syndrome (SuS), an enigmatic neuroinflammatory disease with central nervous system (CNS) endotheliopathy. By investigating immune cells from the blood, cerebrospinal fluid, and CNS of SuS patients, we demonstrate oligoclonal expansion of terminally differentiated activated cytotoxic CD8+ T cells (CTLs). Neuropathological data derived from both SuS patients and a newly-developed transgenic mouse model recapitulating the disease indicate that CTLs adhere to CNS microvessels in distinct areas and polarize granzyme B, which most likely results in the observed endothelial cell injury and microhemorrhages. Blocking T-cell adhesion by anti-α4 integrin-intervention ameliorates the disease in the preclinical model. Similarly, disease severity decreases in four SuS patients treated with natalizumab along with other therapy. Our study identifies CD8+ T-cell-mediated endotheliopathy as a key disease mechanism in SuS and highlights therapeutic opportunities.
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Affiliation(s)
- Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Céline Meyer
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France
| | - Urvashi Bhatia
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Lidia Yshii
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France
| | - Ilka Kleffner
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Anna R Tröscher
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sebastian Herich
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Henrike Plate
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tanja Kuhlmann
- Institute of Neuropathology, University Hospital Münster, University of Münster, Pottkamp 2, 48149, Münster, Germany
| | - Markus Schwaninger
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Straße 40, 37099, Göttingen, Germany
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - David-Axel Laplaud
- UMR 1064, INSERM, Centre de Recherche en Transplantation et Immunologie, Université de Nantes, CHU Nantes - Hôtel Dieu Bd Jean Monnet, 44093, Nantes Cedex 01, France
- Service Neurologie, CHU Nantes, Nantes, France
| | - Delphine Loussouarn
- Service d'Anatomo-Pathologie, CHU Nantes, Hôtel-Dieu, rez-de-jardin, 44093, Nantes Cedex 1, France
| | - John Parratt
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia
- Australia Northern Clinical School, University of Sydney, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia
| | - Michael Barnett
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
| | - Michael E Buckland
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
- Department of Neuropathology, Royal Prince Alfred Hospital, 94, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
| | - Todd A Hardy
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, 2139, Australia
| | - Stephen W Reddel
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, 2139, Australia
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Neurology, Center of Neurology und Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf, Bergische Landstraße 2, 40629, Düsseldorf, Germany
| | - Jan Dörr
- Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure, Experimental and Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus Kraemer
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Strasse 21, 45130, Essen, Germany
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eduardo Beltrán
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians-University Munich, Großhaderner Straße 9, Martinsried, 82152, Munich, Germany
| | - Klaus Dornmair
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians-University Munich, Großhaderner Straße 9, Martinsried, 82152, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
- Cells in Motion (CiM), Münster, Germany
| | - Guillaume Martin-Blondel
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France
- Department of Infectious and Tropical Diseases, Toulouse University Hospital, Toulouse, France
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
- Australia Northern Clinical School, University of Sydney, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia.
- Cells in Motion (CiM), Münster, Germany.
| | - Roland Liblau
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France.
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Patel VA, Dunklebarger M, Zacharia TT, Isildak H. Otologic manifestations of Susac syndrome. ACTA ACUST UNITED AC 2019; 38:544-553. [PMID: 30623900 PMCID: PMC6325654 DOI: 10.14639/0392-100x-2166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/15/2018] [Indexed: 11/23/2022]
Abstract
Susac syndrome, a rare autoimmune disorder first described as a classic triad (encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss) in 1979 by renowned physician John O. Susac, has been an advancing area of clinical interest and scientific research over the last several decades. This comprehensive review aims to succinctly highlight the breadth and detail of this enigmatic disease, with a primary focus on otologic manifestations. Topics discussed include epidemiology, pathophysiology, clinical manifestations, differential diagnoses, classification schema, laboratory investigations, characteristic audiometric findings, high-yield radiographic imaging, temporal bone histopathology, treatment strategies and overall prognosis.
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Affiliation(s)
- V A Patel
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - M Dunklebarger
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - T T Zacharia
- Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - H Isildak
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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Kugler AV, Deppe M. Non-lesional cerebellar damage in patients with clinically isolated syndrome: DTI measures predict early conversion into clinically definite multiple sclerosis. NEUROIMAGE-CLINICAL 2018; 19:633-639. [PMID: 29984171 PMCID: PMC6031094 DOI: 10.1016/j.nicl.2018.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/04/2018] [Accepted: 04/23/2018] [Indexed: 11/30/2022]
Abstract
Background Today, no specific test for the diagnosis of multiple sclerosis (MS) is available due to the lack of characteristic symptoms at beginning. This circumstance also complicates estimation of disease progression. Recent findings provided evidence for early, non-lesional cerebellar damage in patients with (clinically definite) relapsing-remitting MS. Objective To investigate if microstructural cerebellar alterations can also serve as early structural biomarker for disease progression and conversion from clinically isolated syndrome (CIS) to MS. Methods 46 patients diagnosed with CIS and 26 age-matched healthy controls were admitted to high-resolution MRI including diffusion tensor imaging (DTI) to examine atrophy and microstructural integrity of the cerebellum. Microstructural integrity of cerebellar white matter was assessed by fractional anisotropy (FA) as derived from DTI. Results Although all 46 patients of our CIS cohort showed no cerebellar lesions in structural MRI (T1w, T2w, FLAIR), their mean cerebellar FA was already reduced compared to healthy controls. Significant FA reduction at follow-up DTI 6 months after baseline examination was observed. In 16 patients that converted to MS, we found a correlation between initial cerebellar FA and conversion latency (R = 0.71, p < 0.002). Initial cerebellar FA under FAcrit = 0.352 predicted conversion into relapsing-remitting MS within 24 months (FAcrit: mean cerebellar FA of patients with early MS, determined in another study). Conclusion DTI seems to reflect early tissue injury in beginning MS, when atrophy and lesions are not yet detectable. Decreased cerebellar FA in patients with CIS might indicate an active and unstable disease stage, resulting in a shorter conversion time into MS.
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Affiliation(s)
| | - Michael Deppe
- Department of Neurology, Westfälische Wilhelms University, Münster, Germany
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Gomez-Figueroa E, Garcia-Trejo S, Garcia-Santos RA, Quiñones-Pesqueira G, Calleja-Castillo JM. Exquisite response to intravenous immunoglobulin in Susac syndrome during pregnancy. eNeurologicalSci 2017; 10:1-4. [PMID: 29736421 PMCID: PMC5933996 DOI: 10.1016/j.ensci.2017.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/20/2017] [Indexed: 11/26/2022] Open
Abstract
Introduction From its initial report on two female patients in 1979 by J.O. Susac, Susac syndrome (SuS) or SICRET (small infarctions of cochlear, retinal and encephalic tissue) has persisted as an elusive entity. To date the available evidence for its treatment is based on case reports and case series. The largest systematic review described only 304 reported cases since the 1970s. Here we presented the first reported case to our knowledge in Mexican population and the unusual presentation in a pregnant patient. Case presentation A 34-year-old Hispanic woman was brought to the ER in our hospital for apathy and behavioral changes. Upon arrival at the ER, her husband described a one-month history of behavioral changes with apathy, progressive abulia, visuospatial disorientation, and gait deterioration. The initial lab test shows no significance except by a positive qualitative hCG. An MRI was obtained and showed hyperintense periventricular white matter lesions in T2 and FLAIR sequences also involving bilateral basal ganglia and with predominant affection of the corpus callosum, in addition to infratentorial cerebellar lesions. After treatment with intravenous immunoglobulins a marked and prompt clinical and radiological improvement was observed. Conclusion SuS is still an elusive disease. To date, no definitive score or clinical feature can predict the outcome of the disease. The presentation during pregnancy is also rare and therefore the optimal treatment and the prognosis is unknown. We hope that this article will serve as a foundation for future research.
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Affiliation(s)
- Enrique Gomez-Figueroa
- Neurology Department, Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Sofia Garcia-Trejo
- Neurology Department, Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
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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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Ringelstein M, Albrecht P, Kleffner I, Bühn B, Harmel J, Müller AK, Finis D, Guthoff R, Bergholz R, Duning T, Krämer M, Paul F, Brandt A, Oberwahrenbrock T, Mikolajczak J, Wildemann B, Jarius S, Hartung HP, Aktas O, Dörr J. Retinal pathology in Susac syndrome detected by spectral-domain optical coherence tomography. Neurology 2015. [DOI: 10.1212/wnl.0000000000001852] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Distinguishing Susac’s syndrome from multiple sclerosis. J Neurol 2014; 262:1613-21. [DOI: 10.1007/s00415-014-7628-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 12/21/2014] [Accepted: 12/23/2014] [Indexed: 12/11/2022]
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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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Allmendinger AM, Viswanadhan N, Klufas RA, Hsu L. Diffuse cauda equina enhancement in a middle aged male with Susac syndrome and symptomatic cauda equina syndrome. J Neurol Sci 2013; 333:25-8. [DOI: 10.1016/j.jns.2013.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/12/2013] [Accepted: 06/18/2013] [Indexed: 11/29/2022]
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Lehman VT, Doolittle DA, Hunt CH, Eckel LJ, Black DF, Schwartz KM, Diehn FE. Intracranial imaging of uncommon diseases is more frequently reported in clinical publications than in radiology publications. AJNR Am J Neuroradiol 2013; 35:45-8. [PMID: 23828110 DOI: 10.3174/ajnr.a3625] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Descriptions of uncommon diseases with intracranial imaging abnormalities are often difficult to find in the radiology literature. We hypothesized that reported imaging findings of such conditions in the recent literature were more frequent in clinical compared with radiology journals. MATERIALS AND METHODS PubMed searches from December 1, 2007 to December 1, 2012 were performed for 5 uncommon CNS diseases with intracranial imaging manifestations: 1) Susac syndrome; 2) amyloid β-related angiitis; 3) Parry-Romberg syndrome/en coup de sabre; 4) transient lesion of the splenium of the corpus callosum; and 5) reversible cerebral vasoconstriction syndrome. Articles were classified as a case report, case series, or original research. Journals were categorized as radiology or clinical. The 1- and 5-year Impact Factors of the journals were recorded. RESULTS Two hundred two articles were identified for the 5 diseases, including 151 (74%) case reports, 26 case series (13%), and 25 original research articles (13%); 179 (89%) were published in nonradiology journals, compared with 23 (11%) in radiology journals. There was no significant difference between the mean 1- and 5-year Impact Factors of the radiology and clinical journals. CONCLUSIONS Recent reports of the selected uncommon diseases with intracranial manifestations are more frequent in clinical journals when compared with dedicated radiology publications. Most publications are case reports. Radiologists should review both radiology and clinical journals when reviewing imaging features of uncommon diseases affecting the brain. Lack of reporting on such disease in the radiology literature may have significant practice, educational, and research implications for the radiology community.
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Affiliation(s)
- V T Lehman
- Department of Radiology, Mayo Clinic College of Graduate Medical Education, Rochester, Minnesota
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Dörr J, Krautwald S, Wildemann B, Jarius S, Ringelstein M, Duning T, Aktas O, Ringelstein EB, Paul F, Kleffner I. Characteristics of Susac syndrome: a review of all reported cases. Nat Rev Neurol 2013; 9:307-16. [DOI: 10.1038/nrneurol.2013.82] [Citation(s) in RCA: 219] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Wuerfel J, Sinnecker T, Ringelstein EB, Jarius S, Schwindt W, Niendorf T, Paul F, Kleffner I, Dörr J. Lesion morphology at 7 Tesla MRI differentiates Susac syndrome from multiple sclerosis. Mult Scler 2012; 18:1592-9. [DOI: 10.1177/1352458512441270] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Although an orphan disease with still obscure aetiopathogenesis, Susac syndrome has to be considered as differential diagnosis in multiple sclerosis (MS), since its clinical presentation and paraclinical features including routine magnetic resonance imaging (MRI) findings partially overlap. Objective: We aimed to study a potential benefit of 7T MRI for (i) the differentiation between Susac syndrome and MS and (ii) the clarification of pathogenesis of Susac syndrome. Methods: Five patients suffering from Susac syndrome, 10 sex- and age-matched patients with relapsing–remitting MS (median Expanded Disability Status Scale (EDSS) score 1.5) and 15 matching healthy controls were investigated at 7 Tesla MRI. The protocol included T1-weighted MPRAGE, T2*-weighted FLASH, and TIRM sequences. Results: Almost all T2* FLASH lesions in patients with MS were centred by a small central vein (325 lesions; 92%) and often showed a small hypointense rim (145 lesions; 41%). In contrast, white matter lesions in Susac syndrome exhibited a perivascular setting significantly less frequently (148 lesions; 54%, p=0.002), and very rarely exhibited a hypointense rim (12 lesions; 4%, p=0.004). Furthermore, in addition to callosal atrophy, Susac patients showed cerebrospinal fluid-isointense lesions within the central part of corpus callosum that are not commonly seen in MS. Conclusion: At 7T MRI, plaques in MS patients and patients with Susac syndrome differed substantially with respect to morphology and pattern. Thus, lesion morphology at 7T (i) may serve as a marker to distinguish Susac syndrome from MS and (ii) reflects a different pathophysiological mechanism underlying Susac syndrome, for example microinfarction rather than demyelination.
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Affiliation(s)
- Jens Wuerfel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Ultrahigh Field Facility, Max Delbrueck Center for Molecular Medicine, Germany
- Institute of Neuroradiology, University of Luebeck, Germany
| | - Tim Sinnecker
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Sven Jarius
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Germany
| | | | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility, Max Delbrueck Center for Molecular Medicine, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Germany
| | - Ilka Kleffner
- Department of Neurology, University of Münster, Germany
| | - Jan Dörr
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Germany
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Patterns of retinal damage facilitate differential diagnosis between Susac syndrome and MS. PLoS One 2012; 7:e38741. [PMID: 22701702 PMCID: PMC3372471 DOI: 10.1371/journal.pone.0038741] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 05/09/2012] [Indexed: 11/19/2022] Open
Abstract
Susac syndrome, a rare but probably underdiagnosed combination of encephalopathy, hearing loss, and visual deficits due to branch retinal artery occlusion of unknown aetiology has to be considered as differential diagnosis in various conditions. Particularly, differentiation from multiple sclerosis is often challenging since both clinical presentation and diagnostic findings may overlap. Optical coherence tomography is a powerful and easy to perform diagnostic tool to analyse the morphological integrity of retinal structures and is increasingly established to depict characteristic patterns of retinal pathology in multiple sclerosis. Against this background we hypothesised that differential patterns of retinal pathology facilitate a reliable differentiation between Susac syndrome and multiple sclerosis. In this multicenter cross-sectional observational study optical coherence tomography was performed in nine patients with a definite diagnosis of Susac syndrome. Data were compared with age-, sex-, and disease duration-matched relapsing remitting multiple sclerosis patients with and without a history of optic neuritis, and with healthy controls. Using generalised estimating equation models, Susac patients showed a significant reduction in either or both retinal nerve fibre layer thickness and total macular volume in comparison to both healthy controls and relapsing remitting multiple sclerosis patients. However, in contrast to the multiple sclerosis patients this reduction was not distributed over the entire scanning area but showed a distinct sectorial loss especially in the macular measurements. We therefore conclude that patients with Susac syndrome show distinct abnormalities in optical coherence tomography in comparison to multiple sclerosis patients. These findings recommend optical coherence tomography as a promising tool for differentiating Susac syndrome from MS.
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Kleffner I, Duning T, Lohmann H, Deppe M, Basel T, Promesberger J, Dörr J, Schwindt W, Ringelstein EB. A brief review of Susac syndrome. J Neurol Sci 2012; 322:35-40. [PMID: 22640902 DOI: 10.1016/j.jns.2012.05.021] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/29/2012] [Accepted: 05/05/2012] [Indexed: 10/28/2022]
Abstract
Susac syndrome was named after J.O. Susac who first described the syndrome in 1979. It is characterized by the clinical triad of encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss. It mainly occurs in young women. This underdiagnosed disease needs to be considered in the differential diagnosis of a broad variety of disorders. In Susac syndrome, autoimmune processes leading to damage and inflammation-related occlusion of the microvessels in brain, retina, and inner ear are thought to play a causal role. The diagnosis is based primarily on the clinical presentation, the documentation of branch retinal artery occlusion by fluorescence angiography, and characteristic findings on cerebral MRI, that help in distinguishing Susac syndrome from other inflammatory entities, like multiple sclerosis. Antiendothelial cell antibodies could be detected in some patients. Patients are successfully treated with immunosuppression, however, the best regimen still needs to be defined. As a result of the rarity of the disease, controlled therapeutic trials are missing so far. In this review, we want to demonstrate the clinical features, natural history, treatment, and clinical course of Susac syndrome, illustrated by a typical case history.
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Affiliation(s)
- I Kleffner
- Department of Neurology, University of Muenster, Germany.
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Current world literature. Curr Opin Ophthalmol 2011; 22:523-9. [PMID: 22005482 DOI: 10.1097/icu.0b013e32834cb7d7] [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]
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