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Pervin I, Ramanathan S, Cappelen-Smith C, Vucic S, Reddel SW, Hardy TA. Clinical and radiological characteristics and outcomes of patients with recurrent or relapsing tumefactive demyelination. Mult Scler Relat Disord 2024; 82:105408. [PMID: 38219394 DOI: 10.1016/j.msard.2023.105408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Relapsing or recurrent tumefactive demyelination is rare and has not been studied beyond individual case reports. OBJECTIVE We examined the clinical course, neuroimaging, cerebrospinal fluid (CSF), treatment and outcomes of patients with recurrent tumefactive demyelinating lesions (TDLs). METHODS We used PubMed to identify reports of recurrent TDLs and included the details of an additional, unpublished patient. RESULTS We identified 18 cases (11F, 7 M). The median age at onset of the index TDL was 37 years (range 12-72) and most were solitary lesions 72 % (13/18). CSF-restricted oligoclonal bands (OCBs) were detected in 25 % (4/16). Only one of those tested (n = 13) was positive for AQP4-IgG. A moderate-to-marked treatment response (high dose corticosteroid with or without additional plasmapheresis, IVIg or disease modifying therapies) was evident in 89 % of treated patients. Median EDSS at the median follow-up of 36 months (range 6-144) was 2 (range 1-10). Most remained ambulatory (EDSS < 4 in 13/18), but 1 patient died. CONCLUSION The median age of patients with relapsing TDLs is similar to that of typical MS, but differences include a lower female:male sex ratio, larger lesions, and a comparative lack of CSF-restricted OCBs. Outcomes vary among this group of patients ranging from minimal disability through to death.
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Affiliation(s)
- Irin Pervin
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia
| | - Sudarshini Ramanathan
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Translational Neuroimmunology Group, Faculty of medicine and health, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia
| | | | - Steve Vucic
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia
| | - Stephen W Reddel
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia
| | - Todd A Hardy
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia.
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Vakrakou AG, Brinia ME, Svolaki I, Argyrakos T, Stefanis L, Kilidireas C. Immunopathology of Tumefactive Demyelinating Lesions-From Idiopathic to Drug-Related Cases. Front Neurol 2022; 13:868525. [PMID: 35418930 PMCID: PMC8997292 DOI: 10.3389/fneur.2022.868525] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Tumefactive demyelinating lesions (TDL) represent a diagnostic dilemma for clinicians, and in rare atypical cases a collaboration of a neuroradiologist, a neurologist, and a neuropathologist is warranted for accurate diagnosis. Recent advances in neuropathology have shown that TDL represent an umbrella under which many different diagnostic entities can be responsible. TDL can emerge not only as part of the spectrum of classic multiple sclerosis (MS) but also can represent an idiopathic monophasic disease, a relapsing disease with recurrent TDL, or could be part of the myelin oligodendrocyte glycoprotein (MOG)- and aquaporin-4 (AQP4)-associated disease. TDL can appear during the MS disease course, and increasingly cases arise showing an association with specific drug interventions. Although TDL share common features with classic MS lesions, they display some unique features, such as extensive and widespread demyelination, massive and intense parenchymal infiltration by macrophages along with lymphocytes (mainly T but also B cells), dystrophic changes in astrocytes, and the presence of Creutzfeldt cells. This article reviews the existent literature regarding the neuropathological findings of tumefactive demyelination in various disease processes to better facilitate the identification of disease signatures. Recent developments in immunopathology of central nervous system disease suggest that specific pathological immune features (type of demyelination, infiltrating cell type distribution, specific astrocyte pathology and complement deposition) can differentiate tumefactive lesions arising as part of MS, MOG-associated disease, and AQP4 antibody-positive neuromyelitis optica spectrum disorder. Lessons from immunopathology will help us not only stratify these lesions in disease entities but also to better organize treatment strategies. Improved advances in tissue biomarkers should pave the way for prompt and accurate diagnosis of TDL leading to better outcomes for patients.
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Affiliation(s)
- Aigli G. Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Svolaki
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Sánchez P, Chan F, Hardy TA. Tumefactive demyelination: updated perspectives on diagnosis and management. Expert Rev Neurother 2021; 21:1005-1017. [PMID: 34424129 DOI: 10.1080/14737175.2021.1971077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Tumefactive demyelination (TD) can be a challenging scenario for clinicians due to difficulties distinguishing it from other conditions, such as neoplasm or infection; or with managing the consequences of acute lesions, and then deciding upon the most appropriate longer term treatment strategy. AREAS COVERED The authors review the literature regarding TD covering its clinic-radiological features, association with multiple sclerosis (MS), and its differential diagnosis with other neuroinflammatory and non-inflammatory mimicking disorders with an emphasis on atypical forms of demyelination including acute disseminated encephalomyelitis (ADEM), MOG antibody-associated demyelination (MOGAD) and neuromyelitis spectrum disorders (NMOSD). We also review the latest in the acute and long-term treatment of TD. EXPERT OPINION It is important that the underlying cause of TD be determined whenever possible to guide the management approach which differs between different demyelinating and other inflammatory conditions. Improved neuroimaging and advances in serum and CSF biomarkers should one day allow early and accurate diagnosis of TD leading to better outcomes for patients.
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Affiliation(s)
- Pedro Sánchez
- Department of Neurology, Alexianer St. Josefs-Krankenhaus, Potsdam, Germany
| | - Fiona Chan
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Todd A Hardy
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia.,Brain & Mind Centre, University of Sydney, Nsw, Australia
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Baló's concentric sclerosis - A rare entity within the spectrum of demyelinating diseases. J Neurol Sci 2021; 428:117570. [PMID: 34261000 DOI: 10.1016/j.jns.2021.117570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/24/2022]
Abstract
Baló's concentric sclerosis (BCS) is a rare, inflammatory demyelinating disease of the central nervous system (CNS). Historically, BCS was thought to be uniformly fatal and diagnosis was based on postmortem findings. With advances in modern neuroimaging, BCS is currently defined by the presence of concentric layered patterns composed of alternating rings of varying intensity. They are best appreciated on gadolinium-enhanced T1-weighted sequences and predominantly occur in the supratentorial cerebral white matter with sparing of cortical U-fibers. The lamellar pattern of the lesions likely reflects bands of demyelination and relative myelin preservation with minimal axonal loss. While BCS falls within the spectrum of atypical demyelinating diseases, there is ongoing debate over whether BCS is a phenotypical variant of multiple sclerosis (MS) or a separate entity. Corticosteroids comprise first-line therapy but there is ongoing controversy regarding appropriate maintenance therapy. First-line MS disease-modifying therapies such as interferon beta-1a are appropriate for patients who fulfill diagnostic criteria for relapsing-remitting MS. Fingolimod should likely be avoided as Baló-like lesions have been reported during its administration or after withdrawal. Monoclonal antibodies such as natalizumab and rituximab are potentially effective at reducing BCS relapses, but alemtuzumab may be relatively ineffective because humoral immunity does not play a central role in BCS pathogenesis.
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Tzanetakos D, Vakrakou AG, Tzartos JS, Velonakis G, Evangelopoulos ME, Anagnostouli M, Koutsis G, Dardiotis E, Karavasilis E, Toulas P, Stefanis L, Kilidireas C. Heterogeneity of Baló's concentric sclerosis: a study of eight cases with different therapeutic concepts. BMC Neurol 2020; 20:400. [PMID: 33138795 PMCID: PMC7604966 DOI: 10.1186/s12883-020-01971-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/20/2020] [Indexed: 12/27/2022] Open
Abstract
Background Baló’s Concentric Sclerosis (BCS) is a rare heterogeneous demyelinating disease with a variety of phenotypes on Magnetic Resonance Imaging (MRI). Existing literature lacks data especially on the therapeutic approach of the disease which we intended to elucidate by means of suggesting a new possible BCS classification and introducing different therapeutic concepts based on each BCS-subgroup characteristics. Methods We present a retrospective study of eight treated patients with BCS-type lesions, emphasizing on MRI characteristics and differences on therapeutic maneuvers. Results Data analysis showed: at disease onset the BCS-type lesion was tumefactive (size ≥2 cm) in 6 patients, with a mean size of 2.7 cm (± 0.80 SD); a coexistence of MS-like plaques on brain MRI was identified in 7 patients of our cohort. The mean age was 26.3 years (±7.3 SD) at disease onset and the mean follow-up period was 56.8 months (range 9–132 months). According to radiological characteristics and response to therapies, we further categorized them into 3 subgroups: a) Group-1; BCS with or without coexisting nonspecific white matter lesions; poor response to intravenous methylprednisolone (IVMP); treated with high doses of immunosuppressive agents (4 patients), b) Group-2; BCS with typical MS lesions; good response to IVMP; treated with MS-disease modifying therapies (2 patients), c) Group-3; BCS with typical MS lesions; poor response to IVMP; treated with rituximab (2 patients). Conclusions Our study introduces a new insight regarding the categorization of BCS into three subgroups depending on radiological features at onset and during the course of the disease, in combination with the response to different immunotherapies. Immunosuppressive agents such as cyclophosphamide are usually effective in BCS. However, therapeutic alternatives like anti-CD20 monoclonal antibodies or more classical disease-modifying MS therapies can be considered when BCS has also mixed lesions similar to MS. Future studies with a larger sample size are necessary to further establish these findings, thus leading to better treatment algorithms and improved clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-020-01971-2.
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Affiliation(s)
- D Tzanetakos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - A G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - J S Tzartos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - G Velonakis
- Research Unit of Radiology - 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - M E Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - M Anagnostouli
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - G Koutsis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Dardiotis
- Department of Neurology, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - E Karavasilis
- Research Unit of Radiology - 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - P Toulas
- Research Unit of Radiology - 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - L Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - C Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
PURPOSE OF REVIEW To review the clinical findings, differential diagnosis, treatment and outcome of pseudotumoral demyelinating lesions including tumefactive demyelination and Baló's concentric sclerosis. RECENT FINDINGS MRI findings, such as dynamic restricted diffusion changes at the edge of pseudotumoral lesions help to discriminate atypical demyelination from key differential diagnoses, and together with histopathological data, indicate that tissue hypoxia may be important aetiologically. CT-PET imaging can help to distinguish pseudotumoral lesions from high-grade tumours. Although most patients with pseudotumoral lesions have or later develop multiple sclerosis, a proportion will experience a monophasic course or be diagnosed with neuromyelitis optica spectrum disorders (NMOSD), myelin oligodendrocyte glycoprotein (MOG) antibody-associated demyelination or acute disseminated encephalomyelitis (ADEM). Many patients with pseudotumoral demyelinating lesions have a favourable prognosis. SUMMARY Not all patients with pseudotumoral lesions require a brain biopsy but close follow-up of biopsied and nonbiopsied lesions is indicated once a diagnosis is established. Testing for AQP4-IgG and MOG-IgG is recommended when a pseudotumoral demyelinating lesion is identified. In the absence of large, prospective studies, it seems reasonable that patients with pseudotumoral lesions who fulfil multiple sclerosis diagnostic criteria are treated with multiple sclerosis therapies.
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Amini Harandi A, Esfandani A, Pakdaman H, Abbasi M, Sahraian MA. Balo’s concentric sclerosis: an update and comprehensive literature review. Rev Neurosci 2018; 29:873-882. [DOI: 10.1515/revneuro-2017-0096] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/10/2018] [Indexed: 12/17/2022]
Abstract
Abstract
Balo’s concentric sclerosis (BCS) is considered a variant of multiple sclerosis characterized by concentric lamella of alternating demyelinated and partially myelinated tissues. It is a rare and a relatively acute condition. Attacks may proceed rapidly over weeks or months, typically without remission, like Marburg’s variant, resulting in death or severe disability. However, the majority of cases have a more benign, self-limiting course with spontaneous remission. Magnetic resonance imaging is a primary imaging modality in the diagnosis of BCS. Treatment with intense immunosuppression may be indicated in patients with more aggressive form. New reports reveal more evidence regarding the pathophysiology and treatment strategies.
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Affiliation(s)
- Ali Amini Harandi
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Akram Esfandani
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Hossein Pakdaman
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Mehdi Abbasi
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute , Tehran University of Medical Sciences , Tehran 1136746911 , Iran
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Atypical inflammatory demyelinating lesions and atypical multiple sclerosis. Rev Neurol (Paris) 2018; 174:408-418. [PMID: 29673573 DOI: 10.1016/j.neurol.2018.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 02/06/2023]
Abstract
Atypical idiopathic inflammatory demyelinating disorders (IIDDs) of the brain have long been known to be disorders closely related to multiple sclerosis (MS), despite having distinctive clinical and radiological characteristics. Originally, they mostly corresponded to acute-onset variants of MS that classically had poor prognoses, such as Baló's concentric sclerosis, Marburg variant of MS and Schilder's disease, and their relationship with MS was based on their shared pathological findings and the co-occurrence of these variants in patients with typical MS. More recently, other atypical disorders, such as solitary sclerosis, have also been described as belonging to the MS spectrum, raising the question of their links with MS. Meanwhile, multiple MS mimics have been described and need to be considered in the differential diagnosis of MS. In addition, thorough characterization of these atypical entities, including advanced MRI and biological studies, is now warranted to further improve their management.
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Hardy TA, Corboy JR, Weinshenker BG. Baló concentric sclerosis evolving from apparent tumefactive demyelination. Neurology 2017; 88:2150-2152. [DOI: 10.1212/wnl.0000000000003990] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/02/2017] [Indexed: 01/08/2023] Open
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Hardy TA, Reddel SW, Barnett MH, Palace J, Lucchinetti CF, Weinshenker BG. Atypical inflammatory demyelinating syndromes of the CNS. Lancet Neurol 2016; 15:967-981. [DOI: 10.1016/s1474-4422(16)30043-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/02/2016] [Accepted: 04/11/2016] [Indexed: 02/06/2023]
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Hardy TA, Tobin WO, Lucchinetti CF. Exploring the overlap between multiple sclerosis, tumefactive demyelination and Baló's concentric sclerosis. Mult Scler 2016; 22:986-92. [PMID: 27037180 DOI: 10.1177/1352458516641776] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/07/2016] [Indexed: 12/26/2022]
Abstract
The availability of magnetic resonance imaging (MRI) has led to increasing recognition that multiple sclerosis (MS), tumefactive demyelination (TD) and Baló's concentric sclerosis (BCS) share many overlapping features. Baló-like lesions, which exhibit limited features of BCS, may represent an intermediate between BCS and typical MS demyelination. Lesions labeled as tumefactive are typically larger, but otherwise have much in common with conventional MS lesions, and TD and BCS lesions can also overlap. In this article, we explore the similarities between typical MS, TD and BCS cases, and reflect on the potential insights that intermediate or overlapping phenotypes may contribute towards an understanding of MS immunopathogenesis, and question whether these atypical forms of demyelination should be classified as separate demyelinating diseases, as different lesional manifestations of demyelination of any cause or as part of a spectrum with conventional MS.
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Affiliation(s)
- Todd A Hardy
- Neuroimmunology Clinic, Department of Neurology, Concord Repatriation General Hospital, University of Sydney, Concord West, NSW, Australia/Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - W Oliver Tobin
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Pietroboni AM, Arighi A, De Riz MA, Ghezzi L, Calvi A, Avignone S, Scola E, Galimberti D, Triulzi F, Scarpini E. Balò’s concentric sclerosis: still to be considered as a variant of multiple sclerosis? Neurol Sci 2015; 36:2277-80. [DOI: 10.1007/s10072-015-2297-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/16/2015] [Indexed: 01/01/2023]
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