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Keerthiraj DB, Pandey S, Kumar Garg R, Singh Malhotra H, Verma R, Kumar Sharma P, Kumar N, Uniyal R, Rizvi I, Kumar S, Parihar A, Jain A. Neuroimaging Abnormalities in Patients with Subacute Sclerosing Panencephalitis : Prospective Follow-up Study. Clin Neuroradiol 2024; 34:577-585. [PMID: 38451268 DOI: 10.1007/s00062-024-01396-1] [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: 10/16/2023] [Accepted: 01/31/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE This study aimed to assess the neuroimaging abnormalities and their progression in patients with Subacute sclerosing panencephalitis (SSPE) and identify clinical predictors of these imaging findings. METHODS This prospective observational study evaluated clinical and neuroimaging features in patients with SSPE. Patients were categorized using Dyken's criteria, Jabbour's staging system, and the definition of fulminant SSPE. They underwent comprehensive clinical assessments, cerebrospinal fluid examination, Electroencephalogram (EEG), and Magnetic Resonance Imaging (MRI) scans. Treatment involved intrathecal interferon‑α and antiepileptic medications. Functional disability was assessed using the modified Barthel index. Follow-ups were performed at 6 months, including reassessment of Modified Barthel Index (MBI) and Jabbour's staging and EEG and MRI scans. RESULTS The mean age was 13.9 ± 6.7 years, with males comprising 81.5% (44/54) of the cohort. Fulminant SSPE was noted in 33% (18/54) of cases. Disease duration before presentation varied significantly between fulminant and non-fulminant forms (p = 0.001). Neuroimaging abnormalities were more prevalent in JS III stage patients, with diffuse cerebral atrophy being a significant finding (p = 0.011). Basal ganglia involvement correlated with movement disorders. The 6‑month follow-up showed increased cerebral atrophy (p = 0.004). Increasing disease duration was an independent predictor of cerebral atrophy. An Intercomplex interval (ICI) of more than 10 minutes correlated with normal neuroimaging, 10 patients died within the study period, 8 of whom had fulminant SSPE. CONCLUSION Parieto-occipital White matter hyperintensity (WMH) is the most prevalent and sensitive neuroimaging finding for the diagnosis of SSPE. Despite interferon treatment, cerebral atrophy progressed in both aggressive and fulminant SSPE. Increasing disease duration is an independent predictor of cerebral atrophy.
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Affiliation(s)
- D B Keerthiraj
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Shweta Pandey
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India.
| | - Ravindra Kumar Garg
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Hardeep Singh Malhotra
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Rajesh Verma
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Praveen Kumar Sharma
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Neeraj Kumar
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Ravi Uniyal
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Imran Rizvi
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sukriti Kumar
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Anit Parihar
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amita Jain
- Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh, India
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Panda PK, Elwadhi A, Gupta D, Gupta SK, Dasgupta S, Singh G, Sherwani P, Sharawat IK. Association Between Clinical Severity, Neuroimaging, and Electroencephalographic Findings in Children with Subacute Sclerosing Panencephalitis. J Child Neurol 2024; 39:301-309. [PMID: 39175398 DOI: 10.1177/08830738241272074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND Children diagnosed with subacute sclerosing panencephalitis (SSPE) display a range of neuroimaging abnormalities during different stages of the disease, but their exact clinical significance remains unclear. METHODS In this retrospective cohort study, our objective was to examine magnetic resonance imaging (MRI) abnormalities in the brains of patients aged 18 years or younger with subacute sclerosing panencephalitis. We aimed to correlate these MRI abnormalities with clinical severity, sociodemographic variables, electroencephalographic (EEG) abnormalities, and cerebrospinal anti-measles antibody titers. RESULTS The study included 112 cases of subacute sclerosing panencephalitis (mean age at onset: 8.9 ± 2.6 years). MRI analysis at the time of presentation revealed the following abnormalities: subcortical white matter signal changes (n = 95), periventricular white matter signal changes (n = 76), splenium of corpus callosum involvement (n = 39), diffuse corpus callosum involvement (n = 27), cerebral atrophy (n = 35), basal ganglia involvement (n = 10), and brain stem involvement (n = 2). Notably, subcortical white matter involvement, periventricular white matter involvement, diffuse corpus callosum involvement, and basal ganglia involvement were more prevalent in patients with stage III and IV subacute sclerosing panencephalitis (P < .05 for all). Cerebral atrophy was also significantly more common in patients with stage III compared to those with stage IV subacute sclerosing panencephalitis (P < .0001). However, no substantial positive or negative associations were found between MRI findings and EEG abnormalities, other sociodemographic/clinical variables, and cerebrospinal fluid measles-specific antibody titers (P > .05). CONCLUSION Early in the disease progression of subacute sclerosing panencephalitis, the temporoparietal and parietooccipital regions of the subcortical white matter are affected. Neuroimaging abnormalities exhibit a stronger association with Jabbour's clinical staging, but do not show significant associations with other clinical, sociodemographic, and EEG features.
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Affiliation(s)
- Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Aman Elwadhi
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Diksha Gupta
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Swati Kumari Gupta
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Soura Dasgupta
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Garima Singh
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Poonam Sherwani
- Department of Radiodiagnosis and imaging, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Garg D, Patel S, Sankhla CS, Holla VV, Paramanandam V, Kukkle PL, Pandey S, Schneider SA, Pal PK. Movement Disorders in Patients with Subacute Sclerosing Panencephalitis: A Systematic Review. Mov Disord Clin Pract 2024; 11:770-785. [PMID: 38748762 PMCID: PMC11233848 DOI: 10.1002/mdc3.14062] [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: 01/11/2024] [Revised: 03/27/2024] [Accepted: 04/14/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Subacute sclerosing panencephalitis (SSPE) is a complication of measles, occurring after a latency of 4-10 years. It continues to occur in developing countries although resurgence is being reported from developed countries. Characteristic features include progressive neuropsychiatric issues, myoclonus, seizures, movement disorders and visual impairment. Electroencephalography (EEG) typically shows periodic generalized discharges, and elevated CSF anti-measles antibodies are diagnostic. Movement disorders are being increasingly recognized as part of the clinical spectrum, and range from hyperkinetic (chorea, dystonia, tremor, tics) to hypokinetic (parkinsonism) disorders and ataxia. OBJECTIVES This article aims to comprehensively review the spectrum of movement disorders associated with SSPE. METHODS A literature search was conducted in PubMed and EMBASE databases in December 2023 and articles were identified for review. RESULTS Movement disorders reported in SSPE included hyperkinetic (chorea, dystonia, tremor and tics), hypokinetic (parkinsonism), ataxia and extraocular movement disorders. Myoclonus, a core clinical feature, was the most frequent "abnormal movement." Movement disorders were observed in all clinical stages, and could also be a presenting feature, even sans myoclonus. Hyperkinetic movement disorders were more common than hypokinetic movement disorders. An evolution of movement disorders was observed, with ataxia, chorea and dystonia occurring earlier, and parkinsonism later in the disease. Neuroradiological correlates of movement disorders remained unclear. CONCLUSION A wide spectrum of movement disorders was observed throughout the clinical stages of SSPE. Most data were derived from case reports and small case series. Multicentric longitudinal studies are required to better delineate the spectrum and evolution of movement disorders in SSPE.
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Affiliation(s)
- Divyani Garg
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Sahil Patel
- Department of NeurologyP. D. Hinduja National Hospital & Medical Research CentreMumbaiIndia
| | - Charulata S. Sankhla
- Department of NeurologyP. D. Hinduja National Hospital & Medical Research CentreMumbaiIndia
| | - Vikram V. Holla
- Department of NeurologyNational Institute of Mental Health and Neurosciences (NIMHANS)BangaloreIndia
| | | | | | - Sanjay Pandey
- Department of Neurology and Stroke MedicineAmrita Institute of Medical SciencesFaridabadIndia
| | | | - Pramod K. Pal
- Department of NeurologyNational Institute of Mental Health and Neurosciences (NIMHANS)BangaloreIndia
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Garg D, Kakkar V, Kumar A, Kapoor D, Abbey P, Pemde H, Mukherjee SB, Sharma S. Spectrum of Movement Disorders Among Children With Subacute Sclerosing Panencephalitis: A Cross-Sectional Study. J Child Neurol 2022; 37:491-496. [PMID: 35262436 DOI: 10.1177/08830738221085158] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Subacute sclerosing panencephalitis is a progressive devastating condition due to persistence of mutant measles virus, affecting children and adolescents, characterised by myoclonus, seizures, and neuropsychiatric issues. Movement disorders apart from myoclonus are reportedly uncommon. We aimed to describe frequency and proportion of movement disorders among children with subacute sclerosing panencephalitis, hypothesizing that these occur more frequently than previously reported. Methods: In this cross-sectional study, we enrolled children with subacute sclerosing panencephalitis between 1 month and 18 years of age who fulfilled the diagnosis of subacute sclerosing panencephalitis as per modified Dyken criteria, and examined them for movement disorders. We also assessed their clinical profile and disease severity via Jabbour staging and modified Rankin Scale score. We compared demographic, clinical, and laboratory features of children with and without movement disorders. Results: We enrolled 50 children (36 males; 72%) (age range 1.5-14 years). Of these, 28 (56%) had movement disorders. Among movement disorders, the most frequent was myoclonus (92%), followed by ataxia (9; 18%), chorea-athetosis (7; 14%), dystonia (6; 12%), tremor (4; 8%), repetitive behavior (4; 8%), and parkinsonism (3; 6%). Movement disorders were the presenting feature of subacute sclerosing panencephalitis among 7 children. There were no significant differences in clinical or laboratory features among children with and without movement disorders. Conclusions: Movement disorders were frequent in subacute sclerosing panencephalitis. Hyperkinetic disorders were dominant. Dystonia and chorea-athetosis occurred more commonly among nonmyoclonus movement disorders. Movement disorders may manifest even in earlier stages of subacute sclerosing panencephalitis and may be the heralding feature. Recognition of these features is important to plan management and reduce morbidity.
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Affiliation(s)
- Divyani Garg
- Department of Neurology, 28856Lady Hardinge Medical College, New Delhi, India
| | - Vanshika Kakkar
- Department of Pediatrics (Neurology Division), 28856Lady Hardinge Medical College, New Delhi, India
| | - Ashna Kumar
- Department of Pediatrics (Neurology Division), 28856Lady Hardinge Medical College, New Delhi, India
| | - Dipti Kapoor
- Department of Pediatrics (Neurology Division), 28856Lady Hardinge Medical College, New Delhi, India
| | - Pooja Abbey
- Department of Radiology, 28856Lady Hardinge Medical College, New Delhi, India
| | - Harish Pemde
- Department of Pediatrics (Neurology Division), 28856Lady Hardinge Medical College, New Delhi, India
| | - Sharmila B Mukherjee
- Department of Pediatrics (Neurology Division), 28856Lady Hardinge Medical College, New Delhi, India
| | - Suvasini Sharma
- Department of Pediatrics (Neurology Division), 28856Lady Hardinge Medical College, New Delhi, India
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Chaurasia R, Saurabh K, Singh V, Pathak A, Verma A, Mishra V, Joshi D, Kumar A. Clinical Profile and Diffusion Tensor Imaging in Patients of Subacute Sclerosing Pan Encephalitis: A Prospective Follow-up Study from Eastern Part of India. Neurol India 2022; 70:197-202. [DOI: 10.4103/0028-3886.336333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Role of carbamazepine in the symptomatic treatment of subacute sclerosing panencephalitis: a case report and review of the literature. Case Rep Neurol Med 2013; 2013:327647. [PMID: 23533854 PMCID: PMC3606735 DOI: 10.1155/2013/327647] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/13/2013] [Indexed: 11/17/2022] Open
Abstract
We describe the clinical presentation and clinical course of subacute sclerosing panencephalitis in a 13-year-old previously healthy boy who recently immigrated to the United States from Iraq. He presented with macular retinopathy, followed by progressive myoclonus and encephalopathy. After extensive workup, a diagnosis of subacute sclerosing panencephalitis was suspected by the presence of period epileptiform discharges on electroencephalogram and confirmed by elevated measles titers in the cerebrospinal fluid. Combination immunomodulatory therapy with isoprinosine, ribavirin, and intra-Ommaya interferon alpha did not result in clinical improvement. Within days following the administration of carbamazepine, there was remarkable improvement in the myoclonus and he was able to ambulate independently for a period of 4 months at which time he unfortunately progressed to a vegetative state. This case highlights the importance of carbamazepine as a potential first line symptomatic treatment of subacute sclerosing panencephalitis and provides a review of the literature on the subject.
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Almeida KJ, Brucki SMD, Duarte MIS, Pasqualucci CAG, Rosemberg S, Nitrini R. Basal ganglia lesions in subacute sclerosing panencephalitis. Dement Neuropsychol 2012; 6:286-289. [PMID: 29213810 PMCID: PMC5619342 DOI: 10.1590/s1980-57642012dn06040014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The parieto-occipital region of the brain is the most frequently and severely
affected in subacute sclerosing panencephalitis (SSPE). The basal ganglia,
cerebellum and corpus callosum are less commonly involved. We describe a patient
with SSPE confirmed by neuropathology based on brain magnetic resonance imaging
showing extensive basal ganglia involvement and no significant involvement of
other cortical structures. Though rarely described in SSPE, clinicians should be
aware of this involvement. SSPE should be kept in mind when changes in basal
ganglia signal are seen on brain magnetic resonance imaging with or without
involvement of other regions of the human brain to avoid erroneous etiological
diagnosis of other pathologies causing rapidly progressive dementia.
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Affiliation(s)
- Kelson James Almeida
- MD, Behavioral and Cognitive Neurology Unit and Cognitive Disorders Reference Center (CEREDIC), Department of Neurology, São Paulo SP, Brazil
| | - Sonia Maria Dozzi Brucki
- MD, Behavioral and Cognitive Neurology Unit and Cognitive Disorders Reference Center (CEREDIC), Department of Neurology, São Paulo SP, Brazil
| | | | | | - Sérgio Rosemberg
- Department of Pathology, School of Medicine of the University of São Paulo (FMUSP) São Paulo SP, Brazil
| | - Ricardo Nitrini
- MD, Behavioral and Cognitive Neurology Unit and Cognitive Disorders Reference Center (CEREDIC), Department of Neurology, São Paulo SP, Brazil
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