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DiMauro KA, Swetlik C, Cohen JA. Management of multiple sclerosis in older adults: review of current evidence and future perspectives. J Neurol 2024; 271:3794-3805. [PMID: 38689068 PMCID: PMC11233312 DOI: 10.1007/s00415-024-12384-3] [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: 12/20/2023] [Revised: 04/02/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
IMPORTANCE The prevalence of multiple sclerosis (MS) and aging MS patients is increasing worldwide. There is a need to better understand this MS sub-population, which historically is underrepresented in the literature. This narrative review examines the evolving demographics, disease course, and treatments for older adults with MS (OAMS) to address current knowledge gaps and highlight areas critical for future research. OBSERVATIONS OAMS populations require special consideration by clinicians. Older individuals have different care needs than individuals with adult onset MS who are mid-life or younger. Comorbidities, an aging immune system, increasing neurodegeneration, decreasing neurologic reserve, changing benefit/risk relationship for disease modifying therapies (DMTs), and wellness require special attention to provide holistic comprehensive care. Active areas of research include potential cessation of DMTs and novel disease targets. CONCLUSIONS AND RELEVANCE This review highlights both the current knowledge and information gaps in the literature that are critical to understanding and properly managing OAMS. The aims are to inform MS clinicians in their current practice, as well as inspire future studies which are critical to providing quality and evidence-based care for OAMS.
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Affiliation(s)
- Kimberly A DiMauro
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Carol Swetlik
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA.
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Matsuyoshi A, Uchiyama D, Kawanami T, Inamori Y, Shiraishi W. [A case of neurosarcoidosis initially diagnosed as cervical spondylotic myelopathy, leading to diagnosis by gadolinium contrast-enhanced MRI]. Rinsho Shinkeigaku 2024; 64:339-343. [PMID: 38658329 DOI: 10.5692/clinicalneurol.cn-001921] [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] [Indexed: 04/26/2024]
Abstract
A 70-year-old female presented with bilateral numbness in her upper limbs. She was diagnosed with cervical spondylotic myelopathy and underwent cervical laminoplasty. However, there was no significant improvement in sensory disturbance, and at 6 months after surgery, she developed subacute motor and gait disturbance in four extremities. Spinal MRI revealed a long lesion of the spinal cord with edema, and a part of the lesion showed gadolinium contrast enhancement. Bronchoscopy revealed an elevated CD4/8 ratio, and gallium scintigraphy demonstrated an accumulation in the hilar lymph nodes, leading to a diagnosis of neurosarcoidosis. In case of rapid deterioration during the course of cervical spondylotic myelopathy, neurosarcoidosis should be considered as a differential diagnosis, which can be assessed by contrast-enhanced MRI.
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Bateman GA, Bateman AR. The dilated veins surrounding the cord in multiple sclerosis suggest elevated pressure and obstruction of the glymphatic system. Neuroimage 2024; 286:120517. [PMID: 38211705 DOI: 10.1016/j.neuroimage.2024.120517] [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: 11/22/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 01/13/2024] Open
Abstract
Recently, Clarke et al. published a study using spinal cord susceptibility weighted imaging in multiple sclerosis patients at 7T. They discovered dilated intradural extramedullary veins surrounding the cord. The purpose of this commentary is to point out some recent research by our group, which suggests this dilatation also occurs in the bridging cortical veins surrounding the brain. The dilatation indicates a focal elevation in the venous pressure secondary to impedance mismatching. Due to the shared outflow geometry, dilatation of the outflow veins will obstruct the glymphatic pathway of the spinal cord altering the immune response.
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Affiliation(s)
- Grant A Bateman
- Department of Medical Imaging, John Hunter Hospital, Newcastle, NSW, Australia; Newcastle University Faculty of Health, Callaghan Campus, Newcastle, NSW, Australia.
| | - Alexander R Bateman
- School of Mechanical Engineering, University of New South Wales, Sydney, NSW, Australia
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Kurtz RM, Babatunde VD, Schmitt JE, Berger JR, Mohan S. Spinal Cord Sarcoidosis Occurring at Sites of Spondylotic Stenosis, Mimicking Spondylotic Myelopathy: A Case Series and Review of the Literature. AJNR Am J Neuroradiol 2023; 44:105-110. [PMID: 36521966 PMCID: PMC9835907 DOI: 10.3174/ajnr.a7724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/21/2022] [Indexed: 12/23/2022]
Abstract
Sarcoidosis is a multisystem granulomatous disease, with intramedullary spinal cord involvement seen in <1% of cases. This case series illustrates the clinical presentations and imaging findings of 5 patients with intramedullary spinal neurosarcoidosis occurring at sites of spondylotic spinal canal stenosis, which can be indistinguishable from spondylotic myelopathy with cord enhancement. Both entities are most common in middle-aged men and present with weeks to months of motor and sensory symptoms. On imaging, both can have focal spinal cord enhancement and longitudinally extensive signal abnormality centered at or just below the level of spinal canal stenosis. On the basis of our experience, we suggest that in patients with cord enhancement centered at or just below a site of spinal canal stenosis, consideration should be given to chest imaging and lymph node biopsy when applicable, to assess for the possibility of underlying sarcoidosis before surgical decompression.
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Affiliation(s)
- R M Kurtz
- From the Departments of Radiology (R.M.K., V.D.B., J.E.S., S.M.)
| | - V D Babatunde
- From the Departments of Radiology (R.M.K., V.D.B., J.E.S., S.M.)
| | - J E Schmitt
- From the Departments of Radiology (R.M.K., V.D.B., J.E.S., S.M.)
| | - J R Berger
- Neurology (J.R.B.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - S Mohan
- From the Departments of Radiology (R.M.K., V.D.B., J.E.S., S.M.)
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Owiti W, Peev N, Arif S, Brady Z, AbdelHafiz T. Is surgery beneficial for patients with concurrent multiple sclerosis and degenerative cervical myelopathy? A review of literature. BRAIN AND SPINE 2022; 2:100870. [PMID: 36248132 PMCID: PMC9560582 DOI: 10.1016/j.bas.2022.100870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 12/25/2022]
Abstract
Introduction Due to an overlap in symptoms, there is significant delay in surgical treatment of patients that have concomitant multiple sclerosis (MS) and degenerative cervical Myelopathy (DCM). The purpose of this review is to evaluate if surgical intervention is beneficial to patients that have concurrent presentations. Research question Is surgery beneficial in concurrent MS and DCM? Materials and methods A literature search with no date restrictions was conducted on Pubmed and Medline databases. Keywords searched: Degenerative Cervical Myelopathy, Multiple sclerosis, Treatment, Surgery, Quality of Life. Randomised controlled trials, prospective, retrospective, and case series reporting timing of surgery, post-operative outcomes such as improvement in myelopathic symptoms, quality of life, and any serious complications were included. Results The literature search yielded a total of 8 studies across all databases. Seven articles were selected for full text review, and all of them were sectioned for inclusion in this review. Seven studies evaluated 160 participants with concurrent multiple sclerosis and degenerative cervical myelopathy. Earlier studies had discouraged performing surgery in this subset of patients, the majority of studies found it worthwhile to perform early surgery for patients with concomitant multiple sclerosis and degenerative cord compression, if the patients had radiculopathy. Quality of life for MS patients did not improve as much as it did for patients that did not have MS. Discussion and conclusion Patients with radiculopathy, neck pain and cord compression are most likely to benefit from early surgery. There is no need for delaying to offer surgery unless other medical/anaesthetic contraindications exist.
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Affiliation(s)
- William Owiti
- Department of Neurosurgery, Royal Infirmary of Edinburgh, Edinburgh, UK
- Corresponding author. Department of Neurosurgery, Royal infirmary of Edinburgh, 51 little France crescent, Edinburgh, EH16 4SA, UK.
| | - Nikolay Peev
- Department of Neurosurgery, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Shahswar Arif
- Department of Neurosurgery, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
- Medical University ‘Prof. Dr. Paraskev Stoyanov’ Varna, Varna, Bulgaria
| | - Zarina Brady
- Department of Neurosurgery, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
- Medical University ‘Prof. Dr. Paraskev Stoyanov’ Varna, Varna, Bulgaria
| | - Tarek AbdelHafiz
- Department of Neurosurgery, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
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Chhugani S, Agarwal N, Sheikh F, Borca F, Spanoulis A, Galea I. Cervical spinal degenerative disease in multiple sclerosis. Eur J Neurol 2021; 28:2497-2502. [PMID: 33817913 DOI: 10.1111/ene.14855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Root and cord irritation from cervical spinal degenerative disease (SDD) may share clinical features with progressive multiple sclerosis (MS), so diagnostic overshadowing may occur. We hypothesized that cervical stenotic SDD is commoner in people with progressive MS, compared to controls. METHODS A retrospective case-control study of 111 cases (56 with progressive MS and 55 age- and sex-matched controls) was conducted. Five types of cervical SDD (disc degeneration, posterior disc protrusion, endplate changes, canal stenosis and foraminal stenosis) were assessed objectively on magnetic resonance imaging using published scales. Multivariable regression analysis was performed. RESULTS Moderate-to-severe cervical spinal degeneration occurred more frequently in progressive MS, compared to controls. In multivariable regression, foraminal stenosis was three times more likely in progressive MS (odds ratio 3.20, 95% confidence interval 1.27, 8.09; p = 0.014), and was more severe (p = 0.009). This finding was confirmed on retrospective evaluation of clinical radiology reports in the same population. Foraminal stenosis was twice as likely in progressive MS, compared to relapsing-remitting MS. CONCLUSIONS People with progressive MS are susceptible to foraminal stenosis. A higher index of suspicion for cervical SDD is required when appropriate neurological symptoms occur in the setting of progressive MS, to guide appropriate treatment or monitoring.
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Affiliation(s)
- Simran Chhugani
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nivedita Agarwal
- Section of Radiology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | - Faraz Sheikh
- Department of Neuroradiology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Florina Borca
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Aginor Spanoulis
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Alkrenawi M, Osherov M, Simonovich A, Droujin J, Milo R, Appel S. Association between cervical disc disease and lesions of multiple sclerosis. Neuroradiol J 2021; 34:200-204. [PMID: 33393859 DOI: 10.1177/1971400920983565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cervical discopathy and demyelinating lesions often co-exist in patients with multiple sclerosis (MS). Our study examines the possible association between these two pathologies. METHODS Medical records and cervical magnetic resonance imaging scans of MS patients with cervical discopathy who were seen at our MS clinic during 2018 were retrospectively reviewed. The severity of the disc disease was classified as grade I (no compression), grade II (compression of the dural sac) and grade III (cord compression). The spinal cord in each scan was divided into six segments corresponding to the intervertebral space of the spine (C1-C6). Each segment was defined as containing demyelinating lesion and disc pathology (group 1), demyelinating lesion without disc pathology (group 2), disc pathology without demyelinating lesion (group 3) and no demyelinating lesion or disc pathology (group 4). Fisher's exact test was used to test the association between demyelinating lesions and disc pathology. RESULTS Thirty-four MS patients with cervical discopathy were included in the study (26 females; average age 42.9 ± 13.7 years; average disease duration 8.4 ± 5.4 years). A total of 204 spinal cord segments were evaluated. Twenty-four segments were classified as group 1, 27 segments as group 2, 52 segments as group 3 and 101 segments as group 4. There was no association between demyelinating lesions and the grade of disc disease (p = 0.1 for grade I, p = 0.3 for grade II and p = 1 for grade III disc disease). CONCLUSION Our study did not find any association between cervical disc disease and demyelinating spinal cord lesion.
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Affiliation(s)
- Marwan Alkrenawi
- Department of Neurology, Barzilai University Medical Centre, Israel
| | - Michael Osherov
- Department of Neurology, Barzilai University Medical Centre, Israel
| | - Azaria Simonovich
- Department of Radiology, Barzilai University Medical Centre, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Jonathan Droujin
- Department of Radiology, Barzilai University Medical Centre, Israel
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Centre, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Shmuel Appel
- Department of Neurology, Barzilai University Medical Centre, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
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Bomprezzi R, Chen AP, Hemond CC. Cervical spondylosis is a risk factor for localized spinal cord lesions in multiple sclerosis. Clin Neurol Neurosurg 2020; 199:106311. [DOI: 10.1016/j.clineuro.2020.106311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022]
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