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Czeisler BM. Emergent Management of Central Nervous System Demyelinating Disorders. Continuum (Minneap Minn) 2024; 30:781-817. [PMID: 38830071 DOI: 10.1212/con.0000000000001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the various conditions that can present with acute and severe central nervous system demyelination, the broad differential diagnosis of these conditions, the most appropriate diagnostic workup, and the acute treatment regimens to be administered to help achieve the best possible patient outcomes. LATEST DEVELOPMENTS The discovery of anti-aquaporin 4 (AQP4) antibodies and anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in the past two decades has revolutionized our understanding of acute demyelinating disorders, their evaluation, and their management. ESSENTIAL POINTS Demyelinating disorders comprise a large category of neurologic disorders seen by practicing neurologists. In the majority of cases, patients with these conditions do not require care in an intensive care unit. However, certain disorders may cause severe demyelination that necessitates intensive care unit admission because of numerous simultaneous multifocal lesions, tumefactive lesions, or lesions in certain brain locations that lead to acute severe neurologic dysfunction. Intensive care may be necessary for the management and prevention of complications for patients who have severely altered mental status, rapidly progressive neurologic worsening, elevated intracranial pressure, severe cerebral edema, status epilepticus, or respiratory failure.
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Qi F, Zhang Y, Li X, Fan J, Tan H, Quan C. Tumor or Demyelination? Three Tumefactive Multiple Sclerosis Case Reports and Literature Review. World Neurosurg 2024; 187:141-146. [PMID: 38641243 DOI: 10.1016/j.wneu.2024.04.069] [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: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To investigate the clinical diagnosis and treatment of tumefactive multiple sclerosis (TMS). METHODS Clinical data, laboratory and imaging examinations, and treatment of 3 patients with TMS were retrospectively analyzed. Data were further analyzed in relation to the literature. RESULTS All 3 patients had acute or subacute onset with large lesions on imaging, which were difficult to differentiate from tumors. Two cases had relapses on follow-up and one case had a stereotactic biopsy. CONCLUSIONS TMS is difficult to differentiate from brain tumors. It is necessary to improve the understanding of these diseases, to apply the correct diagnosis and treatment and to avoid unnecessary invasive surgery and inappropriate treatment.
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Affiliation(s)
- Feiteng Qi
- Department of Neurology, Ningbo Medical Center Lihuili Hospital, Ningbo, China.
| | - Yong Zhang
- Department of Neurology, The Xinchang Hospital Affiliated to Wenzhou Medical University, Xinchang, China
| | - Xiang Li
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Jie Fan
- Department of pathology, Huashan Hospital of Fudan University, Shanghai, China
| | - Haibo Tan
- Department of PET Centre, Huashan Hospital of Fudan University, Shanghai, China
| | - Chao Quan
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
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Zhang Y, Zhang T, Zhang X, Yan X, Lei J, Liu R, Yang Y, Zhang C, Zhang J, Zhang Y, Yue W. Clinical spectrum and prognosis of pathologically confirmed atypical tumefactive demyelinating lesions. Sci Rep 2023; 13:7773. [PMID: 37179394 PMCID: PMC10183015 DOI: 10.1038/s41598-023-34420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
To describe the clinical spectrum and prognosis of atypical tumefactive demyelinating lesions (TDLs), which were confirmed by pathology. A total of 11 patients were diagnosed with atypical TDLs confirmed by brain biopsy and surgery between January 2006 and December 2017. The clinical spectrum and prognosis in these patients were analyzed. The patients' ages ranged from 29 to 62 years, with a mean age of 48.9 years; 72.7% were males. The Expanded Disability Status Scale (EDSS) of the patients with first onset was 2.36. Most of the patients started with limb numbness and weakness (45.5%) or alalia (27.2%). The mean time from symptom onset to biopsy or surgery was 12.9 days (3-30 days). Most of the patients had solitary lesions (72.7%), supratentorial lesions (90.9%, particularly predominant in the frontal, temporal, and parietal lobes), moderate edema (63.6%), mild mass effect (54.5%), and patchy lesions (54.5%). Among them, three patients were positive for myelin basic protein (MBP) and one patient was positive for myelin oligodendrocyte glycoprotein (MOG). The patients were followed up for an average of 6.9 years (2-14 years), and recurrent TDLs were observed in 2 patients. Except for the 2 patients who relapsed, only 1 of the 9 patients died; the other 8 patients improved or maintained the status quo (the EDSS scores were lower or unchanged). The patients did not have any serious nervous system injury at onset, and the main presentation included extremity weakness, headache or dizziness, and alalia. The most common form was patchy on MRI enhancement. Cerebrospinal fluid and demyelination test can be an indicator of TDLs, and seizures may be a poor prognostic indicator. Most atypical TDLs have monophasic courses and good outcomes. The effect of neurosurgery alone was good in our group, and the effect of surgery on atypical TDLs can be further studied.
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Affiliation(s)
- Yajing Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Ting Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Xuebin Zhang
- Department of Pathology, Tianjin Huanhu Hospital, Tianjin, China
| | - Xiaoling Yan
- Department of Pathology, Tianjin Huanhu Hospital, Tianjin, China
| | - Jing Lei
- Imaging Department, Tianjin Huanhu Hospital, Tianjin, China
| | - Ran Liu
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Yun Yang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Chao Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Jun Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Ying Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Wei Yue
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China.
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Shiraishi W, Miyata T, Matsuyoshi A, Yamada Y, Hatano T, Hashimoto T. [A case of multiple sclerosis with a tumefactive lesion during long-term treatment with fingolimod, leading to decompressive craniotomy]. Rinsho Shinkeigaku 2023; 63:37-44. [PMID: 36567105 DOI: 10.5692/clinicalneurol.cn-001806] [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: 06/17/2023]
Abstract
We report a 57-year-old man with multiple sclerosis since his 30s who was treated with fingolimod for 9 years. He developed left hemiparesis and consciousness disturbance. Brain MRI revealed a mass lesion in the right frontal lobe with gadolinium enhancement. Cerebrospinal fluid examination showed no pleocytosis. The lesion continued to expand after admission, and on the 9th day after admission, decompressive craniectomy and brain biopsy were performed. Brain pathology revealed demyelination in the lesion, leading to the diagnosis of a tumefactive demyelinating lesion. Corticosteroid therapy ameliorated the brain lesion, and we inducted natalizumab. Tumefactive demyelinating lesions requiring decompressive craniotomy are rare, and we report this case for the further accumulation of similar cases.
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Affiliation(s)
- Wataru Shiraishi
- Department of Neurology, Kokura Memorial Hospital
- Shiraishi Internal Medicine Clinic
| | | | | | - Yui Yamada
- Department of Pathology, Kokura Memorial Hospital
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital
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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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Langer-Gould A, Klocke S, Beaber B, Brara SM, Debacker J, Ayeni O, Nielsen AS. Improving quality, affordability, and equity of multiple sclerosis care. Ann Clin Transl Neurol 2021; 8:980-991. [PMID: 33751857 PMCID: PMC8045931 DOI: 10.1002/acn3.51326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/21/2021] [Accepted: 02/06/2021] [Indexed: 12/26/2022] Open
Abstract
Objective The prevailing approaches to selecting multiple sclerosis (MS) disease modifying therapies (DMTs) have contributed to exponential increases in societal expenditures and out‐of‐pocket expenses, without compelling evidence of improved outcomes. Guidance is lacking regarding when and in whom the benefits of preventing MS‐related disability likely outweighs the risks of highly effective DMTs (HET) and when it is appropriate to consider DMT costs. Our objective was to develop a standardized approach to improve the quality, affordability and equity of MS care. Methods MS experts partnered with health plan pharmacists to develop an ethical, risk‐stratified, cost‐sensitive treatment algorithm. We developed a risk‐stratification schema to classify patients with relapsing forms of MS as high, intermediate or low risk of disability based on the best available evidence and, when the evidence was poor or lacking, by consensus. DMTs are grouped as highly, modestly or low/uncertain effectiveness and preferentially ranked within groups by safety based on pre‐specified criteria. We reviewed FDA documents and the published literature. When efficacy and safety are equivalent, the lower cost DMT is preferred. Results Assignment to the high‐risk group prompts treatment with preferred HETs early in the disease course. For persons in the intermediate‐ or low‐risk groups with cost or health care access barriers, we incorporated induction therapy with an affordable B‐cell depleting agent. Based on more favorable safety profiles, our preferred approach prioritizes use of rituximab and natalizumab among HETs and interferon‐betas or glatiramer acetate among modestly effective agents. Interpretation The risk‐stratified treatment approach we recommend provides clear, measurable guidance in whom and when to prescribe HETs, when to prioritize lower cost DMTs and how to accommodate persons with MS with cost or other barriers to DMT use. It can be adapted to other cost structures and updated quickly as new information emerges. We recommend that physician groups partner with health insurance plans to adapt our approach to their settings, particularly in the United States. Future studies are needed to resolve the considerable uncertainty about how much variability in prognosis specific risk factors explain.
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Affiliation(s)
- Annette Langer-Gould
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Shilpa Klocke
- Department of Neurology, Clinical Pharmacy, Colorado Permanente Medical Group, Denver, Colorado, USA
| | - Brandon Beaber
- Department of Neurology, Downey Medical Center, Southern California Permanente Medical Group, Downey, California, USA
| | - Sonu M Brara
- Department of Neurology, Panorama City Medical Center, Southern California Permanente Medical Group, Panorama City, California, USA
| | - Julie Debacker
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Oluwasheyi Ayeni
- Department of Neurology, Glenlake Medical Center, The Southeast Permanente Medical Group, Atlanta, Georgia, USA
| | - Allen S Nielsen
- Department of Neurology, Fontana Medical Center, Southern California Permanente Medical Group, Fontana, California, USA
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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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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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