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Nociti V, Romozzi M, Mirabella M. Challenges in Diagnosis and Therapeutic Strategies in Late-Onset Multiple Sclerosis. J Pers Med 2024; 14:400. [PMID: 38673027 PMCID: PMC11051411 DOI: 10.3390/jpm14040400] [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: 03/17/2024] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory and degenerative demyelinating disease of the central nervous system of unknown etiology, which affects individuals in their early adulthood. However, nearly 5-10% of people with MS can be diagnosed at ages above 50 years old, referred to as late-onset multiple sclerosis (LOMS). Some studies have reported a distinctive presentation, clinical course, and prognosis for LOMS, implicating a different diagnostic and therapeutic approach for this population. Furthermore, similar manifestations between LOMS and other age-related conditions may lead to potential misdiagnosis and diagnostic delays, and a higher burden of multimorbidity associated with aging can further complicate the clinical picture. This review aims to explore the clinical characteristics, the disease course, and the differential diagnosis of LOMS and addresses therapeutic considerations for this population.
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Affiliation(s)
- Viviana Nociti
- Centro Sclerosi Multipla, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Marina Romozzi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Massimiliano Mirabella
- Centro Sclerosi Multipla, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
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Agarwal V, Shah LM, Parsons MS, Boulter DJ, Cassidy RC, Hutchins TA, Jamlik-Omari Johnson, Kendi AT, Khan MA, Liebeskind DS, Moritani T, Ortiz AO, Reitman C, Shah VN, Snyder LA, Timpone VM, Corey AS. ACR Appropriateness Criteria® Myelopathy: 2021 Update. J Am Coll Radiol 2021; 18:S73-S82. [PMID: 33958120 DOI: 10.1016/j.jacr.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 01/22/2023]
Abstract
Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Vikas Agarwal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, Vice Chair of Education, Department of Radiology, University of Pittsburgh Medical Center, Program Director, Neuroradiology Fellowship, University of Pittsburgh Medical Center.
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah, Chair, Committee on Appropriateness Criteria, Co-Chair, Neurological Imaging Panel, member of the ACR Commission on Neuroradiology
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky, American Academy of Orthopaedic Surgeons, Evidence Based Guideline Committee, North American Spine Society
| | | | | | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapies, Mayo Clinic Rochester
| | | | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology, President of SVIN
| | | | | | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina, North American Spine Society
| | - Vinil N Shah
- University of California San Francisco, San Francisco, California
| | - Laura A Snyder
- Barrow Neurological Institute, Phoenix, Arizona, Neurosurgery expert
| | - Vincent M Timpone
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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Combined Cerebellar and Spinal Cord Deficits Caused by an Underlying Gynecologic Malignancy. Case Rep Oncol Med 2020; 2020:9021843. [PMID: 31970005 PMCID: PMC6973182 DOI: 10.1155/2020/9021843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 12/25/2019] [Accepted: 01/02/2020] [Indexed: 11/18/2022] Open
Abstract
Paraneoplastic cerebellar degeneration (PCD) is an uncommon autoimmune disorder targeting antigens within the nervous system and is usually associated with an underlying malignancy. Neurologic symptoms frequently precede the cancer diagnosis, which is most often seen in women with breast or gynecologic tumors. Anti-Yo-related PCD is the most common PCD syndrome, and one of the best understood. Although cerebellar signs are characteristic of anti-Yo PCD, myelopathy is an unusual presentation of anti-Yo PCD based on published case series and reports. Unfortunately, the prognosis for anti-Yo PCD is often poor, and most patients become bedridden. We report a case highlighting a severe presentation of cerebellar degeneration along with an unusual finding of myelopathy in a patient with a newly diagnosed gynecologic cancer.
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Abstract
Myelopathy is an inclusive term, referring to pathology leading to a neurologic deficit related to the spinal cord. The clinical diagnosis of myelopathy requires a detailed history and physical examination to define the clinical syndrome. Neuroimaging is indicated in most instances of new-onset myelopathy. It is indicated also when the worsening of a myelopathy is unexplained. Advances in neuroimaging have proved to play a vital role in diagnosis. Appropriate diagnosis and treatment are dependent upon an adequate imaging evaluation to establish the presence of mechanical stability, extrinsic spinal cord compression, or an intramedullary lesion. The most frequent etiology of myelopathy is related to degenerative disease of the spine from osteophyte or extruded disc material causing compression of the spinal cord in the cervical or thoracic spine. The next common etiologies are spinal cord compression due to extradural masses caused by metastatic disease to bone or blunt trauma. In these cases, emergency imaging should be performed to assess the nature of the lesion causing the myelopathy and plan the most appropriate treatment. Also urgent imaging should be performed when an abscess in the spinal canal is suspected. Less urgent is imaging of primary neoplasms of the meninges, roots, or spinal cord, as well as noninfectious inflammatory processes, such as multiple sclerosis, and neurodegenerative, vascular, nutritional, or idiopathic disorders leading to myelopathy. Although a survey of the entire spinal cord can be performed with imaging, it is more appropriate to define from the clinical findings what levels of the spine and spinal cord should be imaged. This approach helps limit the likelihood of false-positive imaging findings that may encourage needless attempts to fix what is not broken. Similarly, the most appropriate imaging study and protocol should be selected in order to provide a timely and accurate diagnosis. To do so requires detailed knowledge regarding the strengths and limitations of the multiple imaging modalities available. This chapter outlines an approach to proper study selection based on the likely etiology of myelopathy from the clinical findings. Chapters 33-39 cover these disorders in detail.
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Roth CJ, Angevine PD, Aulino JM, Berger KL, Choudhri AF, Fries IB, Holly LT, Kendi ATK, Kessler MM, Kirsch CF, Luttrull MD, Mechtler LL, O'Toole JE, Sharma A, Shetty VS, West OC, Cornelius RS, Bykowski J. ACR Appropriateness Criteria Myelopathy. J Am Coll Radiol 2015; 13:38-44. [PMID: 26653797 DOI: 10.1016/j.jacr.2015.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/04/2015] [Indexed: 12/11/2022]
Abstract
Patients presenting with myelopathic symptoms may have a number of causative intradural and extradural etiologies, including disc degenerative diseases, spinal masses, infectious or inflammatory processes, vascular compromise, and vertebral fracture. Patients may present acutely or insidiously and may progress toward long-term paralysis if not treated promptly and effectively. Noncontrast CT is the most appropriate first examination in acute trauma cases to diagnose vertebral fracture as the cause of acute myelopathy. In most nontraumatic cases, MRI is the modality of choice to evaluate the location, severity, and causative etiology of spinal cord myelopathy, and predicts which patients may benefit from surgery. Myelopathy from spinal stenosis and spinal osteoarthritis is best confirmed without MRI intravenous contrast. Many other myelopathic conditions are more easily visualized after contrast administration. Imaging performed should be limited to the appropriate spinal levels, based on history, physical examination, and clinical judgment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | - Peter D Angevine
- Columbia University Medical Center, New York, New York, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | | | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ian Blair Fries
- Bone, Spine and Hand Surgery, Chartered, Brick, New Jersey, American Academy of Orthopaedic Surgeons
| | - Langston T Holly
- University of California Los Angeles, Los Angeles, California, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | - Marcus M Kessler
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Laszlo L Mechtler
- Dent Neurologic Institute, Amherst, New York, American Academy of Neurology
| | - John E O'Toole
- Rush University, Chicago, Illinois, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | | | | | - Julie Bykowski
- University of California San Diego Health Center, San Diego, California
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Seidenwurm DJ, Wippold FJ, Cornelius RS, Angevine PD, Angtuaco EJ, Broderick DF, Brown DC, Davis PC, Garvin CF, Hartl R, Holly L, McConnell CT, Mechtler LL, Smirniotopoulos JG, Waxman AD. ACR Appropriateness Criteria® Myelopathy. J Am Coll Radiol 2012; 9:315-24. [DOI: 10.1016/j.jacr.2012.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 01/17/2012] [Indexed: 11/26/2022]
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[Acute spinal cord ischemia following deep injection therapy of the neck]. DER NERVENARZT 2008; 79:927-31. [PMID: 18392602 DOI: 10.1007/s00115-008-2458-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We report the case of a 40-year-old woman suffering from neck pain due to mild cervical spine injury. During conventional faceted infiltration therapy with crystalline steroids, the patient developed weakness in both arms and paresthesia of the left arm. While the weakness resolved within a few seconds, a mild deficit in motor coordination and paresthesia of the left arm were still present after 2 months. T2-weighted magnetic resonance imaging of the cervical spine depicted a small hyperintense lesion at the C6 level most likely reflecting embolic infarction due to injection of crystalline steroids into a myelon-feeding artery, which has of late repeatedly been reported. We discuss potential pathomechanisms of this very rare complication and give a review of the literature.
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