Acute myelopathies: Clinical, laboratory and outcome profiles in 79 cases

Isolated Cervical Cord Infarct in a Neonate

Cases of isolated spinal cord ischemia resulting in symptoms in neonates are rare, and there are even fewer reported cases in atraumatic births. We present a case of a presumed isolated cervical cord ischemic injury, discuss differentials to consider when evaluating a neonatal spinal cord injury, and highlight the difficulties of diagnosing a spinal cord infarction.

MRI to differentiate multiple sclerosis, neuromyelitis optica, and myelin oligodendrocyte glycoprotein antibody disease

Differentiating multiple sclerosis (MS) from other relapsing inflammatory autoimmune diseases of the central nervous system such as neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is crucial in clinical practice. The differential diagnosis may be challenging but making the correct ultimate diagnosis is critical, since prognosis and treatments differ, and inappropriate therapy may promote disability. In the last two decades, significant advances have been made in MS, NMOSD, and MOGAD including new diagnostic criteria with better characterization of typical clinical symptoms and suggestive imaging (magnetic resonance imaging [MRI]) lesions. MRI is invaluable in making the ultimate diagnosis. An increasing amount of new evidence with respect to the specificity of observed lesions as well as the associated dynamic changes in the acute and follow-up phase in each condition has been reported in distinct studies recently published. Additionally, differences in brain (including the optic nerve) and spinal cord lesion patterns between MS, aquaporin4-antibody-positive NMOSD, and MOGAD have been described. We therefore present a narrative review on the most relevant findings in brain, spinal cord, and optic nerve lesions on conventional MRI for distinguishing adult patients with MS from NMOSD and MOGAD in clinical practice. In this context, cortical and central vein sign lesions, brain and spinal cord lesions characteristic of MS, NMOSD, and MOGAD, optic nerve involvement, role of MRI at follow-up, and new proposed diagnostic criteria to differentiate MS from NMOSD and MOGAD were discussed.

A Rare Case of Cardioembolic Spinal Stroke in a Young Female: Case Report

Spinal cord infarction (SCI) is a rare neurovascular disorder often presented with acute spinal cord syndrome. The diagnosis is generally made clinically, with appropriate neuroimaging to confirm the diagnosis and exclude other causes. We present an unusual case of a 48-year-old woman with no relevant past medical history, admitted with acute paraparesis and a spinal cord infarct on magnetic resonance imaging. A thorough investigation revealed asymptomatic unknown heart failure secondary to hypertrophic cardiomyopathy, suggestive of a cardioembolic etiology. The patient was treated with anticoagulation and improved significantly with physical rehabilitation.

Myelin oligodendrocyte glycoprotein associated transverse myelitis following brain abscess: Case report and literature review

Transverse myelitis is a subacute immune mediated myelopathy secondary to a range of conditions. Post infectious transverse myelitis can be seen with several infectious etiologies. Myelin oligodendrocyte glycoprotein associated disease (MOGAD) is a relatively recently defined condition frequently manifesting with longitudinally extensive transverse myelitis. Cases of MOGAD have occurred after infection, typically respiratory tract infections. We report an unusual case of MOGAD transverse myelitis following a streptococcal brain abscess which has not been previously reported.

Risk factors for idiopathic myelitis at admission and predictors for late diagnostic change

Immune-mediated myelopathy (IMM) diagnosis is challenging, and its etiology may remain unclear despite extensive investigation. We evaluated diagnostic changes in IMM patients during follow-up. We included 80 patients, 61.3% female, with median follow-up time 62.5 months. Diagnoses at discharge were: 48.8% Multiple Sclerosis-IMM (MS-IMM), 32.5% I-IMM, 11.3% Neuromyelitis Optica Spectrum Disorders-IMM (NMOSD-IMM), 1.3% MOG encephalomyelitis (MOGAD), and 6.2% Others IMM (O-IMM). Twenty-two  patients (27.5%) changed diagnosis (median 15.5  months): 68.8% MS-IMM, 12.5%  NMOSD-IMM, 3.8% MOGAD, 10.0% I-IMM, and 5.0% O-IMM. Most patients that changed diagnosis were I-IMM. Predictive factors for diagnostic change in I-IMM were: autonomous gait (p = 0.029), lesions suggestive of MS (p = 0.039), higher number of lesions (p = 0.043), lesions length < 3 vertebral bodies (p = 0.033), cervical involvement (p = 0.038), and lower EDSS at admission (p = 0.013). Etiologic reclassifications in IMM are common, therefore patients require an appropriate follow-up time to increase diagnostic accuracy.

An Uncommon Cause of Acute Transverse Myelitis Following Acinetobacter Baumannii-Associated UTI, Which Responded to Intravenous Pulse Methylprednisolone Alone

Acute transverse myelitis (ATM) is a non-compressive localized inflammation involving one or more levels of the spinal cord due to various etiologies characterized by motor weakness, sensory impairments, and autonomic dysfunction. It can be idiopathic or primary or secondary due to infection, autoimmune disorder, connective tissue disorder, and uncommonly after vaccination which came to the limelight during the ongoing massive vaccine drive against coronavirus disease 2019 (COVID-19). We report a case of a 21-years-old male who presented with gradually progressive weakness of both lower limbs following urinary tract infection (UTI) with a history of similar illness in the family which improved with high dose methylprednisolone and antibiotic therapy followed by physical rehabilitation. A diagnosis of long segment ATM possibly following UTI was suggested after ruling out other secondary causes and was confirmed by magnetic resonance imaging (MRI) of the spinal cord. Asymmetric symptoms and signs with small lesions involving <two vertebral segments, peripheral lesion, presence of Lhermitte's sign and relapsing-remitting course distinguish ATM from more debilitating disorder multiple sclerosis (MS) in patients with family history. Infection like UTI can precipitate ATM as well as UTI may develop along with neurogenic lower urinary tract dysfunction (NLUTD) even after recovery from the motor and sensory impairment. Patients with acute transverse myelitis need to be on regular follow up particularly those with subacute presentation and positive family history to rule out relapse and development of multiple sclerosis. Common etiologies like UTI may precipitate uncommon disorders like ATM.

Infection-Related Myelopathies

Recent years have seen growing attention to inflammatory and infectious disorders of the spinal cord, not only due to the discovery of autoantibody-mediated disorders of the spinal cord [e.g., aquaporin-4 immunoglobulin G (IgG) antibodies and myelin oligodendrocyte glycoprotein IgG antibodies], but also due to the emergence of clusters of infection-related myelopathy, now known as acute flaccid myelitis. We review the spectrum of infection-related myelopathies and outline a nosological classification system based on association with infection. We describe the epidemiology and definitions of myelopathies, with a discussion of clinical presentation and neuroimaging features, and then turn to specific discussion of myelopathies due to direct pathogen invasion and those considered to be post- or parainfectious. Expected final online publication date for the Annual Review of Pathology: Mechanisms of Disease, Volume 17 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Acute Demyelinating Syndromes: A report of child neurology department of Sfax University Hospital

INTRODUCTION

The yearly incidence of Acute Demyelinating Syndromes (ADS) in a multiethnic cohort of children published by Langer-Gould and al in 2011 was estimated at about 1.66 per 100,000. Nevertheless, the real incidence for these disorders is still underestimated as the iterative revision for diagnosis criteria have failed to classify a significant number of children with ADS.

PURPOSE

This work was aimed to describe clinical and paraclinical characteristics of ADS in a pediatric population.

MATERIAL AND METHODS

Demographic, clinical and paraclinical data of 42 children (24 females; 18 male; SR = 1.33), were collected from the medical records of patients admitted to the child neurology department of Sfax University Hospital between 2008 and 2021 for clinical events with presumed inflammatory origin. Next, patients were categorized as per M. N. Nouri and al. up dated classification for ADS. Finally, characteristics of different ADS categories were compared.

RESULTS

The mean age onset was 6 years (± 3.5 years). For a mean follow-up period of 28 months, 69% of patients had a monophasic course. ADS in our pediatric population were Acute disseminated encephalomyelitis (ADEM) (36%), Clinically isolated syndrome (CIS) (24%), Multiple sclerosis (MS) (19%), Neuromyelitis optica spectrum disorder (NMOSD) (7%), Myelin oligodendrocyte glycoprotein antibodies-associated diseases (MOGAD) (2%) and Recurrent demyelinating disease not otherwise specified (RD-NOS) (10%). At presentation, patients showed different clinical picture according to ADS-subtype with more patients with epileptic seizure in ADEM-group (53.3%), optic neuritis in CIS-group (70%), motor deficit in MS-group (62.5%), area postrema syndrome in NMOSD-group (33.3%) and vesico-sphincter dysfunction in RD-NOS-group (75%). Among patients presenting with visual impairment (21.4%), Visual evoked potential (VEP) guided the diagnosis of NMOSD in 22.2% by objectifying axonal optic nerve damage. Different ADS subtypes were identified according to MRI results in 100% of ADEM-patients and 75% of MS-patients and on antibody testing in three patients. The ADS-subtype was recognized based on antibody testing in three patients. Two patients from CIS-group: the first with isolated optic neuritis (ON) was positive for antiaquaporin 4 antibodies (anti-AQP4) and the other with clinically polyfocal ADS was positive for antinuclear antibodies (ANA) type anti-RNP. The remaining patients who presented with ADEM-phenotype was positive for anti-myelin oligodendrocyte glycoprotein (anti-MOG).

SIGNIFICANCE

Recognizing distinctive features of each ADS category may improve diagnosis accuracy as well as the indication of suitable treatment.

Acute myelitis and ChAdOx1 nCoV-19 vaccine: Casual or causal association?

A 44-year-old previously healthy woman developed acute myelitis in close temporal relationship with ChAdOx1 nCoV-19 vaccine first-dose administration. The neurological involvement was mainly sensory with neuroimaging showing two mono-metameric lesions involving the posterior and lateral cord at dorsal level. Significant improvement was promptly recorded with high-dose intravenous steroids, with complete recovery within one month.

The strict temporal relationship between vaccination and myelitis, together with the absence of clues pointing to alternative diagnoses, might suggest a conceivable role for anti-SARS-CoV-2 vaccine as immunological trigger, although a causal relationship has yet to be established and our preliminary observation suggests caution.

Immune-Mediated Myelopathies: A Review of Etiologies, Diagnostic Approach, and Therapeutic Management

Myelopathy is a broad term used to describe a heterogeneous group of disorders that affects the spinal cord; the focus of this article will be a subgroup of these disorders with an autoimmune and inflammatory-based pathology. Symptoms typically develop over hours or days and then worsen over a matter of days to weeks, but sometimes can have a more insidious or subacute presentation, which can make the diagnosis more puzzling. Despite relatively low incidence rates, almost a third of affected patients are left with severely disabling symptoms. Prompt recognition of the underlying etiology is essential so that a specific targeted therapy can be implemented for optimal outcomes. The authors discuss a systematic approach to immune-mediated myelopathies, with a focus on the unique characteristics of each that may aid in diagnosis.

Fibrocartilagenous embolism case series: is it a zebra?

INTRODUCTION

There have been 30 clinically suspected cases and 41 histopathologically confirmed cases of fibrocartilaginous embolism (FCE) reported in the literature. FCE often has a poor prognosis and is estimated to represent 5.5% of spinal cord infarctions, but may be more common than initially presumed given underdiagnosis due to its vague clinical presentation.

CASE PRESENTATION

We report two cases, a 15-year-old male and a 15-year-old female, whose clinical history, examination, and imaging findings were consistent with spinal cord infarction secondary to FCE.

DISCUSSION

These cases were unique given our patients' neurologic improvement; however, the commonly held assumption of poor prognosis may in part be fueled by the preferential case ascertainment via biopsy on autopsy. These cases highlight the importance of recognizing rare causes of spinal cord pathology and considering FCE in the differential diagnosis of acute myelopathy.

Acute non-traumatic tetraparesis - Differential diagnosis

INTRODUCTION

Potentially life-threatening disorders may present in the emergency department with acute tetraparesis, and their recognition is crucial for an appropriate management and timely treatment. Our review aims to systematize the differential diagnosis of acute non-traumatic tetraparesis.

RESULTS

Causes of tetraparesis can be classified based on the site of defect: upper motor neuron (UMN), peripheral nerve, neuromuscular junction or muscle. History of present illness should include the distribution of weakness (symmetric/asymmetric or distal/proximal/diffuse) and associated clinical features (pain, sensory findings, dysautonomia, and cranial nerve abnormalities such as diplopia and dysphagia). Neurological examination, particularly tendon reflexes, helps further in the localization of nerve lesions and distinction between UMN and lower motor neuron. Ancillary studies include blood and cerebral spinal fluid analysis, neuroaxis imaging, electromyography, muscle magnetic resonance and muscle biopsy.

CONCLUSIONS

Acute tetraparesis is still a debilitating and potentially serious neurological condition. Despite all the supplementary ancillary tests, the neurological examination is the key to achieve a correct diagnosis. The identification of life-threatening neurologic disorders is pivotal, since failing to identify patients at risk of complications, such as acute respiratory failure, may have catastrophic results.

Myelopathies in patients older than 50: not to miss inflammatory etiologies

BACKGROUND

Inflammatory myelopathies are primarily associated with younger age, and there are few studies in the elderly. Longitudinally extensive spinal cord lesions (LECL) are common in inflammatory myelopathies, but when the first event occurs in older age may have a broader differential diagnosis.

OBJECTIVES

To identify all non-traumatic myelopathies' etiologies in patients older than 50 years in a tertiary care hospital and to evaluate characteristics that differentiate inflammatory from non-inflammatory etiologies, focusing on the late-onset (≥50 years old) longitudinally extensive spinal cord lesions (LO-LECL) group.

METHODS

Retrospective study of patients admitted between 2008 to 2019. Demographic, clinical, laboratory, and magnetic resonance imaging (MRI) data of all patients were analyzed to identify predictors that could more easily identify inflammatory from non-inflammatory etiologies and further identify the etiologies of LO-LECL.

RESULTS

One hundred and three patients 50 years or older diagnosed with non-traumatic myelopathy were included, despite the lesion extension. Five were vascular (5%), 10 spondylotic (10%), 16 other etiologies (16%), 22 inflammatory (21%) and 50 neoplastic myelopathies (49%). Among 23 LO-LECL, 3 were vascular (13%), 4 neoplastic (17%), 7 other etiologies (30%) and 9 inflammatory (39%). The inflammatory LO-LECL had the median time to nadir significantly different from the neoplastic and the other etiologies groups and had the median EDSS at last visit (3.5) significantly lower than the non-inflammatory LO-LECL (7.0-7.5).

CONCLUSIONS

Inflammatory etiologies are not to be disregarded in older adults with non-traumatic myelopathies. The symptoms' temporal profile is critical to differentiate inflammatory LO-LECL from other etiologies and it has better functional recovery after adequate treatment.

Frequency and etiology of acute transverse myelitis in Southern Finland

OBJECTIVE

Acute transverse myelitis is a relatively rare, frequently debilitating but potentially treatable emergency. The objective of this study was to evaluate the incidence and etiology of acute transverse myelitis in two major hospital districts in Southern Finland.

METHODS

We identified all patients with acute transverse myelitis admitted to Turku University Hospital and Päijät-Häme Central hospital during nine years. The two hospitals serve a catchment area of 673,000 people in Southern Finland. Acute transverse myelitis was diagnosed according to the 2002 Transverse Myelitis Consortium Working Group. Patient files were reviewed for details of the clinical presentation and disease outcome, for laboratory findings and for neuroimaging. Charts were re-evaluated after an average of 7.7 years for confirmation of the acute transverse myelitis etiology.

RESULTS

In total 63 patients fulfilled the Transverse Myelitis Consortium Working Group diagnostic criteria for acute transverse myelitis. The frequency of the condition was hence 1.04 cases/ 100,000 inhabitants/ year. In the studied cohort, 7/63 (11%) patients had idiopathic transverse myelitis after initial evaluation and in 4/63 (6.3%) patients the idiopathic transverse myelitis remained the final diagnosis after follow-up and re-evaluation. Of the disease-associated myelitis cases MS or clinically isolated syndrome was the largest group, explaining 41% of all myelitis cases. The mean follow-up time before a patient was diagnosed with MS was 1.7 ± 2.2 years. Other etiologies included acute disseminated encephalomyelitis (ADEM), neurosarcoidosis, neuromyelitis optica (NMO), systemic autoimmune diseases and infectious diseases.

CONCLUSIONS

In more than half of the acute transverse myelitis cases the final diagnosis is other than MS. Careful diagnostic work-up is needed for correct early treatment and best long-term outcome.

Differential diagnosis in acute inflammatory myelitis

INTRODUCTION

Establishing differential diagnosis between different inflammatory causes of acute transverse myelitis (ATM) can be difficult. The objective of this study was to see which clinical, imaging or laboratory findings best contribute to confirm ATM etiology.

METHODS

We reviewed clinical history, MRI images, CSF and serum laboratory tests in a retrospective study of patients presenting ATM. Univariate and multivariate multinomial logistic regression analysis was performed for each of the items listed above.

RESULTS

One hundred and seventy-two patients were analyzed in the study: 68 with multiple sclerosis (MS), 67 presenting idiopathic myelitis (IM; 23 of which were recurrent), 21 who developed positive systemic-antibodies associated myelitis (SAb-M) and 16 with neuromyelitis optica spectrum disorders (NMOSD). The following factors were associated with increased risk of developing MS: lower values in the modified Rankin scale at admission; positive oligoclonal bands (OCB); higher spinal cord lesion load; presence of brain demyelinating lesions; and disease recurrence. Longitudinally extended (LE) lesions, brain demyelinating lesions, and recurrences also contributed to final diagnosis of NMOSD. Multivariate multinomial logistic regression analysis showed presence of LE lesions increased risk of NMOSD and recurrence of ATM. Whereas, brain demyelinating lesions, and presence of OCB increased risk of MS.

CONCLUSIONS

ATM etiology may be clarified on the basis of spinal cord and brain MRI findings, together with CSF biochemistry and serum laboratory test results, allowing more timely and exact diagnosis as well as specific therapy for cases of uncertain origin.

Spinal Cord Involvement in MS and Other Demyelinating Diseases

Diagnostic accuracy is poor in demyelinating myelopathies, and therefore a challenge for neurologists in daily practice, mainly because of the multiple underlying pathophysiologic mechanisms involved in each subtype. A systematic diagnostic approach combining data from the clinical setting and presentation with magnetic resonance imaging (MRI) lesion patterns, cerebrospinal fluid (CSF) findings, and autoantibody markers can help to better distinguish between subtypes. In this review, we describe spinal cord involvement, and summarize clinical findings, MRI and diagnostic characteristics, as well as treatment options and prognostic implications in different demyelinating disorders including: multiple sclerosis (MS), neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, anti-myelin oligodendrocyte glycoprotein antibody-associated disease, and glial fibrillary acidic protein IgG-associated disease. Thorough understanding of individual case etiology is crucial, not only to provide valuable prognostic information on whether the disorder is likely to relapse, but also to make therapeutic decision-making easier and reduce treatment failures which may lead to new relapses and long-term disability. Identifying patients with monophasic disease who may only require acute management, symptomatic treatment, and subsequent rehabilitation, rather than immunosuppression, is also important.

Atypical myelitis in patients with multiple sclerosis: Characterization and comparison with typical multiple sclerosis and neuromyelitis optica spectrum disorders

Background:

Atypical myelitis in multiple sclerosis (MS) is characterized by extensive myelitis in the longitudinal (longitudinally extensive transverse myelitis) or axial plane (transverse myelitis).

Objective:

To characterize a cohort of MS patients with atypical myelitis.

Methods:

Atypical myelitis was extracted from the French and Luxembourg MS databases and compared to two cohorts of MS patients with typical myelitis and neuromyelitis optica spectrum disorders (NMOSDs) patients with myelitis.

Results:

We enrolled 28 MS patients with atypical myelitis, 68 MS patients with typical myelitis and 119 NMOSD patients with a first episode of myelitis. MS patients with atypical myelitis were characterized by a mean age of 34.0 (±10.7) years and 64.3% were women. In 82.1% of the patients, atypical myelitis was the first episode of MS. Mean Expanded Disability Status Scale (EDSS) scores at nadir and 3–6 months after onset were 4.1 ± 2.1 and 3.3 ± 2, respectively. Differences between groups revealed a predominance of cervicothoracic myelitis and a higher level of disability in NMOSD patients. Disability in MS patients with atypical myelitis was more severe than in the MS patients with typical myelitis; 28% had already converted to progressive MS within our mean follow-up of 39.6 (±30.4) months.

Conclusion:

Atypical myelitis may be the first presentation of MS and is associated with poorer prognosis.

Clinical features of transverse myelitis associated with systemic lupus erythematosus

Objective

This study aimed to identify the clinical characteristics and prognostic factors of systemic lupus erythematosus with transverse myelitis (SLE-TM) in a relatively large patient series.

Methods

This retrospective study considered 45 SLE-TM individuals treated as inpatients and outpatients at Peking Union Medical College Hospital between 1993 and 2018. SLE-TM patients were compared with 180 controls, and SLE-TM patients with neuromyelitis optica spectrum disorder (NMOSD) were compared to those without NMOSD.

Results

Compared to controls, the SLE-TM group frequently had a fever and had a significantly higher positive rate of anticardiolipin and lupus anticoagulant. Among the 45 patients, 22 met the NMOSD criteria. Compared to non-NMOSD patients, NMOSD patients had a lower incidence of rash ( p = 0.023), serositis ( p = 0.042) and renal disorder ( p = 0.073); a lower prevalence of decreased complement ( p = 0.083); and lower rates of positive anti-dsDNA ( p = 0.074) and anti-Sm ( p = 0.042). Among 22 SLE-TM patients with NMOSD, 18 underwent aquaporin 4 antibody testing, with 11 showing positive results. Out of the 45 patients, 39 were given methylprednisolone pulse treatment. After treatment, 32 patients had lower-limb muscle strength recovery (recovered group), whereas 13 had no change and persistent severe neurological deficits (non-recovered group). Compared to the recovered group, the non-recovered group were younger ( p = 0.002), had a higher likelihood of having a fever ( p = 0.020), initial severe myelitis ( p < 0.001), long spinal segment involvement ( p = 0.017) and higher C-reactive protein levels ( p = 0.020). Methylprednisolone pulse given within two weeks of onset was more frequent in the recovered group than in the non-recovered group ( p = 0.082).

Conclusions

Disease characteristics differed between SLE-TM patients with and without NMOSD. SLE and NMOSD tended to be co-morbidities. Initial severe neurological impairment, extensive spinal cord lesions, hyper-inflammation and delayed steroid impulse treatment could be predictors of poor outcome for SLE-TM.

Urodynamic profile in acute transverse myelitis patients: Its correlation with neurological outcome

Objective:

The objective of this study was to observe urodynamic profile of acute transverse myelitis (ATM) patients and its correlation with neurological outcome.

Patients and Methods:

This prospective study was conducted in the neurorehabilitation unit of a tertiary university research hospital from July 2012 to June 2014. Forty-three patients (19 men) with ATM with bladder dysfunction, admitted in the rehabilitation unit, were included in this study. Urodynamic study (UDS) was performed in all the patients. Their neurological status was assessed using ASIA impairment scale and functional status was assessed using spinal cord independence measure. Bladder management was based on UDS findings.

Results:

In total, 17 patients had tetraplegia and 26 had paraplegia. Thirty-six patients (83.7%) had complaints of increased frequency and urgency of urine with 26 patients reported at least one episode of urge incontinence. Seven patients reported obstructive urinary complaints in the form of straining to void with 13 patients reported both urgency and straining to void and 3 also had stress incontinence. Thirty-seven (86.1%) patients had neurogenic overactive detrusor with or without sphincter dyssynergia and five patients had acontractile detrusor on UDS. No definitive pattern was observed between neurological status and bladder characteristics. All patients showed significant neurological and functional recovery with inpatient rehabilitation (P < 0.05 and P < 0.001, respectively).

Conclusions:

The problem of neurogenic bladder dysfunction is integral to ATM. Bladder management in these patients should be based on UDS findings. Bladder characteristics have no definitive pattern consistent with the neurological status.

Clinical, laboratory features, and prognostic factors in adult acute transverse myelitis: an Italian multicenter study

OBJECTIVES

We compared the clinical, laboratory, and radiological features of different subgroups of acute transverse myelitis (ATM) diagnosed according to the criteria established by the Transverse Myelitis Consortium Working Group (TMCWG) as well as of non-inflammatory acute transverse myelopathies (NIATM) to identify possible short- and long-term prognostic factors.

METHODS

A multicenter and retrospective study comprising 110 patients with ATM and 15 NIATM admitted to five Italian neurological units between January 2010 and December 2014 was carried out.

RESULTS

A significantly higher frequency of isolated sensory disturbances at onset in ATM than in NIATM patients (chi-square = 14. 7; P = 0.005) and a significantly higher frequency of motor symptoms in NIATM than ATM (chi-square = 12.4; P = 0.014) was found. ATM patients with high disability at discharge had more motor-sensory symptoms without (OR = 3.87; P = 0.04) and with sphincter dysfunction at onset (OR = 7.4; P = 0.0009) compared to those with low disability. Higher age (OR = 1.08; P = 0.001) and motor-sensory-sphincter involvement at onset (OR = 9.52; P = 0.002) were significantly associated with a high disability score at discharge and after a median 1-year follow-up.

CONCLUSIONS

The diagnosis of ATM may prevail respect to that of NIATM when a sensory symptomatology at onset occurs. In ATM, patients older and with motor-sensory involvement with or without sphincter impairment at admission could experience a major risk of poor prognosis both at discharge and at longer time requiring a timely and more appropriate treatment.

Prevalence and characteristics of transverse myelitis and neuromyelitis optica spectrum disorders in the United Arab Emirates: A multicenter, retrospective study

Objective

To determine the epidemiology and characteristics of transverse myelitis (TM) and neuromyelitis optica spectrum disorders (NMOSD) in Abu Dhabi, United Arab Emirates.

Methods

Retrospective chart review at four large government-run hospitals in Abu Dhabi between 2010 and 2016. Data collected included year of onset, presentation, laboratory results including aquaporin-4 immunoglobulin G (IgG)/myelin oligodendrocyte glycoprotein IgG antibodies and the occurrence of any relapses.

Results

A total of 46 individuals were identified. Of these, 23 (50%) were Emirati citizens. Within the overall group including pediatrics, the crude prevalence rate for monophasic TM was 1.0 per 100 000, and for NMOSD was 0.34 per 100 000. Incidence rates within the overall group for TM and NMOSD were 0.18 per 100 000 and 0.05 per 100 000, respectively. For Emirati citizens aged ≥20 years, the prevalence rate for monophasic TM was 2.46 per 100 000 and 1.76 per 100 000 for NMOSD, and the incidence was 0.57 per 100 000 and 0.17 per 100 000, respectively. The incidence of monophasic TM and NMOSD within the Emirati pediatric population (aged ≤19 years) was 0.18 per 100 000 and 0.06 per 100 000, respectively. The mean age of onset for monophasic TM was 36 years, and for NMOSD was 43 years. Nine patients had a positive aquaporin-4 IgG or anti-myelin oligodendrocyte glycoprotein IgG antibody result. Of the 30 participants with available laboratory cerebrospinal fluid analysis, 36.6% had elevated white blood counts (>5.0 × 10⁶/L), and 43% had elevated protein levels. A total of 19 participants had documentation of oligoclonal bands or IgG index, and just four (21%) had either oligoclonal bands or elevated IgG index.

Conclusion

The present study describes the epidemiology and characteristics of TM and NMOSD among populations in Abu Dhabi. The adult prevalence rate for Emirati citizens was 2.46 per 100 000 for monophasic TM, and 1.76 per 100 000 for NMOSD. The overall incidence was 0.18 per 100 000 and 0.05 per 100 000, respectively.

Autoimmune Neurological Conditions Associated With Zika Virus Infection

Zika virus (ZIKV) is an emerging flavivirus rapidly spreading throughout the tropical Americas. Aedes mosquitoes is the principal way of transmission of the virus to humans. ZIKV can be spread by transplacental, perinatal, and body fluids. ZIKV infection is often asymptomatic and those with symptoms present minor illness after 3 to 12 days of incubation, characterized by a mild and self-limiting disease with low-grade fever, conjunctivitis, widespread pruritic maculopapular rash, arthralgia and myalgia. ZIKV has been linked to a number of central and peripheral nervous system injuries such as Guillain-Barré syndrome (GBS), transverse myelitis (TM), meningoencephalitis, ophthalmological manifestations, and other neurological complications. Nevertheless, mechanisms of host-pathogen neuro-immune interactions remain incompletely elucidated. This review provides a critical discussion about the possible mechanisms underlying the development of autoimmune neurological conditions associated with Zika virus infection.

Spinal Cord Infarction Mimicking Acute Transverse Myelitis

Spinal cord infarction (SCI) is a rare type of stroke. The initial magnetic resonance imaging (MRI) is usually normal and can mimic the presentation of the acute transverse myelitis (ATM), acute inflammatory demyelinating polyneuropathy, and compressive myelopathies from neoplasm, epidural or subdural hematoma, or abscess. The aim of this report is to describe and discuss the case of a patient with SCI presenting as a diagnostic confusion with acute transverse myelitis. A 64-year-old male with a medical history of hypertension presented with an acute onset of urinary retention with lower limb weakness. Based on the initial MRI and evaluation, a diagnosis of acute transverse myelitis was made. Despite thorough evaluation, the etiology of transverse myelitis was undetermined. Hence, the MRI of the thoracic spine was repeated which showed patchier enhancements of the vertebral body with features suggestive of the spinal cord and vertebral body infarction. Thus, a repeat MRI is required to make an accurate diagnosis. The vertebral body is always involved and can be of diagnostic significance as it reflects the pathology of underlying blood supply.

Predictors of outcome in a large retrospective cohort of patients with transverse myelitis

BACKGROUND

Transverse myelitis (TM) is an inflammatory disorder that can be idiopathic or associated with central nervous system autoimmune/dysimmune inflammatory diseases, connective tissue autoimmune diseases, or post-infectious neurological syndromes. Prognosis of initial TM presentations is uncertain.

OBJECTIVE

To identify outcome predictors in TM.

METHODS

Retrospective study on isolated TM at onset. Scores ⩾3 on the modified Rankin scale (mRS) marked high disability.

RESULTS

A total of 159 patients were identified. TM was classified as follows: idiopathic (I-TM, n = 53), post-infectious (PI-TM, n = 48), associated with multiple sclerosis (MS-TM, n = 51), or neuromyelitis optica spectrum disorders/connective tissue autoimmune diseases/neurosarcoidosis ( n = 7). At follow-up (median, 55 months; interquartile range, 32-80), 42 patients were severely disabled, and patients with I-TM or PI-TM showed the worst outcomes. Predictors of disability were infectious antecedents, sphincter and pyramidal symptoms, high mRS scores, blood-cerebrospinal fluid barrier damage, lumbar magnetic resonance imaging (MRI) lesions on univariate analysis, and older age (odds ratio (OR), 1.1; 95% confidence interval (CI), 1.0-1.1), overt/subclinical involvement of the peripheral nervous system (PNS) (OR, 9.4; 95% CI, 2.2-41.0), complete TM (OR, 10.8; 95% CI, 3.4-34.5) on multivariate analysis.

CONCLUSION

Our findings help define prognosis and therapies in TM at onset. Infectious antecedents and PNS involvement associate with severe prognosis. Nerve conduction studies and lumbar MRI could improve the prognostic assessment of this condition.

Diagnostic and Prognostic Relevance of Magnetic Resonance Imaging and Electrophysiological Findings in Acute Spinal Ischemia

OBJECTIVE

Our purpose was to classify the rare entity of spontaneous spinal ischemia with clinical, magnetic resonance-tomographic, and electrophysiological parameters to determine criteria for outcome prediction.

METHODS

We analyzed the stroke registry database of the University Hospital Mannheim, Germany, from 2004 to 2010 for patients with a diagnosis of vascular spinal cord ischemia.

RESULTS

Ten patients were identified (mean age 65 years [range 50-83], 5 women). In 5 patients an etiology was found. Spinal diffusion-weighted magnetic resonance imaging revealed acute ischemia in 7 patients at initial imaging and this diagnosis was confirmed during the first week in the remaining 3 patients. Electrophysiological studies showed abnormal motor evoked potentials (MEPs) in 8 patients and abnormal somatosensory evoked potentials (SSEPs) in 7 patients. After rehabilitation, 5 patients had regained walking ability, whereas 5 patients stayed wheelchair bound. All patients with unfavorable outcome (American Spinal Injury Association (ASIA) Impairment score [AIS] score of ≤C) showed severe pyramidal tract lesions in MEPs during the first week. All patients with normal MEPs had an excellent outcome (AIS of E, P < .05).

CONCLUSIONS

Diffusion-weighted imaging (DWI) is a useful tool to confirm acute spinal ischemia suspected in patients within the first days after symptom onset. Poor outcome was associated with severe electrophysiological abnormalities in MEPs and SSEPs. Normal MEPs were significantly predictive of an excellent prognosis. A multimodal diagnostic approach combining DWI and electrophysiological evaluation facilitates the prediction of the individual clinical outcome.

Etiological profile of noncompressive myelopathies in a tertiary care hospital of Northeast India

Background:

The discovery of antibodies against aquaporin-4 and evolving concepts of noncompressive myelopathies in the 21^st century have made a major impact on the etiological profile of these diseases, with few cases turning out to be idiopathic.

Objective:

To find causes of noncompressive myelopathy in a tertiary care hospital of Northeast India.

Materials and Methods:

An observational study was carried out in the Neurology Department of Gauhati Medical College, Guwahati, from September 2013 to February 2016. Patients of noncompressive myelopathies who underwent magnetic resonance imaging (MRI) of the spine were segregated into two categories: acute-to-subacute myelopathy (ASM) and chronic myelopathy (CM). In addition to routine blood tests, chest X-ray, urinalysis, and visual evoked potentials, investigations included MRI of the brain, cerebrospinal fluid analysis, and immunological, infectious, and metabolic profile based on the pattern of involvement.

Results:

The study had 151 patients (96 ASM and 55 CM) with a median age of 35 years and male: female ratio 1.4:1. The causes of ASM were neuromyelitis optica spectrum disorder (23), multiple sclerosis (MS) (8), systemic lupus erythematosus (1), Hashimoto's disease (1), postinfectious acute disseminated encephalomyelitis (6), postinfectious myelitis (8), infections (9), spinal cord infarct (5), and electrocution (1). The causes of CM were MS (1), probable or possible sarcoidosis (7), mixed connective tissue disease (1), Hashimoto's disease (2), infections (9), Vitamin B₁₂ deficiency (4), folate deficiency (2), hepatic myelopathy (2), radiation (11), and paraneoplastic (1). No etiology could be found in 48 (31.8%) patients (34 ASM and 14 CM). In 21/96 (21.9%) patients of ASM, acute transverse myelitis was idiopathic based on current diagnostic criteria.

Conclusion:

Underlying etiology (demyelinating, autoimmune, infectious, vascular, metabolic disorder, or physical agent) was found in 68% patients of noncompressive myelopathy.

Idiopathic acute transverse myelitis: a clinical study and prognostic markers in 45 cases

Objective The Transverse Myelitis Consortium Working Group has proposed new diagnostic criteria for idiopathic acute transverse myelitis (ATM). We reviewed patients admitted to our center diagnosed with myelitis with two objectives: (i) to evaluate the usefulness of these criteria in distinguishing between myelitis as the first episode of multiple sclerosis (MS) and idiopathic ATM; and (ii) to analyse the clinical and laboratory variables that may be used as functional prognostic markers.

Methods We selected patients who met the criteria. We recorded clinical epidemiological data, patients treated with methylprednisolone, maximal disability reached and disability at final follow-up. We also recorded cerebrospinal fluid (CSF) data and the number of levels affected in the spinal magnetic resonance imaging (MRI).

Results Twenty-four patients fulfilled the criteria for definite ATM and 21 for possible ATM. Five patients converted to MS. Mean follow-up time was 3.5 years. There was an association between younger patients and female patients with conversion to MS. The highest Rankin score reached and increased CSF glucose levels were associated with a poor outcome. In multivariate analysis, only the admission Rankin score was associated with outcome.

Conclusions (i) About 10% of patients who met the criteria may convert to MS; and (ii) admission Rankin score was the only independent prognostic factor found.

Is Devic's neuromyelitis optica a separate disease? A comparative study with multiple sclerosis

Devic's neuromyelitis optica (NMO) associates optic neuritis and myelopathy without other neurological signs. Many patients with NMO may be diagnosed as having multiple sclerosis (MS). However, there have been no previous studies comparing these two patho logies and it is still unclear if NMO is a separate entity or a subtype of MS. In the present study, we compared a series of NMO patients with a series of MS patients for whom optic neuritis or myelopathy was the presenting symptom, in order to determine the place of NMO in the spectrum of MS. We retrospectively studied 30 patients diagnosed with NMO and we compared these patients with 50 consecutive MS cases revealed by optic neuritis or acute myelopathy. MS patients were only included if a relapse occurred demonstrating time and space dissemination. We compared the two groups in terms of clinical presentatio n, laboratory findings (MRI and C SF) and clinical outcome. NMO patients were older and more frequently women than MS patients but the difference was not significant. C SF and MRI data were clearly different: oligoclonal bands (O C B) were found in 23% of NMO cases and 88% of MS (P B/0.001), abnormal brain MRI data were observed in 10% of NMO cases and 66% of MS (P B/0.001) and a large spinal cord lesion was observed in 67% of NMO cases and 7.4% of MS cases (P B/0.001). C linical outcome was evaluated as more severe in the NMO group (P B/0.001). O n the basis of clinical data, all NMO patients but three had dissemination in time and space. When we included MRI parameters, only two of the NMO patients met criteria for MS and one of the MS patients met criteria for NMO. O ur study demonstrates that NMO and MS should be considered as two different entities. The respective criteria for NMO and MS were able to distinguish these two patho logies but only when MRI data were applied. This finding could have implications for future therapeutic trials.

An Imaging-Based Approach to Spinal Cord Infection

Infections of the spinal cord, nerve roots, and surrounding meninges are uncommon, but highly significant given their potential for severe morbidity and even mortality. Prompt diagnosis can be lifesaving, as many spinal infections are treatable. Advances in imaging technology have now firmly established magnetic resonance imaging (MRI) as the gold standard for spinal cord imaging evaluation, enabling the depiction of infectious myelopathies with exquisite detail and contrast. In this article, we aim to provide an overview of MRI findings for spinal cord infections with special focus on imaging patterns of infection that are primarily confined to the spinal cord, spinal meninges, and spinal nerve roots. In this context, we describe and organize this review around 5 distinct patterns of transverse spinal abnormality that may be detected with MRI as follows: (1) extramedullary, (2) centromedullary, (3) eccentric, (4) frontal horn, and (5) irregular. We seek to classify the most common presentations for a wide variety of infectious agents within this image-based framework while realizing that significant overlap and variation exists, including some infections that remain occult with conventional imaging techniques.

Acute cervical cord infarction in anterior spinal artery territory with acute swelling mimicking myelitis

Acute infarction of the cervical segment of the spinal cord is extremely uncommon. Patients may present with signs and symptoms mimicking that of acute myelitis. On imaging, both conditions may present as a hyperintense area on T-2 weighted MRI. History of sudden onset is essential in establishing the diagnosis. We report a case of cervical spinal cord infarction in a 40-year-old man who was diagnosed with acute transverse myelitis, and was treated with high dose intravenous corticosteroids followed by 5 sessions of plasma exchange. An MRI of the spine revealed abnormal high T2 signal intensity extending from the C2 to C7 level involving the anterior two-thirds of the cord with more central involvement. The findings were consistent with anterior spinal artery territory cervical cord infarction.

Infektionen

In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.

Spinal cord ischemia: aetiology, clinical syndromes and imaging features

INTRODUCTION

The purpose of this study was to analyse MR imaging features and lesion patterns as defined by compromised vascular territories, correlating them to different clinical syndromes and aetiological aspects.

METHODS

In a 19.8-year period, clinical records and magnetic resonance imaging (MRI) features of 55 consecutive patients suffering from spinal cord ischemia were evaluated.

RESULTS

Aetiologies of infarcts were arteriosclerosis of the aorta and vertebral arteries (23.6%), aortic surgery or interventional aneurysm repair (11%) and aortic and vertebral artery dissection (11%), and in 23.6%, aetiology remained unclear. Infarcts occurred in 38.2% at the cervical and thoracic level, respectively, and 49% of patients suffered from centromedullar syndrome caused by anterior spinal artery ischemia. MRI disclosed hyperintense pencil-like lesion pattern on T2WI in 98.2%, cord swelling in 40%, enhancement on post-contrast T1WI in 42.9% and always hyperintense signal on diffusion-weighted imaging (DWI) when acquired.

CONCLUSION

The most common clinical feature in spinal cord ischemia is a centromedullar syndrome, and in contrast to anterior spinal artery ischemia, infarcts in the posterior spinal artery territory are rare. The exclusively cervical location of the spinal sulcal artery syndrome seems to be a likely consequence of anterior spinal artery duplication which is observed preferentially here.

Posterior spinal cord infarction due to fibrocartilaginous embolization in a 16-year-old athlete

Spinal cord infarction is extremely rare in children, and, similar to cerebrovascular infarcts, the pathogenesis is different from adults. Spinal cord infarcts are most commonly reported in adults in the context of aortic surgery; in children, the etiology is frequently unknown. Fibrocartilaginous embolization is a potential cause of spinal cord infarct in both populations. It is a process that occurs when spinal injury has resulted in disc disease, and subsequently disc fragments embolize to the cord, resulting in ischemia and/or infarction. In this report, we present a 16-year-old athlete who presented with symptoms of acute myelopathy after a period of intense exercise. Our original concern was for an inflammatory process of the spinal cord; however, given her history of competitive tumbling and degenerative disc changes on her initial spine magnetic resonance imaging scan, diffusion-weighted imaging was performed, which demonstrated acute spinal cord infarction. Unlike many cases of spinal cord infarction, our patient was fortunate to make a near-complete recovery. This case highlights the importance of recognizing rare causes of spinal cord pathology and considering infarction in the differential diagnosis of acute myelopathy because management and prognosis varies.

Myelitis in systemic lupus erythematosus frequently manifests as longitudinal and sometimes occurs at low disease activity

Background

Transverse myelitis (TM) is a relatively infrequent but severe complication in systemic lupus erythematosus (SLE). Owing to its rarity and unfavorable outcome, we investigated its general features on MRI and incidence in the context of lupus activity, to facilitate early recognition and treatment.

Methods

We report a case of a young man with clinically inactive lupus nephritis but who presented with a sudden attack of myelitis. We performed systematic literature search in Medline to study the clinical features of SLE-related TM.

Results

From 1960 to April 2013, a total of 72 articles containing 194 cases of lupus myelitis were found. Among acquired articles, 93 patients fulfilled the inclusion criteria. The majority of the cases (88.8%) were female. Longitudinal myelitis was the predominant imaging finding on MRI (71.4%, 45/63). Nearly two-thirds (61/94) of lupus myelitis occurred in association with active lupus, and one-third (33/94) occurred in low disease activity.

Conclusions

Upon literature review, we found myelitis in SLE more frequently manifested as longitudinal on MRI. Although lupus myelitis often presented at an active phase of SLE, one-third of events happened in the presence of low disease activity. Early initiation of effective immunosuppressive therapy facilitated recovery.

Spinal cord infarction: a rare cause of paraplegia

Spinal cord infarction is rare and represents a diagnostic challenge for many physicians. There are few reported cases worldwide with a prevalence of 1.2% of all strokes. Circulation to the spinal cord is supplied by a rich anastomosis. The anterior spinal artery supplies the anterior two thirds of the spinal cord and infarction to this area is marked by paralysis, spinothalamic sensory deficit and loss of sphincter control depending on where the lesion is. Treatment of spinal cord infarction focuses on rehabilitation with diverse outcomes. This report presents a case of acute spinal cord infarction with acquisition of MRI to aid diagnosis.

Etiologic spectrum and prognosis of longitudinally extensive transverse myelopathies

BACKGROUND

Patients with a first episode of longitudinal extensive transverse myelopathy (LETM) were reviewed with two objectives: to evaluate the clinical spectrum of LETM and to analyze the related clinical and laboratory variables that can be used as functional prognostic markers.

METHODS

A retrospective review was conducted of clinical, radiologic and biochemical data of patients admitted for LETM between 1993 and 2011.

RESULTS

Our cohort included 72 patients [median age 41 years, interquartile range (IQR) 29-61.5]. Median follow-up was 34 months (IQR 17.2-63). The modified Rankin Scale (mRS) score was ≥2 at the end of follow-up in 72.2%. The final diagnosis was idiopathic LETM in 22 patients, multiple sclerosis in 18, parainfectious disease in 11, systemic disease in 9, spinal cord infarction and neuromyelitis optica spectrum disorders in 3 patients each, and acute demyelinating encephalomyelitis, dural fistula, and tumor-related LETM in 2 patients each. Unfavorable outcome was associated with mRS ≥2 at admission [odds ratio (OR) 1.39, 95% confidence interval (CI) 1.16-1.66] and older age (OR 1.06, 95% CI 1.01-1.11).

CONCLUSION

Idiopathic LETM was the most frequent diagnosis at the end of follow-up. Older age and clinically severe disease at onset were independent prognostic factors of poorer functional recovery.

Partial acute transverse myelitis is a predictor of multiple sclerosis in children

Background:

Acute transverse myelitis (ATM) in children is a rare and often severe disease for which there are few known prognostic factors, particularly the subsequent risk of multiple sclerosis (MS) diagnosis.

Objectives:

To determine the clinical course and prognostic factors after a first episode of ATM in children.

Methods:

Thirty children below 16 years of age diagnosed with a first neurological episode of ATM were included retrospectively. Clinical evaluation, treatment, laboratory, and MRI data were collected.

Results:

Median age at onset was 11 years (range 3–15 years). Follow-up data were available for a median of 4 years (range 0.5–16.7 years). Five patients subsequently had a diagnosis of MS (17%), which was associated with acute partial transverse myelitis (odds ratio 5; 95% confidence interval 2.3–11), with a 60% probability of having a relapse at five years ( p < 0.01). The 2011 Verhey criteria correctly identified MS in children with the highest specificity (96%) and sensitivity (80%).

Conclusion:

Acute partial transverse myelitis and brain MRI abnormalities at initial presentation are significantly predictive of a subsequent diagnosis of MS in children with ATM. These findings suggest that closer brain MRI monitoring after acute partial transverse myelitis might make the earlier introduction of disease-modifying therapies possible.

Diagnosis and differential diagnosis of multiple sclerosis

PURPOSE OF REVIEW

When a patient presents with symptoms or imaging suggestive of multiple sclerosis (MS), making the correct diagnosis may at times be straightforward but in many cases is quite challenging. Symptoms may be difficult for patients to characterize and for clinicians to interpret; findings on examination may be subtle; imaging is not always specific; and the differential diagnosis of possible demyelinating disease is quite broad. Making a correct diagnosis of MS early in the disease course is likely to become even more important over time as new disease-modifying therapies, particularly those with potential neuroprotective benefits, are introduced. This article reviews the current diagnostic criteria for MS and illustrates their application as well as reviews the differential diagnosis for patients presenting with symptoms or imaging suggestive of demyelinating disease.

RECENT FINDINGS

The diagnostic criteria for MS were revised by the International Panel on Diagnosis of Multiple Sclerosis in 2010.

SUMMARY

The diagnostic criteria for MS have been revised several times over the years, most recently giving rise to the McDonald 2010 criteria. The diagnosis of MS begins with a patient who presents with symptoms typical for the disease, termed the "clinically isolated syndrome," which most commonly affects the optic nerves, brainstem, or spinal cord. If the patient's symptoms and imaging are typical for MS, the clinician can then apply the appropriate diagnostic criteria. If atypical clinical or imaging findings are present, alternative etiologies must be pursued as appropriate.