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Pervin I, Ramanathan S, Cappelen-Smith C, Vucic S, Reddel SW, Hardy TA. Clinical and radiological characteristics and outcomes of patients with recurrent or relapsing tumefactive demyelination. Mult Scler Relat Disord 2024; 82:105408. [PMID: 38219394 DOI: 10.1016/j.msard.2023.105408] [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: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Relapsing or recurrent tumefactive demyelination is rare and has not been studied beyond individual case reports. OBJECTIVE We examined the clinical course, neuroimaging, cerebrospinal fluid (CSF), treatment and outcomes of patients with recurrent tumefactive demyelinating lesions (TDLs). METHODS We used PubMed to identify reports of recurrent TDLs and included the details of an additional, unpublished patient. RESULTS We identified 18 cases (11F, 7 M). The median age at onset of the index TDL was 37 years (range 12-72) and most were solitary lesions 72 % (13/18). CSF-restricted oligoclonal bands (OCBs) were detected in 25 % (4/16). Only one of those tested (n = 13) was positive for AQP4-IgG. A moderate-to-marked treatment response (high dose corticosteroid with or without additional plasmapheresis, IVIg or disease modifying therapies) was evident in 89 % of treated patients. Median EDSS at the median follow-up of 36 months (range 6-144) was 2 (range 1-10). Most remained ambulatory (EDSS < 4 in 13/18), but 1 patient died. CONCLUSION The median age of patients with relapsing TDLs is similar to that of typical MS, but differences include a lower female:male sex ratio, larger lesions, and a comparative lack of CSF-restricted OCBs. Outcomes vary among this group of patients ranging from minimal disability through to death.
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Affiliation(s)
- Irin Pervin
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia
| | - Sudarshini Ramanathan
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Translational Neuroimmunology Group, Faculty of medicine and health, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia
| | | | - Steve Vucic
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia
| | - Stephen W Reddel
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia
| | - Todd A Hardy
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia.
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2
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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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3
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Vakrakou AG, Tzanetakos D, Evangelopoulos ME, Argyrakos T, Tzartos JS, Anagnostouli M, Andreadou E, Koutsis G, Velonakis G, Toulas P, Gialafos E, Dimitrakopoulos A, Psimenou E, Stefanis L, Kilidireas C. Clinico-radiologic features and therapeutic strategies in tumefactive demyelination: a retrospective analysis of 50 consecutive cases. Ther Adv Neurol Disord 2021; 14:17562864211006503. [PMID: 34046086 PMCID: PMC8135218 DOI: 10.1177/17562864211006503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022] Open
Abstract
Aims Our goal was to expand the spectrum of clinico-radiologic characteristics and the possible therapeutic choices in patients with tumefactive demyelinating lesions (TDLs). Methods A retrospective analysis of 50 patients with at least one TDL was performed at an academic neurology center (2008-2020). Results Our cohort comprised mostly women (33/50) with a mean age of 38 years at TDL onset. The mean follow-up time was 76 months. The mean Expanded Disability Status Scale score at TDL onset and at the latest neurological evaluation was 3.7 and 2.3, respectively. We subcategorized the patients into seven groups based mainly on the clinical/radiological findings and disease course. Group A included patients presenting with a Marburg-like TDL (n = 4). Groups B and C comprised patients presenting with monophasic (n = 7) and recurrent TDLs (n = 12), respectively. Multiple sclerosis (MS) patients who subsequently developed TDL (n = 16) during the disease course were categorized as Group D. Group E comprised patients who initially presented with TDL and subsequently developed a classical relapsing-remitting MS without further evidence of TDL (n = 5). Groups F (n = 2) and G (n = 4) involved MS patients who developed TDL during drug initiation (natalizumab, fingolimod) and cessation (interferon, fingolimod), respectively. Regarding long-term treatments applied after corticosteroid administration in the acute phase, B-cell-directed therapies were shown to be highly effective especially in cases with recurrent TDLs. Cyclophosphamide was spared for more aggressive disease indicated by a poor response to corticosteroids and plasma exchange failure. Conclusion Tumefactive central nervous system demyelination is an heterogenous disease; its stratification into distinct groups according to different phenotypes can establish more efficient treatment strategies, thus improving clinical outcomes in the future.
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Affiliation(s)
- Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens, National & Kapodistrian University, Aeginition Hospital, 72 Vasilissis Sofias Ave, Athens, 11528, Greece
| | - Dimitrios Tzanetakos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleptheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - John S Tzartos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Anagnostouli
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elissavet Andreadou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Koutsis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Velonakis
- Research Unit of Radiology, 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Toulas
- Research Unit of Radiology, 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Gialafos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Dimitrakopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Erasmia Psimenou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Fereidan-Esfahani M, Tobin WO. Cyclophosphamide in treatment of tumefactive multiple sclerosis. Mult Scler Relat Disord 2020; 47:102627. [PMID: 33246262 DOI: 10.1016/j.msard.2020.102627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE . To review the Mayo clinic experience of cyclophosphamide in the treatment of tumefactive Multiple Sclerosis (TMS). METHODS . Retrospective chart review was performed to identify patients with TMS who did not respond to corticosteroid and plasma exchange and were treated with cyclophosphamide. Demographic, clinical, treatment, and outcome parameters were collected. RESULTS . We identified 12 patients with TMS who were treated with cyclophosphamide. Median follow-up was 17 (range 1-72) months after cyclophosphamide administration. The tumefactive attack was the first clinical symptom in 5/12 patients. The median age at index attack onset was 36 (range 22-57). The median age at the first demyelinating attack was 29.3 (range 20-55). The most common clinical presentation at the index attack was the visual disturbance, followed by motor symptoms. The index attack was accompanied by headache in 5/12 patients. Median attack related Expanded Disability Status Scale (EDSS) score was 6 (range 3-9.5), which improved to 5.25 (range 1-10) after treatment with cyclophosphamide. All patients were treated with corticosteroids and plasma exchange prior to treatment with cyclophosphamide. EDSS score improved in 8/12 patients and targeted neurological deficits improved to a moderate or marked degree in 9/12 patients after cyclophosphamide administration. The number of gadolinium enhancing lesions decreased in 10/12 and 8/12 patients had lack of disease activity (no new T2 or GAD lesions) in a median (range) time of 11 months (1-16) after the last dose of cyclophosphamide. CONCLUSION . Cyclophosphamide could be an effective option for the treatment of TMS, refractory to corticosteroids and plasmapheresis, and is associated with improvement of clinical and radiological disease activity.
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Affiliation(s)
- Mahboobeh Fereidan-Esfahani
- Department of Neurology, Mayo Clinic Rochester, MN, USA; Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, MN, USA
| | - W Oliver Tobin
- Department of Neurology, Mayo Clinic Rochester, MN, USA; Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, MN, 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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6
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Verma R, Kumar C. Tumefactive Demyelination Associated with Bilateral Optic Neuritis in Neuromyelitis Optica Spectrum Disorders. J Neurosci Rural Pract 2019; 10:693-696. [PMID: 31844376 PMCID: PMC6908454 DOI: 10.1055/s-0039-3399614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tumefactive demyelination is an uncommon neurological disorder mimicking tumors. It is one of the rare varieties of demyelinating disorders, often causing diagnostic dilemma among neuroscientists. The literature tells us about approaching these patients added by peculiar neuroimaging findings. Neuromyelitis optica is an immune mediated inflammatory clinical disorder, typically involving optic nerves bilaterally and longitudinally extensive transverse myelitis. With the revelation of aquaporin four channels, its distribution in the brain and related antibody, the concept of neuromyelitis optica spectra disorders has been evolved. In this case report, our intention is to present a young female who presented with bilateral vision loss with tumor-like mass lesion in cerebral cortex. Such an association of bilateral optic neuropathy involving chiasmatic region, suggestive of neuromyelitis optica spectrum disorder (NMOSD) with tumefactive demyelination is rarely reported in the literature.
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Affiliation(s)
- Rajesh Verma
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Chetan Kumar
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
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7
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Brod SA, Lindsey JW, Nelson F. Tumefactive demyelination: Clinical outcomes, lesion evolution and treatments. Mult Scler J Exp Transl Clin 2019; 5:2055217319855755. [PMID: 31245023 PMCID: PMC6582300 DOI: 10.1177/2055217319855755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/04/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Large demyelinating lesions with possible mass effect (tumefactive multiple sclerosis or tumefactive demyelination) can be mistaken for tumour-like space-occupying lesions suggesting a malignant outcome. Methods We reviewed our own experience of multiple sclerosis subjects (n = 28) with tumefactive demyelination to determine the relationship between clinical outcomes and lesion evolution, clinical outcomes and their relationship to different therapies. Patients with central nervous system demyelinating disease were identified from our database over the last 10 years. Results No patient increased in extended disability status scale (EDSS). Overall, lesion regression was associated with improved EDSS. Lesion regression was also associated with therapy versus no therapy. No specific therapy or corticosteroid infusions improved EDSS over the long term. The absence of enhancement on follow up on magnetic resonance imaging portended lesion regression. Conclusion Tumefactive demyelination may predict a more benign overall course and is susceptible to traditional immunomodulatory treatments.
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8
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Sharma A, Foutz TJ, Gonzalez-Cuyar LF, Latimer CS, Longstreth WT, Tirschwell DL, Davis AP. From Herniation to Rehabilitation: A Young Woman With Rapidly Progressive Neurological Deficits. Neurohospitalist 2019; 9:215-221. [PMID: 31534611 DOI: 10.1177/1941874419832437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Akanksha Sharma
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA.,Authors share the first authorship for the article
| | - Thomas J Foutz
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.,Authors share the first authorship for the article
| | | | - Caitlin S Latimer
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA.,Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.,Department of Neuropathology, Harborview Medical Center, Seattle, WA, USA.,Department of Neurology, Harborview Medical Center, Seattle, WA, USA.,Authors share the first authorship for the article
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, Seattle, WA, USA
| | | | - Arielle P Davis
- Department of Neurology, Harborview Medical Center, Seattle, WA, USA
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9
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Wadhwa A, Chatterjee A, Chaudhry N, Laskar S, Chandan S. A Case of Relapsing-Remitting Tumefactive Demyelination. Ann Indian Acad Neurol 2019; 22:124-126. [PMID: 30692778 PMCID: PMC6327689 DOI: 10.4103/aian.aian_375_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ankur Wadhwa
- Department of Neurology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Atri Chatterjee
- Department of Neurology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Neera Chaudhry
- Department of Neurology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sanghamitra Laskar
- Department of Neurology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shishir Chandan
- Department of Neurology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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10
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Al-Afif S, Hatipoglu Majernik G, Al Krinawe Y, Esmaeilzadeh M, Hartmann C, Krauss JK. The Role of Neurosurgery in the Treatment of Intracranial Tumor-Like Inflammatory Lesions. World Neurosurg 2018; 124:S1878-8750(18)32803-1. [PMID: 30554001 DOI: 10.1016/j.wneu.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/30/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Different inflammatory diseases can manifest as intracranial lesions. They may be indistinguishable from intracranial neoplasms in the clinical setting, imaging studies, or laboratory studies. The value of surgery in the diagnosis and the treatment of such lesions is still unclear. METHODS A total of 3066 reports of histopathologic examinations over a 10-year period were reviewed. Forty patients with an inflammatory intracranial lesion were identified. Clinical, radiologic, and follow-up data were analyzed and the diagnostic and therapeutic value of surgery was assessed. RESULTS We identified 24 women and 16 men (mean age, 47 years). The diameter of the lesion varied between 1 and 5.5 cm (mean, 2.6 cm). The location of the inflammatory lesion was intracerebral supratentorial (n = 18, 45%), intrasellar/suprasellar (n = 5, 12.5%), cerebellar (n = 5, 12.5%), in the brainstem (n = 4, 10%), in the cerebellopontine angle (n = 3, 7.5%), meningeal (n = 3, 7.5%), and at other locations (n = 6, 15%). Seventeen patients underwent surgical removal of the mass lesion, whereas in 23 patients a biopsy was taken. The lesions were classified into 7 groups: specific (infectious) granuloma (n = 10, 25%), unspecific granuloma (n = 7, 17.5%), idiopathic inflammatory pseudotumor (n = 5, 12.5%), demyelinating lesions (n = 5, 12.5%) encapsulated hematoma (n = 4, 10%), organized cerebral infarction (n = 3, 7.5%), and vasculitis (n = 4, 10%). Surgery was judged as valuable in 35 patients (87.5%). CONCLUSIONS The differential diagnosis of intracranial inflammatory lesions involves a wide spectrum. Surgery has a diagnostic and/or therapeutic value in most entities and clinical circumstances. However, attention must be taken to avoid surgery without a therapeutic or diagnostic value for the patient.
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Affiliation(s)
- Shadi Al-Afif
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany.
| | | | - Yazeed Al Krinawe
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Majid Esmaeilzadeh
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Christian Hartmann
- Department of Neuropathology, Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany
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Sandi D, Bereg E, Biernacki T, Vörös E, Klivényi P, Bereczki C, Vécsei L, Bencsik K. Pediatric multiple sclerosis and fulminant disease course: Features and approaches to treatment - A case report and review of the literature. J Clin Neurosci 2018; 53:13-19. [PMID: 29731272 DOI: 10.1016/j.jocn.2018.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
Abstract
Multiple sclerosis (MS) is the autoimmune, neurodegenerative disease of the central nervous system (CNS). Typically, it affects the young adult population, however, up to 10% of the cases, it can develop in childhood. Atypical manifestations, such as the tumefactive variant (tMS) or acute disseminated encephalomyelitis (ADEM), especially coupled with fulminant disease course, are even more rare and pose a considerable differential diagnostic and therapeutic challenge. Recently, the therapeutic strategy on the use of disease modifying therapies (DMTs) in MS has shifted to the direction of a more individualized approach, that takes the personal differences heavily into account, in particular regard to the activity and prognosis of the disease. Despite this change has only been applied to adults yet, it is plausible to predict, that it will soon be applied to pediatric patients as well, particularly, as several randomized studies are under way concerning DMTs in pediatric populations. To our best knowledge, we are the first to report a successful natalizumab treatment of pediatric fulminant tMS, in case of a 13.5 years old girl. We feel that this report demonstrates the need of early and adequate treatment in such an aggressive case, because it can reverse the course of a possibly fatal disease.
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Affiliation(s)
- Dániel Sandi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Edit Bereg
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Tamás Biernacki
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Erika Vörös
- Department of Radiology, University of Szeged, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Csaba Bereczki
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, University of Szeged, Szeged, Hungary; MTA-SZTE Neuroscience Research Group, University of Szeged, Szeged, Hungary
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12
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Sánchez P, Meca-Lallana V, Barbosa A, Manzanares R, Palmí I, Vivancos J. Tumefactive demyelinating lesions of 15 patients: Clinico-radiological features, management and review of the literature. J Neurol Sci 2017; 381:32-38. [PMID: 28991707 DOI: 10.1016/j.jns.2017.08.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/28/2017] [Accepted: 08/07/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Tumefactive demyelinating lesions (TDLs) are large inflammatory lesions that can mimic tumors or other space-occupying lesions. Differential diagnosis and management of these lesions remain challenging for neurologists. We aim to review the clinico-radiological features of patients with TDLs, as well as their management. METHODS We performed a retrospective review of cases of TDLs treated in our center from January 2010 to February 2017. We reviewed the literature. RESULTS Out of 711 patients, we found 15 with TDLs (12 women and 3 men), with a mean age of TDL onset of 36years. Out of the 15 patients, 9 had TDLs as a first demyelinating event and 44% (4/15) of these converted to MS by McDonald 2010 criteria in a mean time of 8months (SD 3.10). Clinical presentation was polysymptomatic and the most common radiological findings included solitary lesions (66.66%), located primarily in the frontal (40%) or parietal (33%) lobes, showing mostly an infiltrative morphological pattern (50%) and an open-ring enhancement (43%). Multiple Sclerosis was the most common diagnosis (67%, 10/15). Acute treatment included steroids, plasmapheresis, rituximab and cyclophosphamide. CONCLUSIONS Prevalence of tumefactive demyelination in MS was higher than expected in MS patients, according to literature. Time to conversion to MS was significantly shorter than other published series. Clinical presentation was polysymptomatic and the most common radiological findings were isolated frontal lesions with an open-ring enhancement.
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Affiliation(s)
- Pedro Sánchez
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
| | - Virginia Meca-Lallana
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Antonio Barbosa
- Neuroradiology Section, Radiodiagnostic Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Rafael Manzanares
- Neuroradiology Section, Radiodiagnostic Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Itziar Palmí
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - José Vivancos
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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13
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Tremblay MA, Villanueva-Meyer JE, Cha S, Tihan T, Gelfand JM. Clinical and imaging correlation in patients with pathologically confirmed tumefactive demyelinating lesions. J Neurol Sci 2017; 381:83-87. [PMID: 28991721 DOI: 10.1016/j.jns.2017.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 07/21/2017] [Accepted: 08/08/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To characterize clinical and imaging features in patients with pathologically confirmed demyelinating lesions. METHODS In this retrospective chart review, we analyzed clinical-radiological-pathological correlations in patients >15years old who underwent brain biopsy at our institution between 2000 and 2015 and had inflammatory demyelination on neuropathology. RESULTS Of 31 patients, the mean age was 42years (range 16 to 69years) and 55% were female. All but one of the biopsied lesions were considered tumefactive demyelinating lesions (TDLs) by imaging criteria, measuring >2cm on contrast-enhanced brain MRI. On clinical follow-up, the final diagnosis was a CNS malignancy in 2 patients (6.5%). In patients without malignant tumor, the TDL was solitary in 12 (41%) and multifocal in 17 (59%), with contrast enhancement in all but one case, primarily in an incomplete rim enhancement pattern (75.9%). Of 16 patients with at least 12months of clinical follow-up, 7 (43.8%) had a clinical relapse. Of patients without a prior neurologic history, relapse occurred in 2/7 (29%) in solitary TDL and 2/6 (33%) in multifocal lesions at initial presentation. Recurrent TDLs occurred in 3 patients, all with initially solitary TDLs. Stratifying by CSF analysis, 4 of 6 patients (67%) with either an elevated IgG Index or >2 oligoclonal bands suffered a clinical relapse compared to 2/8 (25%) with non-inflammatory CSF. CONCLUSIONS Pathologically confirmed TDLs call for careful clinical correlation, clinical follow-up and imaging surveillance. Although sometimes clinically monophasic, tumefactive demyelinating lesions carried nearly a 45% risk of near-term clinical relapse in our study, even when presenting initially as a solitary mass lesion.
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Affiliation(s)
- Matthew A Tremblay
- MS Center, Department of Neurology, University of California, San Francisco, Box 3014, 1500 Owens St, Ste 320, San Francisco, CA 94158, United States.
| | - Javier E Villanueva-Meyer
- Neuroradiology Division, Department of Radiology, University of California, San Francisco, 350 Parnassus Ave, Box 0336, Ste 307H, San Francisco, CA 94143-0628, United States.
| | - Soonmee Cha
- Neuroradiology Division, Department of Radiology, University of California, San Francisco, 350 Parnassus Ave, Box 0336, Ste 307H, San Francisco, CA 94143-0628, United States.
| | - Tarik Tihan
- Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, Box 0102, San Francisco, CA 94143-0102, United States.
| | - Jeffrey M Gelfand
- MS Center, Department of Neurology, University of California, San Francisco, Box 3014, 1500 Owens St, Ste 320, San Francisco, CA 94158, United States.
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Dong A, Gao M, Wang Y, Gao L, Zuo C. FDG PET/CT in Acute Tumefactive Multiple Sclerosis Occurring in a Case of Chronic Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation. Clin Nucl Med 2016; 41:e414-6. [DOI: 10.1097/rlu.0000000000001193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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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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16
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Idris AA, Begum T, Verlage KR, Ahmed M. Tumefactive multiple sclerosis presenting with tonic-clonic seizure. BMJ Case Rep 2016; 2016:bcr-2016-215266. [PMID: 27118751 DOI: 10.1136/bcr-2016-215266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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17
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Tumefactive Demyelinating Lesions in Multiple Sclerosis and Associated Disorders. Curr Neurol Neurosci Rep 2016; 16:26. [DOI: 10.1007/s11910-016-0626-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Jeong IH, Kim SH, Hyun JW, Joung A, Cho HJ, Kim HJ. Tumefactive demyelinating lesions as a first clinical event: Clinical, imaging, and follow-up observations. J Neurol Sci 2015; 358:118-24. [DOI: 10.1016/j.jns.2015.08.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/07/2015] [Accepted: 08/20/2015] [Indexed: 11/26/2022]
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Abstract
Tumefactive demyelination refers to large focal demyelinating lesions in the brain, which can be mistaken for malignancy. In some patients, these lesions are monophasic with a self-limited course; however, other patients demonstrate recurrent disease with new tumefactive or non-tumefactive lesions, and a subsequent diagnosis of relapsing-remitting multiple sclerosis is not uncommon. Owing to the limited data available in the literature, many questions about the patterns and prognostic significance of recurrent tumefactive lesions remain unanswered. The current case report involves a patient who recovered from tumefactive demyelination and presented two years later with a new recurrent tumefactive lesion in the contralateral brain.
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Affiliation(s)
| | - Mihail Guranda
- Department of Internal Medicine, Section of Neurology, University of Manitoba, Winnipeg, Canada
| | - Marco Essig
- Department of Radiology, University of Manitoba, Winnipeg, Canada
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20
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Siri A, Carra-Dalliere C, Ayrignac X, Pelletier J, Audoin B, Pittion-Vouyovitch S, Debouverie M, Lionnet C, Viala F, Sablot D, Brassat D, Ouallet JC, Ruet A, Brochet B, Taillandier L, Bauchet L, Derache N, Defer G, Cabre P, de Seze J, Lebrun Frenay C, Cohen M, Labauge P. Isolated tumefactive demyelinating lesions: diagnosis and long-term evolution of 16 patients in a multicentric study. J Neurol 2015; 262:1637-45. [DOI: 10.1007/s00415-015-7758-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/17/2015] [Accepted: 04/20/2015] [Indexed: 12/31/2022]
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21
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Yao J, Huang D, Gui Q, Chen X, Lou X, Wu L, Cheng C, Li J, Wu W. Clinical and radiological characteristics of 17 Chinese patients with pathology confirmed tumefactive demyelinating diseases: Follow-up study. J Neurol Sci 2015; 348:153-9. [DOI: 10.1016/j.jns.2014.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 11/11/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
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22
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23
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Erick M. Hyperemesis gravidarum: A case of starvation and altered sensorium gestosis (ASG). Med Hypotheses 2014; 82:572-80. [DOI: 10.1016/j.mehy.2014.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 11/01/2013] [Accepted: 02/13/2014] [Indexed: 12/24/2022]
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24
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Wallner-Blazek M, Rovira A, Fillipp M, Rocca MA, Miller DH, Schmierer K, Frederiksen J, Gass A, Gama H, Tilbery CP, Rocha AJ, Flores J, Barkhof F, Seewann A, Palace J, Yousry T, Montalban X, Enzinger C, Fazekas F. Atypical idiopathic inflammatory demyelinating lesions: prognostic implications and relation to multiple sclerosis. J Neurol 2013; 260:2016-22. [PMID: 23620065 DOI: 10.1007/s00415-013-6918-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 04/03/2013] [Accepted: 04/05/2013] [Indexed: 12/26/2022]
Abstract
Atypical lesions of a presumably idiopathic inflammatory demyelinating origin present quite variably and may pose diagnostic problems. The subsequent clinical course is also uncertain. We, therefore, wanted to clarify if atypical idiopathic inflammatory demyelinating lesions (AIIDLs) can be classified according to previously suggested radiologic characteristics and how this classification relates to prognosis. Searching the databases of eight tertiary referral centres we identified 90 adult patients (61 women, 29 men; mean age 34 years) with ≥ 1 AIIDL. We collected their demographic, clinical and magnetic resonance imaging data and obtained follow-up (FU) information on 77 of these patients over a mean duration of 4 years. The AIIDLs presented as a single lesion in 72 (80 %) patients and exhibited an infiltrative (n = 35), megacystic (n = 16), Baló (n = 10) or ring-like (n = 16) lesion appearance in 77 (86 %) patients. Additional multiple sclerosis (MS)-typical lesions existed in 48 (53 %) patients. During FU, a further clinical attack occurred rarely (23-35 % of patients) except for patients with ring-like AIIDLs (62 %). Further attacks were also significantly more often in patients with coexisting MS-typical lesions (41 vs. 10 %, p < 0.005). New AIIDLs developed in six (7 %), and new MS-typical lesions in 29 (42 %) patients. Our findings confirm the previously reported subtypes of AIIDLs. Most types confer a relatively low risk of further clinical attacks, except for ring-like lesions and the combination with MS-typical lesions.
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Affiliation(s)
- Mirja Wallner-Blazek
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
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25
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Solomon IH, Perrin RJ, Clifford DB, Ances BM. Tumefactive demyelination in a patient with human immunodeficiency virus. J Neurovirol 2013; 19:265-9. [PMID: 23645348 DOI: 10.1007/s13365-013-0165-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 03/31/2013] [Accepted: 04/10/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Isaac H Solomon
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
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