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Pérez-Chacón P, Lara-Sánchez H, Montero-Moreno JA, Hernández-Herrero M. Neither hear or see, what's happening? Eur Ann Otorhinolaryngol Head Neck Dis 2024:S1879-7296(24)00017-6. [PMID: 38401996 DOI: 10.1016/j.anorl.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 02/26/2024]
Affiliation(s)
- P Pérez-Chacón
- Otorhinolaryngology and Head and Neck Surgery Department, Río Hortega University Hospital, Valladolid, Spain.
| | - H Lara-Sánchez
- Otorhinolaryngology and Head and Neck Surgery Department, Río Hortega University Hospital, Valladolid, Spain
| | - J A Montero-Moreno
- Ophthalmology Department, Río Hortega University Hospital, Valladolid, Spain
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Cviková M, Štefela J, Všianský V, Dufek M, Doležalová I, Vinklárek J, Herzig R, Zemanová M, Červeňák V, Brichta J, Bárková V, Kouřil D, Aulický P, Filip P, Weiss V. Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature. Front Neurol 2024; 15:1339438. [PMID: 38434197 PMCID: PMC10904644 DOI: 10.3389/fneur.2024.1339438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.
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Affiliation(s)
- Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jakub Štefela
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vít Všianský
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Michal Dufek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Irena Doležalová
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jan Vinklárek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czechia
| | - Markéta Zemanová
- Department of Ophthalmology and Optometry, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vladimír Červeňák
- Department of Medical Imaging, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jaroslav Brichta
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Veronika Bárková
- Department of Clinical Pharmacology, St. Anne's University Hospital, Brno, Czechia
| | - David Kouřil
- Department of Neurology, Blansko Hospital, Blansko, Czechia
| | - Petr Aulický
- Department of Anesthesiology, Hospital of the Brothers of Charity Brno, Brno, Czechia
| | - Pavel Filip
- Department of Neurology, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czechia
- Center for Magnetic Resonance Research (CMRR), University of Minnesota, Minneapolis, MN, United States
| | - Viktor Weiss
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
- Department of Neurology, Charles University Faculty of Medicine, Hradec Králové, Czechia
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Bose S, Papathanasiou A, Karkhanis S, Appleton JP, King D, Batra R, Mollan SP, Jacob S. Susac syndrome: neurological update (clinical features, long-term observational follow-up and management of sixteen patients). J Neurol 2023; 270:6193-6206. [PMID: 37608221 PMCID: PMC10632257 DOI: 10.1007/s00415-023-11891-z] [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: 02/09/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/24/2023]
Abstract
Susac syndrome is a likely autoimmune microangiopathy affecting the brain, retina and inner ear. Due to the rarity of this condition, diagnosis and treatment can be challenging. Diagnosis is based on the presence of the clinical triad of central nervous system dysfunction, branch retinal artery occlusions and sensorineural hearing loss. Typical MRI findings of callosal and peri-callosal lesions may assist in diagnosis. Clinical course can be monophasic, polycyclic or chronic continuous. It is important to look out for red flags to attain an accurate diagnosis and follow a therapeutic algorithm based on severity of the disease and response to treatment. Patients are treated with steroids and immunosuppressive agents with a variable response. Early aggressive treatment especially in severe cases, may help in preventing relapses and morbidity/disability. This study highlights important diagnostic features and proposes a treatment algorithm based on clinical experience from management of 16 patients from 2 neuroscience centres in the UK since 2007, who were followed up over a long period of 3-15 years.
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Affiliation(s)
- Smriti Bose
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | | | - Sameep Karkhanis
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Jason P Appleton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, Birmingham, UK
| | - Dominic King
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Ruchika Batra
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Masjuan M, Ivanovski T, Sarasibar Ezcurra H, Rigo Oliver E. Behavioral Impairment and Amnesia at the Onset of Susac Syndrome. Cureus 2023; 15:e38089. [PMID: 37252530 PMCID: PMC10209653 DOI: 10.7759/cureus.38089] [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] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Susac syndrome (SS) is an autoimmune microangiopathy that affects the brain, retina, and inner ear, causing a wide range of clinical manifestations. The triad of encephalopathy, visual disturbances, and hearing loss constitute the classic disease presentation. We describe an original clinical case of a young male with a definitive diagnosis of SS, who presented with disordered behavior and amnesia, initially manifested as a dissociative or anxiety disorder but with a fulminant evolution toward severe encephalopathy associated with retinal infarcts and sensorineural hearing loss. After the diagnosis of SS, aggressive immunosuppressive treatment was started with significant neurological improvement and favorable evolution during the follow-up period. SS is a rare but potentially devastating disease that can cause great disability if not properly diagnosed and treated. The onset of SS with behavioral or psychiatric manifestation can be misleading, causing a diagnostic delay.
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Affiliation(s)
- Marc Masjuan
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | - Trajche Ivanovski
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | | | - Elena Rigo Oliver
- Ophthalmology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
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Susac Syndrome: Description of a Single-Centre Case Series. J Clin Med 2022; 11:jcm11216549. [PMID: 36362776 PMCID: PMC9656090 DOI: 10.3390/jcm11216549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
This study describes the clinical characteristics, diagnostic results, treatment regimens, and clinical course of a cohort of patients with Susac syndrome (SS). It is a retrospective observational study of all patients with the diagnosis of SS evaluated at the Hospital Clinic (Barcelona, Spain) between March 2006 and November 2020. Nine patients were diagnosed with SS. The median time from the onset of the symptoms to diagnosis was five months (IQR 9.0), and the median follow-up time was 44 months (IQR 63.5). There was no clear predominance of sex, and mean age of symptoms onset was 36 years (range 19–59). Six patients (67%) presented with incomplete classical clinical triad, but this eventually developed in six patients during the disease course. Encephalopathy, focal neurological signs, visual disturbances, and hearing loss were the most frequent manifestations. Brain magnetic resonance imaging showed callosal lesions in all patients. Most were in remission within two years. Only four patients met the proposed criteria for definite SS. When SS is suspected, a detailed diagnostic workup should be performed and repeated over time to identify the clinical manifestations that will lead to a definite diagnosis.
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Susac's syndrome - A new ocular finding and disease outcome. Eye (Lond) 2022; 36:781-788. [PMID: 33879856 PMCID: PMC8956676 DOI: 10.1038/s41433-021-01464-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/20/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Susac's syndrome, a rare autoimmune vasculo-occlusive disease, may pose a diagnostic challenge and result in a devastating ocular and systemic outcome. Our study identifies a new retinal finding and evaluates disease outcome. We aimed to assess clinical and imaging findings, systemic manifestations and disease outcome in patients with ocular Susac's syndrome under immunosuppressive/immunomodulation therapies. METHODS Retrospective tertiary center study including patients with a diagnosis of Susac's syndrome with >12 months follow up. Medical record review including ocular, neurological and auditory clinical and imaging findings, and treatment modalities. Main outcome measures were clinical manifestations and disease outcome. RESULTS Seven patients (14 eyes) with a mean age of 34.1 years were included. Mean follow-up was 31.9 months (12.4-72.4). All had bilateral ocular disease. Retinal microaneurysms, a new ocular finding, were demonstrated in 5 patients and persisted at the final visit. In 5 eyes, they further extended during follow-up. All were treated with immunosuppressive drugs and 5/7 additional immunomodulation therapy. At last examination, best corrected visual acuity was >20/40 in all eyes, 1/10 eyes had visual field deterioration, no eye had active ocular disease, all patients achieved neurological stability, and 1 patient had auditory deterioration. CONCLUSION Retinal microaneurysms, a new ocular finding in Susac's syndrome, were present in most of our patients, indicating ischemic retinal damage. Immunosuppressive and immunomodulation therapies seem to be highly effective in the control of disease activity.
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Susac syndrome: A scoping review. Autoimmun Rev 2022; 21:103097. [DOI: 10.1016/j.autrev.2022.103097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/21/2022]
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OUP accepted manuscript. Brain 2022; 145:858-871. [DOI: 10.1093/brain/awab476] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
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Successful Treatment of Incomplete Susac Syndrome with Simultaneous Corticosteroids and Plasmapheresis Followed by Rituximab. Case Rep Neurol Med 2021; 2021:5591559. [PMID: 34567813 PMCID: PMC8457979 DOI: 10.1155/2021/5591559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022] Open
Abstract
We present a case report of a patient with incomplete Susac syndrome. He had cognitive impairment, corpus callosum lesions, and vestibulocochlear dysfunction on brainstem auditory evoked responses. He was treated with methylprednisolone and plasmapheresis, improved, and then, also received rituximab. His improvement has been lasting as of this writing. This case shares our experience with a successful treatment of this rare condition that is incompletely understood and lacks well-established treatment guidelines.
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RECURRENT BRANCH RETINAL ARTERY OCCLUSION FROM SUSAC SYNDROME: CASE REPORT AND REVIEW OF LITERATURE. Retin Cases Brief Rep 2021; 14:315-320. [PMID: 29870024 DOI: 10.1097/icb.0000000000000751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We report a patient with branch retinal artery occlusion predominant Susac syndrome and review the literature on current diagnostic modalities and therapeutic approaches for this rare condition. METHODS Case report. RESULTS A 23-year-old white male presented with a 5-month history of a scotoma in his right eye vision, headaches, and intermittent paresthesias of the lower extremities. Ophthalmic examination was normal with the exception of a hypopigmented small retinal area inferonasal to the fovea in the right eye. Optical coherence tomography demonstrated inner retinal atrophy and optical coherence tomography angiography showed deep capillary layer vessel dropout in both eyes. Ultra-wide-field fluorescein angiography revealed bilateral arteriolar wall hyperfluorescence. Corpus callosal lesions were present on magnetic resonance imaging. Lumbar puncture demonstrated elevated protein. Audiogram was normal. A diagnosis of Susac syndrome was made. The patient initially received oral steroids followed by intravenous steroids and mycophenolate mofetil because of new branch retinal artery occlusions. Thirteen months after initial presentation, the vision was stable at 20/20 in both eyes. CONCLUSION It is a diagnostic challenge when recurrent branch retinal artery occlusion secondary to Susac syndrome presents without the classic symptoms. Optical coherence tomography angiography and subtle magnetic resonance imaging findings aided in early recognition of the diagnosis in our patient. Ultra-wide-field fluorescein angiography was an important tool in disease monitoring. Aggressive management with intravenous corticosteroids and initiation of immunosuppression resulted in long-term preservation of vision and improvement in visual field.
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David C, Sacré K, Papo T. [Update on Susac syndrome]. Rev Med Interne 2021; 43:26-30. [PMID: 34119343 DOI: 10.1016/j.revmed.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
Susac syndrome is a rare disease affecting mainly young women, characterized by a microangiopathy limited to the cerebral, retinal, and cochlear vessels. Although the pathophysiology of Susac syndrome is not yet fully elucidated, recent advances favour a primitive vasculitis affecting the cerebral, retinal and cochlear small vessels. Susac syndrome must be recognized in the presence of the pathognomonic clinical triad associating: 1/subacute encephalopathy with unusual headache and pseudopsychiatric features associated with diffuse white matter, grey matter nuclei and specifically corpus callosum lesions on brain MRI; 2/eye involvement that may be pauci-symptomatic, with occlusions of the branches of the central artery of the retina at fundoscopy and arterial wall hyperfluorescence on fluorescein angiography; and 3/cochleo-vestibular damage with hearing loss predominating at low frequencies on the audiogram. Relapses are frequent during an active period lasting approximately 2 years. Eventually, the disease resolves but isolated retinal arterial wall hyperfluorescence without new occlusions may recur, which should not lead to treatment intensification. First-line treatment consists of a combination of anti-aggregants and high dose corticosteroids. In refractory patients or in case of relapse, immunomodulatory molecules such as intravenous immunoglobulins or immunosuppressive drugs such as mycophenolate mofetil, cyclophosphamide or rituximab should be started. Unfortunately, sequelae-mostly hearing loss- remain frequent in these young patients.
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Affiliation(s)
- C David
- Service de médecine interne, Hôpital Bichat, Paris, France
| | - K Sacré
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - T Papo
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France.
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Yalçınkaya BÇ, Ertürk Çetin Ö, Kılıç H, Demirci O, Çokyaman T, Uygunoğlu U. A rare presentation of Susac syndrome: Report of three pediatric cases. Mult Scler Relat Disord 2021; 53:103074. [PMID: 34139460 DOI: 10.1016/j.msard.2021.103074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 11/25/2022]
Abstract
Susac syndrome is a rare disorder that is clinically characterized by encephalopathy, retinopathy and hearing loss. Most of the reported cases in the literature are adult patients, pediatric presentation is extremely rare. Here we present three pediatric patients aged between 10-15; diagnosed as Susac syndrome. They all had thalamic involvement in addition to typical callosal lesions. All of the three patients had a monophasic course and good treatment response.
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Affiliation(s)
| | - Özdem Ertürk Çetin
- University of Health Sciences, Sancaktepe Sehit Prof.Dr.Ilhan Varank Training and Research Hospital, Department of Neurology, Istanbul, Turkey.
| | - Hüseyin Kılıç
- Istanbul University-Cerrahpasa; Department of Pediatrics, Division of Pediatric Neurology, Istanbul, Turkey.
| | - Onat Demirci
- Vehbi Koc Foundation, American Hospital, Department of Neurology, Sisli, Turkey.
| | - Turgay Çokyaman
- Canakkale Onsekiz Mart University, Faculty of Medicine, Deparment of Pediatrics, Division of Pediatric Neurology.
| | - Uğur Uygunoğlu
- Istanbul University-Cerrahpasa; Department of Neurology, Istanbul, Turkey.
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Willekens B, Kleffner I. Susac syndrome and pregnancy: a review of published cases and considerations for patient management. Ther Adv Neurol Disord 2021; 14:1756286420981352. [PMID: 33796140 PMCID: PMC7970706 DOI: 10.1177/1756286420981352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022] Open
Abstract
Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.
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Affiliation(s)
- Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Ilka Kleffner
- University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Pereira S, Vieira B, Maio T, Moreira J, Sampaio F. Susac's Syndrome: An Updated Review. Neuroophthalmology 2021; 44:355-360. [PMID: 33408428 DOI: 10.1080/01658107.2020.1748062] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Susac's syndrome is a rare immune-mediated endotheliopathy that mainly affects young women. It is characterised by the presence of encephalopathy, retinal vaso-occlusive disease and hearing loss. Diagnosis is based on the clinical presentation, brain magnetic resonance imaging, retinal fluorescein angiography, and audiometry. Treatment consists of immunosuppressive therapy. This review focuses on recent developments in the diagnosis and management of the condition.
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Affiliation(s)
- Sara Pereira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Bruna Vieira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Tiago Maio
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Jorge Moreira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipa Sampaio
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
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Susac Syndrome and Pregnancy. Case Rep Neurol Med 2020; 2020:6049126. [PMID: 33425410 PMCID: PMC7775175 DOI: 10.1155/2020/6049126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022] Open
Abstract
Susac syndrome (SuS) is a rare poorly characterised disorder that affects the brain, retina, and cochlea. Here, we present a case of a 31-year-old pregnant female with a new diagnosis of SuS that was successfully managed to 36 weeks of gestation with minimal disease burden to both the mother and newborn. She was treated initially using intravenous methylprednisolone followed by oral prednisone, and intravenous immunoglobulin (IVIg). We stress the importance of a multidisciplinary approach, involving both neurology and maternal-fetal medicine, and provide guidance in navigating the various options for immunosuppressive therapy during pregnancy.
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020; 30:393-399. [PMID: 33337398 DOI: 10.3233/ves-200007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse and the cervical vestibular-evoked myogenic potentials (cVEMPs). OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cVEMPs and the vHIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020:VES200720. [PMID: 33164965 DOI: 10.3233/ves-200720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse. OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cervical vestibular-evoked myogenic potentials (cVEMPs), and the v-HIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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18
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Abstract
PURPOSE OF REVIEW This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment. RECENT FINDINGS Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information. SUMMARY Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.
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Affiliation(s)
- Yael Redler
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Papasavvas I, Teuchner B, Herbort CP. Susac syndrome (Retino-cochleo-cerebral vasculitis), the ophthalmologist in the role of the whistleblower. J Ophthalmic Inflamm Infect 2020; 10:27. [PMID: 33125601 PMCID: PMC7599291 DOI: 10.1186/s12348-020-00217-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Susac syndrome is a rare microangiopathy of suspected autoimmune origin affecting arteries of the retina, the cochlea and the brain. The aim of the study was to give a review of the disease entity and determine the proportion of cases and their characteristics in a uveitis referral centre. PATIENTS AND METHODS Charts of patients with the diagnosis of Susac syndrome seen in the Uveitis Clinic of the Centre for Ophthalmic Specialised Care (COS), Lausanne, Switzerland were reviewed retrospectively to determine the frequency of such cases in a uveitis referral centre. Clinical symptoms and signs, functional data, imaging signs and evolution were analysed in the 3 COS cases and one case shared with the Uveitis Clinic of the Department of Ophthalmology, University of Innsbruck, Austria. Characteristic signs were searched possibly allowing a prompt diagnosis. RESULTS During the period from 1994 to 2019 (24 years, 2045 patients), 3 charts with the diagnosis of Susac syndrome were found (0.15%). The whole collective, including the additional case, comprised three women aged 28, 32 and 63 at presentation and one man, aged 42. None of the 3 cases that were referred were diagnosed beforehand. The characteristic item found in all 4 cases was the abrupt arterial stop or segmental interruption of arteries and increased staining of arterial wall on angiography more clearly shown on indocyanine green angiography that can potentially be proposed as a crucial diagnostic element. All 4 cases responded to dual steroidal and non-steroidal immunosuppression. Under treatment, all four patients did not show any further evolution. CONCLUSION Susac syndrome is a multilocation arteritis of the head that can involve the eye, ear and brain often first diagnosed by the ophthalmologist. The diagnosis is rapidly reached in uveitis referral centres but seems to be missed otherwise, A helpful angiographic sign to be searched is an abrupt or segmental arterial stop and increased staining of the arterial wall more clearly seen on indocyanine green angiography. Patients often present first to the ophthalmologist who should be acting as a whistleblower to avoid severe involvement of the brain.
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Affiliation(s)
- Ioannis Papasavvas
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland
| | - Barbara Teuchner
- Department of Ophthalmology, University of Innsbruck, Innsbruck, Austria
| | - Carl Peter Herbort
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland.
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20
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Wilf-Yarkoni A, Elkayam O, Aizenstein O, Oron Y, Furer V, Zur D, Goldstein M, Barequet D, Hallevi H, Karni A, Habot-Wilner Z, Regev K. Increased incidence of Susac syndrome: a case series study. BMC Neurol 2020; 20:332. [PMID: 32878610 PMCID: PMC7465403 DOI: 10.1186/s12883-020-01892-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines. METHODS This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study. RESULTS Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability. CONCLUSIONS We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.
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Affiliation(s)
- A Wilf-Yarkoni
- Neuro-Immunology Service and Department of Neurology Rabin Medical Center, 4941492, Petach Tikva, Israel.
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Aizenstein
- Neuroradiology unit, Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Y Oron
- Department of ENT, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Zur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - M Goldstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Barequet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Hallevi
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Karni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience Tel Aviv University, Tel Aviv, Israel
| | - Z Habot-Wilner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - K Regev
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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21
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Abstract
BACKGROUND Susac syndrome (SS) classically presents with the clinical triad of retinal artery occlusion, sensorineural hearing loss, and encephalopathy and the neuroimaging triad of white matter lesions, deep gray matter lesions, and leptomeningeal disease. However, patients can present with an incomplete clinical or neuroimaging triads making diagnosis difficult in certain situations. A standard treatment paradigm also is lacking in this illness. It is important for neuro-ophthalmologists to recognize clinical and radiographic findings that are pathognomonic for this syndrome and have a basic understanding of the available treatment options. EVIDENCE ACQUISITION Review of medical literature. RESULTS A definite diagnosis of SS is made when the clinical triad or the neuroimaging triad is present. There are numerous reports of 2 other imaging findings in this condition: arteriolar wall hyperfluorescence (AWH) on fluorescein angiography in retinal arterioles remote from retinal ischemia and central callosal lesions on MRI. Both of these imaging findings are diagnostic of SS. Gass plaques in retinal arterioles are almost always seen in the acute phase of the illness but are not pathognomonic for SS. The most common medications used in this syndrome are corticosteroids and intravenous immunoglobulin. A number of other medications have been used including mycopheolate, rituximab, azathioprine, and cyclophosphamide. CONCLUSIONS In the absence of the clinical triad or magnetic resonance imaging triad for SS, AWH remote from retinal vascular injury and central callosal lesions are confirmatory of the diagnosis because they have never been described in any other condition. The presence of Gass plaques in retinal arterioles should strongly suggest the diagnosis. Despite the lack of clinical trial data, patients with SS must be treated promptly and aggressively. In more fulminant cases, addition of mycophenolate mofetil or rituximab is required, followed by cyclophosphamide when disease is refractory to other medications.
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22
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The Successful Use of Infliximab in a Relapsing Case of Susac's Syndrome. Case Rep Neurol Med 2020; 2020:9317232. [PMID: 32566335 PMCID: PMC7303758 DOI: 10.1155/2020/9317232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/22/2020] [Accepted: 05/22/2020] [Indexed: 12/31/2022] Open
Abstract
Susac's syndrome is a rare and debilitating disease characterized by the triad of encephalopathy, branch retinal artery occlusions, and sensorineural hearing loss. All manifestations may not be clinically apparent at presentation resulting in delayed diagnosis. Early recognition of the syndrome may prevent disease sequelae such as permanent cognitive, visual, and hearing loss. We present such a case of Susac's syndrome that was also refractory to conventionally prescribed combination of immunosuppressive treatments including high-dose potent corticosteroids, intravenous cyclophosphamide, methotrexate, plasma exchange, rituximab, and mycophenolate. His disease was stabilized with infliximab in combination with a tapering course of low-dose prednisone. After 2 years of remission with TNF treatment, consideration is being given to ceasing therapy. He has the sequelae of bilateral sensorineural hearing loss but no visual impairment or cognitive deficits on follow-up with neuropsychometric testing. This is the first case report to our knowledge of the successful use of infliximab for a patient with Susac's syndrome that was necessary following treatment with cyclophosphamide and then rituximab.
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23
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Ramos-Ruperto L, Martínez-Sánchez N, Bartha-Rasero JL, Robles-Marhuenda Á. Susac syndrome and pregnancy: a relationship to clarify. About two cases and review of the literature. J Matern Fetal Neonatal Med 2020; 35:181-186. [PMID: 31937158 DOI: 10.1080/14767058.2020.1712712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Susac syndrome is a vasculopathy that affects the central nervous system, mainly the brain parenchyma, retina and inner ear. It affects mainly young women and. Management is based on expert consensus and in pregnant women the treatment is not well established. It is necessary to start treatment early because of its potential severity and sequelae.Method: We present two cases of Susac syndrome related to pregnancy/puerperium and performed a review of the literature.Conclusions: Susac syndrome is a disease that requires a high clinical suspicion, especially in pregnant women. Treatment in pregnancy or puerperium is not well established. Précis: Susac syndrome is a disease that requires a high clinical suspicion, especially in pregnant women. Treatment in pregnancy or puerperium is not well established.
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Affiliation(s)
- Luis Ramos-Ruperto
- Internal Medicine Department, Hospital Universitario La Paz, Madrid, Spain
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24
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Wang Y, Burkholder B, Newsome SD. Progressive sensorineural hearing loss many years preceding completion of Susac's syndrome triad: A case report. Mult Scler Relat Disord 2019; 37:101436. [PMID: 32173001 DOI: 10.1016/j.msard.2019.101436] [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: 07/16/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
Susac's syndrome (SuS) is a rare disorder with a clinical triad of encephalopathy, sensorineural hearing loss, and branch retinal artery occlusions. We report a 7-year-old girl who presented with chronic, progressive sensorineural hearing loss, who, years later, presented with encephalopathy and vision loss. Such prolonged period between symptoms is unusual and to our knowledge, this is the longest interval between onset of hearing loss and completion of the full triad in SuS. In addition, she had a protracted disease course, requiring multiple immune therapies for disease control.
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Affiliation(s)
- Yujie Wang
- Johns Hopkins University School of Medicine, Department of Neurology, USA
| | - Bryn Burkholder
- Johns Hopkins University School of Medicine, Department of Ophthalmology, USA
| | - Scott D Newsome
- Johns Hopkins University School of Medicine, Department of Neurology, USA.
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25
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Patel VA, Dunklebarger M, Zacharia TT, Isildak H. Otologic manifestations of Susac syndrome. ACTA ACUST UNITED AC 2019; 38:544-553. [PMID: 30623900 PMCID: PMC6325654 DOI: 10.14639/0392-100x-2166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/15/2018] [Indexed: 11/23/2022]
Abstract
Susac syndrome, a rare autoimmune disorder first described as a classic triad (encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss) in 1979 by renowned physician John O. Susac, has been an advancing area of clinical interest and scientific research over the last several decades. This comprehensive review aims to succinctly highlight the breadth and detail of this enigmatic disease, with a primary focus on otologic manifestations. Topics discussed include epidemiology, pathophysiology, clinical manifestations, differential diagnoses, classification schema, laboratory investigations, characteristic audiometric findings, high-yield radiographic imaging, temporal bone histopathology, treatment strategies and overall prognosis.
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Affiliation(s)
- V A Patel
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - M Dunklebarger
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - T T Zacharia
- Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - H Isildak
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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26
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Heng LZ, Bailey C, Lee R, Dick A, Ross A. A review and update on the ophthalmic implications of Susac syndrome. Surv Ophthalmol 2019; 64:477-485. [DOI: 10.1016/j.survophthal.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/26/2022]
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27
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Zengin Karahan S, Boz C, Saip S, Kale N, Demirkaya S, Celik Y, Demir S, Kurne A, Ozbek SE, Terzi M. Susac Syndrome: Clinical characteristics, diagnostic findings and treatment in 19 cases. Mult Scler Relat Disord 2019; 33:94-99. [PMID: 31176296 DOI: 10.1016/j.msard.2019.05.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/25/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
Abstract
Susac's Syndrome (SS), which was first described in 1979, is a rare and presumably autoimmune disorder characterized by encephalopathy, hearing loss, and visual disturbance resulting from branch retinal artery occlusion (BRAO). This study reports 19 SS patients' clinical characteristics, MRI features, CSF analysis, treatment strategies and outcomes. At initial presentation, only three of 19 patients demonstrated the complete clinical triad. Clinic presentation varied from isolated hemiparesis to the full triad (encephalopathy, hearing loss and visual disturbances). Corpus callosum (CC) involvement was noted in the MRI of 18 patients (97%) and BRAO was detected in 17 (95%) patients. All patients were treated with intravenous methylprednisolone after the initial assessment. This case series is presented to emphasize the differences in clinical presentation of SS and the importance of MRI and FFA in diagnosis.
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Affiliation(s)
- S Zengin Karahan
- Department of Neurology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey.
| | - C Boz
- Department of Neurology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - S Saip
- Department of Neurology, Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - N Kale
- Department of Neurology, Bagcılar Training and Research Hospital, İstanbul, Turkey
| | - S Demirkaya
- Department of Neurology, Ankara Gülhane Training Hospital, Ankara, Turkey
| | - Y Celik
- Department of Neurology, Private Adatip Hospital, Sakarya, Turkey
| | - S Demir
- Department of Neurology, Haydarpaşa Sultan Abdülhamid Training Hospital, İstanbul, Turkey
| | - A Kurne
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - S Erer Ozbek
- Department of Neurology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - M Terzi
- Department of Neurology, Faculty of Medicine, 19 Mayıs University, Samsun, Turkey
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28
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Rennebohm RM, Asdaghi N, Srivastava S, Gertner E. Guidelines for treatment of Susac syndrome - An update. Int J Stroke 2018; 15:484-494. [PMID: 29319463 DOI: 10.1177/1747493017751737] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Susac syndrome is an immune-mediated, pauci-inflammatory, ischemia-producing, occlusive microvascular endotheliopathy/basement membranopathy that affects the brain, retina, and inner ear. Treatment of Susac syndrome is particularly challenging. The organs involved can easily become irreversibly damaged, and the window of opportunity to protect them is often short. Optimal outcome requires rapid and complete disease suppression. Adding to the challenge is the absence of objective biomarkers of disease activity and the great variability in presentation, timing and extent of peak severity, duration of peak severity, and natural disease course. There have been no randomized controlled trials or prospective treatment studies. We offer treatment guidelines based on cumulative clinical experience and a large cohort of patients followed longitudinally in a comprehensive database project. These guidelines state our preferences but do allow flexibility and discuss other options. The guidelines also serve as an initial step in the planning of prospective treatment studies, future consensus-based recommendations, and future randomized controlled trials.
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Affiliation(s)
- Robert M Rennebohm
- The Susac Syndrome Consultation Service and Department of Pediatric Rheumatology, Cleveland Clinic, Cleveland, OH, USA
| | - Negar Asdaghi
- Department of Neurology, Miller 12235 School of Medicine, University of Miami , Miami, FL, USA
| | - Sunil Srivastava
- Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elie Gertner
- Section of Rheumatology, Regions Hospital and Division of Rheumatology, University of Minnesota Medical School, Minneapolis, MN, USA
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29
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Nzenza TC, Hoag N, Hennessey DB, Gani J. Urodynamic findings in Susac syndrome: first reported filling cystometrogram. BMJ Case Rep 2017; 2017:bcr-2017-220200. [PMID: 28705845 DOI: 10.1136/bcr-2017-220200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Susac syndrome is a rare neurological disease, with only 300 cases reported in the literature. Lower urinary symptoms are not an uncommon feature of the disease, yet there is no information on specific dysfunction typical urodynamic findings associated with the disease. We present what we believe to be the first reported filling cystometrogram study of Susac syndrome for the evaluation of voiding dysfunction.
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Affiliation(s)
- Tatenda Calvin Nzenza
- University of Melbourne, Department of Surgery (Urology), Austin Health, Heidleberg, Victoria, Australia.,Young Urology Researchers Organization, YURO, Australia
| | - Nathan Hoag
- University of Melbourne, Department of Surgery (Urology), Austin Health, Heidleberg, Victoria, Australia
| | - Derek Barrry Hennessey
- University of Melbourne, Department of Surgery (Urology), Austin Health, Heidleberg, Victoria, Australia
| | - Johan Gani
- University of Melbourne, Department of Surgery (Urology), Austin Health, Heidleberg, Victoria, Australia
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30
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Marrodan M, Correale J, Alessandro L, Amaya M, Fracaro M, Köhler A, Fiol M. Susac Syndrome: A differential diagnosis of white matter lesions. Mult Scler Relat Disord 2017. [DOI: 10.1016/j.msard.2017.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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31
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Short Follow-up Bias Confounds Estimates of the “Typical” Clinical Course of Susac Syndrome. J Neuroophthalmol 2017; 37:149-153. [DOI: 10.1097/wno.0000000000000472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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32
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Hung J, Leuillette F, Stekelorom T, Devos P, Moritz F. Syndrome de Susac typique. J Fr Ophtalmol 2017; 40:e15-e17. [DOI: 10.1016/j.jfo.2015.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 11/22/2015] [Accepted: 12/18/2015] [Indexed: 11/26/2022]
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33
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Potential benefits of early aggressive immunotherapy in Susac syndrome. Acta Neurol Belg 2016; 116:451-460. [PMID: 26786477 DOI: 10.1007/s13760-016-0599-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022]
Abstract
Susac syndrome is a rare vasculopathy of unknown aetiology, affecting prominently young women and electively targeting brain (encephalopathy), retina (visual field defects), and cochlea (hearing loss), of which optimal treatment has yet to be established. We report clinical, CSF and MRI features together with the long-term outcome in a monocentric series of eight consecutive patients with unusual sex ratio (5 male; 3 female), to define the best diagnostic/therapeutic strategy. Six patients presented with the classical clinical triad within less than 6 months after symptoms onset; two did not suffer from sensorineural hearing loss. All but one received a treatment combining high doses of methylprednisolone and cyclophosphamide intravenously. The first two patients had very delayed diagnosis (6-4 months) resulting in severe cognitive sequelae. The third one had only mildly delayed diagnosis (2 months) with subsequent behaviour impairment and severe right hypoacousia. All three were unable to return to work. The last five patients who had early diagnosis and undelayed aggressive treatment were able to resume their professional activities.
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Seifert-Held T, Langner-Wegscheider BJ, Komposch M, Simschitz P, Franta C, Teuchner B, Offenbacher H, Otto F, Sellner J, Rauschka H, Fazekas F. Susac's syndrome: clinical course and epidemiology in a Central European population. Int J Neurosci 2016; 127:776-780. [DOI: 10.1080/00207454.2016.1254631] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Martina Komposch
- Department of Neurology, Klinikum Klagenfurt, Klagenfurt, Austria
| | | | - Claudia Franta
- Department of Neurology, University Hospital St. Pölten, St. Pölten, Austria
| | - Barbara Teuchner
- Department of Ophthalmology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans Offenbacher
- Department of Neurology, Landeskrankenhaus Judenburg-Knittelfeld, Knittelfeld, Austria
| | - Ferdinand Otto
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
| | - Helmut Rauschka
- Department of Neurology, Sozialmedizinisches Zentrum Ost, Wien, Austria
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
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Vishnevskia-Dai V, Chapman J, Sheinfeld R, Sharon T, Huna-Baron R, Manor RS, Shoenfeld Y, Zloto O. Susac syndrome: clinical characteristics, clinical classification, and long-term prognosis. Medicine (Baltimore) 2016; 95:e5223. [PMID: 27787385 PMCID: PMC5089114 DOI: 10.1097/md.0000000000005223] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Susac syndrome is a rare condition characterized by the clinical triad of central nervous system (CNS) dysfunction, sensorineural hearing impairment, and branch retinal artery occlusion (BRAO). The purpose of this study is to examine the demographics, clinical characteristics, treatment, and long-term prognosis of Susac syndrome. The data recorded for all Susac syndrome patients treated at the Sheba Medical Center between 1998 and 2014 included demographics, clinical signs at presentation and during the disease course, imaging findings, treatment, and prognosis.Susac syndrome was diagnosed in 10 patients (age range 30-45 years). Only 2 patients presented with the full triad and 7 patients developed the full triad during mean follow-up period of 35 months. The average time to full triad was 7 months. Based on our observations at presentation, we divided the disease course into suspected, incomplete, and complete Susac syndrome. All 10 patients were treated at diagnosis with a pulse of high-dose intravenous methylprednisolone. There was improvement in visual acuity and visual field at the end of follow-up compared to baseline, but it was not statistically significant (P = 0.479 and P = 0.053, respectively). Five patients remained with neurological damage, and 5 patients had no improvement of their hearing loss at study closure. In conclusion, Susac syndrome is a rare condition that can mimic other disorders. The diagnosis is challenging because most patients do not initially present with the definitive triad. We suggest a clinical classification for the syndrome that may assist in early diagnosis.
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Affiliation(s)
- Vicktoria Vishnevskia-Dai
- Goldschleger Eye Institute
- Correspondence: Vicktoria Vishnevskia-Dai, Goldschleger Eye Institute; Department of Ophthalmology, Sheba Medical Center, Tel Hshomer, Tel Aviv University, Israel. 52621, Israel (e-mail: )
| | - Joav Chapman
- Department of Neurology, Sagol Neuroscience Center, Tel Hashomer
| | - Roee Sheinfeld
- Department of Neurology, Sagol Neuroscience Center, Tel Hashomer
| | | | | | - Riri S. Manor
- Department of Ophthalmology, Sheba Medical Center, Tel Hshomer
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, are affiliated to the Sackler faculty of medicine Tel Aviv University, Israel
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Visual impairment. HANDBOOK OF CLINICAL NEUROLOGY 2016. [PMID: 27430448 DOI: 10.1016/b978-0-444-53486-6.00045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
This chapter can guide the use of imaging in the evaluation of common visual syndromes: transient visual disturbance, including migraine and amaurosis fugax; acute optic neuropathy complicating multiple sclerosis, neuromyelitis optica spectrum disorder, Leber hereditary optic neuropathy, and Susac syndrome; papilledema and pseudotumor cerebri syndrome; cerebral disturbances of vision, including posterior cerebral arterial occlusion, posterior reversible encephalopathy, hemianopia after anterior temporal lobe resection, posterior cortical atrophy, and conversion blindness. Finally, practical efforts in visual rehabilitation by sensory substitution for blind patients can improve their lives and disclose new information about the brain.
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Gertner E, Rosenbloom MH. Susac syndrome with prominent dermatological findings and a prompt response to intravenous immunoglobulin, steroids, and rituximab: a case report. J Med Case Rep 2016; 10:137. [PMID: 27234436 PMCID: PMC4884366 DOI: 10.1186/s13256-016-0917-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/27/2016] [Indexed: 12/04/2022] Open
Abstract
Background Susac syndrome (retinocochleocerebral vasculopathy) is an autoimmune endotheliopathy affecting the precapillary arterioles of the brain, retina, and inner ear. It presents with encephalopathy, branch retinal artery occlusions, and hearing loss. The condition is often under recognized because the clinical symptoms may present at different times and physicians may be unfamiliar with the syndrome. Peripheral findings would be helpful in early diagnosis. There are numerous treatment regimens proposed with varying effectiveness. Case presentation We report the case of a 22-year-old Caucasian man in whom there were prominent skin findings, including livedo reticularis and a micropapular eruption which responded promptly to treatment suggesting that skin involvement may facilitate earlier diagnosis. Rituximab has occasionally been used in more refractory disease. We observed a prompt response to the combination of intravenous immunoglobulin, corticosteroids, and rituximab instituted immediately after diagnosis. Conclusions A careful search for dermatological manifestations may help with earlier diagnosis. Skin findings may be another marker of endothelial cell involvement. Early use of rituximab as part of the therapeutic regimen may be warranted.
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Affiliation(s)
- Elie Gertner
- Section of Rheumatology, Regions Hospital, 640 Jackson Street, St. Paul, MN, 55101, USA.
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Otologic disorders causing dizziness, including surgery for vestibular disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 137:279-93. [PMID: 27638078 DOI: 10.1016/b978-0-444-63437-5.00020-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This chapter will focus on vertigo/dizziness due to inner-ear malformations, labyrinthine fistula, otosclerosis, infectious processes, and autoimmune inner-ear disorders. Inner-ear malformation due to dehiscence of the superior semicircular canal is the most recently described inner-ear malformation. Vertigo/dizziness is typically induced by sound and pressure stimuli and can be associated with auditory symptoms (conductive or mixed hearing loss). Labyrinthine fistula, except after surgery for otosclerosis, in the context of trauma or chronic otitis media with cholesteatoma, still remains a challenging disorder due to multiple uncertainties regarding diagnostic and management strategies. Otosclerosis typically manifests with auditory symptoms and conductive or mixed hearing loss on audiometry. Vertigo/dizziness is rare in nonoperated otosclerosis and should draw clinical attention to an inner-ear malformation. Computed tomography scan confirms otosclerosis in most cases and should rule out an inner-ear malformation, avoiding needless middle-ear surgical exploration. Labyrinth involvement after an infectious process is unilateral when it complicates a middle-ear infection but can be bilateral after meningitis. Labyrinth involvement due to an inflammatory disease is a challenging issue, particularly when restricted to the inner ear. The diagnosis relies on the bilateral and rapid aggravation of audiovestibular symptoms that will not respond to conventional therapy but to immunosuppressive drugs.
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Susac's Syndrome: A Case with Unusual Cardiac Vestibular and Imaging Manifestations. Case Rep Neurol Med 2015; 2015:419408. [PMID: 26688762 PMCID: PMC4673320 DOI: 10.1155/2015/419408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/18/2015] [Indexed: 11/18/2022] Open
Abstract
Susac's syndrome (SS) is a disease of the microvasculature of the retina, brain, and inner ear. We describe a patient with unusual manifestations of SS with possible involvement of the brainstem, cardiac arrhythmia, and MRI findings lacking the characteristic lesions found in Susac's syndrome.
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Abstract
INTRODUCTION Toxic leukoencephalopathy is a possible but rare complication of chronic cocaine abuse. The role of adulterants, mainly levamisole, is still debated. CASE REPORT We describe an atypical case of fatal leukoencephalopathy mimicking Susac syndrome in a 22-year-old man who was chronically abusing cannabis and cocaine. Exposure to levamisole as adulterant to cocaine was proven by hair analysis. Despite cessation of exposure to cocaine and aggressive immunosuppressive therapy, the patient remained in a minimally conscious state until death. DISCUSSION Susac syndrome is a rare entity, and its etiology is not yet fully elucidated. The toxic etiologies have been poorly investigated to date. Further observations are required to determine if cocaine and/or adulterants might play a significant role.
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Vodopivec I, Venna N, Rizzo JF, Prasad S. Clinical features, diagnostic findings, and treatment of Susac syndrome: A case series. J Neurol Sci 2015; 357:50-7. [DOI: 10.1016/j.jns.2015.06.063] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/25/2015] [Accepted: 06/28/2015] [Indexed: 11/30/2022]
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Beaujeux P, Cloché V, Tréchot F, Conart JB, Angioi-Duprez K. Mise au point sur le syndrome de Susac. À propos d’un cas pédiatrique. J Fr Ophtalmol 2014; 37:804-11. [DOI: 10.1016/j.jfo.2014.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/11/2014] [Indexed: 10/24/2022]
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Pezzella FR, Santalucia P, Vadalà R, Giugni E, Zedde ML, Sessa M, Anticoli S, Caso V. Women Stroke Association Statement on Stroke. Int J Stroke 2014; 9:20-27. [PMID: 28051365 DOI: 10.1111/ijs.12110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebrocardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Association's mission and commitment, highlighting opportunities and critical from the women's health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the association's commitment to combating stroke.
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Affiliation(s)
| | - Paola Santalucia
- 2 Direzione Scientifica and U.O. Medicina d'Urgenza, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Rita Vadalà
- 3 NeuroRadiology, IRCCS Fondazione S Lucia, Rome, Italy
| | | | - Maria Luisa Zedde
- 5 Neurology Department, Arcispedale Santa Maria Nuova, Reggio nell'Emilia, Italy
| | - Maria Sessa
- 6 Stroke Unit - Department of Neurology and Neurophysiology, San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Anticoli
- 1 Stroke Unit - Department of Emergency Medicine, AO S Camillo Forlanini, Rome, Italy
| | - Valeria Caso
- 7 Stroke Unit, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
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Susac-like syndrome in a chronic cocaine abuser: could levamisole play a role? JOURNAL OF MEDICAL TOXICOLOGY : OFFICIAL JOURNAL OF THE AMERICAN COLLEGE OF MEDICAL TOXICOLOGY 2014. [PMID: 25142038 DOI: 10.1007/s13181-014-0422-3"] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
INTRODUCTION Toxic leukoencephalopathy is a possible but rare complication of chronic cocaine abuse. The role of adulterants, mainly levamisole, is still debated. CASE REPORT We describe an atypical case of fatal leukoencephalopathy mimicking Susac syndrome in a 22-year-old man who was chronically abusing cannabis and cocaine. Exposure to levamisole as adulterant to cocaine was proven by hair analysis. Despite cessation of exposure to cocaine and aggressive immunosuppressive therapy, the patient remained in a minimally conscious state until death. DISCUSSION Susac syndrome is a rare entity, and its etiology is not yet fully elucidated. The toxic etiologies have been poorly investigated to date. Further observations are required to determine if cocaine and/or adulterants might play a significant role.
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Feresiadou A, Eriksson U, Larsen HC, Raininko R, Nygren I, Melberg A. Recurrence of Susac Syndrome following 23 Years of Remission. Case Rep Neurol 2014; 6:171-5. [PMID: 24987361 PMCID: PMC4067733 DOI: 10.1159/000362868] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Susac syndrome is an autoimmune microangiopathy affecting the brain, retina and inner ear (cochlea and semicircular canals), leading to encephalopathy, branch retinal artery occlusions (BRAOs) and asymmetric neurosensory hearing loss, respectively. The natural history and long-term prognosis are variable as the disease has been shown to be monophasic and self-limiting, polycyclic or chronic continuous. We describe a 35-year-old woman who presented with a sudden hearing loss in the left ear in the 37th week of her second pregnancy. She subsequently developed BRAO in the right eye 2.5 months after having given birth. MRI findings included round lesions in the corpus callosum which are pathognomonic for Susac syndrome. Previous patient records documented encephalopathy, sudden deafness of the right ear and visual field defects in the left eye at the age of 12, followed by permanent hearing and visual defects. We expand on the variability in the course of Susac syndrome as recurrence may occur after as long as 23 years. Cases of monophasic self-limiting Susac syndrome may in fact turn polycyclic with an interval of more than 2 decades between the bouts of the disease. In these cases, suspecting the development of exacerbation early is important in order to start the treatment promptly.
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Affiliation(s)
- Amalia Feresiadou
- Neurology, Department of Neuroscience, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Urban Eriksson
- Ophthalmology Units, Department of Neuroscience, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Hans-Christian Larsen
- Otolaryngology Unit, Department of Surgical Sciences, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Raili Raininko
- Radiology Unit, Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Ingela Nygren
- Neurology, Department of Neuroscience, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Atle Melberg
- Neurology, Department of Neuroscience, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
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Catarsi E, Pelliccia V, Pizzanelli C, Pesaresi I, Cosottini M, Migliorini P, Tavoni A. Cyclophosphamide and methotrexate in Susac’s Syndrome: a successful sequential therapy in a case with involvement of the cerebellum. Clin Rheumatol 2014; 34:1149-52. [DOI: 10.1007/s10067-014-2638-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/14/2014] [Accepted: 04/17/2014] [Indexed: 11/28/2022]
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Susac's syndrome during pregnancy - the first Croatian case. J Neurol Sci 2014; 341:162-4. [PMID: 24768309 DOI: 10.1016/j.jns.2014.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 03/30/2014] [Accepted: 04/03/2014] [Indexed: 11/20/2022]
Abstract
Susac's syndrome (SS) is an infrequent neurological disorder characterized by the clinical triad of encephalopathy, branch retinal artery occlusion and hearing loss due to an autoimmune endotheliopathy associated with anti-endothelial cell antibodies. At the onset of the disease SS rarely appears with the complete clinical triad. The most important diagnostic procedures involved in the diagnosis of SS are brain MRI, audiometric testing and retinal fluorescein angiography. Presence of at least two components of the SS clinical triad accompanied by specific brain MRI findings is highly suggestive of SS. We report a case of a young pregnant woman with a history of encephalopathy, hearing loss and walking impairment. Brain MRI revealed a spectrum of findings previously described in patients with SS. We induced labor at 37 weeks' gestation to start with immunosuppressive treatment and avoid possible fetal toxicity. To the best of our knowledge this is the first report of SS in Croatia.
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Boukouvala S, Jacob S, Lane M, Denniston AK, Burdon MA. Detection of branch retinal artery occlusions in Susac's syndrome. BMC Res Notes 2014; 7:56. [PMID: 24447473 PMCID: PMC3903029 DOI: 10.1186/1756-0500-7-56] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 01/15/2014] [Indexed: 11/25/2022] Open
Abstract
Background We report an interesting case of asymptomatic retinal involvement in an encephalopathic patient enabling early identification of Susac’s syndrome. Case presentation A 39-year-old Caucasian lady with hearing loss and encephalopathy was referred for ophthalmic assessment, including screening for branch retinal artery occlusions characteristic of Susac’s syndrome. Clinical features included severe headaches, right-sided hypoacusis, dysphasia and poor memory. Routine blood tests were normal. MRI brain showed numerous hyperintense lesions mainly in corpus callosum. Although she was visually asymptomatic, dilated funduscopy detected bilateral multiple peripheral branch retinal artery occlusions which were confirmed on fluorescein angiography. She was subsequently started on intravenous steroids and pulsed cyclophosphamide which improved her symptoms within 48 hours. Full recovery was made with no new arterial occlusions on four months follow-up. Conclusion The case further establishes the crucial role of a detailed ophthalmic examination supported by fluorescein angiography in the assessment of these patients, who are at risk of being misdiagnosed and undertreated.
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Affiliation(s)
| | | | | | - Alastair K Denniston
- University Hospital Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK.
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