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Pardo CA. Clinical Approach to Myelopathy Diagnosis. Continuum (Minneap Minn) 2024; 30:14-52. [PMID: 38330471 DOI: 10.1212/con.0000000000001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article describes an integrative strategy to evaluate patients with suspected myelopathy, provides advice on diagnostic approach, and outlines the framework for the etiologic diagnosis of myelopathies. LATEST DEVELOPMENTS Advances in diagnostic neuroimaging techniques of the spinal cord and improved understanding of the immune pathogenic mechanisms associated with spinal cord disorders have expanded the knowledge of inflammatory and noninflammatory myelopathies. The discovery of biomarkers of disease, such as anti-aquaporin 4 and anti-myelin oligodendrocyte glycoprotein antibodies involved in myelitis and other immune-related mechanisms, the emergence and identification of infectious disorders that target the spinal cord, and better recognition of myelopathies associated with vascular pathologies have expanded our knowledge about the broad clinical spectrum of myelopathies. ESSENTIAL POINTS Myelopathies include a group of inflammatory and noninflammatory disorders of the spinal cord that exhibit a wide variety of motor, sensory, gait, and sensory disturbances and produce major neurologic disability. Both inflammatory and noninflammatory myelopathies comprise a broad spectrum of pathophysiologic mechanisms and etiologic factors that lead to specific clinical features and presentations. Knowledge of the clinical variety of myelopathies and understanding of strategies for the precise diagnosis, identification of etiologic factors, and implementation of therapies can help improve outcomes.
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Safadi AL, Osborne B, Chitnis T, Graves JS, Newsome SD, Zamvil SS, Solomon IH, Shin RK. A 28-Year-Old Woman With Left-Sided Weakness and Atypical MRI Lesions: From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200157. [PMID: 37673687 PMCID: PMC10482384 DOI: 10.1212/nxi.0000000000200157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/10/2023] [Indexed: 09/08/2023]
Abstract
A 28-year-old woman presented with subacute relapsing left-sided weakness. MRI demonstrated both enhancing C3-C6 and nonenhancing T2-T4 lesions. Initial provisional diagnosis was inflammatory/autoimmune. Her left-sided weakness progressed despite immunosuppressive therapies. We reassessed our original suspected diagnosis because of an atypical clinicoradiologic course, leading to biopsy and a definitive diagnosis.
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Affiliation(s)
- Amy L Safadi
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA.
| | - Benjamin Osborne
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
| | - Tanuja Chitnis
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
| | - Jennifer S Graves
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
| | - Scott D Newsome
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
| | - Scott S Zamvil
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
| | - Isaac H Solomon
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
| | - Robert K Shin
- From the Georgetown Multiple Sclerosis and Neuroimmunology Center (A.L.S., B.O., R.K.S.), Department of Neurology, MedStar Georgetown University Hospital, Washington, DC; Brigham Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurosciences (J.S.G.), University of California San Diego School of Medicine, La Jolla; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco; and Department of Pathology (I.H.S.), Brigham and Women's Hospital, Boston, MA
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Solomon AJ, Arrambide G, Brownlee WJ, Flanagan EP, Amato MP, Amezcua L, Banwell BL, Barkhof F, Corboy JR, Correale J, Fujihara K, Graves J, Harnegie MP, Hemmer B, Lechner-Scott J, Marrie RA, Newsome SD, Rocca MA, Royal W, Waubant EL, Yamout B, Cohen JA. Differential diagnosis of suspected multiple sclerosis: an updated consensus approach. Lancet Neurol 2023; 22:750-768. [PMID: 37479377 DOI: 10.1016/s1474-4422(23)00148-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/14/2023] [Accepted: 03/31/2023] [Indexed: 07/23/2023]
Abstract
Accurate diagnosis of multiple sclerosis requires careful attention to its differential diagnosis-many disorders can mimic the clinical manifestations and paraclinical findings of this disease. A collaborative effort, organised by The International Advisory Committee on Clinical Trials in Multiple Sclerosis in 2008, provided diagnostic approaches to multiple sclerosis and identified clinical and paraclinical findings (so-called red flags) suggestive of alternative diagnoses. Since then, knowledge of disorders in the differential diagnosis of multiple sclerosis has expanded substantially. For example, CNS inflammatory disorders that present with syndromes overlapping with multiple sclerosis can increasingly be distinguished from multiple sclerosis with the aid of specific clinical, MRI, and laboratory findings; studies of people misdiagnosed with multiple sclerosis have also provided insights into clinical presentations for which extra caution is warranted. Considering these data, an update to the recommended diagnostic approaches to common clinical presentations and key clinical and paraclinical red flags is warranted to inform the contemporary clinical evaluation of patients with suspected multiple sclerosis.
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Affiliation(s)
- Andrew J Solomon
- Department of Neurological Sciences, Larner College of Medicine at the University of Vermont, University Health Center, Burlington, VT, USA.
| | - Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Wallace J Brownlee
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Eoin P Flanagan
- Departments of Neurology and Laboratory Medicine and Pathology and the Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Lilyana Amezcua
- Department of Neurology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Brenda L Banwell
- Department of Neurology, University of Pennsylvania, Division of Child Neurology, Philadelphia, PA, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - John R Corboy
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jorge Correale
- Department of Neurology, Fleni Institute of Biological Chemistry and Physical Chemistry (IQUIFIB), Buenos Aires, Argentina; National Council for Scientific and Technical Research/University of Buenos Aires, Buenos Aires, Argentina
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, Koriyama, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Koriyama, Japan
| | - Jennifer Graves
- Department of Neurosciences, University of California, San Diego, CA, USA
| | | | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Medical Faculty, Technische Universität München, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany
| | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia; Hunter Medical Research Institute Neurology, University of Newcastle, Newcastle, NSW, Australia
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Walter Royal
- Department of Neurobiology and Neuroscience Institute, Morehouse School of Medicine, Atlanta, GA, USA
| | - Emmanuelle L Waubant
- Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, United Arab Emirates
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Murphy OC, Barreras P, Villabona-Rueda A, Mealy M, Pardo CA. Identification of specific causes of myelopathy in a large cohort of patients initially diagnosed with transverse myelitis. J Neurol Sci 2022; 442:120425. [PMID: 36191573 DOI: 10.1016/j.jns.2022.120425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/12/2022] [Accepted: 09/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Identifying the etiologic diagnosis in patients presenting with myelopathy is essential in order to guide appropriate treatment and follow-up. We set out to examine the etiologic diagnosis after comprehensive clinical evaluation and diagnostic work-up in a large cohort of patients referred to our specialized myelopathy clinic, and to explore the demographic profiles and symptomatic evolution of specific etiologic diagnoses. METHODS In this retrospective study of patients referred to the Johns Hopkins Myelitis and Myelopathy Center between 2006 and 2021 for evaluation of "transverse myelitis", the final etiologic diagnosis determined after comprehensive evaluation in each patient was reviewed and validated. Demographic characteristics and temporal profile of symptom evolution were recorded. RESULTS Of 1193 included patients, 772 (65%) were determined to have an inflammatory myelopathy and 421 (35%) were determined to have a non-inflammatory myelopathy. Multiple sclerosis/clinically isolated syndrome (n = 221, 29%) and idiopathic myelitis (n = 149, 19%) were the most frequent inflammatory diagnoses, while spinal cord infarction (n = 197, 47%) and structural causes of myelopathy (n = 108, 26%) were the most frequent non-inflammatory diagnoses. Compared to patients with inflammatory myelopathies, patients with non-inflammatory myelopathies were more likely to be older, male and experience chronic symptom evolution (p < 0.001 for all). Hyperacute symptom evolution was most frequent in patients with spinal cord infarction (74%), while chronic symptom evolution was most frequent in patients with structural causes of myelopathy (81%), arteriovenous fistula or arteriovenous malformation (81%), myelopathy associated with rheumatologic disorder (71%), and sarcoidosis-associated myelopathy (61%). CONCLUSIONS Patients initially diagnosed with "transverse myelitis" are eventually found to have a more specific inflammatory or even non-inflammatory cause, potentially resulting in inappropriate treatment and follow-up. Demographic characteristics and temporal profile of symptom evolution may help inform a differential diagnosis in these patients. Etiological diagnosis of myelopathies would provide better therapeutic decisions.
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Affiliation(s)
- Olwen C Murphy
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Paula Barreras
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Andres Villabona-Rueda
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Maureen Mealy
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Carlos A Pardo
- Johns Hopkins Myelitis and Myelopathy Center, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA.
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Fadda G, Flanagan EP, Cacciaguerra L, Jitprapaikulsan J, Solla P, Zara P, Sechi E. Myelitis features and outcomes in CNS demyelinating disorders: Comparison between multiple sclerosis, MOGAD, and AQP4-IgG-positive NMOSD. Front Neurol 2022; 13:1011579. [PMID: 36419536 PMCID: PMC9676369 DOI: 10.3389/fneur.2022.1011579] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/11/2022] [Indexed: 07/25/2023] Open
Abstract
Inflammatory myelopathies can manifest with a combination of motor, sensory and autonomic dysfunction of variable severity. Depending on the underlying etiology, the episodes of myelitis can recur, often leading to irreversible spinal cord damage and major long-term disability. Three main demyelinating disorders of the central nervous system, namely multiple sclerosis (MS), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorders (AQP4+NMOSD) and myelin oligodendrocyte glycoprotein-IgG associated disease (MOGAD), can induce spinal cord inflammation through different pathogenic mechanisms, resulting in a more or less profound disruption of spinal cord integrity. This ultimately translates into distinctive clinical-MRI features, as well as distinct patterns of disability accrual, with a step-wise worsening of neurological function in MOGAD and AQP4+NMOSD, and progressive disability accrual in MS. Early recognition of the specific etiologies of demyelinating myelitis and initiation of the appropriate treatment is crucial to improve outcome. In this review article we summarize and compare the clinical and imaging features of spinal cord involvement in these three demyelinating disorders, both during the acute phase and over time, and outline the current knowledge on the expected patterns of disability accrual and outcomes. We also discuss the potential implications of these observations for patient management and counseling.
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Affiliation(s)
- Giulia Fadda
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Eoin P. Flanagan
- Department of Neurology, Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Laura Cacciaguerra
- Department of Neurology, Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
- Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Paolo Solla
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Pietro Zara
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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