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Rocchi C, Forcadela M, Kelly P, Linaker S, Gibbons E, Bhojak M, Jacob A, Hamid S, Huda S. The absence of antibodies in longitudinally extensive transverse myelitis may predict a more favourable prognosis. Mult Scler 2024; 30:345-356. [PMID: 38258822 DOI: 10.1177/13524585231221664] [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: 01/24/2024]
Abstract
BACKGROUND Isolated first episodes of longitudinally extensive transverse myelitis (LETM) have typically been associated with neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). However, in some cases, serological testing and screening for other aetiologies are negative, a condition referred to as double seronegative longitudinally extensive transverse myelitis (dsLETM). OBJECTIVE The objective of this study was to evaluate comparative outcomes of dsLETM, MOGAD-LETM and NMOSD-LETM. METHODS Cohort study of LETM cases seen in the UK NMOSD Highly Specialised Service between January 2008 and March 2022. RESULTS LETM = 87 cases were identified (median onset age = 46 years (15-85); median follow-up = 46 months (1-144); 47% NMOSD-LETM = 41 (aquaporin-4 antibodies (AQP4-IgG) positive = 36), 20% MOGAD-LETM = 17 and 33% dsLETM = 29). Despite similar Expanded Disability Status Scale (EDSS) at nadir, last EDSS was higher in AQP4-IgG and seronegative NMOSD-LETM (sNMOSD) (p = 0.006). Relapses were less common in dsLETM compared to AQP4-IgG NMOSD-LETM and sNMOSD-LETM (19% vs 60% vs 100%; p = 0.001). Poor prognosis could be predicted by AQP4-IgG (odds ratio (OR) = 38.86 (95% confidence interval (CI) = 1.36-1112.86); p = 0.03) and EDSS 3 months after onset (OR = 65.85 (95% CI = 3.65-1188.60); p = 0.005). CONCLUSION dsLETM remains clinically challenging and difficult to classify with existing nosological terminology. Despite a similar EDSS at nadir, patients with dsLETM relapsed less and had a better long-term prognosis than NMOSD-LETM.
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Affiliation(s)
| | | | | | | | | | | | - Anu Jacob
- The Walton Centre Foundation Trust, Liverpool, UK/Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Shahd Hamid
- The Walton Centre Foundation Trust, Liverpool, UK
| | - Saif Huda
- The Walton Centre Foundation Trust, Liverpool, UK
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Dhakal B, Bogati K, Baniya S, Muhammad QUA, Pathak BD, Pokharel R, Adhikari S, Upadhaya Regmi B, Subedi RC, Pant P, Paudel R. Longitudinally extensive transverse myelitis, a disabling disorder with a good prognosis: a case series from Nepal. Ann Med Surg (Lond) 2024; 86:252-256. [PMID: 38222755 PMCID: PMC10783345 DOI: 10.1097/ms9.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/13/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Longitudinally extensive transverse myelitis (LETM) is a rare spinal cord disorder with variable etiologies and presentations. It can present solely or as an association with other neurological disorders. Methodology It was a series of cases of LETM in a tertiary care hospital. Clinical presentation and outcomes The initial three cases presented with bilateral lower extremity weakness and were diagnosed as transverse myelitis while, the fourth case, already diagnosed as LETM presented with seizure followed by loss of consciousness. All four cases had a good prognosis to date with continued physiotherapy. Conclusion The early diagnosis of the disease helps to guide the optimal management and decide the potential need for physiotherapy.
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Affiliation(s)
| | | | | | | | | | - Rojina Pokharel
- Manmohan Cardiothoracic and Vascular Transplant Center, Kathmandu
| | | | | | | | | | - Raju Paudel
- Shree Birendra Hospital, Nepalese Army Institute of Health Sciences
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Gonsalves DG, Raffa PEAZ, de Sousa GG, Rigueiral MEG, Estevão IA, Pacheco CC, Medeiros RTR, Franceschini PR, de Aguiar PHP. B-Cell Lymphoma Intramedullary Tumor: Case Report and Systematic Review. Asian J Neurosurg 2023; 18:231-245. [PMID: 37397032 PMCID: PMC10310451 DOI: 10.1055/s-0043-1768574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Intramedullary tumors represent the major cause of spinal cord injuries, and its symptoms include pain and weakness. Progressive weakness may concomitantly occur in the upper and lower limbs, along with lack of balance, spine tenderness, sensory loss, trophic changes of extremity, hyperreflexia, and clonus. The study protocol was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the MEDLINE electronic database was performed to identify the studies reporting the clinical features of children and adults who presented with an intramedullary lymphoma. Twenty-one studies were included, reporting 25 cases. Manuscripts were excluded if the full-text article was not available, original data were not reported (e.g., review articles), or if the main disease was not intramedullary lymphoma. A structured data extraction form was employed to standardize the identification and retrieval of data from manuscripts. To enlighten the discussion, a case is also presented. An 82-year-old woman with Fitzpatrick skin type II, diagnosed and treated for non-Hodgkin's lymphoma 7 years ago, was admitted with mental confusion and memory loss for the past 2 months-evolving with recurring falls from her own height. One day before admission, she displayed Brown-Séquard syndrome. An expansive lesion from C2 to C4 in the cervical spinal cord was found and a hypersignal spinal cord adjacent was described at the bulb medullary transition to the C6-C7 level. A primary spinal cord tumor was considered, as well as a melanoma metastasis, due to the lesion's flame pattern. The patient presented a partial recovery of symptoms and a reduction of the spinal cord edema after being empirically treated with corticosteroids, but the lesion maintained its extent. Subsequently, a large diffuse B-cell lymphoma with nongerminal center was found in open body biopsy, infiltrating neural tissue. The main objective of the present study is to report a surgical case treated for a large diffuse B-cell lymphoma, in addition to presenting the results of a systematic review of primary intramedullary spinal cord lymphoma.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Paulo Henrique Pires de Aguiar
- Department of Neurosurgery, Santa Paula Hospital, São Paulo, Brazil
- Department of Research and Innovation, Laboratory of Cellular and Molecular Biology, Faculty of Medicine of ABC, Santo André, São Paulo, Brazil
- Department of Neurology, School of Medicine of Pontifical Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
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Dias L, Barbosa L, Martins F, Braz L, Guimarães J. Risk factors for idiopathic myelitis at admission and predictors for late diagnostic change. J Neuroimmunol 2021; 361:577747. [PMID: 34715592 DOI: 10.1016/j.jneuroim.2021.577747] [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: 08/26/2021] [Revised: 10/03/2021] [Accepted: 10/06/2021] [Indexed: 11/30/2022]
Abstract
Immune-mediated myelopathy (IMM) diagnosis is challenging, and its etiology may remain unclear despite extensive investigation. We evaluated diagnostic changes in IMM patients during follow-up. We included 80 patients, 61.3% female, with median follow-up time 62.5 months. Diagnoses at discharge were: 48.8% Multiple Sclerosis-IMM (MS-IMM), 32.5% I-IMM, 11.3% Neuromyelitis Optica Spectrum Disorders-IMM (NMOSD-IMM), 1.3% MOG encephalomyelitis (MOGAD), and 6.2% Others IMM (O-IMM). Twenty-two patients (27.5%) changed diagnosis (median 15.5 months): 68.8% MS-IMM, 12.5% NMOSD-IMM, 3.8% MOGAD, 10.0% I-IMM, and 5.0% O-IMM. Most patients that changed diagnosis were I-IMM. Predictive factors for diagnostic change in I-IMM were: autonomous gait (p = 0.029), lesions suggestive of MS (p = 0.039), higher number of lesions (p = 0.043), lesions length < 3 vertebral bodies (p = 0.033), cervical involvement (p = 0.038), and lower EDSS at admission (p = 0.013). Etiologic reclassifications in IMM are common, therefore patients require an appropriate follow-up time to increase diagnostic accuracy.
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Affiliation(s)
- Leonor Dias
- Department of Neurology, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Clinical Neurosciences and Mental Health Department, Faculty of Medicine of the University of Porto, Portugal.
| | - Leonardo Barbosa
- Clinical Neurosciences and Mental Health Department, Faculty of Medicine of the University of Porto, Portugal
| | - Filipa Martins
- Department of Psychiatry, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal
| | - Luís Braz
- Department of Neurology, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Clinical Neurosciences and Mental Health Department, Faculty of Medicine of the University of Porto, Portugal
| | - Joana Guimarães
- Department of Neurology, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Clinical Neurosciences and Mental Health Department, Faculty of Medicine of the University of Porto, Portugal
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Fujiwara S, Manabe Y, Nakano Y, Omote Y, Yunoki T, Kono S, Narai H, Abe K. Two Cases of Probable Neuro-Behçet's Disease with Longitudinally Extensive Transverse Myelitis. Case Rep Neurol 2021; 13:78-83. [PMID: 33708098 PMCID: PMC7923906 DOI: 10.1159/000512323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022] Open
Abstract
We report 2 cases of probable neuro-Behçet's disease (NBD) with longitudinally extensive transverse myelitis (LETM). In both cases, the patients presented paraplegia, as well as sensory, bladder, and rectal disturbances. Magnetic resonance imaging (MRI) of patient 1 showed continuous high signal intensity extending from the midbrain to the entire spinal cord in the central part of the cord on T2-weighted imaging (T2WI). Spinal MRI of patient 2 revealed high signal intensity extending from Th2 to Th10 in the central part of the cord on T2WI. Both patients received high-dose methylprednisolone. A continuous lesion from the midbrain to the entire spinal cord as in patient 1 has not been previously reported. Patient 2 dramatically improved by infliximab therapy. The present cases suggest that NBD should be considered as a differential diagnosis in patients with LETM.
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Affiliation(s)
- Shunya Fujiwara
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yasuhiro Manabe
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yumiko Nakano
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yoshio Omote
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Taijun Yunoki
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Syoichiro Kono
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hisashi Narai
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Farhat N, Daoud S, Hdiji O, Sakka S, Damak M, Mhiri C. Myelopathy after zoster virus infection in immunocompetent patients: A case series. J Spinal Cord Med 2021; 44:334-338. [PMID: 31013469 PMCID: PMC7952078 DOI: 10.1080/10790268.2019.1607053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
CONTEXT After primary infection, varicella zoster virus (VZV) becomes latent in ganglionic neurons. If immunity declines, VZV is reactivated and can spread to the dermatome depending from this ganglion and in some cases to the spinal cord. Myelopathy is rare and may develop in the absence of skin rash making the diagnosis very difficult. FINDINGS From 1994 to 2014, we collected five observations of clinically and laboratory confirmed zoster myelopathy. The age of our patients ranged from 14 to 78. They did not have any significant past medical history. Four patients had a history of radicular rash. After 3 weeks (4-45 days), patients presented paraparesis, sensory loss, and sphincter dysfunction. Cerebrospinal fluid (CSF) analysis revealed an elevated protein level (5/5cases) and pleocytosis (2/5 cases). Spinal cord magnetic resonance imaging (MRI) demonstrated T2 hyper intense lesions with swelling and contrast enhancement. The diagnosis was supported by laboratory evidence, including the detection of VZV antibodies in the CSF. All patients received intravenous acyclovir and two patients received IV methylprednisolone. A marked improvement was observed in most of the patients within 2 months. CONCLUSION /CLINICAL RELEVANCE Based on our patients and on previous reports, we highlight the possibility of the occurrence of VZV myelopathy in immunocompetent subjects. The diagnosis must be evoked even in the absence of typical skin lesions. In this case, spinal cord MRI and virological tests are useful tools for the diagnosis. We also emphasize on the importance of accurate diagnosis to enable the specific treatment and ameliorate the outcome.
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Affiliation(s)
- Nouha Farhat
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Sawsan Daoud
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia,Correspondence to: Sawsan Daoud, Department of Neurology, Habib Bourguiba University Hospital, CP 3029 – Sfax, Tunisia; Ph: (216) 21 46 46 80.
| | - Olfa Hdiji
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Salma Sakka
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Mariem Damak
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Chokri Mhiri
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
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Choudhary A, Bhargava A, Khichar S, Pradhan S. Etiological spectrum, clinico-radiological profile and treatment outcomes of longitudinally extensive transverse myelitis - A prospective study from Northwest India. J Neuroimmunol 2020; 351:577456. [PMID: 33341581 DOI: 10.1016/j.jneuroim.2020.577456] [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] [Received: 06/01/2020] [Revised: 10/24/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To study etiological, clinical and radiological profile and treatment outcomes in patients of longitudinally extensive transverse myelitis (LETM). METHODS This was a prospective study conducted at Dr. S.N. medical college, Jodhpur, India, of patients presenting with LETM between March 2018 to March 2020. RESULTS Our study included 32 patients (median age 32 years, female to male ratio of 2.5: 1). Neuromyelitis optica spectrum disorders (NMOsd) was the most common diagnosis affecting 14 patients followed by 5 patients of idiopathic myelitis, 4 patients of para-infectious myelitis, 3 patients of multiple sclerosis (MS), 3 patients of acute demyelinating encephalomyelitis (ADEM) and 1 patient each of myelin oligodendrocyte glycoprotein (MOG) antibody disease, sarcoidosis and mixed connective tissue disorder (MCTD). All the patients of NMOsd were positive for aquaporin 4 (AQP4) antibody. Spinal MRI showed central pattern of involvement in NMOsd and eccentric pattern of involvement in MS. All the patients of para-infectious myelitis were varicella myelitis. Twenty-eight (87.5%) patients had good clinical recovery at 6 months. CONCLUSION Although, LETM is classically associated with NMOsd, it can have multiple etiologies. Identifying the etiology is important for long term treatment and prognosis which varies according to the disease. Patients in our study presented with relapses and severe disease but had good clinical recovery with treatment.
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Affiliation(s)
| | - Amita Bhargava
- Department of neurology, Dr S N medical college, Jodhpur, India
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8
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Marrodan M, Hernandez MA, Köhler AA, Correale J. Differential diagnosis in acute inflammatory myelitis. Mult Scler Relat Disord 2020; 46:102481. [PMID: 32905999 DOI: 10.1016/j.msard.2020.102481] [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] [Received: 05/23/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Establishing differential diagnosis between different inflammatory causes of acute transverse myelitis (ATM) can be difficult. The objective of this study was to see which clinical, imaging or laboratory findings best contribute to confirm ATM etiology. METHODS We reviewed clinical history, MRI images, CSF and serum laboratory tests in a retrospective study of patients presenting ATM. Univariate and multivariate multinomial logistic regression analysis was performed for each of the items listed above. RESULTS One hundred and seventy-two patients were analyzed in the study: 68 with multiple sclerosis (MS), 67 presenting idiopathic myelitis (IM; 23 of which were recurrent), 21 who developed positive systemic-antibodies associated myelitis (SAb-M) and 16 with neuromyelitis optica spectrum disorders (NMOSD). The following factors were associated with increased risk of developing MS: lower values in the modified Rankin scale at admission; positive oligoclonal bands (OCB); higher spinal cord lesion load; presence of brain demyelinating lesions; and disease recurrence. Longitudinally extended (LE) lesions, brain demyelinating lesions, and recurrences also contributed to final diagnosis of NMOSD. Multivariate multinomial logistic regression analysis showed presence of LE lesions increased risk of NMOSD and recurrence of ATM. Whereas, brain demyelinating lesions, and presence of OCB increased risk of MS. CONCLUSIONS ATM etiology may be clarified on the basis of spinal cord and brain MRI findings, together with CSF biochemistry and serum laboratory test results, allowing more timely and exact diagnosis as well as specific therapy for cases of uncertain origin.
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Affiliation(s)
- M Marrodan
- Neurology Department, Fleni. Buenos Aires, Montañeses 2325, Buenos Aires (1428), Argentina
| | - M A Hernandez
- Neurology Department, Fleni. Buenos Aires, Montañeses 2325, Buenos Aires (1428), Argentina
| | - A A Köhler
- Neurology Department, Fleni. Buenos Aires, Montañeses 2325, Buenos Aires (1428), Argentina
| | - J Correale
- Neurology Department, Fleni. Buenos Aires, Montañeses 2325, Buenos Aires (1428), Argentina.
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Iwase R, Irioka T, Igarashi S, Ayabe J, Yokota T. Intracranial dural arteriovenous fistula mimicking neuromyelitis optica spectrum disorder: A case report. J Stroke Cerebrovasc Dis 2020; 29:105007. [PMID: 32689639 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105007] [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: 04/15/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 11/15/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is an immune-mediated disorder. It often develops acute myelopathy due to longitudinally extensive transverse myelitis (LETM), although other disorders can cause an LETM-like lesion. Here, we report a 76-year-old patient presenting with acute-onset, progressive myelopathy, which proved to be caused by an intracranial dural arteriovenus fistula (dAVF). Magnetic resonance imaging (MRI) revealed a longitudinally extensive spinal cord lesion, which was further extended rostrally to the medulla. Although cord surface flow voids were absent on T2-weighted MRI, abnormally congested peri-spinal veins showed up with gadolinium contrast. Angiography confirmed dAVF in the posterior fossa, which drained into the peri-spinal veins. Intracranial dAVF should be considered as a differential diagnosis of NMOSD, because it is not immunologically but is surgically treatable.
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Affiliation(s)
- Ryo Iwase
- Department of Neurology, Yokosuka Kyosai Hospital, 1-16, Yonegahama-dori, Yokosuka City, Kanagawa 238-8558, Japan; Department of Neurology and Neurological Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Takashi Irioka
- Department of Neurology, Yokosuka Kyosai Hospital, 1-16, Yonegahama-dori, Yokosuka City, Kanagawa 238-8558, Japan.
| | - Susumu Igarashi
- Department of Neurology, Yokosuka Kyosai Hospital, 1-16, Yonegahama-dori, Yokosuka City, Kanagawa 238-8558, Japan
| | - Junichi Ayabe
- Department of Neurosurgery, Yokosuka Kyosai Hospital, Kanagawa, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
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Rabasté S, Cobo-Calvo A, Nistiriuc-Muntean V, Vukusic S, Marignier R, Cotton F. Diagnostic value of bright spotty lesions on MRI after a first episode of acute myelopathy. J Neuroradiol 2020; 48:28-36. [PMID: 32407908 DOI: 10.1016/j.neurad.2020.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE To determine the diagnostic value of bright spotty lesions (BSLs) for aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (NMOSDAQP4+), the predictive value of axial-BSLs for AQP4-IgG seropositivity, and the radio-clinical differences in NMOSDAQP4+ patients with and without axial-BSLs. MATERIALS AND METHODS Retrospective study that included patients aged≥16 years, with a first acute spinal cord syndrome between 2005 and 2018 and abnormal spinal cord MRI with axial and sagittal T2 sequences. Patients with MRI findings consistent with compressive myelopathy were excluded. All spinal cord MRI were retrospectively evaluated for the presence of BSLs by 2 radiologists blinded to the diagnosis of acute myelopathy. RESULTS A total of 82 patients were included; 15 aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder patients (NMOSDAQP4+), and 67 other patients, considered as the other causes of myelopathy (OM) group. The specificity of axial-BSLs for NMOSDAQP4+ patients was 94.0% (95% CI [85.6 to 97.7]). The sensitivity was 40.0% (95% CI [19.8 to 64.3]). In the multivariable analysis, the only MRI characteristic associated with AQP4-IgG positivity was the presence of axial-BSLs (OR: 9.2, 95% CI [1.2 to 72.9]; P=0.022). In NMOSDAQP4+ patients, the median of cord expansion ratio was higher with axial-BSL (1.2, IQR [1.1-1.3]) than without axial-BSL (1.1, IQR [1.0-1.2]; P=0.046). CONCLUSION After a first acute spinal cord syndrome, the presence of axial-BSLs on spinal cord MRI seems very specific for NMOSDAQP4+ and seems to be a predictor radiological marker of AQP4-IgG positivity.
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Affiliation(s)
- Sylvain Rabasté
- Service de radiologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69310 Pierre-Bénite, France
| | - Alvaro Cobo-Calvo
- Service de neurologie-sclérose en plaques, pathologies de la myéline et neuroinflammation, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 69500 Bron, France; Inserm U1028, CNRS UMR5292, centre de recherche en neuroscience de Lyon, université Lyon-1, 69008 Lyon, France
| | - Veronica Nistiriuc-Muntean
- Service de radiologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69310 Pierre-Bénite, France
| | - Sandra Vukusic
- Service de neurologie-sclérose en plaques, pathologies de la myéline et neuroinflammation, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 69500 Bron, France; Inserm U1028, CNRS UMR5292, centre de recherche en neuroscience de Lyon, université Lyon-1, 69008 Lyon, France
| | - Romain Marignier
- Service de neurologie-sclérose en plaques, pathologies de la myéline et neuroinflammation, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 69500 Bron, France; Inserm U1028, CNRS UMR5292, centre de recherche en neuroscience de Lyon, université Lyon-1, 69008 Lyon, France
| | - François Cotton
- Service de radiologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69310 Pierre-Bénite, France; Inserm U1044, CNRS UMR 5220, CREATIS, université Lyon-1, 69100 Villeurbanne, France.
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Bulut E, Shoemaker T, Karakaya J, Ray DM, Mealy MA, Levy M, Izbudak I. MRI Predictors of Recurrence and Outcome after Acute Transverse Myelitis of Unidentified Etiology. AJNR Am J Neuroradiol 2019; 40:1427-1432. [PMID: 31296526 DOI: 10.3174/ajnr.a6121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 06/06/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE The early prediction of recurrence after an initial event of transverse myelitis helps to guide preventive treatment and optimize outcomes. Our aim was to identify MR imaging findings predictive of relapse and poor outcome in patients with acute transverse myelitis of unidentified etiology. MATERIALS AND METHODS Spinal MRIs of 77 patients (mean age, 36.3 ± 20 years) diagnosed with acute transverse myelitis were evaluated retrospectively. Only the patients for whom an underlying cause of myelitis could not be identified within 3 months of symptom onset were included. Initial spinal MR images of patients were examined in terms of lesion extent, location and distribution, brain stem extension, cord expansion, T1 signal, contrast enhancement, and the presence of bright spotty lesions and the owl's eyes sign. The relapse rates and Kurtzke Expanded Disability Status Scale scores at least 1 year (range, 1-14 years) after a myelitis attack were also recorded. Associations of MR imaging findings with clinical variables were studied with univariate associations and binary log-linear regression. Differences were considered significant for P values < .05. RESULTS Twenty-seven patients (35.1%) eventually developed recurrent disease. Binary logistic regression revealed 3 main significant predictors of recurrence: cord expansion (OR, 5.30; 95% CI, 1.33-21.11), contrast enhancement (OR, 5.05; 95% CI, 1.25-20.34), and bright spotty lesions (OR, 3.63; 95% CI, 1.06-12.43). None of the imaging variables showed significant correlation with the disability scores. CONCLUSIONS Cord expansion, contrast enhancement, and the presence of bright spotty lesions could be used as early MR imaging predictors of relapse in patients with acute transverse myelitis of unidentified etiology. Collaborative studies with a larger number of patients are required to validate these findings.
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Affiliation(s)
- E Bulut
- From the Departments of Radiology (E.B.)
| | - T Shoemaker
- Department of Neurology (T.S., M.A.M., M.L.)
- Department of Neurological Sciences (T.S.), Rush University Medical Center, Chicago, Illinois
| | - J Karakaya
- Statistics (J.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - D M Ray
- Division of Neuroradiology (D.M.R., I.I.), The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M A Mealy
- Department of Neurology (T.S., M.A.M., M.L.)
| | - M Levy
- Department of Neurology (T.S., M.A.M., M.L.)
- Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - I Izbudak
- Division of Neuroradiology (D.M.R., I.I.), The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Devi A, Singh K, Gupta S, Bhutani N, Agarwal P. A descriptive study of clinical and radiological profile of longitudinal extensive myelitis in a tertiary hospital in Rajasthan, India. Clin Neurol Neurosurg 2019; 181:33-40. [DOI: 10.1016/j.clineuro.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/06/2019] [Accepted: 04/07/2019] [Indexed: 10/27/2022]
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13
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Gil-Perotin S, Castillo-Villalba J, Carreres-Polo J, Navarré-Gimeno A, Mallada-Frechín J, Pérez-Miralles F, Gascón F, Alcalá-Vicente C, Cubas-Nuñez L, Casanova-Estruch B. Progressive Demyelination in the Presence of Serum Myelin Oligodendrocyte Glycoprotein-IgG: A Case Report. Front Neurol 2018; 9:340. [PMID: 29867746 PMCID: PMC5962713 DOI: 10.3389/fneur.2018.00340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/30/2018] [Indexed: 01/03/2023] Open
Abstract
The clinical diagnosis of patients with autoantibodies directed to conformational myelin oligodendrocyte glycoprotein MOG-IgG, can be challenging because of atypical clinical presentation. MOG-IgG seropositivity has been reported in several demyelinating diseases, including relapsing opticospinal syndromes [in the neuromyelitis optica spectrum disorders (NMOSD) and less frequently, in multiple sclerosis (MS)], but it has rarely been associated with the progressive course of disease. To contribute to the characterization of MOG-related demyelination, we describe the case of a patient with progressive demyelinating opticospinal disease, IgG-oligoclonal bands (OCB), and serum MOG-IgG.
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Affiliation(s)
- Sara Gil-Perotin
- Multiple Sclerosis and Neural Regeneration Research Group, Hospital Universitari i Politècnic La Fe, València, Spain.,Neuroimmmunology Unit, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Jéssica Castillo-Villalba
- Multiple Sclerosis and Neural Regeneration Research Group, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Joan Carreres-Polo
- Radiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | - Francisco Pérez-Miralles
- Multiple Sclerosis and Neural Regeneration Research Group, Hospital Universitari i Politècnic La Fe, València, Spain.,Neuroimmmunology Unit, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Francisco Gascón
- Neuroimmunology Unit, Hospital Clínic de València, Valencia, Spain
| | - Carmen Alcalá-Vicente
- Multiple Sclerosis and Neural Regeneration Research Group, Hospital Universitari i Politècnic La Fe, València, Spain.,Neuroimmmunology Unit, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Laura Cubas-Nuñez
- Multiple Sclerosis and Neural Regeneration Research Group, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Bonaventura Casanova-Estruch
- Multiple Sclerosis and Neural Regeneration Research Group, Hospital Universitari i Politècnic La Fe, València, Spain.,Neuroimmmunology Unit, Hospital Universitari i Politècnic La Fe, València, Spain
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14
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Birnbaum J, Lalji A, Piccione EA, Izbudak I. Magnetic resonance imaging of the spinal cord in the evaluation of 3 patients with sensory neuronopathies: Diagnostic assessment, indications of treatment response, and impact of autoimmunity: A case report. Medicine (Baltimore) 2017; 96:e8483. [PMID: 29245216 PMCID: PMC5728831 DOI: 10.1097/md.0000000000008483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
RATIONALE Sensory neuronopathy can be a devastating peripheral nervous system disorder. Profound loss in joint position is associated with sensory ataxia, and reflects degeneration of large-sized dorsal root ganglia. Prompt recognition of sensory neuronopathies may constitute a therapeutic window to intervene before there are irreversible deficits. However, nerve-conduction studies may be unrevealing early in the disease course. In such cases, the appearance of dorsal column lesions on spinal-cord MRI can help in the diagnosis. However, most studies have not defined whether such dorsal column lesions may occur within earlier as well as chronic stages of sensory neuronopathies, and whether serial MRI studies can be used to help assess treatment efficacy. In this case-series of three sensory neuronopathy patients, we report clinical characteristics, immunological markers, nerve-conduction and skin-biopsy studies, and neuroimaging features. PATIENT CONCERNS All three patients presented with characteristic features of sensory neuronopathy with abnormal spinal-cord MRI studies. Radiographic findings included non-enhancing lesions in the dorsal columns that were longitudinally extensive (spanning ≥ 3 vertebral segments). DIAGNOSES All patients had anti-Ro/SS-A and/or anti-La/SS-B antibodies, with patients one and two having Sjögren's syndrome. MRI findings were similar when performed in the earlier stages of a sensory neuronopathy (patient one, after four months) and chronic stages (patients two and three, after five and three years, respectively). INTERVENTIONS Patient one was treated with rituximab combined with intravenous immunoglobulin therapy. OUTCOMES Patient one was initially wheelchair-bound and had improved ambulation after treatment. In this patient, serial MRI studies revealed partial resolution of dorsal column lesions, associated with decreased sensory ataxia and improved nerve-conduction studies. LESSONS In addition to vitamin B12 and copper deficiency, it is important to include sensory neuronopathies in the differential diagnosis of dorsal column lesions. MRI spinal-cord lesions have similar appearances in the earlier as well as chronic phases of a sensory neuronopathy, and therefore suggest that such dorsal column lesions may reflect inflammatory as well as a gliotic burden of injury. MRI may also be a useful longitudinal indicator of treatment response.
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Affiliation(s)
- Julius Birnbaum
- Division of Rheumatology and Department of Neurology, The Johns Hopkins University School of Medicine
| | - Aliya Lalji
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ezequiel A. Piccione
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | - Izlem Izbudak
- Division of Neuroradiology, Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Elavarasi A, Dash D, Warrier AR, Bhatia R, Kumar L, Jain D, Tripathi M. Spinal cord involvement in primary CNS lymphoma. J Clin Neurosci 2017; 47:145-148. [PMID: 29110994 DOI: 10.1016/j.jocn.2017.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/09/2017] [Indexed: 11/20/2022]
Abstract
LETM is a common syndrome and the diagnosis of CNS lymphoma is not usually considered in the list of differentials. Primary CNS lymphoma can present as longitudinally extensive transverse myelopathy. Failure to suspect and evaluate leads to delay in diagnosis and treatment. PCNSL may be non contrast enhancing on gadolinium enhanced MRI. CSF analysis should be done preferably before starting corticosteroids as it is usual practice in treatment of transverse myelitis, as steroids may lead to transient improvement and mask the correct diagnosis. Repeated CSF examinations may be needed to clinch the diagnosis.
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Affiliation(s)
| | - Deepa Dash
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Anand R Warrier
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
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16
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Birnbaum J, Atri NM, Baer AN, Cimbro R, Montagne J, Casciola-Rosen L. Relationship Between Neuromyelitis Optica Spectrum Disorder and Sjögren's Syndrome: Central Nervous System Extraglandular Disease or Unrelated, Co-Occurring Autoimmunity? Arthritis Care Res (Hoboken) 2017; 69:1069-1075. [PMID: 27696784 PMCID: PMC5376370 DOI: 10.1002/acr.23107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/26/2016] [Accepted: 09/27/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Sjögren's syndrome (SS) patients may be affected by the neuromyelitis optica spectrum disorder (NMOSD), a severe demyelinating syndrome associated with anti-aquaporin 4 antibodies (anti-AQP-4 antibodies). The relationship between SS and NMOSD has been a sustained focus of investigation. Among SS patients, anti-AQP-4 antibodies have been detected exclusively in those with NMOSD. It has therefore been speculated that NMOSD is not a neurologic complication of SS. However, such studies evaluated small numbers of SS patients, often mixed with other inflammatory disorders. METHODS We compared frequencies of anti-AQP-4 and SS-associated antibodies in 109 SS patients, including 11 with NMOSD, 8 with non-NMOSD demyelinating syndromes, and 90 without demyelinating syndromes. RESULTS When assessed using a fluorescence-activated cell sorting (FACS) assay, anti-AQP-4 antibodies were seen exclusively in those SS patients with NMOSD (72.7%), but not in SS patients without NMOSD (P < 0.01). In contrast, anti-Ro 52, anti-Ro 60, and other autoantibodies were not more prevalent in SS patients with NMOSD versus those without. Anti-AQP-4 antibodies were detected more frequently among NMOSD patients by FACS assay than with a commercial immunohistochemical assay (72.7% versus 54.5%), despite assessment after a more prolonged period of immunosuppressive therapy (median 38 months versus 5 months; P < 0.01). CONCLUSION The syndrome-specificity of anti-AQP-4 antibodies, along with an otherwise similar antibody profile in SS NMOSD patients, indicates that NMOSD is not a direct central nervous system manifestation of SS. Anti-AQP-4 antibodies can persist and be refractory to prolonged immunosuppressive therapy.
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Affiliation(s)
- J Birnbaum
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - N M Atri
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - A N Baer
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - R Cimbro
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Montagne
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - L Casciola-Rosen
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Carnero Contentti E, Hryb J, Leguizamón F, Di Pace J, Celso J, Knorre E, Perassolo M. Differential diagnosis and prognosis for longitudinally extensive myelitis in Buenos Aires, Argentina. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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18
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Carnero Contentti E, Hryb J, Leguizamón F, Di Pace J, Celso J, Knorre E, Perassolo M. Diagnósticos diferenciales y pronóstico de las mielitis longitudinales extensas en Buenos Aires, Argentina. Neurologia 2017; 32:99-105. [DOI: 10.1016/j.nrl.2015.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/12/2015] [Accepted: 06/23/2015] [Indexed: 12/18/2022] Open
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19
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Evaluation and management of longitudinally extensive transverse myelitis: a guide for radiologists. Clin Radiol 2016; 71:960-971. [DOI: 10.1016/j.crad.2016.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 04/22/2016] [Accepted: 05/23/2016] [Indexed: 01/31/2023]
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20
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Etiological, clinical, and radiological features of longitudinally extensive myelopathy in Chinese patients. J Clin Neurosci 2016; 32:61-6. [PMID: 27526974 DOI: 10.1016/j.jocn.2015.12.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/21/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022]
Abstract
Longitudinally extensive myelopathy (LEM) is a rare spinal syndrome, and was mostly assessed in western populations. In order to investigate the etiological, clinical, and radiological features of LEM in Chinese patients, we retrospectively analyzed eighty-nine (40 men and 49 women, median age 45.9±15.7years) patients with LEM hospitalized in China-Japan Friendship Hospital. LEM comprised autoimmune inflammatory myelitis (n=53), metabolic and compressive disorders (n=13), vascular diseases (n=10), neoplastic diseases (n=7), infectious diseases (n=4), and syringomyelia (n=2). Neuromyelitis optica spectrum disorders (NMOSD) was the most common cause of transverse myelopathy identified in LEM (38/89 [42.7%]) characterized by intractable vomiting and hiccups and painful tonic spasms. Subacute combined degeneration and anterior spinal artery syndrome accounted for the largest non-transverse LEM, which selectively affected the spinal dorsal and/or lateral columns and the spinal anterior region, respectively. Radicular pain was common in anterior spinal artery syndrome. Postrema (n=15, 39.5%) and cervical (n=31, 81.6%) lesions were significantly increased in NMOSD versus non-NMOSD (n=7, 13.7% and n=34, 66.7%, respectively, p<0.05]. Axial T2-weighted MRI indicated that 46 (51.7%) patients exhibited complete lesions; 43 (48.3%) patients exhibited non-transverse lesions, mainly unilateral or symmetrical tract lesions. Twenty-four (51.1%) LEM patients exhibited distinct gadolinium contrast enhancement. In this Chinese cohort, LEM was primarily attributed to NMOSD. While the etiological distribution in the non-NMOSD group was different from western populations, clinical and imaging features may facilitate a differential diagnosis.
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