1
|
Megens M, de Souza A. Amyotrophic lateral sclerosis with demyelinating neurophysiology and a motor band sign. Pract Neurol 2024; 24:219-222. [PMID: 38050178 DOI: 10.1136/pn-2023-003963] [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] [Accepted: 11/15/2023] [Indexed: 12/06/2023]
Abstract
We describe an unusual case of clinical amyotrophic lateral sclerosis (ALS) with initial neurophysiological studies suggesting demyelination, along with neuroimaging findings that helped to support the eventual diagnosis. An otherwise well 68-year-old man had 8 weeks of left upper limb weakness. On examination, there were widespread lower and upper motor neurone findings suggesting ALS. However, nerve conduction studies identified sensorimotor demyelinating changes suggesting chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), a diagnosis further supported by cerebrospinal fluid analysis. MR scan of the brain revealed a 'motor band', a feature seen commonly in ALS. His condition was refractory to immunotherapy with clinical progression in-keeping with ALS, establishing the diagnosis. ALS is rarely associated with demyelinating neurophysiological changes resembling CIDP. The clinical phenotype is crucial to support the correct diagnosis and imaging findings may help.
Collapse
Affiliation(s)
- Matthew Megens
- Department of Neurology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Aaron de Souza
- Department of Neurology, Launceston General Hospital, Launceston, Tasmania, Australia
- University of Tasmania Launceston Clinical School, Launceston, Tasmania, Australia
| |
Collapse
|
2
|
Zhang L, Li Y, Niu J, Hu N, Ding J, Cui L, Liu M. Neuromuscular ultrasound in combination with nerve conduction studies helps identify inflammatory motor neuropathies from lower motor neuron syndromes. Eur J Neurol 2024; 31:e16202. [PMID: 38235844 PMCID: PMC11235880 DOI: 10.1111/ene.16202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE Identifying patients with inflammatory motor neuropathies (IMNs) is warranted since effective treatments are available and the prognosis of these patients differs from that of amyotrophic lateral sclerosis patients. METHODS Between January 2019 and May 2022, 102 consecutive treatment-naïve lower motor neuron syndrome (LMNS) patients were recruited; these patients were suspected of having multifocal motor neuropathy, pure motor chronic inflammatory demyelinating polyneuropathy or amyotrophic lateral sclerosis with initial lower motor neuron presentation. Neuromuscular ultrasound (US) and nerve conduction studies (NCSs) were conducted at baseline. Relevant diagnostic investigations were performed if clinically warranted. The proposed US evidence of IMN was as follows: (i) nerve enlargement at ≥1 of the predetermined sites or (ii) absence of high intensity fasciculations in predefined muscle groups. Final diagnoses were made by experienced physicians after a prolonged follow-up period (≥12 months). IMN patients were defined as LMNS patients who experienced convincing improvements in response to immunotherapies. IMN patients without electrodiagnostic demyelinating features were diagnosed with treatment-responsive LMNS (TR-LMNS). RESULTS In total, 16 patients were classified as IMN, including nine chronic inflammatory demyelinating polyneuropathy/multifocal motor neuropathy patients and seven TR-LMNS patients. Six TR-LMNS patients were identified by neuromuscular US. The sensitivity and specificity of NCSs, nerve US and muscle US were 56.3% and 100%, 43.8% and 90.7% and 68.8% and 97.7%, respectively. When these three modalities were combined, the sensitivity and specificity were 93.8% and 88.4%, respectively. CONCLUSION Neuromuscular US studies are supplementary modalities to NCSs, and the combined use of these techniques might improve the identification of IMNs in LMNS patients.
Collapse
Affiliation(s)
- Lei Zhang
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Yi Li
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Nan Hu
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Jianfeng Ding
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Liying Cui
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| |
Collapse
|
3
|
Diagnostic utility of neurofilament markers for MND is limited in restricted disease phenotype and for differentiation from compressive myeloradiculopathies. J Neurol 2023; 270:1600-1614. [PMID: 36456758 DOI: 10.1007/s00415-022-11504-1] [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: 09/12/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022]
Abstract
Misdiagnosis is frequent in early motor neuron disease (MND), typically compressive radiculopathy, or in patients with restricted MND phenotype. In this retrospective, single tertiary centre study, we measured levels of neurofilament light (NfL) and phosphorylated neurofilament heavy (p-NfH) chain in cerebrospinal fluid (CSF) and of p-NfH in serum with commercially available ELISA kits and assessed their respective diagnostic performance as a marker of MND. The entire study population (n = 164) comprised 71 MND patients, 30 patients with compressive myelo- or radiculopathy, and 63 disease controls (DC). Among MND patients, we specified subgroups with only lower motoneuron involvement (MND-LMN, n = 15) and with confounding nerve roots or spinal cord compression (MND-C, n = 18), representing clinical diagnostic pitfalls. MND-LMN displayed significantly lower CSF NfL (p = 0.003) and p-NFH (p = 0.017), but not serum p-NfH (p = 0.347) levels compared to other MND patients (n = 56). The discriminative ability (area under the curve-AUC) of both CSF Nfs towards all MND patients was comparable to each other but significantly higher than that of p-NfH in serum (ps < 0.001). AUC of both CSF Nfs between MND-LMN and DC and also between MND-C and myelo-/radiculopathies were reduced, as compared to AUC between other MND and DC or myelo-/radiculopathies, respectively. Our results suggest that both Nfs in CSF represent a reliable diagnostic marker in a general MND population, fulfilling Awaji criteria. As for diagnostic pitfalls, and also for p-NfH in serum, their discriminative ability and, therefore, clinical utility appears to be limited.
Collapse
|
4
|
Hannaford A, Vucic S, Kiernan MC, Simon NG. Review Article "Spotlight on Ultrasonography in the Diagnosis of Peripheral Nerve Disease: The Evidence to Date". Int J Gen Med 2021; 14:4579-4604. [PMID: 34429642 PMCID: PMC8378935 DOI: 10.2147/ijgm.s295851] [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: 06/22/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Neuromuscular ultrasound is rapidly becoming incorporated into clinical practice as a standard tool in the assessment of peripheral nerve diseases. Ultrasound complements clinical phenotyping and electrodiagnostic evaluation, providing critical structural anatomical information to enhance diagnosis and identify structural pathology. This review article examines the evidence supporting neuromuscular ultrasound in the diagnosis of compressive mononeuropathies, traumatic nerve injury, generalised peripheral neuropathy and motor neuron disease. Extending the sonographic evaluation of nerves beyond simple morphological measurements has the potential to improve diagnostics in peripheral neuropathy, as well as advancing the understanding of pathological mechanisms, which in turn will promote precise therapies and improve therapeutic outcomes.
Collapse
Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Steve Vucic
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, Australia
| |
Collapse
|
5
|
Carroll AS, Simon NG. Current and future applications of ultrasound imaging in peripheral nerve disorders. World J Radiol 2020; 12:101-129. [PMID: 32742576 PMCID: PMC7364285 DOI: 10.4329/wjr.v12.i6.101] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Neuromuscular ultrasound (NMUS) is a rapidly evolving technique used in neuromuscular medicine to provide complimentary information to standard electrodiagnostic studies. NMUS provides a dynamic, real time assessment of anatomy which can alter both diagnostic and management pathways in peripheral nerve disorders. This review describes the current and future techniques used in NMUS and details the applications and developments in the diagnosis and monitoring of compressive, hereditary, immune-mediated and axonal peripheral nerve disorders, and motor neuron diseases. Technological advances have allowed the increased utilisation of ultrasound for management of peripheral nerve disorders; however, several practical considerations need to be taken into account to facilitate the widespread uptake of this technique.
Collapse
Affiliation(s)
- Antonia S Carroll
- Brain and Mind Research Centre, University of Sydney, Camperdown 2050, NSW, Australia
- Department of Neurology, Westmead Hospital, University of Sydney, Westmead 2145, NSW, Australia
- Department of Neurology, St Vincent’s Hospital, Sydney, Darlinghurst 2010, NSW, Australia
| | - Neil G Simon
- Northern Clinical School, University of Sydney, Frenchs Forest 2086, NSW, Australia
| |
Collapse
|
6
|
Herraets IJT, Goedee HS, Telleman JA, van Eijk RPA, van Asseldonk JT, Visser LH, van den Berg LH, van der Pol WL. Nerve ultrasound improves detection of treatment-responsive chronic inflammatory neuropathies. Neurology 2020; 94:e1470-e1479. [PMID: 31959710 DOI: 10.1212/wnl.0000000000008978] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/07/2019] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To examine the diagnostic accuracy of nerve ultrasound in a prospective cohort of consecutive patients with a clinical suspicion of chronic inflammatory neuropathies, including chronic inflammatory demyelinating polyneuropathy, Lewis-Sumner syndrome, and multifocal motor neuropathy, and to determine the added value in the detection of treatment-responsive patients. METHODS Between February 2015 and July 2018, we included 100 consecutive incident patients with a clinical suspicion of chronic inflammatory neuropathy. All patients underwent nerve ultrasound, extensive standardized nerve conduction studies (NCS), and other relevant diagnostic investigations. We evaluated treatment response using predefined criteria. A diagnosis of chronic inflammatory neuropathy was established when NCS were abnormal (fulfilling criteria of demyelination of the European Federation of Neurological Societies/Peripheral Nerve Society) or when the degree of nerve enlargement detected by sonography was compatible with chronic inflammatory neuropathy and there was response to treatment. RESULTS A diagnosis of chronic inflammatory neuropathy was established in 38 patients. Sensitivity and specificity of nerve ultrasound and NCS were 97.4% and 69.4% and 78.9% and 93.5%, respectively. The added value of nerve ultrasound in detection of treatment-responsive chronic inflammatory neuropathy was 21.1% compared to NCS alone. CONCLUSIONS Nerve ultrasound and NCS are complementary techniques with superior sensitivity in the former and specificity in the latter. Addition of nerve ultrasound significantly improves the detection of chronic inflammatory neuropathies. Therefore, it deserves a prominent place in the diagnostic workup of chronic inflammatory neuropathies. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that nerve ultrasound is an accurate diagnostic tool to detect chronic inflammatory neuropathies.
Collapse
Affiliation(s)
- Ingrid J T Herraets
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - H Stephan Goedee
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Johan A Telleman
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - J Thies van Asseldonk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leo H Visser
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - W Ludo van der Pol
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.
| |
Collapse
|
7
|
Goedee HS, Herraets IJT, Visser LH, Franssen H, van Asseldonk JTH, van der Pol WL, van den Berg LH. Nerve ultrasound can identify treatment-responsive chronic neuropathies without electrodiagnostic features of demyelination. Muscle Nerve 2019; 60:415-419. [PMID: 31294858 PMCID: PMC6771613 DOI: 10.1002/mus.26629] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023]
Abstract
Introduction We present a case series of six treatment‐naive patients with clinical phenotypes compatible with chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy without electrodiagnostic features of demyelination but with abnormal peripheral ultrasound findings who responded to treatment. Methods All six patients underwent a complete set of ancillary investigations, including extensive nerve conduction studies. We also performed standardized nerve ultrasound of median nerves and brachial plexus as part of a larger effort to evaluate diagnostic value of sonography. Results Nerve conduction studies did not show conduction block or other signs of demyelination in any of the six patients. Sonographic nerve enlargement was present in all patients and was most prominent in proximal segments of the median nerve and brachial plexus. Treatment with intravenous immunoglobulin resulted in objective clinical improvement. Discussion Our study provides evidence that nerve ultrasound represents a useful complementary diagnostic tool for the identification of treatment‐responsive inflammatory neuropathies.
Collapse
Affiliation(s)
- H Stephan Goedee
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingrid J T Herraets
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Hessel Franssen
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Thies H van Asseldonk
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - W Ludo van der Pol
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
8
|
Goedee HS, van der Pol WL, Hendrikse J, van den Berg LH. Nerve ultrasound and magnetic resonance imaging in the diagnosis of neuropathy. Curr Opin Neurol 2019; 31:526-533. [PMID: 30153189 DOI: 10.1097/wco.0000000000000607] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the most relevant developments in the fields of nerve ultrasound and MRI in the diagnosis of treatable inflammatory neuropathies over the last 18 months. RECENT FINDINGS MRI and nerve ultrasound can accurately identify potentially treatable neuropathies and thereby help to improve diagnosis. Advanced MRI techniques also show potential to dissect pathophysiology. The apparent mismatch between nerve function and morphology is not surprising and reflects different dimensions of the disease process in neuropathies. SUMMARY MRI and nerve ultrasound have become useful tools in the diagnosis of inflammatory neuropathies. VIDEO ABSTRACT.
Collapse
Affiliation(s)
- H Stephan Goedee
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery
| | | | | | | |
Collapse
|
9
|
Intravenous immunoglobulins in patients with clinically suspected chronic immune-mediated neuropathy. J Neurol Sci 2019; 397:141-145. [DOI: 10.1016/j.jns.2018.12.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/28/2018] [Accepted: 12/31/2018] [Indexed: 02/07/2023]
|
10
|
Levine TD, Katz JS, Barohn R, Vaughan LJ, Dimachkie MM, Saperstein DS, Mozaffar T, Wolfe GI, Mayo MS, Badger GJ, Katzin L, Ritt E, Greer M, DiStefano J, Schmidt PM. Review process for IVIg treatment: Lessons learned from INSIGHTS neuropathy study. Neurol Clin Pract 2018; 8:429-436. [PMID: 30564497 PMCID: PMC6276327 DOI: 10.1212/cpj.0000000000000520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background This project is an effort to understand how orders for IV immunoglobulin (IVIg) are documented and prescribed by physicians, and subsequently, how they are reviewed by insurance companies for the treatment of immune neuropathies. Methods A panel of neuromuscular specialists reviewed case records from 248 IVIg-naive patients whose in-home IVIg infusion treatment was submitted to insurance for authorization. After reviewing a case record, 1 panelist was asked to make a diagnosis and to answer several questions about the treatment. A second panelist reviewed the original record and follow-up records that were obtained for reauthorization of additional treatments and was asked to determine whether the patient had responded to the treatment. Results Our specialists believed that only 32.2% of 248 patients had an immune neuropathy and were appropriate candidates for IVIg therapy, whereas 46.4% had neuropathies that were not immune mediated. Only 15.3% of cases met electrodiagnostic criteria for a demyelinating neuropathy. Our specialists believed that 36.7% of 128 cases with follow-up records had responded to therapy. In cases in which the initial reviewer had predicted that there would be a response to IVIg, the second reviewer found that 54% had responded. This is compared with a 27% response rate when the first reviewer predicted that there would be no response (p = 0.019). Conclusions Our expert review finds that the diagnosis of immune neuropathies made by providers, and subsequently approved for IVIg therapy by payers, is incorrect in a large percentage of cases. If payers include an expert in their review process, it would improve patient selection, appropriate use, and continuation of treatment with this expensive therapeutic agent.
Collapse
Affiliation(s)
- Todd D Levine
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Jonathan S Katz
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Richard Barohn
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Leslie J Vaughan
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Mazen M Dimachkie
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - David S Saperstein
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Tahseen Mozaffar
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Gil I Wolfe
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Matthew S Mayo
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Gary J Badger
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Lara Katzin
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Elissa Ritt
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Michelle Greer
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Joseph DiStefano
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Patrick M Schmidt
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| |
Collapse
|
11
|
Garg N, Park SB, Vucic S, Yiannikas C, Spies J, Howells J, Huynh W, Matamala JM, Krishnan AV, Pollard JD, Cornblath DR, Reilly MM, Kiernan MC. Differentiating lower motor neuron syndromes. J Neurol Neurosurg Psychiatry 2017; 88:474-483. [PMID: 28003344 PMCID: PMC5529975 DOI: 10.1136/jnnp-2016-313526] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
Abstract
Lower motor neuron (LMN) syndromes typically present with muscle wasting and weakness and may arise from pathology affecting the distal motor nerve up to the level of the anterior horn cell. A variety of hereditary causes are recognised, including spinal muscular atrophy, distal hereditary motor neuropathy and LMN variants of familial motor neuron disease. Recent genetic advances have resulted in the identification of a variety of disease-causing mutations. Immune-mediated disorders, including multifocal motor neuropathy and variants of chronic inflammatory demyelinating polyneuropathy, account for a proportion of LMN presentations and are important to recognise, as effective treatments are available. The present review will outline the spectrum of LMN syndromes that may develop in adulthood and provide a framework for the clinician assessing a patient presenting with predominantly LMN features.
Collapse
Affiliation(s)
- Nidhi Garg
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Susanna B Park
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Steve Vucic
- Departments of Neurology and Neurophysiology, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Con Yiannikas
- Department of Neurology, Concord and Royal North Shore Hospitals, The University of Sydney, Sydney, New South Wales, Australia
| | - Judy Spies
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - James Howells
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - William Huynh
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - José M Matamala
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Arun V Krishnan
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - John D Pollard
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - David R Cornblath
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mary M Reilly
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, UK
| | - Matthew C Kiernan
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Juntas Morales R, Pageot N, Taieb G, Camu W. Adult-onset spinal muscular atrophy: An update. Rev Neurol (Paris) 2017; 173:308-319. [DOI: 10.1016/j.neurol.2017.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 03/01/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
|
13
|
Lenglet T, Camdessanché JP. Amyotrophic lateral sclerosis or not: Keys for the diagnosis. Rev Neurol (Paris) 2017; 173:280-287. [PMID: 28461025 DOI: 10.1016/j.neurol.2017.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a degenerative motor neuron disease (MND) which prognosis is poor. Early diagnosis permit to set up immediately adapted treatment and cares. Available diagnostic criteria are based on the detection of both central and peripheral motor neuron injury in bulbar, cervical, thoracic and lumbar regions. Electrodiagnostic (EDX) tests are the key tools to identify peripheral motor neuron involvement. Needle examination records abnormal activities at rest, and looks for neurogenic pattern during muscle contraction. Motor unit potentials morphology is modified primary to recruitment. Motor evoked potentials remain the test of choice to identify impairment of central motor neurons. In the absence of diagnostic biomarker of ALS and among essential investigations of suspected MND, a careful clinical and neurophysiological work-up is essential to rule out the differential diagnosis.
Collapse
Affiliation(s)
- T Lenglet
- Département de neurophysiologie clinique, Hôpital de la Salpêtrière, Assistance Publique-Hôpitaux de Paris, France; Centre Référent Maladies du Motoneurone et SLA, Hôpital de la Salpêtrière, Assistance Publique-Hôpitaux de Paris, France
| | - J-P Camdessanché
- Service de Neurologie, Hôpital Nord, CHU de Saint-Etienne, France; Centre Référent Maladies du Motoneurone et SLA, CHU de Saint-Etienne, France.
| |
Collapse
|
14
|
Abstract
Progressive muscular atrophy (PMA) is a rare, sporadic, adult-onset motor neuron disease, clinically characterized by isolated lower motor neuron features; however, clinically evident upper motor neuron signs may emerge in some patients. Subclinical upper motor neuron involvement is identified pathologically, radiologically, and neurophysiologically in a substantial number of patients with PMA. Patients with subclinical upper motor neuron involvement do not fulfill the revised El Escorial criteria to participate in amyotrophic lateral sclerosis clinical trials. Intravenous immunoglobulin therapy is only marginally beneficial in a small subgroup of patients with lower motor neuron syndrome without conduction block.
Collapse
Affiliation(s)
- Teerin Liewluck
- Department of Neurology, University of Colorado School of Medicine, Anschutz Medical Campus, 12631 East 17th Avenue, Mail Stop B-185, Aurora, CO 80045, USA; Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - David S Saperstein
- Phoenix Neurological Associates, University of Arizona College of Medicine, 5090 North 40th Street, Suite 250, Phoenix, AZ 85018, USA
| |
Collapse
|
15
|
Finsterer J, Zarrouk-Mahjoub S. Treatment of muscle weakness in neuromuscular disorders. Expert Rev Neurother 2016; 16:1383-1395. [PMID: 27376189 DOI: 10.1080/14737175.2016.1206471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Weakness is one of the predominant clinical manifestations of neuromuscular disorders (NMDs), which strongly influences daily life, prognosis, and outcome of affected patients. One of the major therapeutic goals in NMD-patients is to completely resolve muscle weakness. Various treatment options are available and include physical therapy, electrotherapy, diet, drugs, avoidance or withdrawal of muscle-toxic and weakness-inducing agents, detoxification, stem-cell-therapy, plasma-exchange, respiratory therapy, or surgery. Most accessible to treatment is weakness from immune-mediated neuropathies, immune-mediated transmission-disorders, and idiopathic immune myopathies. Areas covered: This manuscript aims to summarize and discuss recent findings and future perspectives concerning the treatment of muscle weakness in NMDs. Data were obtained by a literature search in databases such as PubMed and Current-Contents. Expert commentary: Weakness is most easily treatable in acquired NMDs and in hereditary myopathies and neuropathies beneficial treatment options are also available. Research needs to be encouraged and intensified to further expand the spectrum of treatment options for weakness.
Collapse
|
16
|
|
17
|
Abstract
Disorders of peripheral nerve have been traditionally diagnosed and monitored using clinical and electrodiagnostic approaches. The last two decades have seen rapid development of both magnetic resonance imaging (MRI) and ultrasound imaging of peripheral nerve, such that these imaging modalities are increasingly invaluable to the diagnosis of patients with peripheral nerve disorders. Peripheral nerve imaging provides information which is supplementary to clinical and electrodiagnostic diagnosis. Both MRI and ultrasound have particular benefits in specific clinical circumstances and can be considered as complementary techniques. These technologic developments in peripheral nerve imaging will usher in an era of multimodality assessment of peripheral nerve disorders, with clinical evaluations supported by anatomic information from imaging, and functional information from electrodiagnostic studies. Such a multimodality approach will improve the accuracy and efficiency of patient care.
Collapse
Affiliation(s)
- Neil G Simon
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Jason Talbott
- Department of Radiology, University of California, San Francisco, CA, USA
| | - Cynthia T Chin
- Department of Radiology, University of California, San Francisco, CA, USA
| | - Michel Kliot
- Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
18
|
Simon NG, Huynh W, Vucic S, Talbot K, Kiernan MC. Motor neuron disease: current management and future prospects. Intern Med J 2015; 45:1005-13. [DOI: 10.1111/imj.12874] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/27/2015] [Indexed: 12/11/2022]
Affiliation(s)
- N. G. Simon
- Prince of Wales Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - W. Huynh
- Prince of Wales Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - S. Vucic
- Westmead Clinical School; C24 Westmead Hospital; The University of Sydney; Sydney New South Wales Australia
| | - K. Talbot
- Division of Clinical Neurology; University of Oxford; Oxford UK
| | - M. C. Kiernan
- Brain and Mind Research Institute; Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| |
Collapse
|
19
|
Gallardo E, Noto YI, Simon NG. Ultrasound in the diagnosis of peripheral neuropathy: structure meets function in the neuromuscular clinic. J Neurol Neurosurg Psychiatry 2015; 86:1066-74. [PMID: 25653385 DOI: 10.1136/jnnp-2014-309599] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023]
Abstract
Peripheral nerve ultrasound (US) has emerged as a promising technique for the diagnosis of peripheral nerve disorders. While most experience with US has been reported in the context of nerve entrapment syndromes, the role of US in the diagnosis of peripheral neuropathy (PN) has recently been explored. Distinctive US findings have been reported in patients with hereditary, immune-mediated, infectious and axonal PN; US may add complementary information to neurophysiological studies in the diagnostic work-up of PN. This review describes the characteristic US findings in PN reported to date and a classification of abnormal nerve US patterns in PN is proposed. Closer scrutiny of nerve abnormalities beyond assessment of nerve calibre may allow for more accurate diagnostic classification of PN, as well as contribute to the understanding of the intersection of structure and function in PN.
Collapse
Affiliation(s)
- Elena Gallardo
- Service of Radiology, University Hospital Marqués de Valdecilla; Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain University of Cantabria (UC); and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Santander, Spain
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Neil G Simon
- Prince of Wales Clinical School, University of New South Wales, Australia Central Clinical School, The University of Sydney, Australia
| |
Collapse
|
20
|
Simon NG, Kiernan MC. Precise correlation between structural and electrophysiological disturbances in MADSAM neuropathy. Neuromuscul Disord 2015; 25:904-7. [PMID: 26314279 DOI: 10.1016/j.nmd.2015.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 12/17/2022]
Abstract
Multifocal acquired demyelinating sensory and motor neuropathy is characterised by multifocal clinical deficits. Imaging studies have identified multifocal enlargements of nerve trunks, but a precise correlation between structural abnormalities and electrophysiological dysfunction has not been elucidated. Two patients diagnosed with multifocal acquired demyelinating sensory and motor neuropathy were evaluated with nerve conduction studies, including short segment nerve conduction studies to precisely localise motor conduction block, and ultrasound studies of corresponding nerve trunks. Motor conduction block was identified in each patient (upper limb nerves in two patients), superimposed on additional demyelinating neurophysiological features. Upper limb ultrasound studies demonstrated focal nerve enlargement that precisely correlated with neurophysiological conduction block. The results of this study suggest that factors contributing to focal structural abnormalities in multifocal acquired demyelinating sensory and motor neuropathy are also those that produce conduction block.
Collapse
Affiliation(s)
- Neil G Simon
- Brain and Mind Research Institute, Sydney Medical School, The University of Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Australia.
| | - Matthew C Kiernan
- Brain and Mind Research Institute, Sydney Medical School, The University of Sydney, Australia
| |
Collapse
|
21
|
Pitarokoili K, Gold R, Yoon MS. Nerve ultrasound in a case of multifocal motor neuropathy without conduction block. Muscle Nerve 2015; 52:294-9. [DOI: 10.1002/mus.24583] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Kalliopi Pitarokoili
- Department of Neurology; St. Josef Hospital, Ruhr-University of Bochum; Gudrunstr. 56 44791 Bochum Germany
| | - Ralf Gold
- Department of Neurology; St. Josef Hospital, Ruhr-University of Bochum; Gudrunstr. 56 44791 Bochum Germany
| | - Min-Suk Yoon
- Department of Neurology; St. Josef Hospital, Ruhr-University of Bochum; Gudrunstr. 56 44791 Bochum Germany
| |
Collapse
|
22
|
Simon NG, Turner MR, Vucic S, Al-Chalabi A, Shefner J, Lomen-Hoerth C, Kiernan MC. Quantifying disease progression in amyotrophic lateral sclerosis. Ann Neurol 2014; 76:643-57. [PMID: 25223628 PMCID: PMC4305209 DOI: 10.1002/ana.24273] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/12/2014] [Accepted: 09/12/2014] [Indexed: 12/28/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) exhibits characteristic variability of onset and rate of disease progression, with inherent clinical heterogeneity making disease quantitation difficult. Recent advances in understanding pathogenic mechanisms linked to the development of ALS impose an increasing need to develop strategies to predict and more objectively measure disease progression. This review explores phenotypic and genetic determinants of disease progression in ALS, and examines established and evolving biomarkers that may contribute to robust measurement in longitudinal clinical studies. With targeted neuroprotective strategies on the horizon, developing efficiencies in clinical trial design may facilitate timely entry of novel treatments into the clinic.
Collapse
Affiliation(s)
- Neil G Simon
- Department of Neurology, University of California, San Francisco, San Francisco, CA; Prince of Wales Clinical School, University of New South Wales, Randwick, Australia; Neuroscience Research Australia, Barker St, Randwick, Australia
| | | | | | | | | | | | | |
Collapse
|
23
|
Alanazy MH, White C, Korngut L. Diagnostic yield and cost-effectiveness of investigations in patients presenting with isolated lower motor neuron signs. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15:414-9. [DOI: 10.3109/21678421.2014.913635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|