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Wilf-Yarkoni A, Zmira O, Tolkovsky A, Pflantzer B, Gofrit SG, Kleffner I, Paul F, Dörr J. Clinical Characterization and Ancillary Tests in Susac Syndrome: A Systematic Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200209. [PMID: 38364193 PMCID: PMC11073882 DOI: 10.1212/nxi.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 02/18/2024]
Abstract
Susac syndrome (SuS) is an orphan microangiopathic disease characterized by a triad of encephalopathy, visual disturbances due to branch retinal artery occlusions, and sensorineuronal hearing loss. Our previous systematic review on all cases of SuS reported until 2012 allowed for a better understanding of clinical presentation and diagnostic findings. Based on these data, we suggested diagnostic criteria in 2016 to allow early diagnosis and treatment of SuS. In view of the accumulation of new SuS cases reported in the last 10 years and improved diagnostic tools, we here aimed at updating the demographic and clinical features of SuS and to review the updated ancillary tests being used for SuS diagnosis. Therefore, based on the 2016 criteria, we systematically collected and evaluated data on SuS published from January 2013 to March 2022.
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Affiliation(s)
- Adi Wilf-Yarkoni
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Ofir Zmira
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Assaf Tolkovsky
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Barak Pflantzer
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Shany G Gofrit
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Ilka Kleffner
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Friedemann Paul
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Jan Dörr
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
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Strunk D, Sinnecker T, Kleffner I, Doerr J, Ringelstein M, Gross CC, Deuschl C, Maderwald S, Quick HH, Yamac E, Wrede KH, Kraemer M. Central intra-lesional iron deposits as a possible novel imaging marker at 7 Tesla MRI in Susac Syndrome - an exploratory study. BMC Med Imaging 2024; 24:4. [PMID: 38166655 PMCID: PMC10759674 DOI: 10.1186/s12880-023-01171-7] [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: 06/18/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare autoimmune disease that leads to hearing impairment, visual field deficits, and encephalopathy due to an occlusion of precapillary arterioles in the brain, retina, and inner ear. Given the potentially disastrous outcome and difficulties in distinguishing SuS from its differential diagnoses, such as multiple sclerosis (MS), our exploratory study aimed at identifying potential new SuS-specific neuroimaging markers. METHODS Seven patients with a definite diagnosis of SuS underwent magnetic resonance imaging (MRI) at 7 Tesla (7T), including T2* weighted and quantitative susceptibility mapping (QSM) sequences. T2 weighted hyperintense lesions were analyzed with regard to number, volume, localization, central vein sign, T1 hypointensity, and focal iron deposits in the center of SuS lesions ("iron dots"). Seven T MRI datasets from the same institute, comprising 75 patients with, among others, MS, served as controls. RESULTS The "iron dot" sign was present in 71.4% (5/7) of the SuS patients, compared to 0% in our control cohort. Thus, sensitivity was 71.4% and specificity 100%. A central vein sign was only incidentally detected. CONCLUSION We are the first to demonstrate this type of "iron dot" lesions on highly resolving 7T T2*w and QSM images in vivo as a promising neuroimaging marker of SuS, corroborating previous histopathological ex vivo findings.
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Affiliation(s)
- Daniel Strunk
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Tim Sinnecker
- Medical Image Analysis Center (MIAC AG), Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Ilka Kleffner
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Jan Doerr
- Department of Neurology, Oberhavel Kliniken, Hennigsdorf, Germany
- Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Westfälische Wilhelms University of Münster, Münster, Germany
| | - Cornelius Deuschl
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Stefan Maderwald
- Erwin L. Hahn Institute for Magnetic Resonance ImagingEssen, Germany & High Field and Hybrid MR Imaging, University Duisburg-EssenUniversity Hospital Essen, Essen, Germany
| | - Harald H Quick
- Erwin L. Hahn Institute for Magnetic Resonance ImagingEssen, Germany & High Field and Hybrid MR Imaging, University Duisburg-EssenUniversity Hospital Essen, Essen, Germany
| | - Elif Yamac
- Department of Intracranial Endovascular Therapy, Alfried Krupp Hospital, Essen, Germany
| | - Karsten H Wrede
- Erwin L. Hahn Institute for Magnetic Resonance ImagingEssen, Germany & High Field and Hybrid MR Imaging, University Duisburg-EssenUniversity Hospital Essen, Essen, Germany
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany.
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
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Bose S, Papathanasiou A, Karkhanis S, Appleton JP, King D, Batra R, Mollan SP, Jacob S. Susac syndrome: neurological update (clinical features, long-term observational follow-up and management of sixteen patients). J Neurol 2023; 270:6193-6206. [PMID: 37608221 PMCID: PMC10632257 DOI: 10.1007/s00415-023-11891-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/24/2023]
Abstract
Susac syndrome is a likely autoimmune microangiopathy affecting the brain, retina and inner ear. Due to the rarity of this condition, diagnosis and treatment can be challenging. Diagnosis is based on the presence of the clinical triad of central nervous system dysfunction, branch retinal artery occlusions and sensorineural hearing loss. Typical MRI findings of callosal and peri-callosal lesions may assist in diagnosis. Clinical course can be monophasic, polycyclic or chronic continuous. It is important to look out for red flags to attain an accurate diagnosis and follow a therapeutic algorithm based on severity of the disease and response to treatment. Patients are treated with steroids and immunosuppressive agents with a variable response. Early aggressive treatment especially in severe cases, may help in preventing relapses and morbidity/disability. This study highlights important diagnostic features and proposes a treatment algorithm based on clinical experience from management of 16 patients from 2 neuroscience centres in the UK since 2007, who were followed up over a long period of 3-15 years.
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Affiliation(s)
- Smriti Bose
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | | | - Sameep Karkhanis
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Jason P Appleton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, Birmingham, UK
| | - Dominic King
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Ruchika Batra
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Lotti A, Barilaro A, Mariottini A, Vannozzi L, Piergentili M, Fainardi E, Massacesi L. Case report: 3D intracranial vessel wall MRI in Susac syndrome: potential relevance for diagnosis and therapeutic management. Front Neurol 2023; 14:1201643. [PMID: 37638191 PMCID: PMC10456863 DOI: 10.3389/fneur.2023.1201643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/29/2023] [Indexed: 08/29/2023] Open
Abstract
Background Susac syndrome (SS) is a rare immune-mediated vasculitis affecting retina, inner ear and brain. Assessment of central nervous system (CNS) involvement is currently based on standard brain magnetic resonance imaging (MRI) sequences. Accuracy of three dimensional (3D)-vessel wall imaging (VWI) was compared to standard sequences and contrast-enhanced-3D T2-fluid attenuated inversion recovery (CE-FLAIR) to assess CNS disease activity in two cases of definite SS. Methods Brain MRI scan and retinal fluorescein angiogram (RFA) were performed at disease onset and at 1, 3, and 6 months after induction therapy start. CE-FLAIR and VWI based on 3D black-blood proton density weighted (PDW) with and without gadolinium were added to standard sequences on a 3 Tesla MRI scanner. Results Contrast enhanced-VWI (CE-VWI) detected an abnormal diffuse leptomeningeal enhancement (LME) in both cases at onset and during follow-up. Pathological enhancement on CE-VWI persisted at 6-month brain MRI, despite absence of new lesions and disappearance of LME on CE-FLAIR. Follow-up RFA revealed new arterial wall hyperfluorescence in both cases. Conclusions VWI may represent a useful tool for diagnosing and monitoring CNS disease activity in SS patients, as confirmed by concordance with RFA, leading treatment's choice and timing. Moreover, CE-VWI seemed at least as sensitive as CE-FLAIR in detecting LME, possibly being superior to the latter in posterior fossa. LME remission might be not accurate in predicting suppression of CNS inflammation in SS.
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Affiliation(s)
- Antonio Lotti
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | | | - Alice Mariottini
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
| | - Lorenzo Vannozzi
- Department of Ophthalmology, Careggi University Hospital, Florence, Italy
| | - Marco Piergentili
- Department of Ophthalmology, Careggi University Hospital, Florence, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Luca Massacesi
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
- Department of Neurology 2, Careggi University Hospital, Florence, Italy
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