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Mallikarjun KS, Eldaya RW, Miller-Thomas MM, Orlowski HL, Parsons MS. Good Gone Bad: Complications of Chemotherapy, Immunotherapy, and Radiotherapy on the CNS. Curr Probl Diagn Radiol 2024; 53:133-149. [PMID: 37495483 DOI: 10.1067/j.cpradiol.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/28/2023]
Abstract
With recent advancements in cancer therapy, especially immunotherapy, overall survival of many cancers has increased and patient toxicity has been reduced. However, many complications of traditional cancer therapy are still prevalent and complications of novel therapies are just beginning to appear. The neuroradiologist may be the first to visualize signs of these complications on imaging. This article describes the notable imaging findings of several unique and characteristic complications of CNS cancer therapy, including toxicities of chemotherapies, immunotherapies, and radiotherapy. Complications of chemotherapeutic agents covered include methotrexate-induced and disseminated necrotizing leukoencephalopathy, and chemotherapy-induced myelopathy. Immunotherapy complications included are Tacrolimus-related Optic Neuropathy, Rituximab and Immune reconstitution inflammatory syndrome-associated Progressive Multifocal Leukoencephalopathy, Bevacizumab-associated late radiation-induced neurotoxicity, and Ipilimumab-induced hypophysitis. Lastly, radiation-induced neurotoxicities are covered, including myelopathy, radiation necrosis, cerebral atrophy, leukoencephalopathy, optic neuropathy, mineralizing microangiopathy, stroke-like migraine attacks, osteonecrosis, and vasculopathies. Neuroradiologists will increasingly encounter patients who have undergone treatment with more than 1 therapeutic modality, resulting in overlapping findings as well. Recognition of the common complications of these therapies on imaging is critical to minimizing the effects of these potential short- and long-term complications.
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Emmanouilidou E, Kosmara D, Papadaki E, Mastorodemos V, Constantoulakis P, Repa A, Christopoulou G, Kalpadakis C, Avgoustidis N, Thomas K, Boumpas D, Sidiropoulos P, Bertsias G. Progressive Multifocal Leukoencephalopathy in Systemic Lupus Erythematosus: A Consequence of Patient-Intrinsic or -Extrinsic Factors? J Clin Med 2023; 12:6945. [PMID: 37959410 PMCID: PMC10647998 DOI: 10.3390/jcm12216945] [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: 10/04/2023] [Revised: 11/03/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by reactivation of the polyomavirus JC (JCV) typically in immunocompromised individuals. The risk of PML among rheumatic diseases may be higher for systemic lupus erythematosus (SLE), without, however, a clear association with the type and intensity of background therapy. We present the development and outcome of PML in a 32-year-old female lupus patient under mild immunosuppressive treatment, yet with marked B-cell lymphopenia in the peripheral blood and bone marrow (<1% of total lymphocytes). Despite treatment with the immune checkpoint inhibitor pembrolizumab, the patient showed progressive neurological and brain imaging deterioration and eventually died 15 months after PML diagnosis. To unveil possible underlying genetic liabilities, whole exome sequencing was performed which identified deleterious variants in GATA2 and CDH7 genes, which both have been linked to defective T- and/or B-lymphocyte production. These findings reiterate the possible role of disease-/patient-intrinsic factors, rather than that of drug-induced immunosuppression, in driving immune dysregulation and susceptibility to PML in certain patients with SLE.
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Affiliation(s)
- Evgenia Emmanouilidou
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
| | - Despoina Kosmara
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
| | - Efrosini Papadaki
- Department of Radiology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece
- Computational Bio-Medicine Laboratory, Institute of Computer Science, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
| | | | | | - Argyro Repa
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
| | | | - Christina Kalpadakis
- Department of Laboratory Hematology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece
| | - Nestor Avgoustidis
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
| | - Konstantinos Thomas
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, Attikon University General Hospital, 12462 Chaidari, Greece
| | - Dimitrios Boumpas
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, Attikon University General Hospital, 12462 Chaidari, Greece
- Laboratory of Autoimmunity and Inflammation, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, 11527 Athens, Greece
| | - Prodromos Sidiropoulos
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
| | - George Bertsias
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
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Albini F, Pisoni A, Salvatore A, Calzolari E, Casati C, Marzoli SB, Falini A, Crespi SA, Godi C, Castellano A, Bolognini N, Vallar G. Aftereffects to Prism Exposure without Adaptation: A Single Case Study. Brain Sci 2022; 12:brainsci12040480. [PMID: 35448011 PMCID: PMC9028811 DOI: 10.3390/brainsci12040480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/07/2022] [Accepted: 03/24/2022] [Indexed: 02/05/2023] Open
Abstract
Visuo-motor adaptation to optical prisms (Prism Adaptation, PA), displacing the visual scene laterally, is a behavioral method used for the experimental investigation of visuomotor plasticity, and, in clinical settings, for temporarily ameliorating and rehabilitating unilateral spatial neglect. This study investigated the building up of PA, and the presence of the typically occurring subsequent Aftereffects (AEs) in a brain-damaged patient (TMA), suffering from apperceptive agnosia and a right visual half-field defect, with bilateral atrophy of the parieto-occipital cortices, regions involved in PA and AEs. Base-Right prisms and control neutral lenses were used. PA was achieved by repeated pointing movements toward three types of stimuli: visual, auditory, and bimodal audio-visual. The presence and the magnitude of AEs were assessed by proprioceptive, visual, visuo-proprioceptive, and auditory-proprioceptive straight-ahead pointing tasks. The patient’s brain connectivity was investigated by Diffusion Tensor Imaging (DTI). Unlike control participants, TMA did not show any adaptation to prism exposure, but her AEs were largely preserved. These findings indicate that AEs may occur even in the absence of PA, as indexed by the reduction of the pointing error, showing a dissociation between the classical measures of PA and AEs. In the PA process, error reduction, and its feedback, may be less central to the building up of AEs, than the sensorimotor pointing activity per se.
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Affiliation(s)
- Federica Albini
- Department of Psychology, University of Milano-Bicocca, 20126 Milano, Italy; (A.P.); (A.S.); (N.B.)
- Correspondence: or (F.A.); (G.V.)
| | - Alberto Pisoni
- Department of Psychology, University of Milano-Bicocca, 20126 Milano, Italy; (A.P.); (A.S.); (N.B.)
| | - Anna Salvatore
- Department of Psychology, University of Milano-Bicocca, 20126 Milano, Italy; (A.P.); (A.S.); (N.B.)
| | - Elena Calzolari
- Neuro-Otology Unit, Division of Brain Sciences, Imperial College London, London SW7 2AZ, UK;
| | - Carlotta Casati
- Experimental Laboratory of Research in Clinical Neuropsychology, IRCCS Istituto Auxologico Italiano, 20155 Milano, Italy;
- Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, 20155 Milano, Italy
| | - Stefania Bianchi Marzoli
- Laboratory of Neuro-Ophthalmology and Ocular Electrophysiology, IRCCS Istituto Auxologico Italiano, 20155 Milano, Italy;
| | - Andrea Falini
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milano, Italy; (A.F.); (S.A.C.); (C.G.); (A.C.)
| | - Sofia Allegra Crespi
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milano, Italy; (A.F.); (S.A.C.); (C.G.); (A.C.)
| | - Claudia Godi
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milano, Italy; (A.F.); (S.A.C.); (C.G.); (A.C.)
| | - Antonella Castellano
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milano, Italy; (A.F.); (S.A.C.); (C.G.); (A.C.)
| | - Nadia Bolognini
- Department of Psychology, University of Milano-Bicocca, 20126 Milano, Italy; (A.P.); (A.S.); (N.B.)
- Experimental Laboratory of Research in Clinical Neuropsychology, IRCCS Istituto Auxologico Italiano, 20155 Milano, Italy;
| | - Giuseppe Vallar
- Department of Psychology, University of Milano-Bicocca, 20126 Milano, Italy; (A.P.); (A.S.); (N.B.)
- Experimental Laboratory of Research in Clinical Neuropsychology, IRCCS Istituto Auxologico Italiano, 20155 Milano, Italy;
- Correspondence: or (F.A.); (G.V.)
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D'Ettore N, Scheggi V, Alterini B, Marchionni N. Cerebral lesions in hematological malignancies: a case report. J Med Case Rep 2021; 15:603. [PMID: 34924018 PMCID: PMC8684816 DOI: 10.1186/s13256-021-03196-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 11/17/2021] [Indexed: 11/12/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy is a rare central nervous system disease, resulting from reactivation of latent John Cunningham virus. Monoclonal antibodies have recently become a relevant risk factor for developing progressive multifocal leukoencephalopathy.
Case summary We report the case of a 62-year-old Caucasian man who was admitted to our department in June 2020 because of right homonymous hemianopia. Magnetic resonance imaging findings were first interpreted as an intracranial relapsed lymphoma, so brain biopsy was performed, but no neoplastic cell was found. Histological sample only showed a large number of macrophages. The patient came back to our attention because of the worsening of neurological symptoms. A second magnetic resonance imaging showed widespread lesions suggestive of a demyelinating process. John Cunningham virus DNA was detected by polymerase chain reaction assay of the cerebrospinal fluid (over 9 million units/μL). The patient was treated supportively, but the outcome was poor. Discussion A multidisciplinary assessment should be performed for differential diagnosis of cerebral lesions in hematologic malignancies. Progressive multifocal leukoencephalopathy should be suspected in cases of subacute neurological symptoms and imaging findings consistent with it, especially if the patient received immunosuppressive or immunomodulatory drugs.
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Affiliation(s)
- Nicoletta D'Ettore
- Division of General Cardiology, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Largo Brambilla 3, 50133, Florence, Italy.
| | - Valentina Scheggi
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Brunetto Alterini
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Division of General Cardiology, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Largo Brambilla 3, 50133, Florence, Italy
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Khalili A, Craigie M, Donadoni M, Sariyer IK. Host-Immune Interactions in JC Virus Reactivation and Development of Progressive Multifocal Leukoencephalopathy (PML). J Neuroimmune Pharmacol 2019; 14:649-660. [PMID: 31452013 PMCID: PMC6898772 DOI: 10.1007/s11481-019-09877-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022]
Abstract
With the advent of immunomodulatory therapies and the HIV epidemic, the impact of JC Virus (JCV) on the public health system has grown significantly due to the increased incidence of Progressive Multifocal Leukoencephalopathy (PML). Currently, there are no pharmaceutical agents targeting JCV infection for the treatment and the prevention of viral reactivation leading to the development of PML. As JCV primarily reactivates in immunocompromised patients, it is proposed that the immune system (mainly the cellular-immunity component) plays a key role in the regulation of JCV to prevent productive infection and PML development. However, the exact mechanism of JCV immune regulation and reactivation is not well understood. Likewise, the impact of host factors on JCV regulation and reactivation is another understudied area. Here we discuss the current literature on host factor-mediated and immune factor-mediated regulation of JCV gene expression with the purpose of developing a model of the factors that are bypassed during JCV reactivation, and thus are potential targets for the development of therapeutic interventions to suppress PML initiation. Graphical Abstract.
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Affiliation(s)
- Amir Khalili
- Department of Neuroscience and Center for Neurovirology, Lewis Katz School of Medicine at Temple University, 3500 North Broad Street, Medical Education and Research Building, 7th Floor, Philadelphia, PA, 19140, USA
| | - Michael Craigie
- Department of Neuroscience and Center for Neurovirology, Lewis Katz School of Medicine at Temple University, 3500 North Broad Street, Medical Education and Research Building, 7th Floor, Philadelphia, PA, 19140, USA
| | - Martina Donadoni
- Department of Neuroscience and Center for Neurovirology, Lewis Katz School of Medicine at Temple University, 3500 North Broad Street, Medical Education and Research Building, 7th Floor, Philadelphia, PA, 19140, USA
| | - Ilker Kudret Sariyer
- Department of Neuroscience and Center for Neurovirology, Lewis Katz School of Medicine at Temple University, 3500 North Broad Street, Medical Education and Research Building, 7th Floor, Philadelphia, PA, 19140, USA.
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Effects of serial macrocyclic-based contrast materials gadoterate meglumine and gadobutrol administrations on gadolinium-related dentate nuclei signal increases in unenhanced T1-weighted brain: a retrospective study in 158 multiple sclerosis (MS) patients. Radiol Med 2017; 123:125-134. [PMID: 28952018 DOI: 10.1007/s11547-017-0816-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 09/13/2017] [Indexed: 01/07/2023]
Abstract
PURPOSE To perform T1 signal intensity (SI) measurements in the dentate nuclei of adult patients with confirmed multiple sclerosis (MS) after serial administrations of the macrocyclic gadolinium-based contrast agents (GBCAs), gadoterate meglumine and gadobutrol. MATERIALS AND METHODS This retrospective study was approved by the institutional review board and informed consent was waived. A review of our PACS database for the period from March 1, 2007 to July 31, 2016 revealed 158 confirmed MS patients who received exclusively either gadoterate meglumine (n = 81) or gadobutrol (n = 77) for diagnosis and follow-up. SI measurements on unenhanced T1-weighted images were performed on all scans of all patients and at regions of interest (ROIs) positioned on the dentate nucleus (DN) and pons. The dentate nucleus-to-pons (DNP) T1-SI ratio was subsequently calculated. Unpaired T test and regression analysis were used to evaluate statistical differences. RESULTS An increase in DNP was noted between the first and last MR examinations for both gadoterate meglumine (0.0032 ± 0.0216) and gadobutrol (0.0019 ± 0.0346). Although the differences were not statistically significant based across the entire patient population, visible T1 hyperintensity in the DN was noted in approximately one-third of all patients in each group that received at least five administrations of either GBCA. CONCLUSIONS SI increases on unenhanced T1-weighted images possibly indicative of gadolinium retention occur after serial administrations of the macrocyclic GBCAs, gadoterate meglumine and gadobutrol.
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Marsecano C, Bruno F, Michelini G, Perri M, Calvisi G, Di Cesare E, Splendiani A. Systemic metastases from central nervous system ependymoma: case report and review of the literature. Neuroradiol J 2017. [PMID: 28627990 DOI: 10.1177/1971400916689371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ependymal tumours in adults are rare, accounting for less than 4% of primary tumours of the central nervous system, and exceptionally metastasise outside the nervous system. In this study, we present a case of anaplastic ependymoma, which developed metastases outside the nervous system less than a year after its clinical onset. A healthy 65-year-old woman suddenly presented with drowsiness of unknown origin, accompanied by ingravescent fatigue, inability to maintain the upright posture, headache, nausea and vomiting. Computed tomography study performed in the emergency department showed the presence of an inhomogeneously hypodense area, with temporoparietal extension and median line deviation. After surgical excision, performed after two days, the bioptic examination demonstrated an anaplastic ependymoma with multiple areas of necrosis. The patient was submitted to adjuvant radiation therapy. At magnetic resonance imaging follow-up, performed three months after surgery, neither local recurrences nor typical 'drop metastases' to the spinal area were observed. Three months later, magnetic resonance imaging control revealed bone metastases and recurrences in the left insula and at the ipsilateral cerebellar hemisphere. Total body computed tomography examination showed metastases in the liver, vertebrae and pelvic bones, and involvement of paratracheal lymph nodes.
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Affiliation(s)
- Claudia Marsecano
- 1 Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Federico Bruno
- 1 Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Giulia Michelini
- 1 Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Marco Perri
- 1 Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Giuseppe Calvisi
- 2 Department of Pathology, S. Salvatore Hospital L'Aquila, L'Aquila, Italy
| | - Ernesto Di Cesare
- 1 Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Alessandra Splendiani
- 1 Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, L'Aquila, Italy
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Lin J, Xue B, Li X, Xia J. Monoclonal antibody therapy for neuromyelitis optica spectrum disorder: current and future. Int J Neurosci 2016; 127:735-744. [PMID: 27680606 DOI: 10.1080/00207454.2016.1242587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Monoclonal-antibody has been used for patients with autoimmune disorders for several years, and efficacy and safety were appreciated for these patients. Neuromyelitis optica specturm disorder (NMOSD) has been defined as an autoimmune demyelination disorder of the central nervous system (CNS) with a course of relapse-remission. Treatment of prevention is important for patients with NMOSD because of the increased disability after several attacks. Multiple factors were involved in the pathogenesis of NMOSD. Currently, targeting specific factor was favored in the research into the treatment for NMOSD. Previous studies reported the efficacy and tolerance in NMOSD for drugs such as rituximab, tocilizumab, and eculizumab. The aim of this article is to review the current monoclonal therapies for NMOSD patients, and also future alternative options.
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Affiliation(s)
- Jie Lin
- a Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Binbin Xue
- b Department of Anesthesiology , The First Affiliated Hospital of Wenzhou Medical University , Zhejiang , Wenzhou , China
| | - Xiang Li
- a Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Junhui Xia
- a Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , China
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Patriarca L, Torlone S, Ferrari F, Di Carmine C, Totaro R, di Cesare E, Splendiani A. Is size an essential criterion to define tumefactive plaque? MR features and clinical correlation in multiple sclerosis. Neuroradiol J 2016; 29:384-9. [PMID: 27531859 DOI: 10.1177/1971400916665385] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Tumefactive multiple sclerosis is an inflammatory demyelinating disease of the central nervous system. It has recently been described as a rare subtype of multiple sclerosis (MS) characterised by the appearance of solitary or multiple space-occupying lesions associated with imaging characteristics mimicking neoplasm. Atypical features include plaque size >2 cm with mass effect, oedema, and/or ring enhancement on magnetic resonance (MR) images.This study is a retrospective review designed to evaluate the prevalence of tumefactive plaques in a selected population of 440 MS patients referred to our MS centre in Southern Italy between 2005 and 2014. We analysed the radiographic features of lesions ranging in size from 0.5 to 2 cm to establish whether smaller plaques with MR characteristics similar to tumefactive plaques present different symptoms, disease evolution and prognosis. We also aimed to ascertain if MR features suggestive of biological aggressiveness could be useful prognostic criteria for a correct diagnosis of the disease and subsequent treatment. Our data suggest that lesions 0.5-2 cm and >2 cm have similar MR features and clinical evolution.
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Affiliation(s)
- Lucia Patriarca
- Department of Biotechnological and Applied Clinical Sciences, Radiology Unit, University of L'Aquila, Italy
| | - Silvia Torlone
- Department of Biotechnological and Applied Clinical Sciences, Radiology Unit, University of L'Aquila, Italy
| | - Fabiana Ferrari
- Department of Biotechnological and Applied Clinical Sciences, Radiology Unit, University of L'Aquila, Italy
| | - Caterina Di Carmine
- Multiple Sclerosis Center, Department of Neurology, San Salvatore Hospital, L'Aquila, Italy
| | - Rocco Totaro
- Multiple Sclerosis Center, Department of Neurology, San Salvatore Hospital, L'Aquila, Italy
| | - Ernesto di Cesare
- Department of Biotechnological and Applied Clinical Sciences, Radiology Unit, University of L'Aquila, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, Radiology Unit, University of L'Aquila, Italy
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Drug-associated progressive multifocal leukoencephalopathy: a clinical, radiological, and cerebrospinal fluid analysis of 326 cases. J Neurol 2016; 263:2004-21. [PMID: 27401179 PMCID: PMC5037162 DOI: 10.1007/s00415-016-8217-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 02/07/2023]
Abstract
The implementation of a variety of immunosuppressive therapies has made drug-associated progressive multifocal leukoencephalopathy (PML) an increasingly prevalent clinical entity. The purpose of this study was to investigate its diagnostic characteristics and to determine whether differences herein exist between the multiple sclerosis (MS), neoplasm, post-transplantation, and autoimmune disease subgroups. Reports of possible, probable, and definite PML according to the current diagnostic criteria were obtained by a systematic search of PubMed and the Dutch pharmacovigilance database. Demographic, epidemiologic, clinical, radiological, cerebrospinal fluid (CSF), and histopathological features were extracted from each report and differences were compared between the disease categories. In the 326 identified reports, PML onset occurred on average 29.5 months after drug introduction, varying from 14.2 to 37.8 months in the neoplasm and MS subgroups, respectively. The most common overall symptoms were motor weakness (48.6 %), cognitive deficits (43.2 %), dysarthria (26.3 %), and ataxia (24.1 %). The former two also constituted the most prevalent manifestations in each subgroup. Lesions were more often localized supratentorially (87.7 %) than infratentorially (27.4 %), especially in the frontal (64.1 %) and parietal lobes (46.6 %), and revealed enhancement in 27.6 % of cases, particularly in the MS (42.9 %) subgroup. Positive JC virus results in the first CSF sample were obtained in 63.5 %, while conversion after one or more negative outcomes occurred in 13.7 % of cases. 52.2 % of patients died, ranging from 12.0 to 83.3 % in the MS and neoplasm subgroups, respectively. In conclusion, despite the heterogeneous nature of the underlying diseases, motor weakness and cognitive changes were the two most common manifestations of drug-associated PML in all subgroups. The frontal and parietal lobes invariably constituted the predilection sites of drug-related PML lesions.
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Patriarca L, D'Orazio F, Di Cesare E, Splendiani A. Vanishing pineal mass in a young patient without therapy: Case report and review of the literature. Neuroradiol J 2016; 29:303-6. [PMID: 27301457 DOI: 10.1177/1971400916655480] [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: 11/16/2022] Open
Abstract
Spontaneous regression is defined as the decrease in size or disappearance of a primary tumour or metastatic disease without therapeutic intervention. Computed tomography and magnetic resonance imaging (MRI) of the brain was performed in a 14-year-old girl experiencing sudden-onset headaches. First diagnostic exams revealed a mass in the pineal region that disappeared at three-month MRI control. Three-year follow-up MRI studies were performed. No therapy was administered, but the pineal lesion had disappeared at three-year follow-up.
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Affiliation(s)
- Lucia Patriarca
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Federico D'Orazio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
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Splendiani A, Felli V, Di Sibio A, Gennarelli A, Patriarca L, Stratta P, Di Cesare E, Rossi A, Massimo G. Magnetic resonance imaging and magnetic resonance spectroscopy in a young male patient with anti-N-methyl-D-aspartate receptor encephalitis and uncommon cerebellar involvement: A case report with review of the literature. Neuroradiol J 2015; 29:30-5. [PMID: 26613928 DOI: 10.1177/1971400915609333] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We report a case of a 17-year-old man presenting with new onset psychiatric symptoms. Magnetic resonance imaging (MRI) and proton magnetic resonance (MR) spectroscopy revealed some lesions in the right cerebellar hemisphere and ipsilateral cerebellar tonsil suggestive of encephalitis. An extensive workup was negative for both infectious and neoplastic diseases and he was afterward diagnosed with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. This disorder is an autoimmune encephalitis, highly lethal but curable, predominantly found in young female with ovarian teratoma. He received methylprednisolone. His clinical findings gradually improve and he made a complete recovery. Accordingly, repeated brain MRI and proton MR spectroscopy showed a gradual reduction of the lesions; MRI taken six months after starting therapy showed complete resolution of the lesions. Our case shows that, although rare, anti-NMDAR encephalitis should be considered also in young men for whom a rapid onset of psychiatric neurological disorders cannot be explained by more frequent causes. Our report underlines also the usefulness of MRI and proton MR spectroscopic findings in the diagnosis and follow-up of this disease.
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Affiliation(s)
- Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Valentina Felli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Alessandra Di Sibio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Antonio Gennarelli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Lucia Patriarca
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Paolo Stratta
- Department of Mental Health, S. Salvatore Hospital, 67100, L'Aquila, Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Alessandro Rossi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Gallucci Massimo
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
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Froissart A, Veyradier A, Hié M, Benhamou Y, Coppo P. Rituximab in autoimmune thrombotic thrombocytopenic purpura: A success story. Eur J Intern Med 2015; 26:659-65. [PMID: 26293834 DOI: 10.1016/j.ejim.2015.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 11/20/2022]
Abstract
Despite a significant improvement of thrombotic thrombocytopenic purpura (TTP) prognosis since the use of plasma exchange, morbidity and mortality remained significant because of poor response to standard treatment or exacerbations and relapses. Rituximab, a chimeric monoclonal antibody directed against the B-lymphocyte CD20 antigen, has shown a particular interest in this indication. Recent studies also reported strong evidence for its efficiency in the prevention of relapses. This review addresses these recent progresses and still opened questions in this topic: should rituximab be proposed in all patients at the acute phase? Should all patients benefit from a preemptive treatment? Is the infectious risk acceptable in this context?
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Affiliation(s)
- Antoine Froissart
- Service de médecine interne, CHI, Créteil, France; Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Miguel Hié
- Service de Médecine Interne, Hôpital la Pitié-Salpétrière, Paris, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service de médecine interne, CHU Charles Nicolle, Rouen, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1009, Institut Gustave Roussy, Villejuif, France.
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Marsecano C, Perri M, Michelini G, Varrassi M, Splendiani A, di Cesare E, Masciocchi C, Gallucci M. Vascular malformation mimicking multiple sclerosis active plaque: Usefulness of susceptibility weighted imaging (SWI) to perform correct diagnosis. Neuroradiol J 2015; 28:488-92. [PMID: 26450102 PMCID: PMC4757214 DOI: 10.1177/1971400915609337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Brain focal hyperdensity areas are common findings in computed tomography examinations, often further evaluated in magnetic resonance imaging exams. These are usually haemosiderin and calcified perivascular clusters known as cerebral microbleeds and may be secondary signs of brain disorders. Cerebral microbleeds are paramagnetic and ferromagnetic substances determining magnetic field inhomogeneity. Susceptibility weighted imaging (SWI) performed at 3T with phase post-processing is very useful in evaluating this field variation. In fact in the past decade SWI has been increasingly reported for its clinical value in adults with neurologic disorders, traumas, arterial venous malformations, occult venous diseases, tumours and functional brain imaging. The occasional computed tomography findings of single or multiple focal hyperdense areas can mimic many of these brain disorders and lead to misinterpretations. For these reason it is useful to have a more detailed diagnosis with MRI brain examination. The authors highlight the role of SWI sequence in the differential diagnosis among active plaque, vascular malformation and haemorrhagic lesion in a case report of a 41-year-old woman suffering from multiple sclerosis with a focal hyperdense area reported in a computed tomography brain examination.
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Affiliation(s)
- Claudia Marsecano
- Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, Italy
| | - Marco Perri
- Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, Italy
| | - Giulia Michelini
- Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, Italy
| | - Marco Varrassi
- Department of Biotechnological and Applied Clinical Science, Division of Neuroradiology, University of L'Aquila. Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Science, Division of Neuroradiology, University of L'Aquila. Italy
| | - Ernesto di Cesare
- Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Science, Division of Radiology, University of L'Aquila, Italy
| | - Massimo Gallucci
- Department of Biotechnological and Applied Clinical Science, Division of Neuroradiology, University of L'Aquila. Italy
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