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Gupta A, Um D, Samant R, Hasbun R, Samudralwar RD, Sriwastava S, Gupta RK. Idiopathic Hypertrophic Spinal Pachymeningitis. J Med Cases 2023; 14:405-412. [PMID: 38186557 PMCID: PMC10769654 DOI: 10.14740/jmc4149] [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: 08/23/2023] [Accepted: 11/02/2023] [Indexed: 01/09/2024] Open
Abstract
Hypertrophic pachymeningitis (HP) is a rare presentation with duramater thickening and fibrosis which can result in cranial or spinal compressive disease. Most cases of spinal HP require surgical management. We present an uncommon case of idiopathic hypertrophic spinal pachymeningitis (IHSP) in a 40-year-old male who showed complete improvement to steroids without any further relapses. The patient presented with bilateral upper limb weakness with magnetic resonance imaging (MRI) spine showing diffuse dural thickening of the entire spine with cervical cord compression. He had an extensive workup for underlying etiology and worsening symptoms until he was diagnosed with IHSP. Later, he was started on high-dose steroids with good response and no relapse after 2 years. A descriptive analysis of IHSP cases since 2009 including ours showed that it usually occurs after 50s with female preponderance. Weakness and sensory loss are the most common complaints with 50% patients showing clinical signs of myelopathy like hyperreflexia, clonus, Babinski sign and sensory level. Cerebrospinal fluid (CSF) and inflammatory markers like erythrocytic sedimentation rate (ESR) and C-reactive protein (CRP) can be used to assess disease progression and prognosis. Surgical removal of HP followed by steroids is the best line of management while steroids alone can be tried in cases where clinical signs of myelopathy are absent.
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Affiliation(s)
- Ashutosh Gupta
- McGovern Medical School, UT Health Science Center at Houston, Houston, TX 77030, USA
| | - Daniel Um
- McGovern Medical School, UT Health Science Center at Houston, Houston, TX 77030, USA
| | - Rohan Samant
- Department of Radiology, UT Health Science Center at Houston, TX 77030, USA
| | - Rodrigo Hasbun
- Department of Infectious Disease, UT Health Science Center at Houston, TX 77030, USA
| | | | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Rajesh K. Gupta
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Tanaviriyachai T, Chinvattanachot G, Piyapromdee U, Sirisanthiti P. IgG4-Related Spinal Hypertrophic Pachymeningitis With Neurological Deficit: A Report of 2 Cases. JBJS Case Connect 2023; 13:01709767-202306000-00042. [PMID: 37262188 DOI: 10.2106/jbjs.cc.23.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
CASE Immunoglobulin G4 (IgG4)-related spinal hypertrophic pachymeningitis (IgG4-RHP) is a rare disease characterized by diffuse inflammatory fibrosis of the spinal dura mater that can cause myelopathy and neurological deficits. Here, we report 2 cases in which both patients presented with myelopathy and paraplegia. They underwent decompressive laminectomy, and the diagnoses were confirmed through histopathologic examination. Both patients received prednisolone postoperatively, which was subsequently switched to methotrexate for maintenance. CONCLUSION Two cases of IgG4-RHP were successfully treated with decompressive laminectomy and combined therapy with steroids and other immunosuppressive agents.
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Affiliation(s)
- Terdpong Tanaviriyachai
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Guntarat Chinvattanachot
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Urawit Piyapromdee
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Piyaporn Sirisanthiti
- Department of Hematology, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
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Hypertrophic Pachymeningitis in Chinese Patients: Presentation, Radiological Findings, and Clinical Course. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2926419. [PMID: 32879880 PMCID: PMC7448121 DOI: 10.1155/2020/2926419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/05/2020] [Accepted: 08/04/2020] [Indexed: 11/28/2022]
Abstract
Background Hypertrophic pachymeningitis (HP) is generally regarded as a rare inflammatory disease, which results in a diffuse thickening of the dura mater. We retrospectively collected data from patients with HP. Methods A total of 16 patients with HP were included in our study. The clinical features, laboratory evaluation, imaging findings, treatment, and outcome were reviewed. Results Of the 16 cases, half were male, with a mean age of 52.6 ± 13.2 years. The mean duration from onset to diagnosis was 8.6 months. The most frequent presenting symptoms in HP cases were a recurrently chronic headache (81.3%) and multiple cranial nerve injury (50%). Antineutrophil cytoplasmic antibody- (ANCA-) related HP was found in 5 cases and IgG4-related HP in 1 case. The intracranial pressure was elevated in 4 cases. The cerebrospinal fluid (CSF) had lymphocytosis in 5 cases and increased protein in 12 cases. Immunoglobulins (IgG, IgA, and IgM) and protein showed linear relationships in the CSF. On magnetic resonance imaging (MRI), localized or diffuse dura maters were thickened in all cases. HP combined with subacute subdural hemorrhage or hypertrophic spinal pachymeningitis was also observed in individual cases. Biopsy of the dura mater in one case showed amounts of inflammatory cells infiltrating, with an increased percentage of IgG4-positive plasma cells. Of all cases referring to glucocorticoid treatment, the symptoms have improved significantly in 10 cases. In other 6 cases, mycophenolate mofetil or azathioprine was added. All patients showed clinical improvement at the follow-up visits. Conclusion The clinical characters of HP are chronic onset, recurrently chronic headache, and multiple cranial nerves paralysis. Inflammatory changes in CSF caused by intrathecal synthesis of immunoglobulin, characteristic dural enhancement on MRI, and pathologic biopsy are all helpful for diagnosis. The addition of immunosuppressant, especially mycophenolate mofetil, is a good choice for steroid-resistance HP.
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Nardone R, Brigo F, Covi M, Carnicelli L, Caleri F, Tischler H, Hauer L, Sellner J. Hypertrophic chronic pachymeningitis associated with Epstein-Barr virus reactivation: a case report. J Neurovirol 2019; 25:426-428. [PMID: 30747332 DOI: 10.1007/s13365-019-00731-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 12/17/2018] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
Abstract
Hypertrophic pachymeningitis is a rare inflammatory condition characterized by the thickening of the dura mater. We describe a patient who presented with intractable headache and complex cranial nerve palsy. Hypertrophy of the frontal dura was accompanied by pleocytosis and detection of Epstein-Barr virus (EBV) by PCR in cerebrospinal fluid. Clinical symptoms gradually improved after acyclovir and corticosteroid treatment, whereas dural pathology remained unchanged on neuroimaging. This case points at an expansion of the spectrum of neurological manifestations for EBV.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy. .,Department of Neurology, Christian Doppler Medical Center, Salzburg, Austria.
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Markus Covi
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Luca Carnicelli
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Francesca Caleri
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Hannes Tischler
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Salzburg, Austria.,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Kutty R, Sreemathyamma S, Sivanandapanicker J, Peethambaran A. Idiopathic Hypertrophic Spinal Pachymeningitis: A Rare Cause of Spinal Cord Compression. Neurol India 2019; 67:1380-1385. [DOI: 10.4103/0028-3886.271262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Olubajo F, Yermakova T, Highley JR, Arzoglou V. Concomitant idiopathic hypertrophic spinal pachymeningitis and Guillain-Barré syndrome in a patient: coincidence or a triggering mechanism? J Neurosurg Spine 2017. [PMID: 28644069 DOI: 10.3171/2017.3.spine161112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Idiopathic hypertrophic spinal pachymeningitis (IHSP), a rare diffuse inflammatory thickening of the dura mater, and Guillain-Barré syndrome (GBS) are known entities but they have never been reported as concomitant diagnoses. To their knowledge, the authors present the first reported case in the international literature with supportive evidence for both IHSP (based on MRI, intraoperative, and histological findings) and GBS (based on history, clinical examination, and electrophysiological findings). They review the literature on IHSP and the diagnostic criteria for GBS, with the view of identifying a possible causative connection.
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Affiliation(s)
| | | | - J Robin Highley
- Department of Pathology, Hull and East Yorkshire Hospitals, Hull Royal Infirmary, Yorkshire, United Kingdom
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Park TJ, Seo WD, Kim SY, Cho JH, Kim DH, Kim KH. Effective Response of Methotrexate for Recurrent Idiopathic Hypertrophic Spinal Pachymeningitis. KOREAN JOURNAL OF SPINE 2017; 13:200-203. [PMID: 28127378 PMCID: PMC5266097 DOI: 10.14245/kjs.2016.13.4.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/19/2022]
Abstract
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a chronic progressive and diffuse inflammatory fibrosis of the spinal dura mater. Though treatment of IHSP is surgical decompression with steroid therapy, treatment for recurrent IHSP is controversial. Our patient was diagnosed with IHSP based on magnetic resonance imaging (MRI) and underwent laminectomy for decompression following steroid pulse therapy. Despite maintenance of steroid therapy, the patient experienced 3 recurrences. As an alternative immunosuppressant medication, methotrexate was introduced with low-dose steroid. Fortunately, the symptom was resolved, and a decrease of dura thickening was revealed on MRI. We present the case and suggest that methotrexate might be an effective treatment modality for recurrent IHSP.
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Affiliation(s)
- Tae Joon Park
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | | | - Sang Young Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jae Hoon Cho
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Hyun Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Hong Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
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Bang JH, Cho KT, Kim EJ. Idiopathic Hypertrophic Pachymeningitis in the Craniocervical Junction. KOREAN JOURNAL OF SPINE 2015; 12:169-72. [PMID: 26512276 PMCID: PMC4623176 DOI: 10.14245/kjs.2015.12.3.169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 08/21/2015] [Accepted: 09/02/2015] [Indexed: 11/27/2022]
Abstract
Idiopathic hypertrophic pachymeningitis (IHP) is a rare disease, and it is characterized by chronic progressive inflammatory fibrosis and thickening of the dura mater with resultant compression of the spinal cord or neural structure without any identifiable cause. It can occur in the intracranial or spinal dura mater alone or as a craniospinal form. The spinal form is rarer than the cranial form and the craniospinal form is extremely rare. We report a rare case of IHP in the craniocervical junction involving both the cranial and spinal dura mater and discuss the diagnosis and management of the disease.
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Affiliation(s)
- Jin Hyuk Bang
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea and Dongguk University, Seoul, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea and Dongguk University, Seoul, Korea
| | - Eo Jin Kim
- Department of Pathology, Dongguk University Ilsan Hospital, Goyang, Korea and Dongguk University, Seoul, Korea
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Dziedzic T, Wojciechowski J, Nowak A, Marchel A. Hypertrophic pachymeningitis. Childs Nerv Syst 2015; 31:1025-31. [PMID: 25771924 DOI: 10.1007/s00381-015-2680-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare clinical entity characterized by diffuse or localized fibrous thickening of the dura mater. It is well known but rare especially in pediatric population disease of differing origins. The primary (idiopathic) form is diagnosed after excluding other possible etiologies. Similar results from magnetic resonance imaging (MRI) for patients with hypertrophic pachymeningitis and meningiomas may make the diagnosis confusing. Additionally, making a proper diagnosis without histological sampling can be difficult in some cases. CASE DESCRIPTION We present a case of an 18-year-old boy diagnosed with hypertrophic pachymeningitis in the area of the hypoglossal canal. The diagnosis was made after a 2-month history of hypoglossal nerve palsy and dysphagia preceded by a middle ear infection. The patient was treated surgically with suspicion of meningioma, but no evidence of a tumor was found during the operation. The postoperative period was uneventful. At the latest check-up, MRI revealed regression of all previously observed pathological changes.
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Affiliation(s)
- Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland,
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Subrati N, Vaqas B, Peterson D, Patel MC. Hypertrophic pachymeningitis with sarcoidosis: a rare cause of craniocervical compression. BMJ Case Rep 2015; 2015:bcr-2014-208604. [PMID: 26021381 DOI: 10.1136/bcr-2014-208604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of a 58-year-old woman with a suspected dural tumour. She presented with progressive pyramidal weakness. MRI confirmed compression of the medulla oblongata and spinal cord at the level of C1-3. The localised dural mass lesion homogenously enhanced on T1 MRI and was considered most likely to be a meningioma. Incidentally, CT scan of the chest revealed peribronchial soft tissue thickening, suggestive of pulmonary sarcoidosis. Owing to the progressive nature of her weakness, she had a posterior occipitocervical decompression with a C1-3 laminectomy and resection of the thickened dura. Histology showed densely collagenous tissue with scanty psammoma bodies and multinucleate giant cells, consistent with hypertrophic pachymeningitis (HP)-a rare, chronic inflammatory condition, characterised by thickening and fibrosis of the dura. This case demonstrates that masses in the craniocervical junction can be varied in pathology and when there is evidence of systemic inflammation, HP should be considered.
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Affiliation(s)
- Nagina Subrati
- Department of Neurosurgery, Kings College Hospital, London, UK
| | - Babar Vaqas
- Department of Neurosurgery, Charing Cross Hospital, London, UK
| | - David Peterson
- Department of Neurosurgery, Charing Cross Hospital, London, UK
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Qin LX, Wang CY, Hu ZP, Zeng LW, Tan LM, Zhang HN. Idiopathic hypertrophic spinal pachymeningitis: a case report and review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24 Suppl 4:S636-43. [DOI: 10.1007/s00586-015-3958-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 04/12/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022]
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Tosa M, Hara M, Morita A, Ninomiya S, Ebashi M, Kamei S, Maseda M, Tokuhashi Y, Hemmi A, Nemoto N. Idiopathic Hypertrophic Spinal Pachymeningitis. Intern Med 2015; 54:1923-6. [PMID: 26234238 DOI: 10.2169/internalmedicine.54.2641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 63-year-old man revealed a four-month history of muscle weakness of the lower limbs, hypoesthesia of the L5 and S1 area and ischuria. On MRI, the spinal cord was compressed by an encircled mass, which showed hypointensity on T1- and T2-weighted images with gadolinium enhancement at the Th11 to Th12 vertebra. Because of the rapid progression of myelopathy, posterior decompression was performed and idiopathic hypertrophic spinal pachymeningitis (HSP) was finally diagnosed. The patient's neurological signs markedly improved with postoperative corticosteroid treatment. Idiopathic HSP is a clinical emergency and early surgical intervention is essential to prevent irreversible damage to the nervous system.
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Affiliation(s)
- Motofumi Tosa
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Japan
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Hypertrophic spinal pachymeningitis: Idiopathic vs. IgG4-related. J Neurol Sci 2014; 347:398-400. [DOI: 10.1016/j.jns.2014.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/02/2014] [Accepted: 10/06/2014] [Indexed: 12/24/2022]
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Zhovtis Ryerson L, Herbert J, Howard J, Kister I. Adult-onset spastic paraparesis: an approach to diagnostic work-up. J Neurol Sci 2014; 346:43-50. [PMID: 25263600 DOI: 10.1016/j.jns.2014.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/20/2014] [Accepted: 09/12/2014] [Indexed: 11/30/2022]
Abstract
Adult-onset, chronic progressive spastic paraparesis may be due to a large number of causes and poses a diagnostic challenge. There are no recent evidence-based guidelines or comprehensive reviews to help guide diagnostic work-up. We survey the literature on chronic progressive spastic paraparesis, with special emphasis on myelopathies, and propose a practical, MRI-based approach to facilitate the diagnostic process. Building on neuro-anatomic and radiographic conventions, we classify spinal MRI findings into six patterns: extradural; intradural/extramedullary; Intramedullary; Intramedullary-Tract specific; Spinal Cord Atrophy; and Normal Appearing Spinal Cord. A comprehensive differential diagnosis of chronic progressive myelopathy for each of the six patterns is generated. We highlight some of the more common and/or treatable causes of progressive spastic paraparesis and provide clinical pointers that may assist clinicians in arriving at the diagnosis. We outline a practical, comprehensive MRI-based algorithm to diagnosing adult-onset chronic progressive myelopathy.
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Affiliation(s)
| | - Joseph Herbert
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
| | - Jonathan Howard
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
| | - Ilya Kister
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
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Current World Literature. Curr Opin Rheumatol 2012; 24:237-44. [DOI: 10.1097/bor.0b013e3283513e33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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