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Saade A, Denwood HM, Tannoury T, Tannoury C. Surgical management of intramedullary cervical spinal sarcoidosis complicated by transient unilateral weakness: A case report. Surg Neurol Int 2024; 15:76. [PMID: 38628516 PMCID: PMC11021060 DOI: 10.25259/sni_41_2024] [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: 01/16/2024] [Accepted: 01/30/2024] [Indexed: 04/19/2024] Open
Abstract
Background Sarcoidosis, a multisystem inflammatory non-caseating granulomatous disease, can present with neurologic lesions in up to 10% of patients. Case Description A 57-year-old male presented with three months of worsening upper extremity radicular pain associated with dysmetria, hyperreflexia, bilateral Hoffman's, and positive Babinski signs. The contrast magnetic resonance imaging (MRI) showed a diffuse T2 signal hyperintensity and T1-enhancing 2.5 cm lesion extending sagittally between C4 and C6. The cerebrospinal fluid analysis showed a high protein level and lymphocytic pleocytosis. A cardiac positron emission tomography scan was consistent with the diagnosis of cardiac sarcoidosis. With the diagnosis of multisystemic/probable neurosarcoidosis, the patient was unsuccessfully treated with intravenous methylprednisolone, followed by infliximab. Due to severe cord compression/myelopathy, a C3-C6 laminectomy and C3-C7 posterior spinal fusion were performed. Postoperatively, the patient developed a transient right-sided hemiparesis. Over nine postoperative months, the patient had four relapses of transient repeated episodes of paresis, although follow-up cervical MRI scans revealed adequate cord decompression with a stable intramedullary hyperintense lesion. Conclusion Patients with neurosarcoidosis respond unpredictably to surgical decompression and require prolonged medical care, which is often unsuccessful.
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Affiliation(s)
- Aziz Saade
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California, United States
| | - Hayley M. Denwood
- Department of Orthopedic Surgery, Boston Medical Center, One Boston Medical Center Place, Boston, Massachusetts, United States
| | - Tony Tannoury
- Department of Orthopedic Surgery, Boston Medical Center, One Boston Medical Center Place, Boston, Massachusetts, United States
| | - Chadi Tannoury
- Department of Orthopedic Surgery, Boston Medical Center, One Boston Medical Center Place, Boston, Massachusetts, United States
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Cicia A, Nociti V, Bianco A, De Fino C, Carlomagno V, Mirabella M, Lucchini M. Neurosarcoidosis presenting as longitudinally extensive myelitis: Diagnostic assessment, differential diagnosis, and therapeutic approach. Transl Neurosci 2022; 13:191-197. [PMID: 35959214 PMCID: PMC9328025 DOI: 10.1515/tnsci-2022-0231] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Neurosarcoidosis is an uncommon and multiform clinical entity. Its presentation as an isolated longitudinal extensive transverse myelitis (LETM) is rare and challenging to identify. We report a case of LETM in a 60-year-old patient with no significant systemic symptoms nor relevant medical history. The peculiar spinal magnetic resonance imaging finding characterized by a posterior and central canal subpial contrast enhancement, the so-called “trident sign,” together with chest computed tomography scan and lymph node biopsy led to the diagnosis of sarcoidosis. We also discuss the main differential diagnoses of LETM and therapeutic options for sarcoidosis-related myelitis.
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Affiliation(s)
- Alessandra Cicia
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Viviana Nociti
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Assunta Bianco
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Chiara De Fino
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
| | - Vincenzo Carlomagno
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Matteo Lucchini
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
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Park BJ, Ray E, Bathla G, Bruch LA, Streit JA, Cho TA, Hitchon PW. Single Center Experience with Isolated Spinal Cord Neurosarcoidosis. World Neurosurg 2021; 156:e398-e407. [PMID: 34583004 DOI: 10.1016/j.wneu.2021.09.089] [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: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Isolated spinal cord neurosarcoidosis is extremely rare. The potential implications of long-term immunosuppressant therapy make correct diagnosis imperative. However, there are challenges inherent in isolated spinal cord involvement that require a multidisciplinary approach. Here we present the largest series of definite and possible isolated spinal neurosarcoidosis and discuss our institutional experience in managing this rare but morbid condition. METHODS A retrospective review was performed to identify all neurosarcoidosis cases starting from 2002 to 2020 at our institution. Patients were screened for cases of isolated spinal neurosarcoidosis. A descriptive analysis was performed for each case. RESULTS A total of 64 cases of neurosarcoidosis were identified. The spine was involved in 26 (40.6%) patients. Only 4 (6.3%) cases had isolated spinal cord involvement. A full medical and imaging workup was performed in determining isolated spinal cord involvement. Three patients subsequently underwent surgical biopsy, and 1 did not undergo biopsy because of patient preference. One of the patients who underwent biopsy had an initial nondiagnostic biopsy and had a repeat biopsy. Corticosteroids were employed in all cases with additional immunosuppressive agents for maintenance therapy and refractory cases. All showed radiographic improvement and were clinically stable to improved. CONCLUSION Isolated spinal cord involvement of neurosarcoidosis is rare and can present challenges in diagnosis. A biopsy can be performed when necessary. However, a biopsy of the spinal cord carries inherent risks and may not always be possible or result in a nondiagnostic sample. In the setting of high clinical suspicion, maximal medical therapy is still employed.
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Affiliation(s)
- Brian J Park
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Girish Bathla
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Leslie A Bruch
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Judy A Streit
- Department of Internal Medicine-Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Tracey A Cho
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Soni N, Bathla G, Pillenahalli Maheshwarappa R. Imaging findings in spinal sarcoidosis: a report of 18 cases and review of the current literature. Neuroradiol J 2018; 32:17-28. [PMID: 30311851 DOI: 10.1177/1971400918806634] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Spinal sarcoidosis, referring to involvement of the spine in sarcoidosis, is relatively rare and may mimic other neurological disease affecting the spine. The authors present a clinic radiological review of 18 spinal sarcoidosis patients who presented to a tertiary hospital, with emphasis on initial imaging and radiological response to treatment. MATERIALS AND METHODS We retrospectively reviewed our departmental imaging archives over a 15-year period and found 49 cases of neurosarcoidosis out of which 18 patients had spinal magnetic resonance imaging. RESULTS Approximately 72% (13/18) of the neurosarcoidosis patients showed some form of spinal involvement. The clinical, epidemiological and imaging data were reviewed for these 13 patients at presentation and follow-up. The findings on magnetic resonance imaging included leptomeningeal enhancement (61%), pachymeningeal (23%), intramedullary enhancing lesions (38%) and bony involvement (15%). The cervical segment was most frequently involved followed by the thoracic segment. Involvement was often long segment (4.2 spinal segments) with proclivity for the dorsal cord. Mean follow-up was 23.2 months. A complete or near-complete radiological response occurred in 66% while partial response was seen in 25% patients. Four patients had isolated central nervous system involvement including one with isolated spinal cord involvement. On diffusion-weighted imaging, the apparent diffusion coefficient of intramedullary lesions was increased compared to normal-appearing cord on baseline and subsequent follow-up scans. CONCLUSIONS Spinal sarcoidosis was previously considered uncommon but is being increasingly recognized with widespread use of magnetic resonance imaging. Proclivity for dorsal surface involvement is characteristic, although not necessarily pathognomonic. Also, quantitative diffusion studies may serve as a biomarker for the disease activity and parenchymal injury.
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Affiliation(s)
- Neetu Soni
- Neuroradiology Department, University of Iowa Hospitals and Clinics, USA
| | - Girish Bathla
- Neuroradiology Department, University of Iowa Hospitals and Clinics, USA
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Mariano R, Flanagan EP, Weinshenker BG, Palace J. A practical approach to the diagnosis of spinal cord lesions. Pract Neurol 2018; 18:187-200. [PMID: 29500319 DOI: 10.1136/practneurol-2017-001845] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2018] [Indexed: 01/03/2023]
Abstract
Every neurologist will be familiar with the patient with atypical spinal cord disease and the challenges of taking the diagnosis forward. This is predominantly because of the limited range of possible clinical and investigation findings making most individual features non-specific. The difficulty in obtaining a tissue diagnosis further contributes and patients are often treated empirically based on local prevalence and potential for reversibility. This article focuses on improving the diagnosis of adult non-traumatic, non-compressive spinal cord disorders. It is structured to start with the clinical presentation in order to be of practical use to the clinician. We aim, by combining the onset phenotype with the subsequent course, along with imaging and laboratory features, to improve the diagnostic process.
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Affiliation(s)
- Romina Mariano
- Nuffield Department of Clinical Neuroscience, Oxford University, Oxford, UK
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jacqueline Palace
- Nuffield Department of Clinical Neuroscience, Oxford University, Oxford, UK
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Galgano MA, Goulart CR, Chisholm K, Hazen M, Stone S. Rapid-Onset Thoracic Myelopathy due to an Epidural Sarcoid-Like Lesion in a Pediatric Patient. World Neurosurg 2018; 111:377-380. [DOI: 10.1016/j.wneu.2017.12.185] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 12/26/2017] [Accepted: 12/30/2017] [Indexed: 10/18/2022]
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Radwan W, Lucke-Wold B, Robadi IA, Gyure K, Roberts T, Bhatia S. Neurosarcoidosis: unusual presentations and considerations for diagnosis and management. Postgrad Med J 2017; 93:401-405. [PMID: 27920210 PMCID: PMC5500943 DOI: 10.1136/postgradmedj-2016-134475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/02/2016] [Accepted: 11/05/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Sarcoidosis is a chronic, multisystem disease characterised by non-necrotising granulomatous inflammation of unknown aetiology. Most commonly, the lungs, lymph nodes, skin and eyes are affected in sarcoidosis; however, nervous system involvement occurs in approximately 5%-15% of cases. Any part of the nervous system can be affected by sarcoidosis. CASES Herein we describe three unusual patient presentations of neurosarcoidosis, one with optic neuritis, a second with hydrocephalus and a third with cervical myelopathy. CONCLUSIONS We include pertinent details about their presentations, imaging findings, pathology, management and clinical course.
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Affiliation(s)
- Walid Radwan
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | | | - Ibrahim Ahmed Robadi
- Department of Pathology, West Virginia University, Morgantown, West Virginia, USA
| | - Kymberly Gyure
- Department of Pathology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Roberts
- Department of Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Sanjay Bhatia
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
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Abstract
Rheumatic disease represents a broad spectrum of systemic conditions manifested by multisystem involvement and mediated by autoimmunity and inflammation. Their neurological complications may occur at any point in the disease process and are diagnostically challenging. For years central nervous system (CNS) was considered as a system uniquely protected from effects of the immune system because of the blood-brain barrier. Indeed, under physiological conditions immune access to CNS is tightly regulated. Over the past decade, new scientific discoveries highlighted pathways by which immune and neurological systems interact, including a variety of mechanisms controlling permeability of blood-brain barrier, and specific roles that CD4+ and CD8+ T-lymphocytes play in initiation of specific adaptive immune response to neural specific antigens. This leads to release of proinflammatory cytokines (interleukin 1, interleukin 6, and tumor necrosis factor alpha). In addition, B-cells involved in CNS inflammation produce antibodies against membrane bound and soluble antigens. This article describes specific neurological manifestations of the most common autoimmune rheumatic disorders.
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Affiliation(s)
- Svetlana Lvovich
- From the Section of Rheumatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
| | - Donald P Goldsmith
- From the Section of Rheumatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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