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Carnero Contentti E, Wingerchuk DM. MRI of the relevant domain should be performed to confirm whether clinical symptoms represent an attack of NMOSD: Yes. Mult Scler 2024; 30:19-21. [PMID: 38197556 DOI: 10.1177/13524585231222132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
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Elsbernd P, Cacciaguerra L, Krecke KN, Chen JJ, Gritsch D, Lopez-Chiriboga AS, Sechi E, Redenbaugh V, Morris PP, Carter JL, Wingerchuk DM, Tillema JM, Valencia-Sanchez C, Thakolwiboon S, Pittock SJ, Flanagan EP. Cerebral enhancement in MOG antibody-associated disease. J Neurol Neurosurg Psychiatry 2023; 95:14-18. [PMID: 37221051 PMCID: PMC10679850 DOI: 10.1136/jnnp-2023-331137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Limited data exist on brain MRI enhancement in myelin-oligodendrocyte-glycoprotein (MOG) antibody-associated disease (MOGAD) and differences from aquaporin-4-IgG-positive-neuromyelitis-optica-spectrum-disorder (AQP4+NMOSD), and multiple sclerosis (MS). METHODS In this retrospective observational study, we identified 122 Mayo Clinic MOGAD patients (1 January 1996-1 July 2020) with cerebral attacks. We explored enhancement patterns using a discovery set (n=41). We assessed enhancement frequency and Expanded Disability Status Scale scores at nadir and follow-up in the remainder (n=81). Two raters assessed T1-weighted-postgadolinium MRIs (1.5T/3T) for enhancement patterns in MOGAD, AQP4+NMOSD (n=14) and MS (n=26). Inter-rater agreement was assessed. Leptomeningeal enhancement clinical correlates were analysed. RESULTS Enhancement occurred in 59/81 (73%) MOGAD cerebral attacks but did not influence outcome. Enhancement was often patchy/heterogeneous in MOGAD (33/59 (56%)), AQP4+NMOSD (9/14 (64%); p=0.57) and MS (16/26 (62%); p=0.63). Leptomeningeal enhancement favoured MOGAD (27/59 (46%)) over AQP4+NMOSD (1/14 (7%); p=0.01) and MS (1/26 (4%); p<0.001) with headache, fever and seizures frequent clinical correlates. Ring enhancement favoured MS (8/26 (31%); p=0.006) over MOGAD (4/59 (7%)). Linear ependymal enhancement was unique to AQP4+NMOSD (2/14 (14%)) and persistent enhancement (>3 months) was rare (0%-8%) across all groups. Inter-rater agreement for enhancement patterns was moderate. CONCLUSIONS Enhancement is common with MOGAD cerebral attacks and often has a non-specific patchy appearance and rarely persists beyond 3 months. Leptomeningeal enhancement favours MOGAD over AQP4+NMOSD and MS.
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Affiliation(s)
- Paul Elsbernd
- Department of Neurology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Laura Cacciaguerra
- Department of Neurology, Vita-Salute San Raffaele University, Milano, Italy
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John J Chen
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Gritsch
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
- Department of Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | | | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Vyanka Redenbaugh
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Jan-Mendelt Tillema
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of pediatrics, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Majed M, Valencia Sanchez C, Bennett JL, Fryer J, Mulligan MD, Redenbaugh V, McKeon A, Mills JR, Wingerchuk DM, Lennon VA, Weinshenker B, Chen JJ, Flanagan EP, Pittock SJ, Kunchok A. Alterations in Aquaporin-4-IgG Serostatus in 986 Patients: A Laboratory-Based Longitudinal Analysis. Ann Neurol 2023; 94:727-735. [PMID: 37314750 DOI: 10.1002/ana.26722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study was undertaken to investigate factors associated with aquaporin-4 (AQP4)-IgG serostatus change using a large serological database. METHODS This retrospective study utilizes Mayo Clinic Neuroimmunology Laboratory data from 2007 to 2021. We included all patients with ≥2 AQP4-IgG tests (by cell-based assay). The frequency and clinical factors associated with serostatus change were evaluated. Multivariable logistic regression analysis examined whether age, sex, or initial titer was associated with serostatus change. RESULTS There were 933 patients who had ≥2 AQP4-IgG tests with an initial positive result. Of those, 830 (89%) remained seropositive and 103 (11%) seroreverted to negative. Median interval to seroreversion was 1.2 years (interquartile range [IQR] = 0.4-3.5). Of those with sustained seropositivity, titers were stable in 92%. Seroreversion was associated with age ≤ 20 years (odds ratio [OR] = 2.25; 95% confidence interval [CI] = 1.09-4.63; p = 0.028) and low initial titer of ≤1:100 (OR = 11.44, 95% CI = 3.17-41.26, p < 0.001), and 5 had clinical attacks despite seroreversion. Among 62 retested after seroreversion, 50% returned to seropositive (median = 224 days, IQR = 160-371). An initial negative AQP4-IgG test occurred in 9,308 patients. Of those, 99% remained seronegative and 53 (0.3%) seroconverted at a median interval of 0.76 years (IQR = 0.37-1.68). INTERPRETATION AQP4-IgG seropositivity usually persists over time with little change in titer. Seroreversion to negative is uncommon (11%) and associated with lower titers and younger age. Seroreversion was often transient, and attacks occasionally occurred despite prior seroreversion, suggesting it may not reliably reflect disease activity. Seroconversion to positive is rare (<1%), limiting the utility of repeat testing in seronegative patients unless clinical suspicion is high. ANN NEUROL 2023;94:727-735.
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Affiliation(s)
- Masoud Majed
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - James Fryer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Martin D Mulligan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Vyankya Redenbaugh
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Vanda A Lennon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Brian Weinshenker
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - John J Chen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Amy Kunchok
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
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Aktas O, Hartung HP, Smith MA, Rees WA, Fujihara K, Paul F, Marignier R, Bennett JL, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk DM, Cutter G, She D, Gunsior M, Cimbora D, Katz E, Cree BA. Serum neurofilament light chain levels at attack predict post-attack disability worsening and are mitigated by inebilizumab: analysis of four potential biomarkers in neuromyelitis optica spectrum disorder. J Neurol Neurosurg Psychiatry 2023; 94:757-768. [PMID: 37221052 PMCID: PMC10447388 DOI: 10.1136/jnnp-2022-330412] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 04/03/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To investigate relationships between serum neurofilament light chain (sNfL), ubiquitin C-terminal hydrolase L1 (sUCHL1), tau (sTau) and glial fibrillary acidic protein (sGFAP) levels and disease activity/disability in neuromyelitis optica spectrum disorder (NMOSD), and the effects of inebilizumab on these biomarkers in N-MOmentum. METHODS N-MOmentum randomised participants to receive inebilizumab or placebo with a randomised controlled period (RCP) of 28 weeks and an open-label follow-up period of ≥2 years. The sNfL, sUCHL1, sTau and sGFAP were measured using single-molecule arrays in 1260 scheduled and attack-related samples from N-MOmentum participants (immunoglobulin G (IgG) autoantibodies to aquaporin-4-positive, myelin oligodendrocyte glycoprotein-IgG-positive or double autoantibody-negative) and two control groups (healthy donors and patients with relapsing-remitting multiple sclerosis). RESULTS The concentration of all four biomarkers increased during NMOSD attacks. At attack, sNfL had the strongest correlation with disability worsening during attacks (Spearman R2=0.40; p=0.01) and prediction of disability worsening after attacks (sNfL cut-off 32 pg/mL; area under the curve 0.71 (95% CI 0.51 to 0.89); p=0.02), but only sGFAP predicted upcoming attacks. At RCP end, fewer inebilizumab-treated than placebo-treated participants had sNfL>16 pg/mL (22% vs 45%; OR 0.36 (95% CI 0.17 to 0.76); p=0.004). CONCLUSIONS Compared with sGFAP, sTau and sUCHL1, sNfL at attack was the strongest predictor of disability worsening at attack and follow-up, suggesting a role for identifying participants with NMOSD at risk of limited post-relapse recovery. Treatment with inebilizumab was associated with lower levels of sGFAP and sNfL than placebo. TRIAL REGISTRATION NUMBER NCT02200770.
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Affiliation(s)
- Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Medical University Vienna, Vienna, Austria
- Department of Neurology, Palacky University in Olomouc, Olomouc, Czech Republic
| | | | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Koriyama, Fukushima, Japan
- Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Romain Marignier
- Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hopital Neurologique et Neurochirurgical Pierre Wertheimer Centre de reference des syndromes neurologiques paraneoplasiques et encephalites auto-immun, Lyon, Auvergne-Rhône-Alpes, France
| | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Republic of Korea
| | - Brian G Weinshenker
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - Sean J Pittock
- Department of Neurology and Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dewei She
- Horizon Therapeutics plc, Gaithersburg, Maryland, USA
| | | | | | - Eliezer Katz
- Horizon Therapeutics plc, Gaithersburg, Maryland, USA
| | - Bruce A Cree
- Department of Neurology, UCSF, Weill Institute for Neurosciences, University California of San Francisco, San Francisco, California, USA
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Weinshenker BG, Wingerchuk DM, Green AJ, Bennett JL, Kim HJ, Pittock SJ, Fujihara K, Paul F, Cutter G, Marignier R, Aktas O, Hartung HP, She D, Smith M, Rees W, Patterson K, Cimbora D, Katz E, Cree BA. Attack adjudication in neuromyelitis optica spectrum disorder: Substantiation of criteria by magnetic resonance imaging and biomarkers in N-MOmentum. Mult Scler 2023:13524585231172145. [PMID: 37282545 PMCID: PMC10338695 DOI: 10.1177/13524585231172145] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The N-MOmentum trial investigated safety and efficacy of inebilizumab in participants with neuromyelitis optica spectrum disorder (NMOSD). OBJECTIVE Evaluate the attack identification process and adjudication committee (AC) performance in N-MOmentum. METHODS Adults (n = 230) with NMOSD and Expanded Disability Status Scale score ⩽8 were randomized (3:1) to inebilizumab 300 mg or placebo. The randomized controlled period was 28 weeks or until adjudicated attack. Attacks were adjudicated according to 18 predefined criteria. Magnetic resonance imaging (MRI) and biomarker (serum glial fibrillary acidic protein [sGFAP]) analyses were performed. RESULTS A total of 64 participant-reported neurological events occurred; 51 (80%) were investigator-determined to be attacks. The AC confirmed 43 of the investigator-determined attacks (84%). There was high inter- and intra-AC-member agreement. In 25/64 events (39%) and 14/43 AC-adjudicated attacks (33%), MRI was reviewed during adjudication. Retrospective analysis revealed new domain-specific T1 and T2 MRI lesions in 90% of adjudicated attacks. Increased mean sGFAP concentrations (>2-fold change) from baseline were observed in 56% of adjudicated attacks versus 14% of investigator-determined attacks rejected by the AC and 31% of participant-reported events determined not to be attacks. CONCLUSION AC adjudication of NMOSD attacks according to predefined criteria appears robust. MRI lesion correlates and sGFAP elevations were found in most adjudicated attacks.
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Affiliation(s)
| | | | - Ari J Green
- UCSF Weill Institute for Neurosciences, Department of Neurology and Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Sean J Pittock
- Department of Neurology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Clinical Neuroimmunology Department, Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Romain Marignier
- Service de Neurologie Sclérose en Plaques, Pathologies de La Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany/Brain and Mind Center, University of Sydney, Sydney, NSW, Australia/ Department of Neurology, Medical University Vienna, Vienna, Austria/ Department of Neurology, Palacký University Olomouc, Olomouc, Czech Republic
| | - Dewei She
- Horizon Therapeutics plc, Gaithersburg, MD, USA
| | | | | | | | | | | | - Bruce Ac Cree
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
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Mbonde AA, Grill MF, Harahsheh EY, Marks LA, Wingerchuk DM, O'Carroll CB. Is Intravenous Immunoglobulin Effective in Reducing the Risk of Mortality and Morbidity in Neuroinvasive West Nile Virus Infection?: A Critically Appraised Topic. Neurologist 2023; 28:129-134. [PMID: 36728647 DOI: 10.1097/nrl.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The clinical benefit of intravenous immunoglobulin (IVIG) in adult individuals with neuroinvasive West Nile virus (niWNV) infection is not well substantiated. We sought to critically assess current evidence regarding the efficacy of IVIG in treating patients with niWNV. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-infectious diseases. RESULTS The appraised study enrolled 62 participants with suspected niWNV, randomized into 3 different arms [37 participants in the Omr-IgG-am group, 12 in the Polygam group, and 13 in the normal saline (NS) group]. Omr-IgG-am and Polygam are different formulations of IVIG. IVIG safety, measured as rates of serious adverse events, was the primary study outcome while IVIG efficacy, measured as rates of unfavorable outcomes, was a secondary endpoint. The estimated rates of SAE were statistically similar in all groups (51.4% Omr-IgG-am, 58.3% Polygam, and 23.1% NS groups). Unfavorable outcomes also occurred at a similar rate between all the groups (51.5% Omr-IgG-am, 54.5% Polygam, and 27.3% NS). CONCLUSIONS The appraised trial showed that Omr-IgG-am and Polygam are as safe as NS. Data on efficacy from this trial were limited by a small sample size. Phase III clinical trials on IVIG efficacy in NiWNV infection are needed.
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Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Phoenix, AZ
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Min JH, Capobianco M, Welsh C, Lobo P, deFiebre G, Lana-Peixoto M, Wingerchuk DM, Wang J, Ringelstein M. Understanding Treatment Decisions in Neuromyelitis Optica Spectrum Disorder: A Global Clinical Record Review with Patient Interviews. Neurol Ther 2023; 12:619-633. [PMID: 36826458 PMCID: PMC10043119 DOI: 10.1007/s40120-022-00431-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/01/2022] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION We sought insights into neuromyelitis optica spectrum disorder (NMOSD) treatment practices worldwide. METHODS Neurologists from the USA, Germany, Italy, Brazil, South Korea, and China completed an online survey, contributing clinical records for aquaporin-4 (AQP4) immunoglobulin G (IgG)-seropositive adults with NMOSD, which included patient demographics, diagnosis, maintenance treatment history, relapse occurrence, and severity. Interviewed patients receiving NMOSD maintenance therapy provided information about their diagnosis, treatment, perceptions about relapse severity or disease stability, and treatment switches. RESULTS A total of 389 neurologists submitted clinical records for 1185 patients with AQP4-IgG-seropositive NMOSD; 33 patients with NMOSD were interviewed. Approximately 25% (228/910) of patients from the clinical record review (CRR) were initially misdiagnosed; 24% (8/33) of patients interviewed reported formal misdiagnosis. Misdiagnosis was associated with treatment delay and more relapses compared with correct diagnosis (mean 3.3 vs 2.8). Maintenance therapy was not initiated within 2 months for 47% (221/472) of patients from the CRR and 24% (8/33) of interviewed patients. Oral corticosteroids/immunosuppressive therapies were typically the first maintenance treatment initiated, except for the USA, where monoclonal antibodies were equally likely to be prescribed. Relapse severity influenced the decision to initiate/change therapy and use monoclonal antibodies. Of interviewed patients, 76% (25/33) did not recall having a choice of treatment and many did not know the rationale for treatment choice. CONCLUSION Misdiagnosis of NMOSD appears to be common and is associated with a delay in initiation of maintenance therapy, with decisions influenced by relapse severity. Further real-world studies assessing relapse severity in treatment initiation/switch are required to revise NMOSD treatment recommendations.
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Affiliation(s)
- Ju-Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | | | | | | | | | - Marco Lana-Peixoto
- Federal University of Minas Gerais Medical School, Belo Horizonte, Brazil
| | | | - Jiawei Wang
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - 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
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8
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Capobianco M, Ringelstein M, Welsh C, Lobo P, deFiebre G, Lana-Peixoto M, Wang J, Min JH, Wingerchuk DM. Characterization of Disease Severity and Stability in NMOSD: A Global Clinical Record Review with Patient Interviews. Neurol Ther 2023; 12:635-650. [PMID: 36826457 PMCID: PMC10043113 DOI: 10.1007/s40120-022-00432-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/01/2022] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION We sought insights into the classification of and factors associated with relapse severity and disease stability in neuromyelitis optica spectrum disorder (NMOSD) clinical practice worldwide. METHODS Neurologists recruited from six countries (the USA, Germany, Italy, Brazil, South Korea, and China) participated in a 30-60 minute online survey and submitted two to four clinical records for aquaporin-4-immunoglobulin G (AQP4-IgG)-seropositive adults with NMOSD, which included patient demographics, diagnosis, maintenance treatment history, relapse occurrence, and severity. Separately, patients with NMOSD receiving maintenance therapy were interviewed over the telephone about their treatment journey, as well as perceptions of relapse severity and disease stability, and their potential influence on treatment decisions. RESULTS Clinical records for 1185 patients with AQP4-IgG-seropositive NMOSD were provided by 389 neurologists (July-August 2020); 33 patients were interviewed (October-November 2020). There was no clear consensus on how relapse severity was defined in clinical practice, with geographical variations in relapse classification also found. Neurologists tended to rely on clinical assessments when determining severity, viewing each relapse in isolation, whereas patients had a more subjective view based on the changes in their daily lives and comparisons with prior relapses. Similarly, there was a disconnect in the definition of disease stability: the complete absence of relapses was more important for patients than for neurologists. CONCLUSION A clear consensus on how to assess relapse severity and disease stability is needed to ensure that patients receive appropriate and timely treatment. In the future, clinical measures should be combined with patient-focused assessments.
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Affiliation(s)
- Marco Capobianco
- Neurology Department, "S. Croce e Carle" Hospital, Cuneo, Italy.
| | - 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
| | | | | | | | - Marco Lana-Peixoto
- Federal University of Minas Gerais Medical School, Belo Horizonte, Brazil
| | - Jiawei Wang
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ju-Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Berthele A, Levy M, Wingerchuk DM, Pittock SJ, Shang S, Kielhorn A, Royston M, Sabatella G, Palace J. A single relapse induces worsening of disability and health-related quality of life in patients with neuromyelitis optica spectrum disorder. Front Neurol 2023; 14:1099376. [PMID: 37114235 PMCID: PMC10126826 DOI: 10.3389/fneur.2023.1099376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/08/2023] [Indexed: 04/29/2023] Open
Abstract
Background Cumulative damage from multiple relapses in neuromyelitis optica spectrum disorder (NMOSD) is associated with poor health-related quality of life (HRQoL) and long-term disability in patients positive for anti-aquaporin 4 antibodies (AQP4+). This study assessed the effect of an individual relapse on HRQoL and disability outcomes in AQP4+ NMOSD. Methods Post hoc analyses of data pooled from the PREVENT study and its open-label extension, which evaluated the efficacy and safety of eculizumab in AQP4+ NMOSD, examined the effect of a single relapse on 3 disability and 4 HRQoL outcome measures. Assuming the effect of 1 relapse extends to multiple relapses, an extrapolation was done to assess the effect of 2 relapses on these outcomes. Results In 27 patients (placebo: n = 20; eculizumab: n = 7) experiencing an independently adjudicated relapse, 1 relapse led to significantly worse disability (modified Rankin Scale and Expanded Disability Status Scale [EDSS]) and HRQoL (36-item Short-Form Health Survey mental and physical component summaries; European Quality of Life 5-Dimension questionnaire 3-Level visual analogue scale and utility index) scores. In 4 of 7 outcomes, clinically meaningful worsening was more likely for relapsing versus non-relapsing patients (n = 116). Extrapolating the effect of 2 relapses predicted that clinically meaningful worsening was more likely in 6 out of 7 outcomes, including EDSS, for patients experiencing multiple relapses versus patients experiencing no relapses. Conclusion Findings from these clinical trial data demonstrate that a single NMOSD relapse can worsen disability and HRQoL, underscoring the role of relapse prevention in improving long-term outcomes in patients with AQP4+ NMOSD.
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Affiliation(s)
- Achim Berthele
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum Rechts der Isar, München, Germany
- *Correspondence: Achim Berthele,
| | - Michael Levy
- Massachusetts General Hospital and Harvard Medical School, Mass General Neurology, Boston, MA, United States
| | | | | | - Shulian Shang
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Adrian Kielhorn
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Minying Royston
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Guido Sabatella
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Jacqueline Palace
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford, United Kingdom
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Wingerchuk DM, Weinshenker BG, McCormick D, Barron S, Simone L, Jarzylo L. Aligning payer and provider strategies with the latest evidence to optimize clinical outcomes for patients with neuromyelitis optica spectrum disorder. J Manag Care Spec Pharm 2022; 28:S3-S27. [DOI: 10.18553/jmcp.2022.28.12-a.s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gritsch D, Mrugala MM, Marks LA, Wingerchuk DM, O'Carroll CB. In Patients With Melanoma Brain Metastases, Is Combination Immune Checkpoint Inhibition a Safe and Effective First-Line Treatment? A Critically Appraised Topic. Neurologist 2022; 27:290-297. [PMID: 35834790 DOI: 10.1097/nrl.0000000000000439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combined PD-1/PD-L1 and CTLA-4 immune checkpoint inhibition for the has been shown to produce superior results in the treatment of malignant melanoma when compared to monotherapy. However, patients with intracranial disease were excluded from these studies given their poor prognosis. OBJECTIVE The objective of this study was to critically assess current evidence supporting the co-administration of PD-1/PD-L1 and CTLA-4 inhibitors in the treatment of melanoma brain metastases. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-oncology. RESULTS A recent, open-label, non-comparative randomized phase II trial was selected for critical appraisal. This trial evaluated the efficacy and safety of nivolumab alone or in combination with ipilimumab in 79 adult patients with untreated, asymptomatic melanoma brain metastases. The rates of the primary outcome (intracranial response at ≥12 wk) in the primary endpoint cohort were 46% for cohort A (combination therapy) and 20% for cohort B (nivolumab monotherapy). No treatment related deaths were observed in the study. Grade 4 adverse events occurred in 9% of patients in cohort A and none in cohort B. CONCLUSIONS Co-administration of ipilimumab and nivolumab as first-line therapy is effective in the treatment of asymptomatic melanoma brain metastases, with an acceptable safety profile.
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Shah SS, Morris P, Buciuc M, Tajfirouz D, Wingerchuk DM, Weinshenker BG, Eggenberger ER, Di Nome M, Pittock SJ, Flanagan EP, Bhatti MT, Chen JJ. Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD. Neurology 2022; 99:e851-e857. [PMID: 35697504 PMCID: PMC9484733 DOI: 10.1212/wnl.0000000000200838] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Asymptomatic or persistent optic nerve enhancement in aquaporin-4 (AQP4)-immunoglobulin G (IgG)-positive neuromyelitis optica spectrum disorder (NMOSD) is thought to be rare. Improved understanding may have important implications for assessment of treatment efficacy in clinical trials and in clinical practice. Our objective was to characterize NMOSD interattack optic nerve enhancement. METHODS This was a retrospective cohort study performed between 2000 and 2019 (median follow-up 5.5 [range 1-35] years) of patients with AQP4-IgG-positive optic neuritis (ON) evaluated at Mayo Clinic. MRI orbits were reviewed by a neuroradiologist, neuro-ophthalmologist, and neuroimmunologist blinded to the clinical history. Interattack optic nerve enhancement (>30 days after attack) was measured. The correlation between interattack enhancement and Snellen visual acuity (VA), converted to logarithm of the minimum angle of resolution (logMAR), at attack and at follow-up were assessed. RESULTS A total of 198 MRI scans in 100 patients with AQP4-IgG+ NMOSD were identified, with 107 interattack MRIs from 78 unique patients reviewed. Seven scans were performed before any ON (median 61 days before attack [range 21-271 days]) and 100 after ON (median 400 days after attack [33-4,623 days]). Optic nerve enhancement was present on 18/107 (16.8%) interattack scans (median 192.5 days from attack [33-2,943]) of patients with preceding ON. On 15 scans, enhancement occurred at the site of prior attacks; the lesion location was unchanged, but the lesion length was shorter. Two scans (1.8%) demonstrated new asymptomatic lesions (prior scan demonstrated no enhancement). In a third patient with subjective blurry vision, MRI showed enhancement preceding detectable eye abnormalities on examination noted 15 days later. There was no difference in VA at preceding attack nadir (logMAR VA 1.7 vs 2.1; p = 0.79) or long-term VA (logMAR VA 0.4 vs 0.2, p = 0.56) between those with and without interattack optic nerve enhancement. DISCUSSION Asymptomatic optic nerve enhancement occurred in 17% of patients with NMOSD predominantly at the site of prior ON attacks and may represent intermittent blood-brain barrier breakdown or subclinical ON. New asymptomatic enhancement was seen only in 2% of patients. Therapeutic clinical trials for NMOSD require blinded relapse adjudication when assessing treatment efficacy, and it is important to recognize that asymptomatic optic nerve enhancement can occur in patients with ON.
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Affiliation(s)
- Shailee S Shah
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Pearse Morris
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Marina Buciuc
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Deena Tajfirouz
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Dean M Wingerchuk
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Brian G Weinshenker
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Eric R Eggenberger
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Marie Di Nome
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Eoin P Flanagan
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - M Tariq Bhatti
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - John J Chen
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN.
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Affiliation(s)
- Dean M Wingerchuk
- From the Department of Neurology, Mayo Clinic, Scottsdale, AZ (D.M.W.); and the Department of Neurology, Mayo Clinic, Rochester, MN (C.F.L.)
| | - Claudia F Lucchinetti
- From the Department of Neurology, Mayo Clinic, Scottsdale, AZ (D.M.W.); and the Department of Neurology, Mayo Clinic, Rochester, MN (C.F.L.)
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14
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Wingerchuk DM, Zhang I, Kielhorn A, Royston M, Levy M, Fujihara K, Nakashima I, Tanvir I, Paul F, Pittock SJ. A Response to: Letter to the Editor Regarding "Network Meta-analysis of Food and Drug Administration-approved Treatment Options for Adults with Aquaporin-4 Immunoglobulin G-positive Neuromyelitis Optica Spectrum Disorder". Neurol Ther 2022; 11:1445-1449. [PMID: 35780260 PMCID: PMC9338177 DOI: 10.1007/s40120-022-00378-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Friedemann Paul
- Charité-Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, Germany
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Callister MN, Stonnington CB, Cuc A, Alcott SB, Driver-Dunckley ED, Mehta SH, Hasan S, Marks LA, Wingerchuk DM, O'Carroll CB. In Patients With Functional Movement Disorders, Is Specialized Physical Therapy Effective in Improving Motor Symptoms?: A Critically Appraised Topic. Neurologist 2022; 27:82-88. [PMID: 35051971 DOI: 10.1097/nrl.0000000000000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Functional movement disorders (FMD, aka psychogenic movement disorders) are very common and frequently chronic and disabling. Despite this, there is a paucity of evidence-based treatment to manage and alleviate these conditions. Specialized physical therapy (PT), involving sequential motor relearning and redirecting attention, has shown promise as a therapeutic intervention for motor symptoms. METHODS The objective of this study was to critically assess current evidence regarding specialized PT compared with usual care in improving motor symptoms among patients with FMD. This was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, and content experts in the fields of physical medicine and rehabilitation, physical and occupational therapy, psychiatry, and psychology. RESULTS A randomized controlled feasibility trial was identified and selected for critical appraisal. This study randomized 60 patients with FMD to a 5-day specialized outpatient PT program or to general outpatient PT referral, and measured patient-reported and clinician-measured outcomes. At 6 months, 72% of patients in the intervention group had a good outcome compared with 18% of control group patients. Patients in the specialized outpatient PT program had significantly better outcomes in 3 Short-Form 36 (SF36) domains (d=0.46 to 0.79) and multiple other scales of physical and social function as well as clinician-measured outcomes. The intervention resulted in 0.08 additional quality-adjusted life years in a cost-effective manner. CONCLUSIONS Current evidence suggests that in patients with FMD, specialized PT improves motor symptoms in a clinically significant, sustained, and cost-effective manner. This promising intervention warrants further investigation and replication.
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Affiliation(s)
| | | | | | | | | | | | | | - Lisa A Marks
- Library Services, Mayo Clinic Arizona, Scottsdale, AZ
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Redenbaugh V, Montalvo M, Sechi E, Buciuc M, Fryer JP, McKeon A, Lennon VA, Mills JR, Weinshenker BG, Wingerchuk DM, Chen JJ, Tariq Bhatti M, Lopez Chiriboga AS, Pittock SJ, Flanagan EP. Diagnostic value of aquaporin-4-IgG live cell based assay in neuromyelitis optica spectrum disorders. Mult Scler J Exp Transl Clin 2021; 7:20552173211052656. [PMID: 34868626 PMCID: PMC8637716 DOI: 10.1177/20552173211052656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/23/2021] [Indexed: 12/03/2022] Open
Abstract
Objective Determine the utility of aquaporin 4 IgG (AQP4-IgG) testing (live cell-based
assay) for Neuromyelitis Optica Spectrum Disorders (NMOSD). Methods We included Mayo Clinic patients (1/1/2018-12/31/2019) tested for serum
AQP4-IgG by live cell-based flow-cytometric assay. Medical records were
reviewed to assess if patients fulfilled 2015 NMOSD criteria. Results Of 1371 patients tested, 41 were positive (3%) and all fulfilled NMOSD
criteria with AQP4-IgG (specificity = 100%). Only 10/1330 testing negative
met NMOSD criteria without AQP4-IgG (sensitivity = 80%) and seven of these
10 were MOG-IgG positive. Conclusions AQP4-IgG by live cell-based assay was highly specific and without false
positives in a high throughput setting.
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Affiliation(s)
- Vyanka Redenbaugh
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Mayra Montalvo
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Elia Sechi
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Marina Buciuc
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - James P Fryer
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew McKeon
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Vanda A Lennon
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John R Mills
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Brian G Weinshenker
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Dean M Wingerchuk
- Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, AZ, USA
| | - John J Chen
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M Tariq Bhatti
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Sean J Pittock
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eoin P Flanagan
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Pittock SJ, Fujihara K, Palace J, Berthele A, Kim HJ, Oreja-Guevara C, Nakashima I, Levy M, Shang S, Yountz M, Miller L, Armstrong R, Wingerchuk DM. Eculizumab monotherapy for NMOSD: Data from PREVENT and its open-label extension. Mult Scler 2021; 28:480-486. [PMID: 34498507 PMCID: PMC8894682 DOI: 10.1177/13524585211038291] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
During PREVENT (a phase 3, randomized, double-blind, placebo-controlled,
time-to-event study) and its open-label extension (interim analysis), 33 adults
with aquaporin-4 immunoglobulin G-positive neuromyelitis optica spectrum
disorder (AQP4-IgG + NMOSD) received eculizumab monotherapy for a median of 2.8
years (range, 14 weeks–5.2 years). At 192 weeks (~4 years), 96% of these
patients were free from adjudicated relapses (Kaplan–Meier analysis; 95%
confidence interval, 75.7–99.4). During PREVENT, 95% (20/21) of patients
receiving eculizumab monotherapy had no disability worsening. Eculizumab
monotherapy provides effective long-term relapse prevention, relieving the
chronic immunosuppression burden in patients with AQP4-IgG + NMOSD.
ClinicalTrials.gov; PREVENT: NCT01892345; open-label extension: NCT02003144.
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Affiliation(s)
- Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kazuo Fujihara
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan/Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima City, Japan/Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience (STRINS), Koriyama, Japan
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Achim Berthele
- Department of Neurology, School of Medicine, Klinikum rechts der Isar of the Technical University of Munich, Munich, Germany
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clinico Universitario San Carlos, Madrid, Spain/Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain/IdISSC, Madrid, Spain
| | - Ichiro Nakashima
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan/Division of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Michael Levy
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA/Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Róisín Armstrong
- Alexion Pharmaceuticals, Boston, MA, USA/Rallybio, New Haven, CT, USA
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18
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Zhao-Fleming HH, Sanchez CV, Sechi E, Inbarasu J, Wijdicks EF, Pittock SJ, Chen JJ, Wingerchuk DM, Weinshenker BG, Lopez-Chiriboga S, Dubey D, Tillema JM, Toledano M, Yadav H, Flanagan EP. CNS Demyelinating Attacks Requiring Ventilatory Support With Myelin Oligodendrocyte Glycoprotein or Aquaporin-4 Antibodies. Neurology 2021; 97:e1351-e1358. [PMID: 34389648 PMCID: PMC8480400 DOI: 10.1212/wnl.0000000000012599] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Objective Severe attacks of myelin oligodendrocyte glycoprotein (MOG) antibody–associated disorder (MOGAD) and aquaporin-4 (AQP4) antibody–positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) may require ventilatory support, but data on episodes are limited, particularly for MOGAD. We sought to compare the frequency, characteristics, and outcomes of MOGAD and AQP4-NMOSD attacks requiring ventilatory support. Methods This retrospective descriptive study identified Mayo Clinic patients (January 1, 1996–December 1, 2020) with MOGAD or AQP4-NMOSD and an attack requiring noninvasive or invasive ventilation at Mayo Clinic or an outside facility by searching for relevant terms in their electronic medical record. Inclusion criteria were (1) attack-related requirement for noninvasive (bilevel positive airway pressure or continuous positive airway pressure) or invasive respiratory support (mechanical ventilation); (2) MOG or AQP4 antibody positivity with fulfillment of MOGAD and AQP4-NMOSD clinical diagnostic criteria, respectively; and (3) sufficient clinical details. We collected data on demographics, comorbid conditions, indication for and duration of respiratory support, MRI findings, treatments, and outcomes. The races of those with attacks requiring respiratory support were compared to those without such attacks in MOGAD and AQP4-NMOSD. Results Attacks requiring ventilatory support were similarly rare in patients with MOGAD (8 of 279, 2.9%) and AQP4-NMOSD (11 of 503 [2.2%]) (p = 0.63). The age at attack (median years [range]) (MOGAD 31.5 [5–47] vs AQP4-NMOSD 43 [14–65]; p = 0.01) and percentage of female sex (MOGAD 3 of 8 [38%] vs AQP4-NMOSD 10 of 11 [91%]; p = 0.04) differed. The reasons for ventilation differed between MOGAD (inability to protect airway from seizure, encephalitis or encephalomyelitis with attacks of acute disseminated encephalomyelitis 5 [62.5%] or unilateral cortical encephalitis 3 [37.5%]) and AQP4-NMOSD (inability to protect airway from cervical myelitis 9 [82%], rhombencephalitis 1 [9%], or combinations of both 1 [9%]). Median ventilation duration for MOGAD was 2 days (range 1–7 days) vs 19 days (range 6–330 days) for AQP4-NMOSD (p = 0.01). All patients with MOGAD recovered, but 2 of 11 (18%) patients with AQP4-NMOSD died of the attack. For AQP4-NMOSD, Black race was overrepresented for attacks requiring ventilatory support vs those without these episodes (5 of 11 [45%] vs 88 of 457 [19%]; p = 0.045). Discussion Ventilatory support is rarely required for MOGAD and AQP4-NMOSD attacks, and the indications differ. Compared to MOGAD, these attacks in AQP4-NMOSD may have higher morbidity and mortality, and those of Black race were more predisposed, which we suspect may relate to socially mediated health inequality.
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Affiliation(s)
| | | | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Jery Inbarasu
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - John J Chen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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19
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Gritsch D, Mrugala MM, Marks LA, Mangipudi K, Neal M, Wingerchuk DM, O'Carroll CB. Is Autologous Stem Cell Transplantation a Safe and Effective Alternative to Whole Brain Radiation as Consolidation Therapy in Patients With Primary Central Nervous System Lymphoma?: A Critically Appraised Topic. Neurologist 2021; 26:137-142. [PMID: 34190207 DOI: 10.1097/nrl.0000000000000328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-dose chemotherapy followed by autologous stem cell transplantation (HD-ASCT) is a promising alternative to whole brain radiation therapy (WBRT) in the treatment of primary central nervous system lymphoma (PCNSL). The objective of this study was to critically assess current evidence supporting the use of HD-ASCT as first-line consolidative therapy in PCNSL. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-oncology. RESULTS A recent, open-label, noncomparative randomized phase II trial was selected for critical appraisal. This trial evaluated the efficacy and toxicity of consolidative therapy with HD-ASCT and WBRT in PCNSL in 2 separate treatment arms. A total of 140 patients with newly diagnosed PCNSL between the ages of 18 and 60 years were included. The primary endpoint of 2-year progression-free survival was met in 63% of patients in the WBRT arm and 87% in the HD-ASCT arm. Notably, an overall improvement in neurocognitive scores was observed following HD-ASCT, while WBRT was associated with worsened cognitive outcomes. CONCLUSIONS In young patients with newly diagnosed PCNSL, consolidative therapy with HD-ASCT appears to be associated with less neurocognitive toxicity and may be more effective than WBRT at preventing relapses, however, at the cost of a higher treatment-related mortality.
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Affiliation(s)
| | | | | | | | - Matthew Neal
- Department of Neurosurgery, Mayo Clinic, Phoenix
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20
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Kunchok A, Chen JJ, Saadeh RS, Wingerchuk DM, Weinshenker BG, Flanagan EP, Pittock SJ. Application of 2015 Seronegative Neuromyelitis Optica Spectrum Disorder Diagnostic Criteria for Patients With Myelin Oligodendrocyte Glycoprotein IgG-Associated Disorders. JAMA Neurol 2021; 77:1572-1575. [PMID: 32777005 DOI: 10.1001/jamaneurol.2020.2743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amy Kunchok
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Department of Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - John J Chen
- Department of Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Ruba S Saadeh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Department of Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - Brian G Weinshenker
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Department of Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Department of Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Department of Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
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21
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Wingerchuk DM, Fujihara K, Palace J, Berthele A, Levy M, Kim HJ, Nakashima I, Oreja‐Guevara C, Wang K, Miller L, Shang S, Sabatella G, Yountz M, Pittock SJ. Long-Term Safety and Efficacy of Eculizumab in Aquaporin-4 IgG-Positive NMOSD. Ann Neurol 2021; 89:1088-1098. [PMID: 33586143 PMCID: PMC8248139 DOI: 10.1002/ana.26049] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE During PREVENT (NCT01892345), eculizumab significantly reduced relapse risk versus placebo in patients with aquaporin-4 immunoglobulin G-positive neuromyelitis optica spectrum disorder (AQP4-IgG+ NMOSD). We report an interim analysis of PREVENT's ongoing open-label extension (OLE; NCT02003144) evaluating eculizumab's long-term safety and efficacy. METHODS Patients who completed PREVENT could enroll in the OLE to receive eculizumab (maintenance dose = 1,200 mg/2 weeks, after a blinded induction phase). Safety and efficacy data from PREVENT and its OLE (interim data cut, July 31, 2019) were combined for this analysis. RESULTS Across PREVENT and the OLE, 137 patients received eculizumab and were monitored for a median (range) of 133.3 weeks (5.1-276.9 weeks), for a combined total of 362.3 patient-years (PY). Treatment-related adverse event (AE) and serious adverse event (SAE) rates were 183.5 in 100 PY and 8.6 in 100 PY, respectively. Serious infection rates were 10.2 in 100 PY in eculizumab-treated patients versus 15.1 in 100 PY in the PREVENT placebo group. No patient developed a meningococcal infection. At 192 weeks (3.7 years), 94.4% (95% confidence interval [CI], 88.6-97.3) of patients remained adjudicated relapse-free. The adjudicated annualized relapse rate was 0.025 (95% CI = 0.013-0.048) in all eculizumab-treated patients versus 0.350 (95% CI = 0.199-0.616) in the PREVENT placebo group. During the OLE, 37% of patients (44 of 119 patients) stopped or decreased background immunosuppressive therapy use. INTERPRETATION This analysis demonstrates that eculizumab's long-term safety profile in NMOSD is consistent with its established profile across other indications. This analysis also demonstrated the sustained ability of long-term eculizumab treatment to reduce relapse risk in patients with AQP4-IgG+ NMOSD. ANN NEUROL 2021;89:1088-1098.
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Affiliation(s)
| | - Kazuo Fujihara
- Tohoku UniversitySendaiJapan
- Fukushima Medical UniversityFukushima CityJapan
- Southern TOHOKU Research Institute for Neuroscience (STRINS)KoriyamaJapan
| | | | - Achim Berthele
- Department of Neurology, School of MedicineTechnical University of Munich, Klinikum rechts der IsarMunichGermany
| | - Michael Levy
- Massachusetts General Hospital and Harvard Medical SchoolBostonMA
| | - Ho Jin Kim
- Research Institute and HospitalNational Cancer CenterGoyangSouth Korea
| | - Ichiro Nakashima
- Tohoku UniversitySendaiJapan
- Tohoku Medical and Pharmaceutical UniversitySendaiJapan
| | | | - Kai‐Chen Wang
- Cheng‐Hsin General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming UniversityTaipeiTaiwan
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22
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Gritsch D, Mbonde AA, Harahsheh EY, Chong BW, Wingerchuk DM. Reversible Cerebral Vasculopathy, Transverse Myelitis, and Active Systemic Lupus Erythematosus in an Aquaporin-4 Antibody–Positive Patient. Neurol Neuroimmunol Neuroinflamm 2021; 8:8/2/e956. [PMID: 33468561 PMCID: PMC7862100 DOI: 10.1212/nxi.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/03/2020] [Indexed: 11/15/2022]
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23
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Kim HJ, Nakashima I, Viswanathan S, Wang KC, Shang S, Miller L, Yountz M, Wingerchuk DM, Pittock SJ, Levy M, Berthele A, Totolyan N, Palace J, Barnett MH, Fujihara K. Eculizumab in Asian patients with anti-aquaporin-IgG-positive neuromyelitis optica spectrum disorder: A subgroup analysis from the randomized phase 3 PREVENT trial and its open-label extension. Mult Scler Relat Disord 2021; 50:102849. [PMID: 33676197 DOI: 10.1016/j.msard.2021.102849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 11/19/2022]
Abstract
Background Eculizumab, a terminal complement inhibitor, significantly reduced the risk of relapse compared with placebo in patients with anti-aquaporin-4 immunoglobulin G-positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) in the PREVENT trial. We report efficacy and safety analyses in Asian patients in PREVENT and its open-label extension (OLE). Methods PREVENT was a double-blind, randomized, phase 3 trial. Patients with AQP4+ NMOSD were randomly assigned (2:1) to receive intravenous eculizumab (maintenance dose, 1200 mg/2 weeks) or placebo. Patients who completed PREVENT could receive eculizumab in an OLE. Analyses were performed in a prespecified subgroup of Asian patients. Results Of 143 patients enrolled, 52 (36.4%) were included in the Asian subgroup (eculizumab, n = 37; placebo, n = 15); 45 Asian patients received eculizumab in the OLE. Most Asian patients (86.5%) received concomitant immunosuppressive therapy. During PREVENT, one adjudicated relapse occurred in patients receiving eculizumab and six occurred in patients receiving placebo in the Asian subgroup (hazard ratio, 0.05; 95% confidence interval: 0.01-0.35; p = 0.0002). An estimated 95.2% of Asian patients remained relapse-free after 144 weeks of eculizumab treatment. Upper respiratory tract infections, headache, and nasopharyngitis were the most common adverse events with eculizumab in the Asian subgroup. Conclusion Eculizumab reduces the risk of relapse in Asian patients with AQP4+ NMOSD, with a benefit-risk profile similar to the overall PREVENT population. The benefits of eculizumab were maintained during long-term therapy. Clinical trial registration ClinicalTrials.gov identifiers: NCT01892345 (PREVENT); NCT02003144 (open-label extension).
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Affiliation(s)
- Ho Jin Kim
- Department of Neurology, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, South Korea.
| | - Ichiro Nakashima
- Department of Neurology, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi 980-8574, Japan; Division of Neurology, Tohoku Medical and Pharmaceutical University, 1-12-1 Fukumuro, Miyaginoku, Sendai, Miyagi 983-8512, Japan.
| | - Shanthi Viswanathan
- Department of Neurology, Kuala Lumpur Hospital, Jalan Pahang, Kuala Lumpur 50560, Malaysia
| | - Kai-Chen Wang
- Cheng Hsin General Hospital, 45 Zhenxing Street, Beitou District, Taipei, Taiwan 112; School of Medicine, National Yang-Ming University, 155, Section 2, Linong St, Beitou District, Taipei, Taiwan 112
| | - Shulian Shang
- Alexion Pharmaceuticals, 121 Seaport Boulevard, Boston, MA 02210, United States.
| | - Larisa Miller
- Alexion Pharmaceuticals, 121 Seaport Boulevard, Boston, MA 02210, United States.
| | - Marcus Yountz
- Alexion Pharmaceuticals, 121 Seaport Boulevard, Boston, MA 02210, United States.
| | - Dean M Wingerchuk
- Mayo Clinic Arizona, 13400 East Shea Boulevard, Scottsdale, AZ 85259, United States.
| | - Sean J Pittock
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States.
| | - Michael Levy
- Department of Neurology, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States.
| | - Achim Berthele
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Neuro-Kopf-Zentrum, Ismaninger Str. 22, 81675 Munich, Germany.
| | - Natalia Totolyan
- Department of Neurology, First Pavlov State Medical University of St. Petersburg, St. 6/8, Lva Tolstogo str., 197022 Petersburg, Russia.
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford OX3 9DU, United Kingdom.
| | - Michael H Barnett
- Brain and Mind Centre, University of Sydney, 94, Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia.
| | - Kazuo Fujihara
- Department of Neurology, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi 980-8574, Japan; Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima 960-1295, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience (STRINS), Koriyama, 7-115, Yatsuyamada, Koriyama, Fukushima 963-8563, Japan.
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24
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Sechi E, Mariotto S, McKeon A, Krecke KN, Pittock SJ, Ferrari S, Monaco S, Flanagan EP, Zanzoni S, Rabinstein AA, Wingerchuk DM, Nasr DM, Zalewski NL. Serum Neurofilament to Magnetic Resonance Imaging Lesion Area Ratio Differentiates Spinal Cord Infarction From Acute Myelitis. Stroke 2021; 52:645-654. [PMID: 33423516 DOI: 10.1161/strokeaha.120.031482] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE The diagnosis of spontaneous spinal cord infarction (SCI) is limited by the lack of diagnostic biomarkers and MRI features that often overlap with those of other myelopathies, especially acute myelitis. We investigated whether the ratio between serum neurofilament light chain levels and MRI T2-lesion area (neurofilament light chain/area ratio-NAR) differentiates SCI from acute myelitis of similar severity. METHODS We retrospectively identified Mayo Clinic patients (January 1, 2000-December 31, 2019) with (1) SCI, (2) AQP4 (aquaporin 4)-IgG or MOG (myelin oligodendrocyte glycoprotein)-IgG-associated myelitis at disease clinical presentation, or (3) idiopathic transverse myelitis from a previously identified population-based cohort of patients seronegative for AQP4-IgG and MOG-IgG. Serum neurofilament light chain levels (pg/mL) were assessed at the Verona University (SIMOA, Quanterix) in a blinded fashion on available stored samples obtained ≤3 months from myelopathy presentation. For each patient, the largest spinal cord lesion area (mm2) was manually outlined by 2 independent raters on sagittal T2-weighted MRI images, and the mean value was used to determine NAR (pg/[mL·mm2]). RESULTS Forty-eight patients were included SCI, 20 (definite, 11; probable, 6; possible, 3); acute myelitis, 28 (AQP4-IgG-associated, 17; MOG-IgG-associated, 5; idiopathic transverse myelitis, 6). The median expanded disability status scale score (range) at myelopathy nadir were 7.75 (2-8.5) and 5.5 (2-8), respectively. Serum neurofilament light chain levels (median [range] pg/mL) in patients with SCI (188 [14.3-2793.4]) were significantly higher compared with patients with AQP4-IgG-associated myelitis (37 [0.8-6942.9]), MOG-IgG-associated myelitis (45.8 [4-283.8]), and idiopathic transverse myelitis (15.6 [0.9-217.8]); P=0.01. NAR showed the highest accuracy for identification of SCI versus acute myelitis with values ≥0.35 pg/(mL·mm2) yielding 86% specificity and 95% sensitivity (area under the curve=0.93). The positive and negative likelihood ratios were 6.67 and 0.06, respectively. NAR remained independently associated with SCI after adjusting for age, gender, immunotherapy before sampling, and days from myelopathy symptoms onset to sampling (P=0.0007). CONCLUSIONS NAR is a novel and promising clinical biomarker for differentiation of SCI from acute myelitis.
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Affiliation(s)
- Elia Sechi
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester.,Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences (E.S., S. Mariotto, S.F., S. Monaco), University of Verona, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences (E.S., S. Mariotto, S.F., S. Monaco), University of Verona, Italy
| | - Andrew McKeon
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester.,Laboratory Medicine and Pathology (A.M., S.J.P., E.P.F.), Mayo Clinic, Rochester
| | | | - Sean J Pittock
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester.,Laboratory Medicine and Pathology (A.M., S.J.P., E.P.F.), Mayo Clinic, Rochester
| | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences (E.S., S. Mariotto, S.F., S. Monaco), University of Verona, Italy
| | - Salvatore Monaco
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences (E.S., S. Mariotto, S.F., S. Monaco), University of Verona, Italy
| | - Eoin P Flanagan
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester.,Laboratory Medicine and Pathology (A.M., S.J.P., E.P.F.), Mayo Clinic, Rochester
| | - Serena Zanzoni
- Centro Piattaforme Tecnologiche (S.Z.), University of Verona, Italy
| | - Alejandro A Rabinstein
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester
| | | | - Deena M Nasr
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester
| | - Nicholas L Zalewski
- Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester
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25
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Elsbernd PM, Hoffman WR, Carter JL, Wingerchuk DM. Interleukin-6 inhibition with tocilizumab for relapsing MOG-IgG associated disorder (MOGAD): A case-series and review. Mult Scler Relat Disord 2020; 48:102696. [PMID: 33360264 DOI: 10.1016/j.msard.2020.102696] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/03/2020] [Accepted: 12/12/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Myelin oligodendrocyte glycoprotein-immunoglobulin G (MOG-IgG) associated disorder (MOGAD) is a CNS demyelinating disease distinct from neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis. Some patients with MOGAD exhibit a highly-relapsing and steroid-dependent disease course for which optimal treatment is unknown. Interleukin-6 (IL-6) plays an important pathobiologic role in NMOSD with aquaporin-4 antibodies and preliminary data suggest similar mechanisms of CNS damage may occur in MOGAD. OBJECTIVE To summarize our experience with and all current literature on the use of tocilizumab, an IL-6 inhibitor, for highly-relapsing MOGAD along with the underlying immunopathologic rationale. METHODS This is a single-center report from a U.S. military tertiary referral hospital of all patients with clinically, radiographically, and serologically confirmed MOGAD who were treated with tocilizumab compiled with data from five other case series/reports from tertiary referral centers. The main outcomes of interest were reduction in annualized relapse rate and required dose of oral prednisone for symptomatic management. RESULTS Ten total patients with relapsing MOGAD who were treated with intravenous or subcutaneous tocilizumab were identified. At our institution, a 20 year-old female with a 9-year history of highly-relapsing and steroid dependent MOGAD was treated with tocilizumab. In 28 months of follow up, she had no clinical relapses and was able to discontinue corticosteroids. Another 35 year-old female at our institution with a 10-year history of highly-relapsing and steroid dependent MOGAD was treated with tocilizumab for 6 months. Tocilizumab therapy was associated with relapse freedom, resolution of eye pain, and ability to discontinue corticosteroids. When compiled with data from all other case reports of relapsing MOGAD treated with tocilizumab, there have been zero clinical or radiographic relapses in 10 patients over an average treatment duration of 28.6 months. CONCLUSIONS Tocilizumab is an IL-6 inhibitor that may be a promising therapeutic option for patients with relapsing MOGAD that has not responded to other immunotherapies. Our results support a key role for IL-6-related mechanisms in MOGAD disease activity. Its safety and tolerability profile, both in our own experience and based on its use for other FDA approved conditions, may even justify its use a first line therapy in select patients. Further research is needed to establish the safety and efficacy of IL-6 inhibition in MOGAD.
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Affiliation(s)
- Paul M Elsbernd
- Departments of Neurology, Mayo Clinic, Scottsdale, AZ, United States; Brooke Army Medical Center, Fort Sam Houston, TX, United States.
| | | | - Jonathan L Carter
- Departments of Neurology, Mayo Clinic, Scottsdale, AZ, United States
| | - Dean M Wingerchuk
- Departments of Neurology, Mayo Clinic, Scottsdale, AZ, United States
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26
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Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune, inflammatory disorder of the central nervous system that typically presents with recurrent episodes of optic neuritis, longitudinally extensive myelitis, brainstem, diencephalic, and cerebral syndromes. Up to 80% of NMOSD patients have a circulating pathogenic autoantibody that targets the water channel aquaporin-4 (AQP4-IgG). The discovery of AQP4-IgG transformed our understanding of the pathogenesis of the disease and its possible treatment targets. Monoclonal antibodies targeting terminal complement (eculizumab), CD19 (inebilizumab), and the interleukin-6 receptor (satralizumab) have demonstrated efficacy in NMOSD attack prevention in recent phase 3 trials and have gained subsequent regulatory approval in the USA and other countries. We aim to review the evidence supporting the efficacy of these new drugs.
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Affiliation(s)
| | - Dean M Wingerchuk
- Department of Neurology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA.
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Chen JJ, Flanagan EP, Bhatti MT, Jitprapaikulsan J, Dubey D, Lopez Chiriboga ASS, Fryer JP, Weinshenker BG, McKeon A, Tillema JM, Lennon VA, Lucchinetti CF, Kunchok A, McClelland CM, Lee MS, Bennett JL, Pelak VS, Van Stavern G, Adesina OOO, Eggenberger ER, Acierno MD, Wingerchuk DM, Lam BL, Moss H, Beres S, Gilbert AL, Shah V, Armstrong G, Heidary G, Cestari DM, Stiebel-Kalish H, Pittock SJ. Steroid-sparing maintenance immunotherapy for MOG-IgG associated disorder. Neurology 2020; 95:e111-e120. [PMID: 32554760 PMCID: PMC7455322 DOI: 10.1212/wnl.0000000000009758] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Myelin oligodendrocyte glycoprotein-immunoglobulin G (MOG-IgG) associated disorder (MOGAD) often manifests with recurrent CNS demyelinating attacks. The optimal treatment for reducing relapses is unknown. To help determine the efficacy of long-term immunotherapy in preventing relapse in patients with MOGAD, we conducted a multicenter retrospective study to determine the rate of relapses on various treatments. METHODS We determined the frequency of relapses in patients receiving various forms of long-term immunotherapy for MOGAD. Inclusion criteria were history of ≥1 CNS demyelinating attacks, MOG-IgG seropositivity, and immunotherapy for ≥6 months. Patients were reviewed for CNS demyelinating attacks before and during long-term immunotherapy. RESULTS Seventy patients were included. The median age at initial CNS demyelinating attack was 29 years (range 3-61 years; 33% <18 years), and 59% were female. The median annualized relapse rate (ARR) before treatment was 1.6. On maintenance immunotherapy, the proportion of patients with relapse was as follows: mycophenolate mofetil 74% (14 of 19; ARR 0.67), rituximab 61% (22 of 36; ARR 0.59), azathioprine 59% (13 of 22; ARR 0.2), and IV immunoglobulin (IVIG) 20% (2 of 10; ARR 0). The overall median ARR on these 4 treatments was 0.3. All 9 patients treated with multiple sclerosis (MS) disease-modifying agents had a breakthrough relapse on treatment (ARR 1.5). CONCLUSION This large retrospective multicenter study of patients with MOGAD suggests that maintenance immunotherapy reduces recurrent CNS demyelinating attacks, with the lowest ARR being associated with maintenance IVIG therapy. Traditional MS disease-modifying agents appear to be ineffective. Prospective randomized controlled studies are required to validate these conclusions.
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Affiliation(s)
- John J Chen
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel.
| | - Eoin P Flanagan
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - M Tariq Bhatti
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Jiraporn Jitprapaikulsan
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Divyanshu Dubey
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Alfonso Sebastian S Lopez Chiriboga
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - James P Fryer
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Brian G Weinshenker
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Andrew McKeon
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Jan-Mendelt Tillema
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Vanda A Lennon
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Claudia F Lucchinetti
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Amy Kunchok
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Collin M McClelland
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Michael S Lee
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Jeffrey L Bennett
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Victoria S Pelak
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Gregory Van Stavern
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Ore-Ofe O Adesina
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Eric R Eggenberger
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Marie D Acierno
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Dean M Wingerchuk
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Byron L Lam
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Heather Moss
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Shannon Beres
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Aubrey L Gilbert
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Veeral Shah
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Grayson Armstrong
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Gena Heidary
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Dean M Cestari
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Hadas Stiebel-Kalish
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Sean J Pittock
- From the Departments of Ophthalmology (J.J.C., M.T.B.), Neurology (J.J.C., E.P.F., M.T.B., J.J., D.D., A.S.L.C., B.G.W., A.M., J.-M.T., V.A.L., C.F.L., A.K., S.J.P.), Laboratory Medicine and Pathology (E.P.F., J.J., D.D, J.P.F., A.M., V.A.L., S.J.P.), and Immunology (V.A.L.) and Center for MS and Autoimmune Neurology (E.P.F., D.D., B.G.W., A.M., V.A.L., C.F.L., A.K., S.J.P.), Mayo Clinic, Rochester, MN; Department of Ophthalmology and Visual Neurosciences (C.M.M., M.S.L.), University of Minnesota, Minneapolis; Departments of Neurology and Ophthalmology (J.L.B., V.S.P.), University of Colorado Denver School of Medicine, Aurora; Departments of Ophthalmology and Visual Sciences and Neurology (G.V.S.), Washington University, St. Louis School of Medicine, MO; Departments of Ophthalmology and Visual Science and Neurology (O.-O.O.A.), McGovern Medical School, Houston, TX; Departments of Neurology, Neurosurgery, and Neuro-Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Departments of Ophthalmology (M.D.A.) and Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Bascom Palmer Eye Institute (B.L.L.), University of Miami, FL; Department of Neurology and Ophthalmology (H.M., S.B.), Stanford University, Palo Alto, CA; Neuro-Ophthalmology (A.L.G.), Kaiser Permanente, Northern California, Vallejo; Department of Ophthalmology (V.S.), Baylor College of Medicine/Texas Children's Hospital, Houston; Department of Ophthalmology (G.A., D.M.C.), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston; Department of Ophthalmology (G.H.), Boston Children's Hospital, Harvard Medical School, MA; and Neuro-Ophthalmology Unit (H.S.-K.), Department of Ophthalmology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
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Valencia-Sanchez C, Wingerchuk DM, Dhamija R. Teaching NeuroImages: Spinal xanthomatosis: A misdiagnosed, treatable cause of progressive myelopathy. Neurology 2020; 95:e1615-e1616. [PMID: 32636326 DOI: 10.1212/wnl.0000000000010194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Hor JY, Asgari N, Nakashima I, Broadley SA, Leite MI, Kissani N, Jacob A, Marignier R, Weinshenker BG, Paul F, Pittock SJ, Palace J, Wingerchuk DM, Behne JM, Yeaman MR, Fujihara K. Epidemiology of Neuromyelitis Optica Spectrum Disorder and Its Prevalence and Incidence Worldwide. Front Neurol 2020; 11:501. [PMID: 32670177 PMCID: PMC7332882 DOI: 10.3389/fneur.2020.00501] [Citation(s) in RCA: 178] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is an uncommon inflammatory disease of the central nervous system, manifesting clinically as optic neuritis, myelitis, and certain brain and brainstem syndromes. Cases clinically diagnosed as NMOSD may include aquaporin 4 (AQP4)-antibody-seropositive autoimmune astrocytopathic disease, myelin oligodendrocyte glycoprotein (MOG)-antibody-seropositive inflammatory demyelinating disease, and double-seronegative disease. AQP4-antibody disease has a high female-to-male ratio (up to 9:1), and its mean age at onset of ~40 years is later than that seen in multiple sclerosis. For MOG-antibody disease, its gender ratio is closer to 1:1, and it is more common in children than in adults. Its clinical phenotypes differ but overlap with those of AQP4-antibody disease and include acute disseminated encephalomyelitis, brainstem and cerebral cortical encephalitis, as well as optic neuritis and myelitis. Double-seronegative disease requires further research and clarification. Population-based studies over the past two decades report the prevalence and incidence of NMOSD in different populations worldwide. One relevant finding is the varying prevalence observed in different racial groups. Consistently, the prevalence of NMOSD among Whites is ~1/100,000 population, with an annual incidence of <1/million population. Among East Asians, the prevalence is higher, at ~3.5/100,000 population, while the prevalence in Blacks may be up to 10/100,000 population. For MOG-antibody disease, hospital-based studies largely do not observe any significant racial preponderance so far. This disorder comprises a significant proportion of NMOSD cases that are AQP4-antibody-seronegative. A recent Dutch nationwide study reported the annual incidence of MOG-antibody disease as 1.6/million population (adult: 1.3/million, children: 3.1/million). Clinical and radiological differences between AQP4-antibody and MOG-antibody associated diseases have led to interest in the revisions of NMOSD definition and expanded stratification based on detection of a specific autoantibody biomarker. More population-based studies in different geographical regions and racial groups will be useful to further inform the prevalence and incidence of NMOSD and their antibody-specific subgroups. Accessibility to AQP4-antibody and MOG-antibody testing, which is limited in many centers, is a challenge to overcome. Environmental and genetic studies will be useful accompaniments to identify other potential pathogenetic factors and specific biomarkers in NMOSD.
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Affiliation(s)
- Jyh Yung Hor
- Department of Neurology, Penang General Hospital, Penang, Malaysia
| | - Nasrin Asgari
- Department of Neurology, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Ichiro Nakashima
- Department of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Simon A Broadley
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Najib Kissani
- Neurology Department and Neuroscience Research Laboratory of Marrakech Medical School, University Hospital Mohammed VI, Marrakech, Morocco
| | - Anu Jacob
- Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.,Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | | | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, and Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Jacinta M Behne
- The Guthy-Jackson Charitable Foundation, Beverly Hills, CA, United States
| | - Michael R Yeaman
- Divisions of Molecular Medicine and Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles and Harbor-UCLA Medical Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Koriyama, Japan
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Valencia-Sanchez C, Wingerchuk DM. A fine balance: Immunosuppression and immunotherapy in a patient with multiple sclerosis and COVID-19. Mult Scler Relat Disord 2020; 42:102182. [PMID: 32416330 PMCID: PMC7205685 DOI: 10.1016/j.msard.2020.102182] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 12/29/2022]
Abstract
The role of pre-existing immunosuppression on COVID-19 risk and outcomes is unclear Immunotherapy is being evaluated for COVID-19-related cytokine release syndrome We report a fingolimod-treated MS patient who developed severe COVID-19 COVID-19 recovery occurred after stopping fingolimod and treating with tocilizumab
Background Treatment decisions in patients with multiple sclerosis (MS) during the coronavirus disease 2019 (COVID-19) pandemic are challenging. It is not known whether and how various disease modifying therapies, especially immunosuppressive drugs, affect COVID-19 risk and disease course. Methods Case report Results We report a fingolimod-treated MS patient who developed severe COVID-19 but recovered after treatment with tocilizumab. Conclusion This report suggests that a brief course of tocilizumab for the treatment of severe COVID-19 may be effective while not aggravating pre-existing MS.
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Affiliation(s)
- Cristina Valencia-Sanchez
- Neurology Department, Mayo Clinic Arizona, 13400 East Shea Boulevard, 85259 Scottsdale, Arizona, United States
| | - Dean M Wingerchuk
- Neurology Department, Mayo Clinic Arizona, 13400 East Shea Boulevard, 85259 Scottsdale, Arizona, United States.
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Cree BAC, Bennett JL, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk DM, Fujihara K, Paul F, Cutter GR, Marignier R, Green AJ, Aktas O, Hartung HP, Lublin FD, Drappa J, Barron G, Madani S, Ratchford JN, She D, Cimbora D, Katz E. Inebilizumab for the treatment of neuromyelitis optica spectrum disorder (N-MOmentum): a double-blind, randomised placebo-controlled phase 2/3 trial. Lancet 2019; 394:1352-1363. [PMID: 31495497 DOI: 10.1016/s0140-6736(19)31817-3] [Citation(s) in RCA: 363] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND No approved therapies exist for neuromyelitis optica spectrum disorder (NMOSD), a rare, relapsing, autoimmune, inflammatory disease of the CNS that causes blindness and paralysis. We aimed to assess the efficacy and safety of inebilizumab, an anti-CD19, B cell-depleting antibody, in reducing the risk of attacks and disability in NMOSD. METHODS We did a multicentre, double-blind, randomised placebo-controlled phase 2/3 study at 99 outpatient specialty clinics or hospitals in 25 countries. Eligible participants were adults (≥18 years old) with a diagnosis of NMOSD, an Expanded Disability Status Scale score of 8·0 or less, and a history of at least one attack requiring rescue therapy in the year before screening or at least two attacks requiring rescue therapy in the 2 years before screening. Participants were randomly allocated (3:1) to 300 mg intravenous inebilizumab or placebo with a central interactive voice response system or interactive web response system and permuted block randomisation. Inebilizumab or placebo was administered on days 1 and 15. Participants, investigators, and all clinical staff were masked to the treatments, and inebilizumab and placebo were indistinguishable in appearance. The primary endpoint was time to onset of an NMOSD attack, as determined by the adjudication committee. Efficacy endpoints were assessed in all randomly allocated patients who received at least one dose of study intervention, and safety endpoints were assessed in the as-treated population. The study is registered with ClinicalTrials.gov, number NCT02200770. FINDINGS Between Jan 6, 2015, and Sept 24, 2018, 230 participants were randomly assigned to treatment and dosed, with 174 participants receiving inebilizumab and 56 receiving placebo. The randomised controlled period was stopped before complete enrolment, as recommended by the independent data-monitoring committee, because of a clear demonstration of efficacy. 21 (12%) of 174 participants receiving inebilizumab had an attack versus 22 (39%) of 56 participants receiving placebo (hazard ratio 0·272 [95% CI 0·150-0·496]; p<0·0001). Adverse events occurred in 125 (72%) of 174 participants receiving inebilizumab and 41 (73%) of 56 participants receiving placebo. Serious adverse events occurred in eight (5%) of 174 participants receiving inebilizumab and five (9%) of 56 participants receiving placebo. INTERPRETATION Compared with placebo, inebilizumab reduced the risk of an NMOSD attack. Inebilizumab has potential application as an evidence-based treatment for patients with NMOSD. FUNDING MedImmune and Viela Bio.
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Affiliation(s)
- Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
| | - Jeffrey L Bennett
- School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Seoul, South Korea
| | | | | | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany; Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Lyon University Hospital, Lyon, France
| | - Ari J Green
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA; Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Orhan Aktas
- Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Pittock SJ, Berthele A, Fujihara K, Kim HJ, Levy M, Palace J, Nakashima I, Terzi M, Totolyan N, Viswanathan S, Wang KC, Pace A, Fujita KP, Armstrong R, Wingerchuk DM. Eculizumab in Aquaporin-4-Positive Neuromyelitis Optica Spectrum Disorder. N Engl J Med 2019; 381:614-625. [PMID: 31050279 DOI: 10.1056/nejmoa1900866] [Citation(s) in RCA: 454] [Impact Index Per Article: 90.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is a relapsing, autoimmune, inflammatory disorder that typically affects the optic nerves and spinal cord. At least two thirds of cases are associated with aquaporin-4 antibodies (AQP4-IgG) and complement-mediated damage to the central nervous system. In a previous small, open-label study involving patients with AQP4-IgG-positive disease, eculizumab, a terminal complement inhibitor, was shown to reduce the frequency of relapse. METHODS In this randomized, double-blind, time-to-event trial, 143 adults were randomly assigned in a 2:1 ratio to receive either intravenous eculizumab (at a dose of 900 mg weekly for the first four doses starting on day 1, followed by 1200 mg every 2 weeks starting at week 4) or matched placebo. The continued use of stable-dose immunosuppressive therapy was permitted. The primary end point was the first adjudicated relapse. Secondary outcomes included the adjudicated annualized relapse rate, quality-of-life measures, and the score on the Expanded Disability Status Scale (EDSS), which ranges from 0 (no disability) to 10 (death). RESULTS The trial was stopped after 23 of the 24 prespecified adjudicated relapses, given the uncertainty in estimating when the final event would occur. The mean (±SD) annualized relapse rate in the 24 months before enrollment was 1.99±0.94; 76% of the patients continued to receive their previous immunosuppressive therapy during the trial. Adjudicated relapses occurred in 3 of 96 patients (3%) in the eculizumab group and 20 of 47 (43%) in the placebo group (hazard ratio, 0.06; 95% confidence interval [CI], 0.02 to 0.20; P<0.001). The adjudicated annualized relapse rate was 0.02 in the eculizumab group and 0.35 in the placebo group (rate ratio, 0.04; 95% CI, 0.01 to 0.15; P<0.001). The mean change in the EDSS score was -0.18 in the eculizumab group and 0.12 in the placebo group (least-squares mean difference, -0.29; 95% CI, -0.59 to 0.01). Upper respiratory tract infections and headaches were more common in the eculizumab group. There was one death from pulmonary empyema in the eculizumab group. CONCLUSIONS Among patients with AQP4-IgG-positive NMOSD, those who received eculizumab had a significantly lower risk of relapse than those who received placebo. There was no significant between-group difference in measures of disability progression. (Funded by Alexion Pharmaceuticals; PREVENT ClinicalTrials.gov number, NCT01892345; EudraCT number, 2013-001150-10.).
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Affiliation(s)
- Sean J Pittock
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Achim Berthele
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Kazuo Fujihara
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Ho Jin Kim
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Michael Levy
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Jacqueline Palace
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Ichiro Nakashima
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Murat Terzi
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Natalia Totolyan
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Shanthi Viswanathan
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Kai-Chen Wang
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Amy Pace
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Kenji P Fujita
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Róisín Armstrong
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
| | - Dean M Wingerchuk
- From the Mayo Clinic, Rochester, MN (S.J.P.); Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany (A.B.); Tohoku University Graduate School of Medicine (K.F., I.N.) and Tohoku Medical and Pharmaceutical University (I.N.), Sendai, School of Medicine, Fukushima Medical University, Fukushima City (K.F.), and Southern Tohoku Research Institute for Neuroscience, Koriyama (K.F.) - all in Japan; Research Institute and Hospital, National Cancer Center, Goyang, South Korea (H.J.K.); Johns Hopkins University, Baltimore (M.L.); Massachusetts General Hospital and Harvard Medical School (M.L.) and Alexion Pharmaceuticals (A.P., K.P.F., R.A.) - all in Boston; John Radcliffe Hospital, Oxford, United Kingdom (J.P.); Ondokuz Mayis University, Samsun, Turkey (M.T.); First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia (N.T.); Kuala Lumpur Hospital, Kuala Lumpur, Malaysia (S.V.); Cheng-Hsin General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (K.-C.W.); and the Mayo Clinic, Scottsdale, AZ (D.M.W.)
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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, and management of immune-mediated myelopathies. RECENT FINDINGS The discovery of several neural autoantibodies and their antigenic targets has revolutionized the investigation and treatment of immune-mediated myelopathies. Detection of these serologic biomarkers can support or establish a diagnosis of an autoimmune myelopathy, and, in the case of paraneoplastic syndromes, indicate the likely presence of an underlying malignancy. Distinctive lesion patterns detected on spinal cord or brain MRI narrow the differential diagnosis in patients with acute or subacute inflammatory myelopathies, including those not associated with autoantibody markers. SUMMARY Immune-mediated myelopathies usually present acutely or subacutely and have a broad differential diagnosis. A systematic diagnostic approach using data from the clinical setting and presentation, MRI lesion patterns, CSF data, and autoantibody markers can differentiate these disorders from noninflammatory myelopathies, often with precise disease classification. This, in turn, provides prognostic information, especially whether the disorder is likely to relapse, and facilitates therapeutic decision making. Diagnostic accuracy informs selection of acute immunotherapy aimed at arresting and reversing recent neurologic injury and, when necessary, selection of long-term treatment for prevention of disease progression or relapse.
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Sechi E, Morris PP, McKeon A, Pittock SJ, Hinson SR, Weinshenker BG, Aksamit AJ, Krecke KN, Kaufmann TJ, Jolliffe EA, Zalewski NL, Zekeridou A, Wingerchuk DM, Jitprapaikulsan J, Flanagan EP. Glial fibrillary acidic protein IgG related myelitis: characterisation and comparison with aquaporin-4-IgG myelitis. J Neurol Neurosurg Psychiatry 2019; 90:488-490. [PMID: 30032117 DOI: 10.1136/jnnp-2018-318004] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - P Pearse Morris
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Allen J Aksamit
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Evan A Jolliffe
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Jiraporn Jitprapaikulsan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Valencia-Sanchez C, Goodman BP, Carter JL, Wingerchuk DM. The spectrum of acute cardiopulmonary events associated with multiple sclerosis exacerbations. Mult Scler 2019; 25:758-765. [PMID: 30657008 DOI: 10.1177/1352458518823482] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Diverse acute neurological injuries may cause acute cardiopulmonary events including neurogenic pulmonary edema (NPE) and neurogenic stunned myocardium (NSM). The mechanism is probably mediated by sympathetic nervous system activation. Focal central nervous system (CNS) lesions, such as demyelinating lesions in multiple sclerosis (MS), may also cause cardiopulmonary disturbances. We aim to review the acute cardiopulmonary events associated with MS relapses. We performed a literature search using PubMed, and selected case reports of acute cardiac and/or pulmonary events related to MS exacerbations. We grouped these events into three categories: 1) NPE with normal cardiac function; 2) NSM and Takotsubo cardiomyopathy (TTC); 3) coexisting myocardial dysfunction and pulmonary edema. In some cases, cardiac and pulmonary symptoms preceded the onset of neurological symptoms. The majority of cases were associated with acute demyelinating lesions located in the medulla. Acute brainstem MS relapses, with demyelinating lesions affecting the medulla, may cause acute cardiac and pulmonary events presumably secondary to sympathetic hyperstimulation. Specific regions in the medulla that regulate cardiac function, systemic blood pressure and pulmonary hydrostatic pressure seem to be responsible for these events.
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Affiliation(s)
| | - Brent P Goodman
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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McCreary M, Mealy MA, Wingerchuk DM, Levy M, DeSena A, Greenberg BM. Updated diagnostic criteria for neuromyelitis optica spectrum disorder: Similar outcomes of previously separate cohorts. Mult Scler J Exp Transl Clin 2018; 4:2055217318815925. [PMID: 30559975 PMCID: PMC6293372 DOI: 10.1177/2055217318815925] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/28/2018] [Accepted: 10/28/2018] [Indexed: 11/19/2022] Open
Abstract
Background The specificity of the aquaporin-4 antibody to predict recurrent
inflammatory central nervous system disease has led to the
design of the 2015 neuromyelitis optica spectrum disorder
criteria which capture all aquaporin-4 antibody seropositive
patients. Objective The purpose of this study was to compare treatment outcomes in
aquaporin-4 antibody seropositive patients who met the previous
2006 clinical criteria for neuromyelitis optica with patients
who meet the 2015 neuromyelitis optica spectrum disorder
criteria. Methods The study involved a three-center retrospective chart review of
clinical outcomes among aquaporin-4 patients diagnosed with
neuromyelitis optica and neuromyelitis optica spectrum
disorder. Results Hazard ratios of relapse during immunosuppressive therapy, relative
to pre-therapy, were not significantly different for patients
who met the 2006 criteria of neuromyelitis optica versus the
2015 neuromyelitis optica spectrum disorder criteria among those
treated with azathioprine ( p = 0.24),
mycophenolate mofetil ( p = 0.63), or rituximab
( p = 0.97). Conclusion Reductions in the hazard of relapse during treatment with
immunosuppressive therapies, relative to average pre-treatment,
were not different for aquaporin-4 antibody seropositive
patients categorized using the 2006 criteria of neuromyelitis
optica and the 2015 neuromyelitis optica spectrum disorder
criteria. These therapeutic findings support the design of the
2015 neuromyelitis optica spectrum disorder criteria which
capture all aquaporin-4 antibody seropositive patients.
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Affiliation(s)
- M McCreary
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, USA
| | - M A Mealy
- Department of Neurology, Johns Hopkins Hospital, USA
| | | | - M Levy
- Department of Neurology, Johns Hopkins Hospital, USA
| | - A DeSena
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, USA
| | - B M Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, USA
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Chen JJ, Flanagan EP, Jitprapaikulsan J, López-Chiriboga A(SS, Fryer JP, Leavitt JA, Weinshenker BG, McKeon A, Tillema JM, Lennon VA, Tobin WO, Keegan BM, Lucchinetti CF, Kantarci OH, McClelland CM, Lee MS, Bennett JL, Pelak VS, Chen Y, VanStavern G, Adesina OOO, Eggenberger ER, Acierno MD, Wingerchuk DM, Brazis PW, Sagen J, Pittock SJ. Myelin Oligodendrocyte Glycoprotein Antibody-Positive Optic Neuritis: Clinical Characteristics, Radiologic Clues, and Outcome. Am J Ophthalmol 2018; 195:8-15. [PMID: 30055153 DOI: 10.1016/j.ajo.2018.07.020] [Citation(s) in RCA: 225] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/25/2018] [Accepted: 07/18/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE To characterize the clinical phenotype of myelin oligodendrocyte glycoprotein antibody (MOG-IgG) optic neuritis. DESIGN Observational case series. METHODS Setting: Multicenter. Patient/Study Population: Subjects meeting inclusion criteria: (1) history of optic neuritis; (2) seropositivity (MOG-IgG binding index > 2.5); 87 MOG-IgG-seropositive patients with optic neuritis were included (Mayo Clinic, 76; other medical centers, 11). MOG-IgG was detected using full-length MOG-transfected live HEK293 cells in a clinically validated flow cytometry assay. MAIN OUTCOME MEASURES Clinical and radiologic characteristics and visual outcomes. RESULTS Fifty-seven percent were female and median age at onset was 31 (range 2-79) years. Median number of optic neuritis attacks was 3 (range 1-8), median follow-up 2.9 years (range 0.5-24 years), and annualized relapse rate 0.8. Average visual acuity (VA) at nadir of worst attack was count fingers. Average final VA was 20/30; for 5 patients (6%) it was ≤20/200 in either eye. Optic disc edema and pain each occurred in 86% of patients. Magnetic resonance imaging showed perineural enhancement in 50% and longitudinally extensive involvement in 80%. Twenty-six patients (30%) had recurrent optic neuritis without other neurologic symptoms, 10 (12%) had single optic neuritis, 14 (16%) had chronic relapsing inflammatory optic neuropathy, and 36 (41%) had optic neuritis with other neurologic symptoms (most neuromyelitis optica spectrum disorder-like phenotype or acute disseminated encephalomyelitis). Only 1 patient was diagnosed with MS (MOG-IgG-binding index 2.8; normal range ≤ 2.5). Persistent MOG-IgG seropositivity occurred in 61 of 62 (98%). A total of 61% received long-term immunosuppressant therapy. CONCLUSIONS Manifestations of MOG-IgG-positive optic neuritis are diverse. Despite recurrent attacks with severe vision loss, the majority of patients have significant recovery and retain functional vision long-term.
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Corboy JR, Weinshenker BG, Wingerchuk DM. Comment on 2018 American Academy of Neurology guidelines on disease-modifying therapies in MS. Neurology 2018; 90:1106-1112. [DOI: 10.1212/wnl.0000000000005574] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/27/2018] [Indexed: 11/15/2022] Open
Abstract
The American Academy of Neurology has published a comprehensive review and guidelines for the use of disease-modifying therapies (DMTs) in multiple sclerosis (MS) for the first time since 2002. These guidelines represent the work of MS experts, patients, and guideline experts and are based on their review of randomized controlled trials and observational evidence that addresses a set of prespecified questions related to starting, switching, and potentially discontinuing DMTs. Many of the recommendations address decision-making regarding the use of DMTs and incorporate the perspective of patients. Modified Delphi methods were used to establish consensus recommendations that were assigned a level of clinical obligation (actions a clinician must [A], should [B], or may [C] do). Most guideline recommendations are level B. Few reached level A, and several achieved only level C, primarily because of lack of evidence. The guidelines eschew formal treatment algorithms and do not address financial considerations and a variety of other controversies. We identify remaining uncertainties, the most important of which is the choice of available DMTs for the average newly diagnosed patient. We reiterate a number of research needs identified in the guidelines that could affect the use of DMTs, including improved definition of breakthrough disease requiring change in therapy, development of better and universally accepted definitions of both benign and aggressive MS, more and longer-duration comparative effectiveness trials, discovery and validation of biomarkers of disease activity and response to therapy, and development of treatment strategies focused on neuroprotection, remyelination, and neural repair.
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Parks NE, Flanagan EP, Lucchinetti CF, Wingerchuk DM. NEDA treatment target? No evident disease activity as an actionable outcome in practice. J Neurol Sci 2017; 383:31-34. [PMID: 29246616 DOI: 10.1016/j.jns.2017.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/05/2017] [Accepted: 10/08/2017] [Indexed: 11/29/2022]
Abstract
"No evident disease activity" (NEDA) is a proposed measure of disease activity-free status in multiple sclerosis (MS) that is typically defined as absence of relapses, disability progression, and MRI activity over a defined time period. NEDA is increasingly reported in randomized controlled trials of MS disease modifying therapies where it has some perceived advantages over outcomes such as annualized relapse rate. NEDA has also been proposed as a treatment goal in clinical care. At this point, the long-term implications of early NEDA remain largely unknown. We review current NEDA definitions, use in clinical trials, and its prospects for routine use as an actionable treatment target in clinical practice.
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Affiliation(s)
- Natalie E Parks
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA; Division of Neurology, Dalhousie University, 1341 Summer Street, Halifax, NS B3H4K4, Canada.
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | | | - Dean M Wingerchuk
- Department of Neurology, Mayo Clinic, 13400 E Shea Boulevard, Scottsdale, AZ 85259, USA.
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Mealy MA, Kim SH, Schmidt F, López R, Jimenez Arango JA, Paul F, Wingerchuk DM, Greenberg BM, Kim HJ, Levy M. Aquaporin-4 serostatus does not predict response to immunotherapy in neuromyelitis optica spectrum disorders. Mult Scler 2017; 24:1737-1742. [PMID: 28857723 DOI: 10.1177/1352458517730131] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Debate exists about whether neuromyelitis optica spectrum disorder seronegative disease represents the same immune-mediated attack on astrocytic aquaporin-4 as in seropositive disease. OBJECTIVE We investigated whether response to common treatments for neuromyelitis optica spectrum disorder differed by serostatus, as assessed by change in annualized relapse rate. METHODS We performed a multicenter retrospective analysis of 245 patients with neuromyelitis optica spectrum disorder who were treated with either rituximab or mycophenolate mofetil as their first-line immunosuppressive treatment for disease prevention. Patients were followed for a minimum of 6 months following treatment initiation. RESULTS In those started on rituximab, the pre-treatment annualized relapse rates for seropositive and seronegative patients were 1.81 and 1.93, respectively. On-treatment annualized relapse rates significantly declined to 0.32 (seropositive; p < 0.0001) and 0.12 (seronegative; p = 0.0001). In those started on mycophenolate mofetil, the pre-treatment annualized relapse rates for seropositive and seronegative patients were 1.79 and 1.45, respectively. On-treatment annualized relapse rates declined to 0.29 (seropositive; p < 0.0001) and 0.30 (seronegative; p < 0.005). CONCLUSION In this international collaboration involving a large number of neuromyelitis optica spectrum disorder patients, treatment was effective regardless of serostatus. This suggests that treatment should not differ when considering these treatments.
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Affiliation(s)
- Maureen A Mealy
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Su-Hyun Kim
- Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Felix Schmidt
- Charité University Medicine and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | | | | | - Friedemann Paul
- Charité University Medicine and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | | | | | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Michael Levy
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wingerchuk DM, Sathiamoorthi S. Author response: Transient smartphone blindness: Relevance to misdiagnosis in neurologic practice. Neurology 2017; 89:306-307. [DOI: 10.1212/wnl.0000000000004131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Dubey D, Singh J, Britton JW, Pittock SJ, Flanagan EP, Lennon VA, Tillema JM, Wirrell E, Shin C, So E, Cascino GD, Wingerchuk DM, Hoerth MT, Shih JJ, Nickels KC, McKeon A. Predictive models in the diagnosis and treatment of autoimmune epilepsy. Epilepsia 2017; 58:1181-1189. [DOI: 10.1111/epi.13797] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Divyanshu Dubey
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Jaysingh Singh
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | | | - Sean J. Pittock
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Eoin P. Flanagan
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Vanda A. Lennon
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Immunology; Mayo Clinic; Rochester Minnesota U.S.A
| | | | - Elaine Wirrell
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Cheolsu Shin
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Elson So
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | | | | | | | - Jerry J. Shih
- Department of Neurology; Mayo Clinic; Jacksonville Florida U.S.A
| | | | - Andrew McKeon
- Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota U.S.A
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Abstract
The understanding of neuromyelitis optica spectrum disorder (NMOSD) has evolved substantially since its initial description over a century ago. The discovery in 2004 of a pathogenic autoantibody biomarker targeting aquaporin 4 IgG revolutionized diagnosis and therapeutic development. Although NMOSD resembles multiple sclerosis (MS), differences were identified and articulated in the late 1990s. New diagnostic criteria incorporating the biomarker as well as better understanding of the clinical and radiologic features of NMOSD now permit accurate diagnosis and differentiation from MS. Aquaporin 4 IgG-associated NMOSD is now regarded as an immune astrocytopathy with lytic and nonlytic effects on astrocytes. A second autoantibody, myelin oligodendrocyte glycoprotein IgG, which targets myelin rather than astrocytes, leads to an NMOSD syndrome with clinical and radiologic features that overlap but are distinct from those of aquaporin 4 IgG-associated NMOSD and MS. We review current understanding of the clinical aspects, pathophysiology, and treatment of NMOSD.
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Bove R, Elsone L, Alvarez E, Borisow N, Cortez MM, Mateen FJ, Mealy MA, Mutch K, Tobyne S, Ruprecht K, Buckle G, Levy M, Wingerchuk DM, Paul F, Cross AH, Weinshenker B, Jacob A, Klawiter EC, Chitnis T. Female hormonal exposures and neuromyelitis optica symptom onset in a multicenter study. Neurol Neuroimmunol Neuroinflamm 2017; 4:e339. [PMID: 28382320 PMCID: PMC5366671 DOI: 10.1212/nxi.0000000000000339] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/26/2017] [Indexed: 12/03/2022]
Abstract
Objective: To study the association between hormonal exposures and disease onset in a cohort of women with neuromyelitis optica spectrum disorder (NMOSD). Methods: Reproductive history and hormone use were assessed using a standardized reproductive survey administered to women with NMOSD (82% aquaporin-4 antibody positive) at 8 clinical centers. Using multivariable regression, we examined the association between reproductive exposures and age at first symptom onset (FS). Results: Among 217 respondents, the mean age at menarche was 12.8 years (SD 1.7). The mean number of pregnancies was 2.1 (SD 1.6), including 0.3 (SD 0.7) occurring after onset of NMOSD symptoms. In the 117 participants who were postmenopausal at the time of the questionnaire, 70% reported natural menopause (mean age: 48.9 years [SD 3.9]); fewer than 30% reported systemic hormone therapy (HT) use. Mean FS age was 40.1 years (SD 14.2). Ever-use of systemic hormonal contraceptives (HC) was marginally associated with earlier FS (39 vs 43 years, p = 0.05). Because HC use may decrease parity, when we included both variables in the model, the association between HC use and FS age became more significant (estimate = 2.7, p = 0.007). Among postmenopausal participants, 24% reported NMOSD onset within 2 years of (before or after) menopause. Among these participants, there was no association between age at menopause or HT use and age at NMOSD onset. Conclusions: Overall, age at NMOSD onset did not show a strong relationship with endogenous hormonal exposures. An earlier onset age did appear to be marginally associated with systemic HC exposure, an association that requires confirmation in future studies.
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Affiliation(s)
- Riley Bove
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Liene Elsone
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Enrique Alvarez
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Nadja Borisow
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Melissa M Cortez
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Farrah J Mateen
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Maureen A Mealy
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Kerry Mutch
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Sean Tobyne
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Klemens Ruprecht
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Guy Buckle
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Michael Levy
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Dean M Wingerchuk
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Friedemann Paul
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Anne H Cross
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Brian Weinshenker
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Anu Jacob
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Eric C Klawiter
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Tanuja Chitnis
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
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Zalewski NL, Morris PP, Weinshenker BG, Lucchinetti CF, Guo Y, Pittock SJ, Krecke KN, Kaufmann TJ, Wingerchuk DM, Kumar N, Flanagan EP. Ring-enhancing spinal cord lesions in neuromyelitis optica spectrum disorders. J Neurol Neurosurg Psychiatry 2017; 88:218-225. [PMID: 27913626 DOI: 10.1136/jnnp-2016-314738] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/27/2016] [Accepted: 11/16/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We assessed the frequency and characteristics of ring-enhancing spinal cord lesions in neuromyelitis optica spectrum disorder (NMOSD) myelitis and myelitis of other cause. METHODS We reviewed spinal cord MRIs for ring-enhancing lesions from 284 aquaporin-4 (AQP4)-IgG seropositive patients at Mayo Clinic from 1996 to 2014. Inclusion criteria were as follows: (1) AQP4-IgG seropositivity, (2) myelitis attack and (3) MRI spinal cord demonstrating ring-enhancement. We identified two groups of control patients with: (1) longitudinally extensive myelopathy of other cause (n=66) and (2) myelitis in the context of a concurrent or subsequent diagnosis of multiple sclerosis (MS) from a population-based cohort (n=30). RESULTS Ring-enhancement was detected in 50 of 156 (32%) myelitis episodes in 41 patients (83% single; 17% multiple attacks). Ring-enhancement was noted on sagittal and axial images in 36 of 43 (84%) ring enhancing myelitis episodes and extended a median of two vertebral segments (range, 1-12); in 21 of 48 (44%) ring enhancing myelitis episodes, the ring extended greater than or equal to three vertebrae. Ring-enhancement was accompanied by longitudinally extensive (greater than or equal to three vertebral segments) T2-hyperintensity in 44 of 50 (88%) ring enhancing myelitis episodes. One case of a spinal cord biopsy during ring-enhancing myelitis revealed tissue vacuolation and loss of AQP4 immunoreactivity with preserved axons. The clinical characteristics of ring-enhancing myelitis episodes did not differ from non-ring-enhancing episodes. Ring-enhancing spinal cord lesions were more common in NMOSD than other causes of longitudinally extensive myelopathy (50/156 (32%) vs 0/66 (0%); p≤0.001) but did not differ between NMOSD and MS (50/156 (32%) vs 6/30 (20%); p=0.20). CONCLUSIONS Spinal cord ring-enhancement accompanies one-third of NMOSD myelitis episodes and distinguishes NMOSD from other causes of longitudinally extensive myelopathies but not from MS.
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Affiliation(s)
| | | | | | | | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Neeraj Kumar
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Sathiamoorthi S, Wingerchuk DM. Transient smartphone blindness: Relevance to misdiagnosis in neurologic practice. Neurology 2017; 88:809-810. [PMID: 28100724 DOI: 10.1212/wnl.0000000000003639] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/07/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
- Saraniya Sathiamoorthi
- From Mayo Medical School (S.S.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Dean M Wingerchuk
- From Mayo Medical School (S.S.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ.
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Wingerchuk DM, Weinshenker BG. Neuromyelitis optica spectrum disorder diagnostic criteria: Sensitivity and specificity are both important. Mult Scler 2017; 23:182-184. [DOI: 10.1177/1352458516688352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Solomon AJ, Bourdette DN, Cross AH, Applebee A, Skidd PM, Howard DB, Spain RI, Cameron MH, Kim E, Mass MK, Yadav V, Whitham RH, Longbrake EE, Naismith RT, Wu GF, Parks BJ, Wingerchuk DM, Rabin BL, Toledano M, Tobin WO, Kantarci OH, Carter JL, Keegan BM, Weinshenker BG. The contemporary spectrum of multiple sclerosis misdiagnosis: A multicenter study. Neurology 2016; 87:1393-9. [PMID: 27581217 DOI: 10.1212/wnl.0000000000003152] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 06/09/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize patients misdiagnosed with multiple sclerosis (MS). METHODS Neurologists at 4 academic MS centers submitted data on patients determined to have been misdiagnosed with MS. RESULTS Of 110 misdiagnosed patients, 51 (46%) were classified as "definite" and 59 (54%) "probable" misdiagnoses according to study definitions. Alternate diagnoses included migraine alone or in combination with other diagnoses 24 (22%), fibromyalgia 16 (15%), nonspecific or nonlocalizing neurologic symptoms with abnormal MRI 13 (12%), conversion or psychogenic disorders 12 (11%), and neuromyelitis optica spectrum disorder 7 (6%). Duration of misdiagnosis was 10 years or longer in 36 (33%) and an earlier opportunity to make a correct diagnosis was identified for 79 patients (72%). Seventy-seven (70%) received disease-modifying therapy and 34 (31%) experienced unnecessary morbidity because of misdiagnosis. Four (4%) participated in a research study of an MS therapy. Leading factors contributing to misdiagnosis were consideration of symptoms atypical for demyelinating disease, lack of corroborative objective evidence of a CNS lesion as satisfying criteria for MS attacks, and overreliance on MRI abnormalities in patients with nonspecific neurologic symptoms. CONCLUSIONS Misdiagnosis of MS leads to unnecessary and potentially harmful risks to patients. Misinterpretation and misapplication of MS clinical and radiographic diagnostic criteria are important contemporary contributors to misdiagnosis.
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Affiliation(s)
- Andrew J Solomon
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN.
| | - Dennis N Bourdette
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Anne H Cross
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Angela Applebee
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Philip M Skidd
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Diantha B Howard
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Rebecca I Spain
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Michelle H Cameron
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Edward Kim
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Michele K Mass
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Vijayshree Yadav
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Ruth H Whitham
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Erin E Longbrake
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Robert T Naismith
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Gregory F Wu
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Becky J Parks
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Dean M Wingerchuk
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Brian L Rabin
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Michel Toledano
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - W Oliver Tobin
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Orhun H Kantarci
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Jonathan L Carter
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - B Mark Keegan
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
| | - Brian G Weinshenker
- From the Departments of Neurological Sciences (A.J.S., A.A.) and Ophthalmology (P.M.S.), and Center for Clinical and Translational Science (D.B.H.), University of Vermont, Burlington; Department of Neurology (D.N.B., R.I.S., M.H.C., E.K., M.K.M., V.Y., R.H.W.), Oregon Health & Science University, Portland; Department of Neurology (A.H.C., E.E.L., R.T.N., G.F.W., B.J.P.), Washington University, St. Louis, MO; Department of Neurology (D.M.W., B.L.R., J.L.C.), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (M.T., W.O.T., O.H.K., B.M.K., B.G.W.), Mayo Clinic, Rochester, MN
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Abstract
Multiple sclerosis (MS) is a common, disabling, putatively autoimmune neurological disease with worldwide distribution. It typically begins as a relapsing disorder that later evolves to a secondary progressive phase. Inflammatory and neurodegenerative mechanisms seem to operate in both phases, but their relative contributions and interactions are incompletely understood. Disease modifying therapies (DMTs) approved for relapsing multiple sclerosis interfere with a variety of immunological mechanisms to reduce rates of relapse, accumulation of disease burden measured by magnetic resonance imaging (MRI), and decline in neurological function over the two to three year duration of typical randomized controlled trials. Benefits of longer duration of therapy on disability are less clear, as data beyond three years are largely limited to observational studies. However, current DMTs do not slow accrual of disability once progressive multiple sclerosis is established. This review summarizes the evidence about the use of approved DMTs and examines how to individualize treatment despite the absence of validated biomarkers to guide drug selection. Methods such as stratifying patients on the basis of estimated risk for future disability, weighing patient specific factors and preferences, and using objective outcomes to adjudicate treatment success are discussed. Emerging drug therapies and strategies are also reviewed.
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Affiliation(s)
- Dean M Wingerchuk
- Department of Neurology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
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