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Shah M, Staab J, Anderson A, Eggers SD, Lohse C, McCaslin DL. Outcomes and Patient Experience in Individuals With Longstanding Dizziness. Am J Audiol 2023; 32:721-729. [PMID: 37079889 DOI: 10.1044/2023_aja-22-00152] [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: 04/22/2023] Open
Abstract
PURPOSE This study aimed to describe the relationship between changes in pre and post self-perceived dizziness handicap, scores on the patient health questionnaire, and perceptions of patient's value of being evaluated and managed by a multidisciplinary team. METHOD Seventy-eight patients completed the Dizziness Handicap Inventory (DHI) and Patient Health Questionnaire-Fourth Edition (PHQ-4) questionnaires post multidisciplinary clinical consultations and testing for the chief complaints of dizziness, unsteadiness, vertigo, or balance problems. The diagnoses of each patient were recorded from the clinical reports of each specialty consultation and were classified as structural, functional, or psychiatric. They were contacted by phone at least 6 months after their visit to obtain feedback regarding their symptoms and overall patient experience. RESULTS The change in DHI total score did not differ significantly by diagnosis (p = .56), indicating that patients experienced an improvement in DHI total score regardless of diagnosis. PHQ-4 anxiety scores worsened by a mean of 0.7 points for those with structural diagnoses (p = .04), improved by a mean of 0.7 points for psychiatric diagnoses (p = .16), and improved by a mean of 0.3 points for functional diagnoses (p = .39). Only seven patients would not recommend the team to a family or friend; these patients tended to report worsening DHI total scores (p = .27) compared to the significant improvement in DHI total scores for patients who would make such a recommendation (p < .001). Similarly, only 13 patients did not feel the information they received had a positive impact; these patients tended to report worsening DHI total scores (p = .18) compared to the significant improvement in DHI total scores for patients who did feel the information had a positive impact (p < .001). DISCUSSION The assessment and management of patients with chronic dizziness is challenging due to symptoms arising from multiple etiologies. Our finding of a vast difference between high satisfaction and relatively unchanged dizziness handicap suggests that there is value in seeing a multidisciplinary team where consultations are unhurried, care is coordinated, and expectations regarding treatment can be managed.
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Affiliation(s)
- Manami Shah
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Ann Anderson
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | | | - Christine Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Devin L McCaslin
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
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Rinaldo L, Xu SCY, Eggers SD, Salomão DR, Chen JJ, Raghunathan A. Rare Occurrence of an Intraocular Choroidal Solitary Fibrous Tumor/Hemangiopericytoma. Ocul Oncol Pathol 2019; 4:213-219. [PMID: 30643764 DOI: 10.1159/000481947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 08/02/2017] [Revised: 09/26/2017] [Indexed: 12/13/2022] Open
Abstract
Purpose Tumors previously diagnosed as solitary fibrous tumors (SFT) and hemangiopericytomas (HPC) are characterized by the NAB2-STAT6 fusion gene, leading to nuclear STAT6 expression, and are now considered part of one SFT/HPC tumor entity by the 2016 World Health Organization Classification of Tumors of the Central Nervous System. We present the first primary choroidal SFT/HPC with the diagnosis confirmed by STAT6 expression. Procedures A 51-year-old man underwent enucleation for a choroidal mass, which revealed a spindle cell neoplasm involving the optic nerve, without extrascleral extension. Immunohistochemical stains for S-100, melan-A, tyrosinase, and HMB45 were all negative; however, detection of monosomy 3 by FISH favored a choroidal spindle cell melanoma. Four years later, he presented with hepatic metastases of a spindle cell tumor, and a year later with an epithelioid malignancy involving the calvarium. Results The calvarial tumor showed nuclear STAT6 immunoreactivity, supporting the diagnosis of SFT/HPC. Retrospectively, the choroidal and hepatic masses were also found to demonstrate nuclear STAT6 expression, supporting the diagnosis of a primary choroidal SFT/HPC with metachronous metastases to the liver and calvarium. Conclusions This case highlights the significance of considering SFT/HPC in the diagnosis of intraocular spindle cell tumors and the importance of STAT6 immunohistochemistry in the evaluation of such tumors.
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Affiliation(s)
| | | | - Scott D Eggers
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Diva R Salomão
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Jones AL, Flanagan EP, Pittock SJ, Mandrekar JN, Eggers SD, Ahlskog JE, McKeon A. Responses to and Outcomes of Treatment of Autoimmune Cerebellar Ataxia in Adults. JAMA Neurol 2016; 72:1304-12. [PMID: 26414229 DOI: 10.1001/jamaneurol.2015.2378] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Classic Purkinje cell cytoplasmic antibody type 1 (PCA-1, or anti-Yo) paraneoplastic cerebellar ataxia has a poor prognosis, yet little has been published otherwise regarding treatment responses and outcomes among patients with autoimmune cerebellar ataxia. OBJECTIVES To investigate treatment responses and outcomes in adults with autoimmune cerebellar ataxia. DESIGN, SETTING, AND PARTICIPANTS A cohort study conducted at Mayo Clinic, Rochester, Minnesota, included 118 patients who had ataxia, were 18 years or older, were seropositive for at least 1 neural autoantibody, had received at least 1 immunotherapy or cancer therapy, and had neurologist-reported outcomes documented from January 1, 1989, through December 31, 2013. Data were collected from May 14, 2013, through August 9, 2014, and analyzed from August 9, 2014, through April 27, 2015. Responses to immunotherapy (corticosteroids, intravenous immunoglobulin, plasma exchange, and immunosuppressants) and ambulatory outcomes were compared between different subgroups. Subgroups were classified as paraneoplastic vs nonparaneoplastic disorders; neuronal nuclear and/or cytoplasmic (NNC) antibody positivity vs plasma membrane protein (PMP) antibody positivity; and glutamic acid decarboxylase 65-kDa isoform (GAD65) antibody positivity vs PMP antibody positivity. MAIN OUTCOMES AND MEASURES Response to therapy and ambulatory ability, with univariate logistic regression and Kaplan-Meier analyses. RESULTS Inclusion criteria were met by 118 patients. Median age at onset of neurologic symptoms was 58 (range, 27-83) years, and 87 patients (73.7%) were women. Median duration from symptom onset to last follow-up was 25 (range, 2-223) months. Sixty-three patients had paraneoplastic and 55 patients had nonparaneoplastic ataxic disorders. Eighty-one patients were seropositive for NNC antibodies (most commonly PCA-1 [anti-Yo], antineuronal nuclear antibody type 1 [anti-Hu], and GAD65 antibody); 22 patients, for neural PMP receptor or ion channel antibodies (most commonly targeting P/Q- or N-type voltage-gated calcium channels); and 15 patients, for antibodies from both categories. Neurologic improvements occurred in 54 patients (with a robust change in ambulatory ability in 22) attributable to immunotherapy; univariate regression analysis revealed that improvements were significantly more common among patients with nonparaneoplastic disorders (P = .03) and those with exclusively PMP antibodies (P = .02). Kaplan-Meier analyses revealed that progression to wheelchair dependence occurred significantly faster among patients with NNC antibody positivity only (P = .02), although those with GAD65 autoimmunity progressed to wheelchair dependence at a rate similar to those with PMP autoimmunity (P = .92). CONCLUSIONS AND RELEVANCE Although autoimmune ataxia is usually severe, treatment responses can be gratifying, particularly in patients with nonparaneoplastic disorders and in those harboring autoantibodies directed against GAD65 or neural PMPs.
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Affiliation(s)
- Amy L Jones
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Eoin P Flanagan
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sean J Pittock
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota2Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jay N Mandrekar
- Department of Biomedical Statistics and Informatics, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Scott D Eggers
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - J Eric Ahlskog
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota2Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota
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Arena JE, Weigand SD, Whitwell JL, Hassan A, Eggers SD, Höglinger GU, Litvan I, Josephs KA. Progressive supranuclear palsy: progression and survival. J Neurol 2015; 263:380-389. [DOI: 10.1007/s00415-015-7990-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/27/2015] [Accepted: 11/28/2015] [Indexed: 11/27/2022]
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Ariai MS, Eggers SD, Giannini C, Driscoll CL, Link MJ. Solitary Metastasis to the Facial/Vestibulocochlear Nerve Complex: Case Report and Review of the Literature. World Neurosurg 2015; 84:1178.e15-8. [DOI: 10.1016/j.wneu.2015.05.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 05/17/2015] [Indexed: 10/23/2022]
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Carlson ML, Tveiten ØV, Driscoll CL, Neff BA, Shepard NT, Eggers SD, Staab JP, Tombers NM, Goplen FK, Lund-Johansen M, Link MJ. Long-term dizziness handicap in patients with vestibular schwannoma: a multicenter cross-sectional study. Otolaryngol Head Neck Surg 2014; 151:1028-37. [PMID: 25273693 DOI: 10.1177/0194599814551132] [Citation(s) in RCA: 29] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE (1) To characterize long-term dizziness following observation, microsurgery, and stereotactic radiosurgery (SRS) for small to medium-sized vestibular schwannoma (VS) using a validated self-assessment inventory; and (2) to identify clinical variables associated with long-term dizziness handicap. STUDY DESIGN Cross-sectional observational study. SETTING Two independent tertiary academic referral centers: one located in the United States and one in Norway. SUBJECTS AND METHODS All patients with sporadic VS of less than 3 cm who underwent primary microsurgery, SRS, or observation between 1998 and 2008 were identified. Subjects were surveyed via a postal questionnaire using the Dizziness Handicap Inventory (DHI) and a VS symptom questionnaire. RESULTS The overall survey response rate was 79%. A total of 538 respondents (mean age, 64 years; 56% female) were analyzed, and the mean time interval between treatment and survey was 7.7 years. Pretreatment variables associated with greater dizziness handicap included female sex, older age, larger tumor size, preexisting diagnosis of headache or migraine, and symptoms of dizziness predating treatment. Significant posttreatment features strongly associated with poor long-term DHI scores included frequency and severity of ongoing headache. On multivariable analysis, treatment modality did not influence long-term dizziness handicap. CONCLUSION At a mean of approximately 8 years following treatment, over half of patients with VS reported ongoing dizziness. The authors have identified several baseline features that may help predict the risk of lasting dizziness. Treatment modality does not appear to influence long-term DHI score. We found a strong association between posttreatment headache and poor dizziness handicap. Future study is needed to further define this relationship.
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Affiliation(s)
- Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | | | - Colin L Driscoll
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Brian A Neff
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Neil T Shepard
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Scott D Eggers
- Department of Neurology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Nicole M Tombers
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Frederik K Goplen
- Department of Otolaryngology, Bergen University Hospital, Bergen, Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery, Bergen University Hospital, Bergen, Norway Institute of Surgical Sciences, University of Bergen, Bergen, Norway
| | - Michael J Link
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Whitwell JL, Duffy JR, Strand EA, Machulda MM, Senjem ML, Gunter JL, Kantarci K, Eggers SD, Jack CR, Josephs KA. Neuroimaging comparison of primary progressive apraxia of speech and progressive supranuclear palsy. Eur J Neurol 2012; 20:629-37. [PMID: 23078273 DOI: 10.1111/ene.12004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 09/10/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Primary progressive apraxia of speech, a motor speech disorder of planning and programming, is a tauopathy that has overlapping histological features with progressive supranuclear palsy. We aimed to compare, for the first time, atrophy patterns, as well as white matter tract degeneration, between these two syndromes. METHODS Sixteen primary progressive apraxia of speech subjects were age- and gender-matched to 16 progressive supranuclear palsy subjects and 20 controls. All subjects were prospectively recruited, underwent neurological and speech evaluations and 3.0-Tesla magnetic resonance imaging. Grey and white matter atrophy was assessed using voxel-based morphometry and atlas-based parcellation, and white matter tract degeneration was assessed using diffusion tensor imaging. RESULTS All progressive supranuclear palsy subjects had typical oculomotor/gait impairments, but none had speech apraxia. Both syndromes showed grey matter loss in supplementary motor area, white matter loss in posterior frontal lobes and degeneration of the body of the corpus callosum. Whilst lateral grey matter loss was focal, involving superior premotor cortex, in primary progressive apraxia of speech, loss was less focal extending into prefrontal cortex in progressive supranuclear palsy. Caudate volume loss and tract degeneration of superior cerebellar peduncles were also observed in progressive supranuclear palsy. Interestingly, area of the midbrain was reduced in both syndromes compared to controls, although this was greater in progressive supranuclear palsy. CONCLUSIONS Although neuroanatomical differences were identified between these distinctive clinical syndromes, substantial overlap was also observed, including midbrain atrophy, suggesting these two syndromes may have common pathophysiological underpinnings.
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Affiliation(s)
- J L Whitwell
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA.
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Whitwell JL, Master AV, Avula R, Kantarci K, Eggers SD, Edmonson HA, Jack CR, Josephs KA. Clinical correlates of white matter tract degeneration in progressive supranuclear palsy. ACTA ACUST UNITED AC 2011; 68:753-60. [PMID: 21670399 DOI: 10.1001/archneurol.2011.107] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To use diffusion tensor imaging to assess white matter tract degeneration in progressive supranuclear palsy (PSP) and to investigate correlates between tract integrity and clinical measures. DESIGN Case-control study. SETTING Tertiary care medical center. PATIENTS/PARTICIPANTS Twenty patients with probable PSP and 20 age- and sex-matched healthy controls were enrolled. All patients with PSP underwent standardized clinical testing, including the Frontal Behavioral Inventory and Frontal Assessment Battery to assess behavioral change, the PSP Rating Scale to measure disease severity, the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (parts II and III) to measure motor function, and the PSP Saccadic Impairment Scale to measure eye movement abnormalities. METHODS Fractional anisotropy and mean diffusivity were measured using region of interest analysis and tract-based spatial statistics. RESULTS Compared with controls, abnormal diffusivity was observed predominantly in the superior cerebellar peduncles, body of the corpus callosum, inferior longitudinal fasciculus, and superior longitudinal fasciculus in patients with PSP. Fractional anisotropy values in the superior cerebellar peduncles correlated with disease severity (r = -0.59, P = .006), inferior longitudinal fasciculus correlated with motor function (r = -0.51, P = .02), and superior longitudinal fasciculus correlated with severity of saccadic impairments (r = -0.45, P = .047). CONCLUSIONS The results of this study demonstrate that PSP is associated with degeneration of the brainstem, association, and commissural fibers and that this degeneration likely plays an important role in clinical dysfunction.
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Affiliation(s)
- Jennifer L Whitwell
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Josephs KA, Whitwell JL, Eggers SD, Senjem ML, Jack CR. Gray matter correlates of behavioral severity in progressive supranuclear palsy. Mov Disord 2011; 26:493-8. [DOI: 10.1002/mds.23471] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 07/28/2010] [Accepted: 09/13/2010] [Indexed: 11/11/2022] Open
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Affiliation(s)
- John F Nettrour
- Orthopaedic Surgery, Mayo Health System, 907 Montogomery St, Decorah, IA 52101, USA.
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Chang CC, Eggers SD, Johnson JK, Haman A, Miller BL, Geschwind MD. Anti-GAD antibody cerebellar ataxia mimicking Creutzfeldt–Jakob disease. Clin Neurol Neurosurg 2007; 109:54-7. [PMID: 16621241 DOI: 10.1016/j.clineuro.2006.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [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: 09/13/2005] [Revised: 12/24/2005] [Accepted: 01/11/2006] [Indexed: 11/24/2022]
Abstract
In a patient with a rapidly progressive neurological condition with ataxia and cognitive complaints, Creutzfeldt-Jakob disease (CJD) is often high in the differential, particularly when there is an elevated CSF 14-3-3 protein level. We present a case of anti-glutamic acid decarboxylase antibody (anti-GAD65) positive cerebellar ataxia associated with cognitive complaints and elevated CSF 14-3-3 protein.
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Affiliation(s)
- Chiung-Chih Chang
- University of California San Francisco, Department of Neurology, Memory & Aging Center, Box 1207, San Francisco, CA 94143-1207, USA
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Abstract
Although acute intermittent porphyria presents with dramatic neurological findings, the diagnosis is difficult. An 18-year-old woman had a clinical picture of porphyric encephalopathy. Magnetic resonance (MR) imaging demonstrated multiple large contrast-enhancing subcortical white matter lesions, which regressed with glucose and hematin infusions. Diffusion-weighted MR imaging was normal, and MR spectroscopy excluded acute demyelination or tissue necrosis. MR findings of acute intermittent porphyria can differ from those in posterior reversible encephalopathy syndrome by virtue of intense contrast enhancement. Because diffusion-weighted MR imaging and spectroscopy were normal, the lesions are likely caused by reversible vasogenic edema and transient breakdown of the blood-brain barrier.
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Affiliation(s)
- Boby V Maramattom
- Division of Critical Care Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Worrell GA, Wijdicks EF, Eggers SD, Phan T, Damario MA, Mullany CJ. Ovarian hyperstimulation syndrome with ischemic stroke due to an intracardiac thrombus. Neurology 2001; 57:1342-4. [PMID: 11591867 DOI: 10.1212/wnl.57.7.1342-a] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- G A Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Merkel cell carcinoma is a rare primary cutaneous neuroendocrine tumor that is locally aggressive and frequently accompanied by distant metastases. Neurologic complications of Merkel cell carcinoma are rare. We describe a 69-year-old man who presented with Lambert-Eaton myasthenic syndrome and was found to have Merkel cell carcinoma. The paraneoplastic syndrome improved with initial treatment of the malignancy. He subsequently developed a solitary brain metastasis and died of leptomeningeal carcinomatosis.
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Affiliation(s)
- S D Eggers
- Department of Neurology, Mayo Clinic, Rochester, Minn 55905, USA
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