Risk factors for severe hearing loss in Susac syndrome: A national cohort study

BACKGROUND

Nonreversible hearing loss (HL) is the main sequelae of Susac syndrome (SuS). We aimed to identify risk factors for HL in SuS.

METHODS

The CARESS study is a prospective national cohort study that started in December 2011, including all consecutive patients with SuS referred to the French reference center. The CARESS study was designed with a follow-up including fundoscopy, audiometry, and brain magnetic resonance imaging at 1, 3, 6, and 12 months after diagnosis and then annually for 5 years. The primary outcome was the occurrence at last follow-up of severe HL defined as the loss of 70 dB in at least one ear on audiometry or the need for hearing aids.

RESULTS

Thirty-six patients (female 66.7%, median age 37.5 [range 24.5-42.5] years) included in the clinical study were analyzed for the primary outcome. Thirty-three patients (91.7%) had cochleovestibular involvement at SuS diagnosis including HL >20 dB in at least one ear in 25 cases. At diagnosis, 32 (88.9%), 11 (30.6%), and 7 (19.4%) patients had received steroids, intravenous immunoglobulin, and/or immunosuppressive (IS) drugs, respectively. After a median follow-up of 51.8 [range 29.2-77.6] months, 19 patients (52.8%) experienced severe HL that occurred a median of 13 [range 1.5-29.5] months after diagnosis. Multivariable analysis showed that the odds of severe HL were lower in patients who received IS drugs at diagnosis (OR 0.15, 95% CI 0.01-1.07, p = 0.058).

CONCLUSIONS

Severe HL in SuS is associated with the absence of IS drugs given at diagnosis. Our findings support the systematic use of IS drugs in SuS.

Clinical Characterization and Ancillary Tests in Susac Syndrome: A Systematic Review

Susac syndrome (SuS) is an orphan microangiopathic disease characterized by a triad of encephalopathy, visual disturbances due to branch retinal artery occlusions, and sensorineuronal hearing loss. Our previous systematic review on all cases of SuS reported until 2012 allowed for a better understanding of clinical presentation and diagnostic findings. Based on these data, we suggested diagnostic criteria in 2016 to allow early diagnosis and treatment of SuS. In view of the accumulation of new SuS cases reported in the last 10 years and improved diagnostic tools, we here aimed at updating the demographic and clinical features of SuS and to review the updated ancillary tests being used for SuS diagnosis. Therefore, based on the 2016 criteria, we systematically collected and evaluated data on SuS published from January 2013 to March 2022.

Ophthalmological Outcomes in Patients with Susac Syndrome

BACKGROUND

To report ophthalmological outcomes and treatment regimen in patients with Susac syndrome.

METHODS

This is a retrospective analysis of patients with Susac syndrome treated between November 2015 and March 2023. Multimodal imaging findings, ophthalmic examination data, information on neurological and sensorineural involvement, and therapeutic regimen were reviewed. Visual acuity was recorded as the logarithm of the minimum angle of resolution (logMAR). Ophthalmological manifestations and disease severity were assessed using the previously described clinical activity score (CAS).

RESULTS

Ten patients with Susac syndrome m : f = 5 : 5 were identified. The mean follow-up time was 31.2 ± 23.3 months (range 1 to 78 months). The mean age was 41.4 ± 13.8 years (range 21 to 59 years). At baseline, corrected distance visual acuity (CDVA) was 0.03 ± 0.08 logMAR. At the last follow-up, CDVA improved to 0.00 ± 0.03 logMAR (p = 0.029). Three of 20 eyes showed an improvement of 5 letters, while no loss of visual acuity was recorded during the follow-up time. Baseline CAS was 10.65 ± 12.69, and CAS at the last follow-up was 5.15 ± 5.49 (p = 0.068). Except for one patient, all were initially treated with intravenous (i. v.) steroids and subsequent oral tapering. Depending on the treatment response, cyclophosphamide (n = 4), i. v. immunoglobulins (IVIGs) (n = 4), anti-CD20 antibodies (n = 3), or plasmapheresis (n = 1) were applied. All patients under treatment for more than 1 month (n = 9) showed improvement in CAS and CDVA.

CONCLUSION

Susac syndrome is a rare autoimmune vascular endotheliopathy. Treatment of Susac syndrome appears to result in improving CAS and CDVA. The majority of patients, in addition to the systemic steroids, required systemic immunosuppressive agents. Interdisciplinary communication is crucial to reduce the time to diagnosis and initiation of therapy in patients with Susac syndrome.

Clinical characteristics and treatment approaches in patients with Susac syndrome: a scoping review of cases

BACKGROUND

Susac syndrome (SuS) is a rare disease characterized by encephalopathy, hearing impairment and visual disturbances. Immunosuppressive treatments are used based on the hypothesis that an autoimmune endotheliopathy drives the disease. However, a solid evidence-based treatment approach is lacking. The aim of this review is to provide an overview of patient characteristics, disease course and treatment patterns related to successful outcome that have been reported in literature since 2013.

METHODS

Three reviewers conducted a systematic literature search in February 2022. The primary outcome was treatment used, derived from cases classified as probable or definite SuS, describing successful treatment outcome (i.e. no signs of disease activity for ≥ 1 month). Secondary outcomes were time-to-relapse and follow-up time. Published case reports and case series were included. Various clinical characteristics and treatment(s) were extracted and categorized into different phases of treatment.

RESULTS

A total of 810 records was identified. 120 articles met inclusion criteria and 161 cases were extracted. Of these, 151 cases were classified as probable or definite SuS and included in the final analysis. Number of combinations of treatments used per treatment phase were: 6 empirically, 35 after confirmed diagnosis, 43 for maintenance treatment, 22 after relapse, 18 during maintenance post-relapse. Median follow-up time was 12.3 months (0.5; 120) and median time to relapse was 4 months (1; 120).

CONCLUSION

This scoping review summarizes treatment approaches in patients with SuS, highlighting variability. International efforts to collect clinical, imaging and treatment data from patients with SuS in registries are needed, in order to provide less biased and long-term follow-up information on treatment response, predictors of relapse and patient outcomes. This may lead to more evidence-based therapeutic approaches.

Fluorescein Angiography Findings in Susac Syndrome: A Multicenter Retrospective Case Series

BACKGROUND

Susac syndrome is a vasculopathy, resulting in the classic triad of branch retinal artery occlusion (BRAO), inner ear ischemia, and brain ischemia. In this retrospective chart review, we characterize fluorescein angiography (FA) findings and other ancillary studies in Susac syndrome, including the appearance of persistent disease activity and the occurrence of new subclinical disease on FA.

METHODS

This multicenter, retrospective case series was institutional review board-approved and included patients with the complete triad of Susac syndrome evaluated with FA, contrasted MRI of the brain, and audiometry from 2010 to 2020. The medical records were reviewed for these ancillary tests, along with demographics, symptoms, visual acuity, visual field defects, and findings on fundoscopy. Clinical relapse was defined as any objective evidence of disease activity during the follow-up period after initial induction of clinical quiescence. The main outcome measure was the sensitivity of ancillary testing, including FA, MRI, and audiometry, to detect relapse.

RESULTS

Twenty of the 31 (64%) patients had the complete triad of brain, retinal, and vestibulocochlear involvement from Susac syndrome and were included. Median age at diagnosis was 43.5 years (range 21-63), and 14 (70%) were women. Hearing loss occurred in 20 (100%), encephalopathy in 13 (65%), vertigo in 15 (75%), and headaches in 19 (95%) throughout the course of follow-up. Median visual acuity at both onset and final visit was 20/20 in both eyes. Seventeen (85%) had BRAO at baseline, and 10 (50%) experienced subsequent BRAO during follow-up. FA revealed nonspecific leakage from previous arteriolar damage in 20 (100%), including in patients who were otherwise in remission. Of the 11 episodes of disease activity in which all testing modalities were performed, visual field testing/fundoscopy was abnormal in 4 (36.4%), MRI brain in 2 (18.2%), audiogram in 8 (72.7%), and FA in 9 (81.8%).

CONCLUSIONS

New leakage on FA is the most sensitive marker of active disease. Persistent leakage represents previous damage, whereas new areas of leakage suggest ongoing disease activity that requires consideration of modifying immunosuppressive therapy.

Atypical clinical and novel radiological findings in Susac syndrome: Experience from a large monocentric cohort

Susac syndrome (SuS) is a rare immune-mediated endotheliopathy that affects the brain, retina and inner ear and is characterised by the variable clinical triad of encephalopathy, visual and vestibulocochlear dysfunction. Here, we present clinical and paraclinical data of 19 SuS patients followed at Ghent University Hospital and highlight some atypical clinical and novel radiological findings. Our findings suggest that spinal involvement expands the clinical phenotype of SuS. We further introduce dark blood sequences as a more sensitive technique to detect radiological disease activity in SuS. Our data add to the current understanding of the diagnosis, monitoring and treatment of SuS.

Susac syndrome - A review of current knowledge and own experience

Susac syndrome is a rare connective tissue disorder. The pathology affects the small vessels of the brain, retina, and inner ear, and therefore the main symptoms of the disease include encephalopathy, visual disturbances, and sensorineural hearing loss. The aim of this article is to review the current medical knowledge on Susac syndrome and to present our clinical experience regarding this disease entity. In the paper, we are also presenting a case of a 25-year-old patient who was diagnosed with Susac syndrome on the basis of clinical presentation and additional test results. Susac syndrome should be differentiated from multiple sclerosis and other causes of multifocal brain damage as early diagnosis and treatment play a key role in later prognosis.

Susac Syndrome: an uncommon cause of impaired vision

A 35-year-old Caucasian woman presented an abrupt onset of bilateral impaired vision, and arrived to our attention two weeks later. She had a previous episode of mild dizziness. She underwent a fluorescein angiography showing branch retinal artery occlusions and a brain magnetic resonance imaging (MRI) revealing several supraand infratentorial FLAIR-hyperintense white matter lesions, two with contrast enhancement. Thrombophilic, autoimmune and infective (including Human Immunodeficiency Virus, Borrelia burgdorferi, Hepatitis B Virus, Hepatitis C Virus, Herpes Simplex Virus 1-2, Varicella Zoster Virus) screening was negative. Cerebrospinal fluid analysis showed intrathecal IgG synthesis. We suspected a Primary Central Nervous System Vasculitis, and intravenous steroids were started. Three months later a second brain MRI showed seven new lesions without contrast enhancement, and she revealed a cognitive impairment and bilateral hearing loss. Reviewing the clinical history and MRI, she fulfilled diagnostic criteria for Susac syndrome. She had two cycles of cyclophosphamide, and recovered in 6 months and then remained stable with metotrexate.

Susac syndrome as a multidisciplinary diagnostic challenge

INTRODUCTION

Susac syndrome (SuS) is a disease manifested as the clinical triad of encephalopathy, branch retinal artery occlusion, and loss of sensory neural hearing.

CASE REPORT

The case is presented of a 28-year-old patient hospitalized due to visual impairment of the left eye, and whose hearing and neuropsychiatric disorders had appeared two years earlier. Magnetic resonance imaging demonstrated lesions located in the white matter and along the corpus callosum. An audiogram showed bilateral sensory neural hearing loss. Fluorescein angiography examination revealed branch retinal artery occlusion of the left eye. Based on the clinical picture and results of tests, the diagnosis of SuS was made. Despite the use of steroid and immunosuppression therapy the disease progressed.

CONCLUSIONS

The prognosis for SuS depends on the early diagnosis and implementation of treatment. It should be underlined that in case of hearing loss or encephalopathy of unknown cause, SuS should always be excluded.

Susac Syndrome Presenting as Recurrent Strokes

Susac syndrome (SS) is a rare clinical entity that affects primarily young women and might result in significant morbidity. The triad that leads to suspecting the disease has classically been involvement of the brain, retina and inner ear. The likely pathology of the disease is thought to be immune mediated endotheliopathy; given its clinical and, possibly, pathological remission with immunosuppressive therapy. Here we describe an uncommon recurrent stroke in a young female that unfolds to Susac syndrome at the end. We also reviewed the literature behind diagnosis and treatment. Delayed diagnosis is associated with worse morbidity and mortality, and the most important predictor of long-term prognosis in the reported cases is the time to diagnosis. Therapies tried (with variable success) include corticosteroids, IVIG, plasmapheresis, cyclophosphamide, mycophenolate mofetil, and rituximab. The prognosis of SS is difficult to predict given the absence of strong clinical or radiographic features to suggest better/worse prognosis at the time of initial diagnosis. Brain MRIs and hearing/vision impairment have never normalized in previously studied cohort of patients.

Susac syndrome complicating a SARS-CoV-2 infection

In 2020 the world was captivated by the COVID-19 pandemic. Current scientific evidence suggests an interaction of SARS-CoV-2 and the human immune system. Multiple cases were reported of patients with COVID-19 presenting with encephalopathy, confusion or agitation, stroke, and other neurologic symptoms. We present a case of a 40-year-old man diagnosed with Susac syndrome after COVID-19, presenting with acute sensorineural hearing loss, encephalopathy, a splenial "snowball-like" lesion, and branch retinal artery occlusions with distal arterial wall hyperintensity. Although the pathophysiology of Susac syndrome remains unclear, this case is in line with the ongoing debate about the influence of SARS-CoV-2 on the human immune system. Corticosteroid treatment was initiated, followed by two treatments with rituximab, with clinical improvement of the symptomatology. Maintenance treatment currently consists of mycophenolic acid (MPA). Future research will need to focus on the underlying mechanisms for COVID-19-associated (autoimmune) complications.

Neuropsychiatry of Susac syndrome: A case report

Susac syndrome is a rare clinical condition, possibly mediated by an autoimmune process; the classic triad is composed of retinopathy, decreased hearing acuity and neuropsychiatric symptoms (encephalopathy). There are few cases reported with neuropsychiatric symptoms as the main manifestation. We present a case of Susac syndrome in a 34-year-old female with a predominance of neuropsychiatric symptoms, characterised by partial Klüver-Bucy syndrome, apathy syndrome, pathological laughter and crying, and cognitive dysfunction predominantly affecting attention, which showed a qualitative improvement with the use of immunological therapy. This case report highlights the importance of neuropsychiatric manifestations as clinical presentation in patients with neurological conditions.

Neuro-ophthalmic manifestations of Susac syndrome

PURPOSE OF REVIEW

This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment.

RECENT FINDINGS

Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information.

SUMMARY

Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.

Increased incidence of Susac syndrome: a case series study

BACKGROUND

Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines.

METHODS

This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study.

RESULTS

Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability.

CONCLUSIONS

We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.

[Cognitive dysfunction, loss of visual acuity and hearing can be symptoms of Susac syndrome]

This is a case report of a 56-year-old male patient with Susac syndrome. The syndrome is a rare immune-mediated, ischaemic, occlusive microvascular endotheliopathy affecting the brain, retina and inner ear. Diagnosis and treatment are challenging, since the presentation shows great variability. Brain MRI, fundoscopy and audiometry enable the diagnosis. Early treatment with immuno-suppressive medication is crucial and can reduce complications like dementia, loss of visual acuity and hearing. The treatment is empirical and based on the fact, that the histopathology of the syndrome is similar to juvenile dermatomyositis.

ULTRA-WIDE-FIELD FUNDUS IMAGING IN THE DIAGNOSIS AND FOLLOW-UP OF SUSAC SYNDROME

PURPOSE

To present the use of ultra-wide-field (UW) fundus imaging in the diagnosis and follow-up of a patient with Susac syndrome.

METHODS

Case report of a myopic patient presenting initially with rhegmatogenous retinal detachment. A significant portion of the retina was found to be avascular bilaterally at presentation. Surgery was performed with scleral buckle. Then, UW color and autofluorescent imaging and UW fluorescein angiography were obtained.

RESULTS

Successful retinal reattachment was obtained. Enlargement of the avascular area with neovascularization was observed at eight-month follow-up. In addition, the patient presented severe neurosensory hearing loss and clinical depression postoperatively. The results of UW fluorescein angiography revealed hyperfluorescent macular spots, arteriolar wall hyperfluorescence, leakage from retinal neovascularization, and confirmed the avascularity of two thirds of the retina, whereas the results of UW autofluorescence showed absence of the normal hypofluorescent retinal vessels outside the posterior pole. Findings of UW imaging in combination with systemic involvement led to the diagnosis of Susac syndrome. Appropriate treatment stopped the disease progress, ameliorated symptoms, and some of the occluded retinal vessels were reperfused.

CONCLUSION

In conclusion, UW fundus imaging is a valuable modality in the diagnosis and follow-up of patients with Susac syndrome. Early diagnosis and treatment is critical, particularly as it can lead to reperfusion of occluded retinal vessels.

INTRAVITREAL TRIAMCINOLONE IN SUSAC SYNDROME

PURPOSE

To report the use of intravitreal triamcinolone for Susac Syndrome in one patient.

METHODS

Case report.

RESULTS

A 23-year-old woman presented with presented with sudden visual loss in the left eye with associated neurologic symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, bilaterally. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum, and audiometry showed low-frequency sensory hearing loss, compatible with Susac Syndrome. The patient received a single intravitreal injection of triamcinolone (4 mg) in the left eye. One week later, before beginning systemic corticosteroids, all signs and symptoms resolved in the left eye only.

CONCLUSION

In cases of delayed systemic corticosteroid therapy, intravitreal triamcinolone resolves the ocular manifestations of Susac Syndrome.

Autoimmune-Mediated Psychosis: A Case of Susac Syndrome in a Drug User

OBJECTIVE

Susac syndrome, a rare disorder, is thought to be mediated by autoantibodies. One of the potential targets of these autoantibodies could be an antigen in the microvessels of the brain, the retina, and the inner ear leading to central nervous system (CNS) alterations, visual disturbances, and hearing deficits. Our aim is to expand clinicians' diagnostic options when facing psychosis due to medical conditions.

METHODS

A case report was conducted for this study.

RESULTS

This paper reports the case of a young male drug user who presented with psychosis, confusion and CNS vasculitis. First deemed to be drug-induced CNS vasculitis, it was finally diagnosed as Susac syndrome.

CONCLUSIONS

Although an infrequent entity, Susac syndrome should remain an option in the differential diagnosis of several neurological and psychiatric presentations.

Susac syndrome: clinical characteristics, clinical classification, and long-term prognosis

Susac syndrome is a rare condition characterized by the clinical triad of central nervous system (CNS) dysfunction, sensorineural hearing impairment, and branch retinal artery occlusion (BRAO). The purpose of this study is to examine the demographics, clinical characteristics, treatment, and long-term prognosis of Susac syndrome. The data recorded for all Susac syndrome patients treated at the Sheba Medical Center between 1998 and 2014 included demographics, clinical signs at presentation and during the disease course, imaging findings, treatment, and prognosis.Susac syndrome was diagnosed in 10 patients (age range 30-45 years). Only 2 patients presented with the full triad and 7 patients developed the full triad during mean follow-up period of 35 months. The average time to full triad was 7 months. Based on our observations at presentation, we divided the disease course into suspected, incomplete, and complete Susac syndrome. All 10 patients were treated at diagnosis with a pulse of high-dose intravenous methylprednisolone. There was improvement in visual acuity and visual field at the end of follow-up compared to baseline, but it was not statistically significant (P = 0.479 and P = 0.053, respectively). Five patients remained with neurological damage, and 5 patients had no improvement of their hearing loss at study closure. In conclusion, Susac syndrome is a rare condition that can mimic other disorders. The diagnosis is challenging because most patients do not initially present with the definitive triad. We suggest a clinical classification for the syndrome that may assist in early diagnosis.

Neurological, otolaryngological and ophthalmological implications of Susac syndrome - a case report

Susac syndrome is an endotheliopathy affecting the arterioles of the brain, retina, and inner ear. Many cases of Susac syndrome are underdiagnosed, mainly at the early stages of the disease, while prompt diagnosis enables a speedy recovery. Immediate treatment can halt disease progression and even prevent future disability. We report a case of Susac syndrome, describe the difficulties in the diagnosis of this case, and include a detailed history of a 35-year-old man via the presentation of extensive laboratory work-up and imaging studies. Audiometry showed sensorineural hearing loss of about 75 dB in the left ear. Ovoid lesions of the corpus callosum in magnetic resonance (MR) were present as were advanced binocular ophthalmological changes in fluorescent angiography. Methylprednisolone with acetylsalicylic acid and intravenous immunoglobulin (IVIG) were implemented with a positive outcome (clinical and audiometric improvement).

[Diagnosis and treatment of rare causes of ischaemic stroke]

Rare causes of ischaemic stroke comprise a plethora of diagnoses of cardioembolic, inflammatory and genetic origin. The differential diagnosis is challenging but important because these disorders (e.g. monogenetic disorders such as COL4A1 mutations) often affect young individuals, they typically require sophisticated diagnostics (e.g. fluorescence angiography in Susac's syndrome) and they are increasingly treatable (e.g. enzyme replacement for Fabry's disease). This review discusses practical considerations and recent diagnostic and therapeutic advances in uncommon causes of ischaemic stroke.

[Susac's syndrome: psychosis as a presenting symptom of rare angiopathy]

BACKGROUND

Susac's syndrome is a rare angiopathy characterised by the triad of encephalopathy, hearing loss and retinal artery occlusions. The diagnosis relies on the clinical picture, brain MRI scan, audiometry, fundoscopy and fluorescein angiography. Swift, intensive and prolonged treatment with immunosuppressants, immunoglobulins, plasmapheresis and anticoagulants can result in full or partial remission.

CASE DESCRIPTION

A 31-year-old woman became increasingly confused while on holiday in Aruba. On returning to Holland she was admitted for a psychotic episode. Because of the atypical nature of the psychiatric symptoms and subtle neurological deficits, extensive somatic investigations were conducted. Typical lesions in the corpus callosum were found on brain MRI. After treatment with immunosuppressants the psychotic symptoms disappeared.

CONCLUSION

In Susac's syndrome psychiatric symptoms can initially dominate the clinical picture. To diagnose this condition correctly, extensive multidisciplinary collaboration is essential.

Susac syndrome--clinical insight and strategies of therapy

Susac syndrome is an uncommon autoimmune microangiopathy characterized mainly by neurological disorders and, to date, 304 clinical cases have been described. The background of this syndrome is an immune-mediated endotheliopathy that affects the microvasculature of the brain, retina, and inner ear resulting in encephalopathy, hearing loss, and branch retinal artery occlusions. However, the cause and the pathogenesis of this microangiopathy remain unclear. Magnetic resonance imaging, retinal fluorescein angiography, and audiography findings enable the diagnosis of this syndrome. In this review, we have demonstrated the epidemiology and pathology of Susac syndrome with detailed description of clinical signs, diagnostic procedures and therapeutic possibilities.

SUSAC SYNDROME

PURPOSE

To describe an atypical presentation of Susac syndrome.

METHODS

Observational case report.

RESULTS

A 44-year-old man with no significant medical history presented with inferonasal visual field loss in his left eye of several months of duration. He was found to have bilateral migratory arteritis with focal areas of arteriolar occlusion in both eyes and peripheral ischemia superotemporally in his left eye. An extensive hematologic workup was negative for autoimmune disease or coagulopathy. Magnetic resonance imaging with contrast of his brain revealed a hyperintense lesion in the splenium of the corpus callosum. Auditory testing was significant for nonspecific high-frequency hearing loss in the right ear. Given the full clinical picture, a diagnosis of Susac syndrome was made.

CONCLUSION

Susac syndrome is a multisystemic, immune-mediated occlusive endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions, and hearing loss. However, patients may present with varying degrees of this triad; thus, there should be a high index of suspicion in patients presenting with multiple artery occlusions or multifocal arteritis.

Central retinal artery occlusion and Susac syndrome: a case report

BACKGROUND

Susac syndrome is a rare disease attributed to microangiopathy involving the arterioles of the brain, retina, and cochlea. Understanding the pathogenesis is incomplete, but an immune-mediated process remains the leading hypothesis.

METHODS

Report of a single case of a previously healthy 22-year-old female patient showing the complete clinical triad.

RESULTS

Diagnosis of Susac syndrome in this patient was first questioned due to the atypical initial ophthalmologic presentation with central retinal artery occlusion. Multiple relapses occurred in the fellow eye during follow-up, showing the typical branch retinal artery occlusions, allowing definite diagnosis.

CONCLUSION

Susac syndrome should be considered in the differential diagnosis when facing (young) patients with central retinal artery occlusion, especially in the presence of unexplained encephalopathy and/or sensorineural hearing loss.

Susac syndrome. A differential diagnosis for demyelination

Susac syndrome is a microangiopathy of unknown origin, probably autoimmune, affecting capillaries and precapillary arterioles of the brain, retina, and inner ear. It is often misdiagnosed as acute disseminated encephalomyelitis or multiple sclerosis. We report the case of a 25-year-old male with Susac syndrome who developed the clinical triad of encephalopathy, visual and hearing problems over the course of a year. The characteristic MRI findings including central corpus callosal involvement and brain infarctions were supported by branch retinal arterial/arteriolar occlusions on fluorescein retinal angiography. Most patients with Susac syndrome will not have the complete clinical triad initially. A very high index of suspicion is required by the clinician and radiologist in patients with any component of the clinical triad so as not to misdiagnose the MRI findings for demyelination. Even if initial ophthalmologic examinations are normal, these patients should be followed up for later development of branch retinal artery occlusions.

[Differential diagnosis of optic neuritis (review]

Clinical presentations, diagnosis and differential diagnosis of optic neuritis of different etiology are reviewed. This symptom is concomitant with the development of multiple sclerosis in about 30% cases and accompanies the disease in 75% patients. Acute or subacute lesion of the optic nerve can be a symptom of optic myelitis, Leber's disease, systemic lupus erythematosus, Susac's syndrome, idiopathic retinal vasculitis, sarcoidosis and some other diseases. Clinical features and course of optic neuritis in these diseases are discussed.

Sudden sensorineural hearing loss: when ophthalmology meets otolaryngology

OBJECTIVES

Sudden sensorineural hearing loss is a perplexing entity in otology. Susac's syndrome (also called retinocochleocerebral vasculopathy) is a rare disorder that consists of microangiopathy of the brain, retina, and inner ear, and usually affects women in young adulthood. We describe the clinical aspects, radiographic findings, and management of one such case.

CASE REPORT

A 30-year-old woman was admitted to the hospital because of sudden onset of bilateral deafness and headache. During her hospitalization, she developed discrete right hemiparesis and hypoesthesia.

RESULTS

Magnetic resonance imaging revealed multiple signal hyperintensities and atrophy of the corpus callosum. The differential diagnosis was a myelinating condition, such as multiple sclerosis or acute demyelinating encephalomyelitis.

CONCLUSION

Retinal fluorescein angiography helped the diagnosis of Susac's syndrome.

Recurrent bilateral branch retinal artery occlusion with hearing loss and encephalopathy: the first case report of Susac syndrome in Korea

We report the first case of Susac syndrome in Koreans, in a 23-yr-old female patient who presented with sudden visual loss and associated neurological symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, which tended to recur in both eyes. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum and left fornix, and audiometry showed low-frequency sensory hearing loss, compatible with Susac syndrome. She received immunosuppressive therapy with oral steroid and azathioprine. Three months later all the symptoms disappeared but obstructive vasculitis have been relapsing. This patient demonstrated the entire clinical triad of Susac syndrome, which tends to occur in young females. Although this disorder has rarely been reported in Asian populations, a high index of suspicion is warranted for early diagnosis and timely treatment.

[Inaugural audiovisual impairment disclosing specific neurological disorders]

The association of visual and auditory impairments, simultaneously or consecutively, is a rare condition at the onset of neurological diseases. To determine whether audiovisual impairment can be associated with a specific group of neurological disorders at onset, we performed a prospective study of 307 patients over 6 months in a specialized neurological unit in inflammatory diseases. Six patients (2%) experienced inaugural audiovisual impairments. The mean age of patients at onset was 39.5 ± 14.7 years, with a male:female ratio of 1:2. Both deficiencies were reported in three cases, including loss of visual acuity with tinnitus (two cases) or hearing loss (one case). Initial visual dysfunction, characterised by loss of visual acuity, was noted in one patient. Initial auditory impairment, characterised by dizziness and hearing loss, was noted in two patients. The mean interval between the occurrence of visual and auditory impairments was 3.8 ± 4.3 months. A neurological diagnosis was made in four cases (67%) at a mean time of 4.6 ± 4.6 months after disease onset. Visual impairments were optic neuritis for multiple sclerosis, serous retinal detachment for Vogt-Koyanagi-Harada's disease, a central retinal artery occlusion for Susac's syndrome and a retinal vasculitis for Cogan's syndrome. The systematic investigation of inaugural audiovisual impairment in young patients could help shorten the time to a specific neurological diagnosis.