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Anis S, Regev K, Pittock SJ, Flanagan EP, Alcalay Y, Gadoth A. Isolated recurrent myelitis in a persistent MOG positive patient. Mult Scler Relat Disord 2019; 30:163-164. [PMID: 30780123 DOI: 10.1016/j.msard.2019.02.016] [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: 01/08/2019] [Revised: 02/02/2019] [Accepted: 02/11/2019] [Indexed: 11/25/2022]
Abstract
MOG-Ab positive CNS demyelination typically involves the optic nerve and spinal cord. Recurrent episodes of myelitis without optic neuritis are very rare and according to current literature review represent about 3-5% of positive MOG-Ab cases. We report a 30-year-old woman with positive serum MOG-Ab suffering two discrete episodes of transverse myelitis without ophthalmic involvement. Repeated serum MOG-Ab test after the second relapse was positive, correlating with high likelihood of relapsing disease. Of note, our patient relapsed under Rituximab therapy, which does not seem to be uncommon for MOG-Ab patients. Patients with isolated or recurrent myelitis without optic involvement should be screened for anti MOG IgG as a part of their workup.
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Affiliation(s)
- S Anis
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel; Sackler School of Medicine, Tel-Aviv University, Weizman 6 Street, Tel-Aviv, 6423906, Israel.
| | - K Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel; Neuro-immunology Unit, Tel-Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel
| | - S J Pittock
- Department of Laboratory Medicine and Neurology, Mayo Clinic, Rochester, Minnesota, 55905, USA; Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - E P Flanagan
- Department of Laboratory Medicine and Neurology, Mayo Clinic, Rochester, Minnesota, 55905, USA; Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Y Alcalay
- Autoimmune Neurology Laboratory, Tel Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel
| | - A Gadoth
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel; Autoimmune Neurology Laboratory, Tel Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel; Autoimmune encephalitis and paraneoplastic syndromes clinic, Tel-Aviv Sourasky Medical Center, Weizman 6 Street, Tel-Aviv, 6423906, Israel
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Abstract
Most spinal cord injury is seen with trauma. Nontraumatic spinal cord emergencies are discussed in this chapter. These myelopathies are rare but potentially devastating neurologic disorders. In some situations prior comorbidity (e.g., advanced cancer) provides a clue, but in others (e.g., autoimmune myelopathies) it may come with little warning. Neurologic examination helps distinguish spinal cord emergencies from peripheral nervous system emergencies (e.g., Guillain-Barré), although some features overlap. Neurologic deficits are often severe and may quickly become irreversible, highlighting the importance of early diagnosis and treatment. Emergent magnetic resonance imaging (MRI) of the entire spine is the imaging modality of choice for nontraumatic spinal cord emergencies and helps differentiate extramedullary compressive causes (e.g., epidural abscess, metastatic compression, epidural hematoma) from intramedullary etiologies (e.g., transverse myelitis, infectious myelitis, or spinal cord infarct). The MRI characteristics may give a clue to the diagnosis (e.g., flow voids dorsal to the cord in dural arteriovenous fistula). However, additional investigations (e.g., aquaporin-4-IgG) are often necessary to diagnose intramedullary etiologies and guide treatment. Emergency decompressive surgery is necessary for many extramedullary compressive causes, either alone or in combination with other treatments (e.g., radiation) and preoperative neurologic deficit is the best predictor of outcome.
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Affiliation(s)
- E P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - S J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Flanagan EP, Saito YA, Lennon VA, McKeon A, Fealey RD, Szarka LA, Murray JA, Foxx-Orenstein AE, Fox JC, Pittock SJ. Immunotherapy trial as diagnostic test in evaluating patients with presumed autoimmune gastrointestinal dysmotility. Neurogastroenterol Motil 2014; 26:1285-97. [PMID: 25039328 PMCID: PMC4149849 DOI: 10.1111/nmo.12391] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [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: 03/13/2014] [Accepted: 06/07/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic gastrointestinal dysmotility greatly impacts the quality of life. Treatment options are limited and generally symptomatic. Neural autoimmunity is an under-recognized etiology. We evaluated immunotherapy as an aid to diagnosing autoimmune gastrointestinal dysmotility (AGID). METHODS Twenty-three subjects evaluated at the Mayo Clinic for suspected AGID (August 2006-February 2014) fulfilled the following criteria: (1) prominent symptoms of gastrointestinal dysmotility with abnormalities on scintigraphy-manometry; (2) serological evidence or personal/family history of autoimmune disease; (3) treated by immunotherapy on a trial basis, 6-12 weeks (intravenous immune globulin, 16; or methylprednisolone, 5; or both, 2). Response was defined subjectively (symptomatic improvement) and objectively (gastrointestinal scintigraphy/manometry studies). KEY RESULTS Symptoms at presentation: constipation, 18/23; nausea or vomiting, 18/23; weight loss, 17/23; bloating, 13/23; and early satiety, 4/23. Thirteen patients had personal/family history of autoimmunity. Sixteen had neural autoantibodies and 19 had extra-intestinal autonomic testing abnormalities. Cancer was detected in three patients. Preimmunotherapy scintigraphy revealed slowed transit (19/21 evaluated; gastric, 11; small bowel, 12; colonic, 11); manometry studies were abnormal in 7/8. Postimmunotherapy, 17 (74%) had improvement (both symptomatic and scintigraphic, five; symptomatic alone, eight; scintigraphic alone, four). Nine responders re-evaluated had scintigraphic evidence of improvement. The majority of responders who were re-evaluated had improvement in autonomic testing (six of seven) or manometry (two of two). CONCLUSIONS & INFERENCES This proof of principle study illustrates the importance of considering an autoimmune basis for idiopathic gastrointestinal dysmotility and supports the utility of a diagnostic trial of immunotherapy.
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Affiliation(s)
- E P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Fryer JP, Lennon VA, Pittock SJ, Jenkins SM, Fallier-Becker P, Clardy SL, Horta E, Jedynak EA, Lucchinetti CF, Shuster EA, Weinshenker BG, Wingerchuk DM, McKeon A. AQP4 autoantibody assay performance in clinical laboratory service. Neurol Neuroimmunol Neuroinflamm 2014; 1:e11. [PMID: 25340055 PMCID: PMC4202686 DOI: 10.1212/nxi.0000000000000011] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 03/31/2014] [Indexed: 01/23/2023]
Abstract
Objective: To compare performance of contemporary aquaporin-4–immunoglobulin (Ig) G assays in clinical service. Methods: Sera from neurologic patients (4 groups) and controls were tested initially by service ELISA (recombinant human aquaporin-4, M1 isoform) and then by cell-based fluorescence assays: fixed (CBA, M1-aquaporin-4, observer-scored) and live (fluorescence-activated cell sorting [FACS], M1 and M23 aquaporin-4 isoforms). Group 1: all Mayo Clinic patients tested from January to May 2012; group 2: consecutive aquaporin-4-IgG–positive patients from September 2011 (Mayo and non-Mayo); group 3: suspected ELISA false-negatives from 2011 to 2013 (physician-reported, high likelihood of neuromyelitis optica spectrum disorders [NMOSDs] clinically); group 4: suspected ELISA false-positives (physician-reported, not NMOSD clinically). Results: Group 1 (n = 388): M1-FACS assay performed optimally (areas under the curves: M1 = 0.64; M23 = 0.57 [p = 0.02]). Group 2 (n = 30): NMOSD clinical diagnosis was confirmed by: M23-FACS, 24; M1-FACS, 23; M1-CBA, 20; and M1-ELISA, 18. Six results were suspected false-positive: M23-FACS, 2; M1-ELISA, 2; and M23-FACS, M1-FACS, and M1-CBA, 2. Group 3 (n = 31, suspected M1-ELISA false-negatives): results were positive for 5 sera: M1-FACS, 5; M23-FACS, 3; and M1-CBA, 2. Group 4 (n = 41, suspected M1-ELISA false-positives): all negative except 1 (positive only by M1-CBA). M1/M23-cotransfected cells expressing smaller membrane arrays of aquaporin-4 yielded fewer false- positive FACS results than M23-transfected cells. Conclusion: Aquaporin-4-transfected CBAs, particularly M1-FACS, perform optimally in aiding NMOSD serologic diagnosis. High-order arrays of M23-aquaporin-4 may yield false-positive results by binding IgG nonspecifically.
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Affiliation(s)
- J P Fryer
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - V A Lennon
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - S J Pittock
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - S M Jenkins
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - P Fallier-Becker
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - S L Clardy
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - E Horta
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - E A Jedynak
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - C F Lucchinetti
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - E A Shuster
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - B G Weinshenker
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - D M Wingerchuk
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
| | - A McKeon
- Departments of Laboratory Medicine and Pathology (J.P.F., V.A.L., S.J.P., E.H., E.A.J., A.M.), Neurology (V.A.L., S.J.P., S.L.C., C.F.L., B.G.W., A.M.), Immunology (V.A.L.), and Health Sciences Research (S.M.J.), College of Medicine, Mayo Clinic, Rochester, MN; Institute of Pathology and Neuropathology (P. F.-B.), University of Tubingen, Germany; Department of Neurology (E.A.S.), College of Medicine, Mayo Clinic, Jacksonville, FL; and Department of Neurology (D.M.W.), College of Medicine, Mayo Clinic, Scottsdale, AZ
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Toledano M, Britton JW, McKeon A, Shin C, Lennon VA, Quek AML, So E, Worrell GA, Cascino GD, Klein CJ, Lagerlund TD, Wirrell EC, Nickels KC, Pittock SJ. Utility of an immunotherapy trial in evaluating patients with presumed autoimmune epilepsy. Neurology 2014; 82:1578-86. [PMID: 24706013 DOI: 10.1212/wnl.0000000000000383] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate a trial of immunotherapy as an aid to diagnosis in suspected autoimmune epilepsy. METHOD We reviewed the charts of 110 patients seen at our autoimmune neurology clinic with seizures as a chief complaint. Twenty-nine patients met the following inclusion criteria: (1) autoimmune epilepsy suspected based on the presence of ≥ 1 neural autoantibody (n = 23), personal or family history or physical stigmata of autoimmunity, and frequent or medically intractable seizures; and (2) initiated a 6- to 12-week trial of IV methylprednisolone (IVMP), IV immune globulin (IVIg), or both. Patients were defined as responders if there was a 50% or greater reduction in seizure frequency. RESULTS Eighteen patients (62%) responded, of whom 10 (34%) became seizure-free; 52% improved with the first agent. Of those receiving a second agent after not responding to the first, 43% improved. A favorable response correlated with shorter interval between symptom onset and treatment initiation (median 9.5 vs 22 months; p = 0.048). Responders included 14/16 (87.5%) patients with antibodies to plasma membrane antigens, 2/6 (33%) patients seropositive for glutamic acid decarboxylase 65 antibodies, and 2/6 (33%) patients without detectable antibodies. Of 13 responders followed for more than 6 months after initiating long-term oral immunosuppression, response was sustained in 11 (85%). CONCLUSIONS These retrospective findings justify consideration of a trial of immunotherapy in patients with suspected autoimmune epilepsy. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in patients with suspected autoimmune epilepsy, IVMP, IVIg, or both improve seizure control.
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Affiliation(s)
- M Toledano
- From the Departments of Neurology (M.T., J.W.B., A.M., C.S., V.A.L., E.S., G.A.W., G.D.C., C.J.K., T.D.L., E.C.W., K.C.N., S.J.P.), Laboratory Medicine and Pathology (A.M., V.A.L., A.M.L.Q., C.J.K., S.J.P.), and Immunology (V.A.L.), Mayo Clinic, College of Medicine, Rochester, MN
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Braksick SA, Cutsforth-Gregory JK, Black DF, Weinshenker BG, Pittock SJ, Kantarci OH. Teaching NeuroImages: MRI in advanced neuromyelitis optica. Neurology 2014; 82:e101-2. [DOI: 10.1212/wnl.0000000000000246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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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Kotsenas AL, Watson RE, Pittock SJ, Britton JW, Hoye SL, Quek AML, Shin C, Klein CJ. MRI findings in autoimmune voltage-gated potassium channel complex encephalitis with seizures: one potential etiology for mesial temporal sclerosis. AJNR Am J Neuroradiol 2013; 35:84-9. [PMID: 23868165 DOI: 10.3174/ajnr.a3633] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Autoimmune voltage-gated potassium channel complex encephalitis is a common form of autoimmune encephalitis. Patients with seizures due to this form of encephalitis commonly have medically intractable epilepsy and may require immunotherapy to control seizures. It is important that radiologists recognize imaging characteristics of this type of autoimmune encephalitis and suggest it in the differential diagnosis because this seizure etiology is likely under-recognized. Our purpose was to characterize MR imaging findings in this patient population. MATERIALS AND METHODS MR imaging in 42 retrospectively identified patients (22 males; median age, 56 years; age range, 8-79 years) with seizures and voltage-gated potassium channel complex autoantibody seropositivity was evaluated for mesial and extratemporal swelling and/or atrophy, T2 hyperintensity, restricted diffusion, and enhancement. Statistical analysis was performed. RESULTS Thirty-three of 42 patients (78.6%) demonstrated enlargement and T2 hyperintensity of mesial temporal lobe structures at some time point. Mesial temporal sclerosis was commonly identified (16/33, 48.5%) at follow-up imaging. Six of 9 patients (66.7%, P = .11) initially demonstrating hippocampal enhancement and 8/13 (61.5%, P = .013) showing hippocampal restricted diffusion progressed to mesial temporal sclerosis. Conversely, in 6 of 33 patients, abnormal imaging findings resolved. CONCLUSIONS Autoimmune voltage-gated potassium channel complex encephalitis is frequently manifested as enlargement, T2 hyperintensity, enhancement, and restricted diffusion of the mesial temporal lobe structures in the acute phase. Recognition of these typical imaging findings may help prompt serologic diagnosis, preventing unnecessary invasive procedures and facilitating early institution of immunotherapy. Serial MR imaging may demonstrate resolution or progression of radiologic changes, including development of changes involving the contralateral side and frequent development of mesial temporal sclerosis.
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Eggers SDZ, Pittock SJ, Shepard NT, Habermann TM, Neff BA, Klebig RR. Positional periodic alternating vertical nystagmus with PCA-Tr antibodies in Hodgkin lymphoma. Neurology 2012; 78:1800-2. [PMID: 22592362 DOI: 10.1212/wnl.0b013e3182583085] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [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
Affiliation(s)
- S D Z Eggers
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Waters PJ, McKeon A, Leite MI, Rajasekharan S, Lennon VA, Villalobos A, Palace J, Mandrekar JN, Vincent A, Bar-Or A, Pittock SJ. Serologic diagnosis of NMO: a multicenter comparison of aquaporin-4-IgG assays. Neurology 2012; 78:665-71; discussion 669. [PMID: 22302543 DOI: 10.1212/wnl.0b013e318248dec1] [Citation(s) in RCA: 379] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Neuromyelitis optica (NMO) immunoglobulin G (IgG) (aquaporin-4 [AQP4] IgG) is highly specific for NMO and related disorders, and autoantibody detection has become an essential investigation in patients with demyelinating disease. However, although different techniques are now used, no multicenter comparisons have been performed. This study compares the sensitivity and specificity of different assays, including an in-house flow cytometric assay and 2 commercial assays (ELISA and transfected cell-based assay [CBA]). METHODS Six assay methods (in-house or commercial) were performed in 2 international centers using coded serum from patients with NMO (35 patients), NMO spectrum disorders (25 patients), relapsing-remitting multiple sclerosis (39 patients), miscellaneous autoimmune diseases (25 patients), and healthy subjects (22 subjects). RESULTS The highest sensitivities were yielded by assays detecting IgG binding to cells expressing recombinant AQP4 with quantitative flow cytometry (77; 46 of 60) or visual observation (CBA, 73%; 44 of 60). The fluorescence immunoprecipitation assay and tissue-based immunofluorescence assay were least sensitive (48%-53%). The CBA and ELISA commercial assays (100% specific) yielded sensitivities of 68% (41 of 60) and 60% (36 of 60), respectively, and sensitivity of 72% (43 of 60) when used in combination. CONCLUSIONS The greater sensitivity and excellent specificity of second-generation recombinant antigen-based assays for detection of NMO-IgG in a clinical setting should enable earlier diagnosis of NMO spectrum disorders and prompt initiation of disease-appropriate therapies.
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Affiliation(s)
- P J Waters
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, Oxford, UK.
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Iorio R, Lucchinetti CF, Lennon VA, Costanzi C, Hinson S, Weinshenker BG, Pittock SJ. Syndrome of inappropriate antidiuresis may herald or accompany neuromyelitis optica. Neurology 2011; 77:1644-6. [PMID: 21998320 DOI: 10.1212/wnl.0b013e3182343377] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- R Iorio
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Costanzi C, Matiello M, Lucchinetti CF, Weinshenker BG, Pittock SJ, Mandrekar J, Thapa P, McKeon A. Azathioprine: tolerability, efficacy, and predictors of benefit in neuromyelitis optica. Neurology 2011; 77:659-66. [PMID: 21813788 DOI: 10.1212/wnl.0b013e31822a2780] [Citation(s) in RCA: 181] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy, tolerability, optimal dosing, and monitoring of azathioprine in patients with neuromyelitis optica (NMO). METHODS This was a chart review and telephone follow-up study of 99 patients with NMO spectrum of disorders (NMOSD) treated with azathioprine (1994-2009). NMOSD were NMO (2006 diagnostic criteria) or partial NMO forms (NMO-immunoglobulin G seropositive). Wilcoxon signed rank test was used to compare pretreatment and postinitiation of azathioprine (posttreatment) annualized relapse rates (ARR), Expanded Disability Status Scale (EDSS) score, and visual acuity outcome. Linear regression was used to assess the effects of various factors on ARR change and disability. RESULTS The median duration of NMOSD symptoms prior to initiation of azathioprine was 2 years (range 1-27); 79 patients were women. Eighty-six patients had NMO and 13 limited NMO versions, including transverse myelitis in 8 and optic neuritis in 5. Median posttreatment follow-up was 22 months. Thirty-eight patients discontinued drug (side effects, 22; no efficacy, 13; lymphoma, 3). Among 70 patients with >12 months follow-up, 48 received ≥2.0 mg/kg/day (ARR: pretreatment, 2.20; posttreatment, 0.52); 22 received <2.0 mg/kg/day (ARR: pretreatment, 2.09; posttreatment, 0.82); 52 received concomitant prednisone (ARR: pretreatment, 2.20; posttreatment, 0.89) and 18 did not (ARR: pretreatment, 1.54; posttreatment, 0.23); p < 0.0001 for each comparison. EDSS was stable or improved despite ongoing attacks in 22 patients (31%). Twenty-six patients tolerated azathioprine and were relapse-free (37%, median follow-up 24 months; range 12-151). Mean corpuscular volume increase influenced ARR change (p = 0.049). CONCLUSIONS Azathioprine is generally effective and well-tolerated. Early initiation, adequate dosing, and hematologic parameter monitoring may optimize efficacy. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that azathioprine is effective for reducing relapse rates and improving EDSS and visual acuity scores in patients with NMO spectrum of disorders.
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Affiliation(s)
- C Costanzi
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Keegan BM, Giannini C, Pittock SJ. Reply: A new case of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) with initial normal magnetic resonance imaging. Brain 2011. [DOI: 10.1093/brain/awq391] [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: 11/13/2022] Open
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Flanagan EP, McKeon A, Lennon VA, Kearns J, Weinshenker BG, Krecke KN, Matiello M, Keegan BM, Mokri B, Aksamit AJ, Pittock SJ. Paraneoplastic isolated myelopathy: Clinical course and neuroimaging clues. Neurology 2011; 76:2089-95. [DOI: 10.1212/wnl.0b013e31821f468f] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [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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Wingerchuk DM, Lennon VA, Pittock SJ, Lucchinetti CF, Weinshenker BG. Revised diagnostic criteria for neuromyelitis optica. Neurology 2011. [DOI: 10.1212/01.wnl.0000398908.30918.e1] [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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Keegan BM, Krecke KN, Pittock SJ. Reply to Duprez et al. and List et al. regarding chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. Brain 2011. [DOI: 10.1093/brain/awr036] [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] [Indexed: 11/15/2022] Open
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16
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Popescu BFG, Lennon VA, Parisi JE, Howe CL, Weigand SD, Cabrera-Gómez JA, Newell K, Mandler RN, Pittock SJ, Weinshenker BG, Lucchinetti CF. Neuromyelitis optica unique area postrema lesions: nausea, vomiting, and pathogenic implications. Neurology 2011; 76:1229-37. [PMID: 21368286 DOI: 10.1212/wnl.0b013e318214332c] [Citation(s) in RCA: 208] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To characterize the neuropathologic features of neuromyelitis optica (NMO) at the medullary floor of the fourth ventricle and area postrema. Aquaporin-4 (AQP4) autoimmunity targets this region, resulting in intractable nausea associated with vomiting or hiccups in NMO. METHODS This neuropathologic study was performed on archival brainstem tissue from 15 patients with NMO, 5 patients with multiple sclerosis (MS), and 8 neurologically normal subjects. Logistic regression was used to evaluate whether the presence of lesions at this level increased the odds of a patient with NMO having an episode of nausea/vomiting. RESULTS Six patients with NMO (40%), but no patients with MS or normal controls, exhibited unilateral or bilateral lesions involving the area postrema and the medullary floor of the fourth ventricle. These lesions were characterized by tissue rarefaction, blood vessel thickening, no obvious neuronal or axonal pathology, and preservation of myelin in the subependymal medullary tegmentum. AQP4 immunoreactivity was lost or markedly reduced in all 6 cases, with moderate to marked perivascular and parenchymal lymphocytic inflammatory infiltrates, prominent microglial activation, and in 3 cases, eosinophils. Complement deposition in astrocytes, macrophages, and/or perivascularly, and a prominent astroglial reaction were also present. The odds of nausea/vomiting being documented clinically was 16-fold greater in NMO cases with area postrema lesions (95% confidence interval 1.43-437, p = 0.02). CONCLUSIONS These neuropathologic findings suggest the area postrema may be a selective target of the disease process in NMO, and are compatible with clinical reports of nausea and vomiting preceding episodes of optic neuritis and transverse myelitis or being the heralding symptom of NMO.
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Affiliation(s)
- B F Gh Popescu
- Mayo Clinic, College of Medicine, Rochester, MN 55905, USA
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McKeon A, Lindell EP, Atkinson JLD, Weinshenker BG, Piepgras DG, Pittock SJ. Pearls & oy-sters: clues for spinal dural arteriovenous fistulae. Neurology 2011; 76:e10-2. [PMID: 21242488 DOI: 10.1212/wnl.0b013e3182074a42] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [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
Affiliation(s)
- A McKeon
- Department of Laboratory Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Popescu BFG, Parisi JE, Cabrera-Gómez JA, Newell K, Mandler RN, Pittock SJ, Lennon VA, Weinshenker BG, Lucchinetti CF. Absence of cortical demyelination in neuromyelitis optica. Neurology 2011; 75:2103-9. [PMID: 21135384 DOI: 10.1212/wnl.0b013e318200d80c] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To asses the presence of cortical demyelination in brains of patients with neuromyelitis optica (NMO). NMO is an autoimmune inflammatory demyelinating disease that specifically targets aquaporin-4-rich regions of the CNS. Since aquaporin-4 is highly expressed in normal cortex, we anticipated that cortical demyelination may occur in NMO. METHODS This is a cross-sectional neuropathologic study performed on archival forebrain and cerebellar tissue sections from 19 autopsied patients with a clinically and/or pathologically confirmed NMO spectrum disorder. RESULTS Detailed immunohistochemical analyses of 19 archival NMO cases revealed preservation of aquaporin-4 in a normal distribution within cerebral and cerebellar cortices, and no evidence of cortical demyelination. CONCLUSIONS This study provides a plausible explanation for the absence of a secondary progressive clinical course in NMO and shows that cognitive and cortical neuroimaging abnormalities previously reported in NMO cannot be attributed to cortical demyelination. Lack of cortical demyelination is another characteristic that further distinguishes NMO from MS.
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Affiliation(s)
- B F Gh Popescu
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Pittock SJ, Debruyne J, Krecke KN, Giannini C, van den Ameele J, De Herdt V, McKeon A, Fealey RD, Weinshenker BG, Aksamit AJ, Krueger BR, Shuster EA, Keegan BM. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). Brain 2010; 133:2626-34. [DOI: 10.1093/brain/awq164] [Citation(s) in RCA: 237] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Magaña SM, Matiello M, Pittock SJ, McKeon A, Lennon VA, Rabinstein AA, Shuster E, Kantarci OH, Lucchinetti CF, Weinshenker BG. Posterior reversible encephalopathy syndrome in neuromyelitis optica spectrum disorders. Neurology 2009; 72:712-7. [PMID: 19237699 DOI: 10.1212/01.wnl.0000343001.36493.ae] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized by vasogenic subcortical edema without infarction. It has been associated with hypertensive crises and with immunosuppressive medications but not with neuromyelitis optica (NMO). METHODS We reviewed the clinical and neuroimaging features of five NMO-immunoglobulin G (IgG) seropositive white women who experienced an episode of PRES and had a coexisting NMO spectrum disorder (NMOSD). We also tested for the aquaporin-4 (AQP4) water channel autoantibody (NMO-IgG) in 14 patients from an independently ascertained cohort of individuals with PRES. RESULTS All five patients developed abrupt confusion and depressed consciousness consistent with PRES. The encephalopathy resolved completely within 7 days. Comorbid conditions or interventions recognized to be associated with PRES included orthostatic hypotension with supine hypertension, plasma exchange, IV immunoglobulin treatment, and high-dose IV methylprednisolone. Brain MRI studies revealed bilateral T2-weighted (T2W) hyperintense signal abnormalities, primarily in frontal, parieto-occipital, and cerebellar regions. Three patients had highly symmetric lesions and three had gadolinium-enhancing lesions. Follow-up neuroimaging revealed partial or complete disappearance of T2W hyperintensity or gadolinium-enhancing lesions in all five patients. Patients with PRES without NMOSD were uniformly NMO-IgG seronegative. CONCLUSIONS Brain lesions in some patients with neuromyelitis optica spectrum disorder (NMOSD) may be accompanied by vasogenic edema and manifest as posterior reversible encephalopathy syndrome (PRES). Water flux impairment due to aquaporin-4 autoimmunity may predispose to PRES in patients with NMOSD who experience blood pressure fluctuations or who are treated with therapies that can cause rapid fluid shifts.
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Affiliation(s)
- S M Magaña
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Abstract
OBJECTIVE To document neurologic, oncologic, and serologic associations of patients in whom voltage-gated potassium channel (VGKC) autoantibodies were detected in the course of serologic evaluation for neuronal, glial, and muscle autoantibodies. METHODS Indirect immunofluorescence screening of sera from 130,000 patients performed on a service basis for markers of paraneoplastic neurologic autoimmunity identified 80 patients whose IgG bound to the synapse-rich molecular layer of mouse cerebellar cortex in a pattern consistent with VGKC immunoreactivity. Antibody specificity was confirmed in all cases by immunoprecipitation of detergent-solubilized brain synaptic proteins complexed with (125)I-alpha-dendrotoxin. RESULTS Clinical information was available for 72 patients: 51% women, median age at symptom onset 65 years, and median follow-up period 14 months. Neurologic manifestations were acute to subacute in onset in 71% and multifocal in 46%; 71% had cognitive impairment, 58% seizures, 33% dysautonomia, 29% myoclonus, 26% dyssomnia, 25% peripheral nerve dysfunction, 21% extrapyramidal dysfunction, and 19% brainstem/cranial nerve dysfunction. Creutzfeldt-Jakob disease was a common misdiagnosis (14%). Neoplasms encountered (confirmed histologically in 33%) included 18 carcinomas, 5 adenomas, 1 thymoma, and 3 hematologic malignancies. Hyponatremia was documented in 36%, other organ-specific autoantibodies in 49%, and a co-existing autoimmune disorder in 33% (including thyroiditis 21%, type 1 diabetes mellitus 11%). Benefit was reported for 34 of 38 patients (89%) receiving immunotherapy and was marked in 50%. CONCLUSIONS The spectrum of neurologic manifestations and neoplasms associated with voltage-gated potassium channel (VGKC) autoimmunity is broader than previously recognized. Evaluation for VGKC antibodies is recommended in the comprehensive autoimmune serologic testing of subacute idiopathic neurologic disorders.
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Affiliation(s)
- K M Tan
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Lucchinetti CF, Gavrilova RH, Metz I, Parisi JE, Scheithauer BW, Weigand S, Thomsen K, Mandrekar J, Altintas A, Erickson BJ, König F, Giannini C, Lassmann H, Linbo L, Pittock SJ, Brück W. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis. Brain 2008; 131:1759-75. [PMID: 18535080 PMCID: PMC2442427 DOI: 10.1093/brain/awn098] [Citation(s) in RCA: 305] [Impact Index Per Article: 19.1] [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] [Indexed: 12/11/2022] Open
Abstract
Atypical imaging features of multiple sclerosis lesions include size >2 cm, mass effect, oedema and/or ring enhancement. This constellation is often referred to as ‘tumefactive multiple sclerosis’. Previous series emphasize their unifocal and clinically isolated nature, however, evolution of these lesions is not well defined. Biopsy may be required for diagnosis. We describe clinical and radiographic features in 168 patients with biopsy confirmed CNS inflammatory demyelinating disease (IDD). Lesions were analysed on pre- and post-biopsy magnetic resonance imaging (MRI) for location, size, mass effect/oedema, enhancement, multifocality and fulfilment of Barkhof criteria. Clinical data were correlated to MRI. Female to male ratio was 1.2 : 1, median age at onset, 37 years, duration between symptom onset and biopsy, 7.1 weeks and total disease duration, 3.9 years. Clinical course prior to biopsy was a first neurological event in 61%, relapsing–remitting in 29% and progressive in 4%. Presentations were typically polysymptomatic, with motor, cognitive and sensory symptoms predominating. Aphasia, agnosia, seizures and visual field defects were observed. At follow-up, 70% developed definite multiple sclerosis, and 14% had an isolated demyelinating syndrome. Median time to second attack was 4.8 years, and median EDSS at follow-up was 3.0. Multiple lesions were present in 70% on pre-biopsy MRI, and in 83% by last MRI, with Barkhof criteria fulfilled in 46% prior to biopsy and 55% by follow-up. Only 17% of cases remained unifocal. Median largest lesion size on T2-weighted images was 4 cm (range 0.5–12), with a discernible size of 2.1 cm (range 0.5–7.5). Biopsied lesions demonstrated mass effect in 45% and oedema in 77%. A strong association was found between lesion size, and presence of mass effect and/or oedema (P< 0.001). Ring enhancement was frequent. Most tumefactive features did not correlate with gender, course or diagnosis. Although lesion size >5 cm was associated with a slightly higher EDSS at last follow-up, long-term prognosis in patients with disease duration >10 years was better (EDSS 1.5) compared with a population-based multiple sclerosis cohort matched for disease duration (EDSS 3.5; P< 0.001). Given the retrospective nature of the study, the precise reason for biopsy could not always be determined. This study underscores the diagnostically challenging nature of CNS IDDs that present with atypical clinical or radiographic features. Most have multifocal disease at onset, and develop RRMS by follow-up. Although increased awareness of this broad spectrum may obviate need for biopsy in many circumstances, an important role for diagnostic brain biopsy may be required in some cases.
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Affiliation(s)
- C F Lucchinetti
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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McKeon A, Lennon VA, Lotze T, Tenenbaum S, Ness JM, Rensel M, Kuntz NL, Fryer JP, Homburger H, Hunter J, Weinshenker BG, Krecke K, Lucchinetti CF, Pittock SJ. CNS aquaporin-4 autoimmunity in children. Neurology 2008; 71:93-100. [PMID: 18509092 DOI: 10.1212/01.wnl.0000314832.24682.c6] [Citation(s) in RCA: 212] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In adult patients, autoantibodies targeting the water channel aquaporin-4 (AQP4) are a biomarker for a spectrum of CNS inflammatory demyelinating disorders with predilection for optic nerves and spinal cord (neuromyelitis optica [NMO]). Here we describe the neurologic, serologic, and radiographic findings associated with CNS AQP4 autoimmunity in childhood. METHODS A total of 88 consecutive seropositive children were identified through service evaluation for NMO-IgG. Sera of 75 were tested for coexisting autoantibodies. Clinical information was available for 58. RESULTS Forty-two patients (73%) were non-Caucasian, and 20 (34%) had African ethnicity. Median age at symptom onset was 12 years (range 4-18). Fifty-seven (98%) had attacks of either optic neuritis (n = 48; 83%) or transverse myelitis (n = 45; 78%), or both. Twenty-six (45%) had episodic cerebral symptoms (encephalopathy, ophthalmoparesis, ataxia, seizures, intractable vomiting, or hiccups). Thirty-eight (68%) had brain MRI abnormalities, predominantly involving periventricular areas (in descending order of frequency): the medulla, supratentorial and infratentorial white matter, midbrain, cerebellum, thalamus, and hypothalamus. Additional autoantibodies were detected in 57 of 75 patients (76%), and 16 of 38 (42%) had a coexisting autoimmune disorder recorded (systemic lupus erythematosus, Sjögren syndrome, juvenile rheumatoid arthritis, Graves disease). Attacks were recurrent in 54 patients (93%; median follow-up, 12 months). Forty-three of 48 patients (90%) had residual disability: 26 (54%) visual impairment and 21 (44%) motor deficits (median Expanded Disability Status Scale 4.0 at 12 months). CONCLUSIONS Aquaporin-4 autoimmunity is a distinctive recurrent and widespread inflammatory CNS disease in children.
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Affiliation(s)
- A McKeon
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Matiello M, Lennon VA, Jacob A, Pittock SJ, Lucchinetti CF, Wingerchuk DM, Weinshenker BG. NMO-IgG predicts the outcome of recurrent optic neuritis. Neurology 2008; 70:2197-200. [PMID: 18434643 DOI: 10.1212/01.wnl.0000303817.82134.da] [Citation(s) in RCA: 252] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the prognostic value of neuromyelitis optica (NMO)-immunoglobulin G (IgG) in patients with recurrent optic neuritis (ON). The aquaporin-4-specific serum autoantibody, NMO-IgG, is a biomarker for NMO and relapsing transverse myelitis. Recurrent ON may herald multiple sclerosis (MS) or NMO, or it may occur as an isolated syndrome. The prognosis and response to therapy differs in each of these contexts. METHODS We evaluated 34 patients who were tested for NMO-IgG between 2000 and 2007 and who had two or more episodes of ON without satisfying a diagnosis of MS or NMO prior to serologic testing. Clinical data were available for 25 Mayo Clinic patients (5 NMO-IgG positive and 20 NMO-IgG negative) and for an additional 9 seropositive patients whose serum was referred to the Mayo Clinic Neuroimmunology laboratory for testing. RESULTS Twenty percent of the patients with recurrent ON seen at Mayo Clinic were seropositive. All NMO-IgG-positive patients (vs 65% NMO-IgG-negative patients) had at least one attack with visual acuity in the affected eye worse than 20/200 (p = 0.05). In seropositive patients for whom long-term follow-up was possible (median 8.9 years after the initial ON), 6 of 12 (50%) experienced an episode of myelitis and fulfilled criteria for NMO. In contrast, 1 of 15 seronegative patients (6.7%) fulfilled McDonald criteria for MS (p = 0.03). Seropositive patients had a final visual score which was worse than that of seronegative patients (p = 0.02). CONCLUSIONS Neuromyelitis optica (NMO)-immunoglobulin G seropositivity predicts poor visual outcome and development of NMO. Seropositive recurrent optic neuritis is a limited form of NMO.
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Affiliation(s)
- M Matiello
- Department of Neurology, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA
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Banwell B, Tenembaum S, Lennon VA, Ursell E, Kennedy J, Bar-Or A, Weinshenker BG, Lucchinetti CF, Pittock SJ. Neuromyelitis optica-IgG in childhood inflammatory demyelinating CNS disorders. Neurology 2007; 70:344-52. [PMID: 18094334 DOI: 10.1212/01.wnl.0000284600.80782.d5] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine seroprevalence of neuromyelitis optica (NMO)-IgG in childhood CNS inflammatory demyelinating disorders. METHODS We analyzed demographic, clinical, and radiologic data in a blinded fashion and assessed serum NMO-IgG status for 87 children: 41 with relapsing-remitting multiple sclerosis (RRMS), 17 with NMO, 13 with monophasic/recurrent optic neuritis (ON), 13 with transverse myelitis, of whom 10 were longitudinally extensive on MRI spine (LETM), and another 3 with LETM in the context of acute disseminated encephalomyelitis (ADEM). RESULTS Ten of the 87 children (11%) were seropositive. Eight of 17 with NMO (47%) were seropositive (7 of 9 with relapsing NMO [78%], 1 of 8 with monophasic NMO [12.5%]). Two other children were seropositive: 1 of 5 with recurrent ON and one child with recurrent LETM. No seropositive case was identified among 41 with RRMS (14% of whom had LETM at some point in their clinical course), 8 with monophasic ON, 9 with monophasic LETM, or 3 with LETM in the context of ADEM. CONCLUSIONS The similar frequency of neuromyelitis optica (NMO)-IgG in both childhood and adult cases of NMO, and its rarity in relapsing-remitting multiple sclerosis, supports the concept that these diseases have a similar pathogenesis in childhood and adulthood. It is noteworthy that none of nine children with monophasic longitudinally extensive transverse myelitis (LETM) was NMO-IgG-seropositive. Furthermore, LETM does not appear to be as predictive of an NMO spectrum disorder in children as it is in adults. Longitudinal studies of larger pediatric LETM cohorts are required to ascertain whether the absence of NMO-IgG is a negative predictor for relapse in this childhood entity.
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Affiliation(s)
- B Banwell
- Division of Pediatric Neurology and the Research Institute, The Hospital for Sick Children, University of Toronto, Canada
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Hinson SR, Pittock SJ, Lucchinetti CF, Roemer SF, Fryer JP, Kryzer TJ, Lennon VA. Pathogenic potential of IgG binding to water channel extracellular domain in neuromyelitis optica. Neurology 2007; 69:2221-31. [PMID: 17928579 DOI: 10.1212/01.wnl.0000289761.64862.ce] [Citation(s) in RCA: 356] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Autoantibody specific for the aquaporin-4 astrocytic water channel is restricted to serum and CSF of patients with neuromyelitis optica (NMO) and related CNS inflammatory demyelinating disorders (relapsing optic neuritis and longitudinally extensive transverse myelitis). NMO-typical lesions are distinct from MS-typical lesions. Aquaporin-4 is lost selectively at vasculocentric sites of edema/inflammation coinciding with focal deposits of immunoglobulins (Ig) G, M, and terminal complement products, with and without myelin loss. Evidence for antigen-specific autoantibody pathogenicity is lacking. METHODS We used confocal microscopy and flow cytometry to evaluate the selectivity and immunopathological consequences of Ig binding to surface epitopes of living target cells expressing aquaporin-4 fused at its cytoplasmic N-terminus with GFP. We tested serum, IgG-enriched and IgG-depleted serum fractions, and CSF from patients with NMO, neurologic control patients, and healthy subjects. We also analyzed aquaporin-4 immunoreactivity in myelinated adult mouse optic nerves and spinal cord, and plasma cell Ig isotypes in archived brain tissue from an NMO patient. RESULTS Serum IgG from patients with NMO binds to the extracellular domain of aquaporin-4; it is predominantly IgG(1), and it initiates two potentially competing outcomes, aquaporin-4 endocytosis/degradation and complement activation. Serum and CSF lack aquaporin-4-specific IgM, and plasma cells in CNS lesions of NMO contain only IgG. Paranodal astrocytic endfeet highly express aquaporin-4. CONCLUSIONS NMO patients' serum IgG has a selective pathologic effect on cell membranes expressing aquaporin-4. IgG targeting astrocytic processes around nodes of Ranvier could initiate demyelination.
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Affiliation(s)
- S R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Pittock SJ, Reindl M, Achenbach S, Berger T, Bruck W, Konig F, Morales Y, Lassmann H, Bryant S, Moore SB, Keegan BM, Lucchinetti CF. Myelin oligodendrocyte glycoprotein antibodies in pathologically proven multiple sclerosis: frequency, stability and clinicopathologic correlations. Mult Scler 2007; 13:7-16. [PMID: 17294606 DOI: 10.1177/1352458506072189] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [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] [Indexed: 11/17/2022]
Abstract
Controversy exists regarding the pathogenic or predictive role of anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in patients with multiple sclerosis (MS). Four immunopathological patterns (IP) have been recognized in early active MS lesions, suggesting heterogeneous pathogenic mechanisms. Whether MOG antibodies contribute to this pathological heterogeneity and potentially serve as biomarkers to identify specific pathological patterns is unknown. Here we report the frequencies of antibodies to human recombinant MOG (identified by Western blot and enzyme-linked immunoabsorbent assay (ELISA)) in patients with pathologically proven demyelinating disease, and investigate whether antibody status is associated with clinical course, HLA-DR2-genotype, IP or treatment response to plasmapheresis. The biopsy cohort consisted of 72 patients: 12 pattern I, 43 pattern II and 17 pattern III. No association was found between MOG antibody status and conversion to clinically definite MS, DR-2 status, IP or response to plasmapheresis. There was poor agreement between Western blot and ELISA (kappa = 0.07 for MOG IgM). Fluctuations in antibody seropositivity were seen for 3/4 patients tested serially by Western blot. This study does not support a pathologic pattern-specific role for MOG-antibodies. Variable MOG-antibody status on serial measurements, coupled with the lack of Western blot and ELISA correlations, raises concern regarding the use of MOG-antibody as an MS biomarker and underscores the need for methodological consensus.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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Abstract
We compared the clinical course of 96 patients with neuromyelitis optica (NMO) to multiple sclerosis (MS) natural history data. Based on the distribution of follow-up data (median 6.1 year), we estimated that 21 NMO patients would convert to a secondary progressive course, but we observed only two conversions (p = 0.00002; relative risk = 0.08). The disparate natural histories of MS and NMO suggest dissociation between relapses and clinical progression in CNS demyelinating diseases.
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Affiliation(s)
- D M Wingerchuk
- Department of Neurology, Mayo Clinic College of Medicine, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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Abstract
BACKGROUND The authors previously proposed diagnostic criteria for neuromyelitis optica (NMO) that facilitate its distinction from prototypic multiple sclerosis (MS). However, some patients with otherwise typical NMO have additional symptoms not attributable to optic nerve or spinal cord inflammation or have MS-like brain MRI lesions. Furthermore, some patients are misclassified as NMO by the authors' earlier proposed criteria despite having a subsequent course indistinguishable from prototypic MS. A serum autoantibody marker, NMO-IgG, is highly specific for NMO. The authors propose revised NMO diagnostic criteria that incorporate NMO-IgG status. METHODS Using final clinical diagnosis (NMO or MS) as the reference standard, the authors calculated sensitivity and specificity for each criterion and various combinations using a sample of 96 patients with NMO and 33 with MS. The authors used likelihood ratios and logistic regression analysis to develop the most practical and informative diagnostic model. RESULTS Fourteen patients with NMO (14.6%) had extra-optic-spinal CNS symptoms. NMO-IgG seropositivity was 76% sensitive and 94% specific for NMO. The best diagnostic combination was 99% sensitive and 90% specific for NMO and consisted of at least two of three elements: longitudinally extensive cord lesion, onset brain MRI nondiagnostic for MS, or NMO-IgG seropositivity. CONCLUSIONS The authors propose revised diagnostic criteria for definite neuromyelitis optica (NMO) that require optic neuritis, myelitis, and at least two of three supportive criteria: MRI evidence of a contiguous spinal cord lesion 3 or more segments in length, onset brain MRI nondiagnostic for multiple sclerosis, or NMO-IgG seropositivity. CNS involvement beyond the optic nerves and spinal cord is compatible with NMO.
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Affiliation(s)
- D M Wingerchuk
- Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, AZ 85259, USA.
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Balding J, Livingstone WJ, Pittock SJ, Mynett-Johnson L, Ahern T, Hodgson A, Smith OP. The IL-6 G-174C polymorphism may be associated with ischaemic stroke in patients without a history of hypertension. Ir J Med Sci 2006; 173:200-3. [PMID: 16323614 DOI: 10.1007/bf02914551] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [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 Recent data suggest that inflammatory reactions are involved in the pathogenesis of cerebral ischaemia. AIM To investigate whether certain inflammatory genetic polymorphisms are associated with the occurrence of ischaemic stroke. METHODS We investigated the prevalence of six polymorphisms in cytokine genes (IL-6, TNF-alpha, TNF-beta, IL-1beta, IL-10, and IL-1Ralpha) in a group of ischaemic stroke patients (n = 105) and in a control population (n = 389). We analysed the prevalence of these polymorphisms in different stroke subtypes and in relation to outcome six months post-stroke. RESULTS There was no significant variation in cytokine gene polymorphism frequencies between control and stroke populations or for different stroke subtypes. Subgroup analysis demonstrated that the prevalence of the IL-6 -174 CC genotype was significantly lower in stroke patients without a history of hypertension compared to controls. CONCLUSION The IL6 -174 CC genotype may be protective against stroke in those patients who have no history of hypertension. Further studies are required to verify these findings.
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Affiliation(s)
- J Balding
- Thrombosis and Haemostasis Laboratory, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Dublin, Ireland
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32
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Pittock SJ, McClelland RL, Achenbach SJ, Konig F, Bitsch A, Brück W, Lassmann H, Parisi JE, Scheithauer BW, Rodriguez M, Weinshenker BG, Lucchinetti CF. Clinical course, pathological correlations, and outcome of biopsy proved inflammatory demyelinating disease. J Neurol Neurosurg Psychiatry 2005; 76:1693-7. [PMID: 16291895 PMCID: PMC1739469 DOI: 10.1136/jnnp.2004.060624] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND A pathological classification has been developed of early active multiple sclerosis (MS) lesions that reveals four patterns of tissue injury: I-T cell/macrophage associated; II-antibody/complement associated; III-distal oligodendrogliopathy, and IV-oligodendrocyte degeneration in the periplaque white matter. Mechanisms of demyelination in early MS may differ among the subgroups. Previous studies on biopsied MS have lacked clinicopathological correlation and follow up. Critics argue that observations are not generalisable to prototypic MS. OBJECTIVE To describe the clinicopathological characteristics of the MS Lesion Project biopsy cohort. METHODS Clinical characteristics and disability of patients with pathologically confirmed inflammatory demyelinating disease (excluding ADEM) classified immunopathologically (n = 91) and patients from the Olmsted County MS prevalence cohort (n = 218) were determined. RESULTS Most patients who underwent biopsy and had pathologically proved demyelinating disease ultimately developed definite (n = 70) or probable (n = 12) MS (median follow up 4.4 years). Most had a relapsing remitting course and 73% were ambulatory (EDSS < or =4) at last follow up. Nine patients remained classified as having an isolated demyelinating syndrome at last follow up. Patients with different immunopathological patterns had similar clinical characteristics. Although presenting symptoms and sex ratios differed, the clinical course in biopsy patients was similar to the prevalence cohort. Median EDSS was <4.0 in both cohorts when matched for disease duration, sex, and age. CONCLUSIONS Most patients undergoing biopsy, who had pathologically confirmed demyelinating disease, were likely to develop MS and remain ambulatory after a median disease duration of 4.4 years. The immunopathological patterns lacked specific clinical correlations and were not related to the timing of the biopsy. These data suggest that pathogenic implications derived largely from MS biopsy studies may be extrapolated to the general MS population.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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Kantarci OH, Hebrink DD, Achenbach SJ, Pittock SJ, Altintas A, Schaefer-Klein JL, Atkinson EJ, De Andrade M, McMurray CT, Rodriguez M, Weinshenker BG. Association of APOE polymorphisms with disease severity in MS is limited to women. Neurology 2004; 62:811-4. [PMID: 15007140 DOI: 10.1212/01.wnl.0000113721.83287.83] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [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: 11/15/2022] Open
Abstract
The authors studied the association of an exon 4 (E4*epsilon2/3/4) and three promoter polymorphisms of APOE with disease course and severity stratified by gender in 221 patients with multiple sclerosis from two overlapping population-based prevalence cohorts. Women carriers of the E4*epsilon2 allele took longer to attain an Expanded Disability Status Scale score of 6 (p = 0.015) and had more favorable ranked severity scores than noncarriers (p = 0.009). There was no association in men. Alleles epsilon3 or epsilon4 and promoter polymorphisms were not associated with disease course or severity.
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Affiliation(s)
- O H Kantarci
- Departments of Neurology, Health Sciences Research, Neuroscience Program, Mayo Clinic and Foundation, Rochester, MN, USA
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Abstract
Decisions on ventilatory support (VS) in multiple sclerosis (MS) are complex. All patients with MS requiring mechanical ventilation or tracheostomy since 1969 (22) at Mayo Clinic were reviewed. Seventeen had progressive (PMS; 11 secondary and six primary progressive) and one had relapsing remitting MS (RRMS). Four had neuromyelitis optica (NMO). Of those with PMS, all but two required a wheelchair or were bedbound before VS and survived a median of 22 months; 14 were mechanically ventilated and seven underwent subsequent lifelong tracheostomy; three had tracheostomy only. The indications (usually multiple) for VS in PMS patients were aspiration pneumonia, poor ventilation because of mucous plugging, mechanical failure, and airway control/protection for seizures and coma. The RRMS patient required mechanical ventilation for 10 days, with subsequent short-term tracheostomy during a brainstem exacerbation. Of the four patients with NMO one made a dramatic recovery after plasmapheresis. Compared with PMS, the NMO group had a shorter time from disease onset to VS, a longer duration of ventilation, and the three patients not treated with plasma exchange or steroids did worse. The prognosis for independent ventilation (+/- tracheostomy) was worst for patients with NMO, except for one patient who received plasma exchange, and better then expected for PMS, despite poor preventilation functional status.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Mayo Clinic, W8B, 200 First Street SW, Rochester, MN 55905, USA
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35
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Pittock SJ, Mayr WT, McClelland RL, Jorgensen NW, Weigand SD, Noseworthy JH, Weinshenker BG, Rodriguez M. Change in MS-related disability in a population-based cohort: a 10-year follow-up study. Neurology 2004; 62:51-9. [PMID: 14718697 DOI: 10.1212/01.wnl.0000101724.93433.00] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [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] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE S: To study the change in disability over 10 years in individual patients constituting the 1991 Olmsted County, MN, multiple sclerosis (MS) prevalence cohort. METHODS The authors reassessed this 1991 cohort in 2001. The authors determined the Expanded Disability Status Scale scores (EDSS) for each patient still alive, and within the year prior to death for those who died. The authors analyzed determinants of potential prognostic significance on change in disability. RESULTS Follow-up information was available for 161 of 162 patients in the 1991 cohort. Only 15% had received immunomodulatory therapy. The mean change in EDSS for the entire cohort over 10 years was 1 point and 20% worsened by >or=2 points. For patients with EDSS <3 in 1991 (n = 66), 83% were ambulatory without a cane 10 years later. For patients with EDSS of 3 through 5 in 1991 (n = 33), 51% required a cane to ambulate (48%) or worse (3%). For patients with EDSS 6 to 7 in 1991 (n = 39), 51% required a wheelchair or worse in 2001. Gait impairment at onset, progressive disease, or longer duration of disease were associated with more worsening of disability (p < 0.002). The 10-year survival was decreased compared with the Minnesota white population for both men and women. CONCLUSIONS Although survival was reduced and 30% of patients progressed to needing a cane or wheelchair or worse over the 10-year follow-up period, most remained stable or minimally progressed. Patients within the EDSS 3.0 through 5.0 range are at moderate risk of developing important gait limitations over the 10-year period. The authors did not identify factors strongly predictive of worsening disability in this study.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Pittock SJ, Mayr WT, McClelland RL, Jorgensen NW, Weigand SD, Noseworthy JH, Rodriguez M. Disability profile of MS did not change over 10 years in a population-based prevalence cohort. Neurology 2004; 62:601-6. [PMID: 14981177 DOI: 10.1212/wnl.62.4.601] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [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] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess whether the level of multiple sclerosis (MS) -related disability in the Olmsted County population has changed over a decade, and to evaluate how the rate of initial progression to moderate disability impacts further disability. METHODS The Minimal Record of Disability (MRD) measured impairment, disability, and handicap for the 2000 (n = 201) prevalence cohort. The authors compared these results with the 1991 (n = 162) cohort; 115 patients were in both cohorts. The authors assessed retrospectively intervals at which Expanded Disability Status Scale (EDSS) scores of 3 (moderate disability), 6 (cane), and 8 (wheelchair) were reached. RESULTS The distribution of the 2000 EDSS and MRD scores were not significantly different from the 1991 distribution. The median time from MS diagnosis, for the entire cohort, to EDSS scores of 3 and 6 was 17 and 24 years, respectively. At 20 years after onset, only 25% of those with relapsing-remitting MS had EDSS scores > or =3. The median time from diagnosis to EDSS score of 6 for the secondary and primary progressive groups was 10 and 3 years, respectively. Rate of progression from onset or diagnosis to EDSS score of 3 did not affect the rate of further disease progression. However, once an EDSS score of 3 was reached, progression of disability was more likely, and rate of progression increased. CONCLUSIONS The distribution of multiple sclerosis disability in the Olmsted community has remained stable for 10 years. Progression of disability for patients with relapsing-remitting multiple sclerosis or secondary progressive multiple sclerosis may be more favorable than reported previously. Once a clinical threshold of disability is reached, rate of progression increased.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.
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Mayr WT, Pittock SJ, McClelland RL, Jorgensen NW, Noseworthy JH, Rodriguez M. Incidence and prevalence of multiple sclerosis in Olmsted County, Minnesota, 1985-2000. Neurology 2003; 61:1373-7. [PMID: 14638958 DOI: 10.1212/01.wnl.0000094316.90240.eb] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.2] [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: 11/15/2022] Open
Abstract
BACKGROUND Epidemiologic data for multiple sclerosis (MS) in Olmsted County, MN, have been recorded for almost 100 years and have indicated that the increasing prevalence rate was likely due in part to an increasing incidence rate. METHODS All cases of MS diagnosed from 1985 to 2000 were identified using the centralized diagnostic index at the Mayo Clinic and the Rochester Epidemiology Program Project, a shared database of all medical practitioners in the county. Patients were required to have established residency at least 1 year prior to diagnosis of MS. Results were also age- and sex-adjusted to control for shifts in the population structure. RESULTS The raw prevalence of MS was determined to be 177 per 100,000 on December 1, 2000, and the raw incidence rate was 7.5 per 100,000 person-years at risk from 1985 to 2000. CONCLUSIONS After age and sex adjustment to a common population, these prevalence and incidence rates of MS appear to have been stable rather than increasing over the past 20 years.
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Affiliation(s)
- W T Mayr
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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38
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Pittock SJ, Moore AP, Hardiman O, Ehler E, Kovac M, Bojakowski J, Al Khawaja I, Brozman M, Kanovský P, Skorometz A, Slawek J, Reichel G, Stenner A, Timerbaeva S, Stelmasiak Z, Zifko UA, Bhakta B, Coxon E. A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A (Dysport) in the treatment of spastic equinovarus deformity after stroke. Cerebrovasc Dis 2003; 15:289-300. [PMID: 12686794 DOI: 10.1159/000069495] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.0] [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: 03/11/2002] [Accepted: 08/13/2002] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND/OBJECTIVES Calf muscle hypertonicity following stroke may impair walking rehabilitation. The aim of this study was to assess botulinum toxin (Dysport) in post-stroke calf spasticity. METHODS A prospective, multicentre, double-blind, placebo-controlled, dose-ranging study was performed to evaluate dysport at 500, 1,000 or 1,500 units in 234 stroke patients. They were assessed at 4-week intervals over 12 weeks. RESULTS The primary outcome measure, 2-min walking distance and stepping rate increased significantly in each group (p < 0.05, paired test), but there was no significant difference between groups (including placebo). Following dysport treatment, there were small but significant (p = 0.0002-0.0188) improvements in calf spasticity, limb pain, and a reduction in the use of walking aids, compared to placebo. Investigators' and patients' assessments of overall benefit suggested an advantage for dysport over placebo, but this was not significant. Sixty-eight patients reported 130 adverse events, with similar numbers in each group. The few severe events recorded were not considered to be treatment-related. CONCLUSION Dysport resulted in a significant reduction in muscle tone, limb pain and dependence on walking aids. The greatest benefits were in patients receiving dysport 1,500 units, but 1,000 units also had significant effects. Dysport 500 units resulted in some improvements. Since few adverse events were reported, this therapy is considered safe and may be a useful treatment in post-stroke rehabilitation of the leg. Possible reasons why functional improvements in gait parameters were not observed are also discussed.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Beaumont Hospital, Dublin, Ireland.
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Abstract
Two patients with large bilateral subdural haematomas with patterns of non-enhanced brain computed tomography (CT) falsely suggesting coexistent subarachnoid haemorrhage are presented. The CT images showed marked effacement of the basal cisterns with hyperdense signal along the tentorium, sylvian fissure, and the perimesencephalic cisterns. In both cases, the suspicion of subarachnoid haemorrhage led to the performance of angiographic studies to rule out vascular lesions. Thus, recognition of this radiological feature is important to avoid unnecessary testing and treatment delay.
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Affiliation(s)
- A A Rabinstein
- Department of Neurology, Saint Mary's Hospital, Mayo Medical Center, 200 First Street SW, Rochester, MN 55905, USA
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Pittock SJ, Meldrum D, Hardiman O, Deane C, Dunne P, Hussey A, Gorman M, Moroney JT. Patient and hospital delays in acute ischaemic stroke in a Dublin teaching hospital. Ir Med J 2003; 96:167-8, 170-1. [PMID: 12926756] [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] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
A limiting factor for thrombolysis in ischaemic stroke is delayed presentation to hospital. Prolonged A&E stay and delayed rehabilitation affects care. We evaluated the delay in presentation, A&E stay and rehabilitation delivery in 117 consecutive stroke patients. The mean presentation delay was 16.0 +/- 23.7 hours. A prior history of TIA or stroke, a reduced Glascow Coma Scale and larger strokes were associated with shorter delays to presentation. Longer delays occurred in patients living alone. The mean time spent in A&E was 11 hours, those with larger strokes spent shorter time. There were significant delays in referral to, and assessment by certain rehabilitation disciplines. Delayed presentation in stroke is a barrier to thrombolysis. Increasing public awareness may reduce this delay. In addition, prolonged A&E stay and delayed rehabilitation may adversely affect management, outcome and duration of hospital stay. Further study is required to investigate the reasons and possible solutions for such deficiencies.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Beaumont Hospital, Dublin 9, Ireland.
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Pittock SJ, Rodriguez M, Wijdicks EF. Rapid weaning from mechanical ventilator in acute cervical cord multiple sclerosis lesion after steroids. Anesth Analg 2001; 93:1550-1, table of contents. [PMID: 11726441 DOI: 10.1097/00000539-200112000-00045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [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
IMPLICATIONS We report a patient with multiple sclerosis (MS), who developed neuromuscular respiratory failure requiring ventilation because of a cervical cord relapse. Serial pulmonary function tests documented improvement after steroid treatment. Cervical cord or brainstem relapses should be suspected in MS patients with respiratory failure. Identification and management of this critical condition are discussed.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Pittock SJ, Keir G, Alexander M, Brennan P, Hardiman O. Rapid clinical and CSF response to intravenous gamma globulin in acute disseminated encephalomyelitis. Eur J Neurol 2001; 8:725. [PMID: 11784362 DOI: 10.1046/j.1468-1331.2001.00195.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- R D Henderson
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.
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Pittock SJ, Hardiman O, Goode B, Moroney JT. Evaluation of stroke management in an Irish university teaching hospital: the Royal College of Physicians stroke audit package. Ir J Med Sci 2001; 170:163-8. [PMID: 12120966 DOI: 10.1007/bf03173881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [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] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are few data regarding the standard of stroke care in Ireland. AIM To investigate the level of documentation for 13 key areas of stroke management. METHODS Using a validated stroke audit package, this study reviewed the medical records of 100 consecutive patients hospitalised with acute stroke. RESULTS Documentation of stroke symptoms, risk factors, general examination and investigations (cranial computer tomography [CT] and carotid Dopplers) were satisfactory. Neurological documentation was variable, with power (87%), sensation (70%) and eye movements (63%) being the most frequently recorded features, while cognition (3%), visual fields (13%), gait (7%), incontinence (1%) and swallowing (0%) were infrequently recorded. Diagnostic formulation and an acute management plan were documented in less than half of patients, whereas cranial CT (93%) and carotid Dopplers (93%) were well documented. Secondary preventive measures were documented in two-thirds of patients at follow-up. CONCLUSIONS These results serve as a baseline from which to initiate and monitor improvements in the service at our hospital, including the involvement of neurologists in stroke care, and will also allow assessment of the impact of such changes.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Beaumont Hospital, Dublin, Ireland.
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45
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Abstract
A 40-year-old man presented with a major nondominant hemisphere stroke syndrome after a road traffic accident. Cranial computed tomography scan revealed an extensive right hemisphere infarction involving the entire anterior and middle cerebral artery territories. Duplex Doppler ultrasound and cerebral angiography revealed bilateral internal carotid artery dissection with evidence of underlying fibromuscular dysplasia. Anticoagulation with heparin was commenced despite the coexisting large cerebral infarction, with the objective of protecting the uninjured but at-risk left cerebral hemisphere from ischemic injury. Patients with multiple cerebral arterial dissections complicated by cerebral infarction present a significant management dilemma. Our literature review revealed a lack of clear management guidelines for such cases.
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Affiliation(s)
- S J Pittock
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
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46
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Pittock SJ, Joyce C, O'Keane V, Hugle B, Hardiman MO, Brett F, Green AJ, Barton DE, King MD, Webb DW. Rapid-onset dystonia-parkinsonism: a clinical and genetic analysis of a new kindred. Neurology 2000; 55:991-5. [PMID: 11061257 DOI: 10.1212/wnl.55.7.991] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.0] [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: 11/15/2022] Open
Abstract
BACKGROUND Rapid-onset dystonia-parkinsonism (RDP) is an autosomal dominant disorder linked to chromosome 19q13 that is characterized by sudden onset of primarily bulbar and upper limb dystonia with parkinsonism. METHODS The authors evaluated 12 individuals from three generations of an Irish family and obtained detailed medical records on a deceased member. The authors describe the clinical, psychiatric, and genetic features of the affected individuals. RESULTS Five of eight affected members developed sudden-onset (several hours to days) dystonia with postural instability. Four of the five also had bulbar symptoms. Two have stable focal or segmental limb dystonia. One has intermittent hemidystonia with dysarthria that comes on abruptly in times of stress or anxiety. Three had a history of profound difficulty socializing, and at presentation two developed depression. Three patients had a trial of dopamine agonists without benefit. Genetic analysis suggests linkage to chromosome 19 with lod score of 2.1 at zero recombination. CONCLUSION This is the third reported family with chromosome 19q13 rapid-onset dystonia-parkinsonism. Psychiatric morbidity appeared common in affected members of this family and may be part of the RDP phenotype.
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Affiliation(s)
- S J Pittock
- Division of Neurosciences, Beaumont Hospital, Crumlin, Dublin, Ireland
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Ní Dhúill CM, Fox GB, Pittock SJ, O'Connell AW, Murphy KJ, Regan CM. Polysialylated neural cell adhesion molecule expression in the dentate gyrus of the human hippocampal formation from infancy to old age. J Neurosci Res 1999; 55:99-106. [PMID: 9890438 DOI: 10.1002/(sici)1097-4547(19990101)55:1<99::aid-jnr11>3.0.co;2-s] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [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: 11/08/2022]
Abstract
Modulation of neural cell adhesion molecule polysialylation (NCAM PSA) state has been proposed to underlie morphofunctional change associated with consolidation of memory in the rodent, and its age-dependent decline to be related to impaired cognitive function. To establish whether this may be a human correlate of cognitive decline, we determined the age-dependent expression of PSA in the human hippocampal dentate gyrus using postmortem tissue derived from individuals who exhibited no obvious neuropathology. As in the rodent, PSA immunoreactivity in the 5-month human infant was associated mainly with a population of granule-like cells and their mossy fibre axons. Cell numbers were maximal during the first 3 years of life but declined by an order of magnitude between the second and third decades and remained relatively constant thereafter and was restricted to the granule cell layer/hilar border. In contrast to the rodent, diffuse immunostaining was observed in the inner molecular layer; however, as development advanced, this became relocated to the outer molecular layer from 2 years of age onwards. In addition, numerous polysialylated hilar neurons became evident at 2-3 years of age and remained constant until the eighth decade of life. These findings suggest NCAM polysialylation to play a crucial developmental role within a period concluding with adolescence, and that an attenuated NCAM PSA-mediated neuroplasticity continues throughout the human lifespan. The importance of the developmental phase of NCAM PSA expression in the emergence of schizophrenia is discussed.
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Affiliation(s)
- C M Ní Dhúill
- Department of Pharmacology, University College, Belfield, Dublin, Ireland
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