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Cuoco JA, Guilliams EL, Rogers CM, Entwistle JJ, Olasunkanmi AL. Multicentric Benign Demyelinating Pseudotumor: The Great Masquerade. Neurohospitalist 2020; 10:326-328. [PMID: 32983359 DOI: 10.1177/1941874420923539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Joshua A Cuoco
- Carilion Clinic, Section of Neurosurgery, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Virginia Tech School of Neuroscience, Blacksburg, VA, USA
| | - Evin L Guilliams
- Carilion Clinic, Section of Neurosurgery, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Virginia Tech School of Neuroscience, Blacksburg, VA, USA
| | - Cara M Rogers
- The University of Texas MD Anderson Cancer Center, Department of Neurosurgery, Houston, TX, USA
| | - John J Entwistle
- Carilion Clinic, Section of Neurosurgery, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Virginia Tech School of Neuroscience, Blacksburg, VA, USA
| | - Adeolu L Olasunkanmi
- Carilion Clinic, Section of Neurosurgery, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Virginia Tech School of Neuroscience, Blacksburg, VA, USA
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Chinese Guidelines for the Diagnosis and Management of Tumefactive Demyelinating Lesions of Central Nervous System. Chin Med J (Engl) 2017; 130:1838-1850. [PMID: 28748858 PMCID: PMC5547837 DOI: 10.4103/0366-6999.211547] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Indexed: 01/15/2023] Open
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3
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Algahtani H, Shirah B, Alassiri A. Tumefactive demyelinating lesions: A comprehensive review. Mult Scler Relat Disord 2017; 14:72-79. [DOI: 10.1016/j.msard.2017.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/17/2017] [Accepted: 04/07/2017] [Indexed: 12/29/2022]
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Ikeda KM, Lee DH, Fraser JA, Mirsattari S, Morrow SA. Plasma Exchange in a Patient with Tumefactive, Corticosteroid-Resistant Multiple Sclerosis. Int J MS Care 2015; 17:231-5. [PMID: 26472944 DOI: 10.7224/1537-2073.2014-078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tumefactive multiple sclerosis (MS) is an aggressive form of MS that can be difficult to treat with standard therapies. In severe MS relapses, plasma exchange (PLEX) has shown some benefit, but reports of its use in patients with tumefactive MS are limited. This article describes the successful use of PLEX in a patient with tumefactive MS. A 46-year-old right-handed woman with a recent diagnosis of MS presented with drowsiness, dysarthria, horizontal nystagmus, and quadriparesis. Her brain magnetic resonance images demonstrated multiple tumefactive demyelinating lesions in the medulla, bilateral periventricular white matter, and corona radiata white matter. She was initially treated with a 10-day course of intravenous methylprednisolone without benefit; therefore, PLEX was initiated. After the second exchange, the patient started to improve and was discharged initially to rehabilitation and then home. She was started on disease-modifying therapy with natalizumab and did not experience further relapses but had slow clinical decline during the next year, which led to discontinuation of natalizumab treatment. PLEX may be used as second-line treatment in corticosteroid-resistant MS relapses, but there are limited reports of its use in patients with tumefactive MS. This patient presented with aggressive disease with multiple tumefactive lesions and did not respond to standard treatment with corticosteroids. PLEX was successful in improving her symptoms, allowing her to return home, although the disease progressed during the next year.
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Affiliation(s)
- Kristin M Ikeda
- Schulich School of Medicine and Dentistry, Western Uni-versity, London, Ontario, Canada (KMI, DHL, JAF, SMM, SAM); and Department of Clinical Neurological Sciences (KMI, JAF, SM, SAM) and Department of Radiology (DHL), London Health Sciences Centre, London, Ontario, Canada
| | - Donald H Lee
- Schulich School of Medicine and Dentistry, Western Uni-versity, London, Ontario, Canada (KMI, DHL, JAF, SMM, SAM); and Department of Clinical Neurological Sciences (KMI, JAF, SM, SAM) and Department of Radiology (DHL), London Health Sciences Centre, London, Ontario, Canada
| | - J Alexander Fraser
- Schulich School of Medicine and Dentistry, Western Uni-versity, London, Ontario, Canada (KMI, DHL, JAF, SMM, SAM); and Department of Clinical Neurological Sciences (KMI, JAF, SM, SAM) and Department of Radiology (DHL), London Health Sciences Centre, London, Ontario, Canada
| | - Seyed Mirsattari
- Schulich School of Medicine and Dentistry, Western Uni-versity, London, Ontario, Canada (KMI, DHL, JAF, SMM, SAM); and Department of Clinical Neurological Sciences (KMI, JAF, SM, SAM) and Department of Radiology (DHL), London Health Sciences Centre, London, Ontario, Canada
| | - Sarah A Morrow
- Schulich School of Medicine and Dentistry, Western Uni-versity, London, Ontario, Canada (KMI, DHL, JAF, SMM, SAM); and Department of Clinical Neurological Sciences (KMI, JAF, SM, SAM) and Department of Radiology (DHL), London Health Sciences Centre, London, Ontario, Canada
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Makary MS, Kirsch CF. Tumefactive demyelinating disease with isolated spinal cord involvement. Acta Radiol Short Rep 2014; 3:2047981614539324. [PMID: 25298871 PMCID: PMC4184419 DOI: 10.1177/2047981614539324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 05/21/2014] [Indexed: 12/02/2022] Open
Abstract
Tumefactive multiple sclerosis (TMS) is an unusual variant of demyelinating disease. TMS has a variable and unknown progression and presents with features similar to a neoplasm making the determination a diagnostic challenge to clinicians. This report presents one of the very few reported cases of isolated spinal cord TMS, and the second case to describe TMS of the lower spinal cord, given that the lesions are typically cervical. This case study presents a diagnostic approach based on clinical, laboratory, and imaging characteristics, as well as sheds some light on the response to therapy and disease evolution.
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Affiliation(s)
- Mina S Makary
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA ; Department of Radiology, Mount Carmel West Medical Center, Columbus, OH, USA
| | - Claudia F Kirsch
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Sempere AP, Feliu-Rey E, Sanchez-Perez R, Nieto-Navarro J. Neurological picture. Rituximab for tumefactive demyelination refractory to corticosteroids and plasma exchange. J Neurol Neurosurg Psychiatry 2013; 84:1338-9. [PMID: 23804236 DOI: 10.1136/jnnp-2013-305456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Angel P Sempere
- Neurology Department, Hospital General Universitario de Alicante, , Alicante, Spain
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Wang Y, Wang M, Liang H, Yu Q, Yan Z, Kong M. Imaging and clinical properties of inflammatory demyelinating pseudotumor in the spinal cord. Neural Regen Res 2013; 8:2484-94. [PMID: 25206559 PMCID: PMC4146109 DOI: 10.3969/j.issn.1673-5374.2013.26.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 08/29/2013] [Indexed: 11/20/2022] Open
Abstract
Inflammatory demyelinating pseudotumor usually occurs in the brain and rarely occurs in the spinal cord. On imaging, inflammatory demyelinating pseudotumor appears very similar to intramedullary tumors such as gliomas. It is often misdiagnosed as intramedullary tumor and surgically resected. In view of this, the clinical and magnetic resonance imaging manifestations and the pathological fea-tures of 36 cases of inflammatory demyelinating pseudotumor in the spinal cord were retrospec-tively analyzed and summarized. Most of these cases suffered from acute or subacute onset and exhibited a sensorimotor disorder. Among them, six cases were misdiagnosed as having intra-dullary gliomas, and inflammatory demyelinating pseudotumor was only identified and pathologi-cally confirmed after surgical resection. Lesions in the cervical and thoracic spinal cord were com-mon. Magnetic resonance imaging revealed edema and space-occupying lesions to varying grees at the cervical-thoracic junction, with a predominant feature of non-closed rosette-like forcement (open-loop sign). Pathological examination showed perivascular cuffing of predominantly dense lymphocytes, and demyelination was observed in six of the misdiagnosed cases. These re-sults suggest that tumor-like inflammatory demyelinating disease in the spinal cord is a kind of special demyelinating disease that can be categorized as inflammatory pseudotumor. These solitary lesions are easily confused with intramedullary neoplasms. Patchy or non-closed reinforcement (open-ring sign) on magnetic resonance imaging is the predominant property of inflammatory myelinating pseudotumor, and inflammatory cell infiltration and demyelination are additional pa-logical properties.
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Affiliation(s)
- Ying Wang
- Department of Neurology, Yantai Shan Hospital, Yantai 264000, Shandong Province, China
| | - Min Wang
- Department of Neurology, Yantai Shan Hospital, Yantai 264000, Shandong Province, China
| | - Hui Liang
- Department of Neurology, Yantai Shan Hospital, Yantai 264000, Shandong Province, China
| | - Quntao Yu
- Department of Neurology, Yantai Shan Hospital, Yantai 264000, Shandong Province, China
| | - Zhihui Yan
- Department of Neurology, Yantai Shan Hospital, Yantai 264000, Shandong Province, China
| | - Min Kong
- Department of Neurology, Yantai Shan Hospital, Yantai 264000, Shandong Province, China
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Abstract
Tumefactive lesions are an uncommon manifestation of demyelinating disease and can pose a diagnostic challenge in patients without a pre-existing diagnosis of multiple sclerosis. Choosing when to biopsy a tumefactive lesion to exclude alternative pathology can be difficult. Other questions include how best to treat an acute attack as well as the optimal timing of therapy to prevent relapse. This article aims to review the available literature for tumefactive demyelination and to propose an approach to diagnosis and management. We argue that disease modifying therapy should be considered for acute tumefactive demyelinating lesions only once criteria of dissemination in time and space are fulfilled and the diagnosis of multiple sclerosis is confirmed.
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Affiliation(s)
- Todd A Hardy
- Department of Neuroinflammation, National Hospital for Neurology and Neurosurgery, London, UK.
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Sato F, Tanaka H, Hasanovic F, Tsunoda I. Theiler's virus infection: Pathophysiology of demyelination and neurodegeneration. ACTA ACUST UNITED AC 2011; 18:31-41. [PMID: 20537875 DOI: 10.1016/j.pathophys.2010.04.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 02/28/2010] [Accepted: 04/08/2010] [Indexed: 02/08/2023]
Abstract
Multiple sclerosis (MS) has been suggested to be an autoimmune demyelinating disease of the central nervous system (CNS), whose primary target is either myelin itself, or myelin-forming cells, the oligodendrocytes. Although axonal damage occurs in MS, it is regarded as a secondary event to the myelin damage. Here, the lesion develops from the myelin (outside) to the axons (inside) "Outside-In model". The Outside-In model has been supported by an autoimmune model for MS, experimental autoimmune (allergic) encephalomyelitis (EAE). However, recently, (1) EAE-like disease has also been shown to be induced by immune responses against axons, and (2) immune responses against axons and neurons as well as neurodegeneration independent of inflammatory demyelination have been reported in MS, which can not be explained by the Outside-In model. Theiler's murine encephalomyelitis virus (TMEV)-induced demyelinating disease (TMEV-IDD) is a viral model for MS. In TMEV infection, axonal injury precedes demyelination, where the lesion develops from the axons (inside) to the myelin (outside) "Inside-Out model". The initial axonal damage could result in the release of neuroantigens, inducing autoimmune responses against myelin antigens, which potentially attack the myelin from outside the nerve fiber. Thus, the Inside-Out and Outside-In models can make a "vicious" immunological cycle or initiate an immune cascade.
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Affiliation(s)
- Fumitaka Sato
- Department of Microbiology and Immunology, Louisiana State University Health Sciences Center, School of Medicine in Shreveport, Shreveport, LA 71130, USA
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Weller RO, Galea I, Carare RO, Minagar A. Pathophysiology of the lymphatic drainage of the central nervous system: Implications for pathogenesis and therapy of multiple sclerosis. ACTA ACUST UNITED AC 2009; 17:295-306. [PMID: 19954936 DOI: 10.1016/j.pathophys.2009.10.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Revised: 06/11/2009] [Accepted: 10/23/2009] [Indexed: 12/17/2022]
Abstract
In most organs of the body, immunological reactions involve the drainage of antigens and antigen presenting cells (APCs) along defined lymphatic channels to regional lymph nodes. The CNS is considered to be an immunologically privileged organ with no conventional lymphatics. However, immunological reactions do occur in the CNS in response to infections and in immune-mediated disorders such as multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE). Here, we review evidence that cervical lymph nodes play a role in B and T cell mediated immune reactions in the CNS. Then we define the separate pathways by which interstitial fluid (ISF) and CSF drain to cervical lymph nodes. ISF and solutes drain from the brain along the 100-150nm-wide basement membranes in the walls of capillaries and arteries. In humans, this perivascular pathway is outlined by the deposition of insoluble amyloid (Abeta) in capillary and artery walls in cerebral amyloid angiopathy in Alzheimer's disease. The failure of APCs to migrate to lymph nodes along perivascular lymphatic drainage pathways may be a major factor in immunological privilege of the brain. Lymphatic drainage of CSF is predominantly through the cribriform plate into nasal lymphatics. Lymphatic drainage of ISF and CSF and the specialised cervical lymph nodes to which they drain play significant roles in the induction of immunological tolerance and of adaptive immunological responses in the CNS. Understanding the afferent and efferent arms of the CNS lymphatic system will be valuable for the development of therapeutic strategies for diseases such as MS.
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Affiliation(s)
- R O Weller
- Clinical Neurosciences, Southampton University School of Medicine, UK
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Xia L, Lin S, Wang ZC, Li SW, Xu L, Wu J, Hao SY, Gao CC. Tumefactive demyelinating lesions: nine cases and a review of the literature. Neurosurg Rev 2009; 32:171-9; discussion 179. [PMID: 19172322 DOI: 10.1007/s10143-009-0185-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 11/08/2008] [Accepted: 12/06/2008] [Indexed: 12/27/2022]
Abstract
Tumefactive demyelinating lesions (TDLs) are misdiagnosed frequently. To investigate the characteristics of TDLs, clinical and radiological data from nine cases with TDLs were analyzed after admission. All cases underwent surgery and pathological examination; some received postoperative steroid therapy. Onsets were mostly within 3 weeks and main presentation included intracranial hypertension, extremity weakness, epilepsy, and visual disturbance. Symptoms in children were acute and severe, frequently including headache, vomiting, and visual disturbance. Most intracephalic lesions were in cerebral hemispheres. All intraspinal lesions were in cervical segments. Radiological features included mass effect, perifocal edema and enhancement (of which open-ring enhancement was diagnostic), and decreased relative cerebral blood volume. Intraoperative frozen section did not confirm the diagnosis, while postoperative paraffin section did confirm it (by evidence of macrophage infiltration). The patients responded well to steroid therapy and no relapse was found during following up. Thus, intensive analysis of both clinical and radiological data may provide some clues for diagnosis. For suspected cases, it is advisable to take steroid therapy or undergo advanced radiological examinations, such as serial magnetic resonance spectroscopy. However, in difficult cases, pathological evidence is beneficial to a final diagnosis.
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Affiliation(s)
- Lei Xia
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100050, China
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