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Hannan F, Hamilton J, Patriquin CJ, Pavenski K, Jurkiewicz MT, Tristao L, Owen AM, Kosalka PK, Deoni SCL, Théberge J, Mandzia J, Huang SHS, Thiessen JD. Cognitive decline in thrombotic thrombocytopenic purpura survivors: The role of white matter health as assessed by MRI. Br J Haematol 2024; 204:1005-1016. [PMID: 38083818 DOI: 10.1111/bjh.19246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/18/2023] [Accepted: 11/24/2023] [Indexed: 03/14/2024]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare condition caused by severe ADAMTS13 deficiency, leading to platelet aggregation and thrombosis. Despite treatment, patients are prone to cognitive impairment and depression. We investigated brain changes in iTTP patients during remission using advanced magnetic resonance imaging (MRI) techniques, correlating these changes with mood and neurocognitive tests. Twenty iTTP patients in remission (30 days post-haematological remission) were compared with six healthy controls. MRI scans, including standard and specialized sequences, were conducted to assess white matter health. Increased T1 relaxation times were found in the cingulate cortex (p < 0.05), and elevated T2 relaxation times were observed in the cingulate cortex, frontal, parietal and temporal lobes (p < 0.05). Pathological changes in these areas are correlated with impaired cognitive and depressive scores in concentration, short-term memory and verbal memory. This study highlights persistent white matter damage in iTTP patients, potentially contributing to depression and cognitive impairment. Key regions affected include the frontal lobe and cingulate cortex. These findings have significant implications for the acute and long-term management of iTTP, suggesting a need for re-evaluation of treatment approaches during both active phases and remission. Further research is warranted to enhance our understanding of these complexities.
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Affiliation(s)
- F Hannan
- Department of Medical Biophysics, Western University, London, Canada
| | - J Hamilton
- Department of Medical Biophysics, Western University, London, Canada
| | - C J Patriquin
- Department of Hematology, University Health Network, Toronto, Canada
| | - K Pavenski
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Canada
| | - M T Jurkiewicz
- Department of Medical Imaging, Western University, London, Canada
| | - L Tristao
- Department of Medical Imaging, Western University, London, Canada
| | - A M Owen
- Department of Clinical Neurological Sciences, Western University, London, Canada
- Department of Physiology and Pharmacology and Department of Psychology, Western University, London, Canada
| | - P K Kosalka
- Department of Medicine, Division of Nephrology, Western University, London, Canada
| | - S C L Deoni
- Advanced Baby Imaging Lab, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Diagnostic Radiology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
- Lawson Health Research Institute, London, Canada
| | - J Théberge
- Department of Medical Biophysics, Western University, London, Canada
- Department of Medical Imaging, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - J Mandzia
- Department of Clinical Neurological Sciences, Western University, London, Canada
| | - S H S Huang
- Department of Medical Biophysics, Western University, London, Canada
- Department of Medicine, Division of Nephrology, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - J D Thiessen
- Department of Medical Biophysics, Western University, London, Canada
- Department of Medical Imaging, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
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Shaw RJ, Dutt T. Mind and matter: The neurological complications of thrombotic thrombocytopenic purpura. Br J Haematol 2022; 197:529-538. [DOI: 10.1111/bjh.18127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/22/2022] [Indexed: 11/02/2022]
Affiliation(s)
- Rebecca J. Shaw
- Department of Clinical Infection, Microbiology and Immunology University of Liverpool Liverpool UK
- The Roald Dahl Haemostasis and Thrombosis Centre Liverpool University Hospitals NHS Foundation Trust Liverpool UK
| | - Tina Dutt
- The Roald Dahl Haemostasis and Thrombosis Centre Liverpool University Hospitals NHS Foundation Trust Liverpool UK
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Ground-glass opacity (GGO): a review of the differential diagnosis in the era of COVID-19. Jpn J Radiol 2021; 39:721-732. [PMID: 33900542 PMCID: PMC8071755 DOI: 10.1007/s11604-021-01120-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023]
Abstract
Thoracic imaging is fundamental in the diagnostic route of Coronavirus disease 2019 (COVID-19) especially in patients admitted to hospitals. In particular, chest computed tomography (CT) has a key role in identifying the typical features of the infection. Ground-glass opacities (GGO) are one of the main CT findings, but their presence is not specific for this viral pneumonia. In fact, GGO is a radiological sign of different pathologies with both acute and subacute/chronic clinical manifestations. In the evaluation of a subject with focal or diffuse GGO, the radiologist has to know the patient’s medical history to obtain a valid diagnostic hypothesis. The authors describe the various CT appearance of GGO, related to the onset of symptoms, focusing also on the ancillary signs that can help radiologist to obtain a correct and prompt diagnosis.
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Alwan F, Mahdi D, Tayabali S, Cipolotti L, Lakey G, Hyare H, Scully M. Cerebral MRI findings predict the risk of cognitive impairment in thrombotic thrombocytopenic purpura. Br J Haematol 2020; 191:868-874. [DOI: 10.1111/bjh.17126] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ferras Alwan
- Department of Haematology University College London Hospital London UK
| | - Dina Mahdi
- Department of Haematology University College London Hospital London UK
| | - Sarrah Tayabali
- Department of Haematology University College London Hospital London UK
| | - Lisa Cipolotti
- Department of Neuropsychology National Hospital for Neurology and Neurosurgery UCLH NHS Trust London UK
| | - Grace Lakey
- Department of Neuropsychology National Hospital for Neurology and Neurosurgery UCLH NHS Trust London UK
| | - Harpreet Hyare
- Department of Radiology University College London Hospital London UK
| | - Marie Scully
- Department of Haematology University College London Hospital London UK
- Cardiometabolic Programme‐NIHR UCLH/UCL BRC London UK
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Yerdelen D, Göksel BK, Yıldırım T, Karataş M, Karaca S, Reyhan M, Ozdoğu H. Thrombotic Thrombocytopenic Purpura with Reversible Neurological Features: Brain Diffusion MRI with ADC Map, Spect and EEG Findings. A Case Report. Neuroradiol J 2006; 19:609-15. [PMID: 24351263 DOI: 10.1177/197140090601900509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Accepted: 06/12/2006] [Indexed: 11/17/2022] Open
Abstract
Although nervous system involvement is common in thrombotic thrombocytopenic purpura (TTP), abnormalities on computerized tomography, magnetic resonance imaging and electroencephalography are not encountered so frequently and if present, these abnormalities are often reversible. We describe a 39-year-old woman with recurring transient focal neurological findings found to have laboratory findings consistent with TTP. In cerebral diffusion weighted images (DWI), diffuse cortical hyperintensity was noted in right frontal lobe, but the ADC (apparent diffusion coefficient) map was normal. Electroencephalography demonstrated lateralized slowing and repeated DWI showed diffuse cortical hyperintensity in the right hemisphere. SPECT showed luxury perfusion in the right hemisphere areas. The patient's condition resolved with plasmapheresis. Our patient illustrates that diffuse hemispheric involvement can be seen in DWI and EEG, and SPECT may show luxury perfusion after resolution of neurological findings in TTP cases. To our knowledge, this is the first TTP case in which the ADC map was normal.
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Affiliation(s)
- D Yerdelen
- Baskent University Faculty of Medicine, Adana Teaching and Medical Research Center; Adana, Turkey -
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Morrin MJ, Jones FGC, McConville J, Arnold C, Mullan B, Lavery GG, McMullin MF. Thrombotic thrombocytopenic purpura secondary to Streptococcus. Transfus Apher Sci 2006; 34:153-5. [PMID: 16616715 PMCID: PMC7106395 DOI: 10.1016/j.transci.2005.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 06/06/2005] [Indexed: 12/31/2022]
Abstract
We describe a 16 year old female who developed thrombotic thrombocytopenic purpura (TTP) following infection due to Streptococcus. Initially presenting a fever and systemic upset she progressed to develop dialysis dependent acute renal failure, seizures, thrombocytopenia and a haemolytic anaemia—the pentad of features seen in TTP. Prior to the diagnosis she was found to have unexplained and previously undescribed MRI findings of diffuse increased signal intensity in the white matter of the left cerebellar hemisphere posteriorly and also increased signal intensity in the overlying cortex. She was commenced on plasmapheresis, and her anaemia, thrombocytopenia, creatinine and LDH all fully responded. In addition, she had no further seizures following plasmapheresis and has not relapsed to date. We review both the rare association of TTP and streptococcal infection, and the neuroradiological findings described in the literature. This is only the third case report describing TTP following streptococcal infection, and only the second in the era of plasmapheresis.
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Affiliation(s)
- M J Morrin
- Department of Haematology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, United Kingdom.
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Baron Y, Bargemann T, Harten P, Gutschmidt HJ. Thrombocytopenic thrombotic purpura: severe clinic with no CT, minor MRI, but a SPECT correlate. Eur J Radiol 1999; 31:56-62. [PMID: 10477100 DOI: 10.1016/s0720-048x(98)00088-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A 28-year-old woman with primarily therapy refractory TTP was followed neuroradiologically over 6 months. Despite pronounced neurological and neuropsychiatric symptoms including hemiparesis and aphasia she had unremarkable CT scans on two occasions. Three MRI exams showed no correlate for her neurological symptoms except a small petechial cortical hemorrhage in the right parietooccipital gyrus which may account for her TTP-related anxiety disorder. A cerebral HMPAO-SPECT showed long-standing right-sided hypoperfusion compatible with residual vasculature changes. The possible causes for the clinico-neuroradiological discrepancies are discussed in view of the literature.
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Affiliation(s)
- Y Baron
- Radiologische Abteilung, Städtisches Krankenhaus Kiel, Germany.
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Eldor A. Thrombotic thrombocytopenic purpura: diagnosis, pathogenesis and modern therapy. BAILLIERE'S CLINICAL HAEMATOLOGY 1998; 11:475-95. [PMID: 10097821 DOI: 10.1016/s0950-3536(98)80062-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an uncommon multisystem disorder, sometimes associated with predisposing conditions such as pregnancy, cancer, exposure to certain drugs, bone marrow transplantation and HIV-1 infection. An abnormal interaction between the vascular endothelium and platelets which occurs in certain organs leads to thrombosis, endothelial proliferation, minimal inflammation and micro-angiopathic haemolysis. Recent studies suggest that endothelial cell perturbation and apoptosis caused by an as yet unknown plasma factor(s) may lead to the release of abnormal von Willebrand factor which facilitates the deposition of platelet microthrombi. Exchange transfusions of plasma or plasma-cryosupernatant remain the cornerstone of the treatment of TTP along with corticosteroids, platelet inhibitor drugs, vincristine and splenectomy. In most cases remissions can be attained, and cures are now common-although approximately one-half of the patients will relapse. While relapses are usually milder, they still carry a significant mortality and preventive therapies are not always effective.
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Affiliation(s)
- A Eldor
- Institute of Hematology, Tel-Aviv Sourasky Medical Center, Israel
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