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Azzimonti M, Margoni M, Zanetta C, Genovese F, Martinelli V, Rocca MA, Baldoli C, Moiola L, Filippi M. Tumefactive demyelinating lesions: a challenging first manifestation of multiple sclerosis. J Neurol 2024; 271:1663-1667. [PMID: 38153549 DOI: 10.1007/s00415-023-12164-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Matteo Azzimonti
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Monica Margoni
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Zanetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Genovese
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Cristina Baldoli
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lucia Moiola
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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2
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Pervin I, Ramanathan S, Cappelen-Smith C, Vucic S, Reddel SW, Hardy TA. Clinical and radiological characteristics and outcomes of patients with recurrent or relapsing tumefactive demyelination. Mult Scler Relat Disord 2024; 82:105408. [PMID: 38219394 DOI: 10.1016/j.msard.2023.105408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Relapsing or recurrent tumefactive demyelination is rare and has not been studied beyond individual case reports. OBJECTIVE We examined the clinical course, neuroimaging, cerebrospinal fluid (CSF), treatment and outcomes of patients with recurrent tumefactive demyelinating lesions (TDLs). METHODS We used PubMed to identify reports of recurrent TDLs and included the details of an additional, unpublished patient. RESULTS We identified 18 cases (11F, 7 M). The median age at onset of the index TDL was 37 years (range 12-72) and most were solitary lesions 72 % (13/18). CSF-restricted oligoclonal bands (OCBs) were detected in 25 % (4/16). Only one of those tested (n = 13) was positive for AQP4-IgG. A moderate-to-marked treatment response (high dose corticosteroid with or without additional plasmapheresis, IVIg or disease modifying therapies) was evident in 89 % of treated patients. Median EDSS at the median follow-up of 36 months (range 6-144) was 2 (range 1-10). Most remained ambulatory (EDSS < 4 in 13/18), but 1 patient died. CONCLUSION The median age of patients with relapsing TDLs is similar to that of typical MS, but differences include a lower female:male sex ratio, larger lesions, and a comparative lack of CSF-restricted OCBs. Outcomes vary among this group of patients ranging from minimal disability through to death.
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Affiliation(s)
- Irin Pervin
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia
| | - Sudarshini Ramanathan
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Translational Neuroimmunology Group, Faculty of medicine and health, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia
| | | | - Steve Vucic
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia
| | - Stephen W Reddel
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia
| | - Todd A Hardy
- Multiple sclerosis and Neuroimmunology Clinics, Concord Hospital, University of Sydney, NSW, Australia; Brain & Mind Centre, University of Sydney, NSW, Australia.
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Ongphichetmetha T, Aungsumart S, Siritho S, Apiwattanakul M, Tanboon J, Rattanathamsakul N, Prayoonwiwat N, Jitprapaikulsan J. Tumefactive demyelinating lesions: a retrospective cohort study in Thailand. Sci Rep 2024; 14:1426. [PMID: 38228919 PMCID: PMC10791607 DOI: 10.1038/s41598-024-52048-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/12/2024] [Indexed: 01/18/2024] Open
Abstract
Tumefactive demyelinating lesions (TDL), characterized by large (≥ 2 cm) demyelinating lesions mimicking tumors, are a rare manifestation of the central nervous system inflammatory demyelinating diseases (CNS-IDD). Distinguishing TDL from other brain lesions can be challenging, often necessitating biopsy or advanced diagnostics. The natural history of TDL varies among races. This study aimed to assess demographics, clinical and radiological features, laboratory findings, management, and outcomes of Thai patients with TDL. We retrospectively reviewed records of twenty-six patients with TDL from the Multiple Sclerosis and Related Disorders registry from two tertiary medical centers. Among 1102 CNS-IDD patients, 26 (2.4%) had TDL. The median age at TDLs onset was 34.5 years (range 17-75); 69.2% were female. Over 70% manifested TDL as their initial CNS-IDD presentation. Common presenting symptoms included motor deficits, sensory disturbances, and cognitive problems. About two-fifths exhibited multiple lesions, most frequently in the frontoparietal region (46.2%). Half of the patients showed an incomplete ring on post-contrast T1-weighted imaging, with peripheral diffusion-weighted imaging restriction in twenty-one patients. T2-hypointense rims were present in thirteen (56.5%) patients. Brain biopsy was performed in 12 cases (46.1%). Serum aquaporin-4 immunoglobulin was positive in 16.7% of tested (4/24) cases. Serum myelin oligodendrocyte glycoprotein immunoglobulin was negative in all thirteen patients tested. Twenty patients (76.9%) received intravenous corticosteroids for TDL attacks. After the median follow-up period of 48 months (range 6-300), 23.1% experienced CNS-IDD relapses. Median Expanded Disability Status Scale at TDL diagnosis was 4.3 (range 0.0-9.5), and improved to 3.0 (range 0.0-10.0) at the last follow-up. This study suggested that TDL were rare among Thai CNS-IDD patients, frequently presenting as a monophasic condition with a favorable outcome.
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Affiliation(s)
- Tatchaporn Ongphichetmetha
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok-noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
- Division of Clinical Epidemiology, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Saharat Aungsumart
- Neuroimmunology Unit, Department of Neurology, Neurological Institute of Thailand, Bangkok, 10400, Thailand
| | - Sasitorn Siritho
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok-noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
- Bumrungrad International Hospital, Bangkok, 10110, Thailand
| | - Metha Apiwattanakul
- Neuroimmunology Unit, Department of Neurology, Neurological Institute of Thailand, Bangkok, 10400, Thailand
| | - Jantima Tanboon
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Natthapon Rattanathamsakul
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok-noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Naraporn Prayoonwiwat
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok-noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Jiraporn Jitprapaikulsan
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok-noi, Bangkok, 10700, Thailand.
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
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Vickaryous K, Poli De Frias F, Gonzalez GA. A Rare Case of a Balo's Concentric Sclerosis-Like Lesion in a Young Adult Woman. Cureus 2023; 15:e46803. [PMID: 37954773 PMCID: PMC10635639 DOI: 10.7759/cureus.46803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Balo's concentric sclerosis (BCS) is a rare demyelinating disorder of the central nervous system (CNS). Distinguishing BCS from other demyelinating disorders such as multiple sclerosis (MS) or from neoplasms can be difficult clinically; however, MRI aids in the identification of the disease. We describe the case of a 37-year-old female presenting with sudden onset of neurologic symptoms associated with a solitary rounded white-matter lesion suggestive of BCS. This rare disorder can present with heterogenous symptoms, imaging findings, and response to treatment. Furthermore, more in-depth analysis of the presentations and treatment outcomes of BCS are necessary in order to create a more robust plan of care.
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Affiliation(s)
- Kailee Vickaryous
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
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Fereidan‐Esfahani M, Decker PA, Weigand SD, Lopez Chiriboga AS, Flanagan EP, Tillema J, Lucchinetti CF, Eckel‐Passow JE, Tobin WO. Defining the natural history of tumefactive demyelination: A retrospective cohort of 257 patients. Ann Clin Transl Neurol 2023; 10:1544-1555. [PMID: 37443413 PMCID: PMC10502639 DOI: 10.1002/acn3.51844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE To describe demographic, clinical, and radiographic features of tumefactive demyelination (TD) and identify factors associated with severe attacks and poor outcomes. METHODS Retrospective review of TD cases seen at Mayo Clinic, 1990-2021. RESULTS Of 257 patients with TD, 183/257 (71%) fulfilled the 2017 multiple sclerosis (MS) McDonald criteria at the last follow-up, 12/257 (5%) had myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), 0 had aquaporin-4-IgG seropositive neuromyelitis optic spectrum disorders (AQP4+ NMOSD), and 62/257 (24%) were cryptogenic. Onset before age 18 was present in 18/257 (7%). Female to male ratio was 1.3:1. Cerebrospinal fluid oligoclonal (CSF) bands were present in 95/153 (62%). TD was the first demyelinating attack in 176/257 (69%). At presentation, 59/126 (47%) fulfilled Barkhof criteria for dissemination in space, 59/100 (59%) had apparent diffusion coefficient (ADC) restriction, and 57/126 (45%) had mass effect. Despite aggressive clinical presentation at onset, 181/257 (70%) of patients remained fully ambulatory (Expanded Disability Status Scale [EDSS] ≤4) after a 3.0-year median follow-up duration. Severe initial attack-related disability (EDSS ≥4) was more common in patients with motor symptoms (81/143 vs. 35/106, p < 0.0001), encephalopathy (20/143 vs. 2/106, p < 0.0001) and ADC restriction on initial MRI (42/63 vs. 15/33, p = 0.04). Poor long-term outcome (EDSS ≥4) was more common in patients with older onset age (41.9 ± 15 vs. 36.8 ± 15.6, p = 0.02) and motor symptoms at onset (49/76 vs. 66/171, p < 0.0001). INTERPRETATION Most TD patients should be considered part of the MS spectrum after excluding MOGAD and NMOSD. Motor symptoms and older age at presentation portend a poor outcome.
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Affiliation(s)
- Mahboubeh Fereidan‐Esfahani
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
- Dell Medical SchoolUniversity of TexasAustinTexasUSA
| | - Paul A Decker
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - Stephen D. Weigand
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | | | - Eoin P Flanagan
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
- Department of Laboratory Medicine and PathologyMinneapolisMinnesotaUSA
| | - Jan‐Mendelt Tillema
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Claudia F Lucchinetti
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | | | - W. Oliver Tobin
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
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6
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Cluse F, Fenouil T, Vukusic S, Ducray F, Cotton F, Marignier R, Durand-Dubief F. Pseudocystic inflammatory demyelinating lesions in multiple sclerosis: A clinical, radiological, and pathological description. Mult Scler 2023; 29:1340-1344. [PMID: 37622206 DOI: 10.1177/13524585231193345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Pseudocystic inflammatory demyelinating lesions (PIDLs) are poorly described in MS and might represent a diagnostic challenge. OBJECTIVES We described the clinical, radiological, pathological, and follow-up characteristics of 13 PIDL in 9 MS patients. METHODS We constituted a single-center retrospective case series of PIDLs in MS, defined on MRI as expansive cyst-like lesions, with a fluid-signal content, and a diameter of 1 cm or more. RESULTS PIDL often occurred at first event (56%), were often asymptomatic (69%), and encircled by a hypo-T2 diffusion-restricted rim and a thin ring-like gadolinium enhancement (100%) on magnetic resonance imaging (MRI). Associated typical MS lesions were constant. Biopsies from two PIDLs displayed classical features of active MS, except for unusual edema. CONCLUSION PIDLs are clinically unremarkable and associated with a good outcome. Their easily recognizable MRI features could help avoid biopsy.
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Affiliation(s)
- Florent Cluse
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
- Electroneuromyography and Neuromuscular Diseases Unit, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Tanguy Fenouil
- Institut de Pathologie Multisite-Site Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
- Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Eugène Devic EDMUS Foundation against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - François Ducray
- Service de Neuro-oncologie, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - François Cotton
- Service de Radiologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Creatis-LRMN, CNRS UMR 5220, Inserm U630, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Françoise Durand-Dubief
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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7
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Zhang Y, Zhang T, Zhang X, Yan X, Lei J, Liu R, Yang Y, Zhang C, Zhang J, Zhang Y, Yue W. Clinical spectrum and prognosis of pathologically confirmed atypical tumefactive demyelinating lesions. Sci Rep 2023; 13:7773. [PMID: 37179394 PMCID: PMC10183015 DOI: 10.1038/s41598-023-34420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
To describe the clinical spectrum and prognosis of atypical tumefactive demyelinating lesions (TDLs), which were confirmed by pathology. A total of 11 patients were diagnosed with atypical TDLs confirmed by brain biopsy and surgery between January 2006 and December 2017. The clinical spectrum and prognosis in these patients were analyzed. The patients' ages ranged from 29 to 62 years, with a mean age of 48.9 years; 72.7% were males. The Expanded Disability Status Scale (EDSS) of the patients with first onset was 2.36. Most of the patients started with limb numbness and weakness (45.5%) or alalia (27.2%). The mean time from symptom onset to biopsy or surgery was 12.9 days (3-30 days). Most of the patients had solitary lesions (72.7%), supratentorial lesions (90.9%, particularly predominant in the frontal, temporal, and parietal lobes), moderate edema (63.6%), mild mass effect (54.5%), and patchy lesions (54.5%). Among them, three patients were positive for myelin basic protein (MBP) and one patient was positive for myelin oligodendrocyte glycoprotein (MOG). The patients were followed up for an average of 6.9 years (2-14 years), and recurrent TDLs were observed in 2 patients. Except for the 2 patients who relapsed, only 1 of the 9 patients died; the other 8 patients improved or maintained the status quo (the EDSS scores were lower or unchanged). The patients did not have any serious nervous system injury at onset, and the main presentation included extremity weakness, headache or dizziness, and alalia. The most common form was patchy on MRI enhancement. Cerebrospinal fluid and demyelination test can be an indicator of TDLs, and seizures may be a poor prognostic indicator. Most atypical TDLs have monophasic courses and good outcomes. The effect of neurosurgery alone was good in our group, and the effect of surgery on atypical TDLs can be further studied.
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Affiliation(s)
- Yajing Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Ting Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Xuebin Zhang
- Department of Pathology, Tianjin Huanhu Hospital, Tianjin, China
| | - Xiaoling Yan
- Department of Pathology, Tianjin Huanhu Hospital, Tianjin, China
| | - Jing Lei
- Imaging Department, Tianjin Huanhu Hospital, Tianjin, China
| | - Ran Liu
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Yun Yang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Chao Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Jun Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Ying Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China
| | - Wei Yue
- Department of Neurology, Tianjin Huanhu Hospital, Jizhao Road 6, Tianjin, 300060, Jinnan, China.
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Leboyan A, Esselin F, Bascou AL, Duflos C, Ion I, Charif M, Castelnovo G, Carra-Dalliere C, Ayrignac X, Kerschen P, Chbicheb M, Nguyen L, Maria ATJ, Guilpain P, Carriere M, de Champfleur NM, Vincent T, Jentzer A, Labauge P, Devaux JJ, Taieb G. Immune-mediated diseases involving central and peripheral nervous systems. Eur J Neurol 2023; 30:490-500. [PMID: 36366904 DOI: 10.1111/ene.15628] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/03/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND PURPOSE In addition to combined central and peripheral demyelination, other immune diseases could involve both the central nervous system (CNS) and peripheral nervous system (PNS). METHODS To identify immune-mediated diseases responsible for symptomatic combined central/peripheral nervous system involvement (ICCPs), we conducted a multicentric retrospective study and assessed clinical, electrophysiological, and radiological features of patients fulfilling our ICCP criteria. RESULTS Thirty patients (20 males) were included and followed during a median of 79.5 months (interquartile range [IQR] = 43-145). The median age at onset was 51.5 years (IQR = 39-58). Patients were assigned to one of four groups: (i) monophasic disease with concomitant CNS/PNS involvement including anti-GQ1b syndrome (acute polyradiculoneuropathy + rhombencephalitis, n = 2), checkpoint inhibitor-related toxicities (acute polyradiculoneuropathy + encephalitis, n = 3), and anti-glial fibrillary acidic protein astrocytopathy (subacute polyradiculoneuropathy and meningoencephalomyelitis with linear gadolinium enhancements, n = 2); (ii) chronic course with concomitant CNS/PNS involvement including paraneoplastic syndromes (ganglionopathy/peripheral hyperexcitability + limbic encephalitis, n = 4); (iii) chronic course with sequential CNS/PNS involvement including POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome (polyradiculoneuropathy + strokes, n = 2), histiocytosis (polyradiculoneuropathy + lepto-/pachymeningitis, n = 1), and systemic vasculitis (multineuropathy + CNS vasculitis/pachymeningitis, n = 2); and (iv) chronic course with concomitant or sequential CNS/PNS involvement including combined central and peripheral demyelination (polyradiculoneuropathy + CNS demyelinating lesions, n = 10) and connective tissue diseases (ganglionopathy/radiculopathy/multineuropathy + limbic encephalitis/transverse myelitis/stroke, n = 4). CONCLUSIONS We diagnosed nine ICCPs. The timing of central and peripheral manifestations and the disease course help determine the underlying immune disease. When antibody against neuroglial antigen is identified, CNS and PNS involvement is systematically concomitant, suggesting a common CNS/PNS antigen and a simultaneous disruption of blood-nerve and blood-brain barriers.
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Affiliation(s)
- Aurelie Leboyan
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Florence Esselin
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Anne-Laure Bascou
- Clinical Research and Epidemiology Unit, University Hospital Center, University of Montpellier, Montpellier, France
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, University Hospital Center, University of Montpellier, Montpellier, France
| | - Ioana Ion
- Department of Neurology, Caremeau University Hospital Center, Nîmes, France
| | - Mahmoud Charif
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | | | | | - Xavier Ayrignac
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Philippe Kerschen
- Department of Neurology, Luxembourg Hospital Center, Luxembourg City, Luxembourg
| | - Mohamed Chbicheb
- Department of Neurology, Narbonne Hospital Center, Narbonne, France
| | - Ludovic Nguyen
- Department of Neurology, Perpignan Hospital Center, Perpignan, France
| | - Alexandre T J Maria
- Department of Internal Medicine, Saint Eloi University Hospital Center, Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine, Saint Eloi University Hospital Center, Montpellier, France
| | - Mathilde Carriere
- Department of Neuroradiology, Gui de Chauliac University Hospital Center, Montpellier, France
| | | | - Thierry Vincent
- Department of Immunology, Saint Eloi University Hospital Center, Montpellier, France
| | - Alexandre Jentzer
- Department of Immunology, Saint Eloi University Hospital Center, Montpellier, France
| | - Pierre Labauge
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Jérôme J Devaux
- Institute of Functional Genomics, National Center for Scientific Research UMR5203, Montpellier, France
| | - Guillaume Taieb
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
- Institute of Functional Genomics, National Center for Scientific Research UMR5203, Montpellier, France
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9
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Shala N, Tolaj I, Jashari F, Malazogu E, Shala A, Bajraktari G, Ahmetgjekaj I, Dreshaj S. Baló Concentric Sclerosis Mimicking Encephalitis with Seizures and Progressive Aphasia in a 26-Year-Old Woman: A Challenging Diagnostic Dilemma. Case Rep Neurol 2023; 15:227-232. [PMID: 37915316 PMCID: PMC10616666 DOI: 10.1159/000534358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Baló's concentric sclerosis (BCS) is a rare subtype of multiple sclerosis characterized by inflammatory demyelination within the central nervous system. Case Presentation This case report presents a challenging diagnostic scenario involving a 26-year-old woman diagnosed with BCS. Despite treatment, her condition did not ameliorate, and magnetic resonance imaging (MRI) findings remained unchanged. A subsequent stereotactic biopsy revealed tumefactive Balo disease, highlighting the intricate diagnostic and therapeutic issues surrounding BCS. Conclusion The juxtacortical location of the BCS lesion, as observed in our case, suggests an unfavourable prognosis due to treatment-resistant seizures.
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Affiliation(s)
- Nexhmedin Shala
- Department of Neurological Diseases, University Clinical Centre, Pristina, Kosovo
| | - Ilir Tolaj
- Department of Infectious Diseases, Medical Faculty, Pristina, Kosovo
| | - Fisnik Jashari
- Department of Neurological Diseases, University Clinical Centre, Pristina, Kosovo
| | - Edita Malazogu
- Department of Neurological Diseases, University Clinical Centre, Pristina, Kosovo
| | - Argjend Shala
- Department of Neurological Diseases, University Clinical Centre, Pristina, Kosovo
| | | | - Ilir Ahmetgjekaj
- Department of Radiology, University Clinical Centre, Pristina, Kosovo
| | - Shemsedin Dreshaj
- Department of Infectious Diseases, University Clinical Centre, Pristina, Kosovo
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10
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Ortiz AFH, Aristizabal S, Arámbula JG, Castillo VD, Calderon J, Cuenca NTR, Abuchar MJ, Yepes MM, Guarnizo A. Multiple sclerosis with megacystic presentation: A case report. Radiol Case Rep 2022; 18:515-518. [PMCID: PMC9691417 DOI: 10.1016/j.radcr.2022.10.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/26/2022] [Indexed: 11/27/2022] Open
Abstract
Multiple sclerosis is a frequent condition where the diagnosis relies on clinical presentation, neurologic examination, cerebro spinal fluid markers, and diagnostic imaging tests; however, atypical variants of the disease can lead to misdiagnosis in some scenarios. Herein, we describe a case of a 24-year-old patient with multiple sclerosis with megacystic plaques, in which appropriate interpretation of the imaging findings lead to a proper diagnosis and treatment.
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Affiliation(s)
- Andrés Felipe Herrera Ortiz
- Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia,Universidad El Bosque, Bogotá, Colombia,Corresponding author.
| | - Santiago Aristizabal
- Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia,Universidad El Bosque, Bogotá, Colombia
| | | | | | | | | | | | - María Mónica Yepes
- Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia,Universidad El Bosque, Bogotá, Colombia
| | - Angela Guarnizo
- Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia,Universidad El Bosque, Bogotá, Colombia
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11
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Fereidan-Esfahani M, Decker PA, Passow JEE, Lucchinetti CF, Flanagan EP, Tobin WO. Population-based incidence and clinico-radiological characteristics of tumefactive demyelination in Olmsted County, Minnesota, United States. Eur J Neurol 2022; 29:782-789. [PMID: 34773343 PMCID: PMC8831478 DOI: 10.1111/ene.15182] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Tumefactive demyelination (TD) presents with large inflammatory lesions mimicking tumors or other space-occupying lesions. Limited epidemiological, clinical and radiological data exist for TD. We aimed to report the incidence rate, and clinical and radiological features of TD in Olmsted County, Minnesota. METHODS We retrospectively reviewed patients with central nervous system inflammatory demyelination-related diagnostic codes (January 1, 1998 to December 31, 2018) in the Rochester Epidemiology Project database, and adjusted incidence rates by age and sex to the 2010 US total population. We used the Expanded Disability Status Scale (EDSS) to assess outcomes (index attack and last follow-up). RESULTS Of 792 multiple sclerosis (MS) patients, 15 (eight males, seven females) had tumefactive MS, representing 1.9% of the MS population. The median (range) age at attack onset was 34.2 (2-61) years. Tumefactive lesion was the first clinical MS attack in 8/16 patients. Cerebrospinal fluid oligoclonal bands (OCBs) were present in 8/12 patients and 11/16 patients met the Barkhof criteria for dissemination in space. Most patients remained fully ambulatory (EDSS score ≤4 in 13/16 patients [81%]) after a median (range) follow-up duration of 10.5 (1-20.5) years. Age-adjusted annual incidence rates were 0.46/100,000 (95% confidence interval [CI] 0.12-0.81) for female patients, 0.66/100,000 (95% CI 0.23-1.02) for male patients, and 0.56/100,000 [95% CI 0.28-0.83] overall. When age- and sex-adjusted to the 2010 US total population, the overall annual incidence rate was 0.57 (95% CI 0.28-0.84). Despite aggressive clinical presentation at disease onset, most patients remained fully ambulatory (EDSS score ≤4 in 13/16 patients) with a relapsing-remitting course. CONCLUSIONS Although incidence is rare, TD should be suspected in patients presenting with subacutely progressive neurological deficits associated with magnetic resonance imaging findings of ring enhancement, apparent diffusion coefficient restriction, and OCB on spinal fluid analysis.
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Affiliation(s)
- Mahboubeh Fereidan-Esfahani
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Paul A Decker
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jeanette E Eckel Passow
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Claudia F Lucchinetti
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Eoin Patrick Flanagan
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - William Oliver Tobin
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Corresponding Author: William Oliver Tobin, M.B., B.Ch., B.A.O., Ph.D., Mayo Clinic, 200 First Street SW, Rochester, MN 55905, Phone: 507-284-3359,
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12
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Nicoletti T, Bianco A, Lucchini M, Gaudino S, Frisullo G, Mirabella M. Cyclophosphamide in highly aggressive Marburg-like multiple sclerosis. Ther Adv Neurol Disord 2021; 14:17562864211050028. [PMID: 34659455 DOI: 10.1177/17562864211050028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Tommaso Nicoletti
- UOC Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Lgo. A. Gemelli 8, 00168 Rome, Italy
| | - Assunta Bianco
- UOC Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Lgo. A. Gemelli 8, 00168 Rome, Italy
| | - Matteo Lucchini
- Centro di ricerca per la sclerosi multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Gaudino
- UOC Radiodiagnostica e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Giovanni Frisullo
- UOC Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Lgo. A. Gemelli 8, 00168 Rome, Italy
| | - Massimiliano Mirabella
- Centro di ricerca per la sclerosi multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
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13
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Sánchez P, Chan F, Hardy TA. Tumefactive demyelination: updated perspectives on diagnosis and management. Expert Rev Neurother 2021; 21:1005-1017. [PMID: 34424129 DOI: 10.1080/14737175.2021.1971077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Tumefactive demyelination (TD) can be a challenging scenario for clinicians due to difficulties distinguishing it from other conditions, such as neoplasm or infection; or with managing the consequences of acute lesions, and then deciding upon the most appropriate longer term treatment strategy. AREAS COVERED The authors review the literature regarding TD covering its clinic-radiological features, association with multiple sclerosis (MS), and its differential diagnosis with other neuroinflammatory and non-inflammatory mimicking disorders with an emphasis on atypical forms of demyelination including acute disseminated encephalomyelitis (ADEM), MOG antibody-associated demyelination (MOGAD) and neuromyelitis spectrum disorders (NMOSD). We also review the latest in the acute and long-term treatment of TD. EXPERT OPINION It is important that the underlying cause of TD be determined whenever possible to guide the management approach which differs between different demyelinating and other inflammatory conditions. Improved neuroimaging and advances in serum and CSF biomarkers should one day allow early and accurate diagnosis of TD leading to better outcomes for patients.
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Affiliation(s)
- Pedro Sánchez
- Department of Neurology, Alexianer St. Josefs-Krankenhaus, Potsdam, Germany
| | - Fiona Chan
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Todd A Hardy
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia.,Brain & Mind Centre, University of Sydney, Nsw, Australia
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14
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Sacco S, Callegari I, Canavero I, Coloberti E, Farina LM, Ravaglia S, Simoncelli A, Pichiecchio A, Micieli G. Fulminant inflammatory demyelination presenting as stroke-in-evolution in an elderly subject. Brain Behav 2021; 11:e01967. [PMID: 33615744 PMCID: PMC8413797 DOI: 10.1002/brb3.1967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Fulminant inflammatory demyelination is a possible presentation of inflammatory demyelinating disorders, thus representing a potential stroke mimic especially in younger patients. AIMS OF THE STUDY To describe clinical and diagnostic pitfalls in a case of fulminant inflammatory demyelination presenting with stroke-like symptoms in an elderly patient. METHODS Case report and case-based review of the literature. RESULTS A 67-year-old woman, who accessed the emergency room as suspect stroke for hyperacute onset of rapidly worsening speech impairment and drowsiness, was later diagnosed with a huge brain inflammatory demyelination. Clinical, laboratory, and neuroimaging tests did not allow to put a more specific diagnosis. Due to the rapidly deteriorating course, she received immunosuppression with benefit. CONCLUSION This report is meant to highlight the diagnostic challenges connected with fulminant inflammatory demyelination, which sometime can resemble a stroke-in evolution and appear clinically unfitting for inclusion in any specific pathological entities within the broad-spectrum of inflammatory demyelinating disorders.
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Affiliation(s)
- Simone Sacco
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, Institute of Radiology, University of Pavia, Pavia, Italy
| | - Ilaria Callegari
- Neuroscience Consortium, Monza Policlinico and Pavia Mondino, University of Pavia, Pavia, Italy
| | | | - Elisa Coloberti
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Sabrina Ravaglia
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Anna Simoncelli
- Diagnostic Radiology, Interventional Radiology and Neuroradiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Pichiecchio
- Neuroradiology Unit, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Giuseppe Micieli
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
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15
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Martinez HR, Rodriguez-Gonzalez IC, Escamilla-Garza JM, Figueroa-Sanchez JA, Garcia-Aleman AC, Hinojosa-Gonzalez DE. Balo's Concentric Sclerosis with monophasic course: A report of 2 cases. Ann Med Surg (Lond) 2021; 68:102602. [PMID: 34401123 PMCID: PMC8347801 DOI: 10.1016/j.amsu.2021.102602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Balo's Concentric Sclerosis (BCS) is a rare demyelinating disease sometimes considered a variant of multiple sclerosis. It is characterized by an acute or subacute neurological symptoms with characteristic MRI "onion-like" white matter lesions. BCS has a wide range of presentations but is mostly self-limiting. Steroids are indicated in patients with aggressive disease. CASE PRESENTATION We report 2 cases of BCS with monophasic course of stroke-like symptoms and single periventricular concentric lamella with onion-like appearance on MRI without inflammatory reaction in the CSF. They were treated with corticosteroids achieving clinical improvement and without neurological deficit or relapse over the following years. CLINICAL DISCUSSION A number of cases of BCS are described in the literature that show marked recovery with early diagnosis and treatment with steroids. CONCLUSION BCS appears to have a good prognosis when treated early in its diagnosis with steroids.
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Affiliation(s)
- Hector R. Martinez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Mexico
- Neurology and Neurosurgery Institute, Hospital Zambrano Hellion, TecSalud. Tecnologico de Monterrey. Batallón de San Patricio 112, Colonia Real de San Agustin, CP 66278, San Pedro Garza García, N.L, Mexico
| | | | - Juan M. Escamilla-Garza
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Mexico
- Neurology and Neurosurgery Institute, Hospital Zambrano Hellion, TecSalud. Tecnologico de Monterrey. Batallón de San Patricio 112, Colonia Real de San Agustin, CP 66278, San Pedro Garza García, N.L, Mexico
| | - Jose A. Figueroa-Sanchez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Mexico
- Neurology and Neurosurgery Institute, Hospital Zambrano Hellion, TecSalud. Tecnologico de Monterrey. Batallón de San Patricio 112, Colonia Real de San Agustin, CP 66278, San Pedro Garza García, N.L, Mexico
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16
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Plowman RS, Varma H. Prognostic factors in Tumefactive demyelinating lesions: A retrospective study. J Neurol Sci 2021; 428:117591. [PMID: 34333380 DOI: 10.1016/j.jns.2021.117591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/01/2021] [Accepted: 07/23/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Demyelinating lesions occasionally present as mass-like lesions on imaging, raising concern for malignancy. The disease course of such tumefactive demyelinating lesions (TDLs) is still being defined. METHODS We retrospectively analyzed 21 patients with new-onset neurologic symptoms and mass-like lesions on brain magnetic resonance imaging (MRI), which resulted in biopsy-proven diagnoses of demyelination. 18 patients had a median follow-up of 52 months. The clinical, radiologic and histologic features were associated with disease course. RESULTS An aggressive disease course (ADC) was noted in 33% of the patients and was associated with an initial largest lesion size ≥35 mm (p = 0.0007), mass effect (p = 0.01) and perilesional edema (p = 0.01) on MRI. Age 30 years and older, at presentation (p = 0.05), as well as the absence of a prior tonsillectomy (p = 0.0128) were also associated with an ADC. CONCLUSIONS We identified several factors, including initial larger lesion size, mass effect and perilesional edema on MRI, presentation after 30 years of age and the absence of a prior tonsillectomy, that predict an ADC in patients presenting with TDLs. These predictors of disease course can help guide patient follow-up and stratification for intervention.
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Affiliation(s)
- R Skipper Plowman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Hemant Varma
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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17
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Baló's concentric sclerosis - A rare entity within the spectrum of demyelinating diseases. J Neurol Sci 2021; 428:117570. [PMID: 34261000 DOI: 10.1016/j.jns.2021.117570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/24/2022]
Abstract
Baló's concentric sclerosis (BCS) is a rare, inflammatory demyelinating disease of the central nervous system (CNS). Historically, BCS was thought to be uniformly fatal and diagnosis was based on postmortem findings. With advances in modern neuroimaging, BCS is currently defined by the presence of concentric layered patterns composed of alternating rings of varying intensity. They are best appreciated on gadolinium-enhanced T1-weighted sequences and predominantly occur in the supratentorial cerebral white matter with sparing of cortical U-fibers. The lamellar pattern of the lesions likely reflects bands of demyelination and relative myelin preservation with minimal axonal loss. While BCS falls within the spectrum of atypical demyelinating diseases, there is ongoing debate over whether BCS is a phenotypical variant of multiple sclerosis (MS) or a separate entity. Corticosteroids comprise first-line therapy but there is ongoing controversy regarding appropriate maintenance therapy. First-line MS disease-modifying therapies such as interferon beta-1a are appropriate for patients who fulfill diagnostic criteria for relapsing-remitting MS. Fingolimod should likely be avoided as Baló-like lesions have been reported during its administration or after withdrawal. Monoclonal antibodies such as natalizumab and rituximab are potentially effective at reducing BCS relapses, but alemtuzumab may be relatively ineffective because humoral immunity does not play a central role in BCS pathogenesis.
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18
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Weidauer S, Raab P, Hattingen E. Diagnostic approach in multiple sclerosis with MRI: an update. Clin Imaging 2021; 78:276-285. [PMID: 34174655 DOI: 10.1016/j.clinimag.2021.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/06/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
Although neurological examination and medical history are the first and most important steps towards the diagnosis of multiple sclerosis (MS), MRI has taken a prominent role in the diagnostic workflow especially since the implementation of McDonald criteria. However, before applying those on MR imaging features, other diseases must be excluded and MS should be favoured as the most likely diagnosis. For the prognosis the earliest possible and correct diagnosis of MS is crucial, since increasingly effective disease modifying therapies are available for the different forms of clinical manifestation and progression. This review deals with the significance of MRI in the diagnostic workup of MS with special regard to daily clinical practice. The recommended MRI protocols for baseline and follow-up examinations are summarized and typical MS lesion patterns ("green flags") in four defined CNS compartments are introduced. Pivotal is the recognition of neurological aspects as well as imaging findings atypical for MS ("red flags"). In addition, routinely assessment of Aquaporin-4-IgG antibodies specific for neuromyelitis optica spectrum disorders (NMOSD) as well as the knowledge of associated lesion patterns on MRI is recommended. Mistaken identity of such lesions with MS and consecutive implementation of disease modifying therapies for MS can worsen the course of NMOSD.
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Affiliation(s)
- Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Teaching Hospital of the Goethe University, Seckbacher Landstraße 65, 60389 Frankfurt am Main, Germany.
| | - Peter Raab
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Carl Neuberg Straße 1, 30625 Hannover, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Goethe University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
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19
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Abstract
OBJECTIVE. Tumefactive demyelination mimics primary brain neoplasms on imaging, often necessitating brain biopsy. This article reviews the literature for the clinical and radiologic findings of tumefactive demyelination in various disease processes to facilitate identification of tumefactive demyelination on imaging. CONCLUSION. Both clinical and radiologic findings must be integrated to distinguish tumefactive demyelinating lesions from similarly appearing lesions on imaging. Further research on the immunopathogenesis of tumefactive demyelination and associated conditions will elucidate their interrelationship.
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20
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Jolliffe EA, Guo Y, Hardy TA, Morris PP, Flanagan EP, Lucchinetti CF, Tobin WO. Clinical and Radiologic Features, Pathology, and Treatment of Baló Concentric Sclerosis. Neurology 2021; 97:e414-e422. [PMID: 34011576 DOI: 10.1212/wnl.0000000000012230] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/20/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe clinical, radiologic, and pathologic features of Baló concentric sclerosis (BCS) and assess overlap between BCS and other CNS inflammatory demyelinating diseases. METHODS Retrospective review of BCS cases from US and Australian tertiary care centers. RESULTS We identified 40 BCS cases with 38 available MRIs. Solitary MRI lesions were present in 26% (10/38). We saw >1 active concurrent BCS lesion in 45% (17/38). A third (13/38) had multiple sclerosis-suggestive lesions on the index MRI, of which 10 fulfilled Barkhof criteria. In patients with serial MRI performed within 1 month of the index MRI, lesions expanded radially with sequentially increased numbers of T2 hyperintense rings 52% (14/27). Initially nonenhancing or centrally enhancing lesions subsequently developed single or multiple enhancing rings (41%; 9/22) and incomplete enhancing rings (14%; 3/22). Discordance between rings as they appear on apparent diffusion coefficient, diffusion-weighted imaging, and gadolinium-enhanced imaging was observed in 67% (22/33). Aquaporin-4 immunoglobulin G (n = 26) and myelin oligodendrocyte glycoprotein immunoglobulin G (n = 21) were negative in all patients with serum available. Clinical response to steroid treatment was seen in 46% (13/28). A monophasic clinical course was present in 56% (18/32) at last follow-up (median 27.5 months; range 3-100 months). The initial attack was fatal in 10% (4/40). Median time from symptom onset to death was 23 days (range 19-49 days). All 17 patients with pathology available demonstrated typical findings of multiple sclerosis. Patients with active demyelinating lesions all demonstrated oligodendrocytopathy (pattern III). CONCLUSIONS BCS may be a distinct subtype of multiple sclerosis characterized by pattern III immunopathology.
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Affiliation(s)
- Evan A Jolliffe
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Yong Guo
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Todd A Hardy
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - P Pearse Morris
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Eoin P Flanagan
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Claudia F Lucchinetti
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - W Oliver Tobin
- From the Departments of Neurology (E.A.J., Y.G., E.P.F., C.F.L., W.O.T.) and Radiology (P.P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (E.A.J.), Capital and Coast District Health Board, Wellington, New Zealand; Brain & Mind Centre (T.A.H.), University of Sydney; and Department of Neurology (T.A.H.), Concord Repatriation General Hospital, Sydney, NSW, Australia.
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21
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Paoletti M, Muzic SI, Marchetti F, Farina LM, Bastianello S, Pichiecchio A. Differential imaging of atypical demyelinating lesions of the central nervous system. Radiol Med 2021; 126:827-842. [PMID: 33486703 DOI: 10.1007/s11547-021-01334-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/11/2021] [Indexed: 01/04/2023]
Abstract
The detection of atypical and sometimes aggressive or tumefactive demyelinating lesions of the central nervous system often poses difficulties in the differential diagnosis. The clinical presentation is generally aspecific, related to the location and similar to a number of different lesions, including neoplasms and other intracranial lesions with mass effect. CSF analysis may also be inconclusive, especially for lesions presenting as a single mass at onset. As a consequence, a brain biopsy is frequently performed for characterization. Advanced MRI imaging plays an important role in directing the diagnosis, reducing the rate of unnecessary biopsies and allowing a prompt start of therapy that is often crucial, especially in the case of infratentorial lesions. In this review, the main pattern of presentation of atypical inflammatory demyelinating diseases is discussed, with particular attention on the differential diagnosis and how to adequately define the correct etiology.
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Affiliation(s)
- Matteo Paoletti
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, PV, Italy.
| | | | | | - Lisa Maria Farina
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, PV, Italy
| | - Stefano Bastianello
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, PV, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Anna Pichiecchio
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, PV, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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22
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Tzanetakos D, Vakrakou AG, Tzartos JS, Velonakis G, Evangelopoulos ME, Anagnostouli M, Koutsis G, Dardiotis E, Karavasilis E, Toulas P, Stefanis L, Kilidireas C. Heterogeneity of Baló's concentric sclerosis: a study of eight cases with different therapeutic concepts. BMC Neurol 2020; 20:400. [PMID: 33138795 PMCID: PMC7604966 DOI: 10.1186/s12883-020-01971-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/20/2020] [Indexed: 12/27/2022] Open
Abstract
Background Baló’s Concentric Sclerosis (BCS) is a rare heterogeneous demyelinating disease with a variety of phenotypes on Magnetic Resonance Imaging (MRI). Existing literature lacks data especially on the therapeutic approach of the disease which we intended to elucidate by means of suggesting a new possible BCS classification and introducing different therapeutic concepts based on each BCS-subgroup characteristics. Methods We present a retrospective study of eight treated patients with BCS-type lesions, emphasizing on MRI characteristics and differences on therapeutic maneuvers. Results Data analysis showed: at disease onset the BCS-type lesion was tumefactive (size ≥2 cm) in 6 patients, with a mean size of 2.7 cm (± 0.80 SD); a coexistence of MS-like plaques on brain MRI was identified in 7 patients of our cohort. The mean age was 26.3 years (±7.3 SD) at disease onset and the mean follow-up period was 56.8 months (range 9–132 months). According to radiological characteristics and response to therapies, we further categorized them into 3 subgroups: a) Group-1; BCS with or without coexisting nonspecific white matter lesions; poor response to intravenous methylprednisolone (IVMP); treated with high doses of immunosuppressive agents (4 patients), b) Group-2; BCS with typical MS lesions; good response to IVMP; treated with MS-disease modifying therapies (2 patients), c) Group-3; BCS with typical MS lesions; poor response to IVMP; treated with rituximab (2 patients). Conclusions Our study introduces a new insight regarding the categorization of BCS into three subgroups depending on radiological features at onset and during the course of the disease, in combination with the response to different immunotherapies. Immunosuppressive agents such as cyclophosphamide are usually effective in BCS. However, therapeutic alternatives like anti-CD20 monoclonal antibodies or more classical disease-modifying MS therapies can be considered when BCS has also mixed lesions similar to MS. Future studies with a larger sample size are necessary to further establish these findings, thus leading to better treatment algorithms and improved clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-020-01971-2.
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Affiliation(s)
- D Tzanetakos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - A G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - J S Tzartos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - G Velonakis
- Research Unit of Radiology - 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - M E Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - M Anagnostouli
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - G Koutsis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Dardiotis
- Department of Neurology, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - E Karavasilis
- Research Unit of Radiology - 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - P Toulas
- Research Unit of Radiology - 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - L Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - C Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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23
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FILIP RC, CATANĂ MG. Neurorehatilitation and complex therapeutical approaches in a patient with spinal multiple sclerosis. BALNEO RESEARCH JOURNAL 2020. [DOI: 10.12680/balneo.2020.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purely spinal form of multiple sclerosis, presenting as a progressive spastic paraparesis, hemiparesis, or, spastic monoparesis of a leg with varying degrees of posterior column involvement, is a special source of diagnostic difficulty. We present the case of a 47 years old patient, with no personal pathological antecedents, admitted in our department through the emergency ward for motor deficit of the lower limbs, sympthomatology that had an acute onset the day before admittance. The neurologic examination revealed: orthostatism and gait not possible, spastic paraparesis – 3/5 MRC (medical research council), deep tendon reflexes were found to be hyperactive on both lower extremities, bilateral plantar extension, a dermatomic level of sensory disturbance at T10 – T11 vertebral segment and urinary retention. The cerebral MRI revealed no pathological findings. The lumbar punction revealed oligoclonal bands and the spine MRI outlined multiple focal images with demyelination aspect reaching the cervical and dorsal level of the medullary cord. The patient had two more relapses each at approximately 6 months, and this allowed us to establish the final diagnostic: Pure spinal multiple sclerosis.
Key words: spinal multiple sclerosis, paraparesis, neurorehabilitation,
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Affiliation(s)
- Roman Corina FILIP
- ¹ Emergency Clinical Hospital Sibiu, Department of Neurology, Romania ² "Lucian Blaga" University, Sibiu, Romania
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24
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Abstract
PURPOSE OF REVIEW To review the clinical findings, differential diagnosis, treatment and outcome of pseudotumoral demyelinating lesions including tumefactive demyelination and Baló's concentric sclerosis. RECENT FINDINGS MRI findings, such as dynamic restricted diffusion changes at the edge of pseudotumoral lesions help to discriminate atypical demyelination from key differential diagnoses, and together with histopathological data, indicate that tissue hypoxia may be important aetiologically. CT-PET imaging can help to distinguish pseudotumoral lesions from high-grade tumours. Although most patients with pseudotumoral lesions have or later develop multiple sclerosis, a proportion will experience a monophasic course or be diagnosed with neuromyelitis optica spectrum disorders (NMOSD), myelin oligodendrocyte glycoprotein (MOG) antibody-associated demyelination or acute disseminated encephalomyelitis (ADEM). Many patients with pseudotumoral demyelinating lesions have a favourable prognosis. SUMMARY Not all patients with pseudotumoral lesions require a brain biopsy but close follow-up of biopsied and nonbiopsied lesions is indicated once a diagnosis is established. Testing for AQP4-IgG and MOG-IgG is recommended when a pseudotumoral demyelinating lesion is identified. In the absence of large, prospective studies, it seems reasonable that patients with pseudotumoral lesions who fulfil multiple sclerosis diagnostic criteria are treated with multiple sclerosis therapies.
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25
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Kotov AS, Dolgova SG, Bunak MS, Abramenko AS, Stashuk GA, Borodin AV, Tokareva YV, Mukhina EV. [Balo's concentric sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:107-112. [PMID: 31407690 DOI: 10.17116/jnevro2019119061107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Balo's concentric sclerosis (BCS) is a rare demyelinating disease, first described by Hungarian neurologist Josef Balo in 1928. BCS occurs predominantly in young adults, the average age of onset of the disease - 34 years (range from 3 to 62 years). Our case report describes a 27-year woman with acute onset progressive right-side pyramidal weakness, MRI results showed a variant of demyelination as Balo's concentric sclerosis.
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Affiliation(s)
- A S Kotov
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - S G Dolgova
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - M S Bunak
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - A S Abramenko
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - G A Stashuk
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - A V Borodin
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - Yu V Tokareva
- Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - E V Mukhina
- Moscow Regional Research and Clinical Institute, Moscow, Russia
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26
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Pathologic and MRI analysis in acute atypical inflammatory demyelinating lesions. J Neurol 2019; 266:1743-1755. [DOI: 10.1007/s00415-019-09328-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 01/15/2023]
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27
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Jarius S, Haas J, Paul F, Wildemann B. Myelinoclastic diffuse sclerosis (Schilder's disease) is immunologically distinct from multiple sclerosis: results from retrospective analysis of 92 lumbar punctures. J Neuroinflammation 2019; 16:51. [PMID: 30819213 PMCID: PMC6396538 DOI: 10.1186/s12974-019-1425-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/31/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Myelinoclastic diffuse sclerosis (MDS; also termed Schilder's disease) is a rare inflammatory demyelinating disorder of the central nervous system characterised by demyelination of vast areas of the white matter. It is unclear whether MDS is a variant of multiple sclerosis (MS) or a disease entity in its own right. OBJECTIVE To compare the cerebrospinal fluid (CSF) features of MDS with those of MS. METHODS Retrospective analysis of the CSF profile of all patients with MDS reported in the medical literature between 1960 and 2018. RESULTS The most striking finding was a substantial lack of oligoclonal bands (OCBs) in MDS, which were absent in at least 77% (30/39) of all lumbar punctures (LP) in the total cohort and in 86% in the subgroup of patients with normal very long-chain fatty acid serum ratios (VLCFA). Almost all cases published in the past 15 years were negative for OCBs. These findings are in contrast to MS, in which OCBs are present in up to 98% of cases (p < 0.00001 when compared with reference works in MS; both in adult and in pediatric patients). CSF pleocytosis was absent in at least 79% (46/58) of all LP (p < 0.0001 vs. MS) and in 92% (24/26) of LPs in the VLCFA-tested subgroup. CSF total protein levels were elevated in 56% of all LPs (p < 0.0001 vs. MS) and in 63% of LPs in the VLCFA-tested subgroup and were often higher than in typical MS (> 100 mg/dL in 13/22; up to 220 mg/dL). EBV serum antibodies, which are present in virtually all patients with MS, and the so-called MRZ (measles/rubella/zoster) reaction, a highly specific marker of MS, were absent in all of the few patients tested. In addition, we discuss further differences between MS and MDS, taking into account also Schilder's original comprehensive case description from 1912. CONCLUSION In the majority of patients diagnosed with MDS, CSF features differ significantly from those typically found in MS and are more similar to those previously reported in patients with myelin oligodendrocyte glycoprotein-immunoglobulin G (IgG)-positive encephalomyelitis, aquaporin-4-IgG-positive neuromyelitis optica spectrum disorders or Baló's concentric sclerosis. Our data suggest that MDS and MS are immunopathologically distinct entities in the majority of cases.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - J Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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28
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Codjia P, Ayrignac X, Carra-Dalliere C, Cohen M, Charif M, Lippi A, Collongues N, Corti L, De Seze J, Lebrun C, Vukusic S, Durand-Dubief F, Labauge P. Multiple sclerosis with atypical MRI presentation: Results of a nationwide multicenter study in 57 consecutive cases. Mult Scler Relat Disord 2019; 28:109-116. [DOI: 10.1016/j.msard.2018.12.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/30/2018] [Accepted: 12/16/2018] [Indexed: 12/22/2022]
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29
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Ertuğrul Ö, Çiçekçi E, Tuncer MC, Aluçlu MU. Balo’s concentric sclerosis in a patient with spontaneous remission based on magnetic resonance imaging: A case report and review of literature. World J Clin Cases 2018; 6:447-454. [PMID: 30294609 PMCID: PMC6163147 DOI: 10.12998/wjcc.v6.i11.447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/30/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023] Open
Abstract
Balo’s concentric sclerosis (BCS) is a rare monophasic demyelinating disease known as multiple sclerosis subtype and seen as a round lesion with variable hyper and hypo-detoxification layers. Characteristic appearance can be seen as “bulb eye” or “onion bulb”. The initial terminology for this neurological disorder was leukoencephalitis periaxialis concentrica; this is defined as a disease in which the white matter of the brain is destroyed in concentric layers in such a way as to leave the axial cylinders intact. This report presents a case of BCS with spontaneous healing of the patient and a mass lesion with concentric rings adjacent to the left lateral ventricle and the posterior portion of the corpus callosum with peripheral vasogenic edema. The neurological lesion of the patient was similar to the magnetic resonance imaging and clinical findings of the BCS.
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Affiliation(s)
- Özgür Ertuğrul
- Department of Radiology, Memorial Hospital, Diyarbakır 21100, Turkey
| | - Esra Çiçekçi
- Department of Physiotherapy, University of Health Sciences, Gazi Yaşargil Education and Research Hospital, Diyarbakır 21100, Turkey
| | - Mehmet Cudi Tuncer
- Department of Anatomy, Faculty of Medicine, University of Dicle, Diyarbakır 21280, Turkey
| | - Mehmet Ufuk Aluçlu
- Department of Neurology, Faculty of Medicine, University of Dicle, Diyarbakır 21280, Turkey
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30
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Suh CH, Kim HS, Jung SC, Choi CG, Kim SJ. MRI Findings in Tumefactive Demyelinating Lesions: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:1643-1649. [PMID: 30115676 DOI: 10.3174/ajnr.a5775] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/09/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Accurate diagnosis of tumefactive demyelinating lesions is clinically important to avoid unnecessary invasive biopsy or inappropriate treatment. PURPOSE We aimed to evaluate conventional and advanced MR imaging findings of tumefactive demyelinating lesions and determine the diagnostic performance of MR imaging for differentiating tumefactive demyelinating lesions from primary brain tumor. DATA SOURCES A systematic search of Ovid MEDLINE and EMBASE up to December 6, 2017, was conducted. STUDY SELECTION Original articles describing MR imaging findings in patients with tumefactive demyelinating lesions were selected. DATA ANALYSIS The pooled incidences of conventional MR imaging findings of tumefactive demyelinating lesions were obtained with the DerSimonian and Liard random-effects model. The pooled sensitivity and specificity of MR imaging for differentiating tumefactive demyelinating lesions from primary brain tumor were obtained using the bivariate random-effects model. DATA SYNTHESIS Nineteen eligible studies with 476 patients with tumefactive demyelinating lesions were included. The pooled incidence of open ring or incomplete rim enhancement was 35% (95% CI, 24%-47%), which was significantly higher than the incidence of closed ring or complete rim enhancement (18% [95% CI, 11%-29%]; P = .0281). The pooled incidences of T2 hypointense rim, absent or mild mass effect, and absent or mild perilesional edema were 48%, 67%, and 57%, respectively. On advanced MR imaging, tumefactive demyelinating lesions showed a high apparent diffusion coefficient, peripheral restricted diffusion, and low cerebral blood volume. The pooled sensitivity and specificity of MR imaging for differentiating tumefactive demyelinating lesions from primary brain tumor were 89% (95% CI, 82%-93%) and 94% (95% CI, 89%-97%), respectively. LIMITATIONS Seventeen of 19 studies were retrospective studies. CONCLUSIONS Conventional MR imaging findings may help differentiate tumefactive demyelinating lesions from primary brain tumor, though further study is needed to determine the added value of advanced MR imaging.
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Affiliation(s)
- C H Suh
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - H S Kim
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
| | - S C Jung
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - C G Choi
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - S J Kim
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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31
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Balloy G, Pelletier J, Suchet L, Lebrun C, Cohen M, Vermersch P, Zephir H, Duhin E, Gout O, Deschamps R, Le Page E, Edan G, Labauge P, Carra-Dallieres C, Rumbach L, Berger E, Lejeune P, Devos P, N'Kendjuo JB, Coustans M, Auffray-Calvier E, Daumas-Duport B, Michel L, Lefrere F, Laplaud DA, Brosset C, Derkinderen P, de Seze J, Wiertlewski S. Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients. J Neurol 2018; 265:2251-2259. [PMID: 30054790 DOI: 10.1007/s00415-018-8984-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients. METHODS Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded. RESULTS Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD). CONCLUSION This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.
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Affiliation(s)
- G Balloy
- Neurology Department, University of Nantes Hospital, Nantes, France. .,Service de Neurologie, Hopital Laennec, Boulevard Jacques Monod, 44800, Saint Herblain, France.
| | - J Pelletier
- Neurosciences Unit, Neurology Department, Timone Hospital, Aix Marseille University, APHM, Marseille, France
| | - L Suchet
- Neurosciences Unit, Neurology Department, Timone Hospital, Aix Marseille University, APHM, Marseille, France
| | - C Lebrun
- University of Nice Hospital, Nice, France
| | - M Cohen
- University of Nice Hospital, Nice, France
| | | | - H Zephir
- University of Lille Hospital, Lille, France
| | - E Duhin
- University of Lille Hospital, Lille, France
| | - O Gout
- Rothschild Foundation, Paris, France
| | | | - E Le Page
- University of Rennes Hospital, Rennes, France
| | - G Edan
- University of Rennes Hospital, Rennes, France
| | - P Labauge
- University of Montpellier Hospital, Montpellier, France
| | | | - L Rumbach
- University Besançon Hospital, Besançon, France
| | - E Berger
- University Besançon Hospital, Besançon, France
| | - P Lejeune
- La Roche sur Yon Hospital, La Roche-sur-Yon, France
| | - P Devos
- Boulogne-sur-Mer Hospital, Boulogne-sur-Mer, France
| | | | | | | | - B Daumas-Duport
- Radiology Department, University of Nantes Hospital, Nantes, France
| | - L Michel
- Neurology Department, University of Nantes Hospital, Nantes, France
| | - F Lefrere
- Neurology Department, University of Nantes Hospital, Nantes, France
| | - D A Laplaud
- Neurology Department, University of Nantes Hospital, Nantes, France
| | - C Brosset
- Military Hospital, Marseille, France
| | - P Derkinderen
- Neurology Department, University of Nantes Hospital, Nantes, France
| | - J de Seze
- University of Strasbourg Hospital, Strasbourg, France
| | - S Wiertlewski
- Neurology Department, University of Nantes Hospital, Nantes, France
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32
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Behrens JR, Wanner J, Kuchling J, Ostendorf L, Harms L, Ruprecht K, Niendorf T, Jarius S, Wildemann B, Gieß RM, Scheel M, Bellmann-Strobl J, Wuerfel J, Paul F, Sinnecker T. 7 Tesla MRI of Balo's concentric sclerosis versus multiple sclerosis lesions. Ann Clin Transl Neurol 2018; 5:900-912. [PMID: 30128315 PMCID: PMC6093849 DOI: 10.1002/acn3.572] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/18/2018] [Accepted: 04/06/2018] [Indexed: 12/20/2022] Open
Abstract
Background Baló's concentric sclerosis (BCS) is a rare condition characterized by concentrically layered white matter lesions. While its pathogenesis is unknown, hypoxia‐induced tissue injury and chemotactic stimuli have been proposed as potential causes of BCS lesion formation. BCS has been suggested to be a variant of multiple sclerosis (MS). Here, we aimed to elucidate similarities and differences between BCS and MS by describing lesion morphology and localization in high‐resolution 7 Tesla (7 T) magnetic resonance imaging (MRI) scans. Methods Ten patients with Baló‐type lesions underwent 7 T MRI, and 10 relapsing remitting MS patients served as controls. The 7 T MR imaging protocol included 3D T1‐weighted (T1w) magnetization‐prepared rapid gradient echo, 2D high spatial resolution T2*‐weighted (T2*w) fast low‐angle shot and susceptibility‐weighted imaging. Results Intralesional veins were visible in the center of all but one Baló‐type lesion. Four Baló‐type lesions displayed inhomogeneous intralesional T2*w signal intensities, which are suggestive of microhemorrhages or small ectatic venules. Eight of 10 BCS patients presented with 97 additional lesions, 36 of which (37%) had a central vein. Lesions involving the cortical gray matter and the U‐fibers were not detected in BCS patients. Conclusion Our findings support the hypothesis that BCS and MS share common pathogenetic mechanisms but patients present with different lesion phenotypes.
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Affiliation(s)
- Janina R Behrens
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany
| | - Julia Wanner
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany
| | - Joseph Kuchling
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany
| | - Lennard Ostendorf
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany
| | - Lutz Harms
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Clinical and Experimental Multiple Sclerosis Research Center Charite - Universitätsmedizin Berlin Berlin Germany
| | - Klemens Ruprecht
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Clinical and Experimental Multiple Sclerosis Research Center Charite - Universitätsmedizin Berlin Berlin Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility Max Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany.,Experimental and Clinical Research Center Charite - Universitätsmedizin Berlin Berlin Germany.,Max Delbrück Center for Molecular Medicine Berlin Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group Department of Neurology University of Heidelberg Heidelberg Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group Department of Neurology University of Heidelberg Heidelberg Germany
| | - René M Gieß
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany
| | - Michael Scheel
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany
| | - Judith Bellmann-Strobl
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany.,Experimental and Clinical Research Center Charite - Universitätsmedizin Berlin Berlin Germany.,Max Delbrück Center for Molecular Medicine Berlin Germany
| | - Jens Wuerfel
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Medical Image Analysis Center (MIAC AG) Basel Switzerland.,qbig Department of Biomedical Engineering University Basel Basel Switzerland
| | - Friedemann Paul
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Neurology Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin Germany.,Berlin Institute of Health Berlin Germany.,Clinical and Experimental Multiple Sclerosis Research Center Charite - Universitätsmedizin Berlin Berlin Germany.,Experimental and Clinical Research Center Charite - Universitätsmedizin Berlin Berlin Germany.,Max Delbrück Center for Molecular Medicine Berlin Germany
| | - Tim Sinnecker
- Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health NeuroCure Cluster of Excellence NeuroCure Clinical Research Center Berlin Germany.,Medical Image Analysis Center (MIAC AG) Basel Switzerland.,Department of Neurology Universitätsspital Basel Basel Switzerland
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Recurrent pseudotumoral relapses in multiple sclerosis: a case report. Mult Scler Relat Disord 2018; 22:49-51. [DOI: 10.1016/j.msard.2018.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 02/18/2018] [Accepted: 03/04/2018] [Indexed: 11/16/2022]
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Atypical inflammatory demyelinating lesions and atypical multiple sclerosis. Rev Neurol (Paris) 2018; 174:408-418. [PMID: 29673573 DOI: 10.1016/j.neurol.2018.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 02/06/2023]
Abstract
Atypical idiopathic inflammatory demyelinating disorders (IIDDs) of the brain have long been known to be disorders closely related to multiple sclerosis (MS), despite having distinctive clinical and radiological characteristics. Originally, they mostly corresponded to acute-onset variants of MS that classically had poor prognoses, such as Baló's concentric sclerosis, Marburg variant of MS and Schilder's disease, and their relationship with MS was based on their shared pathological findings and the co-occurrence of these variants in patients with typical MS. More recently, other atypical disorders, such as solitary sclerosis, have also been described as belonging to the MS spectrum, raising the question of their links with MS. Meanwhile, multiple MS mimics have been described and need to be considered in the differential diagnosis of MS. In addition, thorough characterization of these atypical entities, including advanced MRI and biological studies, is now warranted to further improve their management.
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Jarius S, Würthwein C, Behrens JR, Wanner J, Haas J, Paul F, Wildemann B. Baló's concentric sclerosis is immunologically distinct from multiple sclerosis: results from retrospective analysis of almost 150 lumbar punctures. J Neuroinflammation 2018; 15:22. [PMID: 29347989 PMCID: PMC5774135 DOI: 10.1186/s12974-017-1043-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/14/2017] [Indexed: 01/01/2023] Open
Abstract
Background Baló’s concentric sclerosis (BCS) is a rare inflammatory demyelinating disorder of the central nervous system characterised by concentric layers of demyelination. It is unclear whether BCS is a variant of multiple sclerosis (MS) or a disease entity in its own right. Objective To compare the cerebrospinal fluid (CSF) features of BCS to those of MS. Methods Retrospective analysis of the CSF profile of all patients with BCS reported in the medical literature between 1980 and 2017. Results In total, the results of 146 lumbar punctures (LP) in 132 patients were analysed. The most striking finding was a lack of CSF-restricted oligoclonal bands (OCB) in 66% (56/85) of all LP in the total BCS group, in 74% (14/19) in the subgroup of patients with both MRI and histological evidence for BCS, and in 82% (18/22) in the subgroup of patients with highest radiological confidence (high MRI quality, ≥ 3 layers of demyelination). OCB disappeared in 1/2 initially OCB-positive patients. These findings are in stark contrast to MS, in which OCB are present in ≥ 95% of patients and are thought to remain stably detectable over the entire course of disease (p < 0.000001). OCB frequency was low both in ‘historic’ patients (1980–2009; 37%) and in more recent patients (2010–2017; 31%). OCB-positive and OCB-negative patients did not differ significantly with regard to age, sex, disease duration, number of Baló-like lesions on MRI, number of relapses, treatment or final outcome. In accordance with the high rate of OCB negativity, Link’s IgG index was negative in 63% of all tested samples (p < 0.000001 vs. MS). CSF pleocytosis was present in 28% (27/96; p < 0.000001 vs. MS) and elevated CSF total protein levels in 41% (31/76) of samples. Conclusion OCB and IgG index frequencies in BCS are much more similar to those reported in neuromyelitis optica or myelin oligodendrocyte glycoprotein antibody-associated encephalomyelitis than to those in MS. Our findings suggest that in most cases, BCS-like lesions denote the presence of a disease entity immunologically distinct from MS. In addition, we provide data on the demographics, clinical course and radiological features of BCS based on the largest cohort analysed to date.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - C Würthwein
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - J R Behrens
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J Wanner
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - F Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Agarwal M, Ulmer JL, Klein AP, Mark LP. Why Is This Auntminnie a Diagnostic Conundrum?: A Knowledge-Based Approach to Balo's Concentric Sclerosis From Reports of 3 Cases and Pooled Data From 68 Other Patients in the Literature. Curr Probl Diagn Radiol 2018; 48:415-422. [PMID: 29428181 DOI: 10.1067/j.cpradiol.2017.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We came across 3 cases of Balo's concentric sclerosis (BCS). The first of these patients presented to an outside hospital and was transferred to our institution due to complications resulting from a biopsy. The other 2 patients, despite having a characteristic imaging appearance and despite insistence on our part on the diagnosis of BCS, underwent a surgical procedure, which could have been prevented. This led us to review the available literature on BCS. MATERIAL AND METHODS A total of 68 patients diagnosed with BCS between 1995 and 2015 were studied and the data collected for the clinical presentation and course, imaging, spinal fluid analysis, treatment, and clinical and imaging outcome. CONCLUSIONS A 25% surgery rate (biopsy or resection) was found in the study. We concluded that this relatively high surgery rate in this auntminnie nonsurgical disease is multifactorial; and includes factors like nonfamiliarity with the disease, anxiety on the part of patients and physicians, due to a sometimes rapidly deteriorating clinical picture; and resemblance of the disease with other entities such as tumor and infection. However, characteristic imaging appearance combined with acute or subacute presentation and dramatic improvement in clinical status after high-dose steroid chemotherapy; are highly suggestive of the disease, and can prevent unnecessary surgery.
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Affiliation(s)
- Mohit Agarwal
- Section of Neuroradiology, Medical College of Wisconsin, Milwaukee, WI.
| | - John L Ulmer
- Section of Neuroradiology, Medical College of Wisconsin, Milwaukee, WI
| | - Andrew P Klein
- Section of Neuroradiology, Medical College of Wisconsin, Milwaukee, WI
| | - Leighton P Mark
- Section of Neuroradiology, Medical College of Wisconsin, Milwaukee, WI
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Sánchez P, Meca-Lallana V, Barbosa A, Manzanares R, Palmí I, Vivancos J. Tumefactive demyelinating lesions of 15 patients: Clinico-radiological features, management and review of the literature. J Neurol Sci 2017; 381:32-38. [PMID: 28991707 DOI: 10.1016/j.jns.2017.08.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/28/2017] [Accepted: 08/07/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Tumefactive demyelinating lesions (TDLs) are large inflammatory lesions that can mimic tumors or other space-occupying lesions. Differential diagnosis and management of these lesions remain challenging for neurologists. We aim to review the clinico-radiological features of patients with TDLs, as well as their management. METHODS We performed a retrospective review of cases of TDLs treated in our center from January 2010 to February 2017. We reviewed the literature. RESULTS Out of 711 patients, we found 15 with TDLs (12 women and 3 men), with a mean age of TDL onset of 36years. Out of the 15 patients, 9 had TDLs as a first demyelinating event and 44% (4/15) of these converted to MS by McDonald 2010 criteria in a mean time of 8months (SD 3.10). Clinical presentation was polysymptomatic and the most common radiological findings included solitary lesions (66.66%), located primarily in the frontal (40%) or parietal (33%) lobes, showing mostly an infiltrative morphological pattern (50%) and an open-ring enhancement (43%). Multiple Sclerosis was the most common diagnosis (67%, 10/15). Acute treatment included steroids, plasmapheresis, rituximab and cyclophosphamide. CONCLUSIONS Prevalence of tumefactive demyelination in MS was higher than expected in MS patients, according to literature. Time to conversion to MS was significantly shorter than other published series. Clinical presentation was polysymptomatic and the most common radiological findings were isolated frontal lesions with an open-ring enhancement.
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Affiliation(s)
- Pedro Sánchez
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
| | - Virginia Meca-Lallana
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Antonio Barbosa
- Neuroradiology Section, Radiodiagnostic Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Rafael Manzanares
- Neuroradiology Section, Radiodiagnostic Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Itziar Palmí
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - José Vivancos
- Demyelinating Disorders Unit, Neurology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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Tremblay MA, Villanueva-Meyer JE, Cha S, Tihan T, Gelfand JM. Clinical and imaging correlation in patients with pathologically confirmed tumefactive demyelinating lesions. J Neurol Sci 2017; 381:83-87. [PMID: 28991721 DOI: 10.1016/j.jns.2017.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 07/21/2017] [Accepted: 08/08/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To characterize clinical and imaging features in patients with pathologically confirmed demyelinating lesions. METHODS In this retrospective chart review, we analyzed clinical-radiological-pathological correlations in patients >15years old who underwent brain biopsy at our institution between 2000 and 2015 and had inflammatory demyelination on neuropathology. RESULTS Of 31 patients, the mean age was 42years (range 16 to 69years) and 55% were female. All but one of the biopsied lesions were considered tumefactive demyelinating lesions (TDLs) by imaging criteria, measuring >2cm on contrast-enhanced brain MRI. On clinical follow-up, the final diagnosis was a CNS malignancy in 2 patients (6.5%). In patients without malignant tumor, the TDL was solitary in 12 (41%) and multifocal in 17 (59%), with contrast enhancement in all but one case, primarily in an incomplete rim enhancement pattern (75.9%). Of 16 patients with at least 12months of clinical follow-up, 7 (43.8%) had a clinical relapse. Of patients without a prior neurologic history, relapse occurred in 2/7 (29%) in solitary TDL and 2/6 (33%) in multifocal lesions at initial presentation. Recurrent TDLs occurred in 3 patients, all with initially solitary TDLs. Stratifying by CSF analysis, 4 of 6 patients (67%) with either an elevated IgG Index or >2 oligoclonal bands suffered a clinical relapse compared to 2/8 (25%) with non-inflammatory CSF. CONCLUSIONS Pathologically confirmed TDLs call for careful clinical correlation, clinical follow-up and imaging surveillance. Although sometimes clinically monophasic, tumefactive demyelinating lesions carried nearly a 45% risk of near-term clinical relapse in our study, even when presenting initially as a solitary mass lesion.
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Affiliation(s)
- Matthew A Tremblay
- MS Center, Department of Neurology, University of California, San Francisco, Box 3014, 1500 Owens St, Ste 320, San Francisco, CA 94158, United States.
| | - Javier E Villanueva-Meyer
- Neuroradiology Division, Department of Radiology, University of California, San Francisco, 350 Parnassus Ave, Box 0336, Ste 307H, San Francisco, CA 94143-0628, United States.
| | - Soonmee Cha
- Neuroradiology Division, Department of Radiology, University of California, San Francisco, 350 Parnassus Ave, Box 0336, Ste 307H, San Francisco, CA 94143-0628, United States.
| | - Tarik Tihan
- Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, Box 0102, San Francisco, CA 94143-0102, United States.
| | - Jeffrey M Gelfand
- MS Center, Department of Neurology, University of California, San Francisco, Box 3014, 1500 Owens St, Ste 320, San Francisco, CA 94158, United States.
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Popova EV, Bryukhov VV, Boyko AN, Krotenkova MV, Konovalova OE, Sharanova SN. [Atypical multiple sclerosis - Balo's concentric sclerosis: two case-reports and a review]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:50-53. [PMID: 28617361 DOI: 10.17116/jnevro20171172250-53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article presents two clinical cases of patients diagnosed with Balo's concentric sclerosis. Distinctive features of the pathogenesis in the aspect of differential diagnosis from other forms of multiple sclerosis and possible treatment are discussed.
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Affiliation(s)
- E V Popova
- Interregional Department of Multiple Sclerosis at Moscow Clinical Hospital #24, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - A N Boyko
- Interregional Department of Multiple Sclerosis at Moscow Clinical Hospital #24, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - O E Konovalova
- Interregional Department of Multiple Sclerosis at Moscow Clinical Hospital #24, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | - S N Sharanova
- Pirogov Russian National Research Medical University, Moscow, Russia
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40
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Tolpeeva OA, Zakharova MN. The diagnostic significance of antibodies to myelin proteins in demyelinating diseases of the central nervous system. NEUROCHEM J+ 2017. [DOI: 10.1134/s1819712417010135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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41
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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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42
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Abstract
The diagnosis of multiple sclerosis is based on neurological symptoms and signs, alongside evidence of dissemination of CNS lesions in space and time. MRI is often sufficient to confirm the diagnosis when characteristic lesions accompany a typical clinical syndrome, but in some patients, further supportive information is obtained from cerebrospinal fluid examination and neurophysiological testing. Differentiation is important from other diseases in which demyelination is a feature (eg, neuromyelitis optica spectrum disorder and acute disseminated encephalomyelitis) and from non-demyelinating disorders such as chronic small vessel disease and other inflammatory, granulomatous, infective, metabolic, and genetic causes that can mimic multiple sclerosis. Advances in MRI and serological and genetic testing have greatly increased accuracy in distinguishing multiple sclerosis from these disorders, but misdiagnosis can occur. In this Series paper we explore the progress and challenges in the diagnosis of multiple sclerosis with reference to diagnostic criteria, important differential diagnoses, controversies and uncertainties, and future prospects.
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Affiliation(s)
- Wallace J Brownlee
- Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK.
| | - Todd A Hardy
- Neuroimmunology Clinic, Concord Hospital and Brain & Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - David H Miller
- Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK; National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
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Hardy TA, Reddel SW, Barnett MH, Palace J, Lucchinetti CF, Weinshenker BG. Atypical inflammatory demyelinating syndromes of the CNS. Lancet Neurol 2016; 15:967-981. [DOI: 10.1016/s1474-4422(16)30043-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/02/2016] [Accepted: 04/11/2016] [Indexed: 02/06/2023]
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44
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Hardy TA, Tobin WO, Lucchinetti CF. Exploring the overlap between multiple sclerosis, tumefactive demyelination and Baló's concentric sclerosis. Mult Scler 2016; 22:986-92. [PMID: 27037180 DOI: 10.1177/1352458516641776] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/07/2016] [Indexed: 12/26/2022]
Abstract
The availability of magnetic resonance imaging (MRI) has led to increasing recognition that multiple sclerosis (MS), tumefactive demyelination (TD) and Baló's concentric sclerosis (BCS) share many overlapping features. Baló-like lesions, which exhibit limited features of BCS, may represent an intermediate between BCS and typical MS demyelination. Lesions labeled as tumefactive are typically larger, but otherwise have much in common with conventional MS lesions, and TD and BCS lesions can also overlap. In this article, we explore the similarities between typical MS, TD and BCS cases, and reflect on the potential insights that intermediate or overlapping phenotypes may contribute towards an understanding of MS immunopathogenesis, and question whether these atypical forms of demyelination should be classified as separate demyelinating diseases, as different lesional manifestations of demyelination of any cause or as part of a spectrum with conventional MS.
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Affiliation(s)
- Todd A Hardy
- Neuroimmunology Clinic, Department of Neurology, Concord Repatriation General Hospital, University of Sydney, Concord West, NSW, Australia/Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - W Oliver Tobin
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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45
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Tumefactive Demyelinating Lesions in Multiple Sclerosis and Associated Disorders. Curr Neurol Neurosci Rep 2016; 16:26. [DOI: 10.1007/s11910-016-0626-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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46
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Preziosa P, Martinelli V, Moiola L, Radaelli M, Gerevini S, Guidetti D, Immovilli P, Michieletti E, Scagnelli P, Comola M, Rocca M, Filippi M, Comi G. Dynamic pattern of clinical and MRI findings in a tumefactive demyelinating lesion: A case report. J Neurol Sci 2016; 361:184-6. [DOI: 10.1016/j.jns.2015.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/14/2015] [Accepted: 12/23/2015] [Indexed: 01/17/2023]
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47
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Hamed SA. Variant of multiple sclerosis with dementia and tumefactive demyelinating brain lesions. World J Clin Cases 2015; 3:525-532. [PMID: 26090374 PMCID: PMC4468900 DOI: 10.12998/wjcc.v3.i6.525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/26/2014] [Accepted: 03/18/2015] [Indexed: 02/05/2023] Open
Abstract
We describe an unusual clinical and diagnostic feature of a patient with multiple sclerosis (MS). A 25-year-old woman was admitted to the Neurology department (December 2009) with one month history of rapid cognitive deterioration. She had poor cognition, dysphasia, reduction in visual acuity and temporal pallor of the optic discs. She had prolonged latencies of P100 component of visual evoked potentials (VEPs). Magnetic resonance imaging (MRI)-brain showed multifocal large (≥ 3 cm) white-matter hypointense lesions in T1W and hyperintense in T2W and fluid-attenuated inversion recovery images and patchy enhancement. A diagnosis of tumefactive MS was given. She received two consecutive 5-d courses of 1 g daily intravenous methylprednisolone for 2 mo and oral prednisolone in dose of 80 mg twice/daily in between. At the 3rd month, Mini Mental State Examination and VEPs returned to normal but not the MRI. Patient continued oral steroids after hospital discharge (March 2010) for 9 mo with significant MRI improvement after which tapering of steroids started for a year. The patient refused immunomodulation therapy due to her low socioeconomic status. Neither clinical relapse nor new MRI lesions were observed throughout the next 4 years. In spite of the aggressive course of tumefactive MS variant, good prognosis may be seen in some patients.
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Ciampi E, Tur C, Montalban X. Commentary on Pique et al.'s paper entitled: Peripheral late reactivation of a previously typical monofocal Balo's concentric sclerosis lesion. Mult Scler 2015; 21:1084-6. [PMID: 26014610 DOI: 10.1177/1352458515586090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ethel Ciampi
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain/Neurology Department, Hospital Clínico UC, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carmen Tur
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain/Department of Neuroinflammation, University College of London Institute of Neurology, UK
| | - Xavier Montalban
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain
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49
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Purohit B, Ganewatte E, Schreiner B, Kollias S. Balo's Concentric Sclerosis with Acute Presentation and Co-Existing Multiple Sclerosis-Typical Lesions on MRI. Case Rep Neurol 2015; 7:44-50. [PMID: 25873888 PMCID: PMC4386112 DOI: 10.1159/000380813] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Balo's disease also known as Balo's concentric sclerosis (BCS) is a rare demyelinating disorder which is characterized pathologically and radiologically by concentric rings of demyelinated and relatively myelin-preserved white matter. We describe the case of a 25-year-old female presenting with stroke-like symptoms who was diagnosed with BCS on MRI. At clinical onset, she also showed co-existing multiple sclerosis (MS)-typical lesions in the brain. This report extends the recent concept that BCS may share similar pathogenesis and radiological progression as MS lesions, that they may occur simultaneously in the same patient and that they may represent different manifestations of the same disease process. Also, BCS needs not be a fulminant disease and may often show a benign self-limiting course as in our case.
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Affiliation(s)
- Bela Purohit
- Institute for Neuroradiology, University Hospital of Zurich, Switzerland
| | - Eranga Ganewatte
- Institute for Neuroradiology, University Hospital of Zurich, Switzerland
| | - Bettina Schreiner
- Department of Neurology, University Hospital of Zurich, Switzerland ; Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Spyros Kollias
- Institute for Neuroradiology, University Hospital of Zurich, Switzerland
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50
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Abstract
Baló's concentric sclerosis is often regarded as a rare variant of multiple sclerosis. Patients with this disorder present with acute or subacute neurological deterioration, with MRI showing one or more concentrically multilayered ring-like lesions usually in the cerebral white matter. Historically, Baló's concentric sclerosis was thought fatal in all cases. However, the availability of MRI has led to a better appreciation of the variable natural history of patients presenting with radiologically evident Baló lesions and the clinical association with multiple sclerosis and, less often, with other neurological disorders. Important advances have increased understanding of the immunopathogenic mechanisms associated with the formation of Baló lesions. However, how to treat an acute lesion and when or whether to start treatment are less well understood, although for patients with Baló lesions who also fulfil standard diagnostic criteria for multiple sclerosis, our opinion is that treatment with multiple sclerosis disease-modifying therapy would seem reasonable.
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Affiliation(s)
- Todd A Hardy
- Neuroimmunology Clinic, Department of Neurology, Concord Repatriation General Hospital, University of Sydney, NSW, Australia; MS Australia Clinic, Brain and Mind Research Institute, Sydney, NSW, Australia.
| | - David H Miller
- Department of Neuroinflammation, University College London Institute of Neurology, Queen Square MS Centre, London, UK
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