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Cviková M, Štefela J, Všianský V, Dufek M, Doležalová I, Vinklárek J, Herzig R, Zemanová M, Červeňák V, Brichta J, Bárková V, Kouřil D, Aulický P, Filip P, Weiss V. Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature. Front Neurol 2024; 15:1339438. [PMID: 38434197 PMCID: PMC10904644 DOI: 10.3389/fneur.2024.1339438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.
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Affiliation(s)
- Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jakub Štefela
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vít Všianský
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Michal Dufek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Irena Doležalová
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jan Vinklárek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czechia
| | - Markéta Zemanová
- Department of Ophthalmology and Optometry, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vladimír Červeňák
- Department of Medical Imaging, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jaroslav Brichta
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Veronika Bárková
- Department of Clinical Pharmacology, St. Anne's University Hospital, Brno, Czechia
| | - David Kouřil
- Department of Neurology, Blansko Hospital, Blansko, Czechia
| | - Petr Aulický
- Department of Anesthesiology, Hospital of the Brothers of Charity Brno, Brno, Czechia
| | - Pavel Filip
- Department of Neurology, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czechia
- Center for Magnetic Resonance Research (CMRR), University of Minnesota, Minneapolis, MN, United States
| | - Viktor Weiss
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
- Department of Neurology, Charles University Faculty of Medicine, Hradec Králové, Czechia
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Cohen DA, Tajfirouz D, Vodopivec I, Kyle K, Bouffard MA, Bhattacharyya S, Douglas VC, Rasool N, Bhatti MT, McKeon A, Pittock S, Flanagan EP, Prasad S, Nagagopal V, Egan RA, Chen JJ, Chwalisz BK. Fluorescein Angiography Findings in Susac Syndrome: A Multicenter Retrospective Case Series. J Neuroophthalmol 2023; 43:481-490. [PMID: 37075250 DOI: 10.1097/wno.0000000000001826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
BACKGROUND Susac syndrome is a vasculopathy, resulting in the classic triad of branch retinal artery occlusion (BRAO), inner ear ischemia, and brain ischemia. In this retrospective chart review, we characterize fluorescein angiography (FA) findings and other ancillary studies in Susac syndrome, including the appearance of persistent disease activity and the occurrence of new subclinical disease on FA. METHODS This multicenter, retrospective case series was institutional review board-approved and included patients with the complete triad of Susac syndrome evaluated with FA, contrasted MRI of the brain, and audiometry from 2010 to 2020. The medical records were reviewed for these ancillary tests, along with demographics, symptoms, visual acuity, visual field defects, and findings on fundoscopy. Clinical relapse was defined as any objective evidence of disease activity during the follow-up period after initial induction of clinical quiescence. The main outcome measure was the sensitivity of ancillary testing, including FA, MRI, and audiometry, to detect relapse. RESULTS Twenty of the 31 (64%) patients had the complete triad of brain, retinal, and vestibulocochlear involvement from Susac syndrome and were included. Median age at diagnosis was 43.5 years (range 21-63), and 14 (70%) were women. Hearing loss occurred in 20 (100%), encephalopathy in 13 (65%), vertigo in 15 (75%), and headaches in 19 (95%) throughout the course of follow-up. Median visual acuity at both onset and final visit was 20/20 in both eyes. Seventeen (85%) had BRAO at baseline, and 10 (50%) experienced subsequent BRAO during follow-up. FA revealed nonspecific leakage from previous arteriolar damage in 20 (100%), including in patients who were otherwise in remission. Of the 11 episodes of disease activity in which all testing modalities were performed, visual field testing/fundoscopy was abnormal in 4 (36.4%), MRI brain in 2 (18.2%), audiogram in 8 (72.7%), and FA in 9 (81.8%). CONCLUSIONS New leakage on FA is the most sensitive marker of active disease. Persistent leakage represents previous damage, whereas new areas of leakage suggest ongoing disease activity that requires consideration of modifying immunosuppressive therapy.
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Affiliation(s)
- Devon A Cohen
- Cleveland Clinic (DAC), Cleveland, Ohio; Mayo Clinic (DT, MTB, AM, SP, EPF, JJC), Rochester, Minnesota; Roche (IV), Basel, Switzerland; Massachusetts General Hospital (KK, VN, BKC), Boston, Massachusetts; Beth Israel Deaconess (MAB), Boston, Massachusetts; Brigham and Women's Hospital (SB, SP), Boston, Massachusetts; UCSF (VD, NR), San Francisco, California; and Eye and Vascular Neurology (RE), Carlton, Oregon
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Plantone D, Sabatelli E, Locci S, Marrodan M, Laakso SM, Mateen FJ, Feresiadou A, Buelens T, Bianco A, Fiol MP, Correale J, Tienari P, Calabresi P, De Stefano N, Iorio R. Clinically relevant increases in serum neurofilament light chain and glial fibrillary acidic protein in patients with Susac syndrome. Eur J Neurol 2023; 30:3256-3264. [PMID: 37335505 DOI: 10.1111/ene.15939] [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: 04/18/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND PURPOSE Serum levels of neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising neuro-axonal damage and astrocytic activation biomarkers. Susac syndrome (SS) is an increasingly recognized neurological condition and biomarkers that can help assess and monitor disease evolution are highly needed for the adequate management of these patients. sNfL and sGFAP levels were evaluated in patients with SS and their clinical relevance in the relapse and remission phase of the disease was assessed. METHODS As part of a multicentre study that enrolled patients diagnosed with SS from six international centres, sNfL and sGFAP levels were assessed in 22 SS patients (nine during a relapse and 13 in remission) and 59 age- and sex-matched healthy controls using SimoaTM assay Neurology 2-Plex B Kit. RESULTS Serum NfL levels were higher than those of healthy controls (p < 0.001) in SS patients and in both subgroups of patients in relapse and in remission (p < 0.001 for both), with significantly higher levels in relapse than in remission (p = 0.008). sNfL levels showed a negative correlation with time from the last relapse (r = -0.663; p = 0.001). sGFAP levels were slightly higher in the whole group of patients than in healthy controls (p = 0.046) and were more pronounced in relapse than in remission (p = 0.013). CONCLUSION In SS patients, both sNFL and sGFAP levels increased compared with healthy controls. Both biomarkers had higher levels during clinical relapse and much lower levels in remission. sNFL was shown to be time sensitive to clinical changes and can be useful to monitor neuro-axonal damage in SS.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Eleonora Sabatelli
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | - Sara Locci
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Sini M Laakso
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amalia Feresiadou
- Department of Neurology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Section of Neurology, Uppsala University, Uppsala, Sweden
| | - Tom Buelens
- Department of Ophthalmology, CHU St Pierre and Brugmann, Brussels, Belgium
| | - Assunta Bianco
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | | | - Jorge Correale
- Neurology Department, Fleni, Buenos Aires, Argentina
- Institute of Biological Chemistry and Biophysics (IQUIFIB) CONICET, University of Buenos Aires, Buenos Aires, Argentina
| | - Pentti Tienari
- Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Research Program of Translational Immunology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Masjuan M, Ivanovski T, Sarasibar Ezcurra H, Rigo Oliver E. Behavioral Impairment and Amnesia at the Onset of Susac Syndrome. Cureus 2023; 15:e38089. [PMID: 37252530 PMCID: PMC10209653 DOI: 10.7759/cureus.38089] [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: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Susac syndrome (SS) is an autoimmune microangiopathy that affects the brain, retina, and inner ear, causing a wide range of clinical manifestations. The triad of encephalopathy, visual disturbances, and hearing loss constitute the classic disease presentation. We describe an original clinical case of a young male with a definitive diagnosis of SS, who presented with disordered behavior and amnesia, initially manifested as a dissociative or anxiety disorder but with a fulminant evolution toward severe encephalopathy associated with retinal infarcts and sensorineural hearing loss. After the diagnosis of SS, aggressive immunosuppressive treatment was started with significant neurological improvement and favorable evolution during the follow-up period. SS is a rare but potentially devastating disease that can cause great disability if not properly diagnosed and treated. The onset of SS with behavioral or psychiatric manifestation can be misleading, causing a diagnostic delay.
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Affiliation(s)
- Marc Masjuan
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | - Trajche Ivanovski
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | | | - Elena Rigo Oliver
- Ophthalmology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
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Susac syndrome: A scoping review. Autoimmun Rev 2022; 21:103097. [DOI: 10.1016/j.autrev.2022.103097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/21/2022]
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OUP accepted manuscript. Brain 2022; 145:858-871. [DOI: 10.1093/brain/awab476] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
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David C, Sacré K, Papo T. [Update on Susac syndrome]. Rev Med Interne 2021; 43:26-30. [PMID: 34119343 DOI: 10.1016/j.revmed.2021.05.014] [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: 03/16/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
Susac syndrome is a rare disease affecting mainly young women, characterized by a microangiopathy limited to the cerebral, retinal, and cochlear vessels. Although the pathophysiology of Susac syndrome is not yet fully elucidated, recent advances favour a primitive vasculitis affecting the cerebral, retinal and cochlear small vessels. Susac syndrome must be recognized in the presence of the pathognomonic clinical triad associating: 1/subacute encephalopathy with unusual headache and pseudopsychiatric features associated with diffuse white matter, grey matter nuclei and specifically corpus callosum lesions on brain MRI; 2/eye involvement that may be pauci-symptomatic, with occlusions of the branches of the central artery of the retina at fundoscopy and arterial wall hyperfluorescence on fluorescein angiography; and 3/cochleo-vestibular damage with hearing loss predominating at low frequencies on the audiogram. Relapses are frequent during an active period lasting approximately 2 years. Eventually, the disease resolves but isolated retinal arterial wall hyperfluorescence without new occlusions may recur, which should not lead to treatment intensification. First-line treatment consists of a combination of anti-aggregants and high dose corticosteroids. In refractory patients or in case of relapse, immunomodulatory molecules such as intravenous immunoglobulins or immunosuppressive drugs such as mycophenolate mofetil, cyclophosphamide or rituximab should be started. Unfortunately, sequelae-mostly hearing loss- remain frequent in these young patients.
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Affiliation(s)
- C David
- Service de médecine interne, Hôpital Bichat, Paris, France
| | - K Sacré
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - T Papo
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France.
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