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Basagni B, Abbruzzese L, Radicchi G, Damora A, Salti G, Malentacchi GM, Caputo N, Zoccolotti P, Scarselli C, Mancuso M. Cognitive profile in a young woman with Susac syndrome: a case report. Neurocase 2024:1-8. [PMID: 38869248 DOI: 10.1080/13554794.2024.2366457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 06/04/2024] [Indexed: 06/14/2024]
Abstract
Susac syndrome is a rare immune-mediated endotheliopathy affecting the microvasculature. It presents three main symptoms: encephalopathy, branch retinal artery occlusions, and hearing loss . Here we present a new case report focusing on the evolution of the cognitive profile. The patient underwent two neuropsychological examinations. The first, one month after the onset of the symptomatology, highlighted a prevalent involvement of verbal executive functions. The second, conducted six months later, revealed a global improvement in most previously deficient areas, although with the persistence of a difficulty in cognitive estimation. . This case illustrates the importance of a comprehensive analysis of patients with Susac syndrome to appreciate the whole range of cognitive deficits and reliably evaluate symptom evolution.
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Affiliation(s)
| | | | | | | | - Giulia Salti
- Tuscany Rehabilitation Clinic, Montevarchi, Italy
| | | | | | - Pierluigi Zoccolotti
- Tuscany Rehabilitation Clinic, Montevarchi, Italy
- Sapienza University, Rome, Italy
| | | | - Mauro Mancuso
- Physical and Rehabilitative Medicine Unit, NHS ASL-Toscana Sud-Est, Grosseto, Italy
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2
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Wilf-Yarkoni A, Zmira O, Tolkovsky A, Pflantzer B, Gofrit SG, Kleffner I, Paul F, Dörr J. Clinical Characterization and Ancillary Tests in Susac Syndrome: A Systematic Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200209. [PMID: 38364193 DOI: 10.1212/nxi.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 02/18/2024]
Abstract
Susac syndrome (SuS) is an orphan microangiopathic disease characterized by a triad of encephalopathy, visual disturbances due to branch retinal artery occlusions, and sensorineuronal hearing loss. Our previous systematic review on all cases of SuS reported until 2012 allowed for a better understanding of clinical presentation and diagnostic findings. Based on these data, we suggested diagnostic criteria in 2016 to allow early diagnosis and treatment of SuS. In view of the accumulation of new SuS cases reported in the last 10 years and improved diagnostic tools, we here aimed at updating the demographic and clinical features of SuS and to review the updated ancillary tests being used for SuS diagnosis. Therefore, based on the 2016 criteria, we systematically collected and evaluated data on SuS published from January 2013 to March 2022.
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Affiliation(s)
- Adi Wilf-Yarkoni
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Ofir Zmira
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Assaf Tolkovsky
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Barak Pflantzer
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Shany G Gofrit
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Ilka Kleffner
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Friedemann Paul
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Jan Dörr
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
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Van Vrekhem T, Miatton M, Hemelsoet D, Van Hijfte L, Dekeyser C, De Zaeytijd J, Van Driessche V, Van Hoecke H, Maes L, Laureys G. Cognitive outcomes in Susac syndrome: A 2-year neuropsychological follow-up study. Eur J Neurol 2024; 31:e16186. [PMID: 38308420 DOI: 10.1111/ene.16186] [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: 09/19/2023] [Revised: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND AND PURPOSE Susac syndrome (SuS) is a rare, autoimmune, neurological disease characterized by a clinical triad of branch retinal artery occlusion, sensorineural hearing loss and encephalopathy. Neuropsychological functioning in SuS is little researched and the prevalence, nature, and evolution over time of cognitive deficits in SuS remain unclear. This study aimed to better understand the long-term neuropsychological outcomes of patients with SuS. METHODS Thirteen patients with SuS (mean [SD] age 39.5 [11.1] years) were enrolled at the Ghent University Hospital by their treating neurologist. The cognitive functioning and emotional well-being of each patient was evaluated by means of a thorough neuropsychological test battery at baseline and after 2 years. Follow-up testing after 2 years was performed in 11 patients (mean [SD] age 42.2 [11.5] years). RESULTS Patients showed normal neuropsychological test results at a group level, both at baseline and follow-up testing. Significant improvements over time were found for information processing speed, verbal recognition, and semantic and phonological fluency. Individual test results showed interindividual variability at baseline, with most impairments being in attention, executive functioning and language, which improved after a 2-year period. In addition, patients reported significantly lower mental and physical well-being, both at baseline and follow-up testing. CONCLUSIONS Our results suggest that neuropsychological dysfunction in SuS is limited at a group level and improves over time. Nonetheless, individual test results reveal interindividual variability, making cognitive screening essential. Furthermore, a high psycho-emotional burden of the disease was reported, for which screening and follow-up are necessary.
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Affiliation(s)
| | - Marijke Miatton
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | | | | | | | - Julie De Zaeytijd
- Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium
| | | | - Helen Van Hoecke
- Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | - Leen Maes
- Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
| | - Guy Laureys
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
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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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Tsikvadze M, Machado De Villafane B, Rose M, Peacock S, Peel JB, Ng L, Kramer C, Freeman WD. Diffuse Cerebral Edema With Uncal Herniation Leading to Brain Death in Patient With Fulminant Susac syndrome: Rare Complication of Rare Disease. Neurohospitalist 2024; 14:87-94. [PMID: 38235024 PMCID: PMC10790605 DOI: 10.1177/19418744231196625] [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: 01/19/2024] Open
Abstract
Susac Syndrome was first described as an inflammatory microangiopathy of the brain and retina. Since then, multiple articles have been published in attempts to improve the understanding of this rare disease. Clinically Susac Syndrome is known to present with triad of encephalopathy, sensorineural hearing loss and branch of retinal artery occlusion (BRAO), along with characteristic "snowball" or "spoke" appearing white matter lesions of the corpus callosum. It has been characterized by vast heterogeneity in terms of its presenting symptoms, severity, and clinical course. Although subset of patients present with severe forms of Susac Syndrome and can develop prominent residual neurologic deficits, it has been reported to be mostly non-life-threatening and only few fatal cases have been described in the literature. Based on the available case reports with fatal outcome, mortality has been related to the systemic complications either during acute disease flare or during chronic-progressive phase. We describe a case of fulminant Susac Syndrome complicated by the sudden and rapid progression of diffuse cerebral edema leading to brain herniation and ultimate brain death, in order to increase awareness of this rare and catastrophic complication.
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Affiliation(s)
- Mariam Tsikvadze
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Mariah Rose
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Sarah Peacock
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jeffrey Brent Peel
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Lauren Ng
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Christopher Kramer
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - William D. Freeman
- Department of Neurocritical Care, Mayo Clinic Florida, Jacksonville, FL, USA
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Kiely C, Douglas KAA, Douglas VP, Miller JB, Lizano P. Overlap between ophthalmology and psychiatry - A narrative review focused on congenital and inherited conditions. Psychiatry Res 2024; 331:115629. [PMID: 38029629 PMCID: PMC10842794 DOI: 10.1016/j.psychres.2023.115629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023]
Abstract
A number of congenital and inherited diseases present with both ocular and psychiatric features. The genetic inheritance and phenotypic variants play a key role in disease severity. Early recognition of the signs and symptoms of those disorders is critical to earlier intervention and improved prognosis. Typically, the associations between these two medical subspecialties of ophthalmology and psychiatry are poorly understood by most practitioners so we hope to provide a narrative review to improve the identification and management of these disorders. We conducted a comprehensive review of the literature detailing the diseases with ophthalmic and psychiatric overlap that were more widely represented in the literature. Herein, we describe the clinical features, pathophysiology, molecular biology, diagnostic tests, and the most recent approaches for the treatment of these diseases. Recent studies have combined technologies for ocular and brain imaging such as optical coherence tomography (OCT) and functional imaging with genetic testing to identify the genetic basis for eye-brain connections. Additional work is needed to further explore these potential biomarkers. Overall, accurate, efficient, widely distributed and non-invasive tests that can help with early recognition of these diseases will improve the management of these patients using a multidisciplinary approach.
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Affiliation(s)
- Chelsea Kiely
- Department of Psychiatry, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, 612, Boston, MA, United States
| | - Konstantinos A A Douglas
- Department of Psychiatry, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, 612, Boston, MA, United States; Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, United States
| | | | - John B Miller
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, United States; Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA, United States; Department of Ophthalmology, Harvard Medical School, Boston, MA, United States
| | - Paulo Lizano
- Department of Psychiatry, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, 612, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States; Division of Translational Neuroscience, Beth Israel Deaconess Medical Center, Boston, MA, United States.
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Stinissen R, Tukanov E, Wyckmans M, Kerstens J, Willekens B. Clinical characteristics and treatment approaches in patients with Susac syndrome: a scoping review of cases. J Neurol 2023; 270:5719-5730. [PMID: 37668702 DOI: 10.1007/s00415-023-11936-3] [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: 05/19/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Susac syndrome (SuS) is a rare disease characterized by encephalopathy, hearing impairment and visual disturbances. Immunosuppressive treatments are used based on the hypothesis that an autoimmune endotheliopathy drives the disease. However, a solid evidence-based treatment approach is lacking. The aim of this review is to provide an overview of patient characteristics, disease course and treatment patterns related to successful outcome that have been reported in literature since 2013. METHODS Three reviewers conducted a systematic literature search in February 2022. The primary outcome was treatment used, derived from cases classified as probable or definite SuS, describing successful treatment outcome (i.e. no signs of disease activity for ≥ 1 month). Secondary outcomes were time-to-relapse and follow-up time. Published case reports and case series were included. Various clinical characteristics and treatment(s) were extracted and categorized into different phases of treatment. RESULTS A total of 810 records was identified. 120 articles met inclusion criteria and 161 cases were extracted. Of these, 151 cases were classified as probable or definite SuS and included in the final analysis. Number of combinations of treatments used per treatment phase were: 6 empirically, 35 after confirmed diagnosis, 43 for maintenance treatment, 22 after relapse, 18 during maintenance post-relapse. Median follow-up time was 12.3 months (0.5; 120) and median time to relapse was 4 months (1; 120). CONCLUSION This scoping review summarizes treatment approaches in patients with SuS, highlighting variability. International efforts to collect clinical, imaging and treatment data from patients with SuS in registries are needed, in order to provide less biased and long-term follow-up information on treatment response, predictors of relapse and patient outcomes. This may lead to more evidence-based therapeutic approaches.
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Affiliation(s)
- Robin Stinissen
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Eldar Tukanov
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Martin Wyckmans
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Jeroen Kerstens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium.
- Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.
- Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.
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8
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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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Bose S, Papathanasiou A, Karkhanis S, Appleton JP, King D, Batra R, Mollan SP, Jacob S. Susac syndrome: neurological update (clinical features, long-term observational follow-up and management of sixteen patients). J Neurol 2023; 270:6193-6206. [PMID: 37608221 PMCID: PMC10632257 DOI: 10.1007/s00415-023-11891-z] [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: 02/09/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/24/2023]
Abstract
Susac syndrome is a likely autoimmune microangiopathy affecting the brain, retina and inner ear. Due to the rarity of this condition, diagnosis and treatment can be challenging. Diagnosis is based on the presence of the clinical triad of central nervous system dysfunction, branch retinal artery occlusions and sensorineural hearing loss. Typical MRI findings of callosal and peri-callosal lesions may assist in diagnosis. Clinical course can be monophasic, polycyclic or chronic continuous. It is important to look out for red flags to attain an accurate diagnosis and follow a therapeutic algorithm based on severity of the disease and response to treatment. Patients are treated with steroids and immunosuppressive agents with a variable response. Early aggressive treatment especially in severe cases, may help in preventing relapses and morbidity/disability. This study highlights important diagnostic features and proposes a treatment algorithm based on clinical experience from management of 16 patients from 2 neuroscience centres in the UK since 2007, who were followed up over a long period of 3-15 years.
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Affiliation(s)
- Smriti Bose
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | | | - Sameep Karkhanis
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Jason P Appleton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, Birmingham, UK
| | - Dominic King
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Ruchika Batra
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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10
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Terrabuio E, Zenaro E, Constantin G. The role of the CD8+ T cell compartment in ageing and neurodegenerative disorders. Front Immunol 2023; 14:1233870. [PMID: 37575227 PMCID: PMC10416633 DOI: 10.3389/fimmu.2023.1233870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
CD8+ lymphocytes are adaptive immunity cells with the particular function to directly kill the target cell following antigen recognition in the context of MHC class I. In addition, CD8+ T cells may release pro-inflammatory cytokines, such as tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ), and a plethora of other cytokines and chemoattractants modulating immune and inflammatory responses. A role for CD8+ T cells has been suggested in aging and several diseases of the central nervous system (CNS), including Alzheimer's disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, limbic encephalitis-induced temporal lobe epilepsy and Susac syndrome. Here we discuss the phenotypic and functional alterations of CD8+ T cell compartment during these conditions, highlighting similarities and differences between CNS disorders. Particularly, we describe the pathological changes in CD8+ T cell memory phenotypes emphasizing the role of senescence and exhaustion in promoting neuroinflammation and neurodegeneration. We also discuss the relevance of trafficking molecules such as selectins, mucins and integrins controlling the extravasation of CD8+ T cells into the CNS and promoting disease development. Finally, we discuss how CD8+ T cells may induce CNS tissue damage leading to neurodegeneration and suggest that targeting detrimental CD8+ T cells functions may have therapeutic effect in CNS disorders.
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Affiliation(s)
- Eleonora Terrabuio
- Department of Medicine, Section of General Pathology, University of Verona, Verona, Italy
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11
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Jiang F, Ma Z, Chen Z, Yang M, Huang H, Chen L, He C. Susac syndrome can be diagnosed by examination and cured by comprehensive therapy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 171:329-337. [PMID: 37783562 DOI: 10.1016/bs.irn.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
- Feifei Jiang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang, P.R. China.
| | - Zhiming Ma
- Department of Neurosurgery, Urumqi General Hospital of Lanzhou Military Region, Urumqi, Xinjiang, P.R. China
| | - Zhizhi Chen
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang, P.R. China
| | - Ming Yang
- Department of Neurology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, Zhejiang, P.R. China
| | - Hongyun Huang
- Beijing Hongtianji Neuroscience Academy, Beijing, P.R. China
| | - Lin Chen
- Department of Neurosurgery, Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing, P.R. China
| | - Chao He
- Department of Neurosurgery, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji, Zhejiang, P.R. China.
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12
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Fisher L, David P, Sobeh T, Liberman RB, Amital H. Susac syndrome following COVID-19 vaccination: a case-based review. Clin Rheumatol 2023; 42:1713-1717. [PMID: 36877303 PMCID: PMC9986653 DOI: 10.1007/s10067-023-06564-1] [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: 10/23/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 03/07/2023]
Abstract
COVID-19 vaccine circulation approval was a turning point for the coronavirus pandemic. The current approved COVID-19 vaccines, including messenger ribonucleic acid (mRNA)-based and adenovirus vector-based vaccines, were shown to significantly reduce the disease mortality and severity, and its adverse reactions are mainly mild ones. However, few cases of autoimmune conditions, both flare-ups and new-onset, were described in association with these vaccines. Susac vasculitis (SaS) is a rare autoimmune disease characterized by the clinical triad of encephalopathy, visual disturbances, and sensorineural hearing loss. Its pathogenesis is still not fully understood but is believed to be related to autoimmune processes, including autoantibodies to anti-endothelial cells and cellular immune processes that lead to microvascular damage and, consequently, micro-occlusions of the cerebral, inner ear, and retinal vessels. It has been previously described following vaccination and, most recently, few cases following coronavirus vaccines. We here describe a case of a previously healthy 49-year-old man diagnosed with SaS 5 days following the first dose of the BNT162b2 COVID-19 vaccine.
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Affiliation(s)
- Lior Fisher
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Paula David
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamer Sobeh
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Diagnostic Imaging, Sheba Medical Center, Tel-Hashomer, Israel
| | - Roberta Bisker Liberman
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Pontifical Catholic University of São Paulo, São Paulo, Brazil
| | - Howard Amital
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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13
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RETINAL FLUORESCEIN ANGIOGRAPHY IN SUSAC SYNDROME: A SHIFTING PATTERN OF ARTERIOLAR WALL HYPERFLUORESCENCE-A REPORT OF TWO CASES. Retin Cases Brief Rep 2023; 17:160-164. [PMID: 36821470 DOI: 10.1097/icb.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Susac syndrome consists of the triad of encephalopathy, branch retinal artery occlusion, and hearing loss and is believed to be an immune-mediated endotheliopathy. Arteriolar wall hyperfluorescence (AWH) on retinal fluorescein angiography (FA) has been described in the literature as a classic ophthalmic sign for Susac syndrome. In this article, we report a pattern of distally shifting segments of AWH on FA over time that was observed in two cases. METHODS Two cases of Susac syndrome are presented with an emphasis on FA findings, obtained at frequent intervals during follow-up. RESULTS In both cases, FA displays a shifting pattern of segments of AWH distal to the localization of the AWH observed on the previous FA. CONCLUSION In patients with Susac syndrome, FA plays an important role in aiding diagnosis and monitoring the efficacy of treatment and disease activity during follow-up. In these two cases, the angiography revealed how the AWH can migrate along the vessel over time. This is the first published report showing an evolving distally shifting pattern of AWH in patients with Susac syndrome.
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14
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Andour H, Rostoum S, Regragui Y, Fikri M, Jiddane M, Touarsa F. Fulminant Susac syndrome-a rare cause of coma: The history of the fatal course in a young man. SAGE Open Med Case Rep 2023; 11:2050313X221149826. [PMID: 36756223 PMCID: PMC9899952 DOI: 10.1177/2050313x221149826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/19/2022] [Indexed: 02/05/2023] Open
Abstract
Susac syndrome is a rare microangiopathy of indeterminate etiology, presumably autoimmune, characterized by a triad of encephalopathy, sensorineural hearing loss, and branch retinal artery occlusions occurring predominantly in women. The onset and progression patterns are multiple, mainly of three modes. Fulminant evolution is exceptional, rarely reported across literature. We report through this case a Susac syndrome in a young man in whom evolution was fatal. Magnetic resonance imaging is essential to raise the diagnosis and for follow-up, with almost pathognomonic findings, all the more useful as the clinical triad is usually incomplete and as the encephalopathy is the most limiting of the symptoms.
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Affiliation(s)
- Hajar Andour
- Department of Neuroradiology, Specialty
Hospital, Rabat, Morocco,Hajar Andour, Department of Neuroradiology,
Specialty Hospital, Hay Riad, Rabat 10100, Morocco.
| | - Soufiane Rostoum
- Department of Neuroradiology, Specialty
Hospital, Rabat, Morocco
| | - Yassine Regragui
- Department of Anesthesiology and
Reanimation, Ibn Sina Hospital, Rabat, Morocco
| | - Meriem Fikri
- Department of Neuroradiology, Specialty
Hospital, Rabat, Morocco
| | - Mohamed Jiddane
- Head of Department of Neuroradiology,
Specialty Hospital, Rabat, Morocco
| | - Firdaous Touarsa
- Department of Neuroradiology, Specialty
Hospital, Rabat, Morocco
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15
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Wu G, Jiang W, Li Z, Huang D, Wu L. Misdiagnosis of Susac syndrome as demyelinating disease and primary angiitis of the central nervous system: A case report. Front Neurol 2022; 13:1055038. [PMID: 36570458 PMCID: PMC9772262 DOI: 10.3389/fneur.2022.1055038] [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] [Received: 09/27/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Susac syndrome (SuS) is a rare neuroinflammatory disease that manifests with a triad of hearing loss, branch retinal artery occlusions, and encephalopathy. Patients with SuS are frequently misdiagnosed because the clinical trial is incompletely present at disease onset. In this report, we present a case of a 29-year-old man manifesting sleepiness, epilepsy, urinary dysfunction, and hemiparesis at the initial stage. Magnetic resonance imaging (MRI) revealed multiple abnormal signals located in the lateral paraventricular, corpus callosal, and pons. In addition, the patient had sustained elevation of CSF pressure and protein. ADEM was considered according to the clinical and radiographic findings. However, symptoms were not significantly improved after methylprednisolone therapy. He showed a vision decline in the third month after the disease onset. It was considered from intracranial hypertension or optic neuritis, and therefore retinal arteriolar impairment was ignored. As the disease progresses, cognitive decline was presented. Brain MRI exhibits multiple significant hyperintensities on the DWI sequence with speck-like gadolinium enhancement. Thus, PACNS was diagnosed. The SuS was not made until the presence of hearing decline in the 4 months after the disease onset. The case will be helpful for clinicians to better recognize the atypical initial manifestation of SuS.
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Affiliation(s)
- Gang Wu
- Department of Neurology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China,Department of Neurology, No 984 Hospital of PLA, Beijing, China
| | - Wei Jiang
- Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, Netherlands
| | - Zunbo Li
- Department of Neurology, Xi'an Gao Xin Hospital, Xi'an, China
| | - Dehui Huang
- Department of Neurology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China,*Correspondence: Dehui Huang
| | - Lei Wu
- Department of Neurology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China,Lei Wu
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16
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Ahmed S, Khan TA, Liaqat T, Ijaz U, Sarfaraz H. A young soldier with Susac syndrome: a case report. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Susac syndrome is a rare disease with multisystem manifestations. While the exact pathogenesis is not known, it has been proposed to be an autoimmune endotheliopathy affecting the microvasculature of the brain, retina, and inner ear. The disease is characterized by a triad of encephalopathy, vision loss, and hearing loss. However, patients may not have the triad at initial presentation and present with only a single finding.
Case presentation
A 25-year-old male resident of Panu Akil presented to Combined Military Hospital Lahore with complaints of dizziness and vertigo associated with severe migraine like headaches. He experienced sudden painless loss of vision in his right eye and was admitted to the medical intensive care unit. On examination, he had right-beating nystagmus and diplopia along with scintillating scotoma. After his admission, contrast-enhanced magnetic resonance imaging (MRI) was done which showed numerous enhancing bilateral white matter internal capsule micro-infarcts indicating typical “string of pearls” sign and a snowball lesion on the corpus callosum. His fundus fluorescein angiography (FFA) did not exhibit any branched retinal artery occlusions (BRAO). Fundoscopy showed the presence of drusen spots. His pure tone audiometry was unremarkable. Based on the highly characteristic findings present on the MRI, a diagnosis of Susac syndrome was made. He was started on injection methylprednisolone 1 gm IV in 500 ml normal saline over 1 h once a day for 5 days and then once a week for 8 weeks. He was also started on tablet mycophenolate mofetil 500 mg once daily for 7 days. Patient showed marked clinical improvement afterwards.
Conclusions
Susac syndrome is a rare multisystem illness with an often insidious presentation. Patients can be misdiagnosed due to the nonspecific nature of the early complaints present in the disease. High index of suspicion is required for timely diagnosis and adequate management. Although no specific guidelines exist, management consists mainly of immunosuppressants.
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17
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Characteristics and management of Susac syndrome in an emergent country: a multi-center case series from Brazil. Neurol Sci 2022; 43:6449-6460. [DOI: 10.1007/s10072-022-06320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/31/2022] [Indexed: 10/15/2022]
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18
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Song KW, Manzano GS, Kharal GA, Venna N. Case Report of Spinal Cord Involvement in Susac Syndrome Masquerading as a Multiple Sclerosis Mimic. Neurohospitalist 2022; 12:556-558. [PMID: 35755220 PMCID: PMC9214945 DOI: 10.1177/19418744221097473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
We present a unique case of a 59-year-old woman with atypical Susac syndrome and prominent involvement of the spinal cord. She initially presented with progressive headaches, lower extremity weakness and hearing loss. Her MRI brain showed multiple enhancing lesions and her MRI spine showed a T8 enhancing lesion as well as a C2 cord infarct. She was treated with IV methylprednisolone with initial stabilization. However, she developed worsening encephalopathy and lower extremity weakness. Her repeat MRI brain showed new bilateral enhancing lesions and subacute infarcts. Given the increased burden of new lesions, she underwent a brain biopsy, which showed perivascular chronic inflammation within a small vessel distribution. Additionally, fluorescein angiography revealed bilateral branch retinal arterial occlusion (BRAO) and an audiogram demonstrated bilateral sensorineural hearing loss. She was diagnosed with Susac syndrome and treated with IV cyclophosphamide with improvement in her clinical exam. Spinal cord involvement is extremely rare for Susac syndrome, which commonly manifests as the classic triad of encephalopathy, BRAO and hearing loss. Her presentation with myelopathy highlights the importance of considering atypical presentations of well-established syndromes for optimal diagnosis and management.
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Affiliation(s)
- Kun-Wei Song
- Department of Neuro-oncology, Dana-Farber Cancer Center/Massachusetts General Hospital, Boston, MA, USA
| | - Giovanna S. Manzano
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - G. Abbas Kharal
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Nagagopal Venna
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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19
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Barbero P, Vecchio D, Virgilio E, Naldi P, Comi C, Cantello R. Susac Syndrome: an uncommon cause of impaired vision. Neurol Sci 2022; 43:3919-3922. [PMID: 35006444 PMCID: PMC9119872 DOI: 10.1007/s10072-022-05865-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022]
Abstract
A 35-year-old Caucasian woman presented an abrupt onset of bilateral impaired vision, and arrived to our attention two weeks later. She had a previous episode of mild dizziness. She underwent a fluorescein angiography showing branch retinal artery occlusions and a brain magnetic resonance imaging (MRI) revealing several supraand infratentorial FLAIR-hyperintense white matter lesions, two with contrast enhancement. Thrombophilic, autoimmune and infective (including Human Immunodeficiency Virus, Borrelia burgdorferi, Hepatitis B Virus, Hepatitis C Virus, Herpes Simplex Virus 1-2, Varicella Zoster Virus) screening was negative. Cerebrospinal fluid analysis showed intrathecal IgG synthesis. We suspected a Primary Central Nervous System Vasculitis, and intravenous steroids were started. Three months later a second brain MRI showed seven new lesions without contrast enhancement, and she revealed a cognitive impairment and bilateral hearing loss. Reviewing the clinical history and MRI, she fulfilled diagnostic criteria for Susac syndrome. She had two cycles of cyclophosphamide, and recovered in 6 months and then remained stable with metotrexate.
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Affiliation(s)
- Paolo Barbero
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy.
| | - Domizia Vecchio
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
- Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Eleonora Virgilio
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
- Neurology Unit, S. Andrea Hospital, Department of Translational Medicine, University of Piemonte Orientale, Vercelli, Italy
| | - Paola Naldi
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
| | - Cristoforo Comi
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
- Neurology Unit, S. Andrea Hospital, Department of Translational Medicine, University of Piemonte Orientale, Vercelli, Italy
| | - Roberto Cantello
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
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Bugallo González I, García Fernández M, Rodríguez Villa S, Scalcione C. Susac syndrome: The importance of an early diagnosis. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:290-294. [PMID: 35526953 DOI: 10.1016/j.oftale.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/18/2021] [Indexed: 06/14/2023]
Abstract
A 38-year-old man who attended the emergency department with headache, accompanied by vomiting, bradypsychia and gait instability, for which he was admitted to Neurology for study. During his admission, he began to present bilateral hearing loss and blurred vision in the left eye, with areas of arterial occlusion and hyperfluorescence of the arterial wall being observed in the ophthalmological examination. As a result, he was diagnosed with Susac syndrome. He was treated with systemic corticosteroids, as well as with rituximab and subsequently, with intravenous immunoglobulins and mycophenolate mofetil. The patient managed to preserve visual acuity, with gait instability and bilateral hearing loss as sequelae. Early diagnosis of Susac syndrome is important, because a delay in the start of treatment can lead to irreversible sequelae such as deafness, blindness or neurological involvement.
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Affiliation(s)
- I Bugallo González
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
| | - M García Fernández
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - S Rodríguez Villa
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - C Scalcione
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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21
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Hoogewoud F, Kawasaki A, Borruat FX, Guex-Crosier Y. Susac Syndrome: A Case Series. Klin Monbl Augenheilkd 2022; 239:518-522. [PMID: 35472796 DOI: 10.1055/a-1766-6243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Susac syndrome (SS) is an autoimmune disorder that involves the eyes, the brain, and the ears. It is a rare cause of recurrent branch retinal artery occlusion. The purpose of this study was to report cases of SS, highlighting the clinical presentations, therapeutic options, and their outcome. PATIENTS AND METHODS Retrospective case series of patients seen at our institution for SS between 2005 and 2020. Demographics, clinical characteristics, treatment, and outcome were studied. RESULTS Four patients (3 females, mean age 29 years old) were included in the study. According to the recently revised diagnostic criteria, three patients had definite and one patient had probable SS (distinctive ophthalmological and brain involvement without ear involvement). Initial visual acuity (VA) was normal in all eyes, but two patients had unilateral visual field impairment. Gass plaques (defined as yellow-white plaques found in the arteriolar wall away from arterial bifurcations) were observed on fundus examination in all patients. Fluorescein angiography revealed arteriolar wall hyperfluorescence and branch retinal arterial occlusions (BRAOs) in the absence of other signs of intraocular inflammation in all patients. Initial treatment consisted of a high-dose corticosteroid (intravenous or oral) with additional immunosuppressive therapy (azathioprine, intravenous immunoglobulins, mycophenolate mofetil, and/or cyclophosphamide). Residual symptoms were present in all patients and included scotoma (n = 2) and hearing loss (n = 3). CONCLUSION SS is a rare disease with characteristic ophthalmological manifestation. The majority of patients present a crude form of the triad, and retinal findings may be the first initial manifestation. Ophthalmologists should consider the possibility of an SS in all young patients presenting with BRAOs.
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Affiliation(s)
- Florence Hoogewoud
- Ocular Immunology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
| | - Aki Kawasaki
- Neuro-ophtalmology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
| | | | - Yan Guex-Crosier
- Ocular Immunology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
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22
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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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23
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[Unusual forms of inflammatory diseases of the central nervous system]. Radiologe 2022; 62:302-307. [PMID: 35301573 DOI: 10.1007/s00117-022-00983-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND White matter lesions of the central nervous system (CNS) are frequently encountered on magnetic resonance imaging (MRI) exams. If the morphologic findings, clinical symptoms and laboratory results are not typical for one of the more common inflammatory CNS diseases, the diagnosis may become challenging, which also means that interesting and sometime emotional discussions may arise. OBJECTIVE While frequent causes of inflammatory CNS diseases were already discussed in a previous article, we now focus on more seldom forms and place attention on morphologic characteristics which may help to find the correct diagnosis.
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24
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Triplett JD, Qiu J, O'Brien B, Gopinath S, Trewin B, Spring PJ, Shaffi M, Ip J, Chan F, Chen L, Wilson I, Muller C, Beadnall HN, Boggild M, Van der Walt A, Roxburgh R, Seery N, Kalincik T, Barnett MH, Parratt JDE, Reddel SW, Tsang B, Hardy TA. Diagnosis, differential diagnosis and misdiagnosis of Susac syndrome. Eur J Neurol 2022; 29:1771-1781. [PMID: 35262238 PMCID: PMC9314104 DOI: 10.1111/ene.15317] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 11/28/2022]
Abstract
Background and purpose Susac syndrome (SuS) is an inflammatory condition of the brain, eye and ear. Diagnosis can be challenging, and misdiagnosis is common. Methods This is a retrospective review of the medical records of 32 adult patients from an Australasian cohort of SuS patients. Results An alternative diagnosis prior to SuS was made in 30 patients (94%) with seven patients receiving two or more diagnoses. The median time to diagnosis of SuS was 3 months (range 0.5–100 months). The commonest misdiagnoses were migraine in 10 patients (31%), cerebral vasculitis in six (19%), multiple sclerosis in five (16%) and stroke in five (16%). Twenty‐two patients were treated for alternative diagnoses, 10 of whom had further clinical manifestations prior to SuS diagnosis. At presentation seven patients (22%) met criteria for definite SuS, 19 (59%) for probable SuS and six (19%) for possible SuS. Six patients (19%) presented with brain–eye–ear involvement, 14 with brain–ear (44%), six with brain–eye (19%) and six (19%) with only brain involvement. In patients with the complete triad of symptoms the median delay to diagnosis was 3 months (range 1–9 months) compared to 5.25 months (range 0.5–100 months) for patients with encephalopathy and ocular symptoms at presentation. Conclusions Susac syndrome patients are frequently misdiagnosed at initial presentation, despite many having symptoms or radiological features that are red flags for the diagnosis. Delayed diagnosis can lead to patient morbidity. The varied ways in which SuS can present, and clinician failure to consider or recognize SuS, appear to be the main factors leading to misdiagnosis.
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Affiliation(s)
- James D Triplett
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Jessica Qiu
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Sumana Gopinath
- Department of Neurology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Benjamin Trewin
- Department of Neurology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Penelope J Spring
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | | | - Jerome Ip
- Section of Neurology, Sydney Adventist Hospital, Sydney, NSW, Australia
| | - Fiona Chan
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Luke Chen
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, The Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Ian Wilson
- Department of Neurology, Cairns Hospital, Cairns, Qld, Australia
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Heidi N Beadnall
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mike Boggild
- Department of Neurology, Townsville Hospital, Townsville, Qld, Australia
| | - Anneke Van der Walt
- Department of Neurology, The Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Richard Roxburgh
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Nabil Seery
- MS Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
| | - Tomas Kalincik
- MS Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Michael H Barnett
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John D E Parratt
- Department of Neurology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Benjamin Tsang
- Department of Neurology, Sunshine Coast Hospital, Sunshine Coast, Qld, 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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Wang A, Hu K, Yang Y, Yang B, Liu J, Chen X, Liu Y, Si Z. Susac syndrome with the typical clinical triad: A case report and literature review. J Neuroimmunol 2022; 367:577822. [DOI: 10.1016/j.jneuroim.2022.577822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/31/2021] [Accepted: 01/29/2022] [Indexed: 11/25/2022]
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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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Susac syndrome with cognitive impairment - case report of 31-year-old woman. CURRENT PROBLEMS OF PSYCHIATRY 2021. [DOI: 10.2478/cpp-2021-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Susac syndrome (SuS) is a rare immune-mediated disease caused by occlusions of microvessels in the brain, retina and inner ear. It is characterized by the clinical triad of encephalopathy, visual disturbances and hearing loss. The diagnosis of SuS is based mainly on the clinical symptoms and the supporting tests in which characteristic changes occur in the MRI.
Case report: Here, we present a case of a patient with possible SuS with psychiatric symptoms. A 31-year-old woman was admitted to the Department of Psychiatry due to deteriorating mental health for several weeks manifested as a negative mood and suicidal thoughts. During hospitalization, a neurological consultation was conducted, in which the patient was identified as conscious, psychomotor sluggish, with impaired verbal contact and persistent hearing and vision impairment. Cross-sectional assessment of cognitive functions revealed that the patient had a generalized syndrome of neuropsychological deficits, which confirms the diagnosis of dementia.
Discussion: This case summary provides an example of a woman diagnosed with SuS manifested as a cognitive impairment with associated vision and hearing deterioration. It is worth emphasizing the fact that such presentation of the triad of at disease onset is rare. The characteristics of the organic changes in the brain described in the MRI probably explain the symptoms described in that case. The prognosis of SuS depends on early diagnosis and treatment.
Conclusions: A diagnosis of SuS should always be considered in the presence of nonspecific neuropsychiatric symptoms and progressive multifocal neurological symptoms, hearing loss, and visual impairment. An important fact is that the typical triad of SuS symptoms in most cases does not occur simultaneously, which makes the diagnostic process very difficult and may lead to misdiagnosis.
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INVESTIGATING MICROANGIOPATHY USING SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN PATIENTS WITH SUSAC SYNDROME. Retina 2021; 41:2172-2178. [PMID: 33758133 DOI: 10.1097/iae.0000000000003170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine whether optical coherence tomography angiography is of diagnostic utility for Susac syndrome (SuS) by quantifying microvascular retinal changes. METHODS We enrolled 18 eyes of 9 healthy controls and 18 eyes of 9 patients with chronic SuS (12 had previous branch retinal artery occlusions and 6 were clinically unaffected). Images of the fovea were taken using an optical coherence tomography angiography system. Analysis included vessel density, fractal dimension, vessel diameter, and measurements of the foveal avascular zone (area, eccentricity, acircularity index, and axis ratio) in deep and superficial retinal layers. RESULTS Skeleton density and inner ring vessel density were significantly lower in patients with SuS (skeleton density: Susac 0.11 ± 0.01 vs. controls 0.12 ± 0.01, P = 0.027. VD: SuS 0.39 ± 0.04 vs. controls 0.42 ± 0.02, P = 0.041). Eccentricity and axis ratio were significantly higher in patients with SuS (EC: Susac 0.61 ± 0.11, controls 0.51 ± 0.10, P = 0.003; axis ratio: Susac 1.57 ± 0.28, controls 1.39 ± 0.11, P = 0.005). SuS eyes (affected and unaffected) had poorer outcomes of the remaining vascular parameters compared with controls (P > 0.05). CONCLUSION Optical coherence tomography angiography identified chronic microvascular changes in the eyes of patients with chronic SuS. Even clinically unaffected SuS eyes showed poorer vascular parameters. Although further research is needed, this noninvasive imaging modality seems to have the potential to serve as a valuable additive diagnostic tool.
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Successful Treatment of Incomplete Susac Syndrome with Simultaneous Corticosteroids and Plasmapheresis Followed by Rituximab. Case Rep Neurol Med 2021; 2021:5591559. [PMID: 34567813 PMCID: PMC8457979 DOI: 10.1155/2021/5591559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022] Open
Abstract
We present a case report of a patient with incomplete Susac syndrome. He had cognitive impairment, corpus callosum lesions, and vestibulocochlear dysfunction on brainstem auditory evoked responses. He was treated with methylprednisolone and plasmapheresis, improved, and then, also received rituximab. His improvement has been lasting as of this writing. This case shares our experience with a successful treatment of this rare condition that is incompletely understood and lacks well-established treatment guidelines.
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RECURRENT BRANCH RETINAL ARTERY OCCLUSION FROM SUSAC SYNDROME: CASE REPORT AND REVIEW OF LITERATURE. Retin Cases Brief Rep 2021; 14:315-320. [PMID: 29870024 DOI: 10.1097/icb.0000000000000751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We report a patient with branch retinal artery occlusion predominant Susac syndrome and review the literature on current diagnostic modalities and therapeutic approaches for this rare condition. METHODS Case report. RESULTS A 23-year-old white male presented with a 5-month history of a scotoma in his right eye vision, headaches, and intermittent paresthesias of the lower extremities. Ophthalmic examination was normal with the exception of a hypopigmented small retinal area inferonasal to the fovea in the right eye. Optical coherence tomography demonstrated inner retinal atrophy and optical coherence tomography angiography showed deep capillary layer vessel dropout in both eyes. Ultra-wide-field fluorescein angiography revealed bilateral arteriolar wall hyperfluorescence. Corpus callosal lesions were present on magnetic resonance imaging. Lumbar puncture demonstrated elevated protein. Audiogram was normal. A diagnosis of Susac syndrome was made. The patient initially received oral steroids followed by intravenous steroids and mycophenolate mofetil because of new branch retinal artery occlusions. Thirteen months after initial presentation, the vision was stable at 20/20 in both eyes. CONCLUSION It is a diagnostic challenge when recurrent branch retinal artery occlusion secondary to Susac syndrome presents without the classic symptoms. Optical coherence tomography angiography and subtle magnetic resonance imaging findings aided in early recognition of the diagnosis in our patient. Ultra-wide-field fluorescein angiography was an important tool in disease monitoring. Aggressive management with intravenous corticosteroids and initiation of immunosuppression resulted in long-term preservation of vision and improvement in visual field.
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Abstract
PURPOSE To present the clinical manifestations and results of key diagnostic investigations in patients with Susac syndrome, with special emphasis on the principal role of fluorescein angiography (FA) of the peripheral retina. METHODS A retrospective analysis of medical records (collected 2000-2019) of 20 patients (15 women and five men), aged 20 to 51 years (mean age: 31.6 years) with complete or incomplete Susac syndrome diagnosed by an ophthalmic examination and widefield fluorescein angiography (WF-FA) by Spectralis and Optos Tx200. RESULTS Fluorescein angiography abnormalities included vascular changes in the posterior pole in 64.7% and in the peripheral retina in 82.4%. Widefield FA abnormalities in the peripheral retina alone were seen in 35.3% and in the posterior pole, but without peripheral vascular involvement, in 17.6%. Secondary leakage from veins was noted in 58.8%. CONCLUSION Widefield FA of the peripheral retina has a key role in cases of suspected Susac syndrome as it confirms the diagnosis and assesses disease activity. In addition to the characteristic findings, late-phase FA revealed leakage from veins which is not a typical sign. Patients experiencing migraine headaches may benefit from increasing awareness of neurologists and otologists who more promptly referred patients with suspected Susac syndrome for ophthalmologic evaluation and WF-FA of the peripheral retina.
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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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Ruiz-García RG, Chacón-González J, Bayliss L, Ramírez-Bermúdez J. Neuropsychiatry of Susac syndrome: A case report. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 50:146-151. [PMID: 34099251 DOI: 10.1016/j.rcpeng.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 10/01/2019] [Indexed: 06/12/2023]
Abstract
Susac syndrome is a rare clinical condition, possibly mediated by an autoimmune process; the classic triad is composed of retinopathy, decreased hearing acuity and neuropsychiatric symptoms (encephalopathy). There are few cases reported with neuropsychiatric symptoms as the main manifestation. We present a case of Susac syndrome in a 34-year-old female with a predominance of neuropsychiatric symptoms, characterised by partial Klüver-Bucy syndrome, apathy syndrome, pathological laughter and crying, and cognitive dysfunction predominantly affecting attention, which showed a qualitative improvement with the use of immunological therapy. This case report highlights the importance of neuropsychiatric manifestations as clinical presentation in patients with neurological conditions.
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Affiliation(s)
- Ramiro Gilberto Ruiz-García
- Unidad de Neuropsiquiatría, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, Mexico.
| | - Jacobo Chacón-González
- Unidad de Neuropsiquiatría, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, Mexico
| | - Leo Bayliss
- Servicio de Neurología, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, Mexico
| | - Jesús Ramírez-Bermúdez
- Unidad de Neuropsiquiatría, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, Mexico
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Ruiz-García RG, Chacón-González J, Bayliss L, Ramírez-Bermúdez J. Neuropsychiatry of Susac Syndrome: a Case Report. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 50:146-151. [PMID: 33735032 DOI: 10.1016/j.rcp.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 08/28/2019] [Accepted: 10/01/2019] [Indexed: 06/12/2023]
Abstract
Susac syndrome is a rare clinical condition, possibly mediated by an autoimmune process; the classic triad is composed of retinopathy, decreased hearing acuity and neuropsychiatric symptoms (encephalopathy). There are few cases reported with neuropsychiatric symptoms as the main manifestation. We present a case of Susac syndrome in a 34-year-old female with a predominance of neuropsychiatric symptoms, characterised by partial Klüver-Bucy syndrome, apathy syndrome, pathological laughter and crying, and cognitive dysfunction predominantly affecting attention, which showed a qualitative improvement with the use of immunological therapy. This case report highlights the importance of neuropsychiatric manifestations as clinical presentation in patients with neurological conditions.
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Affiliation(s)
- Ramiro Gilberto Ruiz-García
- Unidad de Neuropsiquiatría, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, México.
| | - Jacobo Chacón-González
- Unidad de Neuropsiquiatría, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, México
| | - Leo Bayliss
- Servicio de Neurología, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, México
| | - Jesús Ramírez-Bermúdez
- Unidad de Neuropsiquiatría, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Ciudad de México, México
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Multimodal Imaging in Susac Syndrome: A Case Report and Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073435. [PMID: 33810247 PMCID: PMC8038062 DOI: 10.3390/ijerph18073435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 12/03/2022]
Abstract
Susac syndrome (SS) is a rare microangiopathy that involves arterioles of the brain, retina, and cochlea. Diagnosis is extremely difficult because of the rarity of the disease and because the signs and symptoms often occur at different times. Multidisciplinary approaches and multimodal images are mandatory for diagnosis and prompt therapy. In this report, we describe a case of SS and the application of multimodal retinal imaging to evaluate the ophthalmologic changes and to confirm diagnosis. Early diagnosis and therapy based on the associations of steroids and immunosuppressants are necessary to limit the sequelae of the disease.
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Abstract
PURPOSE To evaluate the effect of tumor necrosis factor (TNF) inhibitor therapy on ocular relapses in patients with Susac syndrome. METHODS Multicenter retrospective cohort study of patients diagnosed with Susac syndrome according to classical clinical criteria. We evaluated the disease activity before and after introduction of anti-TNF therapy and its value as a steroid-sparing agent. RESULTS Five patients were included. All were initially treated with a combination of corticosteroids and classical immunosuppressive drugs. Infliximab was started in three patients, and adalimumab was started in two patients. Patients had on average 5 ocular relapses during a mean follow-up time of 2.59 years before introducing a TNF inhibitor, corresponding with on average 1.93 relapses per year. After the introduction of an anti-TNF agent, this number was reduced by factor 5.51 to an average of 0.35 relapses per year for a mean follow-up of 2.86 years (P = 0.10). Before anti-TNF introduction ocular relapses occurred at a mean daily dose of 34 mg of prednisone, whereas with anti-TNF treatment, corticosteroid administration could be completely stopped in four patients with one patient still needing 5 mg daily (P = 0.10). Infliximab and adalimumab generally were well tolerated, and no serious adverse events were reported. CONCLUSION Although not statistically significant, our results suggest that anti-TNF therapy can be a valuable option for the treatment of ocular Susac syndrome and may especially be considered in those patients unresponsive to more conventional immunosuppressive treatment.
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Willekens B, Kleffner I. Susac syndrome and pregnancy: a review of published cases and considerations for patient management. Ther Adv Neurol Disord 2021; 14:1756286420981352. [PMID: 33796140 PMCID: PMC7970706 DOI: 10.1177/1756286420981352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022] Open
Abstract
Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.
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Affiliation(s)
- Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Ilka Kleffner
- University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Pérez PL, McCall AA, Hirsch BE. Scoping review of cochlear implantation in Susac's syndrome. World J Otorhinolaryngol Head Neck Surg 2021; 7:126-132. [PMID: 33997722 PMCID: PMC8103525 DOI: 10.1016/j.wjorl.2020.10.004] [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: 05/30/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac’s Syndrome(SS) who have undergone cochlear implantation (CI). Data sources All published studies of CI in SS and contribution of two of our own patients who have not been reported previously. Methods A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac’s Syndrome, Cochlear Implantation. Results Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19–46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation. Conclusion Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.
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Affiliation(s)
- Philip L Pérez
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Andrew A McCall
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Barry E Hirsch
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Susac Syndrome and Pregnancy. Case Rep Neurol Med 2020; 2020:6049126. [PMID: 33425410 PMCID: PMC7775175 DOI: 10.1155/2020/6049126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022] Open
Abstract
Susac syndrome (SuS) is a rare poorly characterised disorder that affects the brain, retina, and cochlea. Here, we present a case of a 31-year-old pregnant female with a new diagnosis of SuS that was successfully managed to 36 weeks of gestation with minimal disease burden to both the mother and newborn. She was treated initially using intravenous methylprednisolone followed by oral prednisone, and intravenous immunoglobulin (IVIg). We stress the importance of a multidisciplinary approach, involving both neurology and maternal-fetal medicine, and provide guidance in navigating the various options for immunosuppressive therapy during pregnancy.
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020; 30:393-399. [PMID: 33337398 DOI: 10.3233/ves-200007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse and the cervical vestibular-evoked myogenic potentials (cVEMPs). OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cVEMPs and the vHIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020:VES200720. [PMID: 33164965 DOI: 10.3233/ves-200720] [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: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse. OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cervical vestibular-evoked myogenic potentials (cVEMPs), and the v-HIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
PURPOSE OF REVIEW This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment. RECENT FINDINGS Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information. SUMMARY Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.
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Affiliation(s)
- Yael Redler
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Papasavvas I, Teuchner B, Herbort CP. Susac syndrome (Retino-cochleo-cerebral vasculitis), the ophthalmologist in the role of the whistleblower. J Ophthalmic Inflamm Infect 2020; 10:27. [PMID: 33125601 PMCID: PMC7599291 DOI: 10.1186/s12348-020-00217-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Susac syndrome is a rare microangiopathy of suspected autoimmune origin affecting arteries of the retina, the cochlea and the brain. The aim of the study was to give a review of the disease entity and determine the proportion of cases and their characteristics in a uveitis referral centre. PATIENTS AND METHODS Charts of patients with the diagnosis of Susac syndrome seen in the Uveitis Clinic of the Centre for Ophthalmic Specialised Care (COS), Lausanne, Switzerland were reviewed retrospectively to determine the frequency of such cases in a uveitis referral centre. Clinical symptoms and signs, functional data, imaging signs and evolution were analysed in the 3 COS cases and one case shared with the Uveitis Clinic of the Department of Ophthalmology, University of Innsbruck, Austria. Characteristic signs were searched possibly allowing a prompt diagnosis. RESULTS During the period from 1994 to 2019 (24 years, 2045 patients), 3 charts with the diagnosis of Susac syndrome were found (0.15%). The whole collective, including the additional case, comprised three women aged 28, 32 and 63 at presentation and one man, aged 42. None of the 3 cases that were referred were diagnosed beforehand. The characteristic item found in all 4 cases was the abrupt arterial stop or segmental interruption of arteries and increased staining of arterial wall on angiography more clearly shown on indocyanine green angiography that can potentially be proposed as a crucial diagnostic element. All 4 cases responded to dual steroidal and non-steroidal immunosuppression. Under treatment, all four patients did not show any further evolution. CONCLUSION Susac syndrome is a multilocation arteritis of the head that can involve the eye, ear and brain often first diagnosed by the ophthalmologist. The diagnosis is rapidly reached in uveitis referral centres but seems to be missed otherwise, A helpful angiographic sign to be searched is an abrupt or segmental arterial stop and increased staining of the arterial wall more clearly seen on indocyanine green angiography. Patients often present first to the ophthalmologist who should be acting as a whistleblower to avoid severe involvement of the brain.
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Affiliation(s)
- Ioannis Papasavvas
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland
| | - Barbara Teuchner
- Department of Ophthalmology, University of Innsbruck, Innsbruck, Austria
| | - Carl Peter Herbort
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland.
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Alba-Linero C, Liscombe-Sepúlveda JP, Llorenç V, GiraltJosa J, Adán A. Use of ultra-wide field retinal imaging and optical coherence tomography angiography in the diagnosis of incomplete Susac syndrome. Eur J Ophthalmol 2020; 31:3238-3247. [PMID: 33106042 DOI: 10.1177/1120672120965482] [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: 11/15/2022]
Abstract
PURPOSE To describe clinical findings through ultra-wide field (UWF) images and optical coherence tomography angiography (OCT-A), in Susac's syndrome (SS). METHODS SS patients were retrospectively analyzed in a single center. Clinical features, ultra-wide-field retinographies (UWF-PR), UWF fluorescein angiographies (UWF-FA), and optical coherence tomography angiography & en face (OCT-A/EF) were reviewed. RESULTS Twelve eyes from six patients with a mean follow-up of 35.66 months ± SD 36.88 were included. UWF-PR showed areas of retinal whitening and cotton-wool spots in all the eyes after acute attack. Segmentary mid peripheral arteriolitis could be observed in five eyes by UWF-FA in acute and convalescent stages. OCT-A revealed capillary density changes in all of the affected eyes. During the acute phase there was a well-preserved superficial capillary network, while deep retinal plexus showed a lower density in the affected areas. OCT-A/EF revealed deep retinal plexus drop-out and surrounding edematous retina in acute attacks, becoming atrophic over time. Conversely, superficial plexus was much less affected. Perifoveal reperfusion was seen in seven eyes after the acute attack. CONCLUSIONS UWF-PR/FA and OCT-A/EF might be helpful to stablish an early diagnosis and to monitor SS progression.
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Affiliation(s)
| | | | - Victor Llorenç
- Clinic Institute of Ophthalmology (ICOF), Clinic Hospital of Barcelona, Barcelona, Spain
| | - Joan GiraltJosa
- Clinic Institute of Ophthalmology (ICOF), Clinic Hospital of Barcelona, Barcelona, Spain
| | - Alfredo Adán
- Clinic Institute of Ophthalmology (ICOF), Clinic Hospital of Barcelona, Barcelona, Spain
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Wilf-Yarkoni A, Elkayam O, Aizenstein O, Oron Y, Furer V, Zur D, Goldstein M, Barequet D, Hallevi H, Karni A, Habot-Wilner Z, Regev K. Increased incidence of Susac syndrome: a case series study. BMC Neurol 2020; 20:332. [PMID: 32878610 PMCID: PMC7465403 DOI: 10.1186/s12883-020-01892-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines. METHODS This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study. RESULTS Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability. CONCLUSIONS We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.
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Affiliation(s)
- A Wilf-Yarkoni
- Neuro-Immunology Service and Department of Neurology Rabin Medical Center, 4941492, Petach Tikva, Israel.
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Aizenstein
- Neuroradiology unit, Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Y Oron
- Department of ENT, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Zur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - M Goldstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Barequet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Hallevi
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Karni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience Tel Aviv University, Tel Aviv, Israel
| | - Z Habot-Wilner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - K Regev
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Cho TA, Jones A. CNS vasculopathies: Challenging mimickers of primary angiitis of the central nervous system. Best Pract Res Clin Rheumatol 2020; 34:101569. [PMID: 32859518 DOI: 10.1016/j.berh.2020.101569] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Primary angiitis of the central nervous system (CNS) is an inflammatory vasculopathy affecting the brain and spinal cord. It is a difficult diagnosis to make because of its insidious nonspecific course and its multiple mimics. This review identifies and discusses some noninfectious mimickers of primary CNS angiitis, including: reversible cerebral vasoconstriction syndrome, Sneddon's Syndrome, amyloid-beta-related angiopathy, Susac Syndrome, and neurosarcoidosis. Each condition will be reviewed in terms of epidemiology, pathology, clinical presentation, diagnostic approach, and treatment. Distinguishing these mimics from the primary angiitis of the CNS is important for proper treatment and prognosis.
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Affiliation(s)
| | - Ann Jones
- 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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47
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Hardy TA, Taylor RL, Qiu J, O’Brien B, Gopinath S, Trewin B, Spring PJ, Shaffi M, Bolitho SJ, Garsia RJ, Roxburgh R, Mason DF, Ip J, Chan F, Chen L, Wilson I, Beadnall HN, Barnett MH, Parratt JDE, Watson JDG, Welgampola MS, Reddel SW, Tsang B, Halmagyi GM. The neuro-otology of Susac syndrome. J Neurol 2020; 267:3711-3722. [DOI: 10.1007/s00415-020-10086-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/28/2022]
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48
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A case report on Susac syndrome. Chin Med J (Engl) 2020; 133:1754-1756. [PMID: 32649514 PMCID: PMC7401744 DOI: 10.1097/cm9.0000000000000909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Agamanolis DP, Klonk C, Bigley K, Rennebohm RM. Neuropathological Findings in Susac Syndrome: An Autopsy Report. J Neuropathol Exp Neurol 2020; 78:515-519. [PMID: 31100145 DOI: 10.1093/jnen/nlz031] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A 24-year-old woman developed encephalopathy, branch retinal artery occlusion, hearing loss, and had "snowball" lesions in the corpus callosum, classic findings of Susac syndrome (SuS). Despite intensive immunosuppressive therapy, she lapsed into a coma, and died 7 months after the onset of her illness. Neuropathological examination, revealed perivascular inflammation and vasculitis involving small vessels, associated with vascular narrowing and occlusion, and numerous microinfarcts diffusely throughout the brain. The findings establish SuS as a neuroinflammatory condition that can include vasculitis. This represents the most comprehensive report of the neuropathological findings in SuS.
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Affiliation(s)
- Dimitri P Agamanolis
- Department of Pathology, Akron Children's Hospital.,Northeast Ohio Medical University (NEOMED), Akron, Ohio
| | - Collin Klonk
- Northeast Ohio Medical University (NEOMED), Akron, Ohio
| | - Kim Bigley
- Department of Neurology, Renoun Regional Medical Center, Reno, Nevada
| | - Robert M Rennebohm
- Formerly of the Department of Pediatric Rheumatology of the Cleveland Clinic Foundation, Cleveland, Ohio
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50
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Abstract
BACKGROUND Susac syndrome (SS) classically presents with the clinical triad of retinal artery occlusion, sensorineural hearing loss, and encephalopathy and the neuroimaging triad of white matter lesions, deep gray matter lesions, and leptomeningeal disease. However, patients can present with an incomplete clinical or neuroimaging triads making diagnosis difficult in certain situations. A standard treatment paradigm also is lacking in this illness. It is important for neuro-ophthalmologists to recognize clinical and radiographic findings that are pathognomonic for this syndrome and have a basic understanding of the available treatment options. EVIDENCE ACQUISITION Review of medical literature. RESULTS A definite diagnosis of SS is made when the clinical triad or the neuroimaging triad is present. There are numerous reports of 2 other imaging findings in this condition: arteriolar wall hyperfluorescence (AWH) on fluorescein angiography in retinal arterioles remote from retinal ischemia and central callosal lesions on MRI. Both of these imaging findings are diagnostic of SS. Gass plaques in retinal arterioles are almost always seen in the acute phase of the illness but are not pathognomonic for SS. The most common medications used in this syndrome are corticosteroids and intravenous immunoglobulin. A number of other medications have been used including mycopheolate, rituximab, azathioprine, and cyclophosphamide. CONCLUSIONS In the absence of the clinical triad or magnetic resonance imaging triad for SS, AWH remote from retinal vascular injury and central callosal lesions are confirmatory of the diagnosis because they have never been described in any other condition. The presence of Gass plaques in retinal arterioles should strongly suggest the diagnosis. Despite the lack of clinical trial data, patients with SS must be treated promptly and aggressively. In more fulminant cases, addition of mycophenolate mofetil or rituximab is required, followed by cyclophosphamide when disease is refractory to other medications.
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