Neuroradiologie Scan 2018; 08(02): 159-181
DOI: 10.1055/a-0578-3693
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© Georg Thieme Verlag KG Stuttgart · New York

Neuromyelitis optica

Neuromyelitis optica
Florence Pache
,
Brigitte Wildemann
,
Friedemann Paul
,
Sven Jarius

Subject Editor: Wissenschaftlich verantwortlich gemäß Zertifizierungsbestimmungen für diesen Beitrag ist Professor Dr. med. Michael Forsting, Universitätsklinikum Essen.
Further Information

Publication History

Publication Date:
16 April 2018 (online)

Die Neuromyelitis optica mündet ohne Therapie häufig in irreversiblen neurologischen Behinderungen bis hin zu Rollstuhlpflichtigkeit und Erblindung. Dieser Beitrag vermittelt die nötigen Kenntnisse in Diagnostik, Pathogenese und Therapie, um unter verschiedensten Voraussetzungen mit einer frühzeitigen und konsequenten immunsuppressiven Behandlung weitere Schübe mit der Gefahr einer schweren Behinderung zu verhindern.

Abstract

Neuromyelitis optica (NMO) is an autoimmune disorder of the central nervous system (CNS) that predominantly affects the spinal cord and optic nerves. The neuropathologic hallmarks comprise deposits of antibodies and complement as well as loss of astrocytes, secondary degeneration of oligodendrocytes and neurons, and necrotic lesions with infiltration of neutrophilic and eosinophilic granulocytes. Pathognomonic serum autoantibodies against aquaporin-4 (AQP4-IgG, also termed NMO-IgG) are detectable in around 80 % of NMO patients and help to distinguish this rare entity from multiple sclerosis. The target antigen of NMO-IgG, the water channel protein AQP4, is ubiquitously expressed within the CNS and, as a component of the blood-brain barrier, highly concentrated in the endfeet of astrocytes. New international consensus criteria for NMO spectrum disorders, published in 2015, allow earlier diagnosis. Besides the two index manifestations, optic neuritis and transverse myelitis, involvement of the brainstem and diencephalon is relatively common in NMO. Inflammatory lesions of the area postrema typically cause intractable nausea and vomiting and/or hiccups. NMO mostly follows a relapsing course, especially in AQP4-IgG-positive cases. The treatment of acute exacerbations comprises intravenous methylprednisolone pulses and/or plasma exchange, and prevention of attacks requires long-term therapy with immunosuppressants and/or B-cell-depleting monoclonal antibodies.

Kernaussagen
  • Die NMO ist eine autoimmun vermittelte entzündliche Erkrankung des zentralen Nervensystems, die insbesondere das Rückenmark und die Sehnerven betrifft. Neuropathologisch ist die NMO durch Antikörper- und Komplementablagerungen, Astrozytenverlust, nekrotische Veränderungen mit Infiltration neutrophiler und eosinophiler Granulozyten und sekundären Untergang von Oligodendrozyten und Neuronen gekennzeichnet.

  • Bei der Abgrenzung gegenüber der klinisch ähnlichen, aber deutlich häufigeren multiplen Sklerose hilft insbesondere der Nachweis von Autoantikörpern gegen AQP4 (AQP4-Antikörper, NMO-IgG). AQP4-Antikörper können im Serum bei über 80 % der NMO-Patienten nachgewiesen werden.

  • Das Zielantigen des Autoantikörpers, das Wasserkanalprotein AQP4, wird ubiquitär im zentralen Nervensystem, jedoch in höchsten Konzentrationen in den Endfüßchen von Astrozyten der Glia limitans interna und externa exprimiert. Es bildet in dieser Lokalisation einen wichtigen Bestandteil der Blut-Hirn-Schranke.

  • Neben den beiden Indexmanifestationen Optikusneuritis und Myelitis kommen häufig auch Hirnstamm- und Dienzephalitiden vor. Als besonders charakteristisch gilt das Area-postrema-Syndrom, das durch entzündliche Läsionen in der dorsalen Medulla verursacht wird und durch unstillbaren Schluckauf und/oder unstillbares Erbrechen gekennzeichnet ist.

  • Die klinischen Symptome der NMO treten meist schubförmig auf; bei AQP4-IgG-negativen Patienten verläuft die Erkrankung selten auch monophasisch.

  • Akute Schübe werden mit hochdosierten intravenösen Steroiden und/oder Plasmapherese behandelt. Zur Rezidivprophylaxe ist eine Therapie mit Immunsuppressiva oder B-Zell-depletierenden Therapien essenziell.

 
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