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Original Contribution
July 2012

Long-term Outcomes of CLIPPERS (Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids) in a Consecutive Series of 12 Patients

Author Affiliations

Author Affiliations: Departments of Neurology (Drs Taieb, Renard, Thouvenot, de Champfleur, Castelnovo, and Labauge) and Statistics (Drs Duflos and Faillie), Centre Hospitalier Universitaire, Nimes, Department of Neurology, University Hospital (Drs Audoin, Kaphan, and Pelletier), and Department of Neuropathology, Centre Hospitalier Universitaire (Dr Figarella Branger), Marseille, Department of Neurology, University Hospital, Tours (Dr Limousin), Department of Neurology, University Hospital, Strasbourg (Drs Tranchant, Kremer, and de Sèze), Department of Neurology, University Hospital, Rouen (Drs Lefaucheur and Maltête), Department of Neurology, University Hospital (Drs Brassat and Clanet), and Department of Neuropathology, Centre Hospitalier Universitaire (Dr Uro-Coste), Toulouse, Department of Neurology, University Hospital, Dax (Dr Desbordes), Department of Neurology, University Hospital, Limoges (Dr Magy), Department of Immunology, Centre Hospitalier Universitaire, Montpellier (Dr Vincent), and Department of Neuropathology, Centre Hospitalier Universitaire, Bordeaux (Dr Eimer), France.

Arch Neurol. 2012;69(7):847-855. doi:10.1001/archneurol.2012.122

Background Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a central nervous system inflammatory disease.

Objective To describe the disease course of CLIPPERS.

Design A nationwide study was implemented to collect clinical, magnetic resonance imaging, cerebrospinal fluid, and brain biopsy specimen characteristics of patients with CLIPPERS.

Setting Academic research.

Patients Twelve patients with CLIPPERS.

Main Outcome Measures The therapeutic management of CLIPPERS was evaluated.

Results Among 12 patients, 42 relapses were analyzed. Relapses lasted a mean duration of 2.5 months, manifested frequent cerebellar ataxia and diplopia, and were associated with a mean Expanded Disability Status Scale (EDSS) score of 4. Besides typical findings of CLIPPERS, magnetic resonance imaging showed brainstem mass effect in 5 patients, extensive myelitis in 3 patients, and closed ring enhancement in 1 patient. Inconstant oligoclonal bands were found on cerebrospinal fluid investigation in 4 patients, with an increased T-cell ratio of CD4 to CD8. Among 7 available brain biopsy specimens, staining was positive for perivascular CD4 T lymphocytes in 5 samples. Thirty-eight of 42 relapses were treated with pulse corticosteroid therapy, which led to improvement, with a mean residual EDSS score of 1.9 (range, 0-7). In 1 patient with untreated relapses, scores on the EDSS progressively increased to a score of 10 at death. Among 5 patients without long-term corticosteroid therapy, the mean annualized relapse rate was 0.5 (range, 0.25-2.8). Among 7 patients taking oral corticosteroids, no relapses occurred in those whose daily dose was 20 mg or higher. No progressive course of CLIPPERS was observed. Four patients with a final EDSS score of 4 or higher had experienced previous severe relapses (EDSS score, ≥5) and brainstem and spinal cord atrophy.

Conclusions CLIPPERS is a relapsing-remitting disorder without progressive forms. Long-term disability is correlated with the severity of previous relapses. Further studies are needed to confirm that prolonged corticosteroid therapy prevents further relapses.