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Research paper
Short delay to initiate plasma exchange is the strongest predictor of outcome in severe attacks of NMO spectrum disorders
  1. Mickael Bonnan1,
  2. Rudy Valentino2,
  3. Stéphane Debeugny3,
  4. Harold Merle4,
  5. Jean-Louis Fergé2,
  6. Hossein Mehdaoui2,
  7. Philippe Cabre5
  1. 1 Service de neurologie, Centre Hospitalier de Pau, Pau, France
  2. 2 Réanimation médicale, Hopital Pierre Zobda-Quitman, Fort-de-France, Martinique
  3. 3 Unité de Recherche Clinique, Centre Hospitalier de Pau, Pau, Aquitaine-Limousin-Poitou, France
  4. 4 Service d’ophtalmologie, Hopital Pierre Zobda-Quitman, Fort-de-France, Martinique
  5. 5 Service de Neurologie, Hopital Pierre Zobda-Quitman, Fort-de-France, Martinique
  1. Correspondence to Dr Mickael Bonnan, Service de Neurologie, Centre Hospitalier de Pau, 4 Bd Hauterive, 64000 Pau, France; mickael.bonnan{at}


Introduction Severe attacks of neuromyelitis optica spectrum disorder (NMO-SD) are improved by plasma exchange (PLEX) given as an adjunctive therapy. Initial studies failed to demonstrate a delay of PLEX treatment influenced clinical outcome; however PLEX was always used late. We examine the clinical consequences of delay in PLEX initiation on severe optic neuritis and spinal cord attacks in NMO-SD.

Methods All of our patients who suffered attacks of NMO-SD, treated in our centre by PLEX, were retrospectively considered for inclusion. Primary outcome was defined as complete improvement. Secondary poor/good outcomes were respectively defined to be the higher/lower third of Delta-Expanded Disability Status Scale (EDSS) (late minus baseline EDSS). Delays from clinical onset to PLEX initiation were categorised for multivariate analysis.

Results Of the 60 patients included, NMO-SD criteria (2015) were fulfilled in 92%. One hundred and fifteen attacks were included and received PLEX with a median of 7 days (0–54) after clinical onset. The probability to regain complete improvement continuously decreased from 50% for PLEX given at day 0 to 1%–5% after day 20. Through multivariate analysis, the baseline impairment and PLEX delay were associated with the probability to complete improvement (OR 5.3; 95% CI 1.8 to 15.9). Reducing the PLEX delay also influenced the good secondary outcome but not the poor secondary outcome.

Conclusions These results confirm an improved clinical benefit of early initiation of PLEX during severe attacks of NMO-SD. Perceiving PLEX as a rescue therapy only after steroid failure could be deleterious.

  • Neuromyelitis optica
  • plasma exchange
  • transverse myelitis
  • optic neuritis

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  • Contributors The authors’ contributions are as follows: PC and MB: study concept or design and collection of clinical and radiographic data. PC, HM, RV, J-LF and HM: clinical management. MB, PC and SD: data analysis and interpretation. SD performed statistical analysis. MB wrote this draft and all authors critically evaluated the manuscript.

  • Funding None.

  • Competing interests None declared.

  • Ethics approval Local hospital ethic commitee.

  • Provenance and peer review Not commissioned; externally peer reviewed.