What is the treatment for acute transverse myelitis?

Treatment of Acute Transverse Myelitis

High-dose intravenous methylprednisolone (1g/day for 3-5 days) is the recommended first-line treatment for acute transverse myelitis and should be initiated as soon as possible after diagnosis, ideally within the first few hours. 1

First-Line Treatment Options

Corticosteroids

• Methylprednisolone 1g/day IV for 3-5 days 1
• Should be started promptly to reduce inflammation and prevent long-term neurological damage
• Early treatment is associated with better outcomes and faster recovery 1, 2
• A pilot study showed that children treated with high-dose methylprednisolone had:
  • Significantly reduced time to walk independently (23 vs 97 days)
  • Higher rates of full recovery within 12 months (80% vs 10%) 2

Alternative First-Line Treatments

• Intravenous Immunoglobulin (IVIG): 2g/kg divided over 5 days 1
• Plasma Exchange: 5-10 sessions on alternate days 1
  • Consider these options for patients who cannot tolerate or have contraindications to corticosteroids
  • May also be considered if there is inadequate response to corticosteroids

Second-Line Treatment Options

For patients with inadequate response to first-line therapies:

• Cyclophosphamide 1
• Rituximab (particularly for AQP4-IgG positive patients) 1

Important Considerations Before Treatment

Rule Out Infectious Causes

• Complete infectious workup before starting immunosuppressive therapy 1
• Special consideration for:
  • Viral myelitis (e.g., CMV)
  • Parasitic infections (e.g., Schistosomiasis - treated with Praziquantel 40mg/kg twice daily for 5 days plus dexamethasone) 1

Monitor for Complications

• Respiratory function: Early intubation if vital capacity falls below 15 ml/kg or negative inspiratory force is less than -20 cm H₂O 1
• Autonomic dysfunction: Monitor for cardiac arrhythmias, blood pressure fluctuations, and urinary retention 1
• Spasticity: May require baclofen or tizanidine 1

Maintenance Therapy

• Immunosuppressive maintenance therapy is crucial to prevent relapses, which occur in 50-60% of patients during corticosteroid dose reduction 1
• Regular assessment for treatment response, side effects, and remission to determine if treatment can be tapered or discontinued 1

Prognostic Factors

• Better prognosis associated with:

  • Early treatment initiation
  • Prompt neurological response
  • Absence of extensive MRI lesions 1

• Poorer prognosis associated with:

  • Extensive lesions on spinal MRI
  • Reduced muscle strength or sphincter dysfunction at onset
  • Positive antiphospholipid antibodies
  • Delayed initiation of treatment 1

Special Situations

• For pregnant patients: IVIG may be preferred over steroids 1
• For CMV-associated transverse myelitis: High-dose corticosteroids have shown good outcomes even in cases of infectious etiology 3

Symptom Management

• Neuropathic pain: Consider pregabalin, gabapentin, or duloxetine 1
• Bladder dysfunction: May require intermittent catheterization
• Physical therapy: Should be initiated early to prevent complications of immobility

The evidence strongly supports early aggressive treatment with high-dose corticosteroids as the cornerstone of acute transverse myelitis management, with additional immunomodulatory therapies reserved for refractory cases or specific etiologies.