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Susac Syndrome

VERSION: 1.2 CREATED: February 2, 2026 REVISED: February 2, 2026 STATUS: Approved


DIAGNOSIS: Susac Syndrome

ICD-10: H35.89 (Other specified retinal disorders -- branch retinal artery occlusion component), I67.89 (Other cerebrovascular disease -- cerebral endotheliopathy), H93.09 (Unspecified degenerative and vascular disorders of ear -- sensorineural hearing loss component)

CPT CODES: 70553 (MRI brain with/without contrast), 92235 (fluorescein angiography), 92250 (fundus photography), 92557 (comprehensive audiometry), 92588 (distortion product otoacoustic emissions), 89051 (CSF cell count with differential), 84157 (CSF protein), 96365 (IV infusion first hour -- IVIG/steroids), 96366 (IV infusion each additional hour), 36514 (therapeutic apheresis/plasma exchange), 95816 (EEG routine), 95950 (continuous EEG monitoring), 92083 (visual field testing), 85025 (CBC with differential), 80053 (CMP)

SYNONYMS: Susac syndrome, SuS, retinocochleocerebral vasculopathy, small vessel occlusive disease triad, Susac's syndrome, RED-M syndrome (retinopathy-encephalopathy-deafness associated microangiopathy), autoimmune endotheliopathy, retinal-cochlear-cerebral vasculopathy, branch retinal artery occlusion with encephalopathy, Susac triad, corpus callosum microangiopathy syndrome

SCOPE: Diagnosis, immunotherapy, and long-term monitoring of Susac syndrome -- an autoimmune endotheliopathy affecting small vessels of the brain, retina, and cochlea. Covers the classic clinical triad (encephalopathy with corpus callosum lesions, branch retinal artery occlusion, sensorineural hearing loss), diagnostic workup including MRI with characteristic "snowball" corpus callosum lesions, fluorescein angiography, audiometry, CSF analysis, and immunotherapy (IVIG, high-dose corticosteroids, plasma exchange, and long-term immunosuppression with mycophenolate mofetil, azathioprine, or rituximab). Includes differentiation from multiple sclerosis, CNS vasculitis, ADEM, and other autoimmune encephalopathies. Not all patients present with the complete triad simultaneously; a high index of suspicion is required. For primary CNS vasculitis, use "CNS Vasculitis (PACNS)" template. For autoimmune encephalitis with antibody-mediated mechanisms, use "Autoimmune Encephalitis" template. For MS, use "MS - New Diagnosis" template.


PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test Rationale Target Finding ED HOSP OPD ICU
CBC with differential (CPT 85025) Baseline; infection screen; thrombocytopenia or anemia may suggest alternative diagnoses (TTP, SLE); monitor before immunotherapy Normal; thrombocytopenia or schistocytes raise concern for TTP STAT STAT ROUTINE STAT
CMP (BMP + LFTs) (CPT 80053) Metabolic screen; renal function for contrast and IVIG dosing; hepatic function for immunosuppressant clearance; electrolyte derangement as encephalopathy cause Normal STAT STAT ROUTINE STAT
ESR (CPT 85652) Inflammatory marker; typically normal or mildly elevated in Susac syndrome; markedly elevated suggests systemic vasculitis or infection Normal to mildly elevated (ESR is often normal in Susac syndrome) STAT STAT ROUTINE STAT
CRP (CPT 86140) Inflammatory marker; usually normal in Susac syndrome; elevated CRP favors systemic vasculitis, infection, or alternative diagnosis Normal to mildly elevated STAT STAT ROUTINE STAT
PT/INR, aPTT (CPT 85610+85730) Coagulopathy screen pre-LP; baseline before anticoagulation; antiphospholipid evaluation Normal STAT STAT - STAT
Blood glucose (CPT 82947) Pre-steroid baseline; metabolic encephalopathy screen Normal STAT STAT ROUTINE STAT
HbA1c (CPT 83036) Glycemic status before high-dose corticosteroids; diabetic retinopathy as differential for BRAO <5.7% - ROUTINE ROUTINE -
Troponin (CPT 84484) Cardiac involvement rare but reported in Susac syndrome; stress cardiomyopathy in acute presentation Normal STAT STAT - STAT
Blood cultures x2 (CPT 87040) Rule out endocarditis and bacteremia causing embolic retinal artery occlusion No growth STAT STAT - STAT
Urinalysis with microscopy (CPT 81003) Screen for renal involvement suggesting systemic vasculitis (SLE, ANCA vasculitis) rather than Susac syndrome Normal (abnormal suggests systemic disease) STAT STAT ROUTINE STAT
Procalcitonin (CPT 84145) Distinguish infectious from autoimmune CNS process Normal (<0.1 ng/mL) URGENT URGENT - URGENT
Lactate (CPT 83605) Sepsis screen; metabolic assessment Normal (<2.0 mmol/L) STAT STAT - STAT
Magnesium (CPT 83735) Seizure threshold; Susac patients develop seizures from cortical involvement Normal STAT STAT ROUTINE STAT
Pregnancy test (females of childbearing age) (CPT 81025) Teratogenicity of immunosuppressants; imaging with contrast; treatment planning; Susac syndrome has female predominance As applicable STAT STAT ROUTINE STAT
Type and screen (CPT 86900) Potential plasma exchange; transfusion if needed On file URGENT ROUTINE - URGENT

1B. Extended Workup (Second-line)

Test Rationale Target Finding ED HOSP OPD ICU
ANA (CPT 86235) Screen for SLE and other connective tissue diseases; SLE can cause BRAO and CNS disease mimicking Susac Negative or low titer URGENT ROUTINE ROUTINE URGENT
Anti-dsDNA antibodies (CPT 86255) SLE evaluation if ANA positive; lupus can cause retinal vasculitis and encephalopathy Negative - ROUTINE ROUTINE -
Anti-SSA/SSB (Ro/La) (CPT 86235) Sjogren syndrome with CNS involvement and retinal vasculitis Negative - ROUTINE ROUTINE -
ANCA panel (c-ANCA/PR3, p-ANCA/MPO) (CPT 86235+86200) Systemic vasculitis with retinal and CNS involvement (GPA, MPA) Negative URGENT ROUTINE ROUTINE URGENT
Complement C3, C4 (CPT 86160+86161) Low complement suggests SLE or other complement-mediated vasculopathy Normal - ROUTINE ROUTINE -
Antiphospholipid antibodies (anticardiolipin IgG/IgM, anti-beta2-glycoprotein I IgG/IgM, lupus anticoagulant) (CPT 86147+86146+85613) Antiphospholipid syndrome causing BRAO and cerebral infarcts mimicking Susac syndrome Negative - ROUTINE ROUTINE -
Quantitative immunoglobulins (IgG, IgA, IgM) (CPT 82784) Baseline before IVIG; IgA deficiency (IVIG anaphylaxis risk); hypergammaglobulinemia in autoimmune disease Normal; check IgA level before first IVIG dose - ROUTINE ROUTINE -
Hepatitis B surface antigen, surface antibody, core antibody (CPT 87340+86706+86704) Required before rituximab; HBV reactivation risk during immunosuppression Negative or immune (vaccinated) - ROUTINE ROUTINE -
Hepatitis C antibody (CPT 86803) HCV-associated vasculitis; pre-immunosuppression screen Negative - ROUTINE ROUTINE -
HIV 1/2 antigen/antibody (CPT 87389) HIV retinopathy and vasculopathy can mimic Susac; pre-immunosuppression screen Negative - ROUTINE ROUTINE -
RPR/VDRL with reflex FTA-ABS (CPT 86592) Syphilis can cause retinal vasculitis, hearing loss, and encephalopathy (mimics complete Susac triad) Non-reactive URGENT ROUTINE ROUTINE URGENT
QuantiFERON-TB Gold or T-SPOT (CPT 86480) Pre-immunosuppression screen; TB can cause CNS vasculitis Negative - ROUTINE ROUTINE -
TSH (CPT 84443) Thyroid dysfunction in encephalopathy differential; Hashimoto encephalopathy Normal - ROUTINE ROUTINE -
Anti-endothelial cell antibodies (AECA) Elevated in Susac syndrome (supports autoimmune endotheliopathy mechanism); not widely available; research biomarker May be positive (supports diagnosis but not required); not standardized - ROUTINE ROUTINE -
Homocysteine (CPT 83090) Hyperhomocysteinemia as thrombotic risk factor; contributes to retinal artery occlusion Normal - ROUTINE ROUTINE -
D-dimer (CPT 85379) Coagulopathy screen; thrombotic thrombocytopenic purpura evaluation Normal URGENT ROUTINE - URGENT
ACE level (CPT 82164) Neurosarcoidosis can cause cranial neuropathies, retinal disease, and hearing loss Normal - ROUTINE ROUTINE -
Lyme serology (IgG/IgM with reflex Western blot) (CPT 86617) Lyme neuroborreliosis can cause cranial neuropathy (CN VIII) and encephalopathy; endemic areas Negative - ROUTINE ROUTINE -

1C. Rare/Specialized (Refractory or Atypical)

Test Rationale Target Finding ED HOSP OPD ICU
Anti-neuronal antibodies (NMDAR, LGI1, CASPR2) (CPT 86255) Autoimmune encephalitis coexistence or mimicry of the encephalopathic component of Susac syndrome Negative - EXT EXT -
Aquaporin-4 (AQP4) antibody (CPT 83519) NMOSD with brainstem involvement can cause hearing loss and visual symptoms Negative - EXT EXT -
MOG-IgG antibody (CPT 83519) MOGAD can cause encephalopathy and optic pathway disease Negative - EXT EXT -
Von Willebrand factor antigen and ADAMTS13 activity (CPT 85245+85397) Endothelial activation marker; ADAMTS13 deficiency (TTP) can cause multiorgan microangiopathy mimicking Susac VWF elevated (endothelial activation); ADAMTS13 >10% (excludes TTP) - EXT EXT -
Fibrinogen, haptoglobin, peripheral blood smear (CPT 85384+83010+85060) Thrombotic microangiopathy screen (TTP/HUS); schistocytes on smear Normal fibrinogen; normal haptoglobin; no schistocytes - EXT EXT -
Interleukin-6 (serum and CSF) (CPT 83520) Elevated in active autoimmune endotheliopathy; guides treatment response Normal (<7 pg/mL) - EXT EXT -
Anti-endothelial cell antibodies -- research panel Specialized testing at reference laboratories; identifies antibodies targeting endothelial antigens in Susac syndrome May be positive; research use only - EXT EXT -
Paraneoplastic antibody panel (ANNA-1/Hu, CV2/CRMP5) (CPT 86255) Paraneoplastic retinopathy and encephalopathy; rare overlap Negative - EXT EXT -
Cogan syndrome antibodies (anti-HSP70, anti-cochlear antibodies) Cogan syndrome causes interstitial keratitis + vestibuloacoustic dysfunction (audiometric overlap with Susac) Negative - EXT EXT -

2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study Timing Target Finding Contraindications ED HOSP OPD ICU
CT head without contrast (CPT 70450) Immediate (ED triage) Rule out hemorrhage, mass, hydrocephalus; CT is often normal early in Susac syndrome None significant STAT STAT - STAT
MRI brain with and without contrast (CPT 70553) Within 24 hours; STAT if available PATHOGNOMONIC: "Snowball" lesions in central fibers of corpus callosum (best seen on sagittal T2/FLAIR and DWI); multifocal white matter T2/FLAIR hyperintensities in deep gray matter, periventricular white matter, posterior fossa, and internal capsule; leptomeningeal enhancement; callosal lesions with central "hole" pattern (icicle lesions); DWI restriction in acute lesions Pacemaker; metallic implants; GFR <30 for gadolinium STAT STAT ROUTINE STAT
Fluorescein angiography (FA) (CPT 92235) Within 24-48 hours; essential for diagnosis DIAGNOSTIC: Branch retinal artery occlusion (BRAO); arteriolar wall hyperfluorescence (pathognomonic -- represents endothelial damage); non-filling of arteriolar segments; retinal capillary leakage; multiple arterial branch occlusions often bilateral; abnormal even without visual symptoms Fluorescein allergy; severe renal impairment (relative); pregnancy (relative) - URGENT URGENT -
Comprehensive audiometry (CPT 92557) Within 24-48 hours; essential for diagnosis Sensorineural hearing loss (SNHL) predominantly low and mid-frequency (unlike presbycusis which is high-frequency); unilateral or bilateral; fluctuating; progressive to severe/profound None significant - URGENT URGENT -
Fundoscopic examination (dilated) Immediate if visual symptoms Cotton-wool spots; Hollenhorst plaques (rare); arteriolar wall changes; retinal whitening from BRAO; multiple branch artery territory infarcts None STAT STAT ROUTINE STAT
ECG (12-lead) (CPT 93000) On admission Baseline; arrhythmia screen; cardiac source of emboli in differential None STAT STAT ROUTINE STAT
Chest X-ray (CPT 71046) On admission Exclude pulmonary pathology; mediastinal lymphadenopathy (sarcoidosis differential) Pregnancy (relative) STAT STAT - STAT
Echocardiogram (transthoracic) (CPT 93306) Within 24-48 hours Exclude cardiac embolic source (vegetations, PFO, myxoma) as cause of BRAO; rare cardiac involvement reported in Susac syndrome None significant URGENT URGENT ROUTINE URGENT

2B. Extended

Study Timing Target Finding Contraindications ED HOSP OPD ICU
MRI brain with sagittal FLAIR and DWI (dedicated Susac protocol) (CPT 70553) Within 48 hours Sagittal FLAIR is critical: central callosal "snowball" lesions (3-7 mm round lesions in central corpus callosum fibers); "icicle" or "spoke" lesions hanging from inferior surface of corpus callosum; leptomeningeal enhancement; deep gray matter lesions (thalamus, basal ganglia); cerebellar lesions; DWI restriction indicates acute/active disease Same as MRI - URGENT ROUTINE URGENT
Optical coherence tomography (OCT) (CPT 92134) Within 48-72 hours Retinal nerve fiber layer thinning; inner retinal layer loss from ischemia; macular edema; arteriolar wall changes; serial OCT monitors for disease progression and treatment response None significant - ROUTINE ROUTINE -
Visual field testing (CPT 92083) Within 72 hours Scotomas corresponding to BRAO territories; reveals subclinical retinal ischemia Patient cooperation required - ROUTINE ROUTINE -
Distortion product otoacoustic emissions (DPOAE) (CPT 92588) Within 72 hours Absent or reduced emissions indicating outer hair cell damage; cochlear ischemia pattern; complements audiometry None significant - ROUTINE ROUTINE -
Auditory brainstem response (ABR) (CPT 92585) Within 72 hours Prolonged latencies or absent waves; helps differentiate cochlear (Susac) from retrocochlear (acoustic neuroma) pathology None significant - ROUTINE ROUTINE -
MRA head (CPT 70544) With MRI brain Typically normal in Susac syndrome (small vessel disease below MRA resolution); helps exclude large vessel vasculitis or RCVS Same as MRI - ROUTINE ROUTINE ROUTINE
EEG (routine or continuous) (CPT 95816) If seizures or altered consciousness Focal or diffuse slowing; epileptiform discharges; subclinical seizures; encephalopathy pattern; seizures reported in 15-20% of Susac patients None significant URGENT URGENT ROUTINE STAT
CT chest/abdomen/pelvis with contrast (CPT 71260+74178) Within 72 hours if systemic disease suspected Exclude sarcoidosis (hilar adenopathy); systemic vasculitis features; occult malignancy (paraneoplastic retinopathy differential) Contrast allergy; renal insufficiency - ROUTINE ROUTINE -
Transesophageal echocardiogram (TEE) (CPT 93312) If TTE non-diagnostic Vegetations; aortic arch atheroma; PFO with paradoxical embolism; improved sensitivity for small embolic sources Esophageal pathology - ROUTINE ROUTINE -

2C. Rare/Specialized

Study Timing Target Finding Contraindications ED HOSP OPD ICU
Conventional cerebral angiography (DSA) (CPT 36224) If large vessel vasculitis suspected Typically NORMAL in Susac syndrome (small vessel disease); small vessel irregularities in rare cases; helps exclude PACNS and RCVS Contrast allergy; renal insufficiency; coagulopathy - EXT EXT EXT
Brain biopsy (CPT 61140) Only if diagnosis remains uncertain after comprehensive non-invasive workup Arteriolar wall thickening; endothelial cell swelling; perivascular lymphocytic infiltrate WITHOUT transmural vasculitis (key distinction from PACNS); microinfarctions; complement deposition in vessel walls Coagulopathy; inaccessible location; critical instability - EXT - EXT
Muscle/skin biopsy (microvasculature) (CPT 11106) If systemic endotheliopathy suspected Endothelial cell changes; microangiopathy in dermal arterioles; complement deposition Coagulopathy; infection at biopsy site - EXT EXT -
Indocyanine green angiography (ICG) (CPT 92240) Adjunct to FA if equivocal findings Choroidal involvement; choroidal hypoperfusion not seen on FA; complements fluorescein findings Iodine/shellfish allergy; hepatic impairment - EXT EXT -
FDG-PET brain (CPT 78816) If standard imaging inconclusive Focal hypermetabolism at sites of active inflammation; not well-studied in Susac syndrome Uncontrolled diabetes; pregnancy - EXT EXT -

LUMBAR PUNCTURE (CPT 62270)

Indication: Important for Susac syndrome evaluation and exclusion of alternative diagnoses. CSF in Susac syndrome typically shows elevated protein with mild or no pleocytosis -- distinct from the significant pleocytosis seen in PACNS and infectious etiologies. CSF helps exclude MS, infections, and CNS vasculitis.

Timing: URGENT after CT head excludes mass effect; do not delay if clinical suspicion is high

Volume Required: 15-20 mL (extra for cytology, cultures, and OCB)

Study Rationale Target Finding ED HOSP OPD ICU
Opening pressure Elevated ICP assessment; mildly elevated in Susac syndrome 10-20 cm H2O (may be mildly elevated) URGENT ROUTINE ROUTINE URGENT
Cell count with differential (tubes 1 and 4) (CPT 89051) Mild lymphocytic pleocytosis or normal cell count; distinct from PACNS (higher pleocytosis) Normal to mild pleocytosis (WBC 0-30 cells/uL); lymphocyte-predominant if elevated; notably LESS than PACNS URGENT ROUTINE ROUTINE URGENT
Protein (CPT 84157) Elevated protein supports CNS endotheliopathy; protein is elevated in ~75% of Susac syndrome cases Mildly elevated (50-150 mg/dL typical); less elevated than PACNS or infectious causes URGENT ROUTINE ROUTINE URGENT
Glucose with paired serum glucose (CPT 82945) Low glucose suggests infection or carcinomatous meningitis; typically normal in Susac syndrome Normal (>60% of serum glucose) URGENT ROUTINE ROUTINE URGENT
Gram stain and bacterial culture (CPT 87205+87070) Rule out bacterial meningitis No organisms URGENT ROUTINE ROUTINE URGENT
Oligoclonal bands (CSF AND paired serum) (CPT 83916) Differentiate from MS; OCBs present in Susac syndrome but less frequently than MS Often negative; if positive, usually fewer bands than MS; CSF-restricted bands possible - ROUTINE ROUTINE -
IgG index (CPT 86430) Intrathecal antibody production; helps differentiate from MS Mildly elevated; less prominent than MS - ROUTINE ROUTINE -
Cytology (CPT 88104) Exclude CNS lymphoma and carcinomatous meningitis Negative for malignant cells - ROUTINE ROUTINE -
Flow cytometry (CPT 88187) CNS lymphoma as differential for multifocal white matter lesions Normal - ROUTINE ROUTINE -
HSV 1/2 PCR (CPT 87529) HSV encephalitis in encephalopathy differential Negative URGENT ROUTINE - URGENT
VZV PCR (CPT 87798) VZV vasculopathy can cause retinal necrosis and encephalopathy Negative URGENT ROUTINE ROUTINE URGENT
VDRL (CSF) (CPT 86592) Neurosyphilis can mimic complete Susac triad (encephalopathy + visual loss + hearing loss) Non-reactive - ROUTINE ROUTINE -
AFB smear and culture (CPT 87116) TB meningitis in endemic areas or immunocompromised Negative - ROUTINE ROUTINE -
BioFire FilmArray ME Panel (CPT 87483) Rapid multiplex PCR for common infectious meningitis/encephalitis pathogens Negative URGENT ROUTINE - URGENT
Myelin basic protein (CSF) (CPT 83873) Elevated reflecting white matter damage; nonspecific Mildly elevated - ROUTINE ROUTINE -

Special Handling: Oligoclonal bands require paired serum sample drawn within 1 hour. Cytology requires rapid transport (<1 hour). Store extra CSF (frozen at -80C) for future testing. Serial LP is useful to monitor protein levels during treatment.

Contraindications: Elevated ICP without imaging (obtain CT first); coagulopathy (INR >1.5, platelets <50K); skin infection at LP site; posterior fossa mass


3. TREATMENT

3A. Acute/Emergent

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Methylprednisolone IV (CPT 96365) IV Acute immunosuppression for confirmed or strongly suspected Susac syndrome; reduces endothelial inflammation and prevents further ischemic injury to brain, retina, and cochlea 1000 mg daily :: IV :: daily :: 1000 mg IV daily for 3-5 days; infuse over 1-2 hours; begin upon strong clinical suspicion; cornerstone of acute management along with IVIG Active untreated infection; uncontrolled diabetes; active GI bleeding; psychosis from steroids Glucose q6h (target <180 mg/dL); blood pressure; mood and sleep disturbance; GI prophylaxis; I/O URGENT STAT - STAT
IVIG (intravenous immunoglobulin) (CPT 96365) IV FIRST-LINE therapy in Susac syndrome (along with corticosteroids); anti-endothelial cell antibody neutralization; immunomodulation; start early and aggressively 0.4 g/kg daily :: IV :: daily x 5 days :: 0.4 g/kg/day IV x 5 days (total 2 g/kg) for induction; infuse per weight-based protocol; premedicate with acetaminophen 650 mg PO and diphenhydramine 25-50 mg IV/PO; followed by maintenance IVIG (see Section 3D) IgA deficiency (anaphylaxis risk -- check IgA level before first dose); recent thromboembolic event; renal failure (adjust infusion rate); volume overload Renal function daily; headache (aseptic meningitis in 5-10%); thrombosis risk; volume overload; vital signs q15min during first infusion then q30-60min; serum IgA level before initiation URGENT STAT - STAT
Omeprazole (GI prophylaxis) IV/PO Prevention of steroid-induced GI bleeding during high-dose corticosteroid therapy 40 mg daily :: IV :: daily :: 40 mg IV or PO daily during high-dose steroid course and subsequent oral taper PPI allergy None routine URGENT STAT ROUTINE STAT
Insulin sliding scale SC Steroid-induced hyperglycemia management; high-dose methylprednisolone frequently causes glucose >200 mg/dL Per institutional protocol :: SC :: PRN :: Per protocol if glucose >180 mg/dL; anticipate need on days 2-5 of pulse steroids Hypoglycemia risk Glucose q6h; adjust per response URGENT STAT - STAT
Heparin (DVT prophylaxis) SC VTE prophylaxis during hospitalization with immobility and active CNS disease 5000 units q8h :: SC :: q8h :: 5000 units SC q8h; use enoxaparin 40 mg SC daily if no contraindication Active hemorrhage; hemorrhagic transformation; thrombocytopenia Platelet count; signs of bleeding - STAT - STAT
Aspirin (low-dose antiplatelet) PO Antiplatelet therapy for microvascular thrombosis prevention; adjunctive to immunotherapy; targets platelet-endothelial interaction in Susac syndrome 81 mg daily :: PO :: daily :: 81 mg PO daily; start at diagnosis; continue long-term as adjunctive antiplatelet therapy Active bleeding; platelet count <50K; concurrent anticoagulation (relative) GI symptoms; bleeding; platelet count URGENT STAT ROUTINE STAT
Lorazepam (acute seizure) IV Acute seizure management; seizures reported in 15-20% of Susac syndrome patients 0.1 mg/kg IV :: IV :: PRN :: 0.1 mg/kg IV (max 4 mg/dose); repeat x1 in 5 minutes if needed; max 8 mg total Respiratory depression; acute narrow-angle glaucoma Respiratory status; sedation level; airway patency STAT STAT - STAT
Levetiracetam (seizure prophylaxis/treatment) IV/PO Anti-seizure medication if seizures have occurred; prophylaxis if extensive cortical involvement on MRI 1000 mg BID :: IV :: BID :: Load: 1000-1500 mg IV; Maintenance: 500-1500 mg IV/PO BID; max 3000 mg/day Renal impairment (dose adjust per CrCl) Behavioral changes; renal function; suicidality STAT STAT ROUTINE STAT

The standard acute regimen for Susac syndrome is aggressive early combination of high-dose IV corticosteroids PLUS IVIG. Unlike PACNS, Susac syndrome responds best to early aggressive immunotherapy and has a high risk of irreversible damage (hearing loss, visual loss, cognitive impairment) if treatment is delayed. IVIG is particularly important in Susac syndrome due to its immunomodulatory effects on endothelial cell antibodies. Initiate plasma exchange if there is inadequate response to steroids + IVIG within 48-72 hours.

3B. Symptomatic Treatments

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Acetaminophen PO/IV Headache management; headache is common in Susac syndrome, often severe and diffuse 650 mg q6h PRN :: PO :: q6h :: 650-1000 mg PO/IV q6h PRN; max 3g/day (2g/day if hepatic impairment) Severe hepatic impairment; allergy LFTs if prolonged use STAT STAT ROUTINE STAT
Metoclopramide IV Nausea associated with headache, IVIG infusion, or vestibular symptoms from cochlear involvement 10 mg q6h PRN :: IV :: q6h PRN :: 10 mg IV q6-8h PRN; max 30 mg/day Parkinsonian features; bowel obstruction; seizure history (relative) Extrapyramidal symptoms; tardive dyskinesia with prolonged use URGENT ROUTINE - URGENT
Ondansetron IV Nausea and vomiting management; particularly during IVIG or plasma exchange 4 mg q6h PRN :: IV :: q6h PRN :: 4 mg IV q6-8h PRN; max 16 mg/day QTc >500 ms; congenital long QT syndrome QTc if risk factors URGENT ROUTINE - URGENT
Calcium carbonate + Vitamin D PO Bone protection during anticipated prolonged corticosteroid course (treatment duration typically 2+ years) 1000 mg calcium + 1000 IU vitamin D daily :: PO :: daily :: Calcium 500-600 mg PO BID + Vitamin D 1000-2000 IU PO daily; start with steroids Hypercalcemia; renal stones 25-OH Vitamin D level; calcium; DEXA if steroids >3 months - ROUTINE ROUTINE -
Trimethoprim-sulfamethoxazole (PJP prophylaxis) PO Pneumocystis jirovecii prophylaxis during combined immunosuppression (steroids + immunosuppressant) 1 DS tablet 3x/week :: PO :: 3x/week :: 1 double-strength tablet (160/800 mg) PO three times weekly; continue throughout immunosuppression Sulfa allergy; severe renal impairment; hyperkalemia; megaloblastic anemia CBC; renal function; potassium - ROUTINE ROUTINE -
Nimodipine PO Cochlear and retinal vasodilation; calcium channel blocker improves microvascular perfusion; used empirically in Susac protocols for cochlear and retinal ischemia 30 mg q8h :: PO :: q8h :: 30 mg PO q8h; titrate based on blood pressure tolerance; increase to 60 mg q8h if tolerated Hypotension (SBP <90); severe hepatic impairment Blood pressure; heart rate - ROUTINE ROUTINE -
Hearing aid fitting Device Sensorineural hearing loss rehabilitation; early fitting improves quality of life and communication N/A :: device :: ongoing :: Refer to audiology for bilateral hearing aid evaluation once hearing loss documented; obtain cochlear implant evaluation if severe/profound bilateral SNHL None Audiometric follow-up; device adjustment - ROUTINE ROUTINE -
Sertraline PO Depression and anxiety commonly associated with Susac syndrome given multi-organ impairment (visual loss, hearing loss, cognitive decline) 50 mg daily :: PO :: daily :: Start 50 mg PO daily; increase by 50 mg q2-4 weeks; target 100-200 mg/day; max 200 mg/day Concurrent MAOIs; QTc prolongation Suicidality; serotonin syndrome; QTc if risk factors - ROUTINE ROUTINE -
Melatonin PO Insomnia related to high-dose corticosteroids; sleep-wake disruption during hospitalization 3 mg qHS :: PO :: qHS :: 3-5 mg PO at bedtime; up to 10 mg None significant Sleep quality - ROUTINE ROUTINE -

3C. Second-line/Refractory

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Plasma exchange (plasmapheresis, PLEX) (CPT 36514) IV Refractory Susac syndrome not responding to steroids + IVIG; acute deterioration; removal of circulating anti-endothelial cell antibodies and inflammatory mediators 5 exchanges over 10-14 days :: IV :: every other day :: 1-1.5 plasma volumes per exchange; albumin replacement; 5-7 sessions over 10-14 days; extend to 10 sessions in severe cases Hemodynamic instability; severe coagulopathy; central line complications; hypocalcemia risk Hemodynamics during exchange; calcium (citrate-induced hypocalcemia); fibrinogen post-exchange; coagulation studies; electrolytes; line-site infection - URGENT - URGENT
Rituximab (CPT 96365) IV Refractory Susac syndrome failing IVIG + steroids + maintenance immunosuppression; relapsing disease; B-cell mediated endotheliopathy component 375 mg/m2 weekly x 4 doses :: IV :: weekly x 4 :: 375 mg/m2 IV weekly x 4 doses OR 1000 mg IV x 2 doses (day 0, day 14); premedicate with methylprednisolone 100 mg IV, acetaminophen 650 mg PO, diphenhydramine 50 mg IV Active hepatitis B; severe active infection; live vaccines within 4 weeks; PML history Hepatitis B serology before first dose; CBC q2-4 weeks; immunoglobulin levels q3 months; CD19/CD20 B-cell counts q3 months; infusion reactions; PML surveillance - URGENT ROUTINE URGENT
Cyclophosphamide IV (CPT 96365) IV Severe refractory Susac syndrome failing IVIG, steroids, and other immunosuppressants; fulminant disease with rapid progression 750 mg/m2 monthly :: IV :: monthly :: 750 mg/m2 IV monthly x 3-6 months; pre-hydrate with 1L NS; administer with MESNA for uroprotection; used in severe/refractory cases only Pregnancy; active infection; bone marrow failure; hemorrhagic cystitis CBC weekly x 4 weeks after each cycle (nadir day 10-14); urinalysis each cycle; BMP; LFTs; fertility assessment; MESNA + hydration for uroprotection - EXT EXT EXT
Infliximab (CPT 96365) IV Refractory Susac syndrome; TNF-alpha inhibitor targeting endothelial inflammation; limited case reports showing benefit 5 mg/kg at weeks 0, 2, 6 :: IV :: per protocol :: 5 mg/kg IV at weeks 0, 2, 6; then every 8 weeks; premedicate Active TB; decompensated heart failure (NYHA III/IV); demyelinating disease; active infection TB screening before and annually; hepatitis B; CBC; LFTs; heart failure symptoms; infection surveillance - EXT EXT -
Natalizumab (CPT 96365) IV Emerging option for refractory Susac syndrome; anti-VLA4 antibody reduces lymphocyte trafficking across blood-brain barrier; case reports of efficacy 300 mg IV q4 weeks :: IV :: q4 weeks :: 300 mg IV every 4 weeks; JC virus antibody testing required before initiation JC virus antibody positive (PML risk); concurrent immunosuppression (PML risk); progressive multifocal leukoencephalopathy JC virus antibody index q6 months; MRI brain q6-12 months for PML surveillance; LFTs; CBC - EXT EXT -

Plasma exchange is early in the treatment algorithm for Susac syndrome when there is inadequate response to steroids + IVIG. Rituximab has emerging evidence for refractory cases and is increasingly used. Cyclophosphamide is reserved for fulminant or severe refractory disease. Natalizumab and infliximab have only case reports supporting their use. Individualize the choice of second-line agent based on disease severity, organ involvement pattern, and prior treatment response.

3D. Disease-Modifying Therapies (Maintenance)

Treatment Route Indication Dosing Pre-Treatment Requirements Contraindications Monitoring ED HOSP OPD ICU
IVIG maintenance (CPT 96365) IV Maintenance immunomodulation following acute induction; backbone of long-term Susac management; prevents relapse and further end-organ damage 0.4 g/kg monthly :: IV :: monthly :: Maintenance: 0.4 g/kg IV monthly OR 2 g/kg IV divided over 2-5 days every 4 weeks; taper to q6-8 weeks after 12-24 months of stability; minimum 2 years of treatment recommended IgA level; renal function; CBC; coagulation studies IgA deficiency; acute renal failure; recent thromboembolism; volume overload Renal function before each infusion; headache (aseptic meningitis); thrombosis risk; IgG trough levels (target >800 mg/dL); skin reactions; anaphylaxis monitoring - STAT ROUTINE STAT
Prednisone (oral, following IV pulse) PO Oral corticosteroid taper following IV methylprednisolone pulse; bridge to steroid-sparing maintenance therapy 1 mg/kg daily :: PO :: daily :: Start 1 mg/kg/day PO (max 80 mg) after IV pulse; taper by 10 mg every 2 weeks to 20 mg/day; then taper by 5 mg every 2 weeks to 10 mg/day; then 2.5 mg every 2-4 weeks; target off steroids by 6-12 months if on maintenance immunosuppressant Active untreated infection; uncontrolled diabetes; psychosis from steroids; avascular necrosis Glucose; blood pressure; bone density (DEXA if >3 months); weight; mood; cataracts; adrenal assessment on taper; osteoporosis prevention - ROUTINE ROUTINE -
Mycophenolate mofetil (CellCept) PO Long-term steroid-sparing immunosuppression; maintenance agent in Susac syndrome; prevents relapse 500 mg BID :: PO :: BID :: Start 500 mg PO BID; increase to 1000 mg PO BID over 2-4 weeks; target 2000-3000 mg/day in divided doses; minimum 2 years; some patients require indefinite therapy CBC (ANC >1500, Plt >100K); LFTs; renal function; hepatitis B/C screen; pregnancy test Pregnancy (Category D -- teratogenic); active infection; severe GI disease CBC q2 weeks x 3 months, then monthly; LFTs; GI symptoms (diarrhea, nausea); infection surveillance; pregnancy prevention (two forms of contraception) - ROUTINE ROUTINE -
Azathioprine (Imuran) PO Alternative maintenance immunosuppression; steroid-sparing agent; used when mycophenolate not tolerated 50 mg daily :: PO :: daily :: Start 50 mg PO daily; increase by 50 mg every 2 weeks to target 2-3 mg/kg/day; minimum 2 years TPMT genotype/activity before starting (mandatory); CBC; LFTs; renal function; hepatitis B/C screen TPMT deficiency (check genotype before starting); pregnancy (relative); active infection; concurrent allopurinol (reduce dose by 75%) TPMT genotype/activity before starting (mandatory); CBC q2 weeks x 2 months, then monthly; LFTs monthly x 3 months, then q3 months; pancreatitis symptoms; infection surveillance - ROUTINE ROUTINE -

The standard maintenance regimen for Susac syndrome is IVIG (monthly or every 4 weeks) PLUS an oral immunosuppressant (mycophenolate mofetil preferred) PLUS a slow prednisone taper. Susac syndrome has a relapsing-remitting course in many patients, and premature withdrawal of immunotherapy leads to relapse with cumulative end-organ damage (hearing, vision, cognition). European expert consensus recommends minimum 2 years of treatment, with some patients requiring indefinite immunotherapy. Serial MRI, audiometry, and fluorescein angiography guide treatment duration.


4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation ED HOSP OPD ICU
Neurology (neuroimmunology specialist) for Susac syndrome diagnosis confirmation, immunotherapy initiation, and long-term management STAT STAT ROUTINE STAT
Ophthalmology (retinal specialist) for fluorescein angiography, fundoscopic examination, OCT, and serial retinal monitoring; essential for diagnosis and treatment monitoring STAT STAT ROUTINE STAT
Otolaryngology/Audiology for comprehensive audiometry, DPOAE, ABR, hearing aid fitting, and cochlear implant evaluation if severe/profound SNHL URGENT URGENT ROUTINE URGENT
Rheumatology for exclusion of systemic autoimmune disease (SLE, antiphospholipid syndrome) and co-management of immunosuppressive therapy - URGENT ROUTINE URGENT
Neuroradiology for MRI interpretation with Susac protocol (sagittal FLAIR corpus callosum lesion characterization) and serial imaging comparison - URGENT ROUTINE URGENT
Infectious disease for exclusion of infectious etiologies (syphilis, VZV, TB) mimicking Susac triad and infection management during immunosuppression URGENT URGENT ROUTINE URGENT
Hematology if thrombotic microangiopathy suspected (TTP/HUS differential) or for plasma exchange management - URGENT ROUTINE URGENT
Physical therapy for motor rehabilitation, gait training, balance assessment, and fall prevention given potential cerebellar and deep gray matter involvement - ROUTINE ROUTINE ROUTINE
Occupational therapy for ADL assessment, cognitive rehabilitation, and adaptive strategies for visual and hearing impairment - ROUTINE ROUTINE ROUTINE
Speech-language pathology for communication strategies (hearing loss), swallowing evaluation if brainstem involvement, and cognitive-linguistic therapy - ROUTINE ROUTINE ROUTINE
Neuropsychology for formal cognitive assessment given cognitive decline and encephalopathy as core features; serial monitoring to track treatment response - - ROUTINE -
Social work for insurance navigation (IVIG is costly), disability resources, and family support during prolonged treatment - ROUTINE ROUTINE -
Endocrinology for steroid-induced diabetes management if persistent hyperglycemia during corticosteroid therapy - ROUTINE ROUTINE -
Low vision rehabilitation services for patients with permanent visual field deficits from BRAO - - ROUTINE -
Cochlear implant evaluation (otology/neurotology) for severe bilateral sensorineural hearing loss not responding to treatment and not adequately aided - - ROUTINE -

4B. Patient Instructions

Recommendation ED HOSP OPD
Return to ED immediately for new or worsening visual loss (scotomas, blurred vision, visual field cuts), sudden hearing loss, new headache, confusion, or weakness -- these indicate disease relapse with new BRAO or CNS lesion Y Y Y
Do not stop corticosteroids abruptly -- abrupt cessation causes adrenal crisis and disease flare; taper must be supervised by neurology Y Y Y
Report signs of infection promptly (fever >100.4F, cough, dysuria, rash, mouth sores) while on immunosuppressive therapy, as infection risk is significantly increased - Y Y
Avoid live vaccines during immunosuppressive therapy (MMR, varicella, zoster live, yellow fever, intranasal influenza); inform all healthcare providers of immunosuppressed status - Y Y
Do not drive until cleared by neurology and ophthalmology due to risk of seizures, cognitive impairment, and visual field deficits from BRAO Y Y Y
Expect prolonged treatment course (minimum 2 years, often longer); adherence to monthly IVIG and daily immunosuppressant is essential to prevent relapse and cumulative organ damage - Y Y
Avoid pregnancy during mycophenolate therapy; discuss contraception with neurology and OB/GYN before starting treatment - Y Y
Wear medical alert bracelet identifying immunosuppressed status and Susac syndrome diagnosis - Y Y
Report any new visual symptoms (floaters, scotomas, field cuts), hearing changes (new loss, tinnitus, fullness), or cognitive difficulties between visits, as these indicate subclinical relapse - Y Y
Attend all scheduled follow-up appointments including MRI surveillance, fluorescein angiography, audiometry, and laboratory monitoring - Y Y
Use assistive devices for hearing loss (hearing aids, captioning, FM systems) and visual impairment (magnifiers, contrast enhancement) to maintain function and safety - Y Y
Avoid excessive sun exposure while on immunosuppressive therapy due to increased skin cancer risk; use sunscreen SPF 30+ - Y Y

4C. Lifestyle & Prevention

Recommendation ED HOSP OPD
Stop smoking to reduce microvascular disease risk and improve treatment response; smoking worsens endothelial dysfunction - Y Y
Blood pressure target <140/90 mmHg (lower if tolerated) to reduce microvascular risk and prevent further ischemic injury - Y Y
Low-sodium diet to manage steroid-induced fluid retention and hypertension - Y Y
Regular weight-bearing exercise as tolerated to maintain bone density during prolonged corticosteroid therapy; target 150 min/week of moderate activity - - Y
Adequate hydration (minimum 2L/day) to reduce thrombotic risk and support renal function during IVIG therapy - Y Y
Pneumococcal (PCV20) and annual influenza vaccination (inactivated only) before or during immunosuppression when possible; avoid live vaccines - Y Y
Home safety evaluation to address fall hazards given potential visual field deficits, hearing loss, balance impairment, and cognitive dysfunction - Y Y
Cognitive stimulation activities (reading, puzzles, social engagement) to support cognitive recovery alongside formal rehabilitation - - Y
Stress management and psychological support given multi-organ disease with significant functional impact on daily life; referral to support groups - - Y
Regular ophthalmologic monitoring even during remission to detect subclinical retinal artery occlusions before permanent visual loss occurs - - Y

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis Key Distinguishing Features Tests to Differentiate
Multiple sclerosis (MS) White matter lesions BUT: callosal lesions in MS are periventricular (Dawson fingers at calloso-septal interface) NOT central corpus callosum "snowball" lesions; no BRAO; no low-frequency SNHL; CSF shows prominent oligoclonal bands; typical MS relapsing pattern MRI (Dawson fingers vs. central callosal snowballs); fluorescein angiography (normal in MS); audiometry (normal in MS); CSF OCBs (strong positive in MS, weak/absent in Susac)
CNS vasculitis (PACNS) Subacute progressive course; multifocal infarcts in multiple vascular territories; CSF shows significant lymphocytic pleocytosis (WBC 10-150) with elevated protein; angiographic beading; no BRAO pattern; no characteristic low-frequency SNHL CSF (higher pleocytosis in PACNS); conventional angiography (abnormal in PACNS, normal in Susac); fluorescein angiography (BRAO pattern in Susac, not PACNS); MRI (central callosal snowballs absent in PACNS); brain biopsy (transmural vasculitis in PACNS vs. endotheliopathy in Susac)
Acute disseminated encephalomyelitis (ADEM) Monophasic course; often post-infectious or post-vaccination; large, poorly marginated white matter lesions; deep gray matter involvement; no BRAO; no SNHL; pediatric predominance MRI (large fluffy lesions vs. small snowball callosal lesions); fluorescein angiography (normal in ADEM); audiometry (normal in ADEM); CSF (similar mild pleocytosis but no BRAO)
Neurosarcoidosis Cranial neuropathies (CN VII, VIII); basilar leptomeningeal enhancement; hypothalamic involvement; hilar lymphadenopathy; elevated ACE; granulomatous inflammation on biopsy ACE level (serum and CSF); chest CT (bilateral hilar adenopathy); biopsy (non-caseating granulomas); FDG-PET; no central callosal snowball lesions; FA shows retinal periphlebitis (not arteriolar occlusion)
Antiphospholipid syndrome Recurrent arterial/venous thrombosis; pregnancy losses; livedo reticularis; retinal vascular occlusion can occur BUT central retinal artery or vein, not typically branch arteriolar pattern; no central callosal snowball lesions Anticardiolipin, anti-beta2-glycoprotein I, lupus anticoagulant (confirmed on repeat 12 weeks apart); MRI pattern differs; no characteristic low-frequency SNHL
Cogan syndrome Interstitial keratitis (NOT retinal artery occlusion) + vestibuloacoustic dysfunction; systemic vasculitis (aortitis); no characteristic callosal lesions on MRI; audiovestibular symptoms more vestibular-predominant Slit-lamp examination (interstitial keratitis in Cogan, absent in Susac); fluorescein angiography (BRAO in Susac, not Cogan); MRI (no callosal snowballs in Cogan); CT aorta (aortitis in Cogan)
VZV vasculopathy History of zoster; retinal necrosis (NOT typical BRAO pattern); encephalopathy with vasculopathy; CSF pleocytosis with VZV antibodies; responds to acyclovir CSF VZV PCR and VZV IgG (positive in VZV vasculopathy); MRI pattern (not central callosal snowballs); fluorescein angiography (retinal necrosis pattern vs. BRAO); response to acyclovir (no response in Susac)
Neurosyphilis Meningovascular syphilis can cause encephalopathy, hearing loss, and retinal disease (mimics complete triad); Argyll Robertson pupils; positive syphilis serology RPR/VDRL; CSF VDRL; FTA-ABS; MRI pattern differs (no central callosal snowballs); responds to IV penicillin
Embolic retinal artery occlusion (cardiac source) Central or branch retinal artery occlusion from cardiac emboli (atrial fibrillation, endocarditis, PFO); no encephalopathy unless concurrent stroke; no SNHL; Hollenhorst plaques on fundoscopy Echocardiogram (embolic source); cardiac monitoring (atrial fibrillation); FA (single territory vs. multifocal arteriolar occlusions in Susac); no callosal snowballs; no hearing loss
Vogt-Koyanagi-Harada (VKH) disease Bilateral panuveitis with exudative retinal detachments; hearing loss; meningismus; vitiligo, poliosis; CSF pleocytosis; uveal (choroidal) not arteriolar disease Fluorescein angiography (choroidal pattern in VKH vs. arteriolar occlusion in Susac); OCT (subretinal fluid in VKH); skin findings (vitiligo/poliosis in VKH); MRI (no callosal snowballs in VKH)
Eales disease Retinal vasculitis with peripheral retinal ischemia; predominantly venous involvement (periphlebitis); vitreous hemorrhage; young males; no CNS involvement; no SNHL Fluorescein angiography (periphlebitis and peripheral ischemia in Eales vs. arteriolar BRAO in Susac); MRI brain (normal in Eales); audiometry (normal in Eales); no encephalopathy
CADASIL Recurrent subcortical strokes; migraine with aura; progressive cognitive decline; white matter disease; temporal pole and external capsule involvement; autosomal dominant; NOTCH3 mutation Genetic testing (NOTCH3 mutation); MRI (anterior temporal and external capsule involvement characteristic of CADASIL); no BRAO; no SNHL; skin biopsy (GOM deposits); family history
Behcet disease (neuro-Behcet) Oral and genital ulcers; uveitis (not BRAO); brainstem syndrome; venous sinus thrombosis; pathergy; HLA-B51 associated HLA-B51; clinical criteria (oral ulcers, genital ulcers, pathergy); slit-lamp (uveitis not BRAO); MRI pattern (brainstem predilection in neuro-Behcet); no callosal snowballs

6. MONITORING PARAMETERS

6A. Acute Phase Monitoring (Inpatient)

Parameter Frequency Target/Threshold Action if Abnormal ED HOSP OPD ICU
Neurologic examination (mental status, cranial nerves, motor, sensory, coordination) Q4-6h (ICU); Q8-12h (floor) Stable or improving; resolution of encephalopathy; no new focal deficits If worsening: urgent MRI; escalate immunotherapy; initiate PLEX if on steroids + IVIG; ICU transfer STAT STAT - STAT
Visual acuity and confrontational visual fields Daily; Q8h if actively declining Stable or improving; no new scotomas New scotoma or acuity loss: urgent fluorescein angiography; escalate treatment; ophthalmology reassessment STAT STAT - STAT
Hearing assessment (bedside; whispered voice, tuning fork) Daily Stable or improving; no new lateralizing hearing loss New or worsening hearing loss: urgent audiometry; escalate treatment; audiology reassessment - STAT - STAT
Blood glucose Q6h during IV methylprednisolone; QID during oral prednisone <180 mg/dL Insulin sliding scale; endocrine consult if persistent >250 mg/dL STAT STAT ROUTINE STAT
Blood pressure Q1h (ICU); Q4h (floor) SBP 110-160 mmHg Treat hypertension; avoid excessive lowering in setting of CNS ischemia STAT STAT - STAT
Temperature Q4h; continuous in ICU 36.0-37.5C Fever workup (blood/urine cultures); distinguish infection from IVIG reaction STAT STAT - STAT
CBC with differential Daily during acute phase; q48h after stabilization WBC >3.0K; ANC >1500; Plt >100K Hold immunosuppression if critically low; evaluate for alternative diagnosis if unexpected cytopenias - STAT - STAT
BMP (electrolytes, BUN, Cr) Daily; more frequently during IVIG and PLEX Normal electrolytes; stable Cr; monitor for IVIG-related nephrotoxicity Adjust IVIG infusion rate; hold if Cr rising; electrolyte repletion - STAT - STAT
LFTs Q48-72h during acute treatment ALT/AST <3x ULN Dose adjustment or hold hepatotoxic medications - ROUTINE - ROUTINE
Seizure monitoring Continuous observation; EEG if seizures or altered consciousness No seizures Escalate ASMs per Section 3A; continuous EEG if subclinical seizures suspected STAT STAT - STAT
IVIG infusion monitoring (vital signs) Q15min first hour; Q30-60min subsequent No anaphylaxis; no hypotension; no fever; headache management Slow or stop infusion for reaction; premedicate for subsequent infusions; switch IVIG product if recurrent reactions - STAT - STAT
I/O and daily weight Daily Euvolemic; no fluid overload from IVIG volume Adjust IV fluids; diuretics if fluid overload - ROUTINE - ROUTINE

6B. Outpatient/Long-Term Monitoring

Parameter Frequency Target/Threshold Action if Abnormal ED HOSP OPD ICU
Neurologic examination (cognition, focal deficits, headache) Monthly x 6 months; then q3 months x 2 years; then q6 months Sustained improvement or stability; no new deficits If new deficits or worsening: urgent MRI + FA + audiometry; reassess treatment; evaluate for relapse - - ROUTINE -
MRI brain with sagittal FLAIR (Susac protocol) 3 months post-induction; then q6 months x 2 years; then annually x 3 years Stable or resolving callosal and white matter lesions; no new DWI restriction; no new enhancement New lesions (especially DWI-restricting): relapse; escalate treatment; increase IVIG frequency; add or switch immunosuppressant - - ROUTINE -
Fluorescein angiography (CPT 92235) 3 months post-induction; then q6 months x 2 years; then annually No new BRAO; stable or resolving arteriolar wall hyperfluorescence; no new non-perfusion areas New BRAO or arteriolar wall changes: subclinical relapse; escalate treatment even if asymptomatic - - ROUTINE -
Comprehensive audiometry (CPT 92557) 3 months post-induction; then q6 months x 2 years; then annually Stable or improving thresholds; no new frequency losses New hearing loss or worsening thresholds: relapse; escalate treatment; hearing aid adjustment or cochlear implant evaluation - - ROUTINE -
OCT (CPT 92134) Q6 months x 2 years; then annually Stable retinal nerve fiber layer; no progressive inner retinal thinning Progressive thinning: ongoing subclinical retinal ischemia; correlate with FA; adjust treatment - - ROUTINE -
CBC with differential Monthly during first 3 months on immunosuppressant; then q3 months WBC >3.0K; ANC >1500; Plt >100K Hold or reduce immunosuppression; dose adjust; evaluate for alternative agent - - ROUTINE -
LFTs Monthly x 3 months on mycophenolate/azathioprine; then q3 months ALT/AST <3x ULN Dose reduction or switch agent; hepatology referral if persistent - - ROUTINE -
BMP (renal function) Before each IVIG infusion; q3 months Stable GFR; normal electrolytes Adjust IVIG infusion rate; nephrology referral if declining GFR - - ROUTINE -
IgG trough level Q3-6 months during maintenance IVIG IgG trough >800 mg/dL (optimal >1000 mg/dL for Susac) Adjust IVIG dose or frequency; subtherapeutic levels contribute to relapse - - ROUTINE -
ESR, CRP Q3-6 months Stable Rising markers: assess for disease activity vs. infection; clinical correlation required - - ROUTINE -
DEXA scan (bone density) Baseline if steroids >3 months; repeat q1-2 years T-score >-2.5 Bisphosphonate therapy; calcium/vitamin D optimization; endocrine referral - - ROUTINE -
HbA1c Q3 months during steroid therapy <7.0% Adjust diabetes medications; dietary counseling; endocrine referral - - ROUTINE -
TPMT genotype/activity Once before starting azathioprine Normal enzyme activity Dose reduce (intermediate) or avoid (deficient) azathioprine - - ROUTINE -
Neuropsychological testing Baseline (when stable); 6 months; 12 months; then annually Improving cognitive domains (executive function, processing speed, memory) Guide cognitive rehabilitation; adjust treatment; inform return-to-work planning - - ROUTINE -
Visual field testing (CPT 92083) Q6 months x 2 years; then annually Stable or improving; no new scotomas New scotomas: correlate with FA; indicates subclinical BRAO - - ROUTINE -
Immunoglobulin levels (IgG, IgA, IgM) Q3-6 months if on rituximab IgG >400 mg/dL Immunoglobulin replacement if recurrent infections with hypogammaglobulinemia - - ROUTINE -
CD19/CD20 B-cell counts Q3 months if on rituximab Guide re-dosing interval Repopulating B-cells trigger relapse; guide re-dosing timing - - ROUTINE -
Blood pressure Each visit <140/90 mmHg Adjust antihypertensive therapy; dietary counseling - - ROUTINE -

7. DISPOSITION CRITERIA

Disposition Criteria
Discharge home Stable or improving neurologic examination, visual acuity, and hearing; no new lesions on MRI; tolerating oral medications; oral prednisone taper established; outpatient IVIG infusions arranged; follow-up with neurology and ophthalmology within 1-2 weeks; caregiver education completed; no active seizures; adequate home support; assistive devices (hearing aids, magnifiers) addressed
Admit to floor (neurology/medicine) New presentation with suspected Susac syndrome requiring urgent workup (MRI, FA, audiometry, LP); initiation of IV methylprednisolone + IVIG; new visual loss or hearing loss; new neurologic deficits; encephalopathy requiring monitoring; seizures requiring medication adjustment; diagnostic uncertainty requiring expedited evaluation
Admit to ICU Severe encephalopathy (GCS <12); status epilepticus; rapid neurologic deterioration despite treatment; plasma exchange requiring hemodynamic monitoring; severe IVIG reactions; post-brain biopsy monitoring; acute clinical deterioration with multiorgan involvement; need for continuous EEG monitoring
Transfer to higher level of care Fluorescein angiography or retinal specialist not available; neuroimmunology specialist not available; plasma exchange not available; MRI with dedicated Susac protocol not available; cochlear implant evaluation needed
Inpatient rehabilitation Medically stable; significant functional deficits from encephalopathy, visual loss, hearing loss, or motor deficits requiring intensive therapy; unable to safely return home; expected to benefit from structured rehabilitation program incorporating cognitive, visual, and auditory rehabilitation
Outpatient follow-up All patients: neurology follow-up within 1-2 weeks post-discharge; ophthalmology for serial FA and OCT; audiology for serial audiometry; IVIG infusion center arrangements; rheumatology co-management; neuropsychology referral; rehabilitation services; laboratory monitoring per protocol
Readmission criteria New or worsening visual loss (new BRAO); new or worsening hearing loss; new neurologic deficits or cognitive decline; breakthrough seizures; signs of treatment complication (infection, IVIG reaction, renal dysfunction); suspected disease relapse on imaging

8. EVIDENCE & REFERENCES

Recommendation Evidence Level Source
Susac syndrome clinical characterization and natural history Class III, Retrospective Dorr J et al. Nat Rev Neurol 2013;9:307-316
European Susac Consortium diagnostic criteria and treatment recommendations Expert Consensus Kleffner I et al. J Neurol Neurosurg Psychiatry 2016;87:1287-1295
MRI findings in Susac syndrome: snowball corpus callosum lesions as pathognomonic finding Class III, Retrospective Susac JO et al. Neurology 2003;61:1783-1787
Corpus callosum lesion characteristics on MRI differentiate Susac from MS Class III Wuerfel J et al. Mult Scler 2012;18:1592-1599
Fluorescein angiography arteriolar wall hyperfluorescence as diagnostic hallmark Class III Egan RA et al. Am J Ophthalmol 2003;135:483-489
IVIG as first-line treatment in Susac syndrome; early aggressive therapy prevents irreversible damage Class IV, Case Series Rennebohm R et al. J Neurol Sci 2010;299:86-91
Comprehensive treatment protocol: IVIG + steroids + mycophenolate as standard of care Expert Consensus Rennebohm RM et al. Curr Treat Options Neurol 2008;10:36-45
Long-term outcome and treatment guidelines for Susac syndrome Expert Consensus Rennebohm RM et al. Int J Stroke 2020;15:606-614
Anti-endothelial cell antibodies in Susac syndrome supporting autoimmune endotheliopathy mechanism Class III Magro CM et al. Am J Clin Pathol 2011;136:903-912
Plasma exchange for refractory Susac syndrome Class III, Case Series Mateen FJ et al. Eur J Neurol 2012;19:800-811
Rituximab and targeted therapy for refractory Susac syndrome; CD8+ T-cell mediated endotheliopathy Class III Gross CC et al. Nat Commun 2019;10:5779
Original description of Susac syndrome: retinocochleocerebral vasculopathy Class III Susac JO et al. Neurology 1979;29:313-316
Large cohort characterization; clinical, paraclinical and serological findings (international multicenter study) Class III, Retrospective Jarius S et al. J Neuroinflammation 2014;11:46
CSF findings in Susac syndrome; differentiation from MS and PACNS Class III Kleffner I et al. J Neurol Sci 2012;322:178-183
Sensorineural hearing loss patterns and cochlear implantation in Susac syndrome Class III Roeser MM et al. Otol Neurotol 2009;30:59-67
Update on Susac syndrome: brain and retinal imaging, treatment options Class III Dorr J et al. J Alzheimers Dis 2014;42 Suppl 3:S99-S108
Pathology and microangiopathy of Susac syndrome: autoimmune endotheliopathy Class III Susac JO et al. J Neurol Sci 2007;257:270-272
Differentiation of Susac syndrome from MS by retinal OCT patterns Class III Brandt AU et al. PLoS One 2012;7:e38741
Natalizumab use in Susac syndrome (case report with exacerbation) Class IV, Case Report Zhovtis Ryerson L et al. Neurol Neuroimmunol Neuroinflamm 2015;2:e151
Aspirin as adjunctive antiplatelet therapy in Susac syndrome Expert Consensus Rennebohm RM et al. Curr Treat Options Neurol 2008;10:36-45
Susac syndrome relapse risk and treatment duration recommendations Expert Consensus Rennebohm RM et al. Int J Stroke 2020;15:606-614
Bone protection during prolonged corticosteroid therapy Class I (guideline) Buckley L et al. Arthritis Rheumatol 2017;69:1521-1537
PJP prophylaxis during combined immunosuppression Expert Consensus Park JW et al. J Rheumatol 2018;45:135-142
OCT monitoring for retinal pathology in Susac syndrome Class III Ringelstein M et al. Neurology 2015;85:610-618
Proposed diagnostic criteria for Susac syndrome (definite, probable, possible) Expert Consensus Kleffner I et al. J Neurol Neurosurg Psychiatry 2016;87:1287-1295

CLINICAL DECISION SUPPORT NOTES

Diagnostic Criteria for Susac Syndrome (European Susac Consortium 2016)

Definite Susac Syndrome: All three features present: - [ ] Encephalopathy with characteristic MRI findings (central corpus callosum "snowball" lesions on sagittal FLAIR) - [ ] Branch retinal artery occlusion (BRAO) confirmed on fluorescein angiography - [ ] Sensorineural hearing loss (SNHL) confirmed on audiometry (low/mid-frequency predominance)

Probable Susac Syndrome: Two of three features present with characteristic findings: - [ ] Two of three clinical features (encephalopathy + BRAO, encephalopathy + SNHL, or BRAO + SNHL) - [ ] At least one feature with pathognomonic findings (central callosal snowballs on MRI, arteriolar wall hyperfluorescence on FA, or low-frequency SNHL)

Possible Susac Syndrome: - [ ] One feature with highly suggestive findings (e.g., encephalopathy with central callosal snowball lesions but no BRAO or SNHL yet documented)

NOTE: The complete triad is not present simultaneously at onset in most cases. Up to 85% of patients do NOT present with the full triad initially. Serial monitoring (FA, audiometry) is essential even in patients presenting with only encephalopathy, as BRAO and SNHL develop over weeks to months.

Susac Syndrome vs. Multiple Sclerosis: Key Differentiating Features

Feature Susac Syndrome Multiple Sclerosis
Corpus callosum lesions Central fibers ("snowball" pattern); sagittal FLAIR pathognomonic Calloso-septal interface (Dawson fingers); perpendicular to ventricles
Retinal disease BRAO (arteriolar wall hyperfluorescence on FA) Optic neuritis (optic nerve, not retinal artery)
Hearing loss SNHL; low and mid-frequency predominance Rare; if present, retrocochlear pattern
CSF Mild pleocytosis or normal; elevated protein; OCBs often absent Prominent OCBs (>95%); IgG index elevated
Age/Sex 20-50 years; 3:1 female predominance 20-40 years; 2-3:1 female predominance
Course Self-limited (monocyclic), polycyclic, or chronic; tends to burn out over 2-4 years Relapsing-remitting or progressive; lifelong
Treatment response IVIG-responsive; steroids alone often insufficient DMTs (interferons, natalizumab, ocrelizumab); IVIG not standard
Spinal cord Not typically involved Spinal cord lesions in >80%

Pathognomonic MRI Findings in Susac Syndrome

Corpus Callosum Lesions (Sagittal FLAIR): - "Snowball" lesions: 3-7 mm round lesions in the CENTRAL fibers of the corpus callosum - "Icicle" or "spoke" lesions: lesions hanging from the inferior surface of the corpus callosum - "Holes" in the corpus callosum: chronic lesion pattern with callosal atrophy - Key distinction: MS lesions involve the INFERIOR (calloso-septal) interface; Susac involves the CENTRAL fibers - Sagittal FLAIR and sagittal T2 are critical sequences (axial imaging misses characteristic pattern)

Other CNS Lesions: - Deep gray matter involvement (thalamus, basal ganglia, internal capsule) - Periventricular white matter (overlaps with MS pattern) - Posterior fossa (cerebellum, brainstem) - Leptomeningeal enhancement (in active disease) - DWI restriction indicates acute/active ischemic lesions

Disease Course Patterns

Pattern Frequency Description Prognosis
Monocyclic ~30% Single episode of active disease followed by remission; no relapses Best prognosis; taper and discontinue treatment after 2 years of stability
Polycyclic ~40% Multiple episodes of active disease with remissions between relapses Intermediate; cumulative damage with each relapse; longer treatment needed
Chronic continuous ~30% Persistent smoldering disease activity without clear remissions Worst prognosis; highest risk of cumulative hearing, visual, and cognitive damage; requires indefinite treatment

Red Flags Suggesting Susac Syndrome Over Other Diagnoses

  • Young woman (20-40 years) with subacute encephalopathy and multifocal white matter lesions
  • Central corpus callosum "snowball" lesions on sagittal MRI FLAIR (pathognomonic)
  • Branch retinal artery occlusion (not central RAO, not optic neuritis) on fluorescein angiography
  • Low and mid-frequency sensorineural hearing loss (not high-frequency presbycusis)
  • CSF with elevated protein but minimal or no pleocytosis (unlike PACNS)
  • Absent or few oligoclonal bands (unlike MS)
  • Normal conventional angiography (unlike PACNS -- Susac is a small vessel disease below angiographic resolution)
  • Arteriolar wall hyperfluorescence on fluorescein angiography (pathognomonic of endothelial damage)
  • Psychiatric symptoms or personality change as early encephalopathic feature
  • Incomplete triad at presentation -- maintain high suspicion and repeat FA/audiometry serially

CHANGE LOG

v1.2 (February 2, 2026) - Citation Verification: 22 of 25 citations had incorrect PMIDs; all corrected with verified PubMed IDs - 3 citations verified correct (PMIDs 23628737, 571975, 28585373) - 19 citations corrected with verified PMIDs via NCBI E-utilities API - 1 citation (Park JW PJP prophylaxis) unable to verify; left as plain text - Fixed journal names: Kleffner (Nat Rev Neurol -> J Neurol Neurosurg Psychiatry), Wuerfel (J Neurol -> Mult Scler), Magro (J Am Acad Dermatol -> Am J Clin Pathol), Mateen (J Neurol -> Eur J Neurol) - Replaced fabricated citations: Dorr Brain 2013 -> Jarius J Neuroinflammation 2014; Piccolo 2020 -> Gross Nat Commun 2019; Bittner cochlear -> Dorr J Alzheimers Dis 2014 - Removed duplicate Dorr/Rennebohm references; consolidated to verified sources - CPT Code Enrichment: Added 22 CPT codes to items previously missing them - Section 1B: Anti-dsDNA (86255), Anti-SSA/SSB (86235), antiphospholipid panel (86147+86146+85613), homocysteine (83090), Lyme serology (86617) - Section 1C: Anti-neuronal antibodies (86255), AQP4 (83519), MOG-IgG (83519), VWF/ADAMTS13 (85245+85397), fibrinogen/haptoglobin/PBS (85384+83010+85060), IL-6 (83520), paraneoplastic panel (86255) - Section 2B: Dedicated Susac MRI protocol (70553) - Section 2C: Muscle/skin biopsy (11106) - LP: Added CPT 62270 to heading; IgG index (86430), flow cytometry (88187), VZV PCR (87798), myelin basic protein (83873) - Section 3C: Rituximab (96365), cyclophosphamide (96365), infliximab (96365), natalizumab (96365)

v1.1 (February 2, 2026) - Checker validation and rebuilder revision (all findings approved) - Updated version to 1.1; added REVISED date - Fixed Section A/B separator to full-width line - Fixed LP "Volume Required" duplicate "cytology" typo - Added ICU priority tags to key LP studies (opening pressure, cell count, protein, glucose, Gram stain, HSV PCR, VZV PCR, BioFire) per S1 - Changed mycophenolate and azathioprine HOSP column from "-" to "ROUTINE" per S2/R3 - Fixed structured dosing fields to use single starting dose before first :: delimiter: - Sertraline: "50 mg daily; 100 mg daily" changed to "50 mg daily" - Azathioprine: "50 mg daily; 100 mg daily; 150 mg daily; 2 mg/kg daily" changed to "50 mg daily" - IVIG maintenance: "0.4 g/kg monthly; 2 g/kg divided over 2-5 days q4 weeks" changed to "0.4 g/kg monthly" - Prednisone taper: "1 mg/kg daily; 0.75 mg/kg daily; 0.5 mg/kg daily" changed to "1 mg/kg daily" - Calcium/Vitamin D: cleaned up to "1000 mg calcium + 1000 IU vitamin D daily" - Melatonin: "3-5 mg qHS" changed to "3 mg qHS" - Lorazepam: "0.1 mg/kg IV push; 4 mg max" changed to "0.1 mg/kg IV" - Acetaminophen: "650-1000 mg q6h PRN" changed to "650 mg q6h PRN" - Levetiracetam: "1000-1500 mg BID" changed to "1000 mg BID" - Replaced all hedging language with directive language throughout: - Removed "should be", "may", "consider" from treatment notes and clinical decision support notes - Changed "Smoking cessation" to "Stop smoking" in Section 4C - Changed "Pregnancy must be avoided" to "Avoid pregnancy" in Section 4B - Changed "may be" to definitive statements where clinically appropriate - Confirmed all treatment tables have 10 columns (Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU) - Confirmed Section 3D has 11 columns (adds Pre-Treatment Requirements) - Confirmed Section 4A has 5 columns; Sections 4B/4C have 4 columns (no ICU) - All 8 sections present; table formatting intact; priority key included

v1.0 (February 2, 2026) - Initial template creation - Section 1: 15 core labs (1A), 18 extended labs (1B), 9 rare/specialized tests (1C) - Section 2: 8 essential imaging/studies (2A), 9 extended (2B), 5 rare/specialized (2C), 15 LP/CSF studies - Section 3: 4 subsections: - 3A: 8 acute/emergent treatments (IV methylprednisolone, IVIG induction, GI prophylaxis, insulin, DVT prophylaxis, aspirin, seizure management) - 3B: 8 symptomatic treatments (analgesics, antiemetics, bone protection, PJP prophylaxis, nimodipine, hearing aids, antidepressant, sleep) - 3C: 5 second-line/refractory agents (plasma exchange, rituximab, cyclophosphamide, infliximab, natalizumab) - 3D: 4 disease-modifying/maintenance therapies (IVIG maintenance, prednisone taper, mycophenolate, azathioprine) - Section 4: 15 referrals (4A), 12 patient instructions (4B), 10 lifestyle modifications (4C) - Section 5: 13 differential diagnoses with distinguishing features - Section 6: 12 acute monitoring parameters (6A), 17 outpatient/long-term monitoring parameters (6B) - Section 7: 7 disposition criteria - Section 8: 25 evidence references with PubMed links - Clinical Decision Support Notes: European Susac Consortium diagnostic criteria, Susac vs. MS comparison table, pathognomonic MRI findings, disease course patterns, 10 red flags checklist


APPENDIX A: Susac Syndrome Diagnostic Algorithm

  1. Clinical suspicion -- Encephalopathy (especially with psychiatric features or cognitive decline) + any combination of visual symptoms and/or hearing loss in a young patient
  2. MRI brain with sagittal FLAIR -- Look for central corpus callosum "snowball" lesions (pathognomonic); DWI for acute lesions; deep gray matter and white matter involvement
  3. Fluorescein angiography -- BRAO with arteriolar wall hyperfluorescence (pathognomonic); perform even if NO visual symptoms (subclinical BRAO in up to 50%)
  4. Comprehensive audiometry -- Low/mid-frequency SNHL; perform even if NO hearing symptoms (subclinical SNHL common)
  5. Lumbar puncture -- Elevated protein with mild/no pleocytosis; distinguish from PACNS (high pleocytosis) and MS (OCBs)
  6. Exclude mimics -- MRA/DSA (normal in Susac); autoimmune panel (ANA, ANCA, APL); infection panel (RPR, VZV, HIV)
  7. Classify -- Definite (all 3 features), Probable (2 of 3), Possible (1 with characteristic findings)
  8. Initiate treatment -- Do NOT wait for complete triad; early aggressive therapy prevents irreversible damage

APPENDIX B: Susac Syndrome Treatment Protocol (Rennebohm Protocol)

Phase 1: Acute Induction (Weeks 1-4) - IV methylprednisolone 1000 mg daily x 3-5 days - IVIG 2 g/kg IV divided over 5 days - Aspirin 81 mg PO daily - Begin oral prednisone taper after IV pulse (1 mg/kg/day) - Begin mycophenolate mofetil 500 mg PO BID, increase to 1000 mg BID over 2 weeks

Phase 2: Consolidation (Months 1-6) - IVIG 2 g/kg IV divided over 2-5 days every 4 weeks - Mycophenolate mofetil 1000-1500 mg PO BID (target 2000-3000 mg/day) - Prednisone taper: reduce by 10 mg every 2 weeks to 20 mg; then 5 mg every 2 weeks to 10 mg - Aspirin 81 mg PO daily - PJP prophylaxis; bone protection

Phase 3: Maintenance (Months 6-24+) - IVIG 2 g/kg IV every 4 weeks (extend to q6-8 weeks after 12 months of stability) - Mycophenolate mofetil 1000-1500 mg PO BID - Prednisone target: off or lowest effective dose (typically <10 mg/day) - Aspirin 81 mg PO daily - Serial monitoring: MRI q6 months, FA q6 months, audiometry q6 months

Phase 4: Taper/Discontinuation (After 24+ months of stability) - Taper IVIG frequency: q4 weeks to q6 weeks to q8 weeks to q12 weeks to discontinue - Taper mycophenolate after IVIG discontinued: reduce by 500 mg every 3-6 months - Continue serial monitoring q6 months during taper and q6-12 months after discontinuation - Reinitiate treatment promptly if relapse detected (new MRI lesion, new BRAO, new hearing loss)


APPENDIX C: Audiometric Pattern Recognition

Feature Susac Syndrome Meniere Disease Presbycusis Acoustic Neuroma
Frequency pattern Low and mid-frequency SNHL Low-frequency fluctuating SNHL High-frequency bilateral SNHL Unilateral high-frequency SNHL
Laterality Unilateral or bilateral; asymmetric Usually unilateral Bilateral symmetric Unilateral
Course Sudden or subacute; stepwise worsening; fluctuates Episodic with attacks Gradual progressive Progressive
Associated symptoms Encephalopathy, visual loss (BRAO) Vertigo, aural fullness, tinnitus Age-related; noise exposure Tinnitus, facial numbness, balance
ABR Cochlear pattern Cochlear pattern Cochlear pattern Retrocochlear pattern
DPOAE Absent/reduced in affected frequencies Abnormal in affected frequencies Abnormal at high frequencies Normal (neural lesion)