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Neurosarcoidosis

Year 2024, Volume: 5 Issue: 5, 288 - 293, 26.10.2024

Abstract

Sarcoidosis is an autoimmune multisystemic inflammatory disease characterized by non-caseating granulomatous infection, most commonly involving the lung and lymph nodes. About 5–15% of cases involve the central nervous system (CNS), neurologic involvement in sarcoidosis is in the form of peripheral or central nervous system involvement. Recent years have seen substantial advancements in our understanding of neurosarcoidosis, including updated diagnostic standards and improved methods for treatment. We provide an overview of current developments in the identification and management of neurosarcoidosis in this review.

Ethical Statement

Derleme olması nedeniyle etik kurul onayı yoktur.

References

  • Ungprasert P, Carmona EM, Utz JP ,Ryu JH,Crowson CS, Matteson EL.Epidemiology of sarcoidosis 1946-2013: a population-based study. Mayo Clin Proc. 2016;91(2):183-188.
  • Mahadewa TGB., Nakagawa H, Watabe T, Inoue T. Intramedullary neurosarcoidosis in the medulla oblongata: a case report. Surg Neurol. 2004;61:283-287.
  • Fritz D, van de Beek D, Brouwer MC. Clinical features, treatment and outcome in neurosarcoidosis: systematic review and meta-analysis. BMC Neurol. 2016;16(1):220.
  • Scott TF, Yandora K, Valeri A, Chieffe C, Schramke C. Aggressive therapy for neurosarcoidosis: long-term follow-up of 48 treated patients. Arch Neurol. 2007;64(5):691-696.
  • Carlson ML, White JR Jr., Espahbodi M, et al. Cranial base manifestations of neurosarcoidosis: a review of 305 patients. Otol Neurotol. 2015;36(1):156-166.
  • Gelfand JM, Bradshaw MJ, Stern BJ, et al. Infliximab for the treatment of CNS sarcoidosis: a multi-institutional series. Neurology. 2017;89(20):2092-2100.
  • Krumholz A, Stern BJ. Neurologic manifestations of sarcoidosis. Handb Clin Neurol. 2014;119:305-333
  • Nwebube CO, Bou GA, Castilho AJ, Hutto SK. Facial nerve palsy in neurosarcoidosis: clinical course, neuroinflammatory accompaniments, ancillary investigations, and response to treatment. J Neurol. 2022;269(10):5328–5336
  • Makimoto G, Kawakado K, Nakanishi M, et al. Heerfordt’s syndrome associated with trigeminal nerve palsy and reversed halo sign. Intern Med. 2021;60(11):1747–1752
  • Bradshaw MJ, Pawate S, Koth LL, et al. Neurosarcoidosis pathophysiology, diagnosis, and treatment, Neurol Neuroimmunol Neuroinflamm. 2021;8:e1084.
  • Anthony J, Esper GJ, Ioachimescu A. Hypothalamic-pituitary sarcoidosis with vision loss and hypopituitarism: case series and literature review. Pituitary. 2016;19(1):19-29.
  • Langrand C, Bihan H, Raverot G, et al. Hypothalamo-pituitary sarcoidosis: a multicenter study of 24 patients. QJM. 2012;105(10):981-995.
  • Joubert B, Chapelon-Abric C, Biard L, et al. Association of prognostic factors and immunosuppressive treatment with long-term outcomes in neurosarcoidosis. JAMA Neurol. 2017; 74(11):1336-1344.
  • Durel CA, Marignier R, Maucort-Boulch D, et al. Clinical features and prognostic factors of spinal cord sarcoidosis: a multicenter observational study of 20 biopsyproven patients. J Neurol. 2016; 263(5):981-990.
  • Soni N, Bathla G, Pillenahalli Maheshwarappa R. Imaging findings in spinal sarcoidosis: areport of 18 cases and review ofthe current literature. Neuroradiol J.2019; 32(1):17-28.
  • Flanagan EP, Kaufmann TJ, Krecke KN, et al. Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol. 2016;79(3):437-447.
  • Zalewski NL,Krecke KN,Weinshenker BG,et al. Central canal enhancement and the trident sign in spinal cord sarcoidosis. Neurology. 2016;87(7):743-744.
  • Murphy OC, Salazar-Camelo A, Jimenez JA, et al. Clinical and MRI phenotypes of sarcoidosis-associated myelopathy. Neurol Neuroimmunol Neuroinflamm. 2020;7(4):e222.
  • Ramos-Casals M, Pérez-Alvarez R, Kostov B, et al. Clinical characterization and outcomes of 85 patients with neurosarcoidosis. Sci Rep. 2021;11(1):13735.
  • Kidd DP. Sarcoidosis of the central nervous system: clinical features, imaging, and CSF results. J Neurol. 2018;265(8):1906-1915
  • Jachiet V, Lhote R, Rufat P, et al. Clinical, imaging, and histological presentations and outcomes of stroke related to sarcoidosis. J Neurol. 2018;265(10):2333-2341.
  • Bathla G, Watal P, Gupta S, Nagpal P, Mohan S, Moritani T. Cerebrovascular manifestations of neurosarcoidosis: an underrecognized aspect of the imaging spectrum. AJNR Am J Neuroradiol. 2018;39(7):1194-1200.
  • Kupersmith MJ, Alban T, Zeiffer B, Lefton D. Contrast-enhanced MRI in acute optic neuritis: relationship to visual performance. Brain. 2002;125(pt 4):812-822.
  • Tavee JO, Karwa K, Ahmed Z, Thompson N, Parambil J, Culver DA. Sarcoidosis associated small fiber neuropathy in a large cohort: clinical aspects and response to IVIG and anti-TNF alpha treatment. Respir Med. 2017;126:135-138.
  • Stern BJ, Royal W III, Gelfand JM, et al. Definition and consensus diagnostic criteria for neurosarcoidosis: from the neurosarcoidosis consortium consensus group. JAMA Neurol. 2018;75(12):1546-1553.
  • Cohen Aubart F, Abbara S, Maisonobe T, et al. Symptomatic muscular sarcoidosis: lessons from a nationwide multicenter study. Neurol Neuroimmunol Neuroinflamm. 2018;5(3):e452.
  • Ungprasert P, Carmona EM, Crowson CS, Matteson EL. Diagnostic utility of angiotensin-converting enzyme in sarcoidosis: a population-based study. Lung. 2016; 194(1):91-95.
  • Eurelings LEM, Miedema JR, Dalm VASH, et al. Sensitivity and specificity of serum soluble interleukin-2 receptor for diagnosing sarcoidosis in a population of patients suspected of sarcoidosis. PLoS One. 2019;14(10):e0223897.
  • Baud MO, Vitt JR, Robbins NM, et al. Pleocytosis is not fully responsible for low CSF glucose in meningitis. Neurol Neuroimmunol Neuroinflamm. 2018;5(1):e425.
  • Leonhard SE, Fritz D, Eftimov F, van der Kooi AJ, van de Beek D, Brouwer MC. Neurosarcoidosis in a tertiary referral center: a cross-sectional cohort study. Medicine (Baltimore). 2016;95(14):e3277.
  • Bridel C, Courvoisier DS, Vuilleumier N, Lalive PH. Cerebrospinal fluid angiotensin-converting enzyme for diagnosis of neurosarcoidosis. J Neuroimmunol. 2015;285:1-3.
  • Chazal T, Costopoulos M, Maillart E, et al. The cerebrospinal fluid CD4/CD8 ratio and interleukin-6 and -10 levels in neurosarcoidosis: a multicenter, pragmatic, comparative study. Eur J Neurol. 2019;26(10):1274-1280.
  • Zamora C, Hung SC, Tomingas C, Atkinson C, Castillo M. Engorgement of deep medullary veins in neurosarcoidosis: a common-yet-underrecognized cerebrovascular finding on SWI. AJNR Am J Neuroradiol. 2018;39(11):2045-2050.
  • Joseph FG, ScoldingNJ. Neurosarcoidosis: a study of 30 new cases. J Neurol Neurosurg Psychiatry. 2009;80(3):297-304.
  • Pawate S, Moses H, Sriram S. Presentations and outcomes of neurosarcoidosis: a study of 54 cases. QJM. 2009;102(7):449-460.
  • Treglia G, Annunziata S, Sobic-Saranovic D, Bertagna F, Caldarella C, Giovanella L. The role of 18F-FDG-PET and PET/CT in patients with sarcoidosis: an updated evidence-based review. Acad Radiol. 2014;21(5):675-684.
  • Bakkers M, Merkies IS, Lauria G, et al. Intraepidermal nerve fiber density and its application in sarcoidosis. Neurology. 2009;73:1142.
  • Peeples DM, Stern BJ, Jiji V, Sahni KS. Germ cell tumors masquerading as central nervous system sarcoidosis. Arch Neurol. 1991;48:554.
  • Stern BJ, Corbett J. Neuro-ophthalmologic manifestations of sarcoidosis. Curr Treat Options Neurol. 2007;9:63.
  • Agbogu BN, Stern BJ, Sewell C, Yang G. Therapeutic considerations in patients with refractory neurosarcoidosis. Arch Neurol. 1995;52:875.
  • Androdias G, Maillet D, Marignier R, et al. Mycophenolate mofetil may be effective in CNS sarcoidosis but not in sarcoid myopathy. Neurology. 2011;76:1168.
  • Bitoun S, Bouvry D, Borie R, et al. Treatment of neurosarcoidosis: a comparative study of methotrexate and mycophenolate mofetil. Neurology. 2016;87:2517.
  • Pritchard C, Nadarajah K. Tumour necrosis factor alpha inhibitor treatment for sarcoidosis refractory to conventional treatments: a report of five patients. Ann Rheum Dis. 2004;63:318.
  • Morcos Z. Refractory neurosarcoidosis responding to infliximab. Neurology. 2003;60:1220.
  • Katz JM, Bruno MK, Winterkorn JM, Nealon N. The pathogenesis and treatment of optic disc swelling in neurosarcoidosis: a unique therapeutic response to infliximab. Arch Neurol. 2003;60:426.
  • Pettersen JA, Zochodne DW, Bell RB, et al. Refractory neurosarcoidosis responding to infliximab. Neurology. 2002; 59:1660.
  • Carter JD, Valeriano J, Vasey FB, Bognar B. Refractory neurosarcoidosis: a dramatic response to infliximab. Am J Med. 2004;117:277.
  • Hoitsma E, Faber CG, van Santen-Hoeufft M, et al. Improvement of small fiber neuropathy in a sarcoidosis patient after treatment with infliximab. Sarcoidosis Vasc Diffuse Lung Dis. 2006;23:73.
  • Lord J, Paz Soldan MM, Galli J, et al. Neurosarcoidosis: Longitudinal experience in a single-center, academic healthcare system. Neurol Neuroimmunol Neuroinflamm. 2020;7.
  • Moravan M, Segal BM. Treatment of CNS sarcoidosis with infliximab and mycophenolate mofetil. Neurology. 2009;72:337.
  • Marques IB, Giovannoni G, Marta M. Mononeuritis multiplex as the first presentation of refractory sarcoidosis responsive to etanercept. BMC Neurol. 2014; 14:237.
  • Wijnen PA, Cremers JP, Nelemans PJ, et al. Association of the TNF-α G-308A polymorphism with TNF-inhibitor response in sarcoidosis. Eur Respir J. 2014; 43:1730.
  • Bomprezzi R, Pati S, Chansakul C, Vollmer T. A case of neurosarcoidosis successfully treated with rituximab. Neurology. 2010;75:568.
  • Sharp M, Donnelly SC, Moller DR. Tocilizumab in sarcoidosis patients failing steroid sparing therapies and anti-TNF agents. Respir Med X. 2019;1.
  • Damsky W, Young BD, Sloan B, et al. Treatment of multiorgan sarcoidosis with tofacitinib. ACR Open Rheumatol. 2020;2:106.
  • Parambil JG, Tavee JO, Zhou L, et al. Efficacy of intravenous immunoglobulin for small fiber neuropathy associated with sarcoidosis. Respir Med. 2011;105:101.
  • Menninger MD, Amdur RJ, Marcus RB Jr. Role of radiotherapy in the treatment of neurosarcoidosis. Am J Clin Oncol. 2003;26:115.

Nörosarkoidoz

Year 2024, Volume: 5 Issue: 5, 288 - 293, 26.10.2024

Abstract

Sarkoidoz en çok akciğer ve lenf bezlerini tutan, non kazeifiye granülamatöz enfeksiyonla karakterize otoimmün multisistemik inflamatuvar bir hastalıktır. Sarkoidozda nörolojik tutulum periferik ya da santral sinir sistemi tutulumu şeklindedir, görülme sıklığı %5-10 arasındadır. Son yıllarda nörosarkoidozda güncellenmiş tanı kriterleri ve tedavi yöntemlerinde önemli gelişmeler görülmüştür. Bu derlemede nörosarkoidozu tanımlama ve yönetmedeki güncel gelişmelere genel bir bakış sunulmuştur.

References

  • Ungprasert P, Carmona EM, Utz JP ,Ryu JH,Crowson CS, Matteson EL.Epidemiology of sarcoidosis 1946-2013: a population-based study. Mayo Clin Proc. 2016;91(2):183-188.
  • Mahadewa TGB., Nakagawa H, Watabe T, Inoue T. Intramedullary neurosarcoidosis in the medulla oblongata: a case report. Surg Neurol. 2004;61:283-287.
  • Fritz D, van de Beek D, Brouwer MC. Clinical features, treatment and outcome in neurosarcoidosis: systematic review and meta-analysis. BMC Neurol. 2016;16(1):220.
  • Scott TF, Yandora K, Valeri A, Chieffe C, Schramke C. Aggressive therapy for neurosarcoidosis: long-term follow-up of 48 treated patients. Arch Neurol. 2007;64(5):691-696.
  • Carlson ML, White JR Jr., Espahbodi M, et al. Cranial base manifestations of neurosarcoidosis: a review of 305 patients. Otol Neurotol. 2015;36(1):156-166.
  • Gelfand JM, Bradshaw MJ, Stern BJ, et al. Infliximab for the treatment of CNS sarcoidosis: a multi-institutional series. Neurology. 2017;89(20):2092-2100.
  • Krumholz A, Stern BJ. Neurologic manifestations of sarcoidosis. Handb Clin Neurol. 2014;119:305-333
  • Nwebube CO, Bou GA, Castilho AJ, Hutto SK. Facial nerve palsy in neurosarcoidosis: clinical course, neuroinflammatory accompaniments, ancillary investigations, and response to treatment. J Neurol. 2022;269(10):5328–5336
  • Makimoto G, Kawakado K, Nakanishi M, et al. Heerfordt’s syndrome associated with trigeminal nerve palsy and reversed halo sign. Intern Med. 2021;60(11):1747–1752
  • Bradshaw MJ, Pawate S, Koth LL, et al. Neurosarcoidosis pathophysiology, diagnosis, and treatment, Neurol Neuroimmunol Neuroinflamm. 2021;8:e1084.
  • Anthony J, Esper GJ, Ioachimescu A. Hypothalamic-pituitary sarcoidosis with vision loss and hypopituitarism: case series and literature review. Pituitary. 2016;19(1):19-29.
  • Langrand C, Bihan H, Raverot G, et al. Hypothalamo-pituitary sarcoidosis: a multicenter study of 24 patients. QJM. 2012;105(10):981-995.
  • Joubert B, Chapelon-Abric C, Biard L, et al. Association of prognostic factors and immunosuppressive treatment with long-term outcomes in neurosarcoidosis. JAMA Neurol. 2017; 74(11):1336-1344.
  • Durel CA, Marignier R, Maucort-Boulch D, et al. Clinical features and prognostic factors of spinal cord sarcoidosis: a multicenter observational study of 20 biopsyproven patients. J Neurol. 2016; 263(5):981-990.
  • Soni N, Bathla G, Pillenahalli Maheshwarappa R. Imaging findings in spinal sarcoidosis: areport of 18 cases and review ofthe current literature. Neuroradiol J.2019; 32(1):17-28.
  • Flanagan EP, Kaufmann TJ, Krecke KN, et al. Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol. 2016;79(3):437-447.
  • Zalewski NL,Krecke KN,Weinshenker BG,et al. Central canal enhancement and the trident sign in spinal cord sarcoidosis. Neurology. 2016;87(7):743-744.
  • Murphy OC, Salazar-Camelo A, Jimenez JA, et al. Clinical and MRI phenotypes of sarcoidosis-associated myelopathy. Neurol Neuroimmunol Neuroinflamm. 2020;7(4):e222.
  • Ramos-Casals M, Pérez-Alvarez R, Kostov B, et al. Clinical characterization and outcomes of 85 patients with neurosarcoidosis. Sci Rep. 2021;11(1):13735.
  • Kidd DP. Sarcoidosis of the central nervous system: clinical features, imaging, and CSF results. J Neurol. 2018;265(8):1906-1915
  • Jachiet V, Lhote R, Rufat P, et al. Clinical, imaging, and histological presentations and outcomes of stroke related to sarcoidosis. J Neurol. 2018;265(10):2333-2341.
  • Bathla G, Watal P, Gupta S, Nagpal P, Mohan S, Moritani T. Cerebrovascular manifestations of neurosarcoidosis: an underrecognized aspect of the imaging spectrum. AJNR Am J Neuroradiol. 2018;39(7):1194-1200.
  • Kupersmith MJ, Alban T, Zeiffer B, Lefton D. Contrast-enhanced MRI in acute optic neuritis: relationship to visual performance. Brain. 2002;125(pt 4):812-822.
  • Tavee JO, Karwa K, Ahmed Z, Thompson N, Parambil J, Culver DA. Sarcoidosis associated small fiber neuropathy in a large cohort: clinical aspects and response to IVIG and anti-TNF alpha treatment. Respir Med. 2017;126:135-138.
  • Stern BJ, Royal W III, Gelfand JM, et al. Definition and consensus diagnostic criteria for neurosarcoidosis: from the neurosarcoidosis consortium consensus group. JAMA Neurol. 2018;75(12):1546-1553.
  • Cohen Aubart F, Abbara S, Maisonobe T, et al. Symptomatic muscular sarcoidosis: lessons from a nationwide multicenter study. Neurol Neuroimmunol Neuroinflamm. 2018;5(3):e452.
  • Ungprasert P, Carmona EM, Crowson CS, Matteson EL. Diagnostic utility of angiotensin-converting enzyme in sarcoidosis: a population-based study. Lung. 2016; 194(1):91-95.
  • Eurelings LEM, Miedema JR, Dalm VASH, et al. Sensitivity and specificity of serum soluble interleukin-2 receptor for diagnosing sarcoidosis in a population of patients suspected of sarcoidosis. PLoS One. 2019;14(10):e0223897.
  • Baud MO, Vitt JR, Robbins NM, et al. Pleocytosis is not fully responsible for low CSF glucose in meningitis. Neurol Neuroimmunol Neuroinflamm. 2018;5(1):e425.
  • Leonhard SE, Fritz D, Eftimov F, van der Kooi AJ, van de Beek D, Brouwer MC. Neurosarcoidosis in a tertiary referral center: a cross-sectional cohort study. Medicine (Baltimore). 2016;95(14):e3277.
  • Bridel C, Courvoisier DS, Vuilleumier N, Lalive PH. Cerebrospinal fluid angiotensin-converting enzyme for diagnosis of neurosarcoidosis. J Neuroimmunol. 2015;285:1-3.
  • Chazal T, Costopoulos M, Maillart E, et al. The cerebrospinal fluid CD4/CD8 ratio and interleukin-6 and -10 levels in neurosarcoidosis: a multicenter, pragmatic, comparative study. Eur J Neurol. 2019;26(10):1274-1280.
  • Zamora C, Hung SC, Tomingas C, Atkinson C, Castillo M. Engorgement of deep medullary veins in neurosarcoidosis: a common-yet-underrecognized cerebrovascular finding on SWI. AJNR Am J Neuroradiol. 2018;39(11):2045-2050.
  • Joseph FG, ScoldingNJ. Neurosarcoidosis: a study of 30 new cases. J Neurol Neurosurg Psychiatry. 2009;80(3):297-304.
  • Pawate S, Moses H, Sriram S. Presentations and outcomes of neurosarcoidosis: a study of 54 cases. QJM. 2009;102(7):449-460.
  • Treglia G, Annunziata S, Sobic-Saranovic D, Bertagna F, Caldarella C, Giovanella L. The role of 18F-FDG-PET and PET/CT in patients with sarcoidosis: an updated evidence-based review. Acad Radiol. 2014;21(5):675-684.
  • Bakkers M, Merkies IS, Lauria G, et al. Intraepidermal nerve fiber density and its application in sarcoidosis. Neurology. 2009;73:1142.
  • Peeples DM, Stern BJ, Jiji V, Sahni KS. Germ cell tumors masquerading as central nervous system sarcoidosis. Arch Neurol. 1991;48:554.
  • Stern BJ, Corbett J. Neuro-ophthalmologic manifestations of sarcoidosis. Curr Treat Options Neurol. 2007;9:63.
  • Agbogu BN, Stern BJ, Sewell C, Yang G. Therapeutic considerations in patients with refractory neurosarcoidosis. Arch Neurol. 1995;52:875.
  • Androdias G, Maillet D, Marignier R, et al. Mycophenolate mofetil may be effective in CNS sarcoidosis but not in sarcoid myopathy. Neurology. 2011;76:1168.
  • Bitoun S, Bouvry D, Borie R, et al. Treatment of neurosarcoidosis: a comparative study of methotrexate and mycophenolate mofetil. Neurology. 2016;87:2517.
  • Pritchard C, Nadarajah K. Tumour necrosis factor alpha inhibitor treatment for sarcoidosis refractory to conventional treatments: a report of five patients. Ann Rheum Dis. 2004;63:318.
  • Morcos Z. Refractory neurosarcoidosis responding to infliximab. Neurology. 2003;60:1220.
  • Katz JM, Bruno MK, Winterkorn JM, Nealon N. The pathogenesis and treatment of optic disc swelling in neurosarcoidosis: a unique therapeutic response to infliximab. Arch Neurol. 2003;60:426.
  • Pettersen JA, Zochodne DW, Bell RB, et al. Refractory neurosarcoidosis responding to infliximab. Neurology. 2002; 59:1660.
  • Carter JD, Valeriano J, Vasey FB, Bognar B. Refractory neurosarcoidosis: a dramatic response to infliximab. Am J Med. 2004;117:277.
  • Hoitsma E, Faber CG, van Santen-Hoeufft M, et al. Improvement of small fiber neuropathy in a sarcoidosis patient after treatment with infliximab. Sarcoidosis Vasc Diffuse Lung Dis. 2006;23:73.
  • Lord J, Paz Soldan MM, Galli J, et al. Neurosarcoidosis: Longitudinal experience in a single-center, academic healthcare system. Neurol Neuroimmunol Neuroinflamm. 2020;7.
  • Moravan M, Segal BM. Treatment of CNS sarcoidosis with infliximab and mycophenolate mofetil. Neurology. 2009;72:337.
  • Marques IB, Giovannoni G, Marta M. Mononeuritis multiplex as the first presentation of refractory sarcoidosis responsive to etanercept. BMC Neurol. 2014; 14:237.
  • Wijnen PA, Cremers JP, Nelemans PJ, et al. Association of the TNF-α G-308A polymorphism with TNF-inhibitor response in sarcoidosis. Eur Respir J. 2014; 43:1730.
  • Bomprezzi R, Pati S, Chansakul C, Vollmer T. A case of neurosarcoidosis successfully treated with rituximab. Neurology. 2010;75:568.
  • Sharp M, Donnelly SC, Moller DR. Tocilizumab in sarcoidosis patients failing steroid sparing therapies and anti-TNF agents. Respir Med X. 2019;1.
  • Damsky W, Young BD, Sloan B, et al. Treatment of multiorgan sarcoidosis with tofacitinib. ACR Open Rheumatol. 2020;2:106.
  • Parambil JG, Tavee JO, Zhou L, et al. Efficacy of intravenous immunoglobulin for small fiber neuropathy associated with sarcoidosis. Respir Med. 2011;105:101.
  • Menninger MD, Amdur RJ, Marcus RB Jr. Role of radiotherapy in the treatment of neurosarcoidosis. Am J Clin Oncol. 2003;26:115.
There are 57 citations in total.

Details

Primary Language English
Subjects Clinical Sciences (Other)
Journal Section Review [en] Derleme [tr]
Authors

Tuba Akıncı 0000-0001-8521-7003

Berna Akıncı Özyürek 0000-0003-0206-7615

Publication Date October 26, 2024
Submission Date August 28, 2024
Acceptance Date September 17, 2024
Published in Issue Year 2024 Volume: 5 Issue: 5

Cite

AMA Akıncı T, Akıncı Özyürek B. Neurosarcoidosis. J Med Palliat Care / JOMPAC / jompac. October 2024;5(5):288-293.

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Interuniversity Board (UAK) Equivalency: Article published in Ulakbim TR Index journal [10 POINTS], and Article published in other (excuding 1a, b, c) international indexed journal (1d) [5 POINTS]



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