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Carreño M, Martí MJ, Aldecoa I, Painous C, Conde E, Valldeoriola F, Valls-Solé J, Bargalló N, Gil F, Manzanares I, Setoain X, Donaire A, Muñoz E, Roldán P, Boget T, Pintor L, Bailles E, Rumià J. Unilateral pallidal stimulation for disabling dystonia due to Rasmussen's disease. J Neurol Neurosurg Psychiatry 2019; 90:108-110. [PMID: 29986904 DOI: 10.1136/jnnp-2018-318029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe an adult patient with Rasmussen's disease with focal dystonia as the most disabling symptom and the good response to unilateral globus pallidus internus (GPi) deep brain stimulation (DBS). METHODS Retrospective review of clinical records and diagnostic tests. RESULTS The patient had displayedmild focal seizures with sensory and motor symptoms on the left arm and hemiface since the age of 22. Ten years later she experienced abrupt onset of focal left dystonia involving mainly the leg. Brain MRI showed progressive right hemisphere atrophy, and 18 fluorodeoxyglucose-positron emission tomography (18FDG-PET) showed right hypometabolism mainly over the frontal and insular regions. Brain biopsy confirmed chronic encephalitis. The dystonia became very severe and made walking extremely difficult. Different treatments including dopaminergic, anticholinergic, immunomodulatory drugs and botulinum toxin were ineffective. Finally the patient was treated with unilateral GPi DBS. Shortly after the onset of the stimulation, the dystonia started to improve. Parameters have been adjusted, and 18 months after surgery the patient is able to walk and run unaided, although a mild left leg dystonia persists. CONCLUSION Rasmussen's disease may be difficult to diagnose in adult patients. Associated movement disorders may be more disabling than seizures. Focal dystonia may be treated successfully with DBS.
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Affiliation(s)
- Mar Carreño
- Epilepsy Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Maria José Martí
- Movement Disorder Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Ibán Aldecoa
- Department of Pathology, Hospital Clínic, Barcelona, Spain
| | - Celia Painous
- Department of Neurology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Estefanía Conde
- Epilepsy Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | | | - Josep Valls-Solé
- EMG Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Núria Bargalló
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Francisco Gil
- Epilepsy Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Isabel Manzanares
- Epilepsy Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Xavier Setoain
- Department of Nuclear Medicine, Hospital Clínic, Barcelona, Spain
| | - Antonio Donaire
- Epilepsy Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Esteban Muñoz
- Movement Disorder Unit, Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Pedro Roldán
- Functional Neurosurgery Unit, Department of Neurosurgery, Hospital Clínic, Barcelona, Spain
| | - Teresa Boget
- Department of Psychiatry and Psychology, Hospital Clínic, Barcelona, Spain
| | - Luis Pintor
- Department of Psychiatry and Psychology, Hospital Clínic, Barcelona, Spain
| | - Eva Bailles
- Department of Psychiatry and Psychology, Hospital Clínic, Barcelona, Spain
| | - Jordi Rumià
- Functional Neurosurgery Unit, Department of Neurosurgery, Hospital Clínic, Barcelona, Spain
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Morano A, Iannone L, Palleria C, Fanella M, Giallonardo AT, De Sarro G, Russo E, Di Bonaventura C. Pharmacology of new and developing intravenous therapies for the management of seizures and epilepsy. Expert Opin Pharmacother 2018; 20:25-39. [PMID: 30403892 DOI: 10.1080/14656566.2018.1541349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are administered orally for chronic use. Parenteral formulations might be necessary when the oral route is not feasible (e.g. an impairment of consciousness, trauma, dysphagia, gastrointestinal illness) or for treatment of seizure emergencies. At present, few intravenous (IV) formulations are available on the market. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of IV medications that have been recently introduced to the armamentarium of epilepsy therapy or are currently being developed. Apart from AEDs, other compounds belonging to different pharmacological classes (e.g. diuretics, anesthetics), which have shown potential effectiveness in seizure control, are taken into consideration, and the pathophysiological premises supporting their use for epilepsy treatment are illustrated. The authors give particular focus to immunomodulatory and immunosuppressive agents, which have become the therapeutic cornerstones for immune-mediated epilepsies, despite regulatory obstacles. EXPERT OPINION In several circumstances, especially in the case of seizure-related emergencies, clinical practice seems not match literature-based evidence, and several IV AEDs are still used off-label. Strong evidence derived from randomized clinical trials (RCTs) is needed to support the effectiveness and tolerability of any therapeutic approach, however common and "accepted' it may be, in order to guarantee patient safety and well-being.
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Affiliation(s)
- Alessandra Morano
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Luigi Iannone
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Caterina Palleria
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Martina Fanella
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Anna Teresa Giallonardo
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Giovambattista De Sarro
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Emilio Russo
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Carlo Di Bonaventura
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
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Liu D, Wang X, Wang Y, Wang P, Fan D, Chen S, Guan Y, Li T, An J, Luan G. Detection of EBV and HHV6 in the Brain Tissue of Patients with Rasmussen's Encephalitis. Virol Sin 2018; 33:402-409. [PMID: 30374827 DOI: 10.1007/s12250-018-0063-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/10/2018] [Indexed: 11/29/2022] Open
Abstract
Rasmussen's encephalitis (RE) is a rare pediatric neurological disorder, and the exact etiology is not clear. Viral infection may be involved in the pathogenesis of RE, but conflicting results have reported. In this study, we evaluated the expression of both Epstein-Barr virus (EBV) and human herpes virus (HHV) 6 antigens in brain sections from 30 patients with RE and 16 control individuals by immunohistochemistry. In the RE group, EBV and HHV6 antigens were detected in 56.7% (17/30) and 50% (15/30) of individuals, respectively. In contrast, no detectable EBV and HHV6 antigen expression was found in brain tissues of the control group. The co-expression of EBV and HHV6 was detected in 20.0% (6/30) of individuals. In particular, a 4-year-old boy had a typical clinical course, including a medical history of viral encephalitis, intractable epilepsy, and hemispheric atrophy. The co-expression of EBV and HHV6 was detected in neurons and astrocytes in the brain tissue, accompanied by a high frequency of CD8+ T cells. Our results suggest that EBV and HHV6 infection and the activation of CD8+ T cells are involved in the pathogenesis of RE.
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Affiliation(s)
- Dong Liu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Xin Wang
- Department of Microbiology, School of Basic Medical Science, Capital Medical University, Beijing, 100069, China
| | - Yisong Wang
- Department of Microbiology, School of Basic Medical Science, Capital Medical University, Beijing, 100069, China
| | - Peigang Wang
- Department of Microbiology, School of Basic Medical Science, Capital Medical University, Beijing, 100069, China
| | - Dongying Fan
- Department of Microbiology, School of Basic Medical Science, Capital Medical University, Beijing, 100069, China
| | - Sichang Chen
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Yuguang Guan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Tianfu Li
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Beijing, 100093, China
| | - Jing An
- Department of Microbiology, School of Basic Medical Science, Capital Medical University, Beijing, 100069, China. .,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100093, China.
| | - Guoming Luan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China. .,Beijing Key Laboratory of Epilepsy, Beijing, 100093, China. .,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100093, China.
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54
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Marawar R, Basha M, Mahulikar A, Desai A, Suchdev K, Shah A. Updates in Refractory Status Epilepticus. Crit Care Res Pract 2018; 2018:9768949. [PMID: 29854452 PMCID: PMC5964484 DOI: 10.1155/2018/9768949] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/19/2018] [Indexed: 01/01/2023] Open
Abstract
Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.
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Affiliation(s)
- Rohit Marawar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Maysaa Basha
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Advait Mahulikar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aaron Desai
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Kushak Suchdev
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aashit Shah
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
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55
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Kebir H, Carmant L, Fontaine F, Béland K, Bosoi CM, Sanon NT, Alvarez JI, Desgent S, Pittet CL, Hébert D, Langlois MJ, Rébillard RM, Nguyen DK, Cieuta-Walti C, Holmes GL, Goodkin HP, Mytinger JR, Connolly MB, Prat A, Haddad E. Humanized mouse model of Rasmussen's encephalitis supports the immune-mediated hypothesis. J Clin Invest 2018; 128:2000-2009. [PMID: 29629902 DOI: 10.1172/jci97098] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 02/13/2018] [Indexed: 12/21/2022] Open
Abstract
Rasmussen's encephalitis (RE) is a chronic inflammatory brain disorder that causes frequent seizures and unilateral hemispheric atrophy with progressive neurological deficits. Hemispherectomy remains the only treatment that leads to seizure freedom for this refractory epileptic syndrome. The absence of an animal model of disease has been a major obstacle hampering the development of effective therapies. Here, we describe an experimental mouse model that shares several clinical and pathological features with the human disease. Immunodeficient mice injected with peripheral blood mononuclear cells from RE patients and monitored by video electroencephalography developed severe seizures of cortical origin and showed intense astrogliosis and accumulation of human IFN-γ- and granzyme B-expressing T lymphocytes in the brain compared with mice injected with immune cells from control subjects. We also provide evidence for the efficacy of α4 integrin blockade, an approved therapy for the treatment of multiple sclerosis and Crohn's disease, in reducing inflammatory markers associated with RE in the CNS. This model holds promise as a valuable tool for understanding the pathology of RE and for developing patient-tailored experimental therapeutics.
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Affiliation(s)
- Hania Kebir
- Department of Microbiology, Infectious Diseases, and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Lionel Carmant
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada.,Department of Pediatrics, and.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - François Fontaine
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada.,Department of Pediatrics, and
| | - Kathie Béland
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada
| | - Ciprian M Bosoi
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada
| | - Nathalie T Sanon
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada
| | - Jorge I Alvarez
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sébastien Desgent
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada
| | - Camille L Pittet
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - David Hébert
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada
| | - Marie-Josée Langlois
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada
| | | | - Dang K Nguyen
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Cécile Cieuta-Walti
- Centre Hospitalier Universitaire de Sherbrooke, Department of Pediatrics, Université de Sherbrooke, Shebrooke, Quebec, Canada
| | - Gregory L Holmes
- Department of Neurological Sciences, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Howard P Goodkin
- Fontaine Research Park, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - John R Mytinger
- Fontaine Research Park, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Mary B Connolly
- B.C. Children's Hospital, Division of Neurology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandre Prat
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Elie Haddad
- Department of Microbiology, Infectious Diseases, and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, Quebec, Canada.,Department of Pediatrics, and
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56
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Castellano JF, Meyer JA, Lado FA. A Case Series of Adult-Onset Rasmussen's Encephalitis: Diagnostic and Therapeutic Challenges. Front Neurol 2017; 8:564. [PMID: 29118737 PMCID: PMC5660978 DOI: 10.3389/fneur.2017.00564] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 10/09/2017] [Indexed: 12/22/2022] Open
Abstract
Rasmussen’s encephalitis (RE) is a rare neurologic disorder characterized by progressive cerebral hemiatrophy and medically refractory epilepsy. The majority of current literature on this topic is focused on the pediatric population. In this case series, we will review three cases of adult-onset RE, as defined by fulfillment of the 2005 Bien criteria. The diagnostic challenge of characterizing this rare disease will be highlighted by the extensive serum, CSF, and pathologic sampling in all three patients. MR imaging and EEG data will be examined over time to characterize hallmark findings as well as progression. In addition, we will review the various forms of therapy attempted in these three patients, namely anti-epileptic drug therapy and immunomodulatory therapy. We will also utilize this case series to critically evaluate the broader context of atypical presentations of this disease and the value of current diagnostic criteria.
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Affiliation(s)
| | - Jenny A Meyer
- Saul Korey Department of Neurology, Montefiore Medical Center, Bronx, NY, United States
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57
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Nosadini M, Sartori S, Sharma S, Dale RC. Immunotherapeutics in Pediatric Autoimmune Central Nervous System Disease: Agents and Mechanisms. Semin Pediatr Neurol 2017; 24:214-228. [PMID: 29103429 DOI: 10.1016/j.spen.2017.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Beyond the major advances produced by careful clinical-radiological phenotyping and biomarker development in autoimmune central nervous system disorders, a comprehensive knowledge of the range of available immune therapies and a deeper understanding of their action should benefit therapeutic decision-making. This review discusses the agents used in neuroimmunology and their mechanisms of action. First-line treatments typically include corticosteroids, intravenous immunoglobulin, and plasmapheresis, while for severe disease second-line "induction" agents such as rituximab or cyclophosphamide are used. Steroid-sparing agents such as mycophenolate, azathioprine, or methotrexate are often used in potentially relapsing or corticosteroid-dependent diseases. Lessons from adult neuroimmunology and rheumatology could be translated into pediatric autoimmune central nervous system disease in the future, including the potential utility of monoclonal antibodies targeting lymphocytes, adhesion molecules for lymphocytic migration, cytokines or their receptors, or complement. Finally, many agents used in other fields have multiple mechanisms of action, including immunomodulation, with potential usefulness in neuroimmunology, such as antibiotics, psychotropic drugs, probiotics, gut health, and ketogenic diet. All currently accepted and future potential agents have adverse effects, which can be severe; therefore, a "risk-versus-benefit" determination should guide therapeutic decision-making.
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Affiliation(s)
- Margherita Nosadini
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Westmead, NSW, Australia; Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Suvasini Sharma
- Department of Pediatrics, Associated Kalawati Saran Children Hospital, Lady Hardinge Medical College, New Delhi, India
| | - Russell C Dale
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Westmead, NSW, Australia.
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58
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Dupont S, Gales A, Sammey S, Vidailhet M, Lambrecq V. Late-onset Rasmussen Encephalitis: A literature appraisal. Autoimmun Rev 2017; 16:803-810. [DOI: 10.1016/j.autrev.2017.05.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/20/2022]
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Abstract
BACKGROUND Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum immunoglobulin A (IgA) levels, lack of the immunoglobulin G (IgG) subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. This is an updated version of the original Cochrane review published in Issue 1, 2011. OBJECTIVES To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects when used as monotherapy or as add-on treatment for people with epilepsy. SEARCH METHODS For the latest update, we searched the Cochrane Epilepsy Group Specialized Register (2 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (2 February 2017), MEDLINE (Ovid, 1946 to 2 February 2017), Web of Science (1898 to 2 February 2017), ISRCTN registry (2 February 2017), WHO International Clinical Trials Registry Platform (ICTRP, 2 February 2017), the US National Institutes of Health ClinicalTrials.gov (2 February 2017), and reference lists of articles. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life. MAIN RESULTS We included one study (61 participants). The included study was a randomized, double-blind, placebo-controlled, multi-centre trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favour of IVIg. No adverse effects were demonstrated. We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. Overall, the included study was rated as low/unclear risk of bias. Using GRADE methodology, the quality of the evidence was rated as low. AUTHORS' CONCLUSIONS We cannot draw any reliable conclusions regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.
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Affiliation(s)
- JinSong Geng
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - JianCheng Dong
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - Youping Li
- West China Hospital, Sichuan UniversityChinese Cochrane Centre, Chinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduChina610041
| | - Hengjian Ni
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - Kui Jiang
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - Li Li Shi
- Evidence‐based Medicine Center, Medical School of Nantong UniversityNantongChina
| | - GuoHua Wang
- Nantong UniversityInstitute of Nautical Medicine19 Qixiu RoadNantongChina226001
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Guan Y, Chen S, Liu C, Du X, Zhang Y, Chen S, Wang J, Li T, Luan G. Timing and type of hemispherectomy for Rasmussen’s encephalitis: Analysis of 45 patients. Epilepsy Res 2017; 132:109-115. [DOI: 10.1016/j.eplepsyres.2017.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/24/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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Abstract
Seizures are a common manifestation of autoimmune limbic encephalitis and multifocal paraneoplastic disorders. Accumulating evidence supports an autoimmune basis for seizures in the absence of syndromic manifestations of encephalitis. The autoimmune epilepsies are immunologically mediated disorders in which recurrent seizures are a primary and persistent clinical feature. When other etiologies have been excluded, an autoimmune etiology is suggested in a patient with epilepsy upon detection of neural autoantibodies and/or the presence of inflammatory changes on cerebrospinal fluid (CSF) or magnetic resonance imaging. In such patients, immunotherapy may be highly effective, depending on the particular autoimmune epilepsy syndrome present. In this chapter, several autoimmune epilepsy syndromes are discussed. First, epilepsies secondary to other primary autoimmune disorders will be discussed, and then those associated with antibodies that are likely to be pathogenic, such as voltage-gated potassium channel-complex and N-methyl-d-aspartate receptor, gamma-aminobutyric acid A and B receptor antibodies. For each syndrome, the typical clinical, imaging, electroencephaloram, CSF, and serologic features, and pathophysiology and treatment are described. Finally, suggested guidelines for the recognition, evaluation, and treatment of autoimmune epilepsy syndromes are provided.
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62
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Gadian J, Kirk E, Holliday K, Lim M, Absoud M. Systematic review of immunoglobulin use in paediatric neurological and neurodevelopmental disorders. Dev Med Child Neurol 2017; 59:136-144. [PMID: 27900773 DOI: 10.1111/dmcn.13349] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 01/18/2023]
Abstract
AIM A systematic literature review of intravenous immunoglobulin (IVIG) treatment of paediatric neurological conditions was performed to summarize the evidence, provide recommendations, and suggest future research. METHOD A MEDLINE search for articles reporting on IVIG treatment of paediatric neuroinflammatory, neurodevelopmental, and neurodegenerative conditions published before September 2015, excluding single case reports and those not in English. Owing to heterogeneous outcome measures, meta-analysis was not possible. Findings were combined and evidence graded. RESULTS Sixty-five studies were analysed. IVIG reduces recovery time in Guillain-Barré syndrome (grade B). IVIG is as effective as corticosteroids in chronic inflammatory demyelinating polyradiculoneuropathy (grade C), and as effective as tacrolimus in Rasmussen syndrome (grade C). IVIG improves recovery in acute disseminated encephalomyelitis (grade C), reduces mortality in acute encephalitis syndrome with myocarditis (grade C), and improves function and stabilizes disease in myasthenia gravis (grade C). IVIG improves outcome in N-methyl-d-aspartate receptor encephalitis (grade C) and opsoclonus-myoclonus syndrome (grade C), reduces cataplexy symptoms in narcolepsy (grade C), speeds recovery in Sydenham chorea (grade C), reduces tics in selected cases of Tourette syndrome (grade D), and improves symptoms in paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (grade B). INTERPRETATION IVIG is a useful therapy in selected neurological conditions. Well-designed, prospective, multi-centre studies with standardized outcome measures are required to compare treatments.
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Affiliation(s)
- Jonathan Gadian
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Emma Kirk
- Evelina London Children's Hospital, St Thomas' Hospital, Paediatric Pharmacy, London, UK
| | | | - Ming Lim
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Michael Absoud
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
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63
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Cho SM, Zeft A, Knight EP, Kotagal P, Wyllie E, Moosa ANV. Refractory status epilepticus secondary to atypical Rasmussen encephalitis successfully managed with aggressive immunotherapy. Neurol Clin Pract 2017; 7:e5-e8. [PMID: 29849226 DOI: 10.1212/cpj.0000000000000261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sung-Min Cho
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Andrew Zeft
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Elia Pestana Knight
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Prakash Kotagal
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Elaine Wyllie
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Ahsan N V Moosa
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
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64
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Mameniškienė R, Wolf P. Epilepsia partialis continua: A review. Seizure 2017; 44:74-80. [DOI: 10.1016/j.seizure.2016.10.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 11/24/2022] Open
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Abstract
Epilepsy is one of the most common neurologic disorders, affecting about 50 million people worldwide. The disease is characterized by recurrent seizures, which are due to aberrant neuronal networks resulting in synchronous discharges. The term epilepsy encompasses a large spectrum of syndromes and diseases with different etiopathogenesis. The recent development of imaging and epilepsy surgery techniques is now enabling the identification of structural abnormalities that are part of the epileptic network, and the removal of these lesions may result in control of seizures. Access of this clinically well-characterized neurosurgical material has provided neuropathologists with the opportunity to study a variety of structural brain abnormalities associated with epilepsy, by combining traditional routine histopathologic methods with molecular genetics and functional analysis of the resected tissue. This approach has contributed greatly to a better diagnosis and classification of these structural lesions, and has provided important new insights into their pathogenesis and epileptogenesis. The present chapter provides a detailed description of the large spectrum of histopathologic findings encountered in epilepsy surgery patients, addressing in particular the nonneoplastic pathologies, including hippocampal sclerosis, malformations of cortical development, Sturge-Weber syndrome, and Rasmussen encephalitis, and reviews current knowledge regarding the underlying molecular pathomechanisms and cellular mechanisms mediating hyperexcitability.
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Affiliation(s)
- Eleonora Aronica
- Department of Neuropathology, Academic Medical Center and Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands; Stichting Epilepsie Instellingen Nederland, the Netherlands.
| | - Angelika Mühlebner
- Department of Neuropathology, Academic Medical Center and Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands
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Dandekar S, Wijesuriya H, Geiger T, Hamm D, Mathern GW, Owens GC. Shared HLA Class I and II Alleles and Clonally Restricted Public and Private Brain-Infiltrating αβ T Cells in a Cohort of Rasmussen Encephalitis Surgery Patients. Front Immunol 2016; 7:608. [PMID: 28066418 PMCID: PMC5165278 DOI: 10.3389/fimmu.2016.00608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 12/01/2016] [Indexed: 11/26/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare pediatric neuroinflammatory disease characterized by intractable seizures and unilateral brain atrophy. T cell infiltrates in affected brain tissue and the presence of circulating autoantibodies in some RE patients have indicated that RE may be an autoimmune disease. The strongest genetic links to autoimmunity reside in the MHC locus, therefore, we determined the human leukocyte antigen (HLA) class I and class II alleles carried by a cohort of 24 RE surgery cases by targeted in-depth genomic sequencing. Compared with a reference population the allelic frequency of three alleles, DQA1*04:01:01, DQB1*04:02:01, and HLA-C*07:02:01:01 indicated that they might confer susceptibility to the disease. It has been reported that HLA-C*07:02 is a risk factor for Graves disease. Further, eight patients in the study cohort carried HLA-A*03:01:01:01, which has been linked to susceptibility to multiple sclerosis. Four patients carried a combination of three HLA class II alleles that has been linked to type 1 diabetes (DQA1*05:01:01:01~DQB1*02:01:01~DRB1*03:01:01:01), and five patients carried a combination of HLA class II alleles that has been linked to the risk of contracting multiple sclerosis (DQA1*01:02:01:01, DQB1*06:02:01, DRB1*15:01:01:01). We also analyzed the diversity of αβ T cells in brain and blood specimens from 14 of these RE surgery cases by sequencing the third complementarity regions (CDR3s) of rearranged T cell receptor β genes. A total of 31 unique CDR3 sequences accounted for the top 5% of all CDR3 sequences in the 14 brain specimens. Thirteen of these sequences were found in sequencing data from healthy blood donors; the remaining 18 sequences were patient specific. These observations provide evidence for the clonal expansion of public and private T cells in the brain, which might be influenced by the RE patient’s HLA haplotype.
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Affiliation(s)
- Sugandha Dandekar
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles , Los Angeles, CA , USA
| | - Hemani Wijesuriya
- Pathology and Laboratory Medicine, David Geffen School of Medicine at the University of California Los Angeles , Los Angeles, CA , USA
| | - Tim Geiger
- Adaptive Biotechnologies Inc. , Seattle, WA , USA
| | - David Hamm
- Adaptive Biotechnologies Inc. , Seattle, WA , USA
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA; Mattel Children's Hospital, Los Angeles, CA, USA
| | - Geoffrey C Owens
- Department of Neurosurgery, David Geffen School of Medicine at the University of California Los Angeles , Los Angeles, CA , USA
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Lagarde S, Villeneuve N, Trébuchon A, Kaphan E, Lepine A, McGonigal A, Roubertie A, Barthez MAJ, Trommsdorff V, Lefranc J, Wehbi S, des Portes V, Laguitton V, Quartier P, Scavarda D, Giusiano B, Milh M, Bulteau C, Bartolomei F. Anti-tumor necrosis factor alpha therapy (adalimumab) in Rasmussen's encephalitis: An open pilot study. Epilepsia 2016; 57:956-66. [DOI: 10.1111/epi.13387] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Stanislas Lagarde
- Clinical Neurophysiology and Epileptology Department; Timone Hospital; APHM; Marseille France
| | - Nathalie Villeneuve
- Henri Gastaut Hospital; Marseille France
- Pediatric Neurology Department; Timone Hospital; APHM; Marseille France
| | - Agnès Trébuchon
- Clinical Neurophysiology and Epileptology Department; Timone Hospital; APHM; Marseille France
| | - Elsa Kaphan
- Neurology Department; Timone Hospital; APHM; Marseille France
| | - Anne Lepine
- Henri Gastaut Hospital; Marseille France
- Pediatric Neurology Department; Timone Hospital; APHM; Marseille France
| | - Aileen McGonigal
- Clinical Neurophysiology and Epileptology Department; Timone Hospital; APHM; Marseille France
| | - Agathe Roubertie
- Pediatric Neurology Department; “Gui de Chauliac” Hospital; Montpellier France
| | | | | | - Jérémie Lefranc
- Pediatric Neurology Department; Brest Hospital; Brest France
| | - Samer Wehbi
- Pediatrics Department; André Mignot Hospital; Le Chesnay France
| | | | | | - Pierre Quartier
- Pediatric Immunology-Hematology and Rheumatology Unit and IMAGINE Institute; “Necker-Enfants Malades” Hospital; APHP; Paris France
| | - Didier Scavarda
- Pediatric Neurosurgery Department; Timone Hospital; APHM; Marseille France
| | - Bernard Giusiano
- Division of Public Health; Timone Hospital; APHM; Marseille France
- Brain Dynamic Institute; INSERM UMR 1106 and Aix-Marseille University; Marseille France
| | - Mathieu Milh
- Pediatric Neurology Department; Timone Hospital; APHM; Marseille France
| | - Christine Bulteau
- Pediatric Neurosurgery Department; Ophthalmologic Foundation “A. de Rothschild”; Paris France
| | - Fabrice Bartolomei
- Pediatric Neurosurgery Department; Timone Hospital; APHM; Marseille France
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CD8(+) T-cell pathogenicity in Rasmussen encephalitis elucidated by large-scale T-cell receptor sequencing. Nat Commun 2016; 7:11153. [PMID: 27040081 PMCID: PMC4822013 DOI: 10.1038/ncomms11153] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/25/2016] [Indexed: 11/29/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare paediatric epilepsy with uni-hemispheric inflammation and progressive neurological deficits. To elucidate RE immunopathology, we applied T-cell receptor (TCR) sequencing to blood (n=23), cerebrospinal fluid (n=2) and brain biopsies (n=5) of RE patients, and paediatric controls. RE patients present with peripheral CD8+ T-cell expansion and its strength correlates with disease severity. In addition, RE is the only paediatric epilepsy with prominent T-cell expansions in the CNS. Consistently, common clones are shared between RE patients, who also share MHC-I alleles. Public RE clones share Vβ genes and length of the CDR3. Rituximab/natalizumab/basiliximab treatment does not change TCR diversity, stem cell transplantation replaces the TCR repertoire with minimal overlap between donor and recipient, as observed in individual cases. Our study supports the hypothesis of an antigen-specific attack of peripherally expanded CD8+ lymphocytes against CNS structures in RE, which might be ameliorated by restricting access to the CNS. Rasmussen Encephalitis is a rare neurological disease accompanied by inflammation and T cell infiltration in the brain. Here the authors show that the severity of this disease correlates with clonal CD8 T cell expansion.
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Hoffman CE, Ochi A, Snead OC, Widjaja E, Hawkins C, Tisdal M, Rutka JT. Rasmussen's encephalitis: advances in management and patient outcomes. Childs Nerv Syst 2016; 32:629-40. [PMID: 26780781 DOI: 10.1007/s00381-015-2994-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 12/22/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Rasmussen's encephalitis (RE) is a hemispheric inflammatory disorder resulting in progressive epilepsy, hemiparesis, and cognitive decline. Controversy surrounds the most effective timing of surgery with respect to language dominance, functional status, and seizure outcome. We describe our experience with RE to inform treatment decisions. METHODS A retrospective chart review was performed in children diagnosed with RE from 1983 to 2012. RESULTS Thirteen consecutive cases were identified: six males and seven females with a mean age of 10.6 years (range 5-18). Nine patients received immunotherapy, with transient benefit in three, treatment-associated complications in two, and no difference in their mean time to treatment (5.38 vs 6.37 years p = 0.74) or long-term outcome. Mean follow-up was 5.6 years (range 0.58-12.25). There was no difference in outcome based on pre-operative duration of seizures. At last follow-up, 63 % of surgically treated patients achieved seizure freedom, 100 % had improved seizure control, 90 % had improved cognitive function, 36 % stopped medication, and 63 % tapered medication. Language improved in 83 % of patients with dominant disease. These findings were not associated with age at treatment. All surgical patients were ambulatory at last follow-up. CONCLUSIONS Hemispherotomy achieves good seizure control with cognitive improvement and ambulatory status post-operatively. Time to surgery and dominant disease were not associated with outcome, suggesting that hemispherotomy can be offered early or late, with expectations of good seizure control and functional outcome, even with dominant disease.
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Affiliation(s)
- Caitlin E Hoffman
- Division of Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA.
| | - Ayako Ochi
- Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Orlando Carter Snead
- Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Elysa Widjaja
- Division of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cynthia Hawkins
- Division of Neuropathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Martin Tisdal
- Division of Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - James T Rutka
- Division of Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Owens GC, Chang JW, Huynh MN, Chirwa T, Vinters HV, Mathern GW. Evidence for Resident Memory T Cells in Rasmussen Encephalitis. Front Immunol 2016; 7:64. [PMID: 26941743 PMCID: PMC4763066 DOI: 10.3389/fimmu.2016.00064] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/09/2016] [Indexed: 12/19/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare pediatric neuroinflammatory disease of unknown etiology characterized by intractable seizures, and progressive atrophy usually confined to one cerebral hemisphere. Surgical removal or disconnection of the affected cerebral hemisphere is currently the only intervention that effectively stops the seizures. Histopathological evaluation of resected brain tissue has shown that activated brain resident macrophages (microglia) and infiltrating T cells are involved in the inflammatory reaction. Here, we report that T cells isolated from seven RE brain surgery specimens express the resident memory T cell (TRM) marker CD103. CD103 was expressed by >50% of CD8+ αβ T cells and γδ T cells irrespective of the length of time from seizure onset to surgery, which ranged from 0.3 to 8.4 years. Only ~10% of CD4+ αβ were CD103+, which was consistent with the observation that few CD4+ T cells are found in RE brain parenchyma. Clusters of T cells in brain parenchyma, which are a characteristic of RE histopathology, stained for CD103. Less than 10% of T cells isolated from brain specimens from eight surgical cases of focal cortical dysplasia (FCD), a condition that is also characterized by intractable seizures, were CD103+. In contrast to the RE cases, the percent of CD103+ T cells increased with the length of time from seizure onset to surgery. In sections of brain tissue from the FCD cases, T cells were predominantly found around blood vessels, and did not stain for CD103. The presence of significant numbers of TRM cells in RE brain irrespective of the length of time between clinical presentation and surgical intervention supports the conclusion that a cellular immune response to an as yet unidentified antigen(s) occurs at an early stage of the disease. Reactivated TRM cells may contribute to disease progression.
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Affiliation(s)
- Geoffrey C Owens
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Julia W Chang
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - My N Huynh
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Thabiso Chirwa
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Harry V Vinters
- Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Mattel Children's Hospital, Los Angeles, CA, USA
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71
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Martin-Blondel G, Brassat D, Bauer J, Lassmann H, Liblau RS. CCR5 blockade for neuroinflammatory diseases — beyond control of HIV. Nat Rev Neurol 2016; 12:95-105. [DOI: 10.1038/nrneurol.2015.248] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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72
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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73
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Ravindra VM, Mazur MD, Mohila CA, Sweney MT, Hersh A, Bollo RJ. Rasmussen encephalitis with dual pathology in a patient without seizures: case report and literature review. Childs Nerv Syst 2015; 31:2165-71. [PMID: 26033376 DOI: 10.1007/s00381-015-2757-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/21/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Rasmussen encephalitis without seizures is rare. We report a case of Rasmussen encephalitis and cortical dysplasia without epilepsy as well as describe the imaging, pathology, and clinical course and review the literature to investigate whether this may represent a rare subset of Rasmussen encephalitis. CASE REPORT We report the case of a 12-year-old girl with a history of cognitive decline and right arm weakness. Magnetic resonance imaging demonstrated diffuse left hemispheric cortical and subcortical atrophy suggestive of Rasmussen encephalitis. The patient had no clinical history of seizures, and electroencephalography did not demonstrate epileptiform abnormalities. Craniotomy for open brain biopsy was performed, and histopathologic evaluation identified Rasmussen encephalitis with cortical dysplasia (dual pathology). CONCLUSIONS To the best of our knowledge, this is the third case of Rasmussen encephalitis diagnosed by both imaging and histopathology that had no clinical or electroencephalographic evidence of seizures and is the only case of Rasmussen encephalitis with cortical dysplasia without epilepsy.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA
| | - Carrie A Mohila
- Department of Pathology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Matthew T Sweney
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Aimee Hersh
- Department of Rheumatology/Immunology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Rheumatology/Immunology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Robert J Bollo
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA.
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Owens GC, Erickson KL, Malone CC, Pan C, Huynh MN, Chang JW, Chirwa T, Vinters HV, Mathern GW, Kruse CA. Evidence for the involvement of gamma delta T cells in the immune response in Rasmussen encephalitis. J Neuroinflammation 2015; 12:134. [PMID: 26186920 PMCID: PMC4506578 DOI: 10.1186/s12974-015-0352-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/24/2015] [Indexed: 02/03/2023] Open
Abstract
Background Rasmussen encephalitis (RE) is a rare neuroinflammatory disease characterized by intractable seizures and progressive atrophy on one side of the cerebrum. Perivascular cuffing and clusters of T cells in the affected cortical hemisphere are indicative of an active cellular immune response. Methods Peripheral blood mononuclear cells (PBMCs) and brain-infiltrating lymphocytes (BILs) were isolated from 20 RE surgery specimens by standard methods, and CD3+ T cell populations were analyzed by flow cytometry. Gamma delta T cell receptor spectratyping was carried out by nested PCR of reversed transcribed RNA extracted from RE brain tissue, followed by high resolution capillary electrophoresis. A MiSeq DNA sequencing platform was used to sequence the third complementarity determining region (CDR3) of δ1 chains. Results CD3+ BILs from all of the RE brain specimens comprised both αβ and γδ T cells. The median αβ:γδ ratio was 1.9 (range 0.58–5.2) compared with a median ratio of 7.7 (range 2.7–40.8) in peripheral blood from the same patients. The αβ T cells isolated from brain tissue were predominantly CD8+, and the majority of γδ T cells were CD4− CD8−. Staining for the early activation marker CD69 showed that a fraction of the αβ and γδ T cells in the BILs were activated (median 42 %; range 13–91 %, and median 47 %; range 14–99 %, respectively). Spectratyping T cell receptor (TCR) Vδ1-3 chains from 14 of the RE brain tissue specimens indicated that the γδ T cell repertoire was relatively restricted. Sequencing δ1 chain PCR fragments revealed that the same prevalent CDR3 sequences were found in all of the brain specimens. These CDR3 sequences were also detected in brain tissue from 15 focal cortical dysplasia (FCD) cases. Conclusion Neuroinflammation in RE involves both activated αβ and γδ T cells. The presence of γδ T cells with identical TCR δ1 chain CDR3 sequences in all of the brain specimens examined suggests that a non-major histocompatibility complex (MHC)-restricted immune response to the same antigen(s) is involved in the etiology of RE. The presence of the same δ1 clones in CD brain implies the involvement of a common inflammatory pathway in both diseases. Electronic supplementary material The online version of this article (doi:10.1186/s12974-015-0352-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Geoffrey C Owens
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA.
| | - Kate L Erickson
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA.
| | - Colin C Malone
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA.
| | - Calvin Pan
- Department of Human Genetics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, USA.
| | - My N Huynh
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA.
| | - Julia W Chang
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA. .,Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA.
| | - Thabiso Chirwa
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA.
| | - Harry V Vinters
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA. .,Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA. .,Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA. .,Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA.
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA. .,Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA. .,Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA. .,Mattel Children's Hospital, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA.
| | - Carol A Kruse
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Ste. 562, Los Angeles, CA, 90095-6901, USA.,Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
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Esposito S, Di Pietro GM, Madini B, Mastrolia MV, Rigante D. A spectrum of inflammation and demyelination in acute disseminated encephalomyelitis (ADEM) of children. Autoimmun Rev 2015; 14:923-9. [PMID: 26079482 PMCID: PMC7105213 DOI: 10.1016/j.autrev.2015.06.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 11/15/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that involves multifocal areas of the white matter, rarely the gray matter and spinal cord, mainly affecting children and mostly occurring 1-2weeks after infections or more rarely after vaccinations. Though a specific etiologic agent is not constantly identified, to evaluate carefully patient's clinical history and obtain adequate samples for the search of a potential ADEM causal agent is crucial. In the case of a prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with full recovery, but in the case of diagnostic delays or inappropriate treatment some patients might display neurological sequelae and persistent deficits or even show an evolution to multiple sclerosis. The suspicion of ADEM rises on a clinical basis and derives from systemic and neurologic signs combined with magnetic resonance imaging of the central nervous system. Other advanced imaging techniques may help an appropriate differential diagnosis and definition of exact disease extension. Although there is no standardized protocol or management for ADEM, corticosteroids, intravenous immunoglobulin, and plasmapheresis have been successfully used. There is no marker that permits to identify the subset of children with worse prognosis and future studies should try to detect any biological clue for prevision of neurologic damage as well as should optimize treatment strategies using an approach based on the effective risk of negative evolution.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giada Maria Di Pietro
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Madini
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Vincenza Mastrolia
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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Deleo F, Matricardi S, Didato G, Pappalardo I, Villani F. The dilemma of adult-onset Rasmussen encephalitis clinical assessment: Proposal for a new bedside tool to evaluate disease progression. Epilepsy Behav 2015; 46:249-51. [PMID: 25960424 DOI: 10.1016/j.yebeh.2015.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Francesco Deleo
- Clinical Epileptology and Experimental Neurophysiology Unit, Foundation IRCCS "Carlo Besta" Neurological Institute, Milan, Italy.
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Foundation IRCCS "Carlo Besta" Neurological Institute, Milan, Italy; Department of Pediatrics, University of Chieti, Chieti, Italy.
| | - Giuseppe Didato
- Clinical Epileptology and Experimental Neurophysiology Unit, Foundation IRCCS "Carlo Besta" Neurological Institute, Milan, Italy.
| | - Irene Pappalardo
- Clinical Epileptology and Experimental Neurophysiology Unit, Foundation IRCCS "Carlo Besta" Neurological Institute, Milan, Italy.
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Foundation IRCCS "Carlo Besta" Neurological Institute, Milan, Italy.
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Abstract
Rasmussen's encephalitis (RE) is a rare neurological disorder of inflammatory aetiology characterised by encephalitis, intractable seizures, hemiparesis, variable motor deficits, and dementia. It is not commonly considered in the clinical differential diagnosis of a patient with a past history of a stroke-like episode presenting with status epilepticus. It is suspected mainly in children in whom the disease is more common. Here we report a case of an adult man presenting with a common symptom of seizure caused by Rasmussen's encephalitis.
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Affiliation(s)
- Joseph Vimal
- Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Ramesh Nagarajan
- Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Deepika Sriram
- Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
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Liba Z, Muthaffar O, Tang J, Minassian B, Halliday W, Branson H, Ann Yeh E. Rasmussen encephalitis: Response to early immunotherapy in a case of immune-mediated encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2015; 2:e69. [PMID: 25738166 PMCID: PMC4335812 DOI: 10.1212/nxi.0000000000000069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/07/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Zuzana Liba
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
| | - Osama Muthaffar
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
| | - Joyce Tang
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
| | - Berge Minassian
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
| | - William Halliday
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
| | - Helen Branson
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
| | - E Ann Yeh
- Department of Pediatric Neurology (Z.L.), 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic; Division of Neurology (O.M., B.M., E.A.Y.), Division of Pathology (W.H.), and Division of Neuroradiology (H.B.), Hospital for Sick Children, Toronto, Ontario, Canada; and Department of Pediatrics (O.M., B.M., E.A.Y.), Department of Internal Medicine (J.T.), Department of Laboratory Medicine & Pathobiology (W.H.), and Department of Medical Imaging (H.B.), University of Toronto, Ontario, Canada
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79
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Novak M, Čavka M, Šlaus M. Two cases of neurogenic paralysis in medieval skeletal samples from Croatia. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2014; 7:25-32. [DOI: 10.1016/j.ijpp.2014.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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80
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Abstract
The role of immunity and inflammation appears to be an integral part of the pathogenic processes associated with some seizures, particularly with refractory epilepsy. Prompt treatment with immunotherapy may lead to better outcomes. Immune treatment options for treatment of epilepsy include therapies such as corticosteroids, immunoglobulins, plasmapheresis, or steroid-sparing drugs such as azathioprine. Recent alternatives have included even more aggressive treatment with cyclophosphamide, anti-pre-B-lymphocyte monoclonal antibody rituximab, and monoclonal antibodies such as efalizumab or natalizumab, which are presently used for other inflammatory disorders. Randomized controlled trials of immunotherapy in presumed autoimmune epilepsy are needed to provide further support for the rapid use of immunotherapy in patients with immune mediated epilepsy.
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Affiliation(s)
- Joseph J Melvin
- Section of Neurology, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA..
| | - H Huntley Hardison
- Section of Neurology, St. Christopher's Hospital for Children, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA
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81
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Press C, Wallace A, Chapman KE. The Janus-faced nature of Rasmussen's encephalitis. Semin Pediatr Neurol 2014; 21:129-36. [PMID: 25149947 DOI: 10.1016/j.spen.2014.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Rasmussen encephalitis (RE) is an inflammatory unilateral progressive medically refractory epilepsy associated with hemiparesis, cognitive dysfunction, and hemispheric atrophy. Here, we present 2 cases from our institution that demonstrate the dual nature of RE in 2 similarly aged children. Overall, 2 types of RE have been described: type 1 has a short prodromal phase and more explosive onset and type 2 has a longer prodromal of partial seizures followed by hemiparesis and atrophy. Younger patients are more likely to fit into the type 1 presentation and have been described as more likely to have dual pathology. Perhaps the patients with a more acute onset are more likely to have a dual pathology as is found in our 2 cases. We review the typical findings in RE and discuss current treatment options, highlighting new experimental treatments.
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Affiliation(s)
- Craig Press
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Adam Wallace
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kevin E Chapman
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO.
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82
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Granata T, Matricardi S, Ragona F, Freri E, Casazza M, Villani F, Deleo F, Tringali G, Gobbi G, Tassi L, Lo Russo G, Marras CE, Specchio N, Vigevano F, Fusco L. Hemispherotomy in Rasmussen encephalitis: long-term outcome in an Italian series of 16 patients. Epilepsy Res 2014; 108:1106-19. [PMID: 24815913 DOI: 10.1016/j.eplepsyres.2014.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/13/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
Surgical disconnection of the affected hemisphere is considered the treatment of choice for Rasmussen encephalitis (RE), however few data on long-term outcomes after disconnective surgery are available. We report on long-term seizure, cognitive and motor outcomes after disconnective surgery in 16 (8 M, 8 F) RE patients. Pre- and post-operative evaluations included long-term video-EEG monitoring, MRI, assessment of motor function, and cognitive evaluation. Hemispherotomy, by various techniques was used to obtain functional disconnection of the affected hemisphere. The patients, of median current age 23.5 years, range 12-33, were operated on between 1993 and 2009. Median age at disease onset was 5.8 years (range 3-11.4). Median time from seizure onset to surgery was 3.8 years, range 8 months to 21 years. Post-surgical follow-up was a median of 9.5 years, range 3-20. At surgery all patients were receiving two or more antiepileptic drugs (AEDs). All but three patients were seizure-free at latest follow-up. AEDs had been stopped in ten patients; in the remaining six AEDs were markedly reduced. Postural control improved in all patients. Gain in cognitive functioning was significantly (p=0.002) related to disease duration. The long-term outcomes, in terms of seizure control, motor improvement, and cognitive improvement provide important support for disconnective surgery as first choice treatment for RE.
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Affiliation(s)
- Tiziana Granata
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy.
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy; Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Marina Casazza
- Department of Neurophysiology, Carlo Besta Neurological Institute, Milan, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Francesco Deleo
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Giovanni Tringali
- Department of Neurosurgery, Carlo Besta Neurological Institute, Milan, Italy
| | - Giuseppe Gobbi
- Child Neurology Unit, IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy
| | - Laura Tassi
- Epilepsy Surgery Centre C. Munari, Milan, Italy
| | | | | | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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83
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Villani F, Didato G, Deleo F, Tringali G, Garbelli R, Granata T, Marras CE, Cordella R, Spreafico R. Long-term outcome after limited cortical resections in two cases of adult-onset Rasmussen encephalitis. Epilepsia 2014; 55:e38-e43. [DOI: 10.1111/epi.12596] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Flavio Villani
- Division of Clinical Epileptology & Experimental Neurophysiology; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Giuseppe Didato
- Division of Clinical Epileptology & Experimental Neurophysiology; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Francesco Deleo
- Division of Clinical Epileptology & Experimental Neurophysiology; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Giovanni Tringali
- Division of Neurosurgery III; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Rita Garbelli
- Division of Clinical Epileptology & Experimental Neurophysiology; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Tiziana Granata
- Division of Child Neurology; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Carlo Efisio Marras
- Division of Neurosurgery III; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
- Neurosurgery Unit “Bambino Gesù” Children Hospital; Rome Italy
| | - Roberto Cordella
- Division of Neurosurgery III; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
| | - Roberto Spreafico
- Division of Clinical Epileptology & Experimental Neurophysiology; Foundation IRCCS Neurological Institute “Carlo Besta”; Milan Italy
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84
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Pardo CA, Nabbout R, Galanopoulou AS. Mechanisms of epileptogenesis in pediatric epileptic syndromes: Rasmussen encephalitis, infantile spasms, and febrile infection-related epilepsy syndrome (FIRES). Neurotherapeutics 2014; 11:297-310. [PMID: 24639375 PMCID: PMC3996116 DOI: 10.1007/s13311-014-0265-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The mechanisms of epileptogenesis in pediatric epileptic syndromes are diverse, and may involve disturbances of neurodevelopmental trajectories, synaptic homeostasis, and cortical connectivity, which may occur during brain development, early infancy, or childhood. Although genetic or structural/metabolic factors are frequently associated with age-specific epileptic syndromes, such as infantile spasms and West syndrome, other syndromes may be determined by the effect of immunopathogenic mechanisms or energy-dependent processes in response to environmental challenges, such as infections or fever in normally-developed children during early or late childhood. Immune-mediated mechanisms have been suggested in selected pediatric epileptic syndromes in which acute and rapidly progressive encephalopathies preceded by fever and/or infections, such as febrile infection-related epilepsy syndrome, or in chronic progressive encephalopathies, such as Rasmussen encephalitis. A definite involvement of adaptive and innate immune mechanisms driven by cytotoxic CD8(+) T lymphocytes and neuroglial responses has been demonstrated in Rasmussen encephalitis, although the triggering factor of these responses remains unknown. Although the beneficial response to steroids and adrenocorticotropic hormone of infantile spasms, or preceding fever or infection in FIRES, may support a potential role of neuroinflammation as pathogenic factor, no definite demonstration of such involvement has been achieved, and genetic or metabolic factors are suspected. A major challenge for the future is discovering pathogenic mechanisms and etiological factors that facilitate the introduction of novel targets for drug intervention aimed at interfering with the disease mechanisms, therefore providing putative disease-modifying treatments in these pediatric epileptic syndromes.
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Affiliation(s)
- Carlos A Pardo
- Department of Neurology, Division of Neuroimmunology and Neuroinfectious Disorders, Center for Pediatric Rasmussen Syndrome, Johns Hopkins University School of Medicine, Baltimore, MD, USA,
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85
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Varadkar S, Bien CG, Kruse CA, Jensen FE, Bauer J, Pardo CA, Vincent A, Mathern GW, Cross JH. Rasmussen's encephalitis: clinical features, pathobiology, and treatment advances. Lancet Neurol 2014; 13:195-205. [PMID: 24457189 DOI: 10.1016/s1474-4422(13)70260-6] [Citation(s) in RCA: 256] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Rasmussen's encephalitis is a rare chronic neurological disorder, characterised by unilateral inflammation of the cerebral cortex, drug-resistant epilepsy, and progressive neurological and cognitive deterioration. Neuropathological and immunological studies support the notion that Rasmussen's encephalitis is probably driven by a T-cell response to one or more antigenic epitopes, with potential additional contribution by autoantibodies. Careful analysis of the association between histopathology and clinical presentation suggests that initial damage to the brain is mediated by T cells and microglia, suggesting a window for treatment if Rasmussen's encephalitis can be diagnosed early. Advances in neuroimaging suggest that progression of the inflammatory process seen with MRI might be a good biomarker in Rasmussen's encephalitis. For many patients, families, and doctors, choosing the right time to move from medical management to surgery is a real therapeutic dilemma. Cerebral hemispherectomy remains the only cure for seizures, but there are inevitable functional compromises. Decisions of whether or when surgery should be undertaken are challenging in the absence of a dense neurological deficit, and vary by institutional experience. Further, the optimum time for surgery, to give the best language and cognitive outcome, is not yet well understood. Immunomodulatory treatments seem to slow rather than halt disease progression in Rasmussen's encephalitis, without changing the eventual outcome.
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Affiliation(s)
- Sophia Varadkar
- Epilepsy Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and UCL Institute of Child Health, London, UK.
| | | | - Carol A Kruse
- Department of Neurosurgery, Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Frances E Jensen
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Carlos A Pardo
- Department of Neurology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Gary W Mathern
- Departments of Neurosurgery and Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine, Mattel Children's Hospital, University of California, Los Angeles, CA, USA
| | - J Helen Cross
- Neurosciences Unit, UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS Foundation Trust, London, and Young Epilepsy, Lingfield, UK
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86
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Guan Y, Zhou J, Luan G, Liu X. Surgical Treatment of Patients with Rasmussen Encephalitis. Stereotact Funct Neurosurg 2014; 92:86-93. [DOI: 10.1159/000355901] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 09/23/2013] [Indexed: 11/19/2022]
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87
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Wilcox KS, Vezzani A. Does brain inflammation mediate pathological outcomes in epilepsy? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 813:169-83. [PMID: 25012376 PMCID: PMC4867105 DOI: 10.1007/978-94-017-8914-1_14] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Inflammation in the central nervous system (CNS) is associated with epilepsy and is characterized by the increased levels of a complex set of soluble molecules and their receptors in epileptogenic foci with profound neuromodulatory effects. These molecules activate receptor-mediated pathways in glia and neurons that contribute to hyperexcitability in neural networks that underlie seizure generation. As a consequence, exciting new opportunities now exist for novel therapies targeting the various components of the immune system and the associated inflammatory mediators, especially the IL-1β system. This review summarizes recent findings that increased our understanding of the role of inflammation in reducing seizure threshold, contributing to seizure generation, and participating in epileptogenesis. We will discuss preclinical studies supporting the hypothesis that pharmacological inhibition of specific proinflammatory signalings may be useful to treat drug-resistant seizures in human epilepsy, and possibly delay or arrest epileptogenesis.
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Affiliation(s)
- Karen S Wilcox
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, 84108, USA,
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88
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Abstract
OPINION STATEMENT Autoimmune status epilepticus is a rare condition but one that has been increasingly recognized by neurologists and clinicians in the intensive care unit. As more cases are described in the literature and more antibody tests become commercially available, diagnosis is now feasible; however, early diagnosis remains a challenge. For practical purposes, status epilepticus may be considered as possibly autoimmune if it is refractory to anticonvulsant treatment and there is no other known cause; this may then lead to empiric immunomodulatory therapy. Major factors that raise the index of suspicion are recent cognitive or behavioral alterations, a history of malignancy or tumor, or presence of other neurological features. There is a lack of high level evidence in the literature for treatment of status epilepticus, and almost none for autoimmune encephalitis. Patients with autoimmune status epilepticus may be treated with immunomodulatory therapy, including steroids, intravenous immunoglobulin (IVIG), plasmapheresis (PLEX), and other immunosuppressive agents while maximizing their anticonvulsant therapy. For some patients, resective surgery may be necessary, such as hemispherectomy for Rasmussen's encephalopathy. In the case of status epilepticus due to paraneoplastic autoantibodies, urgent and aggressive testing and treatment of a primary malignancy is needed. Importantly, any suspicion of autoimmune mediated status epilepticus should prompt the transfer of the patient to a specialized center with experience in refractory status epilepticus whenever possible.
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