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Gagnon MH, Derenoncourt PR, Rayamahi S, Taylor S, Parikh AK, Ponisio MR, Khanna G. Unusual imaging findings associated with abdominal pediatric germ cell tumors. Pediatr Radiol 2024; 54:1093-1104. [PMID: 38462578 DOI: 10.1007/s00247-024-05894-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024]
Abstract
Germ cell tumors of childhood are tumors arising from germline cells in gonadal or extragonadal locations. Extragonadal germ cell tumors are characteristically located in the midline, arising intracranially or in the mediastinum, retroperitoneum, or pelvis. These tumors are generally easily diagnosed due to typical sites of origin, characteristic imaging findings, and laboratory markers. However, germ cell tumors can be associated with unusual clinical syndromes or imaging features that can perplex the radiologist. This review will illustrate atypical imaging/clinical manifestations and complications of abdominal germ cell tumors in childhood. These features include unusual primary tumors such as multifocal primaries; local complications such as ovarian torsion or ruptured dermoid; atypical presentations of metastatic disease associated with burned-out primary tumor, growing teratoma syndrome, and gliomatosis peritonei; endocrine manifestations such as precocious puberty and hyperthyroidism; and antibody mediated paraneoplastic syndrome such as anti-N-methyl-D-aspartate-receptor antibody-mediated encephalitis. This review aims to illustrate unusual imaging features associated with the primary tumor, metastatic disease, or distant complications of abdominal germ cell tumors of childhood.
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Affiliation(s)
- Marie-Helene Gagnon
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Paul-Robert Derenoncourt
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Sampanna Rayamahi
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Susan Taylor
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Ashishkumar K Parikh
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Maria R Ponisio
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Geetika Khanna
- Department of Radiology & Imaging Sciences, Emory University and Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
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Hartung TJ, Cooper G, Jünger V, Komnenić D, Ryan L, Heine J, Chien C, Paul F, Prüss H, Finke C. The T1-weighted/T2-weighted ratio as a biomarker of anti-NMDA receptor encephalitis. J Neurol Neurosurg Psychiatry 2024; 95:366-373. [PMID: 37798094 PMCID: PMC10958321 DOI: 10.1136/jnnp-2023-332069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis rarely causes visible lesions in conventional MRI, yet advanced imaging detects extensive white matter damage. To improve prognostic capabilities, we evaluate the T1-weighted/T2-weighted (T1w/T2w) ratio, a measure of white matter integrity computable from clinical MRI sequences, in NMDAR encephalitis and examine its associations with cognitive impairment. METHODS T1-weighted and T2-weighted MRI were acquired cross-sectionally at 3 Tesla in 53 patients with NMDAR encephalitis (81% women, mean age 29 years) and 53 matched healthy controls. Quantitative and voxel-wise group differences in T1w/T2w ratios and associations with clinical and neuropsychological outcomes were assessed. P-values were false discovery rate (FDR) adjusted where multiple tests were conducted. RESULTS Patients with NMDAR encephalitis had significantly lower T1w/T2w ratios across normal appearing white matter (p=0.009, Hedges' g=-0.51), which was associated with worse verbal episodic memory performance (r=0.39, p=0.005, p(FDR)=0.026). White matter integrity loss was observed in the corticospinal tract, superior longitudinal fascicle, optic radiation and callosal body with medium to large effects (Cohen's d=[0.42-1.17]). In addition, patients showed decreased T1w/T2w ratios in the hippocampus (p=0.002, p(FDR)=0.005, Hedges' g=-0.62), amygdala (p=0.002, p(FDR)=0.005, Hedges' g=-0.63) and thalamus (p=0.010, p(FDR)=0.019, Hedges' g=-0.51). CONCLUSIONS The T1w/T2w ratio detects microstructural changes in grey and white matter of patients with NMDAR encephalitis that correlate with cognitive performance. Computable from conventional clinical MRI sequences, this measure shows promise in bridging the clinico-radiological dissociation in NMDAR encephalitis and could serve as an imaging outcome measure in clinical trials.
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Affiliation(s)
- Tim Julian Hartung
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Graham Cooper
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Valentin Jünger
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Berlin, Germany
- Neuroscience Clinical Research Center (NCRC), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Darko Komnenić
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lara Ryan
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Josephine Heine
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Chien
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Berlin, Germany
- Neuroscience Clinical Research Center (NCRC), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Medizinische Klinik m.S. Psychosomatik, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Carsten Finke
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Hou C, Li X, Zeng Y, Gao Y, Wu W, Zhu H, Zhang Y, Wu W, Tian Y, Zheng K, Chen L, Peng B, Chen WX. Brain magnetic resonance imaging as predictors in pediatric anti-N-methyl-D-aspartate receptor encephalitis. Mult Scler Relat Disord 2024; 82:105061. [PMID: 38134605 DOI: 10.1016/j.msard.2023.105061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/26/2023] [Accepted: 10/08/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To investigate the associations between brain magnetic resonance imaging (MRI) changes and clinical profiles in children with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHODS Clinical data and brain MRI results of children diagnosed with anti-NMDAR encephalitis in Guangzhou Women and Children's Medical Center from October 2014 to June 2022 were retrospectively studied. RESULTS A total of 143 children (Male: female 54:89) were enrolled, with a mean onset age of 6.8 years (6.8 ± 3.1). 40.6 % (58/143) of patients had abnormal initial brain MRI. Lesions in temporal lobe (34.5 %, 20/58) and frontal lobe (25.9 %, 15/58) were relatively common. Children with abnormal initial brain MRI were prone to have fever (P = 0.023), dystonia (P = 0.037), positive MOG antibodies (P = 0.015), higher cerebrospinal fluid (CSF) white blood cell count (WBC) (P = 0.019) and to receive rituximab treatment (P = 0.037). There were no significant differences in modified Rankin Scale (mRS) scores before immunotherapy, after immunotherapy and at last follow-up between the normal initial brain MRI group and abnormal group. No initial brain MRI changes were found to be associated with relapses. Brain MRI was reviewed in 72 patients at last follow-up with a median follow-up time of 25.5 months and 48.6 % (35/72) of patients had abnormal brain MRI. The mRS score of the group with normal brain MRI at last follow-up was significantly lower than that of the abnormal group. CONCLUSIONS About 40.0 % of children with anti-NMDAR encephalitis had abnormal initial brain MRI. Initial brain MRI was associated with certain clinical profiles, but not with relapse and prognosis. Around half of patients had abnormal brain MRI at last follow-up and were prone to have higher mRS score.
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Affiliation(s)
- Chi Hou
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yiru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yuanyuan Gao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wenxiao Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Haixia Zhu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wenlin Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yang Tian
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Liangfeng Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Bingwei Peng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wen-Xiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China.
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Oertel FC, Hastermann M, Paul F. Delimiting MOGAD as a disease entity using translational imaging. Front Neurol 2023; 14:1216477. [PMID: 38333186 PMCID: PMC10851159 DOI: 10.3389/fneur.2023.1216477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/23/2023] [Indexed: 02/10/2024] Open
Abstract
The first formal consensus diagnostic criteria for myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) were recently proposed. Yet, the distinction of MOGAD-defining characteristics from characteristics of its important differential diagnoses such as multiple sclerosis (MS) and aquaporin-4 antibody seropositive neuromyelitis optica spectrum disorder (NMOSD) is still obstructed. In preclinical research, MOG antibody-based animal models were used for decades to derive knowledge about MS. In clinical research, people with MOGAD have been combined into cohorts with other diagnoses. Thus, it remains unclear to which extent the generated knowledge is specifically applicable to MOGAD. Translational research can contribute to identifying MOGAD characteristic features by establishing imaging methods and outcome parameters on proven pathophysiological grounds. This article reviews suitable animal models for translational MOGAD research and the current state and prospect of translational imaging in MOGAD.
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Affiliation(s)
- Frederike Cosima Oertel
- Experimental and Clinical Research Center, Max-Delbrück-Centrum für Molekulare Medizin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Neuroscience Clinical Research Center, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Hastermann
- Experimental and Clinical Research Center, Max-Delbrück-Centrum für Molekulare Medizin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Neuroscience Clinical Research Center, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max-Delbrück-Centrum für Molekulare Medizin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Neuroscience Clinical Research Center, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Santoro JD, Jafarpour S, Boyd NK, Nguyen L, Khoshnood MM. The Impact of Neuroimmunologic Disease and Developing Nervous System. Pediatr Neurol 2023; 148:189-197. [PMID: 37442652 DOI: 10.1016/j.pediatrneurol.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/16/2023] [Accepted: 06/10/2023] [Indexed: 07/15/2023]
Abstract
Over the last two decades, neuroimmunologic disorders of childhood have been increasingly described, phenotyped, and treated. These disorders remain rare in the general population and while sharing common therapeutic interventions due to their immune pathophysiology, are heterogeneous with regard to presentation and risk of recurrence. As such, the impact of these disorders on the developing brain has come into the forefront of emerging research in pediatric neuroimmunology. Investigations into the singular impact of monophasic disease on long-term development and the impact of early and aggressive disease-modifying therapy in relapsing conditions are quickly becoming areas of ripe investigation as the field's most optimal way to treat and monitor these conditions over time. Although critically important in evaluating the developing brain, research has been heterogeneous among these diseases and limited by small cohort size. This narrative review details the role of common neuroimmunologic disorders in long-term neurological and cognitive outcomes in children as they develop.
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Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Natalie K Boyd
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Lina Nguyen
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Mellad M Khoshnood
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
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Vova JA, Howarth RA. Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children. Pediatr Clin North Am 2023; 70:429-444. [PMID: 37121635 DOI: 10.1016/j.pcl.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.
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Affiliation(s)
- Joshua A Vova
- Department of Physical Medicine and Rehabilitation, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road Northeast, Atlanta, GA 30342, USA; Department of Neuropsychology, Children's Healthcare of Atlanta, 5461 Meridian Mark Road NE, Atlanta, GA 30342, USA; Department of Pediatrics, Division of Neurology, Emory University School of Medicine.
| | - Robyn A Howarth
- Department of Neuropsychology, Children's Healthcare of Atlanta, 5461 Meridian Mark Road NE, Atlanta, GA 30342, USA; Department of Pediatrics, Division of Neurology, Emory University School of Medicine
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Broadley J, Wesselingh R, Beech P, Seneviratne U, Kyndt C, Buzzard K, Nesbitt C, D'Souza W, Brodtmann A, Macdonell R, Kalincik T, O'Brien TJ, Butzkueven H, Monif M. Neuroimaging characteristics may aid in diagnosis, subtyping, and prognosis in autoimmune encephalitis. Neurol Sci 2023; 44:1327-1340. [PMID: 36481972 DOI: 10.1007/s10072-022-06523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the utility of neuroimaging characteristics as biomarkers of prognosis in seropositive autoimmune encephalitis (AE). METHODS In this multi-center study, we retrospectively analyzed 66 cases of seropositive AE. The MRI and PET imaging was assessed by independent visual inspection. Whole brain and regional volumes were imputed by IcoMetrix, an automated volumetric assessment package. The modified Rankin Scale (mRS) was utilized to assess the patients' follow-up disability. Other outcomes were mortality, first line treatment failure, medial temporal lobe (MTL) atrophy, and clinical relapse. Univariate and multivariable regression analysis was performed. RESULTS Abnormalities on MRI were detected in 35.1% of patients, while PET was abnormal in 46.4%. Initial median whole brain and hippocampal volumes were below the 5th and 20th percentile respectively compared to an age-matched healthy database. After a median follow-up of 715 days, 85.2% had good functional outcome (mRS ≤ 2). Nine patients developed MTL atrophy during follow-up. On multivariable analysis, inflammatory MTL changes were associated with development of MTL atrophy (HR 19.6, p = 0.007) and initial hippocampal volume had an inverse relationship with mortality (HR 0.04, p = 0.011). Patients who developed MTL atrophy had a reduced chance of good final mRS (HR 0.16, p = 0.015). CONCLUSIONS Neuroimaging on initial hospital admission may be provide important diagnostic and prognostic information. This study demonstrates that structural and inflammatory changes of the MTL may have importance in clinical and radiological prognosis in seropositive AE.
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Affiliation(s)
- James Broadley
- Department of Neuroscience, Central Clinical School, Monash University, Level 6 Alfred Center, 55 Commercial Road, Melbourne, Australia
- Department of Neuroscience, Barwon Health, Geelong, Australia
| | - Robb Wesselingh
- Department of Neuroscience, Central Clinical School, Monash University, Level 6 Alfred Center, 55 Commercial Road, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
| | - Paul Beech
- Department of Radiology, Alfred Health, Melbourne, Australia
- Department of Radiology, Monash Health, Melbourne, Australia
| | - Udaya Seneviratne
- Department of Neuroscience, Central Clinical School, Monash University, Level 6 Alfred Center, 55 Commercial Road, Melbourne, Australia
- Department of Neuroscience, Monash Health, Melbourne, Australia
| | - Chris Kyndt
- Department of Neurosciences, Eastern Health, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health, Melbourne, Australia
- Department of Neurology, Melbourne Health, Melbourne, Australia
| | - Cassie Nesbitt
- Department of Neuroscience, Barwon Health, Geelong, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
| | - Wendyl D'Souza
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Amy Brodtmann
- Department of Neurosciences, Eastern Health, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | | | - Tomas Kalincik
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Neurology, Melbourne Health, Melbourne, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Level 6 Alfred Center, 55 Commercial Road, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Level 6 Alfred Center, 55 Commercial Road, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Level 6 Alfred Center, 55 Commercial Road, Melbourne, Australia.
- Department of Neurology, Alfred Health, Melbourne, Australia.
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Bartels F, Baumgartner B, Aigner A, Cooper G, Blaschek A, Wendel EM, Bertolini A, Karenfort M, Baumann M, Cleaveland R, Wegener-Panzer A, Leiz S, Salandin M, Krieg P, Reindl T, Reindl M, Finke C, Rostásy K. Impaired Brain Growth in Myelin Oligodendrocyte Glycoprotein Antibody-Associated Acute Disseminated Encephalomyelitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/2/e200066. [PMID: 36754833 PMCID: PMC9909582 DOI: 10.1212/nxi.0000000000200066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/10/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute disseminated encephalomyelitis (ADEM) is the most common phenotype in pediatric myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease. A previous study demonstrated impaired brain growth in ADEM. However, the effect of MOG antibodies on brain growth remains unknown. Here, we performed brain volume analyses in MOG-positive and MOG-negative ADEM at onset and over time. METHODS In this observational cohort study, we included a total of 62 MRI scans from 24 patients with ADEM (54.2% female; median age 5 years), of which 16 (66.7%) were MOG positive. Patients were compared with healthy controls from the NIH pediatric MRI data repository and a matched local cohort. Mixed-effect models were applied to assess group differences and other relevant factors, including relapses. RESULTS At baseline and before any steroid treatment, patients with ADEM, irrespective of MOG antibody status, showed reduced brain volume compared with matched controls (median [interquartile range] 1,741.9 cm3 [1,645.1-1,805.2] vs 1,810.4 cm3 [1,786.5-1,836.2]). Longitudinal analysis revealed reduced brain growth for both MOG-positive and MOG-negative patients with ADEM. However, MOG-negative patients showed a stronger reduction (-138.3 cm3 [95% CI -193.6 to -82.9]) than MOG-positive patients (-50.0 cm3 [-126.5 to -5.2]), independent of age, sex, and treatment. Relapsing patients (all MOG positive) showed additional brain volume loss (-15.8 cm3 [-68.9 to 37.3]). DISCUSSION Patients with ADEM exhibit brain volume loss and failure of age-expected brain growth. Importantly, MOG-negative status was associated with a more pronounced brain volume loss compared with MOG-positive patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kevin Rostásy
- From the Department of Neurology (F.B., G.C., C.F.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health at Charité-Universitätsmedizin Berlin (F.B.); Berlin School of Mind and Brain (F.B., C.F.), Humboldt-Universität zu Berlin; Witten/Herdecke University (B.B., Annikki Bertolini, K.R.), Department of Pediatric Neurology, Children's Hospital Datteln; Charité-Universitätsmedizin Berlin (A.A.), Institute of Biometry and Clinical Epidemiology; Department of Pediatric Neurology and Developmental Medicine (Astrid Blaschek), LMU, Dr. von Hauner Children's Hospital, Munich; Department of Pediatric Neurology (E.M.W.), Olgahospital/Klinikum Stuttgart; Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty (M.K.), Heinrich-Heine-University Düsseldorf, Germany; Department of Pediatric I, Pediatric Neurology (M.B.), Medical University of Innsbruck, Austria; Department of Radiology (R.C., A.W.-P.), Children's Hospital Datteln, Witten/Herdecke University, Germany; Department of Pediatrics and Adolescent Medicine (S.L.), Hospital Dritter Orden, Munich, Germany; Department Neuropediatrics (M.S.), Regional Hospital of Bolzano, Italy; Department of Pediatrics (P.K.), Städtisches Klinikum Karlsruhe, Germany; Department of Pediatrics, Brandenburg (T.R.), Helios Klinik Hohenstücken, Germany; and Clinical Department of Neurology (M.R.), Medical University of Innsbruck, Innsbruck, Austria.
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9
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Quade A, Rostasy K, Wickström R, Aydin ÖF, Sartori S, Nosadini M, Knierim E, Kluger G, Korinthenberg R, Stüve B, Waltz S, Leiz S, Häusler M. Autoimmune Encephalitis with Autoantibodies to NMDAR1 following Herpes Encephalitis in Children and Adolescents. Neuropediatrics 2023; 54:14-19. [PMID: 36543183 DOI: 10.1055/s-0042-1757706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Herpes simplex virus (HSV) type 1 is a frequent pathogen causing infectious encephalitis (HSVE). Early treatment with intravenous acyclovir has led to a significant decrease in mortality. However, especially in children, deterioration during or after HSVE may occur without any evidence of HSV reactivation or improvement following repeated antiviral therapy. Here, we report 15 patients (age range 3 months to 15 years) who suffered from autoimmune encephalitis with autoantibodies to NMDAR1 following Herpes encephalitis, presenting with movement abnormalities (young children) or neuropsychiatric symptoms (older children) as major complaints, respectively. The diagnosis was based on positive cerebrospinal fluid (CSF) and/or serum anti-NMDAR-antibodies with two children showing only positive CSF antibody findings. The time lag between first symptoms and diagnosis of autoimmune encephalitis was significantly longer than between first symptoms and diagnosis of HSVE (p <0.01). All patients improved during immunosuppressive treatment, during which plasmapheresis or rituximab treatments were applied in 11 patients, irrespective of their age. Despite immunotherapy, no patients relapsed with HSVE. Early diagnosis and treatment of autoimmune encephalitis after HSVE may be associated with a better outcome so that high clinical awareness and routine testing for anti-NMDAR-antibodies after HSVE seems advisable. If autoimmune encephalitis is suspected, antibody testing should also be performed on CSF if negative in serum.
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Affiliation(s)
- Annegret Quade
- Department of Pediatrics, Division of Neuropediatrics and Social Pediatrics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Kevin Rostasy
- Department of Paediatric Neurology, Children's Hospital Datteln, Witten/Herdecke University, Witten, Germany
| | - Ronny Wickström
- Department of Women's and Children's Health, Division of Neuropediatrics, Karolinska Institute, Solna, Sweden
| | - Ömer Faruk Aydin
- Department of Pediatric Neurology, Medical Faculty, Ondokuz Mayis University, Turkey
| | - Stefano Sartori
- Department of Women's and Children's Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padua, Italy and Neuroimmunology Group, Paediatric Research Institute "Città della Speranza," Padova, Italy
| | - Margherita Nosadini
- Department of Women's and Children's Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padua, Italy and Neuroimmunology Group, Paediatric Research Institute "Città della Speranza," Padova, Italy
| | - Ellen Knierim
- Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Gerhard Kluger
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Vogtareuth, Germany.,Research Institute "Rehabilitation-Transition-Palliation," PMU Salzburg, Austria
| | - Rudolf Korinthenberg
- Department of Neuropediatrics and Muscular Disorders, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Burkhard Stüve
- Department of Neuropediatrics, Children's Hospital Siegen, Germany
| | - Stephan Waltz
- Neuropediatric Department, Children's Hospital Cologne, Germany
| | - Steffen Leiz
- Department of Pediatrics, Neuropediatrics, Klinikum Dritter Orden München - Nymphenburg, Germany
| | - Martin Häusler
- Department of Pediatrics, Division of Neuropediatrics and Social Pediatrics, Medical Faculty, RWTH Aachen University, Aachen, Germany
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10
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Kwok PL, Lai AYT, Lai BMH, Luk SY, Tang KYK, Wong WWC, Khoo JLS. Magnetic resonance imaging of disorders with white matter changes in children and adolescents: a pictorial essay. Pediatr Radiol 2023; 53:1188-1206. [PMID: 36625927 DOI: 10.1007/s00247-022-05580-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/15/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
White matter changes are seen in a spectrum of disorders in children and adolescents. Understanding their distribution and appearance helps to reach diagnoses in daily radiologic practice. This pictorial essay will outline the magnetic resonance imaging (MRI) appearances of diseases with white matter changes including demyelinating diseases, dysmyelinating disorders/leukodystrophies, infections, autoimmune diseases, vascular causes, mitochondrial disorders and neurocutaneous syndromes, along with a brief overview of clinical aspects of the diseases such as typical age of presentation, etiology, symptoms and signs and treatment options. This article highlights important features in common white matter diseases in children and adolescents.
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Affiliation(s)
- Po Lam Kwok
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, SAR, China.
| | - Alta Y T Lai
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, SAR, China
| | - Billy M H Lai
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Hong Kong, SAR, China
| | - Shiobhon Y Luk
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, SAR, China
| | - Kendrick Y K Tang
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, SAR, China
| | - Wendy W C Wong
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, SAR, China
| | - Jennifer L S Khoo
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, SAR, China
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11
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Abstract
Detection of autoantibodies against neurons and glia cells has brought about the early and specific diagnosis of autoimmune encephalitis in patients with variable neurological and psychiatric symptoms. Growing knowledge not only resulted in profound changes in treatment algorithms including immunotherapy but also in the understanding of disease mechanisms and etiological factors. The still increasing numbers of new autoantibodies calls for continuous updates on the state of the art in antibody diagnostics, frequencies of associated tumors and the clinical spectrum linked to each antibody, which can range from mood changes, cognitive impairment and epileptic seizures to abnormal movements, autonomic dysfunction and impaired levels of consciousness. This article summarizes the recent developments in the predominant clinical presentations of autoimmune encephalitis patients in imaging and cerebrospinal fluid diagnostics and also in prognostic markers, in the establishment of innovative immunotherapies, in the use of diagnostic pathways even before the results of the antibody tests are available and the understanding of the autoimmune etiology.
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12
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Zhao Y, Han B, Qin C, Shi X, Yun W, Wang M, Yuan B, Sun T, Wang H. Brain magnetic resonance imaging predictors in anti-N-methyl-D-aspartate receptor encephalitis. Ann Clin Transl Neurol 2022; 9:1974-1984. [PMID: 36314483 PMCID: PMC9735371 DOI: 10.1002/acn3.51690] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/18/2022] [Accepted: 10/20/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Brain magnetic resonance imaging (MRI) findings in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis are nonspecific and rarely have obvious associations with clinical characteristics and outcomes. This study aimed to comprehensively describe the MRI features of patients with NMDAR encephalitis, examine their associations with clinical characteristics, and evaluate their predictive power for disease recurrence and prognosis. METHODS We retrospectively extracted the clinical data and brain MRI findings of 144 patients with NMDAR encephalitis. Patients underwent a 2-year follow-up to assess disease outcomes. We evaluated the associations of brain MRI findings at the onset with clinical characteristics, recurrence, and prognosis. RESULTS Initial MRI showed typical abnormalities in 65 patients (45.1%); of these, 34 (29.3%) developed recurrence and 10 (9.4%) had poor prognosis (mRS ≥3). Binary logistic regression analyses revealed that insula abnormalities were associated with acute seizure (odds ratio [OR] = 3.048, 95% confidence interval [CI]: 1.026-9.060) and white matter lesions were associated with cognitive impairment (OR = 2.730, 95% CI: 1.096-6.799). Risk factors for a poor 2-year prognosis included a higher number of brain MRI abnormalities (OR = 1.573, 95% CI: 1.129-2.192) and intensive care unit (ICU) admissions (OR = 15.312, 95% CI: 1.684-139.198). The risk factors for 2-year recurrence included abnormalities of the thalamus (HR = 3.780, 95% CI: 1.642-8.699). INTERPRETATIONS Brain MRI features of patients with NMDAR encephalitis were associated with clinical manifestations, prognosis, and recurrence. Higher numbers of MRI abnormalities and ICU admissions were predictive of poor prognosis. Abnormalities of the thalamus constituted a recurrence-related risk factor.
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Affiliation(s)
- Ying‐Ying Zhao
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Bing Han
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Cui‐Hong Qin
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Xue‐Xiu Shi
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Wen‐Jing Yun
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Meng Wang
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Bo Yuan
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Tong‐Wen Sun
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Hai‐Xu Wang
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
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13
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Pointon T, Ward R, Yeshokumar A, Piquet A, Schreiner T, Kammeyer R. Evaluation of multiple consensus criteria for autoimmune encephalitis and temporal analysis of symptoms in a pediatric encephalitis cohort. Front Neurol 2022; 13:952317. [PMID: 36237630 PMCID: PMC9552833 DOI: 10.3389/fneur.2022.952317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the sensitivity and specificity of current criteria for the diagnosis of autoimmune encephalitis (AE) and the temporal onset of neuropsychiatric symptoms (NP) in a pediatric encephalitis cohort. Background Multiple criteria for AE have been developed, including the Graus and pediatric-focused Cellucci consensus criteria, and the Determining Etiology in Encephalitis (DEE) score for patients with encephalitis. Early identification and treatment of AE is crucial to improve outcomes, but this can be difficult given the frequent overlap of clinical presentation between AE and infectious encephalitis (IE). Design/methods A retrospective review was conducted of patients seen at our institution from 2000 to 2021 with a final diagnosis of AE or IE. These were narrowed through multiple exclusions to etiology-confirmed IE or antibody-positive/negative AE. Time of onset or results of all symptoms and diagnostics were recorded. Sensitivity and specificity of each criterion under various clinical scenarios were calculated over the first month after initial NP symptom onset. Results A total of 23 antibody-positive AE, 9 antibody-negative AE and 23 IE patients were included in final analysis. Under an idealized scenario with rapid initial diagnostic evaluations, the sensitivity for pediatric AE by day 28 after onset of NP symptoms approached 90% for both Cellucci and Graus criteria. Specificity within these 28 days was low without infectious testing results, increasing the greatest with rapid PCR testing and second with infectious antibody testing-reaching ~90% with both. A DEE score of 3 provided a specificity of 100% in identifying IE, but low sensitivity (29%). Symptoms were noted to cluster within several days of onset in IE, but in AE were spread out. Personality/behavioral change, speech change, affective disorder, and sleep disturbance were noted more often in AE, while fever, elevated C-reactive protein or CSF protein, and abnormal MRI-Brain occurred more often in IE. Conclusion In this study, we provide the first evaluation of the Cellucci criteria and the first validation of the DEE score in the differentiation of pediatric AE and IE. Further refinement of AE criteria is needed to improve early detection and treatment of pediatric AE.
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Affiliation(s)
- Tiffany Pointon
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ryan Ward
- School of Medicine, University of Colorado, Aurora, CO, United States
| | - Anusha Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Amanda Piquet
- Section of Neuroimmunology, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Teri Schreiner
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Neuroimmunology, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ryan Kammeyer
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Neuroimmunology, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
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Nguyen L, Yang JH, Goyal S, Irani N, Graves JS. A systematic review and quantitative synthesis of the long-term psychiatric sequelae of pediatric autoimmune encephalitis. J Affect Disord 2022; 308:449-457. [PMID: 35429531 DOI: 10.1016/j.jad.2022.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term neuropsychiatric sequelae of autoimmune encephalitis (AE) remain understudied, particularly in pediatric-onset AE. We aimed to synthesize the published data on ongoing psychiatric symptoms in pediatric-onset AE. METHODS The Pubmed, PyscINFO, Web of Science databases were searched from their inception years to August 23, 2021, and 29 studies were identified and analyzed. We also performed a quantitative synthesis of available patient data from the 29 studies combined with a cohort of anti-NMDA receptor (NMDAR) AE from our institution to examine the associations between acute treatment course and long-term psychiatric outcome. RESULTS At long-term follow up, 52.4% of the cases with pediatric-onset AE had any persistent symptom and 36.0% had at least one psychiatric symptom. Pooled data found that 36.3% of pediatric-onset anti-NMDAR AE had ongoing psychiatric symptoms. Using a univariate logistic regression analysis, we found that abnormal initial EEG, use of certain immunotherapies, and persistent cognitive impairments were associated with ongoing psychiatric symptoms. LIMITATIONS Limitations of the existing literature included a significant paucity of outcomes measured using consistent, objective methods. Limitations of the systematic review included the wide variability among the studies reviewed, which rendered a meta-analysis impossible and beyond the scope of the paper. CONCLUSION Chronic psychiatric and behavioral problems remain present in one-third of children months to years after onset of AE. Larger scaled prospective observational studies with a consistent standardized battery of testing are needed to examine impact of specific clinical features and immunotherapies on long-term mental health outcomes.
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Affiliation(s)
- Linda Nguyen
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA.
| | - Jennifer H Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Sajan Goyal
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Najin Irani
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA
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Watanabe Y, Sano F, Fukao T, Shimizu T, Sawanobori E, Kobayashi A, Fujioka K, Yagasaki H, Inukai T, Kaga Y. Arterial spin labeling perfusion imaging in an infant with anti-N-methyl-D-aspartate receptor encephalitis: A case report. Brain Dev 2022; 44:405-409. [PMID: 35346541 DOI: 10.1016/j.braindev.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/31/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an autoimmune encephalitis characterized by complex neuropsychiatric syndromes and the presence of cerebrospinal fluid (CSF) antibodies against NMDAR. The characteristics of anti-NMDAR encephalitis in children, particularly infants, are unclear due to difficulties in neurologic assessment such as psychiatric symptoms. Additionally, subtle or non-specific findings of conventional magnetic resonance imaging (MRI) make early diagnosis even more difficult. Herein, we present the first case of infant anti-NMDAR encephalitis in which perfusion imaging demonstrated marked abnormalities and the absence of conventional MRI findings. CASE PRESENTATION The patient was an 11-month-old boy who was admitted because of seizure and prolonged fever. He presented with involuntary movements of the mouth and tongue. Brain MRI showed no morphological abnormalities, but three-dimensional arterial spin labeling (ASL) perfusion imaging showed reduced blood flow in the left temporal and frontal regions and the right cerebellum. After that, a positive anti-NMDAR antibody test result was received. Despite treatment with IVIG and methylprednisolone, the involuntary movements and autonomic dysfunction gradually became more prominent. After rituximab administration, the clinical symptoms improved slightly, and follow-up MRI revealed diffuse brain atrophy and improvement in the balance of brain perfusion. CONCLUSIONS To the best of our knowledge, this is the first case report of infantile anti-NMDAR encephalitis in which cerebral blood flow was evaluated using three-dimensional ASL perfusion imaging. Indeed, our case, which showed abnormalities only in ASL perfusion imaging, suggests that CBF assessment could aid in the early diagnosis of anti-NMDAR encephalitis in infants.
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Affiliation(s)
- Yuriko Watanabe
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Fumikazu Sano
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan.
| | - Toshimichi Fukao
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tatsuya Shimizu
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Emi Sawanobori
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Anna Kobayashi
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kaoru Fujioka
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hideaki Yagasaki
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takeshi Inukai
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yoshimi Kaga
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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Sabanathan S, Abdel‐Mannan O, Mankad K, Siddiqui A, Das K, Carr L, Eltze C, Eyre M, Gadian J, Hemingway C, Kaliakatsos M, Kneen R, Krishnakumar D, Lynch B, Parida A, Rossor T, Taylor M, Wassmer E, Wright S, Lim M, Hacohen Y. Clinical features, investigations, and outcomes of pediatric limbic encephalitis: A multicenter study. Ann Clin Transl Neurol 2022; 9:67-78. [PMID: 35015932 PMCID: PMC8791799 DOI: 10.1002/acn3.51494] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To describe the clinical presentation, investigations, management, and disease course in pediatric autoimmune limbic encephalitis (LE). METHODS In this retrospective observational study, from the UK Childhood Neuroinflammatory Disease network, we identified children from six tertiary centers with LE <18 years old between 2008 and 2021. Clinical and paraclinical data were retrieved from medical records. RESULTS Twenty-five children fulfilling LE criteria were identified, with median age of 11 years (IQR 8, 14) and median follow-up of 24 months (IQR 18, 48). All children presented with seizures; 15/25 (60%) were admitted to intensive care. Neuroimaging demonstrated asymmetric mesial temporal changes in 8/25 (32%), and extra-limbic changes with claustrum involvement in 9/25 (38%). None were positive for LGI1/CASPR2 antibodies (Abs), 2/25 were positive for serum anti-NMDAR Abs, and 2/15 positive for anti-Hu Abs; one died from relapsing neuroblastoma. Two children had serum and CSF anti-GAD antibodies. Initial immune therapy included steroids in 23/25 (92%), intravenous immunoglobulin (IVIg) in 14/25 (56%), and plasma exchange in 7/25 (28%). The commonest second-line treatment was rituximab in 15/25 (60%). Median duration of hospital admission was 21 days (IQR 11, 30). At last follow-up, 13/25 (52%) had refractory seizures and 16/25 (64%) had memory impairment. Six children (24%) had modified Rankin Scale (mRS) scores ≥3. There was no significant difference in mRS, or long-term cognitive and epilepsy outcomes in those who received rituximab versus those who did not. INTERPRETATION A diagnosis of autoimmune LE was associated with significant morbidity and adverse outcomes in this pediatric cohort.
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Affiliation(s)
- Saraswathy Sabanathan
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
| | - Omar Abdel‐Mannan
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Kshitij Mankad
- Department of NeuroradiologyGreat Ormond Street Hospital for ChildrenLondon
| | - Ata Siddiqui
- Department of Neuroradiology, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
| | - Krishna Das
- Department of NeurophysiologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Lucinda Carr
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Christin Eltze
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Michael Eyre
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
- School of Biomedical Engineering & Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Jon Gadian
- Department of Paediatric NeurologyKing’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Cheryl Hemingway
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Marios Kaliakatsos
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Rachel Kneen
- Department of NeurologyAlder Hey Children’s NHS Foundation TrustLiverpoolUnited Kingdom
| | - Deepa Krishnakumar
- Department of Paediatric NeurologyAddenbrooke’s HospitalCambridgeUnited Kingdom
| | - Bryan Lynch
- Department of Paediatric NeurologyChildren’s University HospitalDublinIreland
| | - Amitav Parida
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
| | - Thomas Rossor
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Micheal Taylor
- Department of Paediatric NeurologyLeeds Children’s HospitalLeedsUnited Kingdom
| | - Evangeline Wassmer
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
- Aston Neuroscience Institute, College of Health and Life SciencesAston UniversityBirminghamUnited Kingdom
| | - Sukhvir Wright
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
- Aston Neuroscience Institute, College of Health and Life SciencesAston UniversityBirminghamUnited Kingdom
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
- King’s Health Partners Academic Health Science CentreLondonUnited Kingdom
| | - Yael Hacohen
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
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Bartels F, Lu A, Oertel FC, Finke C, Paul F, Chien C. Clinical and neuroimaging findings in MOGAD-MRI and OCT. Clin Exp Immunol 2021; 206:266-281. [PMID: 34152000 PMCID: PMC8561692 DOI: 10.1111/cei.13641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 12/16/2022] Open
Abstract
Myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) are rare in both children and adults, and have been recently suggested to be an autoimmune neuroinflammatory group of disorders that are different from aquaporin-4 autoantibody-associated neuromyelitis optica spectrum disorder and from classic multiple sclerosis. In-vivo imaging of the MOGAD patient central nervous system has shown some distinguishing features when evaluating magnetic resonance imaging of the brain, spinal cord and optic nerves, as well as retinal imaging using optical coherence tomography. In this review, we discuss key clinical and neuroimaging characteristics of paediatric and adult MOGAD. We describe how these imaging techniques may be used to study this group of disorders and discuss how image analysis methods have led to recent insights for consideration in future studies.
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Affiliation(s)
- Frederik Bartels
- Department of NeurologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin School of Mind and BrainBerlin Institute of Health at Charité – Universitätsmedizin Berlin andHumboldt‐Universität zu BerlinBerlinGermany
| | - Angelo Lu
- Humboldt‐Universität zu Berlin and Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Experimental and Clinical Research CenterCharité –Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinBerlinGermany
- NeuroCure Clinical Research CenterCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinHumboldt‐Universität zu BerlinBerlinGermany
| | - Frederike Cosima Oertel
- Humboldt‐Universität zu Berlin and Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Experimental and Clinical Research CenterCharité –Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinBerlinGermany
- NeuroCure Clinical Research CenterCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinHumboldt‐Universität zu BerlinBerlinGermany
| | - Carsten Finke
- Department of NeurologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin School of Mind and BrainBerlin Institute of Health at Charité – Universitätsmedizin Berlin andHumboldt‐Universität zu BerlinBerlinGermany
| | - Friedemann Paul
- Department of NeurologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Humboldt‐Universität zu Berlin and Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Experimental and Clinical Research CenterCharité –Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinBerlinGermany
- NeuroCure Clinical Research CenterCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinHumboldt‐Universität zu BerlinBerlinGermany
| | - Claudia Chien
- Humboldt‐Universität zu Berlin and Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Experimental and Clinical Research CenterCharité –Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinBerlinGermany
- NeuroCure Clinical Research CenterCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinHumboldt‐Universität zu BerlinBerlinGermany
- Department for Psychiatry and NeurosciencesCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität BerlinHumboldt‐Universität zu BerlinBerlinGermany
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18
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Jan S, Anilkumar AC. Atypical Brain MRI Findings in a Child With Delayed Diagnosis of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Cureus 2021; 13:e18103. [PMID: 34692314 PMCID: PMC8525688 DOI: 10.7759/cureus.18103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/05/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is the most common cause of autoimmune encephalitis in children with a wide spectrum of clinical presentation and MRI findings. A high index of suspicion is required to avoid a delay in treatment and long-term morbidity. We present a healthy two-year-old male who developed fever and viral prodrome symptoms that rapidly progressed to acute encephalopathy, status epilepticus, quadriparesis, and abnormal movements. Brain MRI showed symmetric involvement of bilateral insula, posterior part of basal ganglia, and thalami. The patient survived the acute phase with supportive therapy but ended up with a devastating neurologic sequela, including developmental delay, inability to communicate, dysphagia, quadriparesis, and cortical visual impairment. Anti-N-methyl-D-aspartate (anti-NMDA) immunoglobulin G (IgG) antibodies were negative in serum and cerebrospinal fluid (CSF). The patient underwent an extensive inflammatory, infectious, metabolic, and genetic workup, including a whole-exome sequence (WES) and mitochondrial panel, which was unremarkable. CSF studies were unremarkable. Repeated anti-NMDA IgG antibodies were positive in serum a year after the presentation. This presentation highlights the crucial role of early immunotherapy in suspected autoimmune encephalitis (AE) cases, even at a young age, to prevent devastating neurologic outcomes. Moreover, clinicians should not rely on antibody results to treat a suspected case of AE due to possible false-negative test results, and the majority of AE cases remain without known antibodies.
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Affiliation(s)
- Saber Jan
- Pediatrics, State University of New York Upstate Medical University, Syracuse, USA
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Banks SA, Sechi E, Flanagan EP. Autoimmune encephalopathies presenting as dementia of subacute onset and rapid progression. Ther Adv Neurol Disord 2021; 14:1756286421998906. [PMID: 33796145 PMCID: PMC7983436 DOI: 10.1177/1756286421998906] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
The terms autoimmune dementia and autoimmune encephalopathy may be used interchangeably; autoimmune dementia is used here to emphasize its consideration in young-onset dementia, dementia with a subacute onset, and rapidly progressive dementia. Given their potential for reversibility, it is important to distinguish the rare autoimmune dementias from the much more common neurodegenerative dementias. The presence of certain clinical features [e.g. facio-brachial dystonic seizures that accompany anti-leucine-rich-glioma-inactivated-1 (LGI1) encephalitis that can mimic myoclonus] can be a major clue to the diagnosis. When possible, objective assessment of cognition with bedside testing or neuropsychological testing is useful to determine the degree of abnormality and serve as a baseline from which immunotherapy response can be judged. Magnetic resonance imaging (MRI) head and cerebrospinal fluid (CSF) analysis are useful to assess for inflammation that can support an autoimmune etiology. Assessing for neural autoantibody diagnostic biomarkers in serum and CSF in those with suggestive features can help confirm the diagnosis and guide cancer search in paraneoplastic autoimmune dementia. However, broad screening for neural antibodies in elderly patients with an insidious dementia is not recommended. Moreover, there are pitfalls to antibody testing that should be recognized and the high frequency of some antibodies in the general population limit their diagnostic utility [e.g., anti-thyroid peroxidase (TPO) antibodies]. Once the diagnosis is confirmed, both acute and maintenance immunotherapy can be utilized and treatment choice varies depending on the accompanying neural antibody present and the presence or absence of cancer. The target of the neural antibody biomarker may help predict treatment response and prognosis, with antibodies to cell-surface or synaptic antigens more responsive to immunotherapy and yielding a better overall prognosis than those with antibodies to intracellular targets. Neurologists should be aware that autoimmune dementias and encephalopathies are increasingly recognized in novel settings, including post herpes virus encephalitis and following immune-checkpoint inhibitor use.
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Affiliation(s)
| | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Eoin P Flanagan
- Departments of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
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Yang S, Yang L, Liao H, Chen M, Feng M, Liu S, Tan L. Clinical Characteristics and Prognostic Factors of Children With Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Front Pediatr 2021; 9:605042. [PMID: 33968840 PMCID: PMC8100243 DOI: 10.3389/fped.2021.605042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/23/2021] [Indexed: 12/24/2022] Open
Abstract
Objective: Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is the most common autoimmune encephalitis in pediatric patients. The study aimed to investigate the clinical characteristics and prognostic factors of anti-NMDA receptor encephalitis in children in South China. Methods: This was a retrospective study of children diagnosed with anti-NMDA receptor encephalitis between 01/2014 and 12/2017 at Hunan Children's Hospital. Laboratory, brain magnetic resonance imaging (MRI), and electroencephalography data were collected. The short-term (6-month) outcomes were assessed using the Liverpool score by the same pediatric neurologist. The children were divided into good (scores 4-5) and poor (score <3) clinical outcomes. Results: Among the 51 patients, 21 (41.2%) were male. The most common clinical symptoms were dyskinesia (88.2%), personality change (84.3%), seizure (82.4%), and cognitive disorder (31.4%). Two were transferred to another hospital, 45 (91.8%) received intravenous immunoglobulins, 41 (83.7%) received methylprednisolone, and 8 (16.3%) received plasma exchange. Eight (16.3%) received rituximab for second-line treatment, six after intravenous immunoglobulin and methylprednisolone treatment, and two after plasma exchange therapy failed. Seven were lost to follow-up. The short-term outcome was good in 23 patients. Cognitive disorder [odds ratio (OR): 23.97, 95% confidence interval (CI): 1.12-513.30, P = 0.042) and abnormal brain MRI (OR: 14.29, 95% CI: 1.36-150.10, P = 0.027] were independently associated with a poor short-term outcome after adjustment for age, GCS, and rituximab use. Conclusions: MRI abnormalities and cognitive disorders are independently associated with poor short-term outcomes in children with anti-NMDA receptor encephalitis. The use of rituximab is not associated with the 6-month outcomes.
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Affiliation(s)
- Sai Yang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Liming Yang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Hongmei Liao
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Mei Chen
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Mei Feng
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Shulei Liu
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Lihong Tan
- Department of Neurology, Hunan Children's Hospital, Changsha, China
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21
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Baumann M, Bartels F, Finke C, Adamsbaum C, Hacohen Y, Rostásy K. E.U. paediatric MOG consortium consensus: Part 2 - Neuroimaging features of paediatric myelin oligodendrocyte glycoprotein antibody-associated disorders. Eur J Paediatr Neurol 2020; 29:14-21. [PMID: 33158737 DOI: 10.1016/j.ejpn.2020.10.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/03/2020] [Accepted: 10/08/2020] [Indexed: 12/31/2022]
Abstract
Imaging plays a crucial role in differentiating the spectrum of paediatric acquired demyelinating syndromes (ADS), which apart from myelin oligodendrocyte glycoprotein antibody associated disorders (MOGAD) includes paediatric multiple sclerosis (MS), aquaporin-4 antibody neuromyelitis optica spectrum disorders (NMOSD) and unclassified patients with both monophasic and relapsing ADS. In contrast to the imaging characteristics of children with MS, children with MOGAD present with diverse imaging patterns which correlate with the main demyelinating phenotypes as well as age at presentation. In this review we describe the common neuroradiological features of children with MOGAD such as acute disseminated encephalomyelitis, optic neuritis, transverse myelitis, AQP4 negative NMOSD. In addition, we report newly recognized presentations also associated with MOG-ab such as the 'leukodystophy-like' phenotype and autoimmune encephalitis with predominant involvement of cortical and deep grey matter structures. We further delineate the features, which may help to distinguish MOGAD from other ADS and discuss the future role of MR-imaging in regards to treatment decisions and prognosis in children with MOGAD. Finally, we propose an MRI protocol for routine examination and discuss new imaging techniques, which may help to better understand the neurobiology of MOGAD.
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Affiliation(s)
- Matthias Baumann
- Division of Paediatric Neurology, Department of Paediatrics I, Medical University of Innsbruck, Austria.
| | - Frederik Bartels
- Department of Neurology, Charité - Universitätsmedizin Berlin / Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité - Universitätsmedizin Berlin / Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Germany
| | - Catherine Adamsbaum
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Paediatric Radiology Department, Le Kremlin-Bicêtre, France
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology / Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Kevin Rostásy
- Department of Paediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Germany
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22
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Choi J. Commentary on "Autoimmune encephalitis and epilepsy: evolving definition and clinical spectrum". Clin Exp Pediatr 2020; 63:310-311. [PMID: 32746531 PMCID: PMC7402983 DOI: 10.3345/cep.2020.00353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/27/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Jieun Choi
- Department of Pediatrics, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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