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Wei M, Bannout F, Dastjerdi M, Phan C, Batarseh S, Guo X, Baker N. Immunotherapy in a case of low titre GAD65 antibody-associated spectrum neurological disorders. BMJ Case Rep 2024; 17:e260503. [PMID: 38871638 DOI: 10.1136/bcr-2024-260503] [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] [Indexed: 06/15/2024] Open
Abstract
We present a rare case of low titre GAD65 antibody-associated autoimmune encephalitis and status epilepticus in a young woman. She initially presented with left arm dystonic movements, contractures and status epilepticus. Due to the concern of autoimmune encephalitis and seizures, the patient received intravenous immunoglobulin empirically. After the detection of low serum GAD65 antibodies, the patient underwent immunomodulation therapy with significant improvement. This case demonstrated that in autoimmune encephalitis, it is important to monitor serum GAD65 antibodies levels and consider immunotherapy, despite mildly elevated serum levels. The patient's history of left arm dystonic movements without impaired awareness may have been due to limb dystonia, a presenting symptom of stiff person syndrome (SPS), despite SPS more commonly affecting axial muscles. This case further demonstrates that GAD65 antibody-related syndromes can manifest with different neurological phenotypes including co-occurrence of epilepsy with possible focal SPS despite low GAD65 antibodies titres.
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Affiliation(s)
- Miao Wei
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Firas Bannout
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Mohammad Dastjerdi
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Cattien Phan
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Sanad Batarseh
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Xiaofan Guo
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Nancy Baker
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
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Oliger A, Nerison C, Tan H, Raslan A, Ernst L, Datta P, Kellogg M. Responsive neurostimulation as a therapy for epilepsy following new-onset refractory status epilepticus: Case series and review of the literature. Clin Neurophysiol 2024; 162:151-158. [PMID: 38640819 DOI: 10.1016/j.clinph.2024.03.032] [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: 09/06/2023] [Revised: 03/07/2024] [Accepted: 03/24/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To report clinical outcomes of patients who presented with new-onset refractory status epilepticus (NORSE), developed drug-resistant epilepsy (DRE), and were treated with responsive neurostimulation (RNS). METHODS We performed a retrospective review of patients implanted with RNS at our institution and identified three who originally presented with NORSE. Through chart review, we retrieved objective and subjective information related to their presentation, workup, and outcomes including patient-reported seizure frequency. We reviewed electrocorticography (ECoG) data to estimate seizure burden at 3, 6, 12, and 24 months following RNS implantation. We performed a review of literature concerning neurostimulation in NORSE. RESULTS Use of RNS to treat DRE following NORSE was associated with reduced seizure burden and informed care by differentiating epileptic from non-epileptic events. CONCLUSIONS Our single-center experience of three cases suggests that RNS is a safe and potentially effective treatment for DRE following NORSE. SIGNIFICANCE This article reports outcomes of the largest case series of NORSE patients treated with RNS. Since patients with NORSE are at high risk of adverse neuropsychiatric and cognitive sequelae beyond seizures, a unique strength of RNS over other surgical options is the ability to distinguish ictal or peri-ictal from non-epileptic events.
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Affiliation(s)
- Audrey Oliger
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA.
| | - Caleb Nerison
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Hao Tan
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Ahmed Raslan
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Lia Ernst
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Proleta Datta
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Marissa Kellogg
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
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Smith KM, Budhram A, Geis C, McKeon A, Steriade C, Stredny CM, Titulaer MJ, Britton JW. Autoimmune-associated seizure disorders. Epileptic Disord 2024. [PMID: 38818801 DOI: 10.1002/epd2.20231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024]
Abstract
With the discovery of an expanding number of neural autoantibodies, autoimmune etiologies of seizures have been increasingly recognized. Clinical phenotypes have been identified in association with specific underlying antibodies, allowing an earlier diagnosis. These phenotypes include faciobrachial dystonic seizures with LGI1 encephalitis, neuropsychiatric presentations associated with movement disorders and seizures in NMDA-receptor encephalitis, and chronic temporal lobe epilepsy in GAD65 neurologic autoimmunity. Prompt recognition of these disorders is important, as some of them are highly responsive to immunotherapy. The response to immunotherapy is highest in patients with encephalitis secondary to antibodies targeting cell surface synaptic antigens. However, the response is less effective in conditions involving antibodies binding intracellular antigens or in Rasmussen syndrome, which are predominantly mediated by cytotoxic T-cell processes that are associated with irreversible cellular destruction. Autoimmune encephalitides also may have a paraneoplastic etiology, further emphasizing the importance of recognizing these disorders. Finally, autoimmune processes and responses to novel immunotherapies have been reported in new-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES), warranting their inclusion in any current review of autoimmune-associated seizure disorders.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Christian Geis
- Department of Neurology and Section Translational Neuroimmunology, Jena University Hospital, Jena, Germany
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, New York, New York, USA
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
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4
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Zuckerman DA, Beaudreault CP, Muh CR, McGoldrick PE, Wolf SM. Myasthenia gravis in a pediatric patient with Lennox-Gastaut syndrome following responsive neurostimulation device implantation: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23334. [PMID: 38011695 PMCID: PMC10684061 DOI: 10.3171/case23334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disorder in which the postsynaptic acetylcholine receptor of the neuromuscular junction is destroyed by autoantibodies. The authors report a case of MG in a pediatric patient who also suffered from Lennox-Gastaut syndrome (LGS) and is one of a limited number of pediatric patients who have undergone placement of a responsive neurostimulation (RNS) device (NeuroPace). OBSERVATIONS A 17-year-old female underwent placement of an RNS device for drug-resistant epilepsy in the setting of LGS. Five months after device placement, the patient began experiencing intermittent slurred speech, fatigue, and muscle weakness. Initially, the symptoms were attributed to increased seizure activity and/or medication side effects. However, despite changing medications and RNS settings, no improvements occurred. Her antiacetylcholine receptor antibodies measured 62.50 nmol/L, consistent with a diagnosis of MG. The patient was then prescribed pyridostigmine and underwent a thymectomy, which alleviated most of her symptoms. LESSONS The authors share the cautionary tale of a case of MG in a pediatric patient who was treated with RNS for intractable epilepsy associated with LGS. Although slurred speech, fatigue, muscle weakness, and other symptoms might stem from increased seizure activity and/or medication side effects, they could also be due to MG development.
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Affiliation(s)
| | | | - Carrie R Muh
- 1New York Medical College, Valhalla, New York
- 2Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Patricia E McGoldrick
- 1New York Medical College, Valhalla, New York
- 3Department of Pediatrics, Division of Pediatric Neurology, Maria Fareri Children's Hospital, Valhalla, New York; and
- 4Boston Children's Hospital Physicians, Hawthorne, New York
| | - Steven M Wolf
- 1New York Medical College, Valhalla, New York
- 3Department of Pediatrics, Division of Pediatric Neurology, Maria Fareri Children's Hospital, Valhalla, New York; and
- 4Boston Children's Hospital Physicians, Hawthorne, New York
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5
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Valinčiūtė J, Jucevičiūtė N, Balnytė R, Jurkevičienė G, Gelžinienė G. GAD65 Antibody-Associated Epilepsy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1135. [PMID: 37374339 DOI: 10.3390/medicina59061135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Autoimmune processes are an increasingly recognized cause of seizures. Antibodies against neuronal surface antigens are implicated in the development of acute symptomatic seizures secondary to autoimmune encephalitis, whereas antibodies against intracellular antigens (anti-glutamic acid decarboxylase (GAD) and onconeural antibodies) are found in cases of autoimmune-associated epilepsy (AAE). AAE is described as isolated drug-resistant epilepsy without any specific magnetic resonance imaging (MRI) or cerebrospinal fluid changes and with a very limited response to immunotherapy. We present a clinical case and a literature review on autoimmune-associated epilepsy to increase awareness of this disease and illustrate its complexity. This is a clinical case of a female with a history of refractory focal epilepsy. The patient had been given several trials of multiple antiepileptic drugs and their combinations without any clear effect. Multiple evaluations including brain MRI, PET, and interictal and ictal electroencephalograms were performed. An APE2 score was calculated with a result of 4 and, in the presence of anti-GAD65 antibodies in the serum, the diagnosis of AAE was confirmed. There was no effect after five sessions of plasma exchange; however, after a course of intravenous immunoglobulin, a positive but temporary clinical effect was noticed: anti-GAD65 levels initially decreased but rebounded to previous levels 6 months later.
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Affiliation(s)
- Justina Valinčiūtė
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Neringa Jucevičiūtė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Renata Balnytė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Giedrė Jurkevičienė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Giedrė Gelžinienė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
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Seizures, Epilepsy, and NORSE Secondary to Autoimmune Encephalitis: A Practical Guide for Clinicians. Biomedicines 2022; 11:biomedicines11010044. [PMID: 36672553 PMCID: PMC9855825 DOI: 10.3390/biomedicines11010044] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
The most recent International League Against Epilepsy (ILAE) classification has included "immune etiology" along with other well-known causes of epilepsy. This was possible thanks to the progress in detection of pathogenic neural antibodies (Abs) in a subset of patients, and resulted in an increased interest in identifying potentially treatable causes of otherwise refractory seizures. Most autoimmune encephalitides (AE) present with seizures, but only a minority of cases evolve to long-term epilepsy. The risk of epilepsy is higher for patients harboring Abs targeting intracellular antigens (T cell-mediated and mostly paraneoplastic, such as Hu, CV2/CRMP5, Ma2, GAD65 Abs), compared with patients with neuronal surface Abs (antibody-mediated and less frequently paraneoplastic, such as NMDAR, GABAbR, LGI1, CASPR2 Abs). To consider these aspects, conceptual definitions for two entities were provided: acute symptomatic seizures secondary to AE, and autoimmune-associated epilepsy, which reflect the different pathophysiology and prognoses. Through this manuscript, we provide an up-to-date review on the current state of knowledge concerning diagnosis and management of patients with Ab-mediated encephalitis and associated epilepsy. Special emphasis is placed on clinical aspects, such as brain magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) specificities, electroencephalographic (EEG) findings, cancer screening and suggestions for a rational therapeutic approach.
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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Chen B, Lundstrom BN, Crepeau AZ, Dacpano L, Lopez-Chiriboga AS, Tatum WO, Freund B, Feyissa AM. Brain responsive neurostimulation device safety and effectiveness in patients with drug-resistant autoimmune-associated epilepsy. Epilepsy Res 2022; 184:106974. [DOI: 10.1016/j.eplepsyres.2022.106974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/23/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
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Madkhali MA, Hao JK, Khan MS, Sharma H, Jaume A, Tiwari A, Imam S, Jaume JC. Intractable Seizures and Limbic Encephalitis, Unaccounted Complications of Type 1 Diabetes Autoimmunity. J Endocr Soc 2022; 6:bvab188. [PMID: 35128296 PMCID: PMC8807154 DOI: 10.1210/jendso/bvab188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Glutamic acid decarboxylase 65kD autoantibody (GAD65Ab) is frequently detected in patients with refractory epilepsy and stiff person syndrome. In contrast to T1D, the pathological role of GAD65Ab in neurological disorders is still debatable. As a result, the implementation of possible immunotherapy is usually delayed. This report presents 2 cases of GAD65Ab-associated brain autoimmunity and their different management. We present clinical data and discuss management based on available evidence in the reviewed literature. Both cases presented with acute on chronic neurological symptoms and were GAD65Ab positive. Case 1, a 30-year-old man with a history of early-onset type 1 diabetes mellitus at 14 months, followed by cryptogenic temporal epilepsy at 11 years of age, presented with intractable seizures. Case 2, a 48-year-old woman, presented with a history of recurrent severe headaches, cognitive impairment, decreased memory, and behavioral symptoms. GAD65Ab was detected in both patients’ sera. Cerebrospinal fluid GAD65Ab was only checked and positive in case 1. Case 2 was diagnosed with limbic encephalitis, treated with immunotherapy, and showed a remarkable clinical improvement. Case 1 with refractory epilepsy failed multiple antiepileptic drugs and responsive-stimulator system treatments. He was finally diagnosed with autoimmune epilepsy. The delay in diagnosis resulted in a lost opportunity for early immunotherapy. In conclusion, autoantibody screening and early initiation of immunotherapy should be considered to manage GAD65Ab-associated neurological disorders.
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Affiliation(s)
- Mohammed A Madkhali
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Jazan University, Jazan, Jizan, Saudi Arabia
| | - Jenifer-Kris Hao
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Mohammad Saud Khan
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Cardiology, University of Kentucky at Bowling Green, Bowling Green, KY
| | - Himani Sharma
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Alexa Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Abhinav Tiwari
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Shahnawaz Imam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Juan Carlos Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
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Levite M, Goldberg H. Autoimmune Epilepsy - Novel Multidisciplinary Analysis, Discoveries and Insights. Front Immunol 2022; 12:762743. [PMID: 35095841 PMCID: PMC8790247 DOI: 10.3389/fimmu.2021.762743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Epilepsy affects ~50 million people. In ~30% of patients the etiology is unknown, and ~30% are unresponsive to anti-epileptic drugs. Intractable epilepsy often leads to multiple seizures daily or weekly, lasting for years, and accompanied by cognitive, behavioral, and psychiatric problems. This multidisciplinary scientific (not clinical) 'Perspective' article discusses Autoimmune Epilepsy from immunological, neurological and basic-science angles. The article includes summaries and novel discoveries, ideas, insights and recommendations. We summarize the characteristic features of the respective antigens, and the pathological activity in vitro and in animal models of autoimmune antibodies to: Glutamate/AMPA-GluR3, Glutamate/NMDA-NR1, Glutamate/NMDA-NR2, GAD-65, GABA-R, GLY-R, VGKC, LGI1, CASPR2, and β2 GP1, found in subpopulations of epilepsy patients. Glutamate receptor antibodies: AMPA-GluR3B peptide antibodies, seem so far as the most exclusive and pathogenic autoimmune antibodies in Autoimmune Epilepsy. They kill neural cells by three mechanisms: excitotoxicity, Reactive-Oxygen-Species, and complement-fixation, and induce and/or facilitate brain damage, seizures, and behavioral impairments. In this article we raise and discuss many more topics and new insights related to Autoimmune Epilepsy. 1. Few autoimmune antibodies tilt the balance between excitatory Glutamate and inhibitory GABA, thereby promoting neuropathology and epilepsy; 2. Many autoantigens are synaptic, and have extracellular domains. These features increase the likelihood of autoimmunity against them, and the ease with which autoimmune antibodies can reach and harm these self-proteins. 3. Several autoantigens have 'frenetic character'- undergoing dynamic changes that can increase their antigenicity; 4. The mRNAs of the autoantigens are widely expressed in multiple organs outside the brain. If translated by default to proteins, broad spectrum detrimental autoimmunity is expected; 5. The autoimmunity can precede seizures, cause them, and be detrimental whether primary or epiphenomenon; 6. Some autoimmune antibodies induce, and associate with, cognitive, behavioral and psychiatric impairments; 7. There are evidences for epitope spreading in Autoimmune Epilepsy; 8. T cells have different 'faces' in the brain, and in Autoimmune Epilepsy: Normal T cells are needed for the healthy brain. Normal T cells are damaged by autoimmune antibodies to Glutamate/AMPA GluR3, which they express, and maybe by additional autoantibodies to: Dopamine-R, GABA-R, Ach-R, Serotonin-R, and Adrenergic-R, present in various neurological diseases (summarized herein), since T cells express all these Neurotransmitter receptors. However, autoimmune and/or cytotoxic T cells damage the brain; 9. The HLA molecules are important for normal brain function. The HLA haplotype can confer susceptibility or protection from Autoimmune Epilepsy; 10. There are several therapeutic strategies for Autoimmune Epilepsy.
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Affiliation(s)
- Mia Levite
- Faculty of Medicine, The Hebrew University, Jerusalem, Israel
- Goldyne Savad Institute of Gene Therapy, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Hadassa Goldberg
- Epilepsy Center, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Chen SH, O'Dea PK, Sianati B, Benavides DR. Role of responsive neurostimulation and immunotherapy in refractory epilepsy due to autoimmune encephalitis: A case report. Front Neurol 2022; 13:1028290. [PMID: 36408512 PMCID: PMC9666681 DOI: 10.3389/fneur.2022.1028290] [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: 08/25/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Autoimmune encephalitis (AE) frequently presents with seizures in the acute setting. Seizures are often refractory to anti-seizure medications (ASM) but have been shown to be responsive to immunomodulatory therapies. A subset of patients with AE continues to have refractory epilepsy, recently named "autoimmune-associated epilepsy (AAE)," for years after the acute AE presentation. Optimal treatment for AAE has not been determined. Furthermore, the efficacy of neuromodulation and immunotherapy has not been well established in AAE. Here, we report a patient with probable autoantibody negative AE who initially presented with new onset refractory status epilepticus (NORSE). After his acute presentation, he continued to have frequent seizures that were refractory to four ASMs at therapeutic doses. A responsive neurostimulation (RNS®, NeuroPace) system was implanted for diagnostic and therapeutic purposes, with minimal change in seizure frequency. Due to continued frequent seizures despite ASMs and neurostimulation, he underwent a trial of immunotherapy consisting of high-dose intravenous (IV) corticosteroids and intravenous immunoglobulin (IVIG). Despite the addition of immunotherapy to his treatment regimen, the patient experienced no significant clinical or electrographic change in seizure frequency. This case does not support the use of immunotherapy for treatment of AAE and illustrates the need for consensus guidelines in the management of patients with AAE. Further, the use of electrocorticography (ECoG) data provided an objective surrogate measure of seizure frequency; this may support the role for early neuromodulation in the management of AAE.
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Affiliation(s)
- Stephanie H Chen
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Pamela K O'Dea
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Bahareh Sianati
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - David R Benavides
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
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Abstract
Three neuromodulation therapies, all using implanted device and electrodes, have been
approved to treat adults with drug-resistant focal epilepsy, namely, the vagus nerve
stimulation in 1995, deep brain stimulation of the anterior nucleus of the thalamus
(ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2014.
Indications for VNS have more recently extended to children down to age of 4. Limited or
anecdotal data are available in other epilepsy syndromes and refractory/super-refractory
status epilepticus. Overall, neuromodulation therapies are palliative, with only a
minority of patients achieving long-term seizure freedom, justifying favoring such
treatments in patients who are not good candidates for curative epilepsy surgery. About
half of patients implanted with VNS, ANT-DBS, and RNS have 50% or greater reduction in
seizures, with long-term data suggesting increased efficacy over time. Besides their
impact on seizure frequency, neuromodulation therapies are associated with various
benefits and drawbacks in comparison to antiseizure drugs. Yet, we lack high-level
evidence to best position each neuromodulation therapy in the treatment pathways of
persons with difficult-to-treat epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lara E. Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Rao VR. Chronic electroencephalography in epilepsy with a responsive neurostimulation device: current status and future prospects. Expert Rev Med Devices 2021; 18:1093-1105. [PMID: 34696676 DOI: 10.1080/17434440.2021.1994388] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Implanted neurostimulation devices are gaining traction as therapeutic options for people with certain forms of drug-resistant focal epilepsy. Some of these devices enable chronic electroencephalography (cEEG), which offers views of the dynamics of brain activity in epilepsy over unprecedented time horizons. AREAS COVERED This review focuses on clinical insights and basic neuroscience discoveries enabled by analyses of cEEG from an exemplar device, the NeuroPace RNS® System. Applications of RNS cEEG covered here include counting and lateralizing seizures, quantifying medication response, characterizing spells, forecasting seizures, and exploring mechanisms of cognition. Limitations of the RNS System are discussed in the context of next-generation devices in development. EXPERT OPINION The wide temporal lens of cEEG helps capture the dynamism of epilepsy, revealing phenomena that cannot be appreciated with short duration recordings. The RNS System is a vanguard device whose diagnostic utility rivals its therapeutic benefits, but emerging minimally invasive devices, including those with subscalp recording electrodes, promise to be more applicable within a broad population of people with epilepsy. Epileptology is on the precipice of a paradigm shift in which cEEG is a standard part of diagnostic evaluations and clinical management is predicated on quantitative observations integrated over long timescales.
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Affiliation(s)
- Vikram R Rao
- Associate Professor of Clinical Neurology, Chief, Epilepsy Division, Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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Chen B, Lopez Chiriboga AS, Sirven JI, Feyissa AM. Autoimmune Encephalitis-Related Seizures and Epilepsy: Diagnostic and Therapeutic Approaches. Mayo Clin Proc 2021; 96:2029-2039. [PMID: 34353466 DOI: 10.1016/j.mayocp.2021.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Baibing Chen
- Department of Neurology, Mayo Clinic, Jacksonville, FL
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Husari KS, Cervenka MC. Ketogenic Diet Therapy for the Treatment of Post-encephalitic and Autoimmune-Associated Epilepsies. Front Neurol 2021; 12:624202. [PMID: 34220664 PMCID: PMC8242936 DOI: 10.3389/fneur.2021.624202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/19/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction: Acute Encephalitis is associated with a high risk of acute symptomatic seizures, status epilepticus, and remote symptomatic epilepsy. Ketogenic diet therapies (KDT) have been established as a feasible and safe adjunctive management of refractory- and super-refractory status epilepticus. However, the role of KDT in the chronic management of Post-encephalitic epilepsy (PE) and autoimmune-associated epilepsy (AE) is unknown. This study aims to investigate the use of KDT in patients with PE and AE. Methods: A retrospective single-center case series examining adult patients with PE and AE treated with the modified Atkins diet (MAD), a KDT commonly used by adults with drug-resistant epilepsy. Results: Ten patients with PE and AE who were treated with adjunctive MAD were included. Four patients had either confirmed or presumed viral encephalitis, five patients had seronegative AE, and one patient had GAD65 AE. The median latency between starting MAD and onset of encephalitis was 6 years (IQR: 1–10). The median duration of MAD was 10 months (IQR: 3.75–36). Three patients (30%) became seizure-free, one patient (10%) achieved 90% seizure freedom, and three patients (30%) achieved a 50–75% reduction in their baseline seizure frequency, while three patients (30%) had no significant benefit. Overall, seven patients (70%) achieved ≥50% seizure reduction. Conclusion: In addition to its established role in the treatment of RSE, KDT may be a safe and feasible option for the treatment of chronic PE and AE, particularly in those with prior history of SE. Prospective studies are warranted to explore the efficacy of KDT in management of patients with PE and AE.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Johns Hopkins Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, United States
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, United States
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16
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Conde-Blanco E, Pascual-Diaz S, Carreño M, Muñoz-Moreno E, Pariente JC, Boget T, Manzanares I, Donaire A, Centeno M, Graus F, Bargalló N. Volumetric and shape analysis of the hippocampus in temporal lobe epilepsy with GAD65 antibodies compared with non-immune epilepsy. Sci Rep 2021; 11:10199. [PMID: 33986308 PMCID: PMC8119423 DOI: 10.1038/s41598-021-89010-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/15/2021] [Indexed: 11/09/2022] Open
Abstract
Glutamic acid decarboxylase 65 antibodies (anti-GAD65) have been found in patients with late-onset chronic temporal lobe epilepsy (TLE). No prior neuroimaging studies have addressed how they affect hippocampal volume and shape and how they relate to cognitive abnormalities. We aimed to investigate both brain structure and function in patients with isolated TLE and high anti-GAD65 levels (RIA ≥ 2000 U/ml) compared to 8 non-immune mesial TLE (niTLE) and 8 healthy controls (HC). Hippocampal subfield volume properties were correlated with the duration of the disease and cognitive test scores. The affected hippocampus of GAD-TLE patients showed no volume changes to matched HC whereas niTLE volumes were significantly smaller. Epilepsy duration in GAD-TLE patients correlated negatively with volumes in the presubiculum, subiculum, CA1, CA2-3, CA4, molecular layer and granule cell-molecular layer of the dentate nucleus. We found differences by advanced vertex-wise shape analysis in the anterior hippocampus of the left GAD-TLE compared to HC whereas left niTLE showed bilateral posterior hippocampus deformation. Verbal deficits were similar in GAD-TLE and niTLE but did not correlate to volume changes. These data might suggest a distinct expression of hippocampal structural and functional abnormalities based on the immune response.
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Affiliation(s)
- Estefanía Conde-Blanco
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain.
| | | | - Mar Carreño
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | | | | | - Teresa Boget
- Epilepsy Program, Neuropsychology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Isabel Manzanares
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - Antonio Donaire
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - María Centeno
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - Francesc Graus
- Clinical and Experimental Neuroimmunology Research Team of IDIBAPS, Barcelona, Spain
| | - Nuria Bargalló
- Magnetic Resonance Imaging Core Facility, IDIBAPS, Barcelona, Spain.,Epilepsy Program, Neuroradiology Section, Radiology Department, Center of Image Diagnosis (CDIC), Barcelona, Spain
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Brain-responsive neurostimulation in adult-onset rasmussen's encephalitis. Epilepsy Behav Rep 2021; 15:100445. [PMID: 33912823 PMCID: PMC8063734 DOI: 10.1016/j.ebr.2021.100445] [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] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/24/2020] [Accepted: 01/20/2021] [Indexed: 12/21/2022] Open
Abstract
Treatment of Rasmussen’s encephalitis in adults is limted. Hemispherotomy is rarely performed in adults due to high morbidity. Immunotherapy in Adult onset rasmussen’s is rarely efficacious alone to control seizures. RNS system could be a therapeutic option for Rasmussen’s encephalitis patients with drug-resistant epilepsy.
Epilepsy associated with Rasmussen’s encephalitis (RE) is highly resistant to standard therapy and continues to present a therapeutic challenge. While epilepsy surgery remains the most effective management for patients with drug-resistant focal epilepsy and RE, hemispherotomy may debilitating consequences on adult patients. Here we present the outcome of a 32-year-old woman with adult-onset Rasmussen’s, who was treated with brain-responsive neurostimulation (RNS) after failure of several immunotherapeutic and anti-seizure medications.
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