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Bauer T, von Wrede RD, Pujar S, Rácz A, Hoppe C, Baumgartner T, Varadkar S, Held NR, Reiter JT, Enders S, David B, Prillwitz CC, Brugues M, Keil VCW, Jeub M, Borger V, Sander JW, Kunz WS, Radbruch A, Weber B, Helmstaedter C, Vatter H, Baldeweg T, Becker AJ, Cross JH, Surges R, Rüber T. Rasmussen's encephalitis: structural, functional, and clinical correlates of contralesional epileptiform activity. J Neurol 2024:10.1007/s00415-024-12607-7. [PMID: 39138652 DOI: 10.1007/s00415-024-12607-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 07/19/2024] [Accepted: 07/21/2024] [Indexed: 08/15/2024]
Abstract
Progressive inflammation of one hemisphere characterises Rasmussen's encephalitis (RE), but contralesional epileptiform activity has been repeatedly reported. We aimed to quantify contralesional epileptiform activity in RE and uncover its functional and structural underpinnings. We retrospectively ascertained people with RE treated between 2000 and 2018 at a tertiary centre (Centre 1) and reviewed all available EEG datasets. The temporal occurrence of preoperative contralesional epileptiform activity (interictal/ictal) was evaluated using mixed-effects logistic regression. Cases with/without contralesional epileptiform activity were compared for cognition, inflammation (ipsilesional brain biopsies), and MRI (cortical and fixel-based morphometry). EEG findings were validated in a second cohort treated at another tertiary centre (Centre 2) between 1995 and 2020. We included 127 people with RE and 687 EEG samples. Preoperatively, contralesional epileptiform activity was seen in 30/68 (44%, Centre 1) and 8/59 (14%, Centre 2). In both cohorts, this activity was associated with younger onset age (OR = 0.9; 95% CI 0.83-0.97; P = 0.006). At centre 1, contralesional epileptiform activity was associated with contralesional MRI alterations, lower intelligence (OR = 5.19; 95% CI 1.28-21.08; P = 0.021), and impaired verbal memory (OR = 10.29; 95% CI 1.97-53.85; P = 0.006). After hemispherotomy, 11/17 (65%, Centre 1) and 28/37 (76%, Centre 2) were seizure-free. Contralesional epileptiform activity was persistent postoperatively in 6/12 (50%, Centre 1) and 2/34 (6%, Centre 2). Preoperative contralesional epileptiform activity reduced the chance of postoperative seizure freedom in both cohorts (OR = 0.69; 95% CI 0.50-0.95; P = 0.029). Our findings question the concept of strict unilaterality of RE and provide the evidence of contralesional epileptiform activity as a possible EEG predictor for persisting postoperative seizures.
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Affiliation(s)
- Tobias Bauer
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Suresh Pujar
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Attila Rácz
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Christian Hoppe
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Sophia Varadkar
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
- Developmental Neurosciences Research and Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Nina R Held
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Johannes T Reiter
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Selma Enders
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Bastian David
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Mar Brugues
- Section for Translational Epilepsy Research, Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Vera C W Keil
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Monika Jeub
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Wolfram S Kunz
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- Institute of Experimental Epileptology and Cognition Research, University Hospital Bonn, Bonn, Germany
| | | | - Bernd Weber
- Institute of Experimental Epileptology and Cognition Research, University Hospital Bonn, Bonn, Germany
| | | | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Torsten Baldeweg
- Developmental Neurosciences Research and Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Albert J Becker
- Section for Translational Epilepsy Research, Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - J Helen Cross
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
- Developmental Neurosciences Research and Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
- Young Epilepsy Lingfield, Lingfield, UK
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Theodor Rüber
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany.
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.
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2
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Gonçalves JIB, de Castro VR, Martins WA, Xavier FAC, Da Costa JC, Neto EP, Palmini A, Marinowic DR. Case Report: Molecular Analyses of Cell-Cycle-Related Genes in Cortical Brain Tissue of a Patient with Rasmussen Encephalitis. Int J Mol Sci 2024; 25:8487. [PMID: 39126055 PMCID: PMC11313535 DOI: 10.3390/ijms25158487] [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: 06/26/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024] Open
Abstract
Rasmussen's encephalitis (RE) stands as a rare neurological disorder marked by progressive cerebral hemiatrophy and epilepsy resistant to medical treatment. Despite extensive study, the primary cause of RE remains elusive, while its histopathological features encompass cortical inflammation, neuronal degeneration, and gliosis. The underlying molecular mechanisms driving disease progression remain largely unexplored. In this case study, we present a patient with RE who underwent hemispherotomy and has remained seizure-free for over six months, experiencing gradual motor improvement. Furthermore, we conducted molecular analysis on the excised brain tissue, unveiling a decrease in the expression of cell-cycle-associated genes coupled with elevated levels of BDNF and TNF-α proteins. These findings suggest the potential involvement of cell cycle regulators in the progression of RE.
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Affiliation(s)
| | - Vinicius Rosa de Castro
- Graduate Program in Medicine and Health Sciences, Medical School, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90619-900, Brazil;
- Epilepsy Surgery Program, Saint Lucas Hospital, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90610-001, Brazil; (W.A.M.); (E.P.N.); (A.P.)
| | - William Alves Martins
- Epilepsy Surgery Program, Saint Lucas Hospital, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90610-001, Brazil; (W.A.M.); (E.P.N.); (A.P.)
| | | | - Jaderson Costa Da Costa
- Brain Institute of Rio Grande do Sul, Porto Alegre 90610-000, Brazil; (J.I.B.G.); (F.A.C.X.); (J.C.D.C.)
- Graduate Program in Medicine and Health Sciences, Medical School, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90619-900, Brazil;
| | - Eliseu Paglioli Neto
- Epilepsy Surgery Program, Saint Lucas Hospital, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90610-001, Brazil; (W.A.M.); (E.P.N.); (A.P.)
| | - André Palmini
- Epilepsy Surgery Program, Saint Lucas Hospital, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90610-001, Brazil; (W.A.M.); (E.P.N.); (A.P.)
| | - Daniel Rodrigo Marinowic
- Brain Institute of Rio Grande do Sul, Porto Alegre 90610-000, Brazil; (J.I.B.G.); (F.A.C.X.); (J.C.D.C.)
- Graduate Program in Medicine and Health Sciences, Medical School, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90619-900, Brazil;
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3
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Eriksson MH, Prentice F, Piper RJ, Wagstyl K, Adler S, Chari A, Booth J, Moeller F, Das K, Eltze C, Cooray G, Perez Caballero A, Menzies L, McTague A, Shavel-Jessop S, Tisdall MM, Cross JH, Martin Sanfilippo P, Baldeweg T. Long-term neuropsychological trajectories in children with epilepsy: does surgery halt decline? Brain 2024; 147:2791-2802. [PMID: 38643018 PMCID: PMC11292899 DOI: 10.1093/brain/awae121] [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: 11/11/2023] [Revised: 02/29/2024] [Accepted: 03/16/2024] [Indexed: 04/22/2024] Open
Abstract
Neuropsychological impairments are common in children with drug-resistant epilepsy. It has been proposed that epilepsy surgery might alleviate these impairments by providing seizure freedom; however, findings from prior studies have been inconsistent. We mapped long-term neuropsychological trajectories in children before and after undergoing epilepsy surgery, to measure the impact of disease course and surgery on functioning. We performed a retrospective cohort study of 882 children who had undergone epilepsy surgery at Great Ormond Street Hospital (1990-2018). We extracted patient information and neuropsychological functioning [obtained from IQ tests (domains: full-scale IQ, verbal IQ, performance IQ, working memory and processing speed) and tests of academic attainment (reading, spelling and numeracy)] and investigated changes in functioning using regression analyses. We identified 500 children (248 females) who had undergone epilepsy surgery [median age at surgery = 11.9 years, interquartile range = (7.8, 15.0)] and neuropsychological assessment. These children showed declines in all domains of neuropsychological functioning in the time leading up to surgery (all P-values ≤0.001; e.g. βFSIQ = -1.9, SEFSIQ = 0.3, PFSIQ < 0.001). Children lost on average one to four points per year, depending on the domain considered; 27%-43% declined by ≥10 points from their first to their last preoperative assessment. At the time of presurgical evaluation, most children (46%-60%) scored one or more standard deviations below the mean (<85) on the different neuropsychological domains; 37% of these met the threshold for intellectual disability (full-scale IQ < 70). On a group level, there was no change in performance from pre- to postoperative assessment on any of the domains (all P-values ≥0.128). However, children who became seizure free through surgery showed higher postoperative neuropsychological performance (e.g. rrb-FSIQ = 0.37, P < 0.001). These children continued to demonstrate improvements in neuropsychological functioning over the course of their long-term follow-up (e.g. βFSIQ = 0.9, SEFSIQ = 0.3, PFSIQ = 0.004). Children who had discontinued antiseizure medication treatment at 1-year follow-up showed an 8- to 13-point advantage in postoperative working memory, processing speed and numeracy, and greater improvements in verbal IQ, working memory, reading and spelling (all P-values ≤0.034) over the postoperative period compared with children who were seizure free and still receiving antiseizure medication. In conclusion, by providing seizure freedom and the opportunity for antiseizure medication cessation, epilepsy surgery might not only halt but reverse the downward trajectory that children with drug-resistant epilepsy display in neuropsychological functioning. To halt this decline as soon as possible or, potentially, to prevent it from occurring in the first place, children with focal epilepsy should be considered for epilepsy surgery as early as possible after diagnosis.
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Affiliation(s)
- Maria H Eriksson
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Freya Prentice
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Rory J Piper
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Konrad Wagstyl
- Department of Imaging Neuroscience, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Sophie Adler
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Aswin Chari
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - John Booth
- Data Research, Innovation and Virtual Environments Unit, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Friederike Moeller
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Krishna Das
- Department of Neurology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Christin Eltze
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Gerald Cooray
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
- Department of Clinical Neuroscience, Karolinska Institutet, Solna 171 77, Sweden
| | - Ana Perez Caballero
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Amy McTague
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Sara Shavel-Jessop
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Martin M Tisdall
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - J Helen Cross
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
- Young Epilepsy, Lingfield, RH7 6PW, UK
| | - Patricia Martin Sanfilippo
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Torsten Baldeweg
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
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4
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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; 26:415-434. [PMID: 38818801 DOI: 10.1002/epd2.20231] [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: 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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5
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Damman S, Sukpornchairak P, Ahituv A, Chen A, Wang D, Sawlani K, Steriade C, Abboud H. Unilateral cortical autoimmune encephalitis: A case series and comparison to late-onset Rasmussen's encephalitis. J Neuroimmunol 2024; 391:578350. [PMID: 38728930 DOI: 10.1016/j.jneuroim.2024.578350] [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: 12/07/2023] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To report a novel anatomical pattern of autoimmune encephalitis characterized by strictly unilateral cortical inflammation and a clinical picture overlapping with late-onset Rasmussen's encephalitis. METHODS We retrospectively gathered data of patients identified at two tertiary referral academic centers who met inclusion criteria. RESULTS We identified twelve cases (average age 65, +/- 19.8 years, 58% female). All patients had unilateral cortical inflammation manifesting with focal seizures, cognitive decline, hemicortical deficits, and unilateral MRI and/or EEG changes. Six cases were idiopathic, two paraneoplastic, two iatrogenic (in the setting of immune checkpoint inhibitors), and two post-COVID-19. Serologically, ten patients were seronegative, one had high titer anti-GAD65, and one had anti-NMDAR. Five patients met Rasmussen's encephalitis criteria, and six did not fully meet the criteria but had symptoms significantly overlapping with the condition. Most patients had significant improvement with immunotherapy. DISCUSSION Unilateral cortical AE seems to be more prevalent in the elderly and more frequently idiopathic and seronegative. Patients with this anatomical variant of autoimmune encephalitis have overlapping features with late-onset Rasmussen's encephalitis but are more responsive to immunotherapy. In cases refractory to immunotherapy, interventions used in refractory Rasmussen's encephalitis may be considered, such as functional hemispherectomy.
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Affiliation(s)
- Sophia Damman
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Persen Sukpornchairak
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Amit Ahituv
- Department of Neurology, New York University Langone Health, 222 East 41st Street, 14th Floor New York, NY 10017, USA
| | - Alex Chen
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - David Wang
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Komal Sawlani
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, 222 East 41st Street, 14th Floor New York, NY 10017, USA
| | - Hesham Abboud
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Multiple Sclerosis and Neuroimmunology Program, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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6
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Doherty A, Knudson K, Fuller C, Leach JL, Wang AC, Marupudi N, Han RH, Tomko S, Ojemann J, Smyth MD, Mangano F, Skoch J. MRI and pathology comparisons in Rasmussen's encephalitis: a multi-institutional examination of hemispherotomy outcomes relative to imaging and histological severity. Childs Nerv Syst 2024; 40:1799-1806. [PMID: 38489033 PMCID: PMC11111524 DOI: 10.1007/s00381-024-06353-4] [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: 01/28/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE Rasmussen encephalitis (RE) is a very rare chronic neurological disorder of unilateral inflammation of the cerebral cortex. Hemispherotomy provides the best chance at achieving seizure freedom in RE patients, but with significant risks and variable long-term outcomes. The goal of this study is to utilize our multicenter pediatric cohort to characterize if differences in pathology and/or imaging characterization of RE may provide a window into post-operative seizure outcomes, which in turn could guide decision-making for parents and healthcare providers. METHODS This multi-institutional retrospective review of medical record, imaging, and pathology samples was approved by each individual institution's review board. Data was collected from all known pediatric cases of peri-insular functional hemispherotomy from the earliest available electronic medical records. Mean follow-up time was 4.9 years. Clinical outcomes were measured by last follow-up visit using both Engel and ILAE scoring systems. Relationships between categorical and continuous variables were analyzed with Pearson correlation values. RESULTS Twenty-seven patients met study criteria. No statistically significant correlations existed between patient imaging and pathology data. Pathology stage, MRI brain imaging stages, and a combined assessment of pathology and imaging stages showed no statistically significant correlation to post-operative seizure freedom rates. Hemispherectomy Outcome Prediction Scale scoring demonstrated seizure freedom in only 71% of patients receiving a score of 1 and 36% of patients receiving a score of 2 which were substantially lower than predicted. CONCLUSIONS Our analysis did not find evidence for either independent or combined analysis of imaging and pathology staging being predictive for post peri-insular hemispherotomy seizure outcomes, prompting the need for other biomarkers to be explored. Our data stands in contrast to the recently proposed Hemispherectomy Outcome Prediction Scale and does not externally validate this metric for an RE cohort.
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Affiliation(s)
| | - Kathleen Knudson
- Department of Neurosurgery and Spine, ECU Health, Greenville, NC, USA
| | | | - James L Leach
- Radiology, Cincinnati Childrens Hospital and Medical Center, Cincinnati, OH, USA
| | - Anthony C Wang
- Department of Neurosurgery, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Neena Marupudi
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Rowland H Han
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Stuart Tomko
- Neurology, Washington University, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Jeff Ojemann
- Department of Neurosurgery, Seattle Childrens Hospital, Seattle, WA, USA
| | - Matthew D Smyth
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Francesco Mangano
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
| | - Jesse Skoch
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA.
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7
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Pechlivanidou M, Vakrakou AG, Karagiorgou K, Tüzün E, Karachaliou E, Chroni E, Afrantou T, Grigoriadis N, Argyropoulou C, Paschalidis N, Şanlı E, Tsantila A, Dandoulaki M, Ninou EI, Zisimopoulou P, Mantegazza R, Andreetta F, Dudeck L, Steiner J, Lindstrom JM, Tzanetakos D, Voumvourakis K, Giannopoulos S, Tsivgoulis G, Tzartos SJ, Tzartos J. Neuronal nicotinic acetylcholine receptor antibodies in autoimmune central nervous system disorders. Front Immunol 2024; 15:1388998. [PMID: 38863705 PMCID: PMC11165060 DOI: 10.3389/fimmu.2024.1388998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/13/2024] [Indexed: 06/13/2024] Open
Abstract
Background Neuronal nicotinic acetylcholine receptors (nAChRs) are abundant in the central nervous system (CNS), playing critical roles in brain function. Antigenicity of nAChRs has been well demonstrated with antibodies to ganglionic AChR subtypes (i.e., subunit α3 of α3β4-nAChR) and muscle AChR autoantibodies, thus making nAChRs candidate autoantigens in autoimmune CNS disorders. Antibodies to several membrane receptors, like NMDAR, have been identified in autoimmune encephalitis syndromes (AES), but many AES patients have yet to be unidentified for autoantibodies. This study aimed to develop of a cell-based assay (CBA) that selectively detects potentially pathogenic antibodies to subunits of the major nAChR subtypes (α4β2- and α7-nAChRs) and its use for the identification of such antibodies in "orphan" AES cases. Methods The study involved screening of sera derived from 1752 patients from Greece, Turkey and Italy, who requested testing for AES-associated antibodies, and from 1203 "control" patients with other neuropsychiatric diseases, from the same countries or from Germany. A sensitive live-CBA with α4β2-or α7-nAChR-transfected cells was developed to detect antibodies against extracellular domains of nAChR major subunits. Flow cytometry (FACS) was performed to confirm the CBA findings and indirect immunohistochemistry (IHC) to investigate serum autoantibodies' binding to rat brain tissue. Results Three patients were found to be positive for serum antibodies against nAChR α4 subunit by CBA and the presence of the specific antibodies was quantitatively confirmed by FACS. We detected specific binding of patient-derived serum anti-nAChR α4 subunit antibodies to rat cerebellum and hippocampus tissue. No serum antibodies bound to the α7-nAChR-transfected or control-transfected cells, and no control serum antibodies bound to the transfected cells. All patients positive for serum anti-nAChRs α4 subunit antibodies were negative for other AES-associated antibodies. All three of the anti-nAChR α4 subunit serum antibody-positive patients fall into the AES spectrum, with one having Rasmussen encephalitis, another autoimmune meningoencephalomyelitis and another being diagnosed with possible autoimmune encephalitis. Conclusion This study lends credence to the hypothesis that the major nAChR subunits are autoimmune targets in some cases of AES and establishes a sensitive live-CBA for the identification of such patients.
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Affiliation(s)
| | - Aigli G. Vakrakou
- First Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Karagiorgou
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Türkiye
| | - Eleni Karachaliou
- Tzartos NeuroDiagnostics, Athens, Greece
- Second Department of Neurology, School of Medicine, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Theodora Afrantou
- Second Department of Neurology, “AHEPA“ University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Grigoriadis
- Second Department of Neurology, “AHEPA“ University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Nikolaos Paschalidis
- Mass Cytometry-CyTOF Laboratory, Center for Clinical Research, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Elif Şanlı
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Türkiye
| | | | | | | | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesca Andreetta
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Leon Dudeck
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Jon Martin Lindstrom
- Department of Neuroscience, Medical School, University of Pennsylvania, Philadelphia, PA, United States
| | - Dimitrios Tzanetakos
- Second Department of Neurology, School of Medicine, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, School of Medicine, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, School of Medicine, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Socrates J. Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Department of Pharmacy, University of Patras, Patras, Greece
| | - John Tzartos
- Second Department of Neurology, School of Medicine, “Attikon” University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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8
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Melzer N, Rosenow F. Autoimmune-associated epilepsy - a challenging concept. Seizure 2024:S1059-1311(24)00156-0. [PMID: 38852019 DOI: 10.1016/j.seizure.2024.05.017] [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: 03/25/2024] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 06/10/2024] Open
Abstract
The current International League Against Epilepsy (ILAE) definition and classification guidelines for the first time introduced the category of immune-mediated focal epilepsy in addition to structural, genetic, infectious, and metabolic aetiologies. Moreover, the ILAE Autoimmunity and Inflammation Taskforce recently provided a conceptual framework for the distinction between acute "provoked" seizures in the acute phase of autoimmune encephalitis from chronic "unprovoked" seizures due to autoimmune-associated epilepsy. The first category predominately applies to those autoimmune encephalitis patients with autoantibodies against cell surface neural antigens, in whom autoantibodies are assumed to exert a direct ictogenic effect without overt structural damage. These patients do not exhibit enduring predisposition to seizures after the "acute phase" encephalitis, and thus do not fulfil the definition of epilepsy. The second category applies to those autoimmune encephalitis patients with autoantibodies against intracellular neural antigens and Rasmussen's encephalitis, in whom T cells are assumed to cause epileptogenic effects through immune-inflammation and overt structural damage. These patients do exhibit enduring predisposition to seizures after the "acute phase" of encephalitis and thus fulfil the definition of epilepsy. AAE may result from both, ongoing brain autoimmunity and associated structural brain damage according to the current ILAE definition and classification guideline. We here discuss the difficulties of this concept and suggest an unbiased translationally validated and data-driven approach to predict in an individual encephalitis patient the propensity to develop (or not) AAE and the cognitive and behavioural outcome.
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Affiliation(s)
- Nico Melzer
- Department of Neurology, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, Düsseldorf 40225, Germany.
| | - Felix Rosenow
- Goethe University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany; Goethe University Frankfurt, LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Frankfurt, Germany
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9
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Borne A, Perrone-Bertolotti M, Ferrand-Sorbets S, Bulteau C, Baciu M. Insights on cognitive reorganization after hemispherectomy in Rasmussen's encephalitis. A narrative review. Rev Neurosci 2024; 0:revneuro-2024-0009. [PMID: 38749928 DOI: 10.1515/revneuro-2024-0009] [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: 01/16/2024] [Accepted: 04/26/2024] [Indexed: 05/24/2024]
Abstract
Rasmussen's encephalitis is a rare neurological pathology affecting one cerebral hemisphere, therefore, posing unique challenges. Patients may undergo hemispherectomy, a surgical procedure after which cognitive development occurs in the isolated contralateral hemisphere. This rare situation provides an excellent opportunity to evaluate brain plasticity and cognitive recovery at a hemispheric level. This literature review synthesizes the existing body of research on cognitive recovery following hemispherectomy in Rasmussen patients, considering cognitive domains and modulatory factors that influence cognitive outcomes. While language function has traditionally been the focus of postoperative assessments, there is a growing acknowledgment of the need to broaden the scope of language investigation in interaction with other cognitive domains and to consider cognitive scaffolding in development and recovery. By synthesizing findings reported in the literature, we delineate how language functions may find support from the right hemisphere after left hemispherectomy, but also how, beyond language, global cognitive functioning is affected. We highlight the critical influence of several factors on postoperative cognitive outcomes, including the timing of hemispherectomy and the baseline preoperative cognitive status, pointing to early surgical intervention as predictive of better cognitive outcomes. However, further specific studies are needed to confirm this correlation. This review aims to emphasize a better understanding of mechanisms underlying hemispheric specialization and plasticity in humans, which are particularly important for both clinical and research advancements. This narrative review underscores the need for an integrative approach based on cognitive scaffolding to provide a comprehensive understanding of mechanisms underlying the reorganization in Rasmussen patients after hemispherectomy.
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Affiliation(s)
- Anna Borne
- Univ. Grenoble Alpes, CNRS, LPNC, 38000 Grenoble, France
| | | | - Sarah Ferrand-Sorbets
- Hôpital Fondation Adolphe de Rothschild, Service de Neurochirurgie Pédiatrique, 75019 Paris, France
| | - Christine Bulteau
- Hôpital Fondation Adolphe de Rothschild, Service de Neurochirurgie Pédiatrique, 75019 Paris, France
- Université de Paris-Cité, MC2Lab EA 7536, Institut de Psychologie, F-92100 Boulogne-Billancourt, France
| | - Monica Baciu
- Univ. Grenoble Alpes, CNRS, LPNC, 38000 Grenoble, France
- Neurology Department, CMRR, University Hospital, 38000 Grenoble, France
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10
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Momoh R. A Case Report of a Positive Antinuclear Ribonucleoprotein Antibody, a Weak-Positive Antinuclear Antibody, Elevated C3 Complement, and Possibly Trauma-Induced Rasmussen's Encephalitis. Cureus 2024; 16:e60415. [PMID: 38883088 PMCID: PMC11179322 DOI: 10.7759/cureus.60415] [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] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
A case of a late-onset Rasmussen's encephalitis (RE) presenting with drug-refractory focal epilepsy and progressive hemispheric cerebral atrophy noted on a serial radiologic head scan done on a gentleman in his 30s is presented. A positive antinuclear ribonucleoprotein antibody test, a weak-positive antinuclear antibody test, an elevated C3 complement, and possible trauma were identified as potential causative or promoting factors for RE in this patient. Literature evidence regarding the challenges with the aetiopathogenesis description, diagnosis, and management of this rare condition has been reviewed in this article. Exploring an aetiological-based diagnosis of this condition could open research and interventional opportunities into aetiology-guided management opportunities in this condition.
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Affiliation(s)
- Rabiu Momoh
- Critical Care, William Harvey Hospital, Ashford, GBR
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11
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Costanza M, Ciotti A, Consonni A, Cipelletti B, Cattalini A, Cagnoli C, Baggi F, de Curtis M, Colciaghi F. CNS autoimmune response in the MAM/pilocarpine rat model of epileptogenic cortical malformation. Proc Natl Acad Sci U S A 2024; 121:e2319607121. [PMID: 38635635 PMCID: PMC11047071 DOI: 10.1073/pnas.2319607121] [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: 11/29/2023] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
The development of seizures in epilepsy syndromes associated with malformations of cortical development (MCDs) has traditionally been attributed to intrinsic cortical alterations resulting from abnormal network excitability. However, recent analyses at single-cell resolution of human brain samples from MCD patients have indicated the possible involvement of adaptive immunity in the pathogenesis of these disorders. By exploiting the MethylAzoxyMethanol (MAM)/pilocarpine (MP) rat model of drug-resistant epilepsy associated with MCD, we show here that the occurrence of status epilepticus and subsequent spontaneous recurrent seizures in the malformed, but not in the normal brain, are associated with the outbreak of a destructive autoimmune response with encephalitis-like features, involving components of both cell-mediated and humoral immune responses. The MP brain is characterized by blood-brain barrier dysfunction, marked and persisting CD8+ T cell invasion of the brain parenchyma, meningeal B cell accumulation, and complement-dependent cytotoxicity mediated by antineuronal antibodies. Furthermore, the therapeutic treatment of MP rats with the immunomodulatory drug fingolimod promotes both antiepileptogenic and neuroprotective effects. Collectively, these data show that the MP rat could serve as a translational model of epileptogenic cortical malformations associated with a central nervous system autoimmune response. This work indicates that a preexisting brain maldevelopment predisposes to a secondary autoimmune response, which acts as a precipitating factor for epilepsy and suggests immune intervention as a therapeutic option to be further explored in epileptic syndromes associated with MCDs.
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Affiliation(s)
- Massimo Costanza
- Neuro-Oncology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Arianna Ciotti
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Alessandra Consonni
- Neuroimmunology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Barbara Cipelletti
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Alessandro Cattalini
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Cinzia Cagnoli
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Fulvio Baggi
- Neuroimmunology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Marco de Curtis
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Francesca Colciaghi
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
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Yang W, Tang CY, Fan DY, Wang YS, Wang PG, An J, Luan GM. Mice with type I interferon signaling deficiency are prone to epilepsy upon HSV-1 infection. Virol Sin 2024; 39:251-263. [PMID: 38219860 PMCID: PMC11074648 DOI: 10.1016/j.virs.2024.01.002] [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: 08/09/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Abstract
Viral encephalitis continues to be a significant public health concern. In our previous study, we discovered a lower expression of antiviral factors, such as IFN-β, STING and IFI16, in the brain tissues of patients with Rasmussen's encephalitis (RE), a rare chronic neurological disorder often occurred in children, characterized by unihemispheric brain atrophy. Furthermore, a higher cumulative viral score of human herpes viruses (HHVs) was also found to have a significant positive correlation with the unihemispheric atrophy in RE. Type I IFNs (IFN-I) signaling is essential for innate anti-infection response by binding to IFN-α/β receptor (IFNAR). In this study, we infected WT mice and IFNAR-deficient A6 mice with herpes simplex virus 1 (HSV-1) via periocular injection to investigate the relationship between IFN-I signaling and HHVs-induced brain lesions. While all mice exhibited typical viral encephalitis lesions in their brains, HSV-induced epilepsy was only observed in A6 mice. The gene expression matrix, functional enrichment analysis and protein-protein interaction network revealed four gene models that were positively related with HSV-induced epilepsy. Additionally, ten key genes with the highest scores were identified. Taken together, these findings indicate that intact IFN-I signaling can effectively limit HHVs induced neural symptoms and brain lesions, thereby confirming the positive correlation between IFN-I signaling repression and brain atrophy in RE and other HHVs encephalitis.
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MESH Headings
- Animals
- Female
- Mice
- Brain/pathology
- Brain/virology
- Disease Models, Animal
- Encephalitis, Herpes Simplex/virology
- Encephalitis, Herpes Simplex/immunology
- Encephalitis, Herpes Simplex/pathology
- Epilepsy/virology
- Epilepsy/pathology
- Herpes Simplex/virology
- Herpes Simplex/pathology
- Herpes Simplex/immunology
- Herpesvirus 1, Human/pathogenicity
- Herpesvirus 1, Human/immunology
- Interferon Type I/metabolism
- Interferon Type I/immunology
- Mice, Inbred C57BL
- Mice, Knockout
- Protein Interaction Maps
- Receptor, Interferon alpha-beta/genetics
- Receptor, Interferon alpha-beta/deficiency
- Signal Transduction
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Affiliation(s)
- Wei Yang
- Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China; Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100093, China
| | - Chong-Yang Tang
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Dong-Ying Fan
- Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing, 100069, China
| | - Yi-Song Wang
- Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing, 100069, China
| | - Pei-Gang Wang
- Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing, 100069, China
| | - Jing An
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100093, China; Department of Microbiology, School of Basic Medical Sciences, Capital Medical University, Beijing, 100069, China
| | - Guo-Ming Luan
- Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China; Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100093, China; Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China; Chinese Institute for Brain Research, Beijing, 102206, China.
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13
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Arcan A, Kızılkılıç EK, Gündüz A, Unkun R, Vezzani A, Özkara Ç. Rasmussen's syndrome treated with anakinra. J Neurol 2024; 271:723-726. [PMID: 37922068 DOI: 10.1007/s00415-023-12072-8] [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: 10/13/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Rasmussen's encephalitis (RE) is a rare chronic neurological disorder, characterized by unilateral inflammation of the cerebral cortex, refractory focal epilepsy or epilepsia partialis continua, hemiparesis, and progressive cognitive decline. Interleukin-1 (IL-1) plays an important role in neuroinflammation as a key element in the activation of the inflammatory IL-1β-IL-1 receptor type 1 (IL-1R1) axis. Anakinra, an IL-1 inhibitor, is successfully used in patients with new onset refractory status epilepticus and febrile infection-related epilepsy syndrome. METHODS AND RESULTS We present 38-year-old male with RE having right-sided hemiparesis and continuous spasms being unresponsive to immune modulatory therapies like pulse steroid, intravenous immunoglobulin and anti-seizure drugs. After treatment with anakinra for three weeks, the continuous spasms almost completely subsided, and his muscle strength returned to normal. DISCUSSION Anakinra may be considered as a treatment option in patients with RE and refractory seizures.
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Affiliation(s)
- Abdullah Arcan
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | | | - Ayşegül Gündüz
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Rümeysa Unkun
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Annamaria Vezzani
- Department of Neuroscience, Istituto Di Ricerche Farmacologiche Mario Negri, Milano, Italy
| | - Çiğdem Özkara
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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14
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Galev G, Prayson RA. Focal cortical dysplasia is a frequent coexistent pathology in patients with Rasmussen's encephalitis. Ann Diagn Pathol 2024; 68:152224. [PMID: 37976976 DOI: 10.1016/j.anndiagpath.2023.152224] [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: 09/11/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Rasmussen's encephalitis (RE) is a rare, predominantly pediatric epilepsy disorder of unknown etiology. It classically affects one of the cerebral hemispheres and histologically shows cortical chronic inflammation, gliosis, and neuronal loss. The etiopathogenesis of RE remains unknown, with genetic, infectious, and autoimmune factors all speculated to play a role. Although the histologic findings in RE are well described, few studies have investigated a large cohort of cases looking for the coexistence of RE with focal cortical dysplasia (FCD). DESIGN The study is a retrospective review of RE patients who underwent surgical resection of brain tissue between 1979 and 2021. Relevant patient history was retrieved, and available histologic slides were reviewed. The histologic severity of RE was described according to the Pardo criteria. In cases where FCD was present, the observed patterns of FCD (namely Ia, Ib, IIa, IIb, etc.) were described using the International League Against Epilepsy (ILAE) classification. RESULTS Thirty-eight resection specimens from 31 patients formed the study cohort. Seventeen patients (54.8 %) were male; average age at surgery was 8 years (range: 2-28 years). Twenty-seven resection specimens (71.1 %) from 23 patients (74 %) showed evidence of coexistent FCD. Most cases with FCD resembled the ILAE type Ib (n = 23) pattern. Cases of RE that did not show FCD were either Pardo stage 1 (n = 5) or 4 (n = 6), with all Pardo stage 2 and 3 cases demonstrating FCD. CONCLUSIONS FCD was found in most patients with RE (74 %). The most observed pattern of FCD was ILAE Ib.
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Affiliation(s)
- Georgi Galev
- Department of Anatomic Pathology, L25, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Richard A Prayson
- Department of Anatomic Pathology, L25, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America.
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15
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Aktan D, Depierreux F. How to face the hemifacial spasm: challenges and misconceptions. Acta Neurol Belg 2024; 124:17-23. [PMID: 37498482 DOI: 10.1007/s13760-023-02342-7] [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: 03/19/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
Hemifacial spasm (HFS) is characterised by intermittent, brief or sustained, repetitive contractions of the muscles innervated by one facial nerve. It is one of the most frequent movement disorders affecting the face. However common and allegedly straightforward to diagnose, it might reveal as a challenge for clinicians in various situations. Indeed, it often needs prior exclusion of many other movement disorders affecting the face, with frequent phenomenological overlaps with blepharospasm, post-facial palsy, facial motor tics, etc. The clinical diagnosis shall be supported by modern brain imaging techniques, and sometimes electromyography, as some particular aetiologies may require specific treatment. Primary forms are associated with vascular compression of the ipsilateral seventh cranial nerve, whereas secondary forms can be caused by any injury occurring on the facial nerve course. This article proposes a global and organised approach to the diagnosis, and the ensuing therapeutic options, as many practitioners still use some inefficient medications when they encounter a case of facial spasm.
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Affiliation(s)
- David Aktan
- Neurology Department, University Hospital of Liège, CHU Liege, Avenue Hippocrate-B35, 4000, Liège, Belgium.
| | - Frédérique Depierreux
- Neurology Department, University Hospital of Liège, CHU Liege, Avenue Hippocrate-B35, 4000, Liège, Belgium
- Movement Disorder Unit, Neurology Department, CHU Liège, Liège, Belgium
- GIGA-CRC in vivo imaging, University of Liège, Liège, Belgium
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16
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Sanchez JC, Belmar MT, Sanchez JC, Nguygen K. Endocrinopathies in a Pediatric Patient Post-anatomical Hemispherectomy for Rasmussen's Encephalitis Treatment: A Case Report. Cureus 2024; 16:e53894. [PMID: 38465024 PMCID: PMC10924956 DOI: 10.7759/cureus.53894] [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: 12/18/2023] [Accepted: 02/09/2024] [Indexed: 03/12/2024] Open
Abstract
Hemispherectomy is a neurosurgical procedure that is frequently performed in pediatric patients diagnosed with Rasmussen's encephalitis. Postoperative complications include immediate complications such as hydrocephalus and hemorrhage and behavioral complications such as language impairments and contralateral weakness. However, there are limited studies or case reports that address the potential endocrinopathies associated with this and other pediatric epileptic surgeries. This case report describes the endocrinopathies following an anatomical hemispherectomy procedure. A four-year-old African-American female had a right anatomical hemispherectomy for the treatment of Rasmussen's encephalitis in 2020. The postoperative course was immediately complicated by central diabetes insipidus which was stabilized with desmopressin. The patient's labs in 2021 were consistent with central precocious puberty with elevated luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Additionally, the patient was found to have secondary adrenal insufficiency in which she failed a low-dose adrenocorticotropic hormone (ACTH) stimulation test. Oral hydrocortisone therapy was initiated for secondary adrenal insufficiency in addition to initiating leuprolide injections for central precocious puberty. Furthermore, at the age of seven years, the patient had her first menarche. This case report emphasizes the need for closer and long-term surveillance for endocrine issues in postepileptic surgical pediatric patients as well as a surveillance plan for the development of other potential endocrine abnormalities throughout the patient's life.
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Affiliation(s)
- Jaron C Sanchez
- Pediatrics, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Markeeta T Belmar
- Pediatrics, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Jason C Sanchez
- Pediatrics, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
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17
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Schijns OE. Functional hemispheric disconnection procedures for chronic epilepsy: history, indications, techniques, complications and current practice in Europe. A consensus statement on behalf of the EANS functional neurosurgery section. BRAIN & SPINE 2024; 4:102754. [PMID: 38510638 PMCID: PMC10951757 DOI: 10.1016/j.bas.2024.102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction The surgical procedure for severe, drug-resistant, unilateral hemispheric epilepsy is challenging. Over the last decades the surgical landscape for hemispheric disconnection procedures changed from anatomical hemispherectomy to functional hemispherotomy with a reduction of complications and stable good seizure outcome. Here, a task force of European epilepsy surgeons prepared, on behalf of the EANS Section for Functional Neurosurgery, a consensus statement on different aspects of the hemispheric disconnection procedure. Research question To determine history, indication, timing, techniques, complications and current practice in Europe for hemispheric disconnection procedures in drug-resistant epilepsy. Material and methods Relevant literature on the topic was collected by a literature search based on the PRISMA 2020 guidelines. Results A comprehensive overview on the historical development of hemispheric disconnection procedures for epilepsy is presented, while discussing indications, timing, surgical techniques and complications. Current practice for this procedure in European epilepsy surgery centers is provided. At present, our knowledge of long-term seizure outcomes primarily stems from open surgical disconnection procedures. Although minimal invasive surgical techniques in epilepsy are rapidly developing and reported in case reports or small case series, long-term seizure outcome remain uncertain and needs to be reported. Discussion and conclusion This is the first paper presenting a European consensus statement regarding history, indications, techniques and complications of hemispheric disconnection procedures for different causes of chronic, drug-resistant epilepsy. Furthermore, it serves as the pioneering document to report a comprehensive overview of the current surgical practices regarding this type of surgery employed in renowned epilepsy surgery centers across Europe.
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Affiliation(s)
- Olaf E.M.G. Schijns
- Corresponding author. Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands.
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18
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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19
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Thomé U, Batista LA, Rocha RP, Terra VC, Hamad APA, Sakamoto AC, Santos AC, Santos MV, Machado HR. The Important Role of Hemispherotomy for Rasmussen Encephalitis: Clinical and Functional Outcomes. Pediatr Neurol 2024; 150:82-90. [PMID: 37992429 DOI: 10.1016/j.pediatrneurol.2023.10.016] [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: 03/22/2022] [Revised: 05/05/2023] [Accepted: 10/20/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is characterized by pharmacoresistant epilepsy and progressive neurological deficits concurrent with unilateral hemispheric atrophy. Evidence of an inflammatory autoimmune process has been extensively described in the literature; however, the precise etiology of RE is still unknown. Despite data supporting a beneficial effect of early immunosuppressive and immunomodulatory interventions, surgical disconnection of the affected hemisphere is considered the treatment of choice for these patients. The aim of this study was to report a series of children and adolescents who underwent hemispheric surgery (HS) for the treatment of RE, analyzing their clinical, electrographic, and neuroimaging features pre-operatively, as well as their postoperative status, including seizure and functional outcomes. METHODS All patients with RE who underwent HS in the Epilepsy Surgery Center (CIREP) of the University Hospital of Ribeirão Preto Medical School, between 1995 and 2020 were retrospectively reviewed. Preoperative and postoperative analyses included gender; age at epilepsy onset; seizure semiology; seizure frequency; interictal and ictal electroencephalographic (EEG) findings; age at surgery; duration of epilepsy; surgical complications; duration of follow-up; histopathological findings; and postoperative seizure, cognitive, and functional outcomes. RESULTS Forty-four patients were evaluated. Mean age at seizure onset and epilepsy duration was 6 years and 2.5 years, respectively. Mean age at surgery was 9 years, with an average follow-up ranging from 3 months to 23 years. All patients presented with severe epilepsy and distinct neurological abnormalities on MRI. Before HS, different degrees of abnormal intellectual performance as well as hemiparesis were seen in 86% and 90%, respectively. Histopathology examination confirmed this diagnosis in 95% patients. At the last follow-up, 68% of patients were seizure free, and 70% were classified as Engel Class I or II. Postoperatively, the cognitive status remained unchanged in 64% of patients. Likewise, the gross motor function remained unchanged in 54% of patients and 74% had functional hand ability after HS. CONCLUSIONS Considering the progressive damage course of RE, hemispheric surgery should be offered to pediatric patients. It has manageable risks and results in good seizure outcome, and the preoperative functional status of these children is often preserved (even when the left hemisphere is involved), thus improving their quality of life.
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Affiliation(s)
- Ursula Thomé
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - Larissa A Batista
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Renata P Rocha
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Vera C Terra
- Epilepsy Center, Nsa Sra das Graças Hospital, Curitiba, Brazil
| | - Ana Paula A Hamad
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Americo C Sakamoto
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Antônio C Santos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Marcelo V Santos
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Hélio R Machado
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
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20
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Polyanskaya MV, Demushkina AA, Vasilyev IG, Kostylev FA, Kurbanova FA, Zavadenko NN, Alikhanov AA. [Neuroradiological and pathohistological markers of the main epileptogenic substrates in children. Other cerebral disorders]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:16-23. [PMID: 38261280 DOI: 10.17116/jnevro202412401116] [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: 01/24/2024]
Abstract
High-resolution MRI is an important tool in the diagnosis of structural epilepsy |in determining the seizure initiation zones, identification of the mechanisms of epileptogenesis in predicting outcomes and preventing postoperative complications in patients. In this article we have tried to demonstrate the neuroradiological and pathohistological characteristics of the main epileptogenic substrates in children using modern classification. The second part of the article is devoted to the spectrum of epileptogenic cerebral disorders, in addition to cortical malformations.
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Affiliation(s)
- M V Polyanskaya
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Demushkina
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I G Vasilyev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - F A Kostylev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - F A Kurbanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - N N Zavadenko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Alikhanov
- Pirogov Russian National Research Medical University, Moscow, Russia
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21
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Kalincik T, Roos I, Sharmin S. Observational studies of treatment effectiveness in neurology. Brain 2023; 146:4799-4808. [PMID: 37587541 PMCID: PMC10690012 DOI: 10.1093/brain/awad278] [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: 01/24/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Abstract
The capacity and power of data from cohorts, registries and randomized trials to provide answers to contemporary clinical questions in neurology has increased considerably over the past two decades. Novel sophisticated statistical methods are enabling us to harness these data to guide treatment decisions, but their complexity is making appraisal of clinical evidence increasingly demanding. In this review, we discuss several methodological aspects of contemporary research of treatment effectiveness in observational data in neurology, aimed at academic neurologists and analysts specializing in outcomes research. The review discusses specifics of the sources of observational data and their key features. It focuses on the limitations of observational data and study design, as well as statistical approaches aimed to overcome these limitations. Among the examples of leading clinical themes typically studied with analyses of observational data, the review discusses methodological approaches to comparative treatment effectiveness, development of diagnostic criteria and definitions of clinical outcomes. Finally, this review provides a brief summary of key points that will help clinical audience critically evaluate design and analytical aspects of studies of disease outcomes using observational data.
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Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, 3050, VIC, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, 3000, VIC, Australia
| | - Izanne Roos
- CORe, Department of Medicine, University of Melbourne, Melbourne, 3050, VIC, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, 3000, VIC, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Melbourne, 3050, VIC, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, 3000, VIC, Australia
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22
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Yahya EH, Khadija L, Nourrelhouda B, Nazik A, Latifa C, Siham EH. A Case Report of Rasmussen Encephalitis and its Stages: The Important Role of Imaging. Glob Pediatr Health 2023; 10:2333794X231214084. [PMID: 38033766 PMCID: PMC10685761 DOI: 10.1177/2333794x231214084] [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: 06/19/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
Relatively rare, Rasmussen encephalitis is a chronic inflammatory disease conditioning a single cerebral hemisphere. It is a progressive pathology with different stages clinically and on MRI. Therefore, imaging has an important role in evoking the diagnosis and also excluding other possible etiologies. We report a case of Rasmussen encephalitis with 2 different stages on MRI and also provide a review of the role of imaging in diagnostic criteria, differential diagnoses, and stages of this pathology.
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23
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Andzelm MM, Stredny CM. Mechanisms and Emerging Therapies for Treatment of Seizures in Pediatric Autoimmune Encephalitis and Autoinflammatory/Autoimmune-Associated Epilepsy. Rheum Dis Clin North Am 2023; 49:875-893. [PMID: 37821201 DOI: 10.1016/j.rdc.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There has been increasing understanding of the role of inflammation in seizures and epilepsy, as well as targeted immunomodulatory treatments. In children, immune-mediated seizures often present acutely in the setting of autoimmune encephalitis and are very responsive to immunotherapy with low rates of subsequent epilepsy. Conversely, seizures in autoimmune-associated epilepsies, such as Rasmussen syndrome, can remain refractory to multimodal therapy, including immunomodulation. In this review, the authors discuss the presentations of immune-mediated seizures in children, underlying mechanisms, and emerging therapies.
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Affiliation(s)
- Milena M Andzelm
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Cabreira V, Ferreira D, Melo C, Rebelo J, Fonseca J, Sousa R, Sampaio M. Child Neurology: Anti-Hu Encephalitis in an Adolescent With a Mediastinal Seminoma. Neurology 2023; 101:e1640-e1645. [PMID: 37527936 PMCID: PMC10585676 DOI: 10.1212/wnl.0000000000207673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 06/06/2023] [Indexed: 08/03/2023] Open
Abstract
Anti-Hu antibodies are associated with autoimmune syndromes, mainly limbic encephalitis, encephalomyelitis, and painful sensory polyneuropathy (Denny-Brown). We report the case of a 15-year-old boy presenting with epilepsia partialis continua (EPC) found to have a right middle frontal gyrus brain lesion without atrophy or contralateral involvement. After partial resection, neuropathology revealed neuronal loss, reactive gliosis and astrocytosis, and perivascular mononuclear inflammatory infiltrate and features of neuronophagia resembling Rasmussen encephalitis. Suboptimal response to antiseizure drugs and surgery prompted further workup with identification of positive serum anti-Hu antibodies and a mediastinal seminoma. The patient was treated with immunotherapy including steroids, IV immunoglobulin, azathioprine, rituximab, plasmapheresis, and mediastinal lesion resection. However, he continued to experience EPC and psychomotor impairment along with left hemiparesis and dysarthria. Given clinical progression with failure to respond to immunotherapy and antiseizure polytherapy, hemispherotomy was attempted and seizure freedom achieved. A review of the literature found only 16 cases of neurologic presentations associated with anti-Hu antibodies in children, confirming the rarity of EPC in these cases. Thus, this report provides a new observation of germ cell mediastinal tumor associated with anti-Hu antibodies in children, broadening the spectrum of anti-Hu-associated neurologic disorders in children and highlighting the importance of considering antineuronal antibody testing in children presenting with EPC and brain lesions suggestive of Rasmussen encephalitis.
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Affiliation(s)
- Veronica Cabreira
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Daniel Ferreira
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Cláudia Melo
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Rebelo
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jacinta Fonseca
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Raquel Sousa
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Mafalda Sampaio
- From the Neurology Department (V.C., D.F.), Centro Hospitalar Universitário de São João; Neurosciences and Mental Health Department (V.C., D.F.), Faculty of Medicine, University of Porto; Neuropediatrics Unit (C.M., J.F., R.S., M.S.), Pediatrics Department, Centro Hospitalar Universitário de São João; Department of Pediatrics and Gynecology-Obstetrics (C.M., J.F., R.S., M.S.), Faculty of Medicine, Universidade do Porto; and Pediatric Oncology Department (J.R.), Centro Hospitalar Universitário de São João, Porto, Portugal
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25
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Ahrendsen JT, Nong Y, Huo Y, Steele J, Anderson MP. CD8 cytotoxic T-cell infiltrates and cellular damage in the hypothalamus in human obesity. Acta Neuropathol Commun 2023; 11:163. [PMID: 37814324 PMCID: PMC10563257 DOI: 10.1186/s40478-023-01659-x] [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: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/11/2023] Open
Abstract
Rare cases of paraneoplastic obesity in children suggest sporadic obesity might also arise from an adaptive immune cell-mediated mechanism. Since the hypothalamus is a central regulator of feeding behavior and energy expenditure, we quantified lymphocytic inflammation in this region in a cohort of obese and non-obese human post-mortem brains. We report that CD8-positive cytotoxic T-cells are increased in hypothalamic median eminence/arcuate nucleus (ME/Arc) and bed nucleus of the stria terminalis in 40% of obese compared to non-obese patients, but not in other hypothalamic nuclei or brain regions. CD8 T-cells were most abundant in individuals with concurrent obesity and diabetes. Markers of cytotoxic T-cell induced damage, activated caspase 3 and poly-ADP ribose, were also elevated in the ME/Arc of obese patients. To provoke CD8 cytotoxic T-cell infiltrates in ventromedial region of hypothalamus in mice we performed stereotactic injections of an adeno-associated virus expressing immunogenic green fluorescent protein or saline. AAV but not saline injections triggered hypothalamic CD8 T-cell infiltrates associated with a rapid weight gain in mice recapitulating the findings in human obesity. This is the first description of the neuropathology of human obesity and when combined with its reconstitution in a mouse model suggests adaptive immunity may drive as much as 40% of the human condition.
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Affiliation(s)
- Jared T Ahrendsen
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yi Nong
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- Neuroscience Therapeutic Focus Area, Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | - Yuda Huo
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- Neuroscience Therapeutic Focus Area, Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | - Jasmine Steele
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew P Anderson
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
- Neuroscience Therapeutic Focus Area, Regeneron Pharmaceuticals, Tarrytown, NY, USA.
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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [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: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Alfonso MA, Piñeros-Fernández MC, Jaimes LF, Ramos NI. Atypical Rasmussen's Encephalitis. Cureus 2023; 15:e46647. [PMID: 37808599 PMCID: PMC10560088 DOI: 10.7759/cureus.46647] [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] [Accepted: 10/07/2023] [Indexed: 10/10/2023] Open
Abstract
A three-year-old female patient was admitted to our institution due to subacute fever, intermittent vomiting, persistent bilateral mydriasis after cycloplegia, right central facial palsy, and mild right hemiparesis with hyperreflexia. Brain MRI shows encephalitis in frontal, parietal, insular, and left putamen course and loss of cortical volume and white matter of the entire left hemisphere which are features described in Rasmussen's encephalitis (RE). Therapy with intravenous methylprednisolone bolus was initiated, with adequate clinical response. We consider in this case the diagnosis of atypical RE by imaging criteria in the subacute stage. There are few reports of atypical RE without epilepsy or continuous partial epilepsy. Our purpose is to present a case of a patient with RE images without epilepsy seizures and review the diagnostic and therapeutic approach of RE.
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Affiliation(s)
| | - Martha C Piñeros-Fernández
- Pediatric Neurology, Los Cobos Medical Center, Bogotá, COL
- Pediatric Neurology, Fundación Cardioinfantil - La Cardio, Bogotá, COL
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Kumar A, Krishnani H, Pande A, Jaiswal S, Meshram RJ. Rasmussen's Encephalitis: A Literary Review. Cureus 2023; 15:e47698. [PMID: 38022088 PMCID: PMC10676233 DOI: 10.7759/cureus.47698] [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: 08/19/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Usually affecting one hemisphere of the brain, Rasmussen's encephalitis (RE) is a persistent inflammatory disease of unclear origin. Rasmussen and colleagues presumed a viral etiology of the sickness in their first description. Later, the condition was linked to autoantibodies that were in the blood. Recently, it was shown that the cause of RE was a cytotoxic T-cell reaction to neurons. RE may be identified histopathologically by cortical inflammation, neuronal degeneration, and cerebral hemispheric-specific gliosis. The hemisphere is affected by increasing multilocular inflammation. To diagnose patients sooner and to evaluate whether the aforementioned phenomena are primary or secondary, it is essential to continue the search for a primary immunological or viral component. This information is crucial for determining the effectiveness of immunotherapy. RE-related seizures can only now be managed surgically. The only procedure that works is complete hemispheric disconnection (hemidisconnection), which may be done as either a (functional) hemispherectomy or hemispherectomy. Although thalidomide has been anecdotally reported, its safety profile prevents it from being used as a first-line treatment despite having a noticeable effect on the frequency and severity of seizures. Finding the disease's root causes more quickly by combining descriptive clinical studies, genetic testing, and early histological evaluation of RE tissue specimens to check for viral and autoimmune pathogenesis. Creating appropriate in vitro or animal models will enable the study of causality, perhaps directing clinical trials.
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Affiliation(s)
- Abhishek Kumar
- Medical Education, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshil Krishnani
- Medical Education, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arundhati Pande
- Medical Education, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Siddhant Jaiswal
- Medical Education, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Revat J Meshram
- Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Nava BC, Costa UT, Hamad APA, Garcia CAB, Sakamoto AC, Aragon DC, Machado HR, Santos MV. Long-term seizure outcome and mobility after surgical treatment for Rasmussen encephalitis in children: A single-center experience. Epileptic Disord 2023; 25:749-757. [PMID: 37589547 DOI: 10.1002/epd2.20147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Rasmussen Encephalitis (RE) is a rare inflammatory neurodegenerative disease associated with refractory seizures, hemiparesis, and cognitive deterioration, due to lateralized cortical atrophy. Hemispheric surgery (hemispherotomy) is the mainstay of treatment, but its unavoidable motor deficits and lack of long-term data regarding seizure outcomes can make patients and families apprehensive to undergo this procedure. The present study aimed at analyzing the results of surgical treatment for RE from a motor and epilepsy standpoint, and mitigate such concerns. METHODS Clinical and operative data were retrospectively collected from medical records of pharmacoresistant patients treated with functional hemispherectomy at a tertiary reference center for epilepsy surgery, during a 24-year period (1996-2020). Variables such as age of epilepsy onset, seizure semiology, seizure frequency, immunomodulatory therapy, age at surgery, duration of epilepsy, surgical procedures and complications, number of medications used preoperatively and postoperatively were described and statistically analyzed. RESULTS Forty-three (43) patients were included in this study. Mean age of epilepsy onset was 6.14 years, the average interval between epilepsy onset and hemispherotomy was 2.21 years. and the mean age at surgery was 8.28 years. Thirty patients (69.7%) were Engel I at their last follow-up, of whom 23 (56.4%) were Engel Ia, within a mean follow-up of 11.3 years. Duration of epilepsy, seizure frequency, and age at surgery, among others, did not correlate with seizure outcome, except the use of immunotherapy which led to worse outcomes (p < .05). Also, after surgery, motor functionality was significantly recovered (i.e., most patients returned to their previous status) with time. SIGNIFICANCE This study tackled some issues regarding the surgical treatment of this disease, particularly showing that hemispherotomy is safe and leads to potentially recoverable disability of motor functions while providing high rates of effective and long-lasting seizure control; therefore, early surgical indication should be warranted once medical refractoriness has been established.
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Affiliation(s)
- Brenda Cristina Nava
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ursula Thome Costa
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Paula Andrade Hamad
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Camila Araujo Bernardino Garcia
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Americo Ceiki Sakamoto
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Davi Casale Aragon
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Helio Rubens Machado
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcelo Volpon Santos
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Rada A, Bien CG. What is autoimmune encephalitis-associated epilepsy? Proposal of a practical definition. Epilepsia 2023; 64:2249-2255. [PMID: 37353891 DOI: 10.1111/epi.17699] [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: 04/12/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 06/25/2023]
Abstract
Seizures resulting from cerebral autoimmunity are either acutely symptomatic in the context of autoimmune encephalitis (AIE) with neural surface antibodies, or they are indicative of an enduring predisposition to seizures, that is, epilepsy. Here, we propose a practical definition for autoimmune encephalitis-associated epilepsy (AEAE): Seizures associated with antibodies against glutamic acid decarboxylase, paraneoplastic syndromes, or Rasmussen encephalitis are classified as AEAE. AEAE secondary to AIE with antibodies against the N-methyl-D-aspartate receptor, leucine-rich glioma inactivated protein 1, contactin-associated protein-2, or γ-aminobutyric acid-B receptor can be diagnosed if the following criteria are met: seizures persist for at least 2 years after immunotherapy initiation; no signs of encephalitis on magnetic resonance imaging and no fluorodeoxyglucose positron emission tomography hypermetabolism; normal cerebrospinal fluid cell count; and a substantial decrease in antibody titers. This classification corresponds to different disease mechanisms. While AIE results from the pathogenic effects of neural antibodies, AEAE is probably the consequence of encephalitis-related tissue damage and thereby mainly structurally mediated. The distinction between AIE and AEAE also has practical consequences: In AIE, immunotherapy is usually highly beneficial, whereas anti-seizure medication has little effect. In AEAE, immunotherapy is less promising and the usual anti-seizure interventions are preferable. In addition, the diagnosis of AEAE has social consequences in terms of driving and professional limitations.
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Affiliation(s)
- Anna Rada
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
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Consoli S, Dono F, Evangelista G, Corniello C, Onofrj M, Thomas A, Sensi SL. Case Report: Brain tumor's pitfalls: two cases of high-grade brain tumors mimicking autoimmune encephalitis with positive onconeuronal antibodies. Front Oncol 2023; 13:1254674. [PMID: 37692853 PMCID: PMC10484219 DOI: 10.3389/fonc.2023.1254674] [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: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 09/12/2023] Open
Abstract
Background Glioblastoma (GBM) is the most common primary brain tumor in adulthood. Initial diagnosis is generally based on clinical and MRI findings, which may be misinterpreted as other neurological pictures, including autoimmune encephalitis (AE). AE is a heterogeneous group of neuroinflammatory diseases due to the presence of auto-antibodies targeting antigens on neuronal synaptic or cell surface. In the present report, we describe two peculiar cases of GBM initially misdiagnosed as AE, focusing on the diagnostic pitfalls and the treatment strategies. Methods We report the case of two patients with high-grade brain tumors, initially misdiagnosed and treated for AE. Clinical, laboratory, and neuroradiological data are discussed in terms of differential diagnosis between AE and GBM. Results The presence of atypical brain MRI findings and the unresponsiveness to immunosuppressive treatment are major red flags in the differential diagnosis between AE and GBM. In these cases, a brain biopsy is necessary to confirm the diagnosis. Conclusions Atypical brain tumor presentation causes a diagnostic and therapeutic delay. A positive onconeural autoantibodies result should always be interpreted cautiously, considering the possibility of a false-positive test. A brain biopsy is mandatory for a definite diagnosis.
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Affiliation(s)
- Stefano Consoli
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
- Epilepsy Center, “SS Annunziata” Hospital, Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
- Epilepsy Center, “SS Annunziata” Hospital, Chieti, Italy
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
- Epilepsy Center, “SS Annunziata” Hospital, Chieti, Italy
| | - Clarissa Corniello
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
- Epilepsy Center, “SS Annunziata” Hospital, Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Stefano L. Sensi
- Department of Neuroscience, Imaging and Clinical Science, “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
- Institute for Advanced Biomedical Technologies, University of Chieti-Pescara, Chieti, Italy
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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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Jaafar F, Obeid M, Beydoun A. Role of Early Intravenous Immunoglobulins in Halting Clinical and Radiographic Disease Progression in Rasmussen Encephalitis. Pediatr Neurol 2023; 145:30-35. [PMID: 37269621 DOI: 10.1016/j.pediatrneurol.2023.05.003] [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: 08/17/2022] [Revised: 03/29/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is a rare progressive presumed autoimmune disorder characterized by pharmacoresistant epilepsy and progressive motor and cognitive deterioration. Despite immunomodulation, more than half of the patients with RE ultimately require functional hemispherotomy. In this study, we evaluated the potential beneficial effects of early initiation of immunomodulation in slowing disease progression and preventing the need for surgical interventions. METHODS A retrospective chart review over a 10-year period was conducted at the American University of Beirut Medical Center to identify patients with RE. Data were collected on seizure characteristics, neurological deficits, electroencephalography, brain magnetic resonance imaging results (including volumetric analyses for an objective assessment of radiographic progression), and treatment modalities. RESULTS Seven patients met the inclusion criteria for RE. All patients received intravenous immunoglobulins (IVIGs) as soon as the diagnosis was entertained. Five patients with only monthly to weekly seizures at the time of IVIG initiation had favorable outcomes without resorting to surgery, along with a relative preservation of the gray matter volumes in the affected cerebral hemispheres. Motor strength was preserved in those patients, and three were seizure free at their last follow-up visit. The two patients who required hemispherotomy were already severely hemiparetic and experiencing daily seizures at the time of IVIG initiation. CONCLUSIONS Our data suggest that the early initiation of IVIG as soon as a diagnosis of RE is suspected, and particularly before the appearance of motor deficits and intractable seizures, can maximize the beneficial effects of immunomodulation in terms of controlling seizures and reducing the rate of cerebral atrophy.
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Affiliation(s)
- Fatima Jaafar
- Division of Child Neurology, Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Makram Obeid
- Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
| | - Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon.
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Pechlivanidou M, Ninou E, Karagiorgou K, Tsantila A, Mantegazza R, Francesca A, Furlan R, Dudeck L, Steiner J, Tzartos J, Tzartos S. Autoimmunity to Neuronal Nicotinic Acetylcholine Receptors. Pharmacol Res 2023; 192:106790. [PMID: 37164280 DOI: 10.1016/j.phrs.2023.106790] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Nicotinic acetylcholine receptors (nAChRs) are widely expressed in many and diverse cell types, participating in various functions of cells, tissues and systems. In this review, we focus on the autoimmunity against neuronal nAChRs, the specific autoantibodies and their mechanisms of pathological action in selected autoimmune diseases. We summarize the current relevant knowledge from human diseases as well as from experimental models of autoimmune neurological disorders related to antibodies against neuronal nAChR subunits. Despite the well-studied high immunogenicity of the muscle nAChRs where autoantibodies are the main pathogen of myasthenia gravis, autoimmunity to neuronal nAChRs seems infrequent, except for the autoantibodies to the ganglionic receptor, the α3 subunit containing nAChR (α3-nAChR), which are detected and are likely pathogenic in Autoimmune Autonomic Ganglionopathy (AAG). We describe the detection, presence and function of these antibodies and especially the recent development of a cell-based assay (CBA) which, contrary to until recently available assays, is highly specific for AAG. Rare reports of autoantibodies to the other neuronal nAChR subtypes include a few cases of antibodies to α7 and/or α4β2 nAChRs in Rasmussen encephalitis, schizophrenia, autoimmune meningoencephalomyelitis, and in some myasthenia gravis patients with concurrent CNS symptoms. Neuronal-type nAChRs are also present in several non-excitable tissues, however the presence and possible role of antibodies against them needs further verification. It is likely that the future development of more sensitive and disease-specific assays would reveal that neuronal nAChR autoantibodies are much more frequent and may explain the mechanisms of some seronegative autoimmune diseases.
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Affiliation(s)
| | | | - Katerina Karagiorgou
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andreetta Francesca
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Rozzano, Milan, Italy; Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Leon Dudeck
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Center for Health and Medical Prevention (CHaMP), Magdeburg, Germany; German Center for Mental Health DZPG, Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health C-I-R-C, Halle-Jena-Magdeburg, Germany
| | - John Tzartos
- 2(nd) Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece; Department of Pharmacy, University of Patras, Patras, Greece.
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Eid T. Exploring CITEs of Inflammation in the Human Epilepsy Brain. Epilepsy Curr 2023; 23:191-192. [PMID: 37334410 PMCID: PMC10273812 DOI: 10.1177/15357597231161460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023] Open
Abstract
Single-Cell Transcriptomics and Surface Epitope Detection in Human Brain Epileptic Lesions Identifies Pro-Inflammatory Signaling Kumar P, Lim A, Hazirah SN, Chua CJH, Ngoh A, Poh SL, Yeo TH, Lim J, Ling S, Sutamam NB, Petretto E, Low DCY, Zeng L, Tan EK, Arkachaisri T, Yeo JG, Ginhoux F, Chan D, Albani S. Nat Neurosci. 2022;25(7):956-966. doi:10.1038/s41593-022-01095-5 Epileptogenic triggers are multifactorial and not well understood. Here we aimed to address the hypothesis that inappropriate pro-inflammatory mechanisms contribute to the pathogenesis of refractory epilepsy (non-responsiveness to antiepileptic drugs) in human patients. We used single-cell cellular indexing of transcriptomes and epitopes by sequencing (CITE-seq) to reveal the immunotranscriptome of surgically resected epileptic lesion tissues. Our approach uncovered a pro-inflammatory microenvironment, including extensive activation of microglia and infiltration of other pro-inflammatory immune cells. These findings were supported by ligand-receptor (LR) interactome analysis, which demonstrated potential mechanisms of infiltration and evidence of direct physical interactions between microglia and T cells. Together, these data provide insight into the immune microenvironment in epileptic tissue, which may aid the development of new therapeutics.
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Affiliation(s)
- Tore Eid
- Professor Department of Laboratory Medicine Yale School of Medicine
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Bangel KA, Pang K, Baker MR. Cathodal Transcranial Direct Current Stimulation for Treatment of Rasmussen Encephalitis. Neurology 2023; 100:484-485. [PMID: 36460475 PMCID: PMC9990854 DOI: 10.1212/wnl.0000000000201644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/18/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Katrin A Bangel
- From the Translational and Clinical Research Institute (K.A.B., K.P., M.R.B.), Newcastle University, The Medical School, Framlington Place; Department of Northern Medical Physics & Clinical Engineering (K.A.B.), Newcastle Hospitals NHS Foundation Trust; Department of Paediatric Neurology (K.P.), The Great North Children's Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne; and Department of Clinical Neurophysiology (M.R.B.), Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom.
| | - Ki Pang
- From the Translational and Clinical Research Institute (K.A.B., K.P., M.R.B.), Newcastle University, The Medical School, Framlington Place; Department of Northern Medical Physics & Clinical Engineering (K.A.B.), Newcastle Hospitals NHS Foundation Trust; Department of Paediatric Neurology (K.P.), The Great North Children's Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne; and Department of Clinical Neurophysiology (M.R.B.), Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Mark R Baker
- From the Translational and Clinical Research Institute (K.A.B., K.P., M.R.B.), Newcastle University, The Medical School, Framlington Place; Department of Northern Medical Physics & Clinical Engineering (K.A.B.), Newcastle Hospitals NHS Foundation Trust; Department of Paediatric Neurology (K.P.), The Great North Children's Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne; and Department of Clinical Neurophysiology (M.R.B.), Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
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Thomé U, Machado HR, Santos MV, Santos AC, Wichert-Ana L. Early Positive Brain 18F-FDG PET and Negative MRI in Rasmussen Encephalitis. Clin Nucl Med 2023; 48:240-241. [PMID: 36723884 DOI: 10.1097/rlu.0000000000004521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
ABSTRACT A 15-year-old adolescent boy with left body epilepsia partialis continua, hemiparesis, and electroencephalogram abnormalities lateralized to the right hemisphere. MRI finding was small hyperintense signal in the left putamen. 18F-FDG PET showed focal glucose hypermetabolism in the right paracentral lobule and hypometabolism in the inferior right frontal and precentral gyri. One month later, a new MRI showed a hyperintense signal over the paracentral lobule. Biopsy on this region confirmed the diagnosis of Rasmussen encephalitis. This patient finally underwent right hemispherotomy and became seizure free. This case emphasize the PET as an important early tool for the diagnosis of Rasmussen encephalitis.
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Affiliation(s)
- Ursula Thomé
- From the Epilepsy Surgery Center, Department of Neuroscience and Behavioral Sciences
| | | | | | - Antonio Carlos Santos
- Magnetic Resonance Laboratory, Department of Medical Imaging, Hematology, and Clinical Oncology
| | - Lauro Wichert-Ana
- Nuclear Medicine and PET/CT Laboratory, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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Flammer J, Neziraj T, Rüegg S, Pröbstel AK. Immune Mechanisms in Epileptogenesis: Update on Diagnosis and Treatment of Autoimmune Epilepsy Syndromes. Drugs 2023; 83:135-158. [PMID: 36696027 PMCID: PMC9875200 DOI: 10.1007/s40265-022-01826-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/26/2023]
Abstract
Seizures and epilepsy can result from various aetiologies, yet the underlying cause of several epileptic syndromes remains unclear. In that regard, autoimmune-mediated pathophysiological mechanisms have been gaining attention in the past years and were included as one of the six aetiologies of seizures in the most recent classification of the International League Against Epilepsy. The increasing number of anti-neuronal antibodies identified in patients with encephalitic disorders has contributed to the establishment of an immune-mediated pathophysiology in many cases of unclear aetiology of epileptic syndromes. Yet only a small number of patients with autoimmune encephalitis develop epilepsy in the proper sense where the brain transforms into a state where it will acquire the enduring propensity to produce seizures if it is not hindered by interventions. Hence, the term autoimmune epilepsy is often wrongfully used in the context of autoimmune encephalitis since most of the seizures are acute encephalitis-associated and will abate as soon as the encephalitis is in remission. Given the overlapping clinical presentation of immune-mediated seizures originating from different aetiologies, a clear distinction among the aetiological entities is crucial when it comes to discussing pathophysiological mechanisms, therapeutic options, and long-term prognosis of patients. Moreover, a rapid and accurate identification of patients with immune-mediated epilepsy syndromes is required to ensure an early targeted treatment and, thereby, improve clinical outcome. In this article, we review our current understanding of pathogenesis and critically discuss current and potential novel treatment options for seizures and epilepsy syndromes of underlying or suspected immune-mediated origin. We further outline the challenges in proper terminology.
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Affiliation(s)
- Julia Flammer
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.,Departments of Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tradite Neziraj
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.,Departments of Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
| | - Anne-Katrin Pröbstel
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland. .,Departments of Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland. .,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland.
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Budhram A, Burneo JG. Acute symptomatic seizures, epilepsy, and autoimmune encephalitis: Clarifying terminology in neural antibody-associated disease. Epilepsia 2023; 64:306-310. [PMID: 36471647 PMCID: PMC10107142 DOI: 10.1111/epi.17478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Jorge G Burneo
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
- Neuroepidemiology Unit, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Dhawan S, Rathod NR, Dhok A, Mitra K, Chordiya R. Dyke-Davidoff-Masson Syndrome: A Classic Case Report. Cureus 2023; 15:e34570. [PMID: 36874310 PMCID: PMC9981480 DOI: 10.7759/cureus.34570] [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] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
Dyke-Davidoff-Masson syndrome (DDMS) is a rare neurological disorder found in children as well as adults. It is characterized by hemi cerebral atrophy. To date, very few cases of this disorder have been reported. Radiological imaging including magnetic resonance imaging (MRI) and computed tomography (CT) are accurate tools for the diagnosis of DDMS. We present a case of a 13-year-old female child who came with complaints of multiple episodes of generalized tonic-clonic seizures. In our case, clinical history and imaging with CT and MRI were accurate enough to diagnose DDMS.
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Affiliation(s)
- Suruchi Dhawan
- Radiodiagnosis, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
| | - Nitin R Rathod
- Radiodiagnosis, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
| | - Avinash Dhok
- Radiodiagnosis, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
| | - Kajal Mitra
- Radiodiagnosis, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
| | - Rushabh Chordiya
- Radiodiagnosis, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
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Fortunato F, Giugno A, Sammarra I, Labate A, Gambardella A. Epilepsy, Immunity and Neuropsychiatric Disorders. Curr Neuropharmacol 2023; 21:1714-1735. [PMID: 35794773 PMCID: PMC10514543 DOI: 10.2174/1570159x20666220706094651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.
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Affiliation(s)
- Francesco Fortunato
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Alessia Giugno
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Ilaria Sammarra
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Angelo Labate
- BIOMORF Department, Neurology Unit, University of Messina, Messina, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
- Institute of Molecular Bioimaging and Physiology, National Research Council, I-88100 Catanzaro, Italy
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Akazawa M, Yan G, Hirai R, Kitagawa H. Anesthetic Management with Propofol in a Patient with Rasmussen's Encephalitis Complicated by Intractable Partial-Onset Epileptic Seizures: A Case Report. Case Rep Neurol 2023; 15:233-237. [PMID: 38022391 PMCID: PMC10651179 DOI: 10.1159/000534754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Rasmussen's encephalitis (RE) is a progressive and chronic ailment characterized by drug-resistant epileptic seizures. RE is uncommon, and no documented accounts of its anesthetic management exist. Anesthetic management without causing epileptic seizures is important in RE. Here, we present a case of safe anesthetic management in a pediatric patient with RE. Case Presentation A 7-year-old boy who was diagnosed with RE at the age of 6 years was scheduled for supernumerary tooth extraction under general anesthesia. The patient was being treated with prednisolone, sodium valproate, zonisamide, lacosamide, and famotidine. Despite receiving antiepileptic therapy, the patient experienced partial epileptic seizures several times per week. The seizures presented as numbness in his right hand and progressed to tonic-clonic seizures affecting the right side of his body. On the day of the surgical procedure, the patient was administered regular doses of antiepileptic drugs and prednisolone. Anesthesia was induced and maintained using a combination of propofol, remifentanil, and rocuronium. The surgical procedure was successfully performed, and the patient awakened smoothly from anesthesia. No epileptic seizures were observed intra- or postoperatively. Conclusion RE typically presents with drug-resistant seizures and the initial symptoms are usually refractory partial seizures. Propofol is well-established as a treatment option for refractory status epilepticus, and it reduces the frequency of spikes in patients with partial epilepsy. In this case, general anesthesia without epileptic seizures was achieved using propofol.
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Affiliation(s)
- Mai Akazawa
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Japan
| | - Guoshan Yan
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Japan
| | - Rina Hirai
- Department of Oral and Maxillofacial Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Hirotoshi Kitagawa
- Department of Anesthesiology, Shiga University of Medical Science, Otsu, Japan
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A Special Case of Relapsing-Remitting Bilateral Encephalitis: Without Epilepsy, but Responding to Rituximab and with a Brain Biopsy Coinciding with Rasmussen Encephalitis. Brain Sci 2022; 13:brainsci13010017. [PMID: 36671998 PMCID: PMC9856488 DOI: 10.3390/brainsci13010017] [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: 10/17/2022] [Revised: 12/05/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
A nine-year-old boy manifested with headache, progressive mild cognitive decline and hemiparesis, but without clinical epileptic seizures (with abnormal EEG waves). Brain magnetic resonance imaging (MRI) showed bilateral cortical lesions mainly on the right hemisphere, and new lesions developed in frontal, parietal, occipital and temporal lobes around the old lesions presenting as a lace-like or ring-like enhancement in T1 with contrast over a disease course of five years. A suspected diagnosis of primary angiitis of the central nervous system was initially considered. Treated with high-dose corticosteroids, intravenous immunoglobulins and monthly pulse cyclophosphamide, his symptoms worsened with the intracranial lesion progression. Brain biopsy of the right frontal lobe was performed nearly five years after onset; prominent neuronal loss, a microglial nodule, as well as parenchymal and perivascular lymphocytic infiltrate within the cortex were found, which coincided with RE pathology changes. Encouragingly, after a regimen of rituximab, lesions on the follow-up brain MRI tended to be stable. Apparently, it was immune-mediated, but did not strictly fit any known disease entity, although it was similar to RE. We summarize this unique case, including clinical characteristics, imaging and pathology findings. We also discuss the diagnosis and treatment, focusing on comparison to RE as well as other possible neurological diseases.
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Borne A, Perrone-Bertolotti M, Jambaqué I, Castaignède C, Dorfmüller G, Ferrand-Sorbets S, Baciu M, Bulteau C. Cognitive outcome after left functional hemispherectomy on dominant hemisphere in patients with Rasmussen encephalitis: beyond the myth of aphasia. Patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22410. [PMID: 36443955 PMCID: PMC9705523 DOI: 10.3171/case22410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Rasmussen encephalitis is a rare chronic neurological pathology frequently treated with functional hemispherectomy (or hemispherotomy). This surgical procedure frees patients of their severe epilepsy associated with the disease but may induce cognitive disorders and notably language alterations after disconnection of the left hemisphere. OBSERVATIONS The authors describe longitudinally 3 cases of female patients with Rasmussen encephalitis who underwent left hemispherotomy in childhood and benefited from a favorable cognitive outcome. In the first patient, the hemispherotomy occurred at a young age, and the recovery of language and cognitive abilities was rapid and efficient. The second patient benefited from the surgery later in childhood. In addition, she presented a reorganization of language and memory functions that seem to have been at the expense of nonverbal ones. The third patient was a teenager during surgery. She benefited from a more partial cognitive recovery with persistent disorders several years after the surgery. LESSONS Recovery of cognitive functions, including language, occurs after left hemispherotomy, even when performed late in childhood. Therefore, the surgery should be considered as early as possible to promote intercognitive reorganization.
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Affiliation(s)
- Anna Borne
- University of Grenoble Alpes, CNRS, LPNC, Grenoble, France
| | | | - Isabelle Jambaqué
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
- University of Paris Cité, MCLab, Institute of Psychology, Boulogne-Billancourt, France
| | - Clémence Castaignède
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
| | - Georg Dorfmüller
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
| | - Sarah Ferrand-Sorbets
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
| | - Monica Baciu
- University of Grenoble Alpes, CNRS, LPNC, Grenoble, France
| | - Christine Bulteau
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
- University of Paris Cité, MCLab, Institute of Psychology, Boulogne-Billancourt, France
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Molecular and spatial heterogeneity of microglia in Rasmussen encephalitis. Acta Neuropathol Commun 2022; 10:168. [PMID: 36411471 PMCID: PMC9677917 DOI: 10.1186/s40478-022-01472-y] [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: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/22/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare childhood neurological disease characterized by progressive unilateral loss of function, hemispheric atrophy and drug-resistant epilepsy. Affected brain tissue shows signs of infiltrating cytotoxic T-cells, microglial activation, and neuronal death, implicating an inflammatory disease process. Recent studies have identified molecular correlates of inflammation in RE, but cell-type-specific mechanisms remain unclear. We used single-nucleus RNA-sequencing (snRNA-seq) to assess gene expression across multiple cell types in brain tissue resected from two children with RE. We found transcriptionally distinct microglial populations enriched in RE compared to two age-matched individuals with unaffected brain tissue and two individuals with Type I focal cortical dysplasia (FCD). Specifically, microglia in RE tissues demonstrated increased expression of genes associated with cytokine signaling, interferon-mediated pathways, and T-cell activation. We extended these findings using spatial proteomic analysis of tissue from four surgical resections to examine expression profiles of microglia within their pathological context. Microglia that were spatially aggregated into nodules had increased expression of dynamic immune regulatory markers (PD-L1, CD14, CD11c), T-cell activation markers (CD40, CD80) and were physically located near distinct CD4+ and CD8+ lymphocyte populations. These findings help elucidate the complex immune microenvironment of RE.
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Ismail FS, Faustmann PM, Kümmel ML, Förster E, Faustmann TJ, Corvace F. Brivaracetam exhibits mild pro-inflammatory features in an in vitro astrocyte-microglia co-culture model of inflammation. Front Cell Neurosci 2022; 16:995861. [DOI: 10.3389/fncel.2022.995861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Implications of glia in the pathophysiology of epilepsy raise the question of how these cells besides neurons are responsive to antiseizure medications (ASMs). Understanding ASM effects on glia and glia-mediated inflammation may help to explore astrocytes and microglia as potential targets for alternative anti-epileptogenic therapies. The aim of this study was to investigate the effects of the new generation ASM brivaracetam (BRV) in an astrocyte-microglia co-culture model of inflammation. Primary rat astrocytes co-cultures containing 5%–10% (M5, “physiological” conditions) or 30%–40% (M30, “pathological inflammatory” conditions) of microglia were treated with different concentrations of BRV (0.5, 2, 10, and 20 μg/ml) for 24 h. Glial cell viability was measured by MTT assay. Microglial activation states were analyzed by immunocytochemistry and astroglial connexin 43 (Cx43) expression by Western blot analysis and immunocytochemistry. Gap-junctional coupling was studied via Scrape Loading. Incubation with high, overdose concentration (20 μg/ml) of BRV significantly reduced the glial cell viability under physiological conditions (p < 0.01: **). Treatment with BRV in therapeutic concentrations (0.5 and 2 μg/ml) reduced the resting microglia (p < 0.05: *) and increased the microglial activation under inflammatory conditions (p < 0.01: **). Astroglial Cx43 expression was not affected. The gap-junctional coupling significantly increased only by 0.5 μg/ml BRV under physiological conditions (p < 0.05: *). Our findings suggest mild pro-inflammatory, in vitro features of BRV with regard to microglia morphology. BRV showed no effects on Cx43 expression and only limited effects on gap-junctional coupling. Reduction of glial viability by overdose BRV indicates possible toxic effects.
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Tang C, Yang W, Luan G. Progress in pathogenesis and therapy of Rasmussen's encephalitis. Acta Neurol Scand 2022; 146:761-766. [PMID: 36189924 DOI: 10.1111/ane.13712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/20/2022] [Indexed: 01/15/2023]
Abstract
Rasmussen's encephalitis (RE) is a rare condition of unknown etiology that causes a severe chronically neurological disorder with mostly affecting children. The main clinical feature of RE includes frequent seizures with drug-resistant, unilateral hemispheric atrophy, and progressive neurological deficits. In this review, we summarized five pathogenesis on the basis of the current research including virus infection, antibody-mediated degeneration, cell-mediated immunity, microglia-induced degeneration, and genetic mutations. So far, no exact virus in RE brain tissue or definite antigen in humoral immune system was confirmed as the determined etiology. The importance of cytotoxic CD8+ T lymphocytes and activated microglial and the role of their immune mechanism in RE development are gradually emerging with the deep study. Genetic researches support the notion that the pathogenesis of RE is probably associated with single nucleotide polymorphisms on immune-related genes, which is driven by affecting inherent antiretroviral innate immunity. Recent advances in treatment suggest immunotherapy could partially slows down the progression of RE according to the histopathology and clinical presentation, which aimed at the initial damage to the brain by T cells and microglia in the early stage. However, the cerebral hemispherectomy is an effective means to controlling the intractable seizure, which is accompanied by neurological complications inevitably. So, the optimal timing for surgical intervention is still a challenge for RE patient. On the contrary, exploration on other aspects of pathogenesis such as dysfunction of adenosine system may offer a new therapeutic option for the treatment of RE in future.
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Affiliation(s)
- Chongyang Tang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Wei Yang
- Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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Foss CA, Ordonez AA, Naik R, Das D, Hall A, Wu Y, Dannals RF, Jain SK, Pomper MG, Horti AG. PET/CT imaging of CSF1R in a mouse model of tuberculosis. Eur J Nucl Med Mol Imaging 2022; 49:4088-4096. [PMID: 35713665 PMCID: PMC9922090 DOI: 10.1007/s00259-022-05862-1] [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: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE Macrophages represent an essential means of sequestration and immune evasion for Mycobacterium tuberculosis. Pulmonary tuberculosis (TB) is characterized by dense collections of tissue-specific and recruited macrophages, both of which abundantly express CSF1R on their outer surface. 4-Cyano-N-(5-(1-(dimethylglycyl)piperidin-4-yl)-2',3',4',5'-tetrahydro-[1,1'-biphenyl]-2-yl)-1H-imidazole-2-carboxamide (JNJ-28312141) is a reported high affinity, CSF1R-selective antagonist. We report the radiosynthesis of 4-cyano-N-(5-(1-(N-methyl-N-([11C]methyl)glycyl)piperidin-4-yl)-2',3',4',5'-tetrahydro-[1,1'-biphenyl]-2-yl)-1H-imidazole-2-carboxamide ([11C]JNJ-28312141) and non-invasive detection of granulomatous and diffuse lesions in a mouse model of TB using positron emission tomography (PET). METHODS Nor-methyl-JNJ-28312141 precursor was radiolabeled with [11C]iodomethane to produce [11C]JNJ-28312141. PET/CT imaging was performed in the C3HeB/FeJ murine model of chronic pulmonary TB to co-localize radiotracer uptake with granulomatous lesions observed on CT. Additionally, CSF1R, Iba1 fluorescence immunohistochemistry was performed to co-localize CSF1R target with reactive macrophages in infected and healthy mice. RESULTS Radiosynthesis of [11C]JNJ-28312141 averaged a non-decay-corrected yield of 18.7 ± 2.1%, radiochemical purity of 99%, and specific activity averaging 658 ± 141 GBq/µmol at the end-of-synthesis. PET/CT imaging in healthy mice showed hepatobiliary [13.39-25.34% ID/g, percentage of injected dose per gram of tissue (ID/g)] and kidney uptake (12.35% ID/g) at 40-50 min post-injection. Infected mice showed focal pulmonary lesion uptake (5.58-12.49% ID/g), hepatobiliary uptake (15.30-40.50% ID/g), cervical node uptake, and renal uptake (11.66-29.33% ID/g). The ratio of infected lesioned lung/healthy lung uptake is 5.91:1, while the ratio of lesion uptake to adjacent infected radiolucent lung is 2.8:1. Pre-administration of 1 mg/kg of unlabeled JNJ-28312141 with [11C]JNJ-28312141 in infected animals resulted in substantial blockade. Fluorescence microscopy of infected and uninfected whole lung sections exclusively co-localized CSF1R staining with abundant Iba1 + macrophages. Healthy lung exhibited no CSF1R staining and very few Iba1 + macrophages. CONCLUSION [11C]JNJ-28312141 binds specifically to CSF1R + macrophages and delineates granulomatous foci of disease in a murine model of pulmonary TB.
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Affiliation(s)
- Catherine A Foss
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA.
- Department of Pediatrics, Center for Infection and Inflammation Imaging Research, Baltimore, MD, USA.
| | - Alvaro A Ordonez
- Department of Pediatrics, Center for Infection and Inflammation Imaging Research, Baltimore, MD, USA
| | - Ravi Naik
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Deepankar Das
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew Hall
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Yunkou Wu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Robert F Dannals
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Sanjay K Jain
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
- Department of Pediatrics, Center for Infection and Inflammation Imaging Research, Baltimore, MD, USA
| | - Martin G Pomper
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew G Horti
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
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Sharma S, Dhakal P, Aryal S, Bhandari S, Sharma A. Role of diagnostic imaging in Rasmussen's encephalitis – A case report from Nepal. Radiol Case Rep 2022; 17:3587-3590. [PMID: 35923344 PMCID: PMC9340115 DOI: 10.1016/j.radcr.2022.06.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/26/2022] [Indexed: 12/04/2022] Open
Abstract
Rasmussen's encephalitis (RE) is a relatively rare chronic inflammatory neurological disease that usually only affects one hemisphere of the brain. It primarily affects children under the age of 10, although it can also affect teens and adults, causing drug-resistant seizures, progressive hemiparesis, and dementia. RE presents as a challenging diagnosis with MRI as the cornerstone of the evaluation and nuclear imaging as a complementary tool. We'd like to present a case of a 12-year-old girl who was diagnosed with RE after an MRI. In this study, we examine the diagnostic criteria, differential diagnoses, and issues that underpin the diagnostic challenge in great detail.
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50
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Galym A, Akhmetova N, Zhaksybek M, Safina S, Boldyreva MN, Rakhimbekova FK, Idrissova ZR. Clinical and Genetic Analysis in Pediatric Patients with Multiple Sclerosis and Related Conditions: Focus on DR Genes of the Major Histocompatibility Complex. Open Neurol J 2022. [DOI: 10.2174/1874205x-v16-e2207200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction:
There are several diseases recognized as variants of MS: post-infectious acute disseminated encephalitis, multiple sclerosis (MS), Rasmussen leukoencephalitis and Schilder's leukoencephalitis and related, but separate neuroimmune condition – Neuromyelitis Devic’s. In Kazakhstan diagnosis of such diseases was rare and immune modified treatment was only admitted after the age of 18. Clinical and immunogenetic study of MS spectrum diseases in Kazakhstan would allow to justify early targeted treatment.
Objective:
The aim of the study was to investigate genes of the main complex of human histocompatibility (MHC) associated with diseases of MS spectrum in Kazakhstani population.
Methods:
Complex clinical, neuroimaging and immunogenetic studies were performed in 34 children (24 girls, 10 boys) aged 4 to 18 years. 21 children were diagnosed with MS (11 Kazakh origin and 10 – Russian; 4 boys, 17 girls), 7 with leucoencephalitis (all Kazakh, 5 boys, 2 girls) and 6 with Devic neuromyelitis optica (all Kazakh, 1 boy, 5 girls). Genotyping of HLA DRB1, DQA1, DQB1 genes was performed for all patients.
Results:
MS group was characterized by classical relapsing-remitting MS. Predominant haplotype as a linkage complex was DRB1*15:01~DQA1*01:02~DQB1*06:02 in 20 (47.6%) of 42 DR-alleles, in 16 (76.2%) patients. MS relative risk (RR) was 13,36 for ethnic Kazakhs and RR=5,55 in Russians.
Leukoencephalitis had 7 children, with 28.6% mortality rate. The haplotype DRB1*15:01~DQA1*01:02~DQB1*06:02 as a linkage complex was detected 3 patients (4 alleles), RR=5,88.
Devic’s neuromyelitis optica (NMO) clinical course was characterized by fast and prolonged progression. There was predominance of DRB1*14 allele with RR=3,38.
Conclusion:
Summarizing, in the Kazakh population the haplotype DRB1*15:01∼DQA1*01:02∼DQB1*06:02 as a linkage complex was associated with prediction to MS and leukoencephalitis, but not to Devic’s NMO. Our study highlights the importance of awareness of MS and related disorders diagnosis which allows to implement early admission of disease-modified treatment in pediatric MS in Kazakhstan.
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