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Griffith SP, Wesselingh R, Seery N, Rushen T, Kyndt C, Long B, Seneviratne U, Kalincik T, Buzzard K, Butzkueven H, O'Brien TJ, Alpitsis R, Malpas CB, Monif M. Memory function in autoimmune encephalitis: a cross-sectional prospective study utilising multiple memory paradigms. J Neurol 2024:10.1007/s00415-024-12520-z. [PMID: 38918245 DOI: 10.1007/s00415-024-12520-z] [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: 03/19/2024] [Revised: 06/10/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND AND OBJECTIVE Autoimmune encephalitis (AE) is often associated with clinically significant memory impairment. This study aimed to evaluate memory in a cross-sectional prospective AE cohort using multiple memory paradigms. METHODS 52 patients (50% seropositive) meeting Graus criteria for possible AE were prospectively recruited between October 2019 and August 202. A comprehensive examination of memory was performed, including tests of supraspan verbal memory (list learning), logicosemantic memory (story learning), figural memory (learning of geometric designs), and verbal associative learning (verbal paired associates). Memory scores were compared to demographically adjusted normative data. Pattern analysis was conducted to assist in the identification of patterns in memory performances. RESULTS Mean memory scores were not significantly below the normative mean. At an individual patient level, over 20% of the cohort exhibited impaired delayed figural memory, supraspan verbal memory learning and recall. Observed performances were significantly below expected performance for story learning (p = 0.017) and recall (p = 0.003), figural recall (p < 0.0001), initial acquisition (p < 0.001) and final acquisition of a list (p < 0.001) and all delayed recall measures of the list (p < 0.00001). 54.76% of patients exhibited intact psychometrics, and 16 distinct patterns of impairment emerged, indicating variability in memory outcomes. DISCUSSION While statistical evidence for memory impairment did not emerge at an aggregate level, a proportion of patients present with evidence of abnormal memory performance on psychometrics. Variability in impaired memory measures argues for an individualised patient-focused approach to clinical assessment in AE. Future research should validate these findings with a larger sample size and explore the relationships between memory profiles and other cognitive functions.
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Affiliation(s)
- Sarah P Griffith
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Robb Wesselingh
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Nabil Seery
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Tiffany Rushen
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Chris Kyndt
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia
- Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Brian Long
- Neuropsychology Unit, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Udaya Seneviratne
- Department of Neurosciences, Monash Health, Clayton Road, Clayton, VIC, 3168, Australia
| | - Tomas Kalincik
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia
- CoRE, Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Terence J O'Brien
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Rubina Alpitsis
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Charles B Malpas
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia
- CoRE, Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia
- Melbourne School of Psychological Sciences, The University of Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia.
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Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Autoimmune Encephalitis. J Clin Neurol 2024; 20:3-22. [PMID: 38179628 PMCID: PMC10782092 DOI: 10.3988/jcn.2023.0242] [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: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.
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Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA.
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France
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3
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Galioto R, Grezmak T, Swetlik C, Abbatemarco JR, Titulaer MJ, Finke C, Kunchok A. Neuropsychological Testing in Autoimmune Encephalitis: A Scoping Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200179. [PMID: 37949665 PMCID: PMC10691228 DOI: 10.1212/nxi.0000000000200179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Identifying optimal methods for evaluation and monitoring of cognitive outcomes in AE is important for clinical care and research. This scoping review aimed to evaluate neuropsychological tests (NPT) that are most frequently impaired in AE cohorts to provide recommendations for a standardized NPT battery for AE outcome. METHODS PubMed search for studies examining NPT in patients with AE was conducted on June 9, 2023. Studies were screened for inclusion/exclusion criteria as follows: at least 1 NPT, individual NPT test scores with comparison with healthy controls or normative data and neural-IgG status, total sample size ≥5, and English manuscript available. RESULTS The search yielded 5,393 studies, of which 3,359 were screened, 107 were full text reviewed, and 32 met inclusion/exclusion criteria, anti-NMDA-R (k = 18), anti-LGI1 (k = 10), anti-GABAB-R (k = 2), anti-GAD-65 (k = 4), and anti-CASPR2 (k = 3). The cognitive domains most frequently impaired were visual and verbal episodic memory, attention/working memory, processing speed, and aspects of executive functions. DISCUSSION Given the dearth of literature examining NPT in AE in combination with small sample sizes and methodological differences, more research in this area is needed. However, we provide recommendations for a test battery to be used in future studies, with the aim of standardizing research in this area. Based on the available literature, we recommend the use of comprehensive NPT batteries, spanning all cognitive domains. The highest yield measures may include the tests of (1) visual and verbal learning/memory, (2) basic and sustained attention, (3) processing speed, and (4) executive functions.
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Affiliation(s)
- Rachel Galioto
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany.
| | - Tiffany Grezmak
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany
| | - Carol Swetlik
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany
| | - Justin R Abbatemarco
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany
| | - Maarten J Titulaer
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany
| | - Carsten Finke
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany
| | - Amy Kunchok
- From the Cleveland Clinic Mellen Center for MS (R.G., J.R.A., A.K.); Department of Neurology (T.G., C.S.), Cleveland Clinic, OH; Neurology (M.J.T.), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Neurology (C.F.), Charité - Universitätsmedizin Berlin, Germany
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Alkhayat D, Khawaji ZY, Sunyur AM, Sanyour OA, Badawi AS. Overview of Paraneoplastic Autoantibody-Mediated Cognitive Impairment and Behavioral Changes: A Narrative Review. Cureus 2024; 16:e51787. [PMID: 38322089 PMCID: PMC10846349 DOI: 10.7759/cureus.51787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Cognitive dysfunction and behavioral change can be some of the manifestations of cancer, occurring as a part of paraneoplastic neurological syndrome, most commonly in small cell lung cancer. Paraneoplastic limbic encephalitis is the leading cause of cognitive disturbance and abnormal behavior in paraneoplastic syndromes, which is usually autoantibody-mediated. Autoantibodies are the main contributors to the development of cognitive dysfunction and behavioral change in cancer patients, with studies suggesting a higher liability for antibody-positive cancer patients to be affected. Anti-NMDAR and anti-AMPAR are antibodies targeted against surface antigens, manifesting predominantly as memory disturbance, abnormal behavior, psychiatric symptoms, and seizures. Other surface antigen-targeted antibodies include anti-GABA, anti-CASPR2, and anti-LGI1, which were shown to have cognitive function impairment and abnormal behavior as some of the main presentations, predominantly affecting memory. Cognitive deterioration and changes in behavior were also relatively common with some of the intracellular antigen-targeted antibodies, including anti-Hu, anti-SOX1, anti-PCA2, and anti-Zic2. Affected behavior and cognition, however, were reported less commonly in other paraneoplastic antibodies against intracellular antigens (anti-Yo, anti-GAD, anti-Ma2, anti-Ri, anti-CV2, and anti-KLHL11). Our article will provide a comprehensive review of the clinical manifestations of cognitive impairment and behavioral changes among cancer patients who develop paraneoplastic syndrome. Additionally, this review will discuss the role of specific paraneoplastic autoantibodies and the clinical spectrum linked to each separately.
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Affiliation(s)
| | | | - Amal M Sunyur
- Medicine and Surgery, Taibah University, Medina, SAU
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Brenner J, Olijslagers SHC, Crijnen YS, de Vries JM, Mandarakas MR, Titulaer MJ. Clinical Outcome Assessments in Encephalitis: A Systematic Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200168. [PMID: 38086078 PMCID: PMC10758981 DOI: 10.1212/nxi.0000000000200168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Most patients with encephalitis experience persisting neurocognitive and neuropsychiatric sequelae in the years following this acute illness. Reported outcomes are often based on generic clinical outcome assessments that rarely capture the patient perspective. This may result in an underestimation of disease-specific sequelae. Disease-specific clinical outcome assessments can improve clinical relevance of reported outcomes and increase the power of research and trials. There are no patient-reported outcome measures (PROMs) developed or validated specifically for patients with encephalitis. The primary objective of this systematic literature review was to identify PROMs that have been developed for or validated in patients with encephalitis. METHODS We performed a systematic review of the literature published from inception until May 2023 in 3 large international databases (MEDLINE, EMBASE and Cochrane libraries). Eligible studies should have developed or validated a PROM in patients with encephalitis or encephalopathy. Methodologic quality was evaluated using the Consensus-based Standards for the selection of health status Measurement Instruments study design checklist for PROMs. RESULTS We identified no disease-specific PROMs developed or validated for patients with encephalitis. We identified one study on the development and validation of a disease-specific PROM for hepatic encephalopathy, although this disease course is substantially different to that of patients with encephalitis. The methodologic quality of the included study was generally rated as "doubtful." We identified 30 PROMs that have been applied in 46 studies on encephalitis or encephalopathy, although not validated in these populations. The most commonly applied PROMs for measuring Health-Related Quality of Life were the Medical Outcomes Study Short Form-36 and the Sickness Impact Profile. Emotional well-being was often assessed with the Beck Depression Inventory (BDI-II). Sporadically, PROMs were applied to address other aspects of outcome including daily functioning and sleep quality. DISCUSSION This systematic review confirms a critical gap in clinical outcome assessments in patients with encephalitis, failing to identify a validated measuring tool for detecting neurocognitive, functional, and health status. It is therefore essential to develop and/or validate disease-specific PROMs for the population with encephalitis to capture relevant information for patient management and clinical trials about the effects of disease that are at risk of being overlooked.
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Affiliation(s)
- Juliette Brenner
- From the Department of Neurology (J.B., Y.S.C., J.M.V., M.R.M., M.J.T.), Erasmus University Medical Center, Rotterdam; and Department of Neurology (S.H.C.O.), Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Sammy H C Olijslagers
- From the Department of Neurology (J.B., Y.S.C., J.M.V., M.R.M., M.J.T.), Erasmus University Medical Center, Rotterdam; and Department of Neurology (S.H.C.O.), Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Yvette S Crijnen
- From the Department of Neurology (J.B., Y.S.C., J.M.V., M.R.M., M.J.T.), Erasmus University Medical Center, Rotterdam; and Department of Neurology (S.H.C.O.), Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Juna M de Vries
- From the Department of Neurology (J.B., Y.S.C., J.M.V., M.R.M., M.J.T.), Erasmus University Medical Center, Rotterdam; and Department of Neurology (S.H.C.O.), Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Melissa R Mandarakas
- From the Department of Neurology (J.B., Y.S.C., J.M.V., M.R.M., M.J.T.), Erasmus University Medical Center, Rotterdam; and Department of Neurology (S.H.C.O.), Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (J.B., Y.S.C., J.M.V., M.R.M., M.J.T.), Erasmus University Medical Center, Rotterdam; and Department of Neurology (S.H.C.O.), Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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6
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Griffith SP, Wesselingh R, Seery N, Rushen T, Kyndt C, Long B, Seneviratne U, Buzzard K, Butzkueven H, O'Brien TJ, Alpitsis R, Malpas CB, Monif M. Characterizing cognitive function in patients with autoimmune encephalitis: an Australian prospective study. J Neurol 2024; 271:310-324. [PMID: 37709946 PMCID: PMC10770222 DOI: 10.1007/s00415-023-11967-w] [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: 05/29/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE This study uses the Wechsler intelligence and memory scales to characterize the cognitive function of patients with autoimmune encephalitis (AE) in the chronic stage of the disease. AE is a group of neuroinflammatory disorders, and cognitive impairment is a significant source of chronic morbidity in these patients. METHODS Fifty patients with an average disease duration of 3.2 years after diagnosis were prospectively recruited from four hospitals. They underwent a comprehensive cognitive examination using the Wechsler Abbreviated Scale of Intelligence (WASI-II), Wechsler Adult Intelligence Scale (WAIS-IV) and Wechsler Memory Scale (WMS-IV). Summary statistics were computed, and single-sample and independent-samples t tests were used to compare the cohort to normative data. RESULTS The results revealed significantly reduced performances in perceptual reasoning, processing speed, and working memory among AE patients. Seropositive AE patients exhibited below-norm processing speed, while the seronegative group showed reduced working memory and processing speed. Delayed memory performance was significantly below expectations only in seronegative patients. Pattern analysis indicated that intact cognition was the most observed outcome after AE, but significant heterogeneity was observed among the impaired patients. CONCLUSIONS The study identified deficits in perceptual reasoning, processing speed, and working memory among chronic AE patients. Pattern analysis highlighted positive long-term cognitive outcomes for many but varied outcomes for those with ongoing difficulties. Although severely cognitively impaired patients were not included, the findings apply to AE cohorts who attend outpatient clinical neuropsychology consultations emphasizing the need for thorough cognitive assessment. The results suggest a need for further research targeting other cognitive domains, including executive functions.
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Affiliation(s)
- Sarah P Griffith
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Robb Wesselingh
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Nabil Seery
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Tiffany Rushen
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Chris Kyndt
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia
- Department of Neurosciences, Eastern Health Clinical School, Box Hill Hospital, Monash University, Melbourne, VIC, Australia
| | - Brian Long
- Neuropsychology Unit, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Udaya Seneviratne
- Department of Neurosciences, Monash Health, Clayton Road, Clayton, VIC, 3168, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health Clinical School, Box Hill Hospital, Monash University, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Terence J O'Brien
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Rubina Alpitsis
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Charles B Malpas
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, 3052, Australia
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC, 3052, Australia
| | - Mastura Monif
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Neurology, Alfred Health, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, VIC, 3050, Australia.
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Huang D, Lv C, Chen Z, Li Z, Zheng J. Abnormalities in modular connectivity of functional brain networks and cognitive changes in patients with anti -N-methyl-D-aspartate receptor encephalitis. Brain Res 2023; 1820:148605. [PMID: 37775074 DOI: 10.1016/j.brainres.2023.148605] [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: 04/14/2023] [Revised: 07/07/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To explore potential mechanisms of cognitive changes in patients with anti-NMDAR encephalitis (ANMDARE) from intramodule and intermodule effects of brain functional networks. METHODS Resting-state functional MRI(rs-fMRI) imaging data was collected from 30 ANMDARE and 30 healthy controls (HCs). A brain functional matrix was constructed, and sparsity was established by module similarity. For both groups, changes in functional connectivity (FC) within and between modules was calculated, and whole-brain functional topology was analyzed. Finally, the association of brain functional with cognitive function in ANMDARE was further analyzed. RESULTS Compared to HCs, ANMDARE had enhanced connectivity within the modules that included the occipito-parietal-temporal and parahippocampal gyri. ANMDARE had significantly higher participation coefficients (PC) in the right inferior frontal gyrus than HCs and significantly lower PC in the left superior parietal lobule, left caudate nucleus, and right putamen. No statistically significant differences in global topological properties were found between the two groups. No correlations were found between functional and structural brain indicators and the Cognitive Assessment Scale and the Emotional Deficit Scale. CONCLUSIONS Patients with ANMDARE are manifested by enhanced intramodular FC and intermodular connectivity changes in the brain. This may help to understand the pathophysiological mechanisms of the disease from a global perspective.
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Affiliation(s)
- Dongying Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Caitiao Lv
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zexiang Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhekun Li
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jinou Zheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
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Depreitere J, De Meulenaere J, Verhelst H. Atypical psychiatric presentation of relapsing anti-N-methyl-D-aspartate receptor encephalitis in childhood. Clin Child Psychol Psychiatry 2023; 28:1333-1340. [PMID: 36426777 DOI: 10.1177/13591045221129728] [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] [Indexed: 11/27/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune encephalitis caused by antibodies (Ab) against the GluN1 subunit of the NMDAR. The disease typically presents with a combination of psychiatric and neurological symptoms. Presentation solely with psychiatric symptoms is rare, especially in childhood. After treatment substantial recovery with mild or no residual symptoms is seen in most cases in both children and adults. Relapse occurs in 10%-25% of patients, with recurrent episodes presenting less severe than initial presentation in most cases. We herein describe a child with a pure psychiatric presentation of anti-NMDAR encephalitis. Diagnosis and treatment was delayed because of the atypical presentation. The child relapsed several times and severe residual psychiatric symptoms persisted after recovery. This case illuminates the need to consider the diagnosis of anti-NMDAR encephalitis in both adults and children with an atypical psychiatric presentation. It also demonstrates the need for a multidisciplinary approach and brings attention to the possible severe impact of the disease on long-term psychosocial functioning.
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Affiliation(s)
- Joke Depreitere
- Department of Pediatrics, Division of Pediatric Neurology, Ghent University Hospital, Ghent, Belgium
| | - Jan De Meulenaere
- Department of Child and Adolescent Psychiatry, Ghent University Hospital, Ghent, Belgium
| | - Helene Verhelst
- Department of Pediatrics, Division of Pediatric Neurology, Ghent University Hospital, Ghent, Belgium
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Wu D, Jiang L, He R, Chen B, Yao D, Wang K, Xu P, Li F. Brain rhythmic abnormalities in convalescent patients with anti-NMDA receptor encephalitis: a resting-state EEG study. Front Neurol 2023; 14:1163772. [PMID: 37545720 PMCID: PMC10398954 DOI: 10.3389/fneur.2023.1163772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Objective Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is autoimmune encephalitis with a characteristic neuropsychiatric syndrome and persistent cognition deficits even after clinical remission. The objective of this study was to uncover the potential noninvasive and quantified biomarkers related to residual brain distortions in convalescent anti-NMDARE patients. Methods Based on resting-state electroencephalograms (EEG), both power spectral density (PSD) and brain network analysis were performed to disclose the persistent distortions of brain rhythms in these patients. Potential biomarkers were then established to distinguish convalescent patients from healthy controls. Results Oppositely configured spatial patterns in PSD and network architecture within specific rhythms were identified, as the hyperactivated PSD spanning the middle and posterior regions obstructs the inter-regional information interactions in patients and thereby leads to attenuated frontoparietal and frontotemporal connectivity. Additionally, the EEG indexes within delta and theta rhythms were further clarified to be objective biomarkers that facilitated the noninvasive recognition of convalescent anti-NMDARE patients from healthy populations. Conclusion Current findings contributed to understanding the persistent and residual pathological states in convalescent anti-NMDARE patients, as well as informing clinical decisions of prognosis evaluation.
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Affiliation(s)
- Dengchang Wu
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lin Jiang
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
- School of Life Science and Technology, Center for Information in BioMedicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Runyang He
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
- School of Life Science and Technology, Center for Information in BioMedicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Baodan Chen
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
- School of Life Science and Technology, Center for Information in BioMedicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Dezhong Yao
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
- School of Life Science and Technology, Center for Information in BioMedicine, University of Electronic Science and Technology of China, Chengdu, China
- Research Unit of NeuroInformation, Chinese Academy of Medical Sciences, Chengdu, China
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China
| | - Kang Wang
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Peng Xu
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
- School of Life Science and Technology, Center for Information in BioMedicine, University of Electronic Science and Technology of China, Chengdu, China
- Research Unit of NeuroInformation, Chinese Academy of Medical Sciences, Chengdu, China
- Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Fali Li
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
- School of Life Science and Technology, Center for Information in BioMedicine, University of Electronic Science and Technology of China, Chengdu, China
- Research Unit of NeuroInformation, Chinese Academy of Medical Sciences, Chengdu, China
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Son S, Lim KB, Yoo J, Song P, Kim J. Cognitive Impairment in a Child With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report. BRAIN & NEUROREHABILITATION 2023; 16:e12. [PMID: 37554261 PMCID: PMC10404809 DOI: 10.12786/bn.2023.16.e12] [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: 09/07/2022] [Revised: 01/31/2023] [Accepted: 02/28/2023] [Indexed: 08/10/2023] Open
Abstract
Anti-N-methyl-D-aspartate-receptor encephalitis is a complex autoimmune inflammatory neurological disorder that presents with epileptic seizures and rapid functional deterioration, including movement disorders and cognitive impairment, especially in young patients. Despite aggressive initial treatment with immune therapy, such as corticosteroids, intravenous immunoglobulin, and plasmapheresis, patients often need intensive rehabilitative therapies for their long-lasting deficits. We report a pediatric case of anti-N-methyl-D-aspartate receptor encephalitis in Korea that presented with symptoms of muscle weakness of the four extremities, dysarthria, dysphagia, and cognitive impairment in the acute phase. The patient underwent 4 weeks of comprehensive rehabilitative treatment, including physical therapy, occupational therapy, swallowing rehabilitation therapy, cognitive rehabilitation therapy, and speech therapy. At the follow-up evaluation after 4 weeks of treatment, she showed significant improvements in limb muscle strength, balance ability, swallowing, language function, and the ability to perform activities of daily living. However, when assessed using the Korean Wechsler Intelligence Scale for Children-IV, there was little improvement in cognitive function, particularly in working memory. While only a few cases have reported the progression of cognitive function using a standardized cognitive evaluation tool in patients with anti-N-methyl-D-aspartate receptor encephalitis, this present case report adds to the accumulation of evidence of neurocognitive deficits in these patients.
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Affiliation(s)
- Seongsik Son
- Department of Rehabilitation Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Kil-Byung Lim
- Department of Rehabilitation Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jeehyun Yoo
- Department of Rehabilitation Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Pamela Song
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jiyong Kim
- Department of Rehabilitation Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
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11
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Hirose S, Hara M, Yokota Y, Nakajima H. Long-term effects of anti- N-methyl-d-aspartate receptor encephalitis on quality of life. Front Neurol 2023; 14:1170961. [PMID: 37273709 PMCID: PMC10232987 DOI: 10.3389/fneur.2023.1170961] [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: 02/21/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
Background Patients with anti-N-methyl-d-aspartate receptor encephalitis (NMDARE) usually achieve neurologically favorable outcomes in the post-acute-phase. Even when motor function recovers, many patients experience numerous non-motor sequelae and cannot resume their pre-NMDARE lives even years later. Additionally, the needs of patients with NMDARE may impose a severe caregiver burden. Unfortunately, few studies have comprehensively examined patients recovering from NMDARE. We investigated the long-term effects of NMDARE on patients' quality of life (QOL). Methods Data collected via structured self-reported questionnaires included clinical features, long-term outcomes, and QOL. These questionnaires were administered to adult members of the Japanese Anti-NMDARE Patients' Association. We used the NeuroQOL battery to assess QOL in physical, mental, and social domains. Raw NeuroQOL scores were converted to T-scores for comparison with controls. Results Twenty-two patients completed the questionnaire. The median interval between disease onset and questionnaire response was 78 months. Forty-six percent of patients reported persistent sequelae, with only 73% able to resume prior work/school activities. Although patients' Global QOL was similar to controls, patients with NMDARE had significantly worse social QOL. Patients with worse social QOL had more frequent sequelae than those with better social QOL. Furthermore, patients with persistent sequelae had significantly worse Global QOL than those without sequelae and controls. Conclusion Patients with NMDARE had worse social QOL than controls. Given the adverse effects of disease sequelae on QOL, treatment strategies that minimize sequelae during the acute-phase may improve patients' QOL, even years post-disease onset.
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Bayliss L, Sandoval AM, Nava A, Diaz-Victoria AR, Espinola-Nadurille M, Ramírez-Bermúdez J, Galvez V. Cognitive follow-up in anti-N-methyl-D-aspartate receptor encephalitis: Hospital discharge, 4, 8, and 12 months. Clin Neurol Neurosurg 2023; 228:107701. [PMID: 36996670 DOI: 10.1016/j.clineuro.2023.107701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023]
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Nikolaus M, Rausch P, Rostásy K, Bertolini A, Wickström R, Johannsen J, Denecke J, Breu M, Schimmel M, Diepold K, Haeusler M, Quade A, Berger A, Rosewich H, Steen C, von Au K, Dreesmann M, Finke C, Bartels F, Kaindl AM, Schuelke M, Knierim E. Retrospective Pediatric Cohort Study Validates NEOS Score and Demonstrates Applicability in Children With Anti-NMDAR Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200102. [PMID: 36948591 PMCID: PMC10032577 DOI: 10.1212/nxi.0000000000200102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/18/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) is the most common form of autoimmune encephalitis in children and adults. Although our understanding of the disease mechanisms has progressed, little is known about estimating patient outcomes. Therefore, the NEOS (anti-NMDAR Encephalitis One-Year Functional Status) score was introduced as a tool to predict disease progression in NMDARE. Developed in a mixed-age cohort, it currently remains unclear whether NEOS can be optimized for pediatric NMDARE. METHODS This retrospective observational study aimed to validate NEOS in a large pediatric-only cohort of 59 patients (median age of 8 years). We reconstructed the original score, adapted it, evaluated additional variables, and assessed its predictive power (median follow-up of 20 months). Generalized linear regression models were used to examine predictability of binary outcomes based on the modified Rankin Scale (mRS). In addition, neuropsychological test results were investigated as alternative cognitive outcome. RESULTS The NEOS score reliably predicted poor clinical outcome (mRS ≥3) in children in the first year after diagnosis (p = 0.0014) and beyond (p = 0.036, 16 months after diagnosis). A score adapted to the pediatric cohort by adjusting the cutoffs of the 5 NEOS components did not improve predictive power. In addition to these 5 variables, further patient characteristics such as the "Herpes simplex virus encephalitis (HSE) status" and "age at disease onset" influenced predictability and could potentially be useful to define risk groups. NEOS also predicted cognitive outcome with higher scores associated with deficits of executive function (p = 0.048) and memory (p = 0.043). DISCUSSION Our data support the applicability of the NEOS score in children with NMDARE. Although not yet validated in prospective studies, NEOS also predicted cognitive impairment in our cohort. Consequently, the score could help identify patients at risk of poor overall clinical outcome and poor cognitive outcome and thus aid in selecting not only optimized initial therapies for these patients but also cognitive rehabilitation to improve long-term outcomes.
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Affiliation(s)
- Marc Nikolaus
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Philipp Rausch
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Kevin Rostásy
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Annikki Bertolini
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Ronny Wickström
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Jessika Johannsen
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Jonas Denecke
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Markus Breu
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Mareike Schimmel
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Katharina Diepold
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Martin Haeusler
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Annegret Quade
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Andrea Berger
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Hendrik Rosewich
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Claudia Steen
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Katja von Au
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Mona Dreesmann
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Carsten Finke
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Frederik Bartels
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Angela M Kaindl
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Markus Schuelke
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Ellen Knierim
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
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14
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Neuropsychological functioning in children and adolescents with anti-NMDA receptor encephalitis (anti-NMDARE). J Neurol 2023; 270:402-412. [PMID: 36112199 DOI: 10.1007/s00415-022-11372-9] [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: 05/24/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 01/07/2023]
Abstract
The objective of this study was to describe neuropsychological functioning and associated medical features in pediatric patients with anti-NMDA receptor encephalitis (anti-NMDARE). Retrospective data were collected from electronic medical records and neuropsychological reports of 15 children and adolescents with cerebral spinal fluid antibody-confirmed anti-NMDARE who were 7-21 years old at the time of the neuropsychological evaluation. The median time between treatment initiation for anti-NMDARE and neuropsychological testing was 228 days (IQR 431, range 41-927). Consistent with the limited literature, this pediatric sample with anti-NMDARE generally had average IQs, but had scores falling in the low average range on tests of verbal and visual memory as well as aspects of executive functioning (set shifting and phonemic verbal fluency). Other relative weaknesses were observed in visuo-constructional ability and reading comprehension. Future prospective studies are needed to replicate these data and explore disease and treatment variables that reduce or exacerbate the risk for neuropsychological sequelae, while longitudinal analyses are required to better characterize academic, vocational, and social outcomes.
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15
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Long Q, Lv Z, Zhao J, Shi K, Li C, Fan B, Zheng J. Cerebral gray matter volume changes in patients with anti-N-methyl-D-aspartate receptor encephalitis: A voxel-based morphometry study. Front Neurol 2022; 13:892242. [PMID: 35959389 PMCID: PMC9358280 DOI: 10.3389/fneur.2022.892242] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/04/2022] [Indexed: 01/19/2023] Open
Abstract
Background: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disease with typical clinical features. Whether and how cerebral gray matter structural damage inherent to the disorder affects cognitive function in patients is still unclear. Therefore, this study aimed to explore the changes in cerebral gray matter volume and whether these alterations contribute to cognitive impairment and mood disorders. Methods Forty patients with anti-NMDAR encephalitis and forty healthy controls (HCs) matched for gender, age, and education were recruited. All participants underwent attention network tests (ANT), neuropsychological tests and magnetic resonance imaging (MRI). Voxel-based morphological analysis (VBM) and correlation analysis was performed on all participants. Finally, according to the course of disease, patients were divided into two groups: NMDARE_SD (short duration; course ≤ 2 years since diagnosis) and NMDARE_LD (long duration; course >2 years since diagnosis), to evaluate gray matter volume changes that differ as a function of disease course. Results Compared to HCs, patients with anti-NMDAR encephalitis showed decreased executive control ability and lower MoCA score, while increased anxiety and depression as reflected by HAMA and HAMD24 scores (all P < 0.05). In VBM analysis, patients showed decreased gray matter volume in bilateral thalamus, left medial prefrontal cortex (mPFC_L), left superior temporal gyrus (STG_L), and left rectus gyrus. In the analysis stratified by disease course, the NMDARE_LD group exhibited decreased gray matter volume in the left precuneus and right posterior cerebellar lobe compared to the NMDARE_SD group. Conclusions Patients with anti-NMDAR encephalitis have cognitive, executive, and emotional dysfunction, and the sites of gray matter atrophy are concentrated in the thalamus, frontal lobe, and temporal lobe. These abnormalities may be involved in the process of cognitive and affective dysfunction.Patients with different courses of anti-NMDAR encephalitis have different brain atrophy sites. These results may help to clarify the contradiction between clinical and imaging manifestations of anti NMDAR encephalitis, which is worthy of further longitudinal studies.
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16
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Nguyen L, Yang JH, Goyal S, Irani N, Graves JS. A systematic review and quantitative synthesis of the long-term psychiatric sequelae of pediatric autoimmune encephalitis. J Affect Disord 2022; 308:449-457. [PMID: 35429531 DOI: 10.1016/j.jad.2022.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term neuropsychiatric sequelae of autoimmune encephalitis (AE) remain understudied, particularly in pediatric-onset AE. We aimed to synthesize the published data on ongoing psychiatric symptoms in pediatric-onset AE. METHODS The Pubmed, PyscINFO, Web of Science databases were searched from their inception years to August 23, 2021, and 29 studies were identified and analyzed. We also performed a quantitative synthesis of available patient data from the 29 studies combined with a cohort of anti-NMDA receptor (NMDAR) AE from our institution to examine the associations between acute treatment course and long-term psychiatric outcome. RESULTS At long-term follow up, 52.4% of the cases with pediatric-onset AE had any persistent symptom and 36.0% had at least one psychiatric symptom. Pooled data found that 36.3% of pediatric-onset anti-NMDAR AE had ongoing psychiatric symptoms. Using a univariate logistic regression analysis, we found that abnormal initial EEG, use of certain immunotherapies, and persistent cognitive impairments were associated with ongoing psychiatric symptoms. LIMITATIONS Limitations of the existing literature included a significant paucity of outcomes measured using consistent, objective methods. Limitations of the systematic review included the wide variability among the studies reviewed, which rendered a meta-analysis impossible and beyond the scope of the paper. CONCLUSION Chronic psychiatric and behavioral problems remain present in one-third of children months to years after onset of AE. Larger scaled prospective observational studies with a consistent standardized battery of testing are needed to examine impact of specific clinical features and immunotherapies on long-term mental health outcomes.
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Affiliation(s)
- Linda Nguyen
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA.
| | - Jennifer H Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Sajan Goyal
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Najin Irani
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA
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17
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Lee WJ, Lee ST, Kim DY, Kim S, Chu K. Disease progression and brain atrophy in NMDAR encephalitis: Associated factor & clinical implication. Ann Clin Transl Neurol 2022; 9:912-924. [PMID: 35715951 PMCID: PMC9268893 DOI: 10.1002/acn3.51604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/23/2022] [Accepted: 05/17/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE We investigated the longitudinal pattern, determining factors, and clinical implications of brain volume changes in N-methyl d-aspartate receptor-antibody (NMDAR) encephalitis. METHODS Baseline clinical profiles, treatment profiles, and outcome measured using the Clinical Assessment Scale in Autoimmune Encephalitis (CASE) and modified Rankin scale (mRS) were obtained from a long-term clinical database documenting an NMDAR encephalitis cohort. In serial MRI, the change in the normalized volume of different brain regions from the baseline evaluation was measured. At each MRI evaluation time point, the cumulative disease burden (CASE score × months) and the cumulative duration of status epilepticus were also evaluated. RESULTS Thirty-six patients were followed-up for 28.5 months (range 12-63 months). The volume ratio at last MRI to baseline was the lowest in the cerebellum (94.4 ± 5.7%, p < 0.001). Once developed, cerebellar volume reduction followed a progressive course until 2 years from disease onset. The degree of cerebellar volume reduction was positively correlated with mRS and total CASE scores (all, p < 0.001), and CASE scores in the domains of memory, language, and psychiatric problems, gait instability/ataxia, and weakness (all, p < 0.01). In linear mixed model analyses, the degree of cerebellar volume reduction was associated with cumulative disease burden up to 2 years (p < 0.001) and duration of status epilepticus (p < 0.001), and delayed removal of teratoma for ≥1 month (p = 0.006). INTERPRETATION In NMDAR encephalitis, cerebellar volume reduction was progressive once developed. Cerebellar volume reduction might reflect disease burden and extent of progression and be associated with poor outcomes in multiple functional domains.
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Affiliation(s)
- Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Do-Yong Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Soyun Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
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18
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Griffith S, Wesslingh R, Broadley J, O'Shea M, Kyndt C, Meade C, Long B, Seneviratne U, Reidy N, Bourke R, Buzzard K, D'Souza W, Macdonell R, Brodtmann A, Butzkueven H, O'Brien TJ, Alpitsis R, Malpas CB, Monif M. Psychometric Deficits in Autoimmune Encephalitis: A retrospective study from the Australian Autoimmune Encephalitis Consortium. Eur J Neurol 2022; 29:2355-2366. [PMID: 35460305 DOI: 10.1111/ene.15367] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite the rapid increase in research examining outcomes in Autoimmune Encephalitis (AE) patients, there are few cohort studies examining cognitive outcomes in this population. METHODS This retrospective observational study collected psychometric data from 59 patients across six secondary and tertiary referral centres in metropolitan hospitals in Victoria, Australia between January 2008 and July 2019. Frequency and pattern analysis were employed to define and characterise psychometric outcomes. Univariable logistic regression was performed to examine predictors of intact and pathological psychometric outcomes. RESULTS Deficits in psychometric markers of executive dysfunction were the most commonly observed in this cohort, followed by deficits on tasks sensitive to memory. 54.2% were classified as having psychometric impairments across at least two cognitive domains. 29 patterns were observed, suggesting outcomes in AE are complex. None of the demographic data, clinical features, and auxiliary examination variables were predictors of psychometric outcome. CONCLUSIONS Cognitive outcomes in AE are complex. Further detailed and standardised cognitive testing in combination with MRI volumetrics and serum/CSF biomarkers is required to provide rigorous assessments of disease outcomes.
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Affiliation(s)
- Sarah Griffith
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004
| | - Robb Wesslingh
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004
| | - James Broadley
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004
| | - Marie O'Shea
- Department of Clinical Neuropsychology, Austin Health, Heidelberg, Victoria, Australia, 3084.,Melbourne School of Psychological Sciences, The University of Melbourne, Victoria, Australia
| | - Chris Kyndt
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, Victoria, Australia, 3050.,Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Catherine Meade
- Department of Neurosciences, Building D - Daly Wing, Level 5, St Vincent's Hospital, Fitzroy, Victoria, Australia, 3065
| | - Brian Long
- Neuropsychology Unit, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria, Australia, 3168
| | - Udaya Seneviratne
- Department of Neurosciences, Monash Health, Clayton Road, Clayton, Victoria, Australia, 3168
| | - Natalie Reidy
- Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Robert Bourke
- Neuropsychology Unit, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria, Australia, 3168
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia
| | - Wendyl D'Souza
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia, 3065
| | - Richard Macdonell
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia, 3084
| | - Amy Brodtmann
- Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, Victoria, Australia, 3050.,Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, VIC, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia, 3084
| | - Helmut Butzkueven
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004
| | - Terence J O'Brien
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004
| | - Rubina Alpitsis
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004
| | - Charles B Malpas
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, Victoria, Australia, 3050.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia.,Melbourne School of Psychological Sciences, The University of Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Alfred Health, Alfred Centre, Level 6, 99 Commercial Road, Melbourne, Victoria, Australia, 3004.,Department of Neurology, Melbourne Health, 300 Grattan Street, Parkville, Victoria, Australia, 3050
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19
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Herrera E, Rodríguez S, González-Nosti M. Neuropsychological follow-up of a case of encephalitis by anti-nmda receptor. Neurocase 2022; 28:96-101. [PMID: 35073821 DOI: 10.1080/13554794.2022.2032186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anti-NMDA receptor encephalitis is an autoimmune disease with psychiatric and cognitive symptoms. Our aim is to describe the cognitive follow-up of a patient diagnosed with the disease for 4 years. The results revealed severe cognitive impairment at the initial evaluation. At 3 months, memory and executive function deficits prevailed. At 9 months, only a deficit in verbal memory was found. At 4 years, she presented a mild memory deficit. These results revealed a significant short-term cognitive deficit. Subsequently, executive functions, memory and verbal fluency recovered, while a mild deficit in verbal memory persisted.
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Affiliation(s)
- Elena Herrera
- Department of Psychology, Universidad de Oviedo, Oviedo, Spain
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20
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Impaired neurovascular coupling and cognitive deficits in anti-N-methyl-D-aspartate receptor encephalitis. Brain Imaging Behav 2021; 16:1065-1076. [PMID: 34735667 DOI: 10.1007/s11682-021-00588-4] [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: 01/05/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a recently identified autoimmune disorder with heterogeneous neurological, psychiatric, and cognitive manifestations. The NMDAR is a key signaling node for neurovascular coupling, the mechanism by which cerebral blood perfusion is enhanced to meet local metabolic requirements from increased neuronal activity. Therefore, anti-NMDAR encephalitis may disrupt neurovascular coupling and induce cognitive deficits. This study examined neurovascular coupling and cognitive function in anti-NMDAR encephalitis patients to identify prognostic biomarkers, reveal potential pathogenic mechanisms, and provide clues to possible therapeutic strategies. In this study, twenty-three anti-NMDAR encephalitis patients and thirty healthy controls received neuropsychological testing and multimodal magnetic resonance imaging (MRI). Cerebral blood flow (CBF) was calculated from arterial spin labeling, and regional homogeneity (ReHo) was computed from functional MRI. Pearson's correlation coefficients between CBF and ReHo were calculated to obtain neurovascular coupling. At the whole gray matter level, CBF‒ReHo coupling was reduced in patients compared to healthy controls. At the regional level, CBF‒ReHo was significantly lower among patients in the precentral gyrus, frontal gyrus, insula, cuneus, inferior parietal lobe, supramarginal gyrus, angular gyrus, precuneus, temporal gyrus, and temporal pole. Reduced CBF‒ReHo in the left superior medial frontal gyrus of patients was significantly correlated with a deficit in verbal inhibition control, and the reduced CBF‒ReHo in the left insula was significantly correlated with impaired executive function. In conclusion, anti-NMDAR encephalitis is associated with both global and regional disruptions in neurovascular coupling that may in turn lead to deficits in specific cognitive domains.
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21
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Tarantino S, Averna R, Ruscitto C, Ursitti F, Ferilli MAN, Moavero R, Papetti L, Proietti Checchi M, Sforza G, Balestri M, Grimaldi Capitello T, Vigevano F, Vicari S, Valeriani M. Neuropsychological Sequelae, Quality of Life and Adaptive Behavior in Children and Adolescents with Anti-NMDAR Encephalitis: A Narrative Review. Brain Sci 2021; 11:brainsci11111387. [PMID: 34827386 PMCID: PMC8615663 DOI: 10.3390/brainsci11111387] [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: 09/16/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a rare autoimmune illness characterized by a constellation of often severe, but treatable, psychiatric and neurological symptoms. Whereas symptoms such as psychosis and bizarre and abnormal motor behavior are common in adults, pediatric patients typically present with behavioral changes, irritability and sleep dysfunction. The recovery phase is usually slow and may be associated with longstanding adaptive, behavioral and neuropsychological problems. Very few studies explored the cognitive and adaptive sequelae in children with anti-NMDAR encephalitis. The present review article suggests that, although most children and adolescents return to their daily life and previous activities, they may have a low quality of life and show neuropsychological sequelae involving language, memory, especially verbal memory, and attentional resources, even after several months from the hospital discharge. In particular, the available results reveal difficulties in cognitive skills involving executive functions. This impairment is considered the “core” of the cognitive profile of young patients with anti-NMDAR encephalitis. On the other hand, some cognitive skills, such as general intelligence, show good overall recovery over time. Additional neuropsychological research evaluating larger samples, more homogenous methods and longitudinal studies is required.
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Affiliation(s)
- Samuela Tarantino
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
- Correspondence:
| | - Roberto Averna
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Claudia Ruscitto
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
| | - Fabiana Ursitti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Michela Ada Noris Ferilli
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Laura Papetti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Proietti Checchi
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Giorgia Sforza
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Balestri
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Teresa Grimaldi Capitello
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Federico Vigevano
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Stefano Vicari
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Massimiliano Valeriani
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
- Center for Sensory-Motor Interaction, Denmark Neurology Unit, Aalborg University, 9100 Aalborg, Denmark
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22
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Heine J, Kopp UA, Klag J, Ploner CJ, Prüss H, Finke C. Long-Term Cognitive Outcome in Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Ann Neurol 2021; 90:949-961. [PMID: 34595771 DOI: 10.1002/ana.26241] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Cognitive dysfunction is a core symptom of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, but detailed studies on prevalence, characteristics of cognitive deficits, and the potential for recovery are missing. Here, we performed a prospective longitudinal study to assess cognitive long-term outcome and identify clinical predictors. METHODS Standardized comprehensive neuropsychological assessments were performed in 43 patients with NMDAR encephalitis 2.3 years and 4.9 years (median) after disease onset. Cognitive assessments covered executive function, working memory, verbal/visual episodic memory, attention, subjective complaints, and depression and anxiety levels. Cognitive performance of patients was compared to that of 30 healthy participants matched for age, sex, and education. RESULTS All patients had persistent cognitive deficits 2.3 years after onset, with moderate or severe impairment in >80% of patients. Core deficits included memory and executive function. After 4.9 years, significant improvement of cognitive function was observed, but moderate to severe deficits persisted in two thirds of patients, despite favorable functional neurological outcomes (median modified Rankin Scale = 1). Delayed treatment, higher disease severity, and longer duration of the acute phase were predictors for impaired cognitive outcome. The recovery process was time dependent, with greater gains earlier after the acute phase, although improvements were possible for several years after disease onset. INTERPRETATION Cognitive deficits are the main contributor to long-term morbidity in NMDAR encephalitis and persist beyond functional neurological recovery. Nonetheless, cognitive improvement is possible for several years after the acute phase and should be supported by continued cognitive rehabilitation. Cognition should be included as an outcome measure in future clinical studies. ANN NEUROL 2021;90:949-961.
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Affiliation(s)
- Josephine Heine
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychology, Humboldt Universität zu Berlin, Berlin, Germany
| | - Ute A Kopp
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johanna Klag
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases, Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Center for Advanced Neuroimaging, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany
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23
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McKeon G, Parker S, Warren N, Scott JG. The Patient Experience of Recovery Following Anti-NMDA Receptor Encephalitis: A Qualitative Content Analysis. J Neuropsychiatry Clin Neurosci 2021; 33:57-63. [PMID: 32873136 DOI: 10.1176/appi.neuropsych.20030049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined patients' perceptions of the factors affecting their recovery from anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, which is a rare, severe immune-mediated neurological disorder. METHODS Seven patients completed semistructured interviews exploring their experience of recovery. Participants were interviewed between 7 and 41 months after the initiation of treatment. Interviews were transcribed and subjected to qualitative content analysis. RESULTS Facilitators of recovery included the presence of a support system and treatment-related factors. Barriers to recovery included perceived psychiatric stigma, insufficient illness education, and lifestyle disruptions to accommodate ongoing treatment. Adverse physical, psychological, and neurocognitive sequelae of anti-NMDAR encephalitis continued to affect participants' daily functioning. Most participants described strategies to manage neurocognitive deficits, fatigue, and anxiety. CONCLUSIONS Anti-NMDAR encephalitis contributes to persistent burden on patients, their families, and health services after the resolution of acute symptoms. Physical, psychological, and cognitive changes contribute to long-term disease morbidity. To optimize recovery and reduce disability, further attention must be directed toward illness education, reducing stigma, and role disruption. Longer-term disability support may benefit those who do not fully recover.
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Affiliation(s)
- Gemma McKeon
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - Stephen Parker
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - James G Scott
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
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24
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Wu P, Pang X, Liang X, Wei W, Li X, Zhao J, Zheng J. Correlation analysis between regional homogeneity and executive dysfunction in anti-N-methyl-D-aspartate receptor encephalitis patients. Eur J Neurol 2021; 29:277-285. [PMID: 34546615 DOI: 10.1111/ene.15119] [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: 06/20/2021] [Revised: 07/19/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is characterized by a range of cognitive impairments, especially in executive function. Our study aims to identify the abnormal regional homogeneity (ReHo) in anti-NMDAR encephalitis patients and its relationship with the executive function. METHODS Forty patients and 42 healthy volunteers undertook an Attention Network Test and a resting-state functional magnetic resonance imaging scan. ReHo analysis was performed to investigate the neuronal activity synchronization in all subjects. Based on ReHo analysis, a multivariate pattern analysis (MVPA) was carried out to identify the brain regions that differed the most between the two groups. RESULTS Compared to controls, the patients had higher executive control scores (p < 0.05). The patients presented reduced ReHo values in the bilateral posterior cerebellar lobe, anterior cerebellar lobe, midbrain, bilateral caudate nucleus, right superior frontal gyrus, right middle temporal gyrus, bilateral inferior parietal lobule and the left middle frontal gyrus. The ReHo values of the bilateral inferior parietal lobule in patients were found to be negatively associated with executive control scores. The classification of patients and controls using MVPA had an accuracy of 76.83%, a sensitivity of 82.50%, a specificity of 71.43% and the area under the curve was 0.83. CONCLUSIONS Our study provides evidence of abnormal cerebral function in anti-NMDAR encephalitis patients, which may contribute to unveiling the neuropathological mechanisms of anti-NMDAR encephalitis and their influences on executive dysfunction. The MVPA classifier, based on ReHo, is helpful in identifying anti-NMDAR encephalitis patients from healthy controls.
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Affiliation(s)
- Peirong Wu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaomin Pang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiulin Liang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wutong Wei
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinrong Li
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jingyuan Zhao
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jinou Zheng
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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25
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Nissen MS, Ørvik MS, Nilsson AC, Ryding M, Lydolph M, Blaabjerg M. NMDA-receptor encephalitis in Denmark from 2009 to 2019: a national cohort study. J Neurol 2021; 269:1618-1630. [PMID: 34351472 DOI: 10.1007/s00415-021-10738-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND To describe the national Danish N-methyl-D-aspartate receptor encephalitis (NMDARE) cohort. METHODS All NMDAR immunoglobulin G (IgG) positive cases in Denmark from 2009 to 2019 were included. Medical information was assessed retrospectively for clinical phenotype, workup, treatment and outcome. RESULTS Seventy-seven patients were NMDAR IgG positive in serum/CSF. Fifty-five fulfilled the criteria of NMDARE, 18 did not and 4 had missing data. Incidence was 0.17/100,000 persons per year in 2018, and incidence rates increased since 2009. Of the 55 NMDARE patients (median age 27; 60% female), 9 had post-herpes simplex (HSE) NMDARE and 7 had a tumor (four teratomas). MRI was normal in 51% of patients. Brain FDG PET was performed in 17 patients, and was abnormal in 47% of patients with a normal MRI. First-line therapy was administered to 91%, and 24% required second-line therapy. Maintenance therapy during recovery was given 84% of patients, with no effect on relapse-risk. ICU admission occurred in 29%. Poor outcome (mRS > 2) was reported in 27% and dependent on age and etiology. Patients > 45 years had a poorer outcome (71% vs 8%, p < 0.0001), more frequently post-HSE NMDARE (47% vs 3%, p < 0.0001) and underlying malignancies (18% vs 0%). CONCLUSION The incidence of NMDARE in Denmark is currently 0.17/100,000 persons per year, and has increased since 2009. NMDARE patients in Denmark display a higher median age, lower female:male ratio, a less frequent tumor association and need for ICU admission. Maintenance therapy did not reduce relapse rate. Poor outcome was seen with higher age, likely related to underlying etiology.
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Affiliation(s)
- Mette Scheller Nissen
- Department of Neurology, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Brain Research-Inter Disciplinary Guided Excellence (BRIDGE), Odense, Denmark.
| | | | - Anna Christine Nilsson
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Matias Ryding
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Brain Research-Inter Disciplinary Guided Excellence (BRIDGE), Odense, Denmark
| | - Magnus Lydolph
- Danish National Biobank, Statens Serum Institut, Copenhagen, Denmark
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Brain Research-Inter Disciplinary Guided Excellence (BRIDGE), Odense, Denmark.
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.
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26
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Ketheesan S, Bertram G, Adam R, Stark A, Scott JG. Muddying the waters? A false positive case of autoimmune psychosis. Australas Psychiatry 2021; 29:278-281. [PMID: 33070625 DOI: 10.1177/1039856220965041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To discuss challenges with the diagnosis of autoimmune psychosis (AP) in people with chronic psychotic disorders. METHOD We present a case of a 23-year-old man with an exacerbation of treatment-refractory psychosis after receiving intravenous immunoglobulin (IVIG) for suspected AP, diagnosed 4 years after the onset of psychosis. We highlight the diagnostic and management challenges in such cases. RESULTS The diagnosis of AP in people with long-standing illness relies on the interpretation of non-specific clinical and laboratory findings in individuals with psychosocial problems and challenges of acceptance and adherence to complex medical investigations and treatments. Equivocal results from investigations undertaken without logical clinical reasoning can lead to inappropriate interventions that are costly and can cause iatrogenic harm. CONCLUSION Psychiatrists should restrict screening for antineuronal antibodies in people with chronic psychosis to those with higher risk features such as persistent treatment refractory symptoms with concurrent neurological signs and symptoms. Further research informing the clinical circumstances for antineuronal antibody testing is needed.
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Affiliation(s)
- Sarangan Ketheesan
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia.,Laboratory of Psychiatric Neuroscience, James Cook University, Douglas, QLD, Australia
| | - Georgia Bertram
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia
| | - Robert Adam
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,University of Queensland Centre for Clinical Research, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Anne Stark
- Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Metro North Mental Health Service, Herston, QLD, Australia
| | - James G Scott
- Metro North Mental Health Service, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Queensland Centre for Mental Health Research, Wacol, QLD, Australia
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27
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Lee WJ. Symptomatologic pathomechanism of N-methyl D-aspartate receptor encephalitis. ENCEPHALITIS 2021; 1:36-44. [PMID: 37469763 PMCID: PMC10295887 DOI: 10.47936/encephalitis.2021.00017] [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: 02/01/2021] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 07/21/2023] Open
Abstract
N-methyl D-aspartate receptor (NMDAR) encephalitis is a well-characterized clinical syndrome. The main molecular mechanism of NMDAR encephalitis is autoantibody-mediated NMDAR hypofunction in the neuronal synapse. Several pathomechanistic hypotheses might explain how NMDAR hypofunction causes the typical symptoms and prognosis of NMDAR encephalitis. Suppression of NMDAR-dependent gamma-aminobutyric acid interneurons provokes an accelerated activation of the positive feedback loops of the dorsolateral prefrontal cortex/subiculum-nucleus accumbens circuit in the striatum, the ventral tegmental area (VTA), and the nucleus reuniens in the thalamus-hippocampus-VTA loop. Dysregulated activation of the VTA and cortex via those positive feedback loops may explain the rapid clinical deterioration at acute stages of the disease and the well-characterized syndrome that includes limbic system dysfunction, intractable seizures, dyskinesia, coma, and the characteristic extreme delta brush. Progressive cerebellar atrophy is correlated with cumulative disease burden and is associated with worse long-term outcomes, which might be explained by the NMDAR-dependent pathways required to maintain neuronal survival. Those pathomechanistic hypotheses for NMDAR encephalitis support the rationale for the early introduction of combination immunotherapy and the use of adjuvant immunotherapy in patients with persisting symptoms in chronic disease phases.
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Affiliation(s)
- Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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28
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Paraneoplastic and autoimmune encephalitis: Alterations of mood and emotion. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:221-234. [PMID: 34389119 DOI: 10.1016/b978-0-12-822290-4.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Autoimmune encephalitis often produces signs and symptoms that appear to be at the interface between neurology and psychiatry. Since psychiatric symptoms are often prominent, patients are often first seen in a psychiatric setting. Therefore it is important that psychiatrists, as well as neurologists, be able to recognize autoimmune encephalitis, a task that is often difficult. Early diagnosis of autoimmune encephalitis is crucial as this will usually result in a better outcome for the patient. This chapter provides an introduction to various autoimmune encephalitides and describes their pathophysiology and the possible associated neuropsychiatric, neuropsychological (cognitive), and neurological (sensory-motor) signs and symptoms. This chapter also reviews the possible treatments of these associated signs and symptoms.
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Vova JA. A narrative review of pharmacologic approaches to symptom management of pediatric patients diagnosed with anti-NMDA receptor encephalitis. J Pediatr Rehabil Med 2021; 14:333-343. [PMID: 34486993 DOI: 10.3233/prm-200677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Anti-N-Methyl-D-Aspartate Receptor Encephalitis (ANMDARE) is one of the most common autoimmune encephalitis in the pediatric population. Patients with ANMDARE initially present with a prodrome of neuropsychiatric symptoms followed by progressively worsening seizures, agitation, and movement disorders. Complications can include problems such as aggression, insomnia, catatonia, and autonomic instability. Due to the complexity of this disease process, symptom management can be complex and may lead to significant polypharmacy. The goal of this review is to educate clinicians about the challenges of managing this disorder and providing guidance in symptom management.
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Affiliation(s)
- Joshua A Vova
- Department of Physiatry, Children's Healthcare of Atlanta, Johnson Ferry Rd NE. Atlanta, GA, USA
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30
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Gibson LL, McKeever A, Coutinho E, Finke C, Pollak TA. Cognitive impact of neuronal antibodies: encephalitis and beyond. Transl Psychiatry 2020; 10:304. [PMID: 32873782 PMCID: PMC7463161 DOI: 10.1038/s41398-020-00989-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/22/2022] Open
Abstract
Cognitive dysfunction is a common feature of autoimmune encephalitis. Pathogenic neuronal surface antibodies are thought to mediate distinct profiles of cognitive impairment in both the acute and chronic phases of encephalitis. In this review, we describe the cognitive impairment associated with each antibody-mediated syndrome and, using evidence from imaging and animal studies, examine how the nature of the impairment relates to the underlying neuroimmunological and receptor-based mechanisms. Neuronal surface antibodies, particularly serum NMDA receptor antibodies, are also found outside of encephalitis although the clinical significance of this has yet to be fully determined. We discuss evidence highlighting their prevalence, and association with cognitive outcomes, in a number of common disorders including cancer and schizophrenia. We consider mechanisms, including blood-brain barrier dysfunction, which could determine the impact of these antibodies outside encephalitis and account for much of the clinical heterogeneity observed.
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Affiliation(s)
- L. L. Gibson
- grid.13097.3c0000 0001 2322 6764Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - A. McKeever
- grid.5335.00000000121885934University of Cambridge, Cambridge, UK
| | - E. Coutinho
- grid.13097.3c0000 0001 2322 6764Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,grid.13097.3c0000 0001 2322 6764MRC Centre for Neurodevelopmental Disorders, King’s College London, London, UK
| | - C. Finke
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany ,grid.7468.d0000 0001 2248 7639Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - T. A. Pollak
- grid.13097.3c0000 0001 2322 6764Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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31
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Blum RA, Tomlinson AR, Jetté N, Kwon CS, Easton A, Yeshokumar AK. Assessment of long-term psychosocial outcomes in anti-NMDA receptor encephalitis. Epilepsy Behav 2020; 108:107088. [PMID: 32375094 DOI: 10.1016/j.yebeh.2020.107088] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/30/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to assess long-term psychosocial outcomes of anti-N-methyl-d-aspartate (NMDA) receptor encephalitis (anti-NMDARE). METHODS Adolescents and adults with self-reported anti-NMDARE were invited to complete an online survey distributed by relevant patient organizations. Demographic and clinical information was collected, including the diagnoses initially given for anti-NMDARE symptoms and posthospital care received. Patient-Reported Outcomes Measurement Information System (PROMIS) Psychosocial Impact Illness - Negative short form (Negative PSII) was administered to assess psychosocial outcome of anti-NMDARE. Associations between clinical factors and psychosocial outcomes were evaluated. RESULTS Sixty-one individuals with anti-NMDARE age 15 years and above participated. Mean age was 33.7 years (standard deviation [SD]: 12.8), and participants were predominantly female (90.2%, n = 55). Mean T-score on PROMIS Negative PSII was 60.7, >1 SD higher (worse psychosocial function) than that of the provided normalized sample enriched for chronic illness (50, SD: 10). Initial misdiagnosis of anti-NMDARE symptoms was associated with decreased odds (odds ratio [OR]: 0.11, p < 0.05), and follow-up with a psychiatrist after hospitalization with increased odds (OR: 8.46, p < 0.05), of return to work/school after illness. Younger age of symptom onset and presence of ongoing neuropsychiatric issues were predictive of worse Negative PSII scores (p < 0.05). CONCLUSION Individuals with anti-NMDARE demonstrate poor psychosocial outcomes, yet there are no current standards for long-term assessment or management of such symptoms in this population. These findings highlight the need for use of more comprehensive outcome measures that include assessment of psychosocial function and the importance of developing interventions that address this domain for individuals with anti-NMDARE.
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Affiliation(s)
- Raia A Blum
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Amanda R Tomlinson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Churl-Su Kwon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Ava Easton
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool L69 7BE, UK; The Encephalitis Society, 32 Castlegate, Malton YO17 7DT, North Yorkshire, UK.
| | - Anusha K Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA; Autoimmune Encephalitis Alliance, 920 Urban Avenue, Durham, NC 27701, USA.
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Current Progress on Assessing the Prognosis for Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7506590. [PMID: 32352007 PMCID: PMC7178504 DOI: 10.1155/2020/7506590] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/01/2020] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most common antineuronal antibody encephalitis in autoimmune encephalitis found at present. It has complex clinical manifestations such as psychiatric and behavioral abnormalities, seizures, movement disorders, consciousness, and autonomic dysfunction. The relationship between those manifestations and prognosis is unclear. Electroencephalography (EEG) is gradually becoming useful in the evaluation of the prognosis of anti-NMDAR encephalitis patients, while imaging and antibody testing have a limited prognostic value. Starting the patients on adequate treatments (such as immunotherapy) in a timely fashion has a positive impact on their prognosis. Nevertheless, research on the prognosis of anti-NMDAR encephalitis remains scarce. Here, we review the current advances of prognosis-related research from the clinical manifestations of the disease and auxiliary examinations such as EEG, magnetic resonance imaging (MRI), 18F fluorodeoxyglucose positron emission tomography (FDG-PET), and antibody measurement. In addition, we also discuss the impact of different treatment options on prognosis. In-depth research on the prognosis of patients with anti-NMDAR encephalitis will contribute to a better understanding of this disease, leading to better treatments options and, ultimately, a better prognosis.
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Characterisation and outcome of neuropsychiatric symptoms in patients with anti-NMDAR encephalitis. Acta Neuropsychiatr 2020; 32:92-98. [PMID: 31753060 DOI: 10.1017/neu.2019.46] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Encephalitis due to anti-N-methyl-D-aspartate receptor antibodies (ANMDARE) is the most frequent immune-mediated encephalitis. It is distinguished by the subacute onset of neuropsychiatric symptoms. OBJECTIVE To evaluate the characteristic neuropsychiatric symptoms and their outcome in patients diagnosed with ANMDARE. METHODS This was a prospective, longitudinal study in patients with a diagnostic suspicion of ANMDARE that presented to the National Institute of Neurology from March 2018 to February 2019. A comparative analysis of two groups (positive N-methyl-D-aspartate receptor [NMDAR] vs. negative NMDAR antibodies in cerebrospinal fluid [CSF]) was done on admission and at discharge. Neuropsychiatric systematic assessments included the Neuropsychiatric Inventory Questionnaire, the Bush Francis Catatonia Rating Scale, the Confusion Assessment Method Severity, the Montreal Cognitive Assessment, and the Overt Agitation Severity Scale. RESULTS 24 individuals were analysed: 14 had positive NMDAR antibodies, and 10 had negative NMDAR antibodies in CSF. On admission, agitation/aggression, euphoria/exaltation, and disinhibition were more common in patients with positive antibodies. Excited catatonia and delirium were diagnosed more frequently in patients with positive antibodies. At discharge, there was an important decrease in neuropsychiatric symptoms, but substantial cognitive impairment remained. The mean hospitalisation length was 41.71 (SD 39.33) days for patients with definitive ANMDARE (p 0.259). CONCLUSIONS Neuropsychiatric symptoms profile in ANMDARE was associated with the early onset of euphoria/exaltation and disinhibition, accompanied by marked psychomotor agitation. When ANMDARE was suspected, the presence of excited-type catatonia and delirium showed a tendency to predict definitive ANMDARE. At discharged, most patients recovered from catatonia, delirium, and psychosis, but marked cognitive symptoms, anxiety, and depression persisted at discharge.
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Huang X, Ding W, Wu F, Zhou S, Deng S, Ning Y. Increased Plasma Kynurenic Acid Levels are Associated with Impaired Attention/Vigilance and Social Cognition in Patients with Schizophrenia. Neuropsychiatr Dis Treat 2020; 16:263-271. [PMID: 32158211 PMCID: PMC6986175 DOI: 10.2147/ndt.s239763] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/13/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Preclinical studies have reported that abnormal kynurenic acid (KYNA) may play a role in cognitive deficits. Schizophrenia (SCZ) is characterized by a wide range of cognitive deficits that may evolve from abnormal KYNA. This study aimed to explore the relationship between KYNA and cognitive impairment in SCZ, which has not yet been reported. METHODS We recruited 30 SCZ patients and 34 healthy controls, measured clinical symptoms by using the Positive and Negative Syndrome Scale and performed cognitive tests using the MATRICS Consensus Cognitive Battery (MCCB). Plasma levels of tryptophan, kynurenine, and KYNA were determined by high-performance liquid chromatography-tandem mass spectrometry. RESULTS We found that plasma KYNA levels were significantly higher in patients than in healthy controls (p=0.009). The cognitive performance of patients in the total MCCB scores and the scores of all subscales were significantly lower than those in healthy controls (all P < 0.01). Correlation analysis showed that KYNA levels were negatively correlated with attention/vigilance (r=-0.457, p=0.019) and social cognition (r=-0.481, p=0.013) only in SCZ patients. CONCLUSION Our results indicate that elevated plasma KYNA levels may serve as a biomarker of cognitive impairment in SCZ patients.
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Affiliation(s)
- Xingbing Huang
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong, People's Republic of China
| | - Wenhua Ding
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong, People's Republic of China
| | - Fengchun Wu
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong, People's Republic of China
| | - Sumiao Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong, People's Republic of China
| | - Shuhua Deng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong, People's Republic of China
| | - Yuping Ning
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, Guangdong, People's Republic of China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, Guangdong, People's Republic of China
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Ferri SL, Pallathra AA, Kim H, Dow HC, Raje P, McMullen M, Bilker WB, Siegel SJ, Abel T, Brodkin ES. Sociability development in mice with cell-specific deletion of the NMDA receptor NR1 subunit gene. GENES BRAIN AND BEHAVIOR 2019; 19:e12624. [PMID: 31721416 DOI: 10.1111/gbb.12624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/13/2022]
Abstract
Social affiliative behavior is an important component of everyday life in many species and is likely to be disrupted in disabling ways in various neurodevelopmental and neuropsychiatric disorders. Therefore, determining the mechanisms involved in these processes is crucial. A link between N-methyl-d-aspartate (NMDA) receptor function and social behaviors has been clearly established. The cell types in which NMDA receptors are critical for social affiliative behavior, however, remain unclear. Here, we use mice carrying a conditional allele of the NMDA R1 subunit to address this question. Mice bearing a floxed NMDAR1 (NR1) allele were crossed with transgenic calcium/calmodulin-dependent kinase IIα (CaMKIIα)-Cre mice or parvalbumin (PV)-Cre mice targeting postnatal excitatory forebrain or PV-expressing interneurons, respectively, and assessed using the three-chambered Social Approach Test. We found that deletion of NR1 in PV-positive interneurons had no effect on social sniffing, but deletion of NR1 in glutamatergic pyramidal cells resulted in a significant increase in social approach behavior, regardless of age or sex. Therefore, forebrain excitatory neurons expressing NR1 play an important role in regulating social affiliative behavior.
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Affiliation(s)
- Sarah L Ferri
- Department of Neuroscience and Pharmacology, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa
| | - Ashley A Pallathra
- Center for Neurobiology and Behavior, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hyong Kim
- Center for Neurobiology and Behavior, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Holly C Dow
- Center for Neurobiology and Behavior, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Praachi Raje
- Center for Neurobiology and Behavior, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary McMullen
- Center for Neurobiology and Behavior, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Warren B Bilker
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Siegel
- Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ted Abel
- Department of Neuroscience and Pharmacology, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa
| | - Edward S Brodkin
- Center for Neurobiology and Behavior, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Liu X, Zhang L, Chen C, Gong X, Lin J, An D, Zhou D, Hong Z. Long-term cognitive and neuropsychiatric outcomes in patients with anti-NMDAR encephalitis. Acta Neurol Scand 2019; 140:414-421. [PMID: 31483852 DOI: 10.1111/ane.13160] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/07/2019] [Accepted: 08/29/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the long-term cognitive or neuropsychiatric outcomes and potential risk factors associated with prolonged cognitive deficits or neuropsychiatric symptoms in patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. METHODS In this cohort follow-up study, patients with a definitive diagnosis of anti-NMDAR encephalitis from the inpatient of West China Hospital between June 2012 and December 2017 were included and underwent a prospective cognitive and neuropsychiatric assessment every 3 months by cognitive impairment rating scale, Neuropsychiatric Inventory (NPI) and/or Montreal Cognitive Assessment. RESULTS Up to 97.5% patients had severe cognitive deficits and neuropsychiatric symptoms in acute phase. Decreasing proportion of patients with prolonged cognitive deficits was observed and time dependent. At 2 years' follow-up, 7.8% of patients with cognitive deficits were unable to complete some previous activities or return to work. The risk factors associated with persistent cognitive deficits included age of disease onset over 40 years old (HR, 1.77; 95% CI, 1.11-2.82; P = .01) and with clinical relapses (HR, 2.22; 95% CI, 1.21-4.09; P = .02). The predictors of prolonged neuropsychiatric symptoms included clinical relapses (HR, 2.79; 95% CI, 1.21-6.43; P = .02). Among the 12 neuropsychiatric symptoms of NPI, irritability was shown as the most prevalent and persistent. CONCLUSIONS Combined cognitive and neuropsychiatric assessment and intervention are essential elements of comprehensive care of anti-NMDAR encephalitis.
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Affiliation(s)
- Xu Liu
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Le Zhang
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Chu Chen
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Xue Gong
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Jingfang Lin
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Dongmei An
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Dong Zhou
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Zhen Hong
- Department of Neurology West China Hospital Sichuan University Chengdu China
- Department of Pathology University of Washington School of Medicine Seattle WA USA
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Voxel-based analysis and multivariate pattern analysis of diffusion tensor imaging study in anti-NMDA receptor encephalitis. Neuroradiology 2019; 62:231-239. [PMID: 31784810 DOI: 10.1007/s00234-019-02321-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/30/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aimed to investigate brain white matter (WM) changes and their relationship to cognition in patients with anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis. Multivariate pattern analysis (MVPA) was used to explore brain regions that play an important role in classification. METHODS Fifteen patients and fifteen controls underwent Montreal Cognitive Assessment (MoCA) and diffusion tensor imaging. Based on fractional anisotropy (FA) and mean diffusivity (MD) for MVPA classification, the weights of each brain region were calculated. RESULTS Compared with the controls, the patients showed an FA reduction in right middle temporal gyrus, left middle cerebellar peduncle, right praecuneus, and an MD increase in left medial temporal gyrus and left frontal lobe. The MoCA score for patients was lower than controls, especially in executive function, fluency, delayed recall and visual perception items. The FA value of right praecuneus was positively correlated with total MoCA score and fluency score. The MD of left frontal lobe was negatively correlated with total MoCA score, and MD of the left medial temporal gyrus was positively correlated with delayed recall. The accuracy, sensitivity and specificity of classification based on FA were 70%, 60% and 80%, respectively. Based on MD, they were each 80%. The brain regions with large weights from FA and MD overlap in temporal lobe, cerebellum and hippocampus. CONCLUSIONS These results suggest that WM changes are associated with cognitive deficits. MVPA based on FA and MD has good classification ability. Our study may provide new insights into the pathophysiological mechanisms of residual cognitive deficits.
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Zhang M, Li W, Zhou S, Zhou Y, Yang H, Yu L, Wang J, Wang Y, Zhang L. Clinical Features, Treatment, and Outcomes Among Chinese Children With Anti-methyl-D-aspartate Receptor (Anti-NMDAR) Encephalitis. Front Neurol 2019; 10:596. [PMID: 31244759 PMCID: PMC6562280 DOI: 10.3389/fneur.2019.00596] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is the most common form of autoimmune encephalitis in pediatric patients. In this study, we aimed to investigate the clinical features and long-term outcomes of pediatric patients with anti-NMDAR encephalitis in China. Methods: We conducted a retrospective study of children (age range: 0–18 years) with anti-NMDAR encephalitis treated at Children's Hospital of Fudan University between July 2015 and November 2018. Demographic characteristics, clinical features, treatment, and outcomes were reviewed. Results: Thirty-four patients with anti-NMDAR encephalitis were enrolled (age range: 5 months to 14 years; median age: 7 years; female: 18). The median follow- up duration was 20 months (range: 6–39 months). Eighteen (52.9%) patients initially presented with seizures and 10 (29.4%) with abnormal (psychiatric) behaviors or cognitive dysfunction. Thirty (88.2%) patients exhibited more than two symptoms during the disease course. No neoplasms were detected. Twelve (35.2%) patients had abnormal cerebrospinal fluid (CSF) findings, including leukocytosis, and increased protein concentration. Eighteen (52.9%) patients exhibited normal brain MRI findings. Electroencephalography revealed abnormal background activity in 27 (79.4%) patients, and epileptiform discharges in 16 (47.0%) patients prior to immunotherapy. All patients received first-line immunotherapy, with 30 (88.2%) and four (11.8%) patients achieving good (Modified Rankin Scale [mRS] score of 0–2) and poor outcomes (mRS score of 3–5), respectively. Initial mRS scores differed significantly between the good and poor outcome groups. Fourteen out of 18 patients (77.7%) with seizures accepted anti-epileptic drug (AED) administration, and seizure freedom was achieved in 12 out of 14 (85.7%) patients at the last follow-up. Ten of these 12 (83.3%) patients withdrew from AED treatment within 1 year. Conclusions: Most patients achieved seizure freedom, so long-term use of AEDs may not be necessary for pediatric patients with anti-NMDAR encephalitis. Among our patients, 83.3% were sensitive to first-line immunotherapy and achieved good outcomes. Higher mRS scores before immunotherapy predicted poor outcomes, highlighting the need for a comprehensive assessment of patients with anti-NMDAR encephalitis.
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Affiliation(s)
- Min Zhang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Haowei Yang
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, China
| | - Lifei Yu
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Ji Wang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Linmei Zhang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
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Abstract
PURPOSE OF REVIEW To describe the clinical, laboratory, and MRI features that characterize cognitive decline in the setting of central nervous system (CNS) autoimmunity, and provide an overview of current treatment modalities. RECENT FINDINGS The field of autoimmune neurology is rapidly expanding due to the increasing number of newly discovered autoantibodies directed against specific CNS targets. The clinical syndromes associated with these autoantibodies are heterogeneous but frequently share common, recognizable clinical, and MRI characteristics. While the detection of certain autoantibodies strongly suggest the presence of an underlying malignancy (onconeural autoantibodies), a large proportion of cases remain idiopathic. Cognitive decline and encephalopathy are common manifestations of CNS autoimmunity, and can mimic neurodegenerative disorders. Recent findings suggest that the frequency of autoimmune encephalitis in the population is higher than previously thought, and potentially rivals that of infectious encephalitis. Moreover, emerging clinical scenarios that may predispose to CNS autoimmunity are increasingly been recognized. These include autoimmune dementia/encephalitis post-herpes simplex virus encephalitis, post-transplant and in association with immune checkpoint inhibitor treatment of cancer. Early recognition of autoimmune cognitive impairment is important given the potential for reversibility and disability prevention with appropriate treatment. Autoimmune cognitive impairment is treatable and may arise in a number of different clinical settings, with important treatment implications. Several clinical and para-clinical clues may help to differentiate these disorders from dementia of other etiologies.
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Department Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Kelleher E, Barry H, Cotter DR, Corvin A, Murphy KC. Autoantibodies and Psychosis. Curr Top Behav Neurosci 2019; 44:85-123. [PMID: 31292938 DOI: 10.1007/7854_2019_90] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Research into antibody-mediated disease, in response to immune dysfunction or to tumour development, has rapidly expanded in recent years. Antibodies binding to neuroreceptors can cause psychiatric features, including psychosis, in a minority of patients as well as neurological features. The responsiveness of some of these cases to immunotherapy supports the hypothesis that antibody-associated mechanisms play a role in the pathogenesis of psychotic diseases. The purpose of this chapter is to review autoantibodies that are most likely to be relevant for patients with psychotic symptoms. Herein, we describe receptor structure and mechanism of action, clinical and psychiatric features for the growing number of neuronal surface antibodies, including those to the N-methyl-D-aspartate (NMDA) receptor. The identification of a subgroup of patients with psychiatric features having antibody-mediated disease highlights the importance of considering the diagnosis, particularly in those patients presenting with a first episode of psychosis.
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Affiliation(s)
- Eric Kelleher
- Department of Psychiatry and Neurobehavioral Science, University College Cork, Cork, Ireland.
| | - Helen Barry
- Department of Psychiatry, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - David R Cotter
- Department of Psychiatry, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Aiden Corvin
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - Kieran C Murphy
- Department of Psychiatry, Royal College of Surgeons of Ireland, Dublin, Ireland
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Chen Z, Wu D, Wang K, Luo B. Cognitive Function Recovery Pattern in Adult Patients With Severe Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Longitudinal Study. Front Neurol 2018; 9:675. [PMID: 30177907 PMCID: PMC6109783 DOI: 10.3389/fneur.2018.00675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/27/2018] [Indexed: 12/19/2022] Open
Abstract
Objective: To observe the dynamic characteristics of cognitive function following early application of immunotherapy in adult patients with severe anti N-methyl D-aspartate receptor (anti-NMDAR) encephalitis. Methods: Serial neuropsychological assessments were performed at three sequential time points in five adult patients with severe anti-NMDAR encephalitis following early-initiated immunotherapy. The three sequential points were 1–2, 6, and 11–12 months after treatment. Five normal subjects without psychological or neurological diseases were assessed as a control group. Results: Following early-initiated immunotherapy, all five patients demonstrated a gradual improvement of overall cognitive function over the 1-year follow-up period. All patients had suffered from a comprehensive cognitive function disorder from the early stages of the illness. Six months after the immunotherapy, the treatment group showed no significant differences in verbal episodic memory function compared with the control group. One year after the immunotherapy, non-verbal episodic memory function in the treatment group had normalized. The results of other tests related to frontoparietal cognitive function revealed damage of varying degrees during these three phases. Conclusion: The results of this sequential observation study indicated a three-phase recovery pattern of cognitive function in adult patients with severe anti-NMDAR encephalitis following early initiated immunotherapy. These findings extend current understanding of the recovery mechanisms of cognitive function impairment in this disease.
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Affiliation(s)
- Zhongqin Chen
- Department of Neurology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dengchang Wu
- Department of Neurology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kang Wang
- Department of Neurology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Scott JG, Gillis D, Swayne A, Blum S. Testing for antibodies to N-methyl-d-aspartate receptor and other neuronal cell surface antigens in patients with early psychosis. Aust N Z J Psychiatry 2018; 52:727-729. [PMID: 29923413 DOI: 10.1177/0004867418782421] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- James G Scott
- 1 Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,2 Metro North Mental Health, Royal Brisbane and Women's Hospital (RBWH), Herston, QLD, Australia.,3 Queensland Centre for Mental Health Research (QCMHR), Wacol, QLD, Australia.,4 Centre for Clinical Research, The University of Queensland, Herston, QLD, Australia
| | - David Gillis
- 5 Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital (RBWH), Herston, QLD, Australia
| | - Andrew Swayne
- 1 Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,6 Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,7 Mater Centre for Neurosciences, Brisbane, QLD, Australia
| | - Stefan Blum
- 1 Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,6 Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,7 Mater Centre for Neurosciences, Brisbane, QLD, Australia
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de Bruijn MAAM, Aarsen FK, van Oosterhout MP, van der Knoop MM, Catsman-Berrevoets CE, Schreurs MWJ, Bastiaansen DEM, Sillevis Smitt PAE, Neuteboom RF, Titulaer MJ. Long-term neuropsychological outcome following pediatric anti-NMDAR encephalitis. Neurology 2018; 90:e1997-e2005. [PMID: 29703768 PMCID: PMC5980521 DOI: 10.1212/wnl.0000000000005605] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/15/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To provide detailed long-term outcome data of children and adolescents following pediatric anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, to identify neuropsychological impairments, and to evaluate the influence of these factors on quality of life (QoL). METHODS All Dutch children diagnosed with anti-NMDAR encephalitis were identified. Patients currently aged 4 years or older were included in the follow-up study, consisting of a visit to our clinic for a detailed interview and a standardized neuropsychological assessment. The following domains were included: attention, memory, language, executive functioning, QoL, and fatigue. Primary outcome measures were z scores on sustained attention, long-term verbal memory, QoL, fatigue, and working memory. RESULTS Twenty-eight patients were included. Median Pediatric Cerebral Performance Category at last visit was 1 (interquartile range 1-2, range 1-4), and 64% (18/28) of patients returned consistently to their previous school level. Twenty-two patients were included in the cross-sectional part of the long-term follow-up study. Median follow-up time was 31 months (interquartile range 15-49, range 5-91). There were problems with sustained attention (z = -2.10, 95% confidence interval = -2.71 to -1.46, p < 0.0001) and fatigue (z = -0.96, 95% confidence interval = -1.64 to -0.28, p = 0.008). Cognitive deficits were not correlated with QoL, while fatigue was strongly correlated with QoL (r = 0.82, p < 0.0001). CONCLUSIONS Although follow-up is often reported as "good" following pediatric anti-NMDAR encephalitis, many patients have cognitive problems and fatigue, even up until adolescence, resulting in academic achievement problems and lower QoL. For physicians, it is essential to be aware of these problems, to provide valuable advice to patients and caregivers in the acute and follow-up phase, and to consider early neuropsychological counseling.
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Affiliation(s)
- Marienke A A M de Bruijn
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Femke K Aarsen
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marielle P van Oosterhout
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke M van der Knoop
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Coriene E Catsman-Berrevoets
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Danielle E M Bastiaansen
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rinze F Neuteboom
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maarten J Titulaer
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
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Nicolle DCM, Moses JL. A Systematic Review of the Neuropsychological Sequelae of People Diagnosed with Anti N-Methyl-D-Aspartate Receptor Encephalitis in the Acute and Chronic Phases. Arch Clin Neuropsychol 2018; 33:964-983. [DOI: 10.1093/arclin/acy005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/16/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Della C M Nicolle
- Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
| | - Jennifer L Moses
- Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
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Scott JG, Gillis D, Ryan AE, Hargovan H, Gundarpi N, McKeon G, Hatherill S, Newman MP, Parry P, Prain K, Patterson S, Wong RCW, Wilson RJ, Blum S. The prevalence and treatment outcomes of antineuronal antibody-positive patients admitted with first episode of psychosis. BJPsych Open 2018; 4:69-74. [PMID: 29971149 PMCID: PMC6020277 DOI: 10.1192/bjo.2018.8] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 12/05/2017] [Accepted: 01/21/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Antineuronal antibodies are associated with psychosis, although their clinical significance in first episode of psychosis (FEP) is undetermined. AIMS To examine all patients admitted for treatment of FEP for antineuronal antibodies and describe clinical presentations and treatment outcomes in those who were antibody positive. METHOD Individuals admitted for FEP to six mental health units in Queensland, Australia, were prospectively tested for serum antineuronal antibodies. Antibody-positive patients were referred for neurological and immunological assessment and therapy. RESULTS Of 113 consenting participants, six had antineuronal antibodies (anti-N-methyl-D-aspartate receptor antibodies [n = 4], voltage-gated potassium channel antibodies [n = 1] and antibodies against uncharacterised antigen [n = 1]). Five received immunotherapy, which prompted resolution of psychosis in four. CONCLUSIONS A small subgroup of patients admitted to hospital with FEP have antineuronal antibodies detectable in serum and are responsive to immunotherapy. Early diagnosis and treatment is critical to optimise recovery. DECLARATION OF INTEREST None.
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Affiliation(s)
- James G. Scott
- Centre for Clinical Research, The University of Queensland
(UQCCR), Metro North Mental Health, Royal Brisbane and Women's
Hospital (RBWH), and the Queensland Centre for Mental Health Research (QCMHR),
Australia
| | - David Gillis
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, Australia
| | | | | | | | | | - Sean Hatherill
- Metro South Addiction and Mental Health Service,
Child and Youth Academic Clinical Unit,
Queensland, Australia
| | - Martin P. Newman
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Faculty of Medicine,
University of Queensland, Australia
| | - Peter Parry
- Child and Youth Mental Health Service,
Children's Health Queensland, Australia
| | - Kerri Prain
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, Australia
| | - Sue Patterson
- Metro North Mental Health, RBWH,
and Department of Applied Psychology, Griffith
University, Queensland, Australia
| | - Richard C. W. Wong
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Department of Immunology,
Princess Alexandra Hospital, Queensland,
Australia
| | - Robert J. Wilson
- Division of Immunology, Pathology Queensland
Central Laboratory, RBWH, and Department of Immunology,
Princess Alexandra Hospital, Queensland,
Australia
| | - Stefan Blum
- Faculty of Medicine, University of
Queensland and Department of Neurology,
Princess Alexandra Hospital, Queensland,
Australia
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46
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Baird A, Robinson GA. Novel cognitive insights from the first year after bi-thalamic infarct. Neurocase 2018; 24:76-81. [PMID: 29493434 DOI: 10.1080/13554794.2018.1444779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Neuropsychological consequences of bi-thalamic damage are scarcely known. This case study documents cognitive (in particular memory and executive) functioning in a man with a medial bi-thalamic infarct in the first year (8 and 12 months) post injury. NG showed persistent memory (including autobiographical) impairment, but improved executive functions at one year post injury. On a response inhibition task his speed of response improved but his ability to inhibit a "prepotent" automatic response declined, corresponding to an increase in behavioral disinhibition. Despite this, he showed intact performances on several social cognition tasks. This case contributes to our understanding of the role of the thalamus in mediating retrograde memory, executive, and social cognition functions.
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Affiliation(s)
- Amee Baird
- a Department of Psychology , Macquarie University , Sydney , Australia.,b Australian Research Council Centre of Excellence in Cognition and its Disorders , Macquarie University , Sydney , Australia
| | - Gail A Robinson
- c Neuropsychology Research Unit, School of Psychology , The University of Queensland , Brisbane , Australia
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47
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Mutti C, Barocco F, Zinno L, Negrotti A, Spallazzi M, Pavesi G, Gardini S, Caffarra P. A case of reversible anti-NMDA-receptor encephalitis: neuropsychological and neuroradiological features. Neurol Sci 2017; 38:2231-2236. [PMID: 28905135 DOI: 10.1007/s10072-017-3105-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/30/2017] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune encephalitis mainly affecting young women. We report a case of a mild paraneoplastic anti-NMDAR encephalitis in a 31-year-old female with an ovarian immature teratoma. The patient exhibited a severe short-term episodic memory impairment and psychiatric symptoms. A detailed diagnostic work-up including complete clinical and laboratory examinations, neuropsychological assessments, and neuroradiological investigations has been done at the onset and during follow-up. The amnestic syndrome and MRI medial-temporal abnormalities reversed after medical and surgical treatment. The present report indicates that the disease can be rapidly reversible if promptly diagnosed and treated. While the disease has already been described elsewhere, the course of neurospychological deficits in adults is not as much known. Usually, when the diagnosis of anti-NMDAR encephalitis is made, the severity of the disease makes the assessment of the neuropsycological profile particulary challenging. The present report is of interest because it describes the complete neuropsychological profile of a mild form of anti-NMDAR encephalitis.
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Affiliation(s)
- Carlotta Mutti
- Department of Medicine and Surgery, Section of Neurology, University of Parma, Via Gramsci 14, 43126, Parma (PR), Italy
| | | | - Lucia Zinno
- Department of Emergency care, General and Specialist Medical Area, AOU, Parma, Italy
| | - Anna Negrotti
- Department of Emergency care, General and Specialist Medical Area, AOU, Parma, Italy
| | | | - Giovanni Pavesi
- Department of Medicine and Surgery, Section of Neurology, University of Parma, Via Gramsci 14, 43126, Parma (PR), Italy
| | | | - Paolo Caffarra
- Department of Medicine and Surgery, Section of Neurology, University of Parma, Via Gramsci 14, 43126, Parma (PR), Italy.
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48
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49
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Shin YW, Lee ST, Park KI, Jung KH, Jung KY, Lee SK, Chu K. Treatment strategies for autoimmune encephalitis. Ther Adv Neurol Disord 2017; 11:1756285617722347. [PMID: 29399043 PMCID: PMC5784571 DOI: 10.1177/1756285617722347] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022] Open
Abstract
Autoimmune encephalitis is one of the most rapidly growing research topics in neurology. Along with discoveries of novel antibodies associated with the disease, clinical experience and outcomes with diverse immunotherapeutic agents in the treatment of autoimmune encephalitis are accumulating. Retrospective observations indicate that early aggressive treatment is associated with better functional outcomes and fewer relapses. Immune response to first-line immunotherapeutic agents (corticosteroids, intravenous immunoglobulin, plasma exchange, and immunoadsorption) is fair, but approximately half or more of patients are administered second-line immunotherapy (rituximab and cyclophosphamide). A small but significant proportion of patients are refractory to all first- and second-line therapies and require further treatment. Although several investigations have shown promising alternatives, the low absolute number of patients involved necessitates more evidence to establish further treatment strategies. In this review, the agents used for first- and second-line immunotherapy are discussed and recent attempts at finding new treatment options are introduced.
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Affiliation(s)
- Yong-Won Shin
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea Yeongjusi Health Center, Gyeongsangbuk-do, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National niversity Hospital, 101, Daehangno, Jongno-gu, Seoul 110-744, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
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50
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McKeon GL, Robinson GA, Ryan AE, Blum S, Gillis D, Finke C, Scott JG. Cognitive outcomes following anti-N-methyl-D-aspartate receptor encephalitis: A systematic review. J Clin Exp Neuropsychol 2017; 40:234-252. [DOI: 10.1080/13803395.2017.1329408] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Gemma L. McKeon
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
- Child and Youth Mental Health Group, Queensland Centre for Mental Health Research (QCMHR), The Park–Centre for Mental Health, Brisbane, QLD, Australia
- School of Psychology, The University of Queensland (UQ), Brisbane, QLD, Australia
| | - Gail A. Robinson
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
- School of Psychology, The University of Queensland (UQ), Brisbane, QLD, Australia
| | - Alexander E. Ryan
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
- Child and Youth Mental Health Group, Queensland Centre for Mental Health Research (QCMHR), The Park–Centre for Mental Health, Brisbane, QLD, Australia
| | - Stefan Blum
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
- Neurosciences Department, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - David Gillis
- Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
- Pathology Queensland, Herston, QLD, Australia
| | - Carsten Finke
- Department of Neurology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - James G. Scott
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
- Child and Youth Mental Health Group, Queensland Centre for Mental Health Research (QCMHR), The Park–Centre for Mental Health, Brisbane, QLD, Australia
- Metro North Mental Health, Royal Brisbane and Women’s Hospital (RBWH), Brisbane, QLD, Australia
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