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Andzelm MM, Stredny CM. Mechanisms and Emerging Therapies for Treatment of Seizures in Pediatric Autoimmune Encephalitis and Autoinflammatory/Autoimmune-Associated Epilepsy. Rheum Dis Clin North Am 2023; 49:875-893. [PMID: 37821201 DOI: 10.1016/j.rdc.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There has been increasing understanding of the role of inflammation in seizures and epilepsy, as well as targeted immunomodulatory treatments. In children, immune-mediated seizures often present acutely in the setting of autoimmune encephalitis and are very responsive to immunotherapy with low rates of subsequent epilepsy. Conversely, seizures in autoimmune-associated epilepsies, such as Rasmussen syndrome, can remain refractory to multimodal therapy, including immunomodulation. In this review, the authors discuss the presentations of immune-mediated seizures in children, underlying mechanisms, and emerging therapies.
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Affiliation(s)
- Milena M Andzelm
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Doniselli FM, Deleo F, Criscuolo S, Stabile A, Pastori C, Di Giacomo R, Didato G, Chiapparini L, Villani F. MRI in Late-Onset Rasmussen Encephalitis: A Long-Term Follow-Up Study. Diagnostics (Basel) 2022; 12:diagnostics12020502. [PMID: 35204592 PMCID: PMC8871246 DOI: 10.3390/diagnostics12020502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Abstract
Late-onset Rasmussen encephalitis (LoRE) is a rare unihemispheric progressive inflammatory disorder causing neurological deficits and epilepsy. The long-term radiological evolution has never been fully described. We retrospectively analyzed the MR images of 13 LoRE patients from a total of 136 studies, and searched for focal areas of volume loss or signal intensity abnormality in grey matter or white matter. Each subject had a median of nine MRI studies (IQR 7–13). Frontal and temporal lobes were the most affected regions (13/13 and 8/13, respectively) and showed the greatest worsening over time in terms of atrophic changes (9/13 and 5/8, respectively). A milder cortical atrophy was found in the insular and parietal lobes. The caudate nucleus was affected in seven patients. Hyperintensities of grey matter and white matter on T2-WI and FLAIR images were observed in all patients, and transiently in eight patients. In two cases out of the latter patients, these transient alterations evolved into atrophy of the same region. Disease duration was significantly associated with signal abnormalities in the grey matter at last follow-up. LoRE MRI alterations are milder, and their progression is markedly slower compared to radiological findings described in the childhood form.
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Affiliation(s)
- Fabio Martino Doniselli
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (F.M.D.); (L.C.)
- Department of Biomedical Sciences for Health, University of Milan, Via Mangiagalli 31, 20122 Milan, Italy
| | - Francesco Deleo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
- Correspondence: ; Tel.: +39-02-23942242
| | - Stefania Criscuolo
- Postgraduational School of Radiodiagnostics, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy;
| | - Andrea Stabile
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Chiara Pastori
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Roberta Di Giacomo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Luisa Chiapparini
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (F.M.D.); (L.C.)
| | - Flavio Villani
- Division of Clinical Neurophysiology and Epilepsy Center, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy;
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Lagarde S, Boucraut J, Bartolomei F. Medical treatment of Rasmussen's Encephalitis: A systematic review. Rev Neurol (Paris) 2022; 178:675-691. [DOI: 10.1016/j.neurol.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
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Alvim RP, Aguiar P, Amado DK, Rocha MSG, Rodriguez RD, Brucki SMD. Rasmussen encephalitis: an older adult presentation? Dement Neuropsychol 2020; 14:434-437. [PMID: 33354299 PMCID: PMC7735055 DOI: 10.1590/1980-57642020dn14-040016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Rasmussen encephalitis (RE) is a classic disorder in the child age group, and only 10% of cases are described in adults. We bring two proven cases of RE in older adults aged over 55 years. Objective To describe the clinical characteristics, progression, diagnostic assessment, neuropathological findings, and treatment of RE in two clinical cases of patients over 55 years of age. Furthermore, we address progressive cognitive decline as an important feature of the RE presentation in older adults in association with focal epilepsy. Methods This is a case series from two tertiary hospitals from São Paulo - Brazil. Retrospective data were collected from one case. Results: Two male individuals aged >55 years with clinical presentation of focal epilepsy along with progressive cognitive deterioration. Conclusions RE could be considered the cause of progressive cognitive decline in older adults, especially if focal epilepsy is described together with asymmetrical neuroimaging findings.
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Affiliation(s)
- Ricardo Pires Alvim
- Behavioral and Cognitive Neurology Unit, Department of Neurology, Universidade de São Paulo - São Paulo, SP, Brazil
| | - Patrick Aguiar
- Behavioral and Cognitive Neurology Unit, Department of Neurology, Universidade de São Paulo - São Paulo, SP, Brazil.,Department of Neurology, Hospital Santa Marcelina - São Paulo, SP, Brazil
| | - Daniel Kempel Amado
- Behavioral and Cognitive Neurology Unit, Department of Neurology, Universidade de São Paulo - São Paulo, SP, Brazil.,Department of Neurology, Hospital Santa Marcelina - São Paulo, SP, Brazil
| | | | - Roberta Diehl Rodriguez
- Behavioral and Cognitive Neurology Unit, Department of Neurology, Universidade de São Paulo - São Paulo, SP, Brazil.,Biobank for Aging Studies, LIM-22, Universidade de São Paulo - São Paulo, SP, Brazil
| | - Sonia Maria Dozzi Brucki
- Behavioral and Cognitive Neurology Unit, Department of Neurology, Universidade de São Paulo - São Paulo, SP, Brazil.,Department of Neurology, Hospital Santa Marcelina - São Paulo, SP, Brazil
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Differential long-term evolution after surgery or pharmacotherapy of Rasmussen encephalopathy in adult patients. J Neurol 2019; 266:773-774. [PMID: 30610427 DOI: 10.1007/s00415-018-09168-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
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Matricardi S, Farello G, Savasta S, Verrotti A. Understanding Childhood Neuroimmune Diseases of the Central Nervous System. Front Pediatr 2019; 7:511. [PMID: 31921724 PMCID: PMC6930888 DOI: 10.3389/fped.2019.00511] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Immune-mediated diseases of the central nervous system (CNS) in childhood are a heterogeneous group of rare conditions sharing the inflammatory involvement of the CNS. This review highlights the growing knowledge of childhood neuroimmune diseases that primarily affect the CNS, outlining the clinical and diagnostic features, the pathobiological mechanisms and genetics, current treatment options, and emerging challenges. The clinical spectrum of these conditions is increasingly expanded, and the underlying mechanisms of dysregulation of the immune system could vary widely. Cell-mediated and antibody-mediated disorders, infection-triggered and paraneoplastic conditions, and genetically defined mechanisms can occur in previously healthy children and can contribute to different stages of the disease. The careful evaluation of the clinical presentation and temporal course of symptoms, the specific neuroimaging and immunological findings, and the exclusion of alternative causes are mandatory in clinical practice for the syndromic diagnosis. A common feature of these conditions is that immunotherapeutic agents could modulate the clinical course and outcomes of the disease. Furthermore, specific symptomatic treatments and comprehensive multidisciplinary care are needed in the overall management. We focus on recent advances on immune-mediated demyelinating CNS disorders, autoimmune encephalitis, interferonopathies, and possible neuroimmune disorders as Rasmussen encephalitis. Better knowledge of these conditions could allow prompt diagnosis and targeted immunotherapy, to decrease morbidity and mortality as well as to improve clinical outcomes, reducing the burden of the disease due to possible long-term neuropsychiatric sequelae. Persisting controversies remain in the rigorous characterization of each specific clinical entity because of the relative rarity in children; moreover, in a large proportion of suspected neuroimmune diseases, the immune "signature" remains unidentified; treatment guidelines are mostly based on retrospective cohort studies and expert opinions; then advances in specific molecular therapies are required. In the future, a better characterization of specific immunological biomarkers may provide a useful understanding of the underlying pathobiological mechanisms of these conditions in order to individualize more tailored therapeutic options and paradigms. Multicenter collaborative research on homogeneous groups of patients who may undergo immunological studies and therapeutic trials could improve the characterization of the underlying mechanisms, the specific phenotypes, and tailored management.
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Affiliation(s)
- Sara Matricardi
- Department of Neuropsychiatry, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Ancona, Italy
| | - Giovanni Farello
- Pediatric Clinic, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Salvatore Savasta
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
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