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Abunada M, Nierobisch N, Ludovichetti R, Simmen C, Terziev R, Togni C, Michels L, Kulcsar Z, Hainc N. Autoimmune encephalitis: Early and late findings on serial MR imaging and correlation to treatment timepoints. Eur J Radiol Open 2024; 12:100552. [PMID: 38327544 PMCID: PMC10847996 DOI: 10.1016/j.ejro.2024.100552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction MRI is negative in a large percentage of autoimmune encephalitis cases or lacks findings specific to an antibody. Even rarer is literature correlating the evolution of imaging findings with treatment timepoints. We aim to characterize imaging findings in autoimmune encephalitis at presentation and on follow up correlated with treatment timepoints for this rare disease. Methods A full-text radiological information system search was performed for "autoimmune encephalitis" between January 2012 and June 2022. Patients with laboratory-identified autoantibodies were included. MRI findings were assessed in correlation to treatment timepoints by two readers in consensus. For statistical analysis, cell-surface vs intracellular antibody groups were assessed for the presence of early limbic, early extralimbic, late limbic, and late extralimbic findings using the χ2 test. Results Thirty-seven patients (female n = 18, median age 58.8 years; range 25.7 to 82.7 years) with 15 different autoantibodies were included in the study. Twenty-three (62%) patients were MRI-negative at time of presentation; 5 of these developed MRI findings on short-term follow up. Of the 19 patients with early MRI findings, 9 (47%) demonstrated improvement upon treatment initiation (7/9 cell-surface group). There was a significant difference (p = 0.046) between the MRI spectrum of cell-surface vs intracellular antibody syndromes as cell-surface antibody syndromes demonstrated more early classic findings of limbic encephalitis and intracellular antibody syndromes demonstrated more late extralimbic abnormalities. Conclusion MRI can be used to help narrow the differential diagnosis in autoimmune encephalitis and can be used as a monitoring tool for certain subtypes of this rare disease.
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Affiliation(s)
- Mahmoud Abunada
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Riccardo Ludovichetti
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Cyril Simmen
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Terziev
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Claudio Togni
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolin Hainc
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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2
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Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
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Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
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Gallus M, Roll W, Dik A, Barca C, Zinnhardt B, Hicking G, Mueller C, Naik VN, Anstötz M, Krämer J, Rolfes L, Wachsmuth L, Pitsch J, van Loo KM, Räuber S, Okada H, Wimberley C, Strippel C, Golombeck KS, Johnen A, Kovac S, Groß CC, Backhaus P, Seifert R, Lewerenz J, Surges R, Elger CE, Wiendl H, Ruck T, Becker AJ, Faber C, Jacobs AH, Bauer J, Meuth SG, Schäfers M, Melzer N. Translational imaging of TSPO reveals pronounced innate inflammation in human and murine CD8 T cell-mediated limbic encephalitis. SCIENCE ADVANCES 2023; 9:eabq7595. [PMID: 37294768 PMCID: PMC10256169 DOI: 10.1126/sciadv.abq7595] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/08/2023] [Indexed: 06/11/2023]
Abstract
Autoimmune limbic encephalitis (ALE) presents with new-onset mesial temporal lobe seizures, progressive memory disturbance, and other behavioral and cognitive changes. CD8 T cells are considered to play a key role in those cases where autoantibodies (ABs) target intracellular antigens or no ABs were found. Assessment of such patients presents a clinical challenge, and novel noninvasive imaging biomarkers are urgently needed. Here, we demonstrate that visualization of the translocator protein (TSPO) with [18F]DPA-714-PET-MRI reveals pronounced microglia activation and reactive gliosis in the hippocampus and amygdala of patients suspected with CD8 T cell ALE, which correlates with FLAIR-MRI and EEG alterations. Back-translation into a preclinical mouse model of neuronal antigen-specific CD8 T cell-mediated ALE allowed us to corroborate our preliminary clinical findings. These translational data underline the potential of [18F]DPA-714-PET-MRI as a clinical molecular imaging method for the direct assessment of innate immunity in CD8 T cell-mediated ALE.
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Affiliation(s)
- Marco Gallus
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurosurgery, University of Münster, Münster, Germany
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Wolfgang Roll
- Department of Nuclear Medicine, University of Münster, Münster, Germany
| | - Andre Dik
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Cristina Barca
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Bastian Zinnhardt
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
- Biomarkers and Translational Technologies (BTT), Pharma Research and Early Development (pRED), F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Gordon Hicking
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Christoph Mueller
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Venu Narayanan Naik
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Max Anstötz
- Institute of Anatomy II, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Julia Krämer
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Leoni Rolfes
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Lydia Wachsmuth
- Department of Clinical Radiology, University of Münster, Münster, Germany
| | - Julika Pitsch
- Department of Epileptology, University of Bonn, Bonn, Germany
| | - Karen M. J. van Loo
- Section for Translational Epilepsy Research, Department of Neuropathology, University of Bonn, Bonn, Germany
- Department of Epileptology and Neurology, RWTH Aachen University, Aachen, Germany
| | - Saskia Räuber
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Hideho Okada
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Christine Strippel
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Kristin S. Golombeck
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Andreas Johnen
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Stjepana Kovac
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Catharina C. Groß
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Philipp Backhaus
- Department of Nuclear Medicine, University of Münster, Münster, Germany
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, University of Münster, Münster, Germany
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Jan Lewerenz
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Rainer Surges
- Department of Epileptology, University of Bonn, Bonn, Germany
| | | | - Heinz Wiendl
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Tobias Ruck
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Albert J. Becker
- Section for Translational Epilepsy Research, Department of Neuropathology, University of Bonn, Bonn, Germany
| | - Cornelius Faber
- Department of Clinical Radiology, University of Münster, Münster, Germany
| | - Andreas H. Jacobs
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Sven G. Meuth
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Michael Schäfers
- Department of Nuclear Medicine, University of Münster, Münster, Germany
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Nico Melzer
- Department of Neurology Institute of Translational Neurology, University of Münster, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
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4
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Rácz A, Hummel CA, Becker A, Helmstaedter C, Schuch F, Baumgartner T, von Wrede R, Borger V, Solymosi L, Surges R, Elger CE. Histopathologic Characterization and Neurodegenerative Markers in Patients With Limbic Encephalitis Undergoing Epilepsy Surgery. Front Neurol 2022; 13:859868. [PMID: 35493848 PMCID: PMC9051082 DOI: 10.3389/fneur.2022.859868] [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: 01/21/2022] [Accepted: 03/09/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose Limbic encephalitis is an increasingly recognized cause of medial temporal lobe epilepsy (mTLE) and associated cognitive deficits, potentially resulting in hippocampal sclerosis (HS). For several reasons, these patients usually do not undergo epilepsy surgery. Thus, histopathologic examinations in surgical specimens of clearly diagnosed limbic encephalitis are scarce. The purpose of this study was a detailed histopathologic analysis of surgical tissue alterations, including neurodegenerative markers, in patients with limbic encephalitis undergoing epilepsy surgery. Methods We investigated the surgical specimens of six patients operated on with mTLE related to limbic encephalitis (among them four patients were with GAD65 and one with Ma1/2 antibodies), and compared the findings to a control group with six patients matched according to age at the time of surgery without limbic encephalitis and without early inciting events. Results Histopathologic analysis in the group with limbic encephalitis revealed HS in four patients, while three of them also displayed signs of an active inflammatory reaction with lymphocytes. In one of the patients with GAD65-encephalitis who was suffering from a late-onset mTLE and a long disease course, neurodegenerative protein markers (β-amyloid and hyperphosphorylated tau) were found coexisting with inflammatory reactions and HS. Investigations in the control group did not reveal any inflammatory reaction or neurodegenerative marker. Conclusion Our findings suggest a possible link between long-lasting immune reactions in the medial temporal lobe, HS, and further toward the development of neurodegenerative diseases. Presently, however, a causal relationship between these entities cannot yet be established. Furthermore, our results suggest that an immunological etiology should always be considered in late onset (> 18 years) mTLE, also in cases of long disease duration and the presence of HS.
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Affiliation(s)
- Attila Rácz
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- *Correspondence: Attila Rácz
| | - Chiara A. Hummel
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Albert Becker
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | | | - Fabiane Schuch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Randi von Wrede
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - László Solymosi
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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5
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Taube J, Witt JA, Baumgartner T, Helmstaedter C. All’s well that ends well? Long-term course of a patient with anti-amphiphysin associated limbic encephalitis. Epilepsy Behav Rep 2022; 18:100534. [PMID: 35360257 PMCID: PMC8960971 DOI: 10.1016/j.ebr.2022.100534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/02/2022] Open
Abstract
Limbic encephalitis due to anti-amphiphysin antibodies can occur without a tumor. Amnesia, delirium, and seizures responded well to autoimmune and antiseizure therapy. Cognition recovered more slowly, behavioral problems persisted. Relapse is common and may even present with different clinical features. This case highlights the need for long-term multimodal monitoring.
Anti-amphiphysin associated limbic encephalitis (LE) is a paraneoplastic autoimmune disorder. The initial clinical presentation features seizures, cognitive and neuropsychiatric symptoms. We present the case of a 25-year-old female patient hospitalized after four consecutive tonic-clonic seizures, followed by confusion, psychotic symptoms, nonconvulsive seizure series, and severe global amnesia. Diagnostic workup revealed anti-amphiphysin associated LE without a tumor. MRI and PET indicated inflammatory processes affecting the bilateral mesial temporal structures more pronounced on the left side. Antiseizure medication, benzodiazepines, and immunotherapy resulted in rapid seizure cessation. Subsequent MRI and PET indicated left hippocampal sclerosis and a left mesial temporal hypometabolism. Executive dysfunction resolved in the following weeks. Global amnesia persisted for almost three months. Two years later, episodic memory was normal with residual visual memory impairments. While this patient’s seizure and cognitive outcome has been favorable, behavioral problems persisted long after disease onset. The persisting behavioral problems and subsequent MRI evidence (13 years after onset) of a swollen right amygdala indicated a possible relapse. This case report illustrates the importance of early diagnosis of LE for best clinical management. Antiseizure medication and immunotherapy led to seizure freedom and almost complete recovery of cognition. However, long-lasting neuropsychiatric symptoms and possible recurrent inflammation highlight the need for a multimodal long-term monitoring of such patients to rule out a relapse.
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6
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Dik A, Widman G, Schulte-Mecklenbeck A, Witt JA, Pitsch J, Golombeck KS, Wagner J, Gallus M, Strippel C, Hansen N, Mönig C, Räuber S, Wiendl H, Elger CE, Surges R, Meuth SG, Helmstaedter C, Gross CC, Becker AJ, Melzer N. Impact of T cells on neurodegeneration in anti-GAD65 limbic encephalitis. Ann Clin Transl Neurol 2021; 8:2289-2301. [PMID: 34841709 PMCID: PMC8670322 DOI: 10.1002/acn3.51486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/01/2021] [Accepted: 11/15/2021] [Indexed: 12/13/2022] Open
Abstract
Objective Direct pathogenic effects of autoantibodies to the 65 kDa isoform of glutamic acid decarboxylase (GAD65) in autoimmune limbic encephalitis (LE) have been questioned due to its intracellular localization. We therefore hypothesized a pathogenic role for T cells. Methods We assessed magnet resonance imaging, neuropsychological and peripheral blood, and CSF flow cytometry data of 10 patients with long‐standing GAD65‐LE compared to controls in a cross‐sectional manner. These data were related to each other within the GAD65‐LE group and linked to neuropathological findings in selective hippocampectomy specimen from another two patients. In addition, full‐resolution human leukocyte antigen (HLA) genotyping of all patients was performed. Results Compared to controls, no alteration in hippocampal volume but impaired memory function and elevated fractions of activated HLADR+ CD4+ and CD8+ T cells in peripheral blood and cerebrospinal fluid were found. Intrathecal fractions of CD8+ T cells negatively correlated with hippocampal volume and memory function, whereas the opposite was true for CD4+ T cells. Consistently, antigen‐experienced CD8+ T cells expressed increased levels of the cytotoxic effector molecule perforin in peripheral blood, and perforin‐expressing CD8+ T cells were found attached mainly to small interneurons but also to large principal neurons together with wide‐spread hippocampal neurodegeneration. 6/10 LE patients harbored the HLA‐A*02:01 allele known to present the immunodominant GAD65114–123 peptide in humans. Interpretation Our data suggest a pathogenic effect of CD8+ T cells and a regulatory effect of CD4+ T cells in patients with long‐standing GAD65‐LE.
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Affiliation(s)
- Andre Dik
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Guido Widman
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Juri-Alexander Witt
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Institute of Neuropathology, Medical Faculty, University of Bonn, Section for Translational Epilepsy Research, Bonn, Germany
| | - Julika Pitsch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kristin S Golombeck
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jan Wagner
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Marco Gallus
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Niels Hansen
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Constanze Mönig
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Saskia Räuber
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Albert J Becker
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Institute of Neuropathology, Medical Faculty, University of Bonn, Section for Translational Epilepsy Research, Bonn, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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7
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Mueller C, Langenbruch LM, Rau JMH, Brix T, Strippel C, Dik A, Golombeck KS, Moenig C, Raeuber SJ, Kovac S, Wiendl H, Meuth SG, Bölte J, Johnen A, Melzer N. Determinants of cognition in autoimmune limbic encephalitis-A retrospective cohort study. Hippocampus 2021; 31:1092-1103. [PMID: 34270832 DOI: 10.1002/hipo.23375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 12/24/2022]
Abstract
Autoimmune limbic encephalitis (ALE) is the most common type of autoimmune encephalitis (AIE). Subacute memory disturbance, temporal lobe seizures, and psychiatric symptoms are clinical hallmarks of the disease. However, little is known on the factors contributing to cognitive functioning in ALE. Hence, we here investigate major determinants of cognitive functioning in ALE. In a retrospective analysis of 102 patients with ALE, we first compared verbal learning capacity, nonverbal learning capacity, and attentional and executive functioning by absence or presence of different types of neural autoantibodies (AABs). Subsequently we established three linear regression models including 63, 38, and 61 patients, respectively to investigate how cognitive functioning in these domains may depend on common markers of ALE such as intrathecal inflammation, blood-cerebrospinal fluid (CSF)-barrier function, mesiotemporal epileptiform discharges and slowing, determined by electroencephalography (EEG) and structural mesiotemporal changes, measured with magnetic resonance imaging (MRI). We also accounted for possible effects of cancer- and immunotherapy and other centrally effective medication. There was no effect of AAB status on cognitive functioning. Although the regression models could not predict verbal and nonverbal learning capacity, structural mesiotemporal neural network alterations on T2-/fluid attenuated inversion recovery (FLAIR)-signal-weighted MRI and mesiotemporal epileptiform discharges or slowing on EEG exerted a significant impact on memory functions. In contrast, the regression model significantly predicted attentional and executive functioning with CSF white blood cell count and centrally effective medication being significant determinants. In this cohort, cognitive functioning in ALE does not depend on the AAB status. Common markers of ALE cannot predict memory functioning that only partially depends on structural and functional alterations of mesiotemporal neural networks. Common markers of ALE significantly predict attentional and executive functioning that is significantly related to centrally effective medication and CSF white blood cell count, which may point toward inflammation affecting brain regions beyond the limbic system.
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Affiliation(s)
- Christoph Mueller
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Lisa M Langenbruch
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Johanna M H Rau
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Tobias Brix
- Institute of Medical Informatics, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Andre Dik
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Kristin S Golombeck
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Constanze Moenig
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Saskia J Raeuber
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Jens Bölte
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Andreas Johnen
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
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8
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Helmstaedter C, Hansen N, Leelaarporn P, Schwing K, Oender D, Widman G, Racz A, Surges R, Becker A, Witt JA. Specific B- and T-cell populations are associated with cognition in patients with epilepsy and antibody positive and negative suspected limbic encephalitis. J Neurol 2021; 268:455-466. [PMID: 32816110 PMCID: PMC7880943 DOI: 10.1007/s00415-020-10158-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/30/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Neuropsychological impairments are major symptoms of autoimmune limbic encephalitis (LE) epilepsy patients. In LE epilepsy patients with an autoimmune response against intracellular antigens as well as in antibody-negative patients, the antibody findings and magnetic resonance imaging pathology correspond poorly to the clinical features. Here, we evaluated whether T- and B-cells are linked to cognitive impairment in these groups. METHODS In this cross-sectional, observational, case-controlled study, we evaluated 106 patients with adult-onset epilepsies with a suspected autoimmune etiology. We assessed verbal and visual memory, executive function, and mood in relation to the presence or absence of known auto-antibodies, and regarding T- and B-cell activity as indicated by flow cytometry (fluorescence-activated cell sorting = FACS, peripheral blood = PB and cerebrospinal fluid = CSF). RESULTS 56% of the patients were antibody-negative. In the other patients, auto-antibodies were directed against intracellular antigens (GAD65, paraneoplastic: 38%), or cellular surface antigens (LGI1/CASPR2/NMDA-R: 6%). Excluding LGI1/CASPR2/NMDA-R, the groups with and without antibodies did not differ in disease features, cognition, or mood. CD4+ T-cells and CD8+ T-cells in blood and CD4+ T-cells in CSF were prominent in the auto-antibody positive group. Regression analyses indicated the role education, drug load, amygdala and/or hippocampal pathology, and CD4+ T-cells play in verbal memory and executive function. Depressed mood revealed no relation to flow cytometry results. CONCLUSION Our results indicate a link between T- and B-cell activity and cognition in epilepsy patients with suspected limbic encephalitis, thus suggesting that flow cytometry results can provide an understanding of cognitive impairment in LE patients with autoantibodies against intracellular antigens.
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Affiliation(s)
- Christoph Helmstaedter
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Niels Hansen
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Pitshaporn Leelaarporn
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Kerstin Schwing
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Demet Oender
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Guido Widman
- SEIN Epilepsy Center, Hemsteede, The Netherlands
| | - Attila Racz
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Albert Becker
- Department of Neuropathology, University Hospital, Bonn, Germany
| | - Juri-Alexander Witt
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
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9
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Diagnostic Value of Structural and Functional Neuroimaging in Autoimmune Epilepsy. CONTRAST MEDIA & MOLECULAR IMAGING 2020; 2020:8894213. [PMID: 33380947 PMCID: PMC7752299 DOI: 10.1155/2020/8894213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/14/2020] [Accepted: 12/02/2020] [Indexed: 01/15/2023]
Abstract
Epilepsy is a common nervous system disease, which affects about 70 million people all over the world. In 2017, the International League Against Epilepsy (ILAE) considered immune factors as its independent cause, and the concept of autoimmune epilepsy (AE) was widely accepted. Early diagnosis and timely treatment can effectively improve the prognosis of the disease. However, due to the diversity of clinical manifestations, the expensive cost of autoantibody detection, and the increased prevalence in Western China, the difficulty for clinicians in early diagnosis and treatment has increased. Fortunately, convenient and fast imaging examinations are expected to help even more. The imaging manifestations of AE patients were characteristic, especially the combined application of structural and functional neuroimaging, which improved the diagnostic value of imaging. In this paper, several common autoantibodies associated with AE and their structure and function changes in neuroimaging were reviewed to provide help for neurologists to achieve the goal of precision medicine.
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10
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18F-FDG-PET/MRI in the diagnostic work-up of limbic encephalitis. PLoS One 2020; 15:e0227906. [PMID: 31951636 PMCID: PMC6968877 DOI: 10.1371/journal.pone.0227906] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/02/2020] [Indexed: 01/18/2023] Open
Abstract
Introduction Limbic encephalitis (LE) is an immune-related, sometimes paraneoplastic process of the central nervous system. Initial diagnosis and treatment are based on the clinical presentation as well as antibody profiles and MRI. This study investigated the diagnostic value of integrated 18F-FDG-PET/MRI in the diagnostic work-up of patients with LE for a cerebral and whole-body imaging concept. Material and methods Twenty patients with suspected LE were enrolled in this prospective study. All patients underwent a dedicated PET/MRI protocol of the brain as well as the whole-body. Two neuroradiologists, one body radiologist and one nuclear medicine physician performed blinded consensus readings of each corresponding MRI and PET/MRI dataset of the brain and whole-body. Diagnostic confidence was evaluated on a Likert scale. Results Based on integrated PET/MRI 19 / 20 patients were found to show morphologic and / or metabolic changes indicative of LE, whereas sole MRI enabled correct identification in 16 / 20 patients. Three patients with negative MRI showed metabolic changes of the limbic system or extra-limbic regions, shifting the diagnosis from (negative) MRI to positive for LE in PET/MRI. Whole-body staging revealed suspected lesions in 2/20 patients, identified by MRI and PET, one confirmed as malignant and one false positive. Diagnostic confidence for cerebral and whole-body imaging reached higher scores for PET/MRI (cerebral: 2.7 and whole body: 4.8) compared to MRI alone (cerebral: 2.4 and whole body: 4.5). Conclusion LE diagnosis remains challenging for imaging as it shows only subtle imaging findings in most patients. Nevertheless, based on the simultaneous and combined analysis of morphologic and metabolic data, integrated PET/MRI may enable a dual platform for improved diagnostic confidence and overall detection of LE as well as whole-body imaging for exclusion of paraneoplastic LE.
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11
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Geran R, Uecker FC, Prüss H, Haeusler KG, Paul F, Ruprecht K, Harms L, Schmidt FA. Olfactory and Gustatory Dysfunction in Patients With Autoimmune Encephalitis. Front Neurol 2019; 10:480. [PMID: 31156532 PMCID: PMC6528690 DOI: 10.3389/fneur.2019.00480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/23/2019] [Indexed: 12/21/2022] Open
Abstract
Objective: To test the hypothesis that olfactory (OF) and gustatory function (GF) is disturbed in patients with autoimmune encephalitides (AE). Methods: The orthonasal OF was tested in 32 patients with AE and 32 age- and sex-matched healthy controls (HC) with the standardized Threshold Discrimination Identification (TDI) score. This validated olfactory testing method yields individual scores for olfactory threshold (T), odor discrimination (D), and identification (I), along with a composite TDI score. The GF was determined by the Taste Strip Test (TST). Results: Overall, 24/32 (75%) of patients with AE, but none of 32 HC (p < 0.001) had olfactory dysfunction in TDI testing. The results of the threshold, discrimination and identification subtests were significantly reduced in patients with AE compared to HC (all p < 0.001). Assessed by TST, 5/19 (26.3%) of patients with AE, but none of 19 HC presented a significant limitation in GF (p < 0.001). The TDI score was correlated with the subjective estimation of the olfactory capacity on a visual analog scale (VAS; rs = 0.475, p = 0.008). Neither age, sex, modified Rankin Scale nor disease duration were associated with the composite TDI score. Conclusions: This is the first study investigating OF and GF in AE patients. According to unblinded assessment, patients with AE have a reduced olfactory and gustatory capacity compared to HC, suggesting that olfactory and gustatory dysfunction are hitherto unrecognized symptoms in AE. Further studies with larger number of AE patients would be of interest to verify our results.
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Affiliation(s)
- Rohat Geran
- Department of Neurology, Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Florian C Uecker
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Harald Prüss
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | | | - Friedemann Paul
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lutz Harms
- Department of Neurology, Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix A Schmidt
- Department of Neurology, Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
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12
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Zoccarato M, Valeggia S, Zuliani L, Gastaldi M, Mariotto S, Franciotta D, Ferrari S, Lombardi G, Zagonel V, De Gaspari P, Ermani M, Signori A, Pichiecchio A, Giometto B, Manara R. Conventional brain MRI features distinguishing limbic encephalitis from mesial temporal glioma. Neuroradiology 2019; 61:853-860. [PMID: 31028423 DOI: 10.1007/s00234-019-02212-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/04/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Radiological hallmark of autoimmune limbic encephalitis (LE) is a hyperintense signal in MRI T2-weighted images of mesial temporal structures. We aimed to identify conventional magnetic resonance imaging (MRI) features that can help distinguish LE from temporal glioma. METHODS Brain MRIs of 25 patients affected by antibody-positive autoimmune LE, 24 patients affected by temporal glioma (tumor group), and 5 negative controls were retrospectively blindly evaluated in random order. RESULTS Ten brain MRIs from the LE group were correctly recognized; one additional patient with mesial temporal hyperintensity with anti-AK5 abs LE was wrongly diagnosed as having a tumor. The brain MRIs of the remaining 14 of the 25 patients with LE were judged negative or, in three cases, showed features not typical for LE. In the tumor group, all MRIs showed pathological alterations diagnosed as tumors in 22/24 cases and as LE in two (2/22, 9%). Unilateral lesions were more common in tumors than in neuroradiologically abnormal LE (96% vs. 18%, p < 0.001). T2/FLAIR hyperintensity of the parahippocampal gyrus was associated more with tumor than with LE (71% vs. 18%) (p = 0,009), as T2/FLAIR hyperintensity of extralimbic structures (p = 0.015), edema (p = 0.041), and mass effect (p = 0.015). Maintenance of gray/white matter distinction was strongly associated with LE (91% vs. 17%, p < 0.001). CONCLUSION Conventional brain MRI is a fundamental tool in the differential diagnosis between LE and glioma. Bilateral involvement and maintenance of gray/white matter distinction at the cortical/subcortical interface are highly suggestive of LE.
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Affiliation(s)
- Marco Zoccarato
- Neurology Unit, AULSS 6 Euganea, Padua, Italy. .,Neuroimmunology Group, Istituto di Ricerca Pediatrica, Padua, Italy.
| | | | - Luigi Zuliani
- Neuroimmunology Group, Istituto di Ricerca Pediatrica, Padua, Italy.,Department of Neurology, Ospedale San Bortolo, AULSS 8 Berica, Vicenza, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCSS Mondino Foundation, Pavia, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCSS Mondino Foundation, Pavia, Italy
| | - Sergio Ferrari
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Piera De Gaspari
- Neuroimmunology Group, Istituto di Ricerca Pediatrica, Padua, Italy
| | - Mario Ermani
- Department of Neurosciences (DNS), Statistic and Informatics Unit, School of Medicine, University of Padua, Padua, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Anna Pichiecchio
- Department of Neuroradiology, IRCSS Mondino Foundation, Pavia, Italy
| | - Bruno Giometto
- Department of Neurology, Ospedale Santa Chiara, Trento, Italy
| | - Renzo Manara
- Neuroradiology, Department of Medicine and Surgery, Sezione di Neuroscienze, University of Salerno, Salerno, Italy
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13
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Abstract
PURPOSE OF REVIEW MRI has a crucial position in the diagnostic routine of epilepsy patients. It relevantly contributes to etiological diagnostics and is indispensable in presurgical evaluation. As modern MRI research has been a boon to clinical neuroscience in general, it also holds the promise of enhancing diagnostics of epilepsy patients; i.e. increasing the diagnostic yield while decreasing the number of MRI-negative patients. Its rapid progress, however, has caused uncertainty about which of its latest developments already are of clinical interest and which still are of academic interest. It is the purpose of this review to clarify what, to the authors' mind, good practice of MRI in epilepsy patient care is today and what it might be tomorrow. RECENT FINDINGS Progress of diagnostic MRI in epilepsy patients is driven by development of scanner hardware, scanner sequence and data postprocessing. Ultra high-field MRI and elaborate sequences provide datasets of novel quality which can be fed into postprocessing programs extracting pathognomonic features of structural or functional anatomy. The integration of these features by means of computerized classifiers yield previously unsurpassed diagnostic validity. Enthusiasm about Diffusion Tensor Imaging and functional MRI in the evaluation before epilepsy surgery is quelled. SUMMARY The application of an epilepsy tailored MRI protocol at 3 Tesla followed by meticulous expert evaluation early after the onset of epilepsy is most crucial. It is hoped that future research will result in MRI workups more standardized than today and widely used postprocessing routines analyzing co-registered three-dimensional volumes from different modalities.
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14
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Strohm T, Steriade C, Wu G, Hantus S, Rae-Grant A, Larvie M. FDG-PET and MRI in the Evolution of New-Onset Refractory Status Epilepticus. AJNR Am J Neuroradiol 2019; 40:238-244. [PMID: 30679215 DOI: 10.3174/ajnr.a5929] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE New-onset refractory status epilepticus is a clinical condition characterized by acute and prolonged pharmacoresistant seizures without a pre-existing relevant neurologic disorder, prior epilepsy, or clear structural, toxic, or metabolic cause. New-onset refractory status epilepticus is often associated with antineuronal antibodies and may respond to early immunosuppressive therapy, reflecting an inflammatory element of the condition. FDG-PET is a useful diagnostic tool in inflammatory and noninflammatory encephalitis. We report here FDG-PET findings in new-onset refractory status epilepticus and their correlation to disease activity, other imaging findings, and outcomes. MATERIALS AND METHODS Twelve patients who met the criteria for new-onset refractory status epilepticus and who had FDG-PET and MR imaging scans and electroencephalography at a single academic medical center between 2008 and 2017 were retrospectively identified. Images were independently reviewed by 2 radiologists specialized in nuclear imaging. Clinical characteristics and outcome measures were collected through chart review. RESULTS Twelve patients underwent 21 FDG-PET scans and 50 MR imaging scans. Nine (75%) patients were positive for autoantibodies. All patients had identifiable abnormalities on the initial FDG-PET in the form of hypermetabolism (83%) and/or hypometabolism (42%). Eight (67%) had medial temporal involvement. All patients (n = 3) with N-methyl-D-aspartic acid receptor antibodies had profound bilateral occipital hypometabolism. Initial MR imaging findings were normal in 6 (50%) patients. Most patients had some degree of persistent hyper- (73%) or hypometabolism (45%) after immunosuppressive therapy. FDG-PET hypometabolism was predictive of poor outcome (mRS 4-6) at hospital discharge (P = .028). CONCLUSIONS Both FDG-PET hypometabolism and hypermetabolism are seen in the setting of new-onset refractory status epilepticus and may represent markers of disease activity.
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Affiliation(s)
- T Strohm
- From the Department of Neurology (T.S.), Neurovascular Stroke Center, Ohio State University, Columbus, Ohio
| | | | - G Wu
- Department of Nuclear Medicine (G.W., M.L.)
| | - S Hantus
- Department of Epilepsy (C.S., S.H.)
| | - A Rae-Grant
- Department of Neuroimmunology (A.R.-G.), Cleveland Clinic, Cleveland, Ohio
| | - M Larvie
- Department of Nuclear Medicine (G.W., M.L.)
- Department of Neuroradiology (M.L.)
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15
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Falip M, Rodriguez-Bel L, Castañer S, Sala-Padró J, Miro J, Jaraba S, Casasnovas C, Morandeira F, Berdejo J, Carreño M. Hippocampus and Insula Are Targets in Epileptic Patients With Glutamic Acid Decarboxylase Antibodies. Front Neurol 2019; 9:1143. [PMID: 30687213 PMCID: PMC6334555 DOI: 10.3389/fneur.2018.01143] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/11/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Antibodies to glutamic acid decarboxylase (GAD ab) have been found in patients with limbic encephalitis (LE) and chronic pharmacoresistant focal epilepsy (FE). The objectives of the study were to: (1) analyze the clinical and neuroimaging course of patients with FE+GAD ab, (2) compare these characteristics with a control group, and (3) describe the most affected cerebral areas with structural and functional imaging. Methods: Patients with FE + high titers of GAD ab and a follow-up of at least 5 years were selected. Titers of serum GAD ab exceeding 2,000 UI/ml were considered high. Evolutive clinical and radiological characteristics were studied in comparison to two different control groups: patients with bilateral or with unilateral mesial temporal sclerosis (BMTS or UMTS) of a non-autoimmune origin. Results: A group of 13 patients and 17 controls were included (8 BMTS, 9 UMTS). The most frequent focal aware seizures (FAS) reported by patients were psychic (5/13: 33%). Somatosensorial, motor, and visual FAS (4/13:32%) (p: 0.045), musicogenic reflex seizures (MRS), and a previous history of cardiac syncope were reported only patients (2/13:16% each) (p: NS). Comparing EEG characteristics between patients and controls, a more widespread distribution of interictal epileptiform discharges (IED) was observed in FE+ GAD ab patients than in controls (p:0.01). Rhythmic delta activity was observed in all controls in anterior temporal lobes while in patients this was less frequent (p: 0.001). No IED, even in 24 h cVEEG, was seen in 6 patients (46%).First MRI was normal in 4/5 (75%) patients. During the follow-up mesial temporal lobe (MTsL) sclerosis was observed in 5/8 (62%) of patients. All patients had abnormal FDG-PET study. MTL hypometabolism was observed in 10/11 (91%) patients, being bilateral in 7/11 (63%). In controls, this was observed in 16/17 (94%), and it was bilateral in 8/17 (47%) (p: NS). Insular hypometabolism was observed in 5/11 (45%) patients (P:0.002). Conclusions: Clinical, EEG, and FDG-PET findings in FE+GAD ab suggest a widespread disease not restricted to the temporal lobe. Progressive MTL sclerosis may be observed during follow-up. In comparison to what is found in patients with non-autoimmune MTL epilepsy, insular hypometabolism is observed only in patients with GAD ab, so it may be an important diagnostic clue.
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Affiliation(s)
- Mercè Falip
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Rodriguez-Bel
- PET Division, Institute of Diagnostic Imaging (IDI), Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Sara Castañer
- MRI Division, Institute of Diagnostic Imaging (IDI), Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Jacint Sala-Padró
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Júlia Miro
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Sónia Jaraba
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos Casasnovas
- Neuromuscular Unit, Department of Neurology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Morandeira
- Immunology Unit, Biochemistry Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Berdejo
- Department of Cardiology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Mar Carreño
- Epilepsy Unit, Department of Neurology, Hospital Clinic i Provincial, Barcelona, Spain
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16
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Guerin J, Watson RE, Carr CM, Liebo GB, Kotsenas AL. Autoimmune epilepsy: findings on MRI and FDG-PET. Br J Radiol 2018; 92:20170869. [PMID: 30235015 DOI: 10.1259/bjr.20170869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Autoimmune epilepsy (AE) is becoming increasingly recognized as a potentially reversible cause of frequent or medically intractable seizures and cognitive deterioration. We describe various presentations of autoimmune encephalopathy which have specifically presented with seizure and describe reported imaging findings. This is organized as a review of the more common autoantibodies which can specifically precipitate seizure according to the intracellular or extracellular location of the targeted antigen. For each antibody, we illustrate their pathophysiology, characteristic clinical presentations with typical effective treatments and prognoses and imaging findings on MRI and PET/CT exams. Parenchymal involvement is variable with the limbic structures typically affected; however, non-limbic cortex, cerebellum, brainstem and basal ganglia can also be involved. In the acute setting, affected regions typically demonstrate T2 hyperintensity with mild mass effect from edema and increased 18F-fludeoxyglucose uptake. Chronically involved parenchyma will often undergo atrophy and demonstrate decreased metabolism; mesial temporal sclerosis is often the end result when the limbic system is involved. Without treatment, long-term effects from AE range from ongoing cognitive dysfunction and refractory seizures to death. Familiarity with AE may prompt appropriate antibody screening, particularly in cases of refractory seizure disorders. Early investigation and proper management of AE cases may help to prevent parenchymal and neurologic deterioration in these patients.
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Affiliation(s)
- Julie Guerin
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Robert E Watson
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Carrie M Carr
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Greta B Liebo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Amy L Kotsenas
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
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17
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Schievelkamp AH, Jurcoane A, Rüber T, Ernst L, Müller A, Mädler B, Schild HH, Hattingen E. Limbic Encephalitis in Patients with Epilepsy-is Quantitative MRI Diagnostic? Clin Neuroradiol 2018; 29:623-630. [PMID: 30014154 DOI: 10.1007/s00062-018-0705-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Limbic encephalitis (LE) is an immune-related disease with limbic symptoms, variable and asymmetric magnetic resonance imaging (MRI) aspects and antibody profiles. This study investigated the diagnostic value of quantitative relaxation times T2 (qT2) and MRI signal intensities (SI) in LE. METHODS The prospective 3T-MRI study included 39 epilepsy patients with initially suspected LE and 20 healthy controls. Values and asymmetry indices of qT2, T2-weighted (T2-w) and proton density (PD)-w SI of manually delineated and automatically segmented amygdala and hippocampus were measured. Additionally, two raters made a blinded visual analysis on FLAIR (fluid attenuation inversion recovery) and T2-w images. RESULTS According to diagnostic guidelines, 22 patients had probable LE and 17 patients had possible LE. The qT2 was higher (p < 0.01) in patients than in controls (mean ± SD, amygdala 98 ± 7 ms vs. 90 ± 5 ms, hippocampus 101 ± 7 ms vs. 92 ± 3 ms), but was not different between probable and possible LE or between sides (left and right). The PD-w SI and T2-w SI were lower in patients than in controls but were not different between patient subgroups or between sides. Diagnostic performance of visual analysis was relatively poor. CONCLUSIONS Epilepsy patients with suspected LE had elevated qT2 in amygdala and hippocampus, whereas the expected T2-w SI increase was not found; however, the diagnostic value of qT2 remains questionable since it did not discriminate probable from possible LE.
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Affiliation(s)
- Arndt-Hendrik Schievelkamp
- Neuroradiology, Department of Radiology, University Hospital Bonn, Sigmund Freud Str. 25, 53127, Bonn, Germany
| | - Alina Jurcoane
- Neuroradiology, Department of Radiology, University Hospital Bonn, Sigmund Freud Str. 25, 53127, Bonn, Germany
| | - Theodor Rüber
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Leon Ernst
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Andreas Müller
- Neuroradiology, Department of Radiology, University Hospital Bonn, Sigmund Freud Str. 25, 53127, Bonn, Germany
| | - Burkhard Mädler
- Philips GmbH, UB Healthcare, Lübeckertordamm 5, 20099, Hamburg, Germany
| | - Hans Heinz Schild
- Department of Radiology, University Hospital Bonn, Sigmund Freud Str. 25, 53127, Bonn, Germany
| | - Elke Hattingen
- Neuroradiology, Department of Radiology, University Hospital Bonn, Sigmund Freud Str. 25, 53127, Bonn, Germany.
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Lv RJ, Ren HT, Guan HZ, Cui T, Shao XQ. Seizure semiology: an important clinical clue to the diagnosis of autoimmune epilepsy. Ann Clin Transl Neurol 2018; 5:208-215. [PMID: 29468181 PMCID: PMC5817820 DOI: 10.1002/acn3.520] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/29/2017] [Accepted: 12/06/2017] [Indexed: 12/12/2022] Open
Abstract
Objective The purpose of this study is to analyze the seizure semiologic characteristics of patients with autoimmune epilepsy (AE) and describe the investigation characteristics of AE using a larger sample size. Methods This observational retrospective case series study was conducted from a tertiary epilepsy center between May 2014 and March 2017. Cases of new‐onset seizures were selected based on laboratory evidence of autoimmunity. At the same time, typical mesial temporal lobe epilepsy (MTLE) patients with hippocampal sclerosis (HS) were recruited as the control group from the subjects who underwent presurgical evaluation during the same period. Results A total of 61 patients with AE were identified. Specific autoimmune antibodies were detected in 39 patients (63.93%), including anti‐VGKC in 23 patients (37.70%), anti‐NMDA‐R in 9 patients (14.75%), anti‐GABAB‐R in 6 patients (9.84%), and anti‐amphiphysin in 1 patient (1.64%). Regarding the seizure semiology, no significant differences were noted between AE patients with autoantibody and patients with suspected AE without antibody. Compared to typical MTLE patients with HS, both AE patients with autoantibody and patients with suspected AE without antibody had the same seizure semiologic characteristics, including more frequent SPS or CPS, shorter seizure duration, rare postictal confusion, and common sleeping SGTC seizures. Significance This study highlights important seizure semiologic characteristics of AE. Patients with autoimmune epilepsy had special seizure semiologic characteristics. For patients with autoimmune epilepsy presenting with new‐onset seizures in isolation or with a seizure‐predominant neurological disorder, the special seizure semiologic characteristics may remind us to test neuronal nuclear/cytoplasmic antibodies early and initiate immunomodulatory therapies as soon as possible. Furthermore, the absence of neural‐specific autoantibodies does not rule out AE.
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Affiliation(s)
- Rui-Juan Lv
- Department of Neurology Beijing Tiantan Hospital Capital Medical University 6 Tiantanxili, Dongcheng District Beijing 100050 China.,China National Clinical Research Center for Neurological Diseases 6 Tiantanxili, Dongcheng District Beijing 100050 China
| | - Hai-Tao Ren
- Department of Neurology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing 100730 China
| | - Hong-Zhi Guan
- Department of Neurology Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing 100730 China
| | - Tao Cui
- Department of Neurology Beijing Tiantan Hospital Capital Medical University 6 Tiantanxili, Dongcheng District Beijing 100050 China.,China National Clinical Research Center for Neurological Diseases 6 Tiantanxili, Dongcheng District Beijing 100050 China
| | - Xiao-Qiu Shao
- Department of Neurology Beijing Tiantan Hospital Capital Medical University 6 Tiantanxili, Dongcheng District Beijing 100050 China.,China National Clinical Research Center for Neurological Diseases 6 Tiantanxili, Dongcheng District Beijing 100050 China
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19
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Tröscher AR, Klang A, French M, Quemada-Garrido L, Kneissl SM, Bien CG, Pákozdy Á, Bauer J. Selective Limbic Blood-Brain Barrier Breakdown in a Feline Model of Limbic Encephalitis with LGI1 Antibodies. Front Immunol 2017; 8:1364. [PMID: 29093718 PMCID: PMC5651237 DOI: 10.3389/fimmu.2017.01364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/05/2017] [Indexed: 12/30/2022] Open
Abstract
Human leucine-rich glioma-inactivated protein 1 encephalitis (LGI1) is an autoimmune limbic encephalitis in which serum and cerebrospinal fluid contain antibodies targeting LGI1, a protein of the voltage gated potassium channel (VGKC) complex. Recently, we showed that a feline model of limbic encephalitis with LGI1 antibodies, called feline complex partial seizures with orofacial involvement (FEPSO), is highly comparable to human LGI1 encephalitis. In human LGI1 encephalitis, neuropathological investigations are difficult because very little material is available. Taking advantage of this natural animal model to study pathological mechanisms will, therefore, contribute to a better understanding of its human counterpart. Here, we present a brain-wide histopathological analysis of FEPSO. We discovered that blood–brain barrier (BBB) leakage was present not only in all regions of the hippocampus but also in other limbic structures such as the subiculum, amygdale, and piriform lobe. However, in other regions, such as the cerebellum, no leakage was observed. In addition, this brain-region-specific immunoglobulin leakage was associated with the breakdown of endothelial tight junctions. Brain areas affected by BBB dysfunction also revealed immunoglobulin and complement deposition as well as neuronal cell death. These neuropathological findings were supported by magnetic resonance imaging showing signal and volume increase in the amygdala and the piriform lobe. Importantly, we could show that BBB disturbance in LGI1 encephalitis does not depend on T cell infiltrates, which were present brain-wide. This finding points toward another, so far unknown, mechanism of opening the BBB. The limbic predilection sites of immunoglobulin antibody leakage into the brain may explain why most patients with LGI1 antibodies have a limbic phenotype even though LGI1, the target protein, is ubiquitously distributed across the central nervous system.
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Affiliation(s)
- Anna R Tröscher
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Andrea Klang
- Department for Pathobiology, Institute of Pathology and Forensic Veterinary Medicine, University of Veterinary Medicine, Vienna, Austria
| | - Maria French
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Lucía Quemada-Garrido
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Sibylle Maria Kneissl
- Diagnostic Imaging, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | | | - Ákos Pákozdy
- Clinical Unit of Internal Medicine Small Animals, University of Veterinary Medicine, Vienna, Austria
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
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20
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Abstract
This paper reviews advances in epilepsy in recent years with an emphasis on therapeutics and underlying mechanisms, including status epilepticus, drug and surgical treatments. Lessons from rarer epilepsies regarding the relationship between epilepsy type, mechanisms and choice of antiepileptic drugs (AED) are explored and data regarding AED use in pregnancy are reviewed. Concepts evolving towards a move from treating seizures to treating epilepsy are discussed, both in terms of the mechanisms of epileptogenesis, and in terms of epilepsy's broader comorbidity, especially depression.
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21
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von Rhein B, Wagner J, Widman G, Malter MP, Elger CE, Helmstaedter C. Suspected antibody negative autoimmune limbic encephalitis: outcome of immunotherapy. Acta Neurol Scand 2017; 135:134-141. [PMID: 26940288 DOI: 10.1111/ane.12575] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Whether and when to immunologically treat epilepsy patients with suggested autoantibody (AB)-negative limbic encephalitis (LE) is clinically challenging. Therefore, we evaluated the clinical outcome and eventual outcome predictors of immunotherapy in a group of AB-negative patients with recent-onset temporal lobe epilepsy (TLE), magnetic resonance imaging (MRI) indicators of LE, subjective cognitive decline, and/or psychiatric symptoms. METHODS This retrospective, observational, uncontrolled study monitored 28 TLE patients with suggested AB-negative LE along with methylprednisolone immunotherapy. RESULTS All patients had seizures, amygdala and/or -hippocampal enlargement, subjective cognitive decline and/or behavioral problems. Eighty-six percent (24/28) were impaired in executive or memory functions, 39% (10/25) depressed, 81% were on antiepileptic drugs when pulse therapy started. After a median follow-up of 18 months, 46% (13/28) of the patients were seizure free (>2 months), 48% (13/27) showed MRI improvements (amygdala and/or hippocampal volume reduction), cognition improved in 57% (16/28), worsened in 32% (9/28), mood improved in 14% (4/25), and deteriorated in 11% (3/25). Immunotherapy was discontinued in 75% (21/28). Clinical changes did not correlate to each other. Outcomes could not be predicted. CONCLUSION Immunological treatment of suggested AB-negative LE showed reasonable seizure control, MRI and cognitive improvements. Treatment success was not predictable from clinical features, nor definitely attributable to immunological treatment. Lacking biomarkers for the reliable diagnosis of AB-negative LE, we suggest that in presence of mild manifestations, and after initiating antiepileptic drug therapy, negative dynamics in MRI, seizures, cognition, and behavior should be documented before immunosuppressive treatment is initiated.
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Affiliation(s)
- B. von Rhein
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - J. Wagner
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - G. Widman
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - M. P. Malter
- Department of Neurology; University Hospital Cologne; Cologne Germany
| | - C. E. Elger
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - C. Helmstaedter
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
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22
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Malter MP, Widman G, Galldiks N, Stoecker W, Helmstaedter C, Elger CE, Wagner J. Suspected new-onset autoimmune temporal lobe epilepsy with amygdala enlargement. Epilepsia 2016; 57:1485-94. [PMID: 27418040 DOI: 10.1111/epi.13471] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Recent reports define temporal lobe epilepsy with amygdala enlargement (TLE-AE) as a distinct electroclinical syndrome comparable to TLE with hippocampal sclerosis. In this retrospective observational study, we present the largest consecutive series of patients with new-onset TLE-AE to date and describe clinical characteristics and seizure outcome, and we aim to explore underlying autoimmune mechanisms within this syndrome. METHODS We reviewed all consecutive patients between 2004 and 2014 at our tertiary epilepsy center at the University of Bonn, Germany, with new-onset (<5 years) TLE-AE, negative serum antibody (ab) test results, and with available follow-up data for at least 12 months. RESULTS We identified 40 patients (23 male) with TLE-AE with a median age at epilepsy onset of 51 years (range 10-73) and a median disease duration of 11 months (range 0.5-55) at first presentation. At follow-up, 50% of the entire cohort achieved seizure freedom. Of interest, patients with remittent features of AE at follow-up (N = 24) had a superior outcome compared to those with stable magnetic resonance imaging (MRI) features of AE (N = 16): 17 (71%) of 24 were seizure-free for at least 6 months compared to 3 (19%) of 16, respectively (p = 0.003). MRI volumetry confirmed significantly enlarged amygdalae in TLE-AE in relation to healthy controls, and additionally showed significantly greater volume reductions in patients with remittent AE compared to those with stable AE. SIGNIFICANCE TLE-AE is a clinical syndrome beginning mostly in middle age, and in addition to its known association with ab-positive limbic encephalitis, it occurs in an ab-negative condition. Remission of AE in the course of the disease could be identified as a predictor for a favorable clinical outcome and is suspicious of an autoimmune etiology, although we could not confirm this hypothesis unequivocally with currently available noninvasive diagnostic tools.
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Affiliation(s)
- Michael P Malter
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of Neurology, University of Cologne, Cologne, Germany
| | - Guido Widman
- Department of Epileptology, University of Bonn, Bonn, Germany
| | - Norbert Galldiks
- Department of Neurology, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine, Research Center Juelich, Juelich, Germany
| | - Winfried Stoecker
- Institute of Experimental Immunology, Affiliated to Euroimmun AG, Luebeck, Germany
| | | | - Christian E Elger
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Centre, Bonn, Germany
| | - Jan Wagner
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Centre, Bonn, Germany.,Department of Neurology, Epilepsy Center Hessen-Marburg, University of Marburg Medical Centre, Marburg, Germany
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23
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Dubey D, Blackburn K, Greenberg B, Stuve O, Vernino S. Diagnostic and therapeutic strategies for management of autoimmune encephalopathies. Expert Rev Neurother 2016; 16:937-49. [PMID: 27171736 DOI: 10.1080/14737175.2016.1189328] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The understanding of the etio-pathogenesis of autoimmune encephalopathy syndromes has grown significantly in recent years. These are potentially reversible conditions, with variable clinical presentation and potential dramatic response to immunotherapy. AREAS COVERED In this article we review various diagnostic techniques and therapeutic options for management of autoimmune encephalopathy. We also review medication adverse effects and monitoring strategies. Expert commentary: Early diagnosis and immunomodulatory treatment remains the cornerstone of management, to halt the underlying neuro-inflammatory process and prevent permanent neuronal injury. The availability of serological testing and various imaging modalities has further improved detection of these immune-mediated neurological disorders. Understanding the mechanisms and potential adverse effects of immunomodulatory therapies will help physicians to choose the most favorable therapeutic strategy for each patient.
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Affiliation(s)
- Divyanshu Dubey
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Kyle Blackburn
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Benjamin Greenberg
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Olaf Stuve
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA.,b Neurology Section , VA North Texas Health Care System, Medical Service , Dallas , TX , USA
| | - Steven Vernino
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
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24
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Wagner J, Schoene-Bake JC, Witt JA, Helmstaedter C, Malter MP, Stoecker W, Probst C, Weber B, Elger CE. Distinct white matter integrity in glutamic acid decarboxylase and voltage-gated potassium channel-complex antibody-associated limbic encephalitis. Epilepsia 2016; 57:475-83. [PMID: 26749370 DOI: 10.1111/epi.13297] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Autoantibodies against glutamic acid decarboxylase (GAD) and the voltage-gated potassium channel (VGKC) complex are associated with distinct subtypes of limbic encephalitis regarding clinical presentation, response to therapy, and outcome. The aim of this study was to investigate white matter changes in these two limbic encephalitis subtypes by means of diffusion tensor imaging (DTI). METHODS Diffusion data were obtained in 14 patients with GAD antibodies and 16 patients with VGKC-complex antibodies and compared with age- and gender-matched control groups. Voxelwise statistical analysis was carried out using tract-based spatial statistics. The results were furthermore compared with those of 15 patients with unilateral histologically confirmed hippocampal sclerosis and correlated with verbal and figural memory performance. RESULTS We found widespread changes of fractional anisotropy and all diffusivity parameters in GAD-associated limbic encephalitis, whereas no changes were found in VGKC-complex-associated limbic encephalitis. The changes observed in the GAD group were even more extensive when compared against those of the hippocampal sclerosis group, although the disease duration was markedly shorter in patients with GAD antibodies. Correlation analysis revealed areas with a trend toward a negative correlation of diffusivity parameters with figural memory performance located mainly in the right temporal lobe in the GAD group as well. SIGNIFICANCE The present study provides further evidence that, depending on the associated antibody, limbic encephalitis features clearly distinct imaging characteristics by showing widespread white matter changes in GAD-associated limbic encephalitis and preserved white matter integrity in VGKC-complex-associated limbic encephalitis. Furthermore, our results contribute to a better understanding of the specific pathophysiologic properties in these two subforms of limbic encephalitis by revealing that patients with GAD antibodies show widespread affections of white matter across various regions of the brain. In contrast to this, the inflammatory process seems to be more localized in VGKC-complex-associated limbic encephalitis, primarily affecting mesiotemporal gray matter.
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Affiliation(s)
- Jan Wagner
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany
| | - Jan-Christoph Schoene-Bake
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany.,Department of Pediatrics, Klinikum Braunschweig, Braunschweig, Germany
| | | | | | - Michael P Malter
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of Neurology, University of Cologne, Cologne, Germany
| | - Winfried Stoecker
- Institute of Experimental Immunology, affiliated with Euroimmun AG Luebeck, Luebeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, affiliated with Euroimmun AG Luebeck, Luebeck, Germany
| | - Bernd Weber
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany.,Center for Economics and Neuroscience, University of Bonn, Bonn, Germany
| | - Christian E Elger
- Department of Epileptology, University of Bonn, Bonn, Germany.,Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany.,Center for Economics and Neuroscience, University of Bonn, Bonn, Germany
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25
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Abstract
In recent years a large number of antibody-associated or antibody-defined encephalitides have been discovered. These conditions are often referred to as autoimmune encephalitides. The clinical features include prominent epileptic seizures, cognitive and psychiatric disturbance. These encephalitides can be divided in those with antibodies against intracellular antigens and those with antibodies against surface antigens. The discovery of new antibodies against targets on the surface of neurons is especially interesting since patients with such antibodies can be successfully treated immunologically. This chapter focuses on the pathology and the pathogenetic mechanisms involved in these encephalitides and discusses some of the questions that are raised in this exciting new field. It is important to realise, however, that because of the use of antibodies to diagnose the patients, and their improvement with treatment, there are relatively few biopsy or postmortem reports, limiting the neuropathological data and conclusions that can be drawn. For this reason we especially focus on the most frequent autoimmune encephalitides, those with antibodies to the NMDA receptor and with antibodies to the known protein components of the VGKC complex. Analysis of these encephalitides show completely different pathogenic mechanisms. In VGKC complex encephalitis, antibodies seem to bind to their target and activate complement, leading to destruction and loss of neurons. On the other hand, in NMDAR encephalitis, complement activation and neuronal degeneration seems to be largely absent. Instead, binding of antibodies leads to a decrease of NMDA receptors resulting in a hypofunction. This hypofunction offers an explanation for some of the clinical features such as psychosis and episodic memory impairment, but not for the frequent seizures. Thus, additional analysis of the few human brain specimens present and the use of specific animal models are needed to further understand the effects of these antibodies in autoimmune encephalitides.
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Affiliation(s)
- Jan Bauer
- Center for Brain Research, Medical University Vienna, Vienna, Austria.
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26
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Schröder O, Schriewer E, Golombeck KS, Kürten J, Lohmann H, Schwindt W, Wiendl H, Bruchmann M, Melzer N, Straube T. Impaired Autonomic Responses to Emotional Stimuli in Autoimmune Limbic Encephalitis. Front Neurol 2015; 6:250. [PMID: 26648907 PMCID: PMC4663278 DOI: 10.3389/fneur.2015.00250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/13/2015] [Indexed: 12/19/2022] Open
Abstract
Limbic encephalitis (LE) is an autoimmune-mediated disorder that affects structures of the limbic system, in particular, the amygdala. The amygdala constitutes a brain area substantial for processing of emotional, especially fear-related signals. The amygdala is also involved in neuroendocrine and autonomic functions, including skin conductance responses (SCRs) to emotionally arousing stimuli. This study investigates behavioral and autonomic responses to discrete emotion evoking and neutral film clips in a patient suffering from LE associated with contactin-associated protein-2 (CASPR2) antibodies as compared to a healthy control group. Results show a lack of SCRs in the patient while watching the film clips, with significant differences compared to healthy controls in the case of fear-inducing videos. There was no comparable impairment in behavioral data (emotion report, valence, and arousal ratings). The results point to a defective modulation of sympathetic responses during emotional stimulation in patients with LE, probably due to impaired functioning of the amygdala.
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Affiliation(s)
- Olga Schröder
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | - Elisabeth Schriewer
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | | | - Julia Kürten
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | - Hubertus Lohmann
- Department of Neurology, University of Muenster , Muenster , Germany
| | - Wolfram Schwindt
- Department of Clinical Radiology, University of Muenster , Muenster , Germany
| | - Heinz Wiendl
- Department of Neurology, University of Muenster , Muenster , Germany
| | - Maximilian Bruchmann
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
| | - Nico Melzer
- Department of Neurology, University of Muenster , Muenster , Germany
| | - Thomas Straube
- Institute of Medical Psychology and Systems Neuroscience, University of Muenster , Muenster , Germany
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27
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Heine J, Prüss H, Bartsch T, Ploner C, Paul F, Finke C. Imaging of autoimmune encephalitis – Relevance for clinical practice and hippocampal function. Neuroscience 2015; 309:68-83. [DOI: 10.1016/j.neuroscience.2015.05.037] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/04/2015] [Accepted: 05/15/2015] [Indexed: 12/25/2022]
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28
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Urbach H, Rauer S, Mader I, Paus S, Wagner J, Malter MP, Prüss H, Lewerenz J, Kassubek J, Hegen H, Auer M, Deisenhammer F, Ufer F, Bien CG, Baumgartner A. Supratentorial white matter blurring associated with voltage-gated potassium channel-complex limbic encephalitis. Neuroradiology 2015; 57:1203-9. [PMID: 26293130 DOI: 10.1007/s00234-015-1581-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/11/2015] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Limbic encephalitis (LE) associated with voltage-gated potassium channel-complex antibodies (VGKC-LE) is frequently non-paraneoplastic and associated with marked improvement following corticosteroid therapy. Mesial temporal lobe abnormalities are present in around 80 % of patients. If associated or preceded by faciobrachial dystonic seizures, basal ganglia signal changes may occur. In some patients, blurring of the supratentorial white matter on T2-weighted images (SWMB) may be seen. The purpose of this study was to evaluate the incidence of SWMB and whether it is specific for VGKC-LE. METHODS Two experienced neuroradiologists independently evaluated signal abnormalities on FLAIR MRI in 79 patients with LE while unaware on the antibody type. RESULTS SWMB was independently assessed as present in 10 of 36 (28 %) compared to 2 (5 %) of 43 non-VGKC patients (p = 0.009). It was not related to the presence of LGI1 or CASPR2 proteins of VGKC antibodies. MRI showed increased temporomesial FLAIR signal in 22 (61 %) VGKC compared to 14 (33 %) non-VGKC patients (p = 0.013), and extratemporomesial structures were affected in one VGKC (3 %) compared to 11 (26 %) non-VGKC patients (p = 0.005). CONCLUSION SWMB is a newly described MRI sign rather specific for VGKC-LE.
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Affiliation(s)
- H Urbach
- Department of Neuroradiology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - S Rauer
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
| | - I Mader
- Department of Neuroradiology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - S Paus
- Department of Neurology, University Medical Center, Bonn, Germany
| | - J Wagner
- Department of Epileptology, University Medical Center, Bonn, Germany
| | - M P Malter
- Department of Neurology, University of Cologne, Cologne, Germany
| | - H Prüss
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - J Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
| | - J Kassubek
- Department of Neurology, Ulm University, Ulm, Germany
| | - H Hegen
- Department of Neurology, University Innsbruck, Innsbruck, Austria
| | - M Auer
- Department of Neurology, University Innsbruck, Innsbruck, Austria
| | - F Deisenhammer
- Department of Neurology, University Innsbruck, Innsbruck, Austria
| | - F Ufer
- Department of Neurology, University Medical Center, Hamburg, Germany
| | - C G Bien
- Epilepsy Centre Bethel, Bielefeld-Bethel, Germany
| | - A Baumgartner
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
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Melzer N, Budde T, Stork O, Meuth SG. Limbic Encephalitis: Potential Impact of Adaptive Autoimmune Inflammation on Neuronal Circuits of the Amygdala. Front Neurol 2015; 6:171. [PMID: 26284026 PMCID: PMC4522870 DOI: 10.3389/fneur.2015.00171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/20/2015] [Indexed: 12/31/2022] Open
Abstract
Limbic encephalitis is characterized by adaptive autoimmune inflammation of the gray matter structures of the limbic system. It has recently been identified as a major cause of temporal lobe epilepsy accompanied by progressive declarative – mainly episodic – memory disturbance as well as a variety of rather poorly defined emotional and behavioral changes. While autoimmune inflammation of the hippocampus is likely to be responsible for declarative memory disturbance, consequences of autoimmune inflammation of the amygdala are largely unknown. The amygdala is central for the generation of adequate homoeostatic behavioral responses to emotionally significant external stimuli following processing in a variety of parallel neuronal circuits. Here, we hypothesize that adaptive cellular and humoral autoimmunity may target and modulate distinct inhibitory or excitatory neuronal networks within the amygdala, and thereby strongly impact processing of emotional stimuli and corresponding behavioral responses. This may explain some of the rather poorly understood neuropsychiatric symptoms in limbic encephalitis.
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Affiliation(s)
- Nico Melzer
- Department of Neurology, University of Münster , Münster , Germany
| | - Thomas Budde
- Institute of Physiology I, University of Münster , Münster , Germany
| | - Oliver Stork
- Department of Genetics and Molecular Neurobiology, Institute of Biology, Otto-von-Guericke University Magdeburg , Magdeburg , Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster , Münster , Germany ; Department of Neuropathophysiology, Institute of Physiology I, University of Münster , Münster , Germany
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Ehling P, Melzer N, Budde T, Meuth SG. CD8(+) T Cell-Mediated Neuronal Dysfunction and Degeneration in Limbic Encephalitis. Front Neurol 2015; 6:163. [PMID: 26236280 PMCID: PMC4502349 DOI: 10.3389/fneur.2015.00163] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/02/2015] [Indexed: 12/31/2022] Open
Abstract
Autoimmune inflammation of the limbic gray matter structures of the human brain has recently been identified as major cause of mesial temporal lobe epilepsy with interictal temporal epileptiform activity and slowing of the electroencephalogram, progressive memory disturbances, as well as a variety of other behavioral, emotional, and cognitive changes. Magnetic resonance imaging exhibits volume and signal changes of the amygdala and hippocampus, and specific anti-neuronal antibodies binding to either intracellular or plasma membrane neuronal antigens can be detected in serum and cerebrospinal fluid. While effects of plasma cell-derived antibodies on neuronal function and integrity are increasingly becoming characterized, potentially contributing effects of T cell-mediated immune mechanisms remain poorly understood. CD8+ T cells are known to directly interact with major histocompatibility complex class I-expressing neurons in an antigen-specific manner. Here, we summarize current knowledge on how such direct CD8+ T cell–neuron interactions may impact neuronal excitability, plasticity, and integrity on a single cell and network level and provide an overview on methods to further corroborate the in vivo relevance of these mechanisms mainly obtained from in vitro studies.
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Affiliation(s)
- Petra Ehling
- Department of Neurology, Westfälische Wilhelms-University of Münster , Münster , Germany ; Institute of Physiology I - Neuropathophysiology, Westfälische Wilhelms-University , Münster , Germany
| | - Nico Melzer
- Department of Neurology, Westfälische Wilhelms-University of Münster , Münster , Germany
| | - Thomas Budde
- Institute of Physiology I, Westfälische Wilhelms-University , Münster , Germany
| | - Sven G Meuth
- Department of Neurology, Westfälische Wilhelms-University of Münster , Münster , Germany ; Institute of Physiology I - Neuropathophysiology, Westfälische Wilhelms-University , Münster , Germany
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31
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Lin Q, Wang X. Differences in epileptic symptoms depending on the type of autoimmune-mediated limbic encephalitis. Expert Rev Clin Immunol 2015; 11:897-910. [PMID: 26163176 DOI: 10.1586/1744666x.2015.1055253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Limbic encephalitis (LE) is an inflammatory disease of the central nervous system that is characterized by the selective involvement of limbic structures. The clinical manifestations of LE include the acute or sub-acute onset of recent memory disorders, mental disorders and seizures. Autoimmune-mediated LE is a major type of non-infectious LE; seizure is a hallmark of this type of LE. The treatment of epilepsy, which is a key factor that affects the prognosis of LE patients, warrants special attention. Understanding the characteristics of epilepsy caused by autoimmune-mediated LE and providing the appropriate treatment will help to improve patients' outcomes. In this article, we extensively review the literature related to autoimmune-mediated LE epidemiology, mechanisms, characteristics and seizure frequency and onset, and we discuss the possible diagnosis and treatment of this disease.
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Affiliation(s)
- Qingxia Lin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Wagner J, Witt JA, Helmstaedter C, Malter MP, Weber B, Elger CE. Automated volumetry of the mesiotemporal structures in antibody-associated limbic encephalitis. J Neurol Neurosurg Psychiatry 2015; 86:735-42. [PMID: 25185210 DOI: 10.1136/jnnp-2014-307875] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/12/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Limbic encephalitis (LE) is an autoimmune mediated disease leading to temporal lobe epilepsy, mnestic and psychiatric symptoms. In recent years, several LE subforms defined by serum antibody findings have been described. MRI usually shows volume changes of the amygdala and hippocampus. However, studies quantifying longitudinal volume changes in the acute disease stage are lacking. METHODS The aim of this retrospective observational study was to evaluate and quantify these volume changes by applying a fully automated volumetric approach to serial MRIs of 28 patients with antibody-associated LE. The results were compared with those of 28 age-matched and gender-matched healthy controls and analysed separately for the different antibody profiles and correlated with clinical parameters. Antibody profile analyses were exploratory due to the relatively small sample sizes. RESULTS We found distinct volumetric and clinical courses depending on the associated antibody. While LE associated with voltage-gated potassium channel-complex antibodies (VGKC-LE) showed highly significant larger volumes of both the amygdala and the hippocampus within the first 12 months after disease onset, LE associated with glutamic acid decarboxylase antibodies (GAD-LE) only displayed greater amygdala volumes at this disease stage. Both subgroups showed a reduction of the amygdala and hippocampus volumes during follow-up with higher volume changes in VGKC-LE. CONCLUSIONS These differences in the volumetric evolution corresponded to distinct clinical courses in terms of a more severe initial symptomatology regarding seizure, mnestic and psychiatric disturbances in VGKC-LE, which improved rapidly, corresponding to the evolution of the volumetric changes. In contrast to this, patients with GAD-LE were less severely affected at disease onset, showing a more unmodulated and chronic disease course during follow-up.
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Affiliation(s)
- Jan Wagner
- Department of Epileptology, University of Bonn, Bonn, Germany Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany
| | | | | | - Michael P Malter
- Department of Epileptology, University of Bonn, Bonn, Germany Department of Neurology, Marien-Krankenhaus, Bergisch Gladbach, Germany
| | - Bernd Weber
- Department of Epileptology, University of Bonn, Bonn, Germany Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany Center for Economics and Neuroscience, University of Bonn, Bonn, Germany
| | - Christian E Elger
- Department of Epileptology, University of Bonn, Bonn, Germany Department of NeuroCognition/Imaging, Life & Brain Center, Bonn, Germany Center for Economics and Neuroscience, University of Bonn, Bonn, Germany
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Wagner J, Weber B, Elger CE. Early and chronic gray matter volume changes in limbic encephalitis revealed by voxel-based morphometry. Epilepsia 2015; 56:754-61. [DOI: 10.1111/epi.12968] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2015] [Indexed: 12/26/2022]
Affiliation(s)
- Jan Wagner
- Department of Epileptology; University of Bonn; Bonn Germany
- Department of NeuroCognition/Imaging; Life & Brain Center; Bonn Germany
| | - Bernd Weber
- Department of Epileptology; University of Bonn; Bonn Germany
- Department of NeuroCognition/Imaging; Life & Brain Center; Bonn Germany
- Center for Economics and Neuroscience; University of Bonn; Bonn Germany
| | - Christian E. Elger
- Department of Epileptology; University of Bonn; Bonn Germany
- Department of NeuroCognition/Imaging; Life & Brain Center; Bonn Germany
- Center for Economics and Neuroscience; University of Bonn; Bonn Germany
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Narayanan L, Murray AD. What is the role of neuroimaging in dementia? A review. IMAGING 2014. [DOI: 10.1259/img.20120015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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