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Jaafar F, Obeid M, Beydoun A. Role of Early Intravenous Immunoglobulins in Halting Clinical and Radiographic Disease Progression in Rasmussen Encephalitis. Pediatr Neurol 2023; 145:30-35. [PMID: 37269621 DOI: 10.1016/j.pediatrneurol.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/29/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is a rare progressive presumed autoimmune disorder characterized by pharmacoresistant epilepsy and progressive motor and cognitive deterioration. Despite immunomodulation, more than half of the patients with RE ultimately require functional hemispherotomy. In this study, we evaluated the potential beneficial effects of early initiation of immunomodulation in slowing disease progression and preventing the need for surgical interventions. METHODS A retrospective chart review over a 10-year period was conducted at the American University of Beirut Medical Center to identify patients with RE. Data were collected on seizure characteristics, neurological deficits, electroencephalography, brain magnetic resonance imaging results (including volumetric analyses for an objective assessment of radiographic progression), and treatment modalities. RESULTS Seven patients met the inclusion criteria for RE. All patients received intravenous immunoglobulins (IVIGs) as soon as the diagnosis was entertained. Five patients with only monthly to weekly seizures at the time of IVIG initiation had favorable outcomes without resorting to surgery, along with a relative preservation of the gray matter volumes in the affected cerebral hemispheres. Motor strength was preserved in those patients, and three were seizure free at their last follow-up visit. The two patients who required hemispherotomy were already severely hemiparetic and experiencing daily seizures at the time of IVIG initiation. CONCLUSIONS Our data suggest that the early initiation of IVIG as soon as a diagnosis of RE is suspected, and particularly before the appearance of motor deficits and intractable seizures, can maximize the beneficial effects of immunomodulation in terms of controlling seizures and reducing the rate of cerebral atrophy.
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Affiliation(s)
- Fatima Jaafar
- Division of Child Neurology, Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Makram Obeid
- Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
| | - Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon.
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Lagarde S, Boucraut J, Bartolomei F. Medical treatment of Rasmussen's Encephalitis: A systematic review. Rev Neurol (Paris) 2022; 178:675-691. [DOI: 10.1016/j.neurol.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
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Jagtap SA, Patil S, Joshi A, Kurwale N, Jain V, Deshmukh Y. Rituximab in Rasmussen’s encephalitis: A single center experience and review of the literature. Epilepsy Behav Rep 2022; 19:100540. [PMID: 35509501 PMCID: PMC9058598 DOI: 10.1016/j.ebr.2022.100540] [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: 02/24/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022] Open
Abstract
Rituximab in the early course of the disease results in good control of seizures and EPC. Rituximab can reverse or stabilize motor deficits as well as MRI changes and halt progression of disease. Rituximab is a safe, efficacious, well tolerated and rapidly acting drug in RE, and can be used as a steroid sparing agent.
Rasmussen's encephalitis (RE) is a rare chronic inflammatory disease of the brain resulting in unilateral hemispheric atrophy with drug-resistant focal epilepsy associated with a variable degree of progressive hemiparesis and cognitive decline. The precise etiology of RE is unknown but presumed to have a neuroinflammatory pathobiological basis. Only surgery halts progression of the disease, but may occur at the expense of a fixed but otherwise inevitable neurological deficit. Therefore, the question of medical management is an important consideration. Reports of rituximab use in patients with RE were presented at the American Epilepsy Society annual meeting in 2008. Good published evidence for its usage has been very slow to emerge since then. However, rituximab continues to be listed in discussions of treatment options for patients with RE, though other monoclonal antibodies have since been used with comparable outcomes. We describe a series of nine patients including two with adult-onset RE. Rituximab was used early in the disease course (range 1–108 months; mean 32 months). Of nine patients with RE, there was significant benefit in their seizure burden with rituxamab. Seizure freedom occurred in 3 patients. Epilepsia partialis continua (EPC) was present in 4/9 and no focal motor deficit noted in 4/9. No progression of a neurological deficit was present in 2/9 and evidence of progression with neuroimaging was terminated with rituxamab in 5/9 supporting early use of rituxamab in patients with RE.
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Affiliation(s)
- Sujit A. Jagtap
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
- Corresponding author.
| | - Sandeep Patil
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
- Pediatrics, D.Y. Patil Medical College, Pune, India
| | - Aniruddha Joshi
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Nilesh Kurwale
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
- Neurosurgery, D.Y. Patil Medical College, Pune, India
| | - Vivek Jain
- Santokba Durlabhji Hospital Jaipur, India
| | - Yogeshwari Deshmukh
- Department of Radiology, Star Imaging Centre and Research Centre, Pune, India
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Mochol M, Taubøll E, Sveberg L, Tennøe B, Berg Olsen K, Heuser K, Svalheim S. Seizure control after late introduction of anakinra in a patient with adult onset Rasmussen's encephalitis. Epilepsy Behav Rep 2021; 16:100462. [PMID: 34189453 PMCID: PMC8219739 DOI: 10.1016/j.ebr.2021.100462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/05/2021] [Accepted: 05/08/2021] [Indexed: 02/07/2023] Open
Abstract
Neuroinflammation has been considered an important pathophysiological process involved in epileptogenesis and may provide possibilities for new treatment possibilities. We present the case of a 45-year-old female with drug resistant epilepsy and progressive right-sided cerebral hemiatrophy associated with adult onset Rasmussen's encephalitis. Over a period of 26 years, she was treated with 14 different antiseizure medications, intravenous immunoglobulins, glucocorticosteroids, underwent two operations with focal resection and subpial transections, and tried out trigeminal nerve stimulation. Extensive blood tests, including antibodies relevant for autoimmune encephalitis, and brain biopsy did not show any signs of neuroinflammation. Eventually, the patient received the interleukin-1 receptor antagonist, anakinra. Within 1-2 days after injection, seizure frequency decreased significantly, and, after one week, the seizures stopped completely. Anakinra treatment was continued for 2 months. Stopping medication led to a relapse of seizures after 2 weeks, with a frequency of up to 45 seizures per day. Reintroduction of anakinra led to rapid recovery. Treatment with anakinra was continued for 7 months. The treatment was discontinued in April 2020, and the patient has been completely seizure free since then. There have been no other changes in antiseizure medication.
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Affiliation(s)
- Monika Mochol
- Department of Neurology, Østfold Hospital Trust, PO Box 300, 1714 Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, PO Box 1072 Blindern, 0316 Oslo, Norway
- ERGO – Epilepsy Research Group of Oslo, Department of Neurology, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
- Corresponding author at: Department of Neurology, Østfold Hospital Trust, PO box 300, 1714 Grålum, Norway.
| | - Erik Taubøll
- Institute of Clinical Medicine, University of Oslo, PO Box 1072 Blindern, 0316 Oslo, Norway
- ERGO – Epilepsy Research Group of Oslo, Department of Neurology, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Line Sveberg
- ERGO – Epilepsy Research Group of Oslo, Department of Neurology, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Bjørn Tennøe
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Ketil Berg Olsen
- Department of Neurology, Østfold Hospital Trust, PO Box 300, 1714 Grålum, Norway
- ERGO – Epilepsy Research Group of Oslo, Department of Neurology, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Kjell Heuser
- ERGO – Epilepsy Research Group of Oslo, Department of Neurology, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
| | - Sigrid Svalheim
- ERGO – Epilepsy Research Group of Oslo, Department of Neurology, Oslo University Hospital, PO Box 4950 Nydalen, 0424 Oslo, Norway
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Tang C, Luan G, Li T. Rasmussen's encephalitis: mechanisms update and potential therapy target. Ther Adv Chronic Dis 2020; 11:2040622320971413. [PMID: 33294146 PMCID: PMC7705182 DOI: 10.1177/2040622320971413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/15/2020] [Indexed: 12/11/2022] Open
Abstract
Rasmussen’s encephalitis (RE) is rare neurological diseases characterized as epilepsia partialis continua, invariably hemiparesis, and cognitive impairment. This disease is encountered frequently in childhood and presents with progressive atrophy of the unilateral hemisphere, and there are also sustained neurological complications. Owing to uncertain pathogenesis, the most effective way to limit the influence of seizures currently is cerebral hemispherectomy. In this review, we focus on four main lines of pathogenesis: virus infection, antibody-mediated, cell-mediated immunity, and microglia activation. Although one or more antigenic epitopes may give rise to infiltrating T cell responses in RE brain tissue, no exact antigen was confirmed as the definite cause of the disease. On the other hand, the appearance of antibodies related with RE seem to be a secondary pathological process. Synthetic studies have suggested an adaptive immune mechanism mediated by CD8+ T cells and an innate immune mechanism mediated by activated microglia and neuroglia. Accordingly, opinions have been raised that immunomodulatory treatments aimed at initial damage to the brain that are induced by cytotoxic CD8+ T cell lymphocytes and microglia in the early stage of RE slow down disease progression. However, systematic exploration of the theory behind these therapeutic effects based on multicenter and large sample studies are needed. In addition, dysfunction of the adenosine system, including the main adenosine removing enzyme adenosine kinase and adenosine receptors, has been demonstrated in RE, which might provide a novel therapeutic target for treatment of RE in future.
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Affiliation(s)
- Chongyang Tang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, SanBo Brain Hospital, Capital Medical University No. 50 Xiangshanyikesong Road, Haidian District, Beijing, 100093, China
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