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Taraschenko O, Fox HS, Heliso P, Al-Saleem F, Dessain S, Kim WY, Samuelson MM, Dingledine R. Memory loss and aberrant neurogenesis in mice exposed to patient anti-N-methyl-d-aspartate receptor antibodies. Exp Neurol 2024; 378:114838. [PMID: 38801989 DOI: 10.1016/j.expneurol.2024.114838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/14/2024] [Accepted: 05/24/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis results in chronic epilepsy and permanent cognitive impairment. One of the possible causes of cognitive impairment in anti-NMDAR could be aberrant neurogenesis, an established contributor to memory loss in idiopathic drug-resistant epilepsy. We developed a mouse model of anti-NMDAR encephalitis and showed that mice exposed to patient anti-NMDAR antibodies for 2 weeks developed seizures and memory loss. In the present study, we assessed the delayed effects of patient-derived antibodies on cognitive phenotype and examined the corresponding changes in hippocampal neurogenesis. METHODS Monoclonal anti-NMDAR antibodies or control antibodies were continuously infused into the lateral ventricle of male C56BL/6J mice (8-12 weeks) via osmotic minipumps for 2 weeks. The motor and anxiety phenotypes were assessed using the open field paradigm, and hippocampal memory and learning were assessed using the object location, Y maze, and Barnes maze paradigms during weeks 1 and 3-4 of antibody washout. The numbers of newly matured granule neurons (Prox-1+) and immature progenitor cells (DCX+) as well as their spatial distribution within the hippocampus were assessed at these time points. Bromodeoxyuridine (BrdU, 50 mg/kg, i.p., daily) was injected on days 2-12 of the infusion, and proliferating cell immunoreactivity was compared in antibody-treated mice and control mice during week 4 of the washout. RESULTS Mice infused with anti-NMDAR antibodies demonstrated spatial memory impairment during week 1 of antibody washout (p = 0.02, t-test; n = 9-11). Histological analysis of hippocampal sections from these mice revealed an increased ectopic displacement of Prox-1+ cells in the dentate hilus compared to the control-antibody-treated mice (p = 0.01; t-test). Mice exposed to anti-NMDAR antibodies also had an impairment of spatial memory and learning during weeks 3-4 of antibody washout (object location: p = 0.009; t-test; Y maze: p = 0.006, t-test; Barnes maze: p = 0.008, ANOVA; n = 8-10). These mice showed increased ratios of the low proliferating (bright) to fast proliferating (faint) BrdU+ cell counts and decreased number of DCX+ cells in the hippocampal dentate gyrus (p = 0.006 and p = 0.04, respectively; t-tests) suggesting ectopic migration and delayed cell proliferation. SIGNIFICANCE These findings suggest that memory and learning impairments induced by patient anti-NMDAR antibodies are sustained upon removal of antibodies and are accompanied by aberrant hippocampal neurogenesis. Interventions directed at the manipulation of neuronal plasticity in patients with encephalitis and cognitive loss may be protective and therapeutically relevant.
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Affiliation(s)
- Olga Taraschenko
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States of America.
| | - Howard S Fox
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Priscilla Heliso
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Fetweh Al-Saleem
- Lankenau Institute for Medical Research, Wynnewood, PA, United States of America
| | - Scott Dessain
- Lankenau Institute for Medical Research, Wynnewood, PA, United States of America
| | - Woo-Yang Kim
- Department of Biological Sciences, Kent State University, Kent, OH, United States of America
| | - Mystera M Samuelson
- Department of Environmental, Agricultural and Occupational Health, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Raymond Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA, United States of America
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Dai Y, Zhu Z, Tang Y, Xiao L, Liu X, Zhang M, Xiao B, Hu K, Long L, Xie Y, Hu S. The clinical and predictive value of 18F-FDG PET/CT metabolic patterns in a clinical Chinese cohort with autoimmune encephalitis. CNS Neurosci Ther 2024; 30:e14821. [PMID: 38948940 PMCID: PMC11215490 DOI: 10.1111/cns.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/29/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024] Open
Abstract
AIMS To investigate the diagnostic and predictive role of 18F-FDG PET/CT in patients with autoimmune encephalitis (AE) as a whole group. METHODS Thrty-five patients (20 females and 15 males) with AE were recruited. A voxel-to-voxel semi-quantitative analysis based on SPM12 was used to analyze 18F-FDG PET/CT imaging data compared to healthy controls. Further comparison was made in different prognostic groups categorized by modified Rankin Scale (mRS). RESULTS In total, 24 patients (68.6%) were tested positive neuronal antibodies in serum and/or CSF. Psychiatric symptoms and seizure attacks were major clinical symptoms. In the acute stage, 13 patients (37.1%) demonstrated abnormal brain MRI results, while 33 (94.3%) presented abnormal metabolism patterns. 18F-FDG PET/CT was more sensitive than MRI (p < 0.05). Patients with AE mainly presented mixed metabolism patterns compared to the matched controls, demonstrating hypermetabolism mainly in the cerebellum, BG, MTL, brainstem, insula, middle frontal gyrus, and relatively hypometabolism in the frontal cortex, occipital cortex, temporal gyrus, right parietal gyrus, left cingulate gyrus (p < 0.05, FWE corrected). After a median follow-up of 26 months, the multivariable analysis identified a decreased level of consciousness as an independent risk factor associated with poor outcome of AE (HR = 3.591, p = 0.016). Meanwhile, decreased metabolism of right superior frontal gyrus along with increased metabolism of the middle and upper brainstem was more evident in patients with poor outcome (p < 0.001, uncorrected). CONCLUSION 18F-FDG PET/CT was more sensitive than MRI to detect neuroimaging abnormalities of AE. A mixed metabolic pattern, characterized by large areas of cortical hypometabolism with focal hypermetabolism was a general metabolic pattern. Decreased metabolism of right superior frontal gyrus with increased metabolism of the middle and upper brainstem may predict poor long-term prognosis of AE.
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Affiliation(s)
- Yuwei Dai
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Zehua Zhu
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Division of Life Sciences and Medicine, Department of Nuclear Medicine, The First Affiliated Hospital of USTCUniversity of Science and Technology of ChinaHefeiAnhuiP.R. China
| | - Yongxiang Tang
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
| | - Ling Xiao
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
| | - Xianghe Liu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Min Zhang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Bo Xiao
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Kai Hu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Lili Long
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Yuanyuan Xie
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Clinical Research Center for Epileptic disease of Hunan ProvinceCentral South UniversityChangshaHunanP.R. China
| | - Shuo Hu
- National Clinical Research Center for Geriatric Diseases, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Department of Nuclear Medicine, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya HospitalCentral South UniversityChangshaHunanP.R. China
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Huang W, Zhang H, Li X, Zhang J, Chen J, Chen Z, Ni G. Prognostic factors underlying the development of drug-resistant epilepsy in patients with autoimmune encephalitis: a retrospective cohort study. J Neurol 2024:10.1007/s00415-024-12432-y. [PMID: 38801431 DOI: 10.1007/s00415-024-12432-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/14/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE The aim of our study was to analyze the characteristics of patients with autoimmune encephalitis (AE) to identify prognostic factors associated with the development of drug-resistant epilepsy (DRE). METHODS In this retrospective observational cohort study, we enrolled adult patients with AE between January 2016 and December 2022. The patients were categorized into two groups based on the presence or absence of DRE at the last follow-up. The predictors of the development of DRE were investigated using logistic regression analysis. RESULTS Among 121 AE patients, 75.2% (n = 91) experienced acute symptomatic seizures, and 29.8% (n = 36) developed DRE at the last follow-up. On multivariate regression analysis, the factors associated with DRE were antibody negativity (OR 3.628, 95% CI 1.092-12.050, p = 0.035), focal seizure (OR 6.431, 95% CI 1.838-22.508, p = 0.004), refractory status epilepticus (OR 8.802, 95% CI 2.445-31.689, p = 0.001), interictal epileptiform discharges on EEG (OR 6.773, 95% CI 2.206-20.790, p = 0.001), and T2/FLAIR hyperintensity in the limbic system (OR 3.286, 95% CI 1.060-10.183, p = 0.039). CONCLUSIONS In this study, the risk of developing DRE was mainly observed among AE patients who were negative for antibodies or had focal seizures, refractory status epilepticus, interictal epileptiform discharges on EEG, and T2/FLAIR hyperintensity in the limbic system.
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Affiliation(s)
- Wenyao Huang
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China
| | - Heyu Zhang
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China
| | - Xi Li
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China
| | - Jinming Zhang
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China
| | - Jingjing Chen
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China
| | - Ziyi Chen
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China.
| | - Guanzhong Ni
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2 Road, Guangzhou, 510080, Guangdong, China.
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Taraschenko O, Fox HS, Eldridge E, Heliso P, Al-Saleem F, Dessain S, Casale G, Willcockson G, Anderson K, Wang W, Dingledine R. MyD88-mediated signaling is critical for the generation of seizure responses and cognitive impairment in a model of anti-N-methyl-D-aspartate receptor encephalitis. Epilepsia 2024; 65:1475-1487. [PMID: 38470097 PMCID: PMC11087204 DOI: 10.1111/epi.17931] [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: 08/17/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE We previously demonstrated that interleukin-1 receptor-mediated immune activation contributes to seizure severity and memory loss in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. In the present study, we assessed the role of the myeloid differentiation primary response gene 88 (MyD88), an adaptor protein in Toll-like receptor signaling, in the key phenotypic characteristics of anti-NMDAR encephalitis. METHODS Monoclonal anti-NMDAR antibodies or control antibodies were infused into the lateral ventricle of MyD88 knockout mice (MyD88-/-) and control C56BL/6J mice (wild type [WT]) via osmotic minipumps for 2 weeks. Seizure responses were measured by electroencephalography. Upon completion of the infusion, the motor, anxiety, and memory functions of the mice were assessed. Astrocytic (glial fibrillary acidic protein [GFAP]) and microglial (ionized calcium-binding adaptor molecule 1 [Iba-1]) activation and transcriptional activation for the principal inflammatory mediators involved in seizures were determined using immunohistochemistry and quantitative real-time polymerase chain reaction, respectively. RESULTS As shown before, 80% of WT mice infused with anti-NMDAR antibodies (n = 10) developed seizures (median = 11, interquartile range [IQR] = 3-25 in 2 weeks). In contrast, only three of 14 MyD88-/- mice (21.4%) had seizures (0, IQR = 0-.25, p = .01). The WT mice treated with antibodies also developed memory loss in the novel object recognition test, whereas such memory deficits were not apparent in MyD88-/- mice treated with anti-NMDAR antibodies (p = .03) or control antibodies (p = .04). Furthermore, in contrast to the WT mice exposed to anti-NMDAR antibodies, the MyD88-/- mice had a significantly lower induction of chemokine (C-C motif) ligand 2 (CCL2) in the hippocampus (p = .0001, Sidak tests). There were no significant changes in the expression of GFAP and Iba-1 in the MyD88-/- mice treated with anti-NMDAR or control antibodies. SIGNIFICANCE These findings suggest that MyD88-mediated signaling contributes to the seizure and memory phenotype in anti-NMDAR encephalitis and that CCL2 activation may participate in the expression of these features. The removal of MyD88 inflammation may be protective and therapeutically relevant.
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Affiliation(s)
- Olga Taraschenko
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Howard S. Fox
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Ember Eldridge
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Priscilla Heliso
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | | | - Scott Dessain
- Lankenau Institute for Medical Research, Wynnewood, PA
| | - George Casale
- Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, NE
| | | | - Kayley Anderson
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Wenyi Wang
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA
| | - Raymond Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA
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Morillos MB, Borelli WV, Noll G, Piccini CD, Leite MB, Finkelsztejn A, Bianchin MM, Castilhos RM, Torres CM. Autoimmune encephalitis in a resource-limited public health setting: a case series analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-10. [PMID: 38325385 PMCID: PMC10849825 DOI: 10.1055/s-0044-1779054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/22/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Autoimmune encephalitis (AE) consists of a group of acquired diseases that affect the central nervous system. A myriad of phenotypes may be present at the onset. Due to the heterogeneity of clinical presentations, it is difficult to achieve uniformity for the diagnostic and therapeutic processes and follow-up strategies. OBJECTIVE To describe a series of patients diagnosed with AE in a resource-limited public hospital in southern Brazil and to analyze therapeutics and outcomes. METHODS We retrospectively reviewed the electronic medical records of patients diagnosed with AE at the Hospital de Clínicas de Porto Alegre from 2014 to 2022. Data collected included clinical presentation, neuroimaging, cerebrospinal fluid testings, electroencephalogram, autoantibodies, treatments, outcomes, follow-up time, degree of neurological impairment, and mortality. RESULTS Data from 17 patients were retrieved. Eleven cases were classified as definite AE and 6 as possible AE. Autoantibodies were identified in 9 patients. Timing for diagnosis was impacted by the high costs associated with autoantibody testing. Most patients became functionally dependent (82.4%) and most survivors remained with autoimmune-associated epilepsy (75%). Five patients died during hospitalization, and one after a 26-month of follow-up. CONCLUSION In this resource-limited hospital, patients with AE had a worse clinical outcome than that previously described in the literature. Development of epilepsy during follow-up and mortality were greater, whilst functional outcome was inferior. Autoantibody testing was initially denied in most patients, which impacted the definitive diagnosis and the use of second-line therapies.
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Affiliation(s)
| | | | - Giovani Noll
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
| | | | - Martim Bravo Leite
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
| | | | - Marino Muxfeldt Bianchin
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Medicina Interna, Porto Alegre RS, Brazil.
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Medicina: Ciências Médicas, Porto Alegre RS, Brazil.
| | - Raphael Machado Castilhos
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Medicina: Ciências Médicas, Porto Alegre RS, Brazil.
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Hou C, Li X, Zeng Y, Gao Y, Wu W, Zhu H, Zhang Y, Wu W, Tian Y, Zheng K, Chen L, Peng B, Chen WX. Brain magnetic resonance imaging as predictors in pediatric anti-N-methyl-D-aspartate receptor encephalitis. Mult Scler Relat Disord 2024; 82:105061. [PMID: 38134605 DOI: 10.1016/j.msard.2023.105061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/26/2023] [Accepted: 10/08/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To investigate the associations between brain magnetic resonance imaging (MRI) changes and clinical profiles in children with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHODS Clinical data and brain MRI results of children diagnosed with anti-NMDAR encephalitis in Guangzhou Women and Children's Medical Center from October 2014 to June 2022 were retrospectively studied. RESULTS A total of 143 children (Male: female 54:89) were enrolled, with a mean onset age of 6.8 years (6.8 ± 3.1). 40.6 % (58/143) of patients had abnormal initial brain MRI. Lesions in temporal lobe (34.5 %, 20/58) and frontal lobe (25.9 %, 15/58) were relatively common. Children with abnormal initial brain MRI were prone to have fever (P = 0.023), dystonia (P = 0.037), positive MOG antibodies (P = 0.015), higher cerebrospinal fluid (CSF) white blood cell count (WBC) (P = 0.019) and to receive rituximab treatment (P = 0.037). There were no significant differences in modified Rankin Scale (mRS) scores before immunotherapy, after immunotherapy and at last follow-up between the normal initial brain MRI group and abnormal group. No initial brain MRI changes were found to be associated with relapses. Brain MRI was reviewed in 72 patients at last follow-up with a median follow-up time of 25.5 months and 48.6 % (35/72) of patients had abnormal brain MRI. The mRS score of the group with normal brain MRI at last follow-up was significantly lower than that of the abnormal group. CONCLUSIONS About 40.0 % of children with anti-NMDAR encephalitis had abnormal initial brain MRI. Initial brain MRI was associated with certain clinical profiles, but not with relapse and prognosis. Around half of patients had abnormal brain MRI at last follow-up and were prone to have higher mRS score.
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Affiliation(s)
- Chi Hou
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yiru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yuanyuan Gao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wenxiao Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Haixia Zhu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wenlin Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yang Tian
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Liangfeng Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Bingwei Peng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wen-Xiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China.
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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Macher S, Bsteh G, Pataraia E, Berger T, Höftberger R, Rommer PS. The three pillars in treating antibody-mediated encephalitis. Wien Klin Wochenschr 2024; 136:13-24. [PMID: 37278857 PMCID: PMC10776469 DOI: 10.1007/s00508-023-02214-3] [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: 11/21/2022] [Accepted: 04/20/2023] [Indexed: 06/07/2023]
Abstract
The rapid initiation of immunotherapy has a decisive impact on the course of the disease in patients with antibody-mediated encephalitis (AE). The importance of treating AE with antiseizure medication and antipsychotics is discussed controversially; however, standardized procedures should be ensured, especially for the initiation of treatment in severe disease. Recommendations and guidelines for further interventions in refractory courses are needed. In this review, we contrast the three mainstays of treatment options in patients with AE and attempt to highlight the importance of 1) antiseizure therapy, 2) antipsychotic therapy, and 3) immunotherapy/tumor resection from today's perspective.
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Affiliation(s)
- S Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - G Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - E Pataraia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - T Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - R Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - P S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
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9
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Li D, Huang T, Zhang F, Zhang X, Dou J, Wang C, Guo S. Long-term efficacy and safety of different corticosteroid courses plus mycophenolate mofetil for autoimmune encephalitis with neuronal surface antibodies without tumor. Front Immunol 2023; 14:1195172. [PMID: 37503335 PMCID: PMC10369784 DOI: 10.3389/fimmu.2023.1195172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/22/2023] [Indexed: 07/29/2023] Open
Abstract
Objective To compare the efficacy and safety of different-course corticosteroids plus mycophenolate mofetil (MMF) as maintenance therapy in autoimmune encephalitis (AE) with neuronal surface antibodies (NSAbs) without tumor and explore the optimal course of corticosteroids. Methods Fifty-five patients with definite AE without tumor were enrolled consecutively between June 2015 and November 2020 and retrospectively divided three groups according to the course of treatment with corticosteroid, i.e., a group of patients with a course of 3-6 months (Group 3-6mo), 6-12 months (Group 6-12mo), and >12 months (Group >12mo). Demographic data, clinical manifestation and ancillary tests results were recorded. The dosage and courses of corticosteroid treatment, the recovery of neurological function, the occurrence of adverse effects, and relapses were followed up. Results A total of 55 patients were included in the final analysis. The numbers of patients in Group 3-6 mo, Group 6-12 mo, and Group >12 mo was 14, 17, and 24, respectively. A significantly higher proportion of patients in Group >12 mo showed a decreased level of consciousness at the onset (12, 50%) than in Group 3-6 mo and Group 6-12 mo (2,14.3%; 3, 17.6%) (p = 0.033). The incidence of MRI abnormalities was significantly higher in Group 6-12 mo and Group >12 mo (10, 58.8%; 16, 66.7%) than in Group 3-6 mo (3, 21.4%) (P=0.023). Ordinal regression analysis indicated that decreased level of consciousness was associated with the course of corticosteroid (OR=3.838, 95% CI: 1.103-13.323, P=0.035). No significant difference was observed between the three groups regarding the cumulative dose of corticosteroids administered during the first three months of long-term treatment (P>0.05). Additionally, no significant difference in the cumulative dosage of corticosteroids was found between patients in Group 6-12 months and Group >12 months during the first 6 months after beginning long-term treatment. The mRS scores of the three groups were not statistically significant before and after first-line treatment or at the last follow-up. Bonferroni multiple comparison test indicated that the mRS scores of patients in Group 6-12 months and Group >12 months were not statistically significant at 3 months and 12 months after the start of long-term treatment. During the follow-up, 50 (90.9%) patients achieved satisfactory neurological function (mRS score ≤2). Five patients (9.1%) experienced a first relapse and 2 of them were overlapped with both anti-NMDA receptor and glial antibodies. The incidence of adverse effects was significantly higher in Group >12 mo (17, 70.8%) than in Group 3-6 mo (3, 21.4%) and Group 6-12 mo (5, 29.4%) (P=0.003). Conclusions The beneficial effects of oral corticosteroid treatment may do not persist beyond 12 months and may even contribute to an increased incidence of adverse effects. In order to optimize the effectiveness and safety of treatment, we recommend a corticosteroid course of 3-12 months. Patients with reduced levels of consciousness may be more inclined to choose longer courses of corticosteroids for long-term treatment. Patients with an "overlapping syndrome" may require more intense immunotherapy to prevent relapse.
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Affiliation(s)
- Dong Li
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Teng Huang
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, Shandong, China
| | - Fangyuan Zhang
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Xiaoyu Zhang
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Jingjing Dou
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Chunjuan Wang
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, China
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10
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Lim KS, Khoo CS, Fong SL, Tan HJ, Fong CY, Mohamed AR, Rashid AA, Law WC, Shaikh MF, Khalid RA, Yen-Leong Tan R, Ahmad SB, Chinnasami S, Wong SW, Raymond AA. Management of status epilepticus in Malaysia: A national survey of current practice and treatment gap. J Clin Neurosci 2023; 114:25-31. [PMID: 37279626 DOI: 10.1016/j.jocn.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Early and effective treatment is fundamental in status epilepticus (SE) management. At the initiative of the Epilepsy Council of Malaysia, this study aimed to determine the treatment gap in SE across different healthcare settings in Malaysia. METHODS A web-based survey was sent to clinicians involved in the management of SE, across all states and at all levels of healthcare services. RESULTS A total of 158 responses were received from 104 health facilities, including 23 tertiary government hospitals (95.8% of all government tertiary hospitals in Malaysia), 4 (80.0%) universities, 14 (6.7%) private, 15 (11.5%) district hospitals and 21 clinics. Intravenous (IV) diazepam was available in 14 (93.3%) district and 33 (80.5%) tertiary hospitals for prehospital management. Non-IV benzodiazepine (rectal diazepam and intramuscular midazolam) was not widely available in prehospital services (75.8% and 51.5%). Intramuscular midazolam was underutilised (60.0% in district and 65.9% in tertiary hospitals). IV sodium valproate and levetiracetam were only available in 66.7% and 53.3% of the district hospitals, respectively. Electroencephalogram (EEG) services were available in only 26.7% of the district hospitals. Non-pharmacological therapies such as ketogenic diet, electroconvulsive therapy, and therapeutic hypothermia were not available in most district and tertiary hospitals for refractory and super-refractory SE. CONCLUSIONS We identified several gaps in the current practice of SE management, including limited availability and underutilization of non-IV midazolam in prehospital services, underutilization of non-IV midazolam and other second-line ASMs, and lack of EEG monitoring in district hospitals and limited treatment options for refractory and super-refractory SE in tertiary hospitals.
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Affiliation(s)
- Kheng-Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Malaysia.
| | - Ching-Soong Khoo
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Si-Lei Fong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Malaysia
| | - Hui-Jan Tan
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Choong Yi Fong
- Division of Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Malaysia
| | | | | | - Wan-Chung Law
- Division of Neurology, Department of Medicine, Sarawak General Hospital, Malaysia
| | - Mohd Farooq Shaikh
- Neuropharmacology Research Laboratory, Jeffrey CheahSchool of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | - Raihanah Abdul Khalid
- School of Dentistry and Medical Sciences, Charles Sturt University, Orange, New South Wales, Australia
| | | | | | | | - Sau-Wei Wong
- Neurology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Azman Ali Raymond
- Neurology Unit, Department of Medicine, Faculty of Medicine, MARA University of Technology, Malaysia; Epilepsy Council Malaysia, Malaysian Society of Neurosciences, Malaysia
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Guarino M, La Bella S, Santoro M, Caposiena D, Di Lembo E, Chiarelli F, Iannetti G. The Leading Role of Brain and Abdominal Radiological Features in the Work-Up of Anti-NMDAR Encephalitis in Children: An Up-To-Date Review. Brain Sci 2023; 13:brainsci13040662. [PMID: 37190627 DOI: 10.3390/brainsci13040662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis (NMDARe) is the most common cause of nonviral encephalitis, mostly affecting young women and adolescents with a strong female predominance (F/M ratio of around 4:1). NMDARe is characterized by the presence of cerebrospinal fluid (CSF) antibodies against NMDARs, even though its pathophysiological mechanisms have not totally been clarified. The clinical phenotype of NMDARe is composed of both severe neurological and neuropsychiatric symptoms, including generalized seizures with desaturations, behavioral abnormalities, and movement disorders. NMDARe is often a paraneoplastic illness, mainly due to the common presence of concomitant ovarian teratomas in young women. Abdominal ultrasonography (US) is a key imaging technique that should always be performed in suspected patients. The timely use of abdominal US and the peculiar radiological features observed in NMDARe may allow for a quick diagnosis and a good prognosis, with rapid improvement after the resection of the tumor and the correct drug therapy.
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Affiliation(s)
- Miriana Guarino
- Department of Pediatrics, University of Chieti-Pescara "G. D'Annunzio", Via Dei Vestini 5, Ospedale Clinicizzato Chieti (CH), 66100 Chieti, Italy
| | - Saverio La Bella
- Department of Pediatrics, University of Chieti-Pescara "G. D'Annunzio", Via Dei Vestini 5, Ospedale Clinicizzato Chieti (CH), 66100 Chieti, Italy
| | - Marco Santoro
- Department of Radiology, Pescara Public Hospital "Santo Spirito", 65124 Pescara, Italy
| | - Daniele Caposiena
- Department of Radiology, Pescara Public Hospital "Santo Spirito", 65124 Pescara, Italy
| | - Enza Di Lembo
- Department of Internist Ultrasound, Pescara Public Hospital "Santo Spirito", 65124 Pescara, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti-Pescara "G. D'Annunzio", Via Dei Vestini 5, Ospedale Clinicizzato Chieti (CH), 66100 Chieti, Italy
| | - Giovanni Iannetti
- Department of Internist Ultrasound, Pescara Public Hospital "Santo Spirito", 65124 Pescara, Italy
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Bartolini E, Ferrari AR, Lattanzi S, Pradella S, Zaccara G. Drug-resistant epilepsy at the age extremes: Disentangling the underlying etiology. Epilepsy Behav 2022; 132:108739. [PMID: 35636351 DOI: 10.1016/j.yebeh.2022.108739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
The incidence of epilepsy is highest at the extreme age ranges: childhood and elderly age. The most common syndromes in these demographics - self-limited epilepsies of childhood and idiopathic generalized epilepsies in pediatric age, focal epilepsy with structural etiology in older people - are expected to be drug responsive. In this work, we focus on such epilepsy types, overviewing the complex clinical background of unexpected drug-resistance. For self-limited epilepsies of childhood and idiopathic generalized epilepsies, we illustrate drug-resistance resulting from syndrome misinterpretation, reason on possible unexpected courses of epilepsy, and explicate the influence of inappropriate treatments. For elderly-onset epilepsy, we show the challenges in differential diagnosis possibly leading to pseudoresistance and analyze how drug-resistant epilepsy can arise in stroke, neurocognitive disorders, brain tumors, and autoimmune encephalitis. In children and senior people, drug-resistance can be regarded as a hint to review the diagnosis or explore alternative therapeutic strategies. Refractory seizures are not only a therapeutic challenge, but also a cardinal sign not to be overlooked in syndromes commonly deemed to be drug-responsive.
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Affiliation(s)
- Emanuele Bartolini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy.
| | - Anna Rita Ferrari
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Silvia Pradella
- USL Centro Toscana, Neurology Unit, Nuovo Ospedale Santo Stefano, Prato, Italy.
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Chen TS, Lai MC, Huang HYI, Wu SN, Huang CW. Immunity, Ion Channels and Epilepsy. Int J Mol Sci 2022; 23:ijms23126446. [PMID: 35742889 PMCID: PMC9224225 DOI: 10.3390/ijms23126446] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 12/10/2022] Open
Abstract
Epilepsy is a common chronic neurological disorder in modern society. One of the major unmet challenges is that current antiseizure medications are basically not disease-modifying. Among the multifaceted etiologies of epilepsy, the role of the immune system has attracted considerable attention in recent years. It is known that both innate and adaptive immunity can be activated in response to insults to the central nervous system, leading to seizures. Moreover, the interaction between ion channels, which have a well-established role in epileptogenesis and epilepsy, and the immune system is complex and is being actively investigated. Some examples, including the interaction between ion channels and mTOR pathways, will be discussed in this paper. Furthermore, there has been substantial progress in our understanding of the pathophysiology of epilepsy associated with autoimmune encephalitis, and numerous neural-specific autoantibodies have been found and documented. Early recognition of immune-mediated epilepsy is important, especially in cases of pharmacoresistant epilepsy and in the presence of signs of autoimmune encephalitis, as early intervention with immunotherapy shows promise.
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Affiliation(s)
- Tsang-Shan Chen
- Department of Neurology, Tainan Sin-Lau Hospital, Tainan 701002, Taiwan;
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan;
| | | | - Sheng-Nan Wu
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan;
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan 70101, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5485)
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14
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Liu X, Yu T, Qi J, Lv R, Wang Q. Factors predicting neuronal surface antibodies in the elderly with new-onset and unknown seizures. Ann Clin Transl Neurol 2022; 9:1039-1049. [PMID: 35598111 PMCID: PMC9268868 DOI: 10.1002/acn3.51597] [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: 03/23/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate risk factors of neuronal surface antibodies (NSAbs) and develop a nomogram that could identify patients at the odds of NSAbs among the elderly (aged 60 years or older) with new‐onset seizures of unknown etiology. Methods Clinical data for aged ≥60 years diagnosed with new‐onset seizures of unknown etiology were retrospectively reviewed. A nomogram based on multivariable logistic regression was constructed. Model performance of nomogram was evaluated using area under the curve (AUC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC). Meanwhile, it was internally validated by bootstrap validation in current cohort. Results Of 147 patients included in final analysis, 68 (46.3%) had NSAbs‐mediated encephalitis. Six factors were identified: duration of seizures less than 3 months (OR:14.259; 95% CI: 4.480–45.386), focal‐onset seizures (OR:12.457; 95% CI: 2.710–57.261), psychiatric deficits (OR:10.063; 95% CI: 3.231–31.343), sleep disorders (OR:3.091; 95% CI: 1.011–9.454), hyponatremia (OR:6.252; 95% CI: 1.445–27.043), and medial temporal lobe (MTL) lesions on MRI (OR:4.102; 95% CI: 1.382–12.169). The nomogram had a good discrimination with an AUC of 0.916 and with a corrected AUC of 0.881 after the bootstrapping validation, our model also exhibited a better predictive performance than scoring systems commonly used clinically. Additionally, the calibration curve showed that predicted NSAbs‐positive rates of nomogram were closely aligned with actual observed results. Moreover, the nomogram achieved well on clinical utility by using the DCA and CIC. Interpretation Our nomogram may provide a convenient and useful tool for identifying the elderly with new‐onset seizures of unknown etiology who are at risk of NSAbs‐mediated encephalitis, which would allow these patients receive earlier immunotherapy.
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Affiliation(s)
- Xiao Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tingting Yu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Qi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruijuan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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15
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Gillinder L, Britton J. Autoimmune-Associated Seizures. Continuum (Minneap Minn) 2022; 28:363-398. [PMID: 35393963 DOI: 10.1212/con.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article focuses on the seizure manifestations and presentations of autoimmune-associated epilepsy and acute symptomatic seizures in autoimmune encephalitis. It discusses the specificity of the various central nervous system autoantibodies and clarifies when their presence can be considered indicative of an immune etiology. Finally, current recommendations regarding patient selection for autoimmune antibody evaluation are reviewed, and an approach to immunotherapy is provided. RECENT FINDINGS Although autoimmune seizures are caused by a heterogeneous group of autoantibodies, key features reported in the literature should alert clinicians to the possible diagnosis. In particular, seizure characteristics including frequency, timing, duration, and symptomatology can provide vital clues to help differentiate autoimmune-associated seizures from other causes of epilepsy. Diagnostic certainty also requires an understanding and integration of the spectrum of clinical and paraclinical presentations, and several scoring systems have been developed that may be useful to aid the identification of autoimmune seizures. SUMMARY Seizures due to autoimmune etiology are increasingly encountered in clinical practice. It is critical that clinicians recognize immune seizure etiologies early in their course given they are often responsive to immunotherapy but are usually resistant to antiseizure medications. Currently, however, it is unfortunately not uncommon for autoimmune-associated seizure disorders to remain undiagnosed, resulting in missed opportunities to administer effective therapies. Efforts to better understand autoimmune seizure manifestations and treatment strategies are ongoing.
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Lei C, Chang X, Li H, Zhong L. Abnormal Brain MRI Findings in Anti-N-Methyl-D-Aspartate Receptor Encephalitis and Correlation With Outcomes. Front Neurol 2022; 13:834929. [PMID: 35359628 PMCID: PMC8963947 DOI: 10.3389/fneur.2022.834929] [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: 12/14/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The reported prevalence of abnormal findings by brain MRI varies from 11 to 83% among patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. Here, we investigated the prevalence of abnormal MRI findings in Chinese patients and explored whether such findings are correlated with clinical outcomes. Methods This retrospective study analyzed a consecutive series of 52 patients with anti-NMDAR encephalitis admitted to our hospital. The patients were assigned to the “MRI-normal” or the “MRI-abnormal” group based on brain MRI after admission. The groups were compared in terms of clinicodemographic characteristics and scores on the Mini-Mental State Examination (MMSE) and modified Rankin Scale (mRS) 3 and 12 months after admission. Results Thirty-seven (71.15%) of the patients showed abnormalities on brain MRI; these patients were more likely to be men and showed abnormalities on electroencephalography. Patients who showed normal or abnormal MRI findings did not differ significantly in terms of clinical symptoms, rates of mortality or relapse, or mRS scores after 3 and 12 months. However, patients with abnormal MRI showed significantly lower MMSE scores than those with normal MRI after 3 and 12 months. Conclusions We found high prevalence of abnormal MRI findings in our sample of Chinese patients with anti-NMDAR encephalitis. We also found that the abnormal findings were associated with cognitive decline but not necessarily with mortality or functional outcomes in the short or long term.
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Costagliola G, Depietri G, Michev A, Riva A, Foiadelli T, Savasta S, Bonuccelli A, Peroni D, Consolini R, Marseglia GL, Orsini A, Striano P. Targeting Inflammatory Mediators in Epilepsy: A Systematic Review of Its Molecular Basis and Clinical Applications. Front Neurol 2022; 13:741244. [PMID: 35359659 PMCID: PMC8961811 DOI: 10.3389/fneur.2022.741244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Recent studies prompted the identification of neuroinflammation as a potential target for the treatment of epilepsy, particularly drug-resistant epilepsy, and refractory status epilepticus. This work provides a systematic review of the clinical experience with anti-cytokine agents and agents targeting lymphocytes and aims to evaluate their efficacy and safety for the treatment of refractory epilepsy. Moreover, the review analyzes the main therapeutic perspectives in this field. Methods A systematic review of the literature was conducted on MEDLINE database. Search terminology was constructed using the name of the specific drug (anakinra, canakinumab, tocilizumab, adalimumab, rituximab, and natalizumab) and the terms “status epilepticus,” “epilepsy,” and “seizure.” The review included clinical trials, prospective studies, case series, and reports published in English between January 2016 and August 2021. The number of patients and their age, study design, specific drugs used, dosage, route, and timing of administration, and patients outcomes were extracted. The data were synthesized through quantitative and qualitative analysis. Results Our search identified 12 articles on anakinra and canakinumab, for a total of 37 patients with epilepsy (86% febrile infection-related epilepsy syndrome), with reduced seizure frequency or seizure arrest in more than 50% of the patients. The search identified nine articles on the use of tocilizumab (16 patients, 75% refractory status epilepticus), with a high response rate. Only one reference on the use of adalimumab in 11 patients with Rasmussen encephalitis showed complete response in 45% of the cases. Eight articles on rituximab employment sowed a reduced seizure burden in 16/26 patients. Finally, one trial concerning natalizumab evidenced a response in 10/32 participants. Conclusion The experience with anti-cytokine agents and drugs targeting lymphocytes in epilepsy derives mostly from case reports or series. The use of anti-IL-1, anti-IL-6, and anti-CD20 agents in patients with drug-resistant epilepsy and refractory status epilepticus has shown promising results and a good safety profile. The experience with TNF inhibitors is limited to Rasmussen encephalitis. The use of anti-α4-integrin agents did not show significant effects in refractory focal seizures. Concerning research perspectives, there is increasing interest in the potential use of anti-chemokine and anti-HMGB-1 agents.
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Affiliation(s)
- Giorgio Costagliola
- Pediatric Immunology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Greta Depietri
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alexandre Michev
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
- *Correspondence: Alexandre Michev
| | - Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “Giannina Gaslini”, Genova, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Salvatore Savasta
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Diego Peroni
- Pediatric Immunology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Pediatric Immunology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “Giannina Gaslini”, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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Smith KM, Dubey D, Liebo GB, Flanagan EP, Britton JW. Clinical Course and Features of Seizures Associated With LGI1-Antibody Encephalitis. Neurology 2021; 97:e1141-e1149. [PMID: 34233939 DOI: 10.1212/wnl.0000000000012465] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/18/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine risk factors associated with clinical relapses and development of chronic epilepsy in patients with anti-leucine-rich glioma-inactivated 1 (LGI1) IgG encephalitis. METHODS Patients with seizures related to LGI1-antibody encephalitis with ≥ 24 months of follow-up from disease onset were identified in the Mayo Clinic electronic medical record and Neuroimmunology lab records. Charts were reviewed to determine clinical factors, seizure types, imaging, treatment, occurrence of relapse, and outcome. Binary logistic regression analysis was performed to identify predictors of the development of chronic epilepsy. Univariate Cox proportional hazards regression was used to examine the influence of baseline characteristics on relapse risk. RESULTS Forty-nine patients with LGI1-antibody encephalitis and acute symptomatic seizures were identified. Almost all patients (n=48, 98%) were treated with immunotherapy. Eight had definite, and two had possible chronic epilepsy at last follow-up (10/49, 20.4%). Female sex (P=0.048) and younger age at disease onset (P=0.02) were associated with development of chronic epilepsy. Relapses occurred in 20 (40.8%), with a median time to first relapse of 7.5 months (range 3-94 months). Initial treatment with chronic steroid sparing immunotherapy was associated with reduced risk of relapse (hazards ratio=0.28, 95% CI 0.11-0.73, P=0.009). CONCLUSIONS Chronic epilepsy occurred in 20.4% of our patients with LGI1-antibody encephalitis despite aggressive immunotherapy. Risk factors for chronic epilepsy were female sex and earlier age of onset. Relapses occurred in 40.8% of patients with prolonged follow-up, and chronic steroid sparing immunotherapy was associated with a lower relapse rate.
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Affiliation(s)
| | | | - Greta B Liebo
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Rochester, MN
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Wang Y, Li X, He P, Yin J, Dong R, Fu Y, Zhang H. Characteristics and outcome-related factors of seizure at the first onset of autoimmune encephalitis: A retrospective study. CNS Neurosci Ther 2021; 27:694-701. [PMID: 33683811 PMCID: PMC8111501 DOI: 10.1111/cns.13633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 01/17/2023] Open
Abstract
Aims Seizure outcome of autoimmune encephalitis (AE) varies from seizure‐free to refractory epilepsy, and the associated factors remain unclear. We aimed to describe seizure characteristics, identify seizure outcome‐related factors, and discuss the medication strategy of antiepileptic drugs (AEDs) at the first onset of AE. Methods We retrospectively studied the data of 86 patients with clinically diagnosed AE. The clinical characteristics were described using a chi‐square test. Seizure outcome‐related factors were assessed using multivariable logistic regression analysis. Results 56 patients were finally enrolled, with antibodies to N‐methyl‐D‐aspartate receptor found in 29, to γ‐aminobutyric acid receptor B found in 13, and to leucine‐rich glioma‐inactivated protein 1 found in 14. Status epilepticus occurrence and onset with seizure lead to a poor seizure outcome, while administration of human gamma globulin and a low antibody titer contributed to a good seizure outcome. Conclusions In the acute phase, seizure characteristics may be considered in the utilization of AEDs. For patients with seizure‐free status in the acute phase, clinical manifestation (onset with seizure or not, whether status epilepticus occurs or not), therapy regimen (human gamma globulin administered or not), and antibody titer may be considered when formulating the strategy for withdrawal of AEDs post‐acute phase.
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Affiliation(s)
- Yilin Wang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xin Li
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Pingping He
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jiangning Yin
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ruofei Dong
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yu Fu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hong Zhang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
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Taraschenko O, Fox HS, Zekeridou A, Pittock SJ, Eldridge E, Farukhuddin F, Al-Saleem F, Devi Kattala C, Dessain SK, Casale G, Willcockson G, Dingledine R. Seizures and memory impairment induced by patient-derived anti-N-methyl-D-aspartate receptor antibodies in mice are attenuated by anakinra, an interleukin-1 receptor antagonist. Epilepsia 2021; 62:671-682. [PMID: 33596332 DOI: 10.1111/epi.16838] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Neuroinflammation associated with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis may facilitate seizures. We previously showed that intraventricular administration of cerebrospinal fluid from patients with anti-NMDAR encephalitis to mice precipitates seizures, thereby confirming that antibodies are directly pathogenic. To determine whether interleukin (IL)-1-mediated inflammation exacerbates autoimmune seizures, we asked whether blocking the effects of IL-1 by anakinra, a selective IL-1 receptor antagonist, blunts antibody-induced seizures. METHODS We infused C57BL/6 mice intraventricularly with purified serum IgG from patients with anti-NMDAR encephalitis or monoclonal anti-NMDAR IgG; subdural electroencephalogram was continuously recorded. After a 6-day interval, mice received anakinra (25 mg/kg sc, twice daily) or vehicle for 5 days. Following a 4-day washout period, we performed behavioral tests to assess motor function, anxiety, and memory, followed by hippocampus tissue analysis to assess astrocytic (glial fibrillary acidic protein [GFAP]) and microglial (ionized calcium-binding adapter molecule [Iba]-1) activation. RESULTS Of 31 mice infused with purified patient NMDAR-IgG (n = 17) or monoclonal NMDAR-IgG (n = 14), 81% developed seizures. Median baseline daily seizure count during exposure to antibodies was 3.9; most seizures were electrographic. Median duration of seizures during the baseline was 82.5 s. Anakinra administration attenuated daily seizure frequency by 60% (p = .02). Anakinra reduced seizure duration; however, the effect was delayed and became apparent only after the cessation of treatment (p = .04). Anakinra improved novel object recognition in mice with antibody-induced seizures (p = .03) but did not alter other behaviors. Anakinra reduced the expression of GFAP and Iba-1 in the hippocampus of mice with seizures, indicating decreased astrocytic and microglial activation. SIGNIFICANCE Our evidence supports a role for IL-1 in the pathogenesis of seizures in anti-NMDAR encephalitis. These data are consistent with therapeutic effects of anakinra in other severe autoimmune and inflammatory seizure syndromes. Targeting inflammation via blocking IL-1 receptor-mediated signaling may be promising for developing novel treatments for refractory autoimmune seizures.
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Affiliation(s)
- Olga Taraschenko
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Howard S Fox
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anastasia Zekeridou
- Departments of Neurology, Laboratory Medicine, and Pathology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Sean J Pittock
- Departments of Neurology, Laboratory Medicine, and Pathology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Ember Eldridge
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fnu Farukhuddin
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fetweh Al-Saleem
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Scott K Dessain
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - George Casale
- Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Gregory Willcockson
- Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Raymond Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia, USA
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21
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Nepal G, Shing YK, Yadav JK, Rehrig JH, Ojha R, Huang DY, Gajurel BP. Efficacy and safety of rituximab in autoimmune encephalitis: A meta-analysis. Acta Neurol Scand 2020; 142:449-459. [PMID: 32484900 DOI: 10.1111/ane.13291] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE. METHODS This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment. RESULTS Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease. CONCLUSION Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Yow K. Shing
- Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Jayant K. Yadav
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Jessica H. Rehrig
- University of New England College of Osteopathic Medicine Biddeford ME USA
| | - Rajeev Ojha
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Dong Y Huang
- Department of Neurology Shanghai East Hospital of Tongji University School of Medicine Shanghai China
| | - Bikram P. Gajurel
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
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Ni G, Lin W, Cai X, Qin J, Feng L, Zhu S, Zhou L, Chen Z. Associations between seizures and MRI in patients with anti-NMDAR encephalitis. Acta Neurol Scand 2020; 142:460-465. [PMID: 32533702 DOI: 10.1111/ane.13298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/22/2020] [Accepted: 06/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Seizures are a prominent feature of anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. Nearly half of brain magnetic resonance image (MRI) results are abnormal. The aim of our study was to evaluate the associations between seizures and brain MRI results in patients with anti-NMDAR encephalitis. METHODS Patients with anti-NMDAR encephalitis were enrolled between January 2015 and December 2018. The patients included were divided into normal and abnormal MRI groups. Seizure outcomes and modified Rankin Scale scores at the 1-year follow-up were assessed. Seizure characteristics and outcomes were compared between groups. RESULTS Of 35 patients with anti-NMDAR encephalitis, 28 patients (80%) had reported seizures in the acute phase. Patients with abnormal MRI findings more frequently had focal seizures than patients with normal MRI findings (72.7% vs 17.6%, P < .01). The incidence of patients treated with 2 or more antiepileptic drugs was higher in the normal MRI group than in the abnormal MRI group (100% vs 45.4%, P < .01). The onset-immunotherapy time was shorter in the abnormal MRI group than in the normal MRI group (P < .05). There were no statistically significant differences in seizure outcomes between the normal and abnormal MRI groups (P > .05). CONCLUSIONS Focal seizures were most common in patients with abnormal MRI lesions. In the acute stage of the disease, the abnormal MRI group was more likely than the normal MRI group to achieve seizure control. Abnormal MRI findings did not affect the overall good prognosis of patients with anti-NMDAR encephalitis with seizures.
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Affiliation(s)
- Guanzhong Ni
- Department of Neurology The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases National Key Clinical Department and Key Discipline of Neurology Guangzhou China
| | - Wanrong Lin
- Department of Neurology The Seventh Affiliated Hospital Sun Yat‐sen University Shenzhen China
| | - Xiaodong Cai
- Department of Neurology The Sixth Affiliated Hospital Sun Yat‐sen University Guangzhou China
| | - Jiaming Qin
- Department of Pulmonary and Critical Care Medicine The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
| | - Li Feng
- Department of Neurology The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases National Key Clinical Department and Key Discipline of Neurology Guangzhou China
| | - Shaofang Zhu
- Department of Neurology The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases National Key Clinical Department and Key Discipline of Neurology Guangzhou China
| | - Liemin Zhou
- Department of Neurology The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases National Key Clinical Department and Key Discipline of Neurology Guangzhou China
- Department of Neurology The Seventh Affiliated Hospital Sun Yat‐sen University Shenzhen China
| | - Ziyi Chen
- Department of Neurology The First Affiliated Hospital Sun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases National Key Clinical Department and Key Discipline of Neurology Guangzhou China
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Rada A, Birnbacher R, Gobbi C, Kurthen M, Ludolph A, Naumann M, Neirich U, von Oertzen TJ, Ransmayr G, Riepe M, Schimmel M, Schwartz O, Surges R, Bien CG. Seizures associated with antibodies against cell surface antigens are acute symptomatic and not indicative of epilepsy: insights from long-term data. J Neurol 2020; 268:1059-1069. [PMID: 33025119 PMCID: PMC7914192 DOI: 10.1007/s00415-020-10250-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
Background Clinicians have questioned whether any disorder involving seizures and neural antibodies should be called “(auto)immune epilepsy.” The concept of “acute symptomatic seizures” may be more applicable in cases with antibodies against neural cell surface antigens. We aimed at determining the probability of achieving seizure-freedom, the use of anti-seizure medication (ASM), and immunotherapy in patients with either constellation. As a potential pathophysiological correlate, we analyzed antibody titer courses. Methods Retrospective cohort study of 39 patients with seizures and neural antibodies, follow-up ≥ 3 years. Results Patients had surface antibodies against the N-methyl-d-aspartate receptor (NMDAR, n = 6), leucine-rich glioma inactivated protein 1 (LGI1, n = 11), contactin-associated protein-2 (CASPR2, n = 8), or antibodies against the intracellular antigens glutamic acid decarboxylase 65 kDa (GAD65, n = 13) or Ma2 (n = 1). Patients with surface antibodies reached first seizure-freedom (88% vs. 7%, P < 0.001) and terminal seizure-freedom (80% vs. 7%, P < 0.001) more frequently. The time to first and terminal seizure-freedom and the time to freedom from ASM were shorter in the surface antibody group (Kaplan–Meier curves: P < 0.0001 for first seizure-freedom; P < 0.0001 for terminal seizure-freedom; P = 0.0042 for terminal ASM-freedom). Maximum ASM defined daily doses were higher in the groups with intracellular antibodies. Seizure-freedom was achieved after additional immunotherapy, not always accompanied by increased ASM doses. Titers of surface antibodies but not intracellular antibodies decreased over time. Conclusion Seizures with surface antibodies should mostly be considered acute symptomatic and transient and not indicative of epilepsy. This has consequences for ASM prescription and social restrictions. Antibody titers correlate with clinical courses. Electronic supplementary material The online version of this article (10.1007/s00415-020-10250-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Rada
- Epilepsy Center Bethel, Krankenhaus Mara, Epilepsy Centre Bethel, Krankenhaus Mara, Maraweg 17-21, 33617, Bielefeld, Germany
| | - Robert Birnbacher
- Department of Pediatrics and Adolescent Medicine, Villach General Hospital, Villach, Austria
| | - Claudio Gobbi
- Department of Neurology, Neurocenter of Southern Switzerland (NSI), 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana (USI), 6900, Lugano, Switzerland
| | | | - Albert Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University of Augsburg, Augsburg, Germany
| | - Ulrike Neirich
- Department of Pediatrics, Neurology, Stiftungskrankenhäuser Frankfurt Am Main, Clementine Kinderhospital, Frankfurt am Main, Germany
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Gerhard Ransmayr
- Department of Neurology 2, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Matthias Riepe
- Division of Gerontopsychiatry, Ulm University, Günzburg, Germany
| | - Mareike Schimmel
- Department of Pediatrics, Section of Neuropediatrics, University of Augsburg, Augsburg, Germany
| | - Oliver Schwartz
- Department of Pediatric Neurology, Münster University Hospital, Münster, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital of Bonn, Bonn, Germany
| | - Christian G Bien
- Epilepsy Center Bethel, Krankenhaus Mara, Epilepsy Centre Bethel, Krankenhaus Mara, Maraweg 17-21, 33617, Bielefeld, Germany.
- Laboratory Krone, Bad Salzuflen, Germany.
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Wesselingh R, Butzkueven H, Buzzard K, Tarlinton D, O'Brien TJ, Monif M. Seizures in autoimmune encephalitis: Kindling the fire. Epilepsia 2020; 61:1033-1044. [DOI: 10.1111/epi.16515] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Robb Wesselingh
- Department of Neurosciences Central Clinical School Faculty of Medicine, Nursing, and Health Sciences Monash University Melbourne Victoria Australia
- Department of Neurology Alfred Health Melbourne Victoria Australia
| | - Helmut Butzkueven
- Department of Neurosciences Central Clinical School Faculty of Medicine, Nursing, and Health Sciences Monash University Melbourne Victoria Australia
- Department of Neurology Alfred Health Melbourne Victoria Australia
| | - Katherine Buzzard
- Department of Neurology Melbourne Health Parkville Victoria Australia
- Department of Neurology Eastern Health Box Hill Victoria Australia
| | - David Tarlinton
- Department of Immunology Central Clinical School Faculty of Medicine, Nursing, and Health Sciences Monash University Melbourne Victoria Australia
| | - Terence J. O'Brien
- Department of Neurosciences Central Clinical School Faculty of Medicine, Nursing, and Health Sciences Monash University Melbourne Victoria Australia
- Department of Neurology Alfred Health Melbourne Victoria Australia
| | - Mastura Monif
- Department of Neurosciences Central Clinical School Faculty of Medicine, Nursing, and Health Sciences Monash University Melbourne Victoria Australia
- Department of Neurology Alfred Health Melbourne Victoria Australia
- Department of Neurology Melbourne Health Parkville Victoria Australia
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Kolls BJ, O'Keefe YA, Sahgal AK. Autoimmune Encephalitis: NMDA Receptor Encephalitis as an Example of Translational Neuroscience. Neurotherapeutics 2020; 17:404-413. [PMID: 32394329 PMCID: PMC7283418 DOI: 10.1007/s13311-020-00861-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Autoimmune encephalitis (AE) is a group of disorders causing synaptic receptor dysfunction with a broad range of neurological symptoms that has been historically difficult to differentiate clinically. Today, AE represents an excellent example of the rapid determination of the cause of a disease and the ability to identify potential treatments using relatively simple basic science techniques of investigation. Of the number of autoimmune encephalitides identified thus far, one of the best examples of the impact of basic science studies on disease management is NMDA receptor mediated autoimmune encephalitis (NMDAr-AE). In this review, we will provide an overview of the epidemiology of NMDAr-AE, clinical features and treatments, and the basic science tools and techniques that were used to identify the cause, correlate symptoms to underlying pathophysiology, and to understand the mechanism of disease pathology.
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Affiliation(s)
- Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA.
- Brain Injury Translational Research Laboratories, Bryan Research Building, 227F, 311 Research Drive, Durham, NC, 27710, USA.
| | - Yasmin A O'Keefe
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Alok K Sahgal
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
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Seizure Characteristics, Outcome, and Risk of Epilepsy in Pediatric Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Pediatr Neurol 2020; 105:35-40. [PMID: 31917096 DOI: 10.1016/j.pediatrneurol.2019.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND We identified seizure characteristics, long-term outcome, and predictors of persistent seizures in children with anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. METHOD Data were analyzed from patients with anti-NMDAR encephalitis who presented with seizures at our center between August 2012 and June 2018. RESULTS Sixty-two of 86 patients with anti-NMDAR encephalitis experienced seizures. Seizures occurred within two weeks of disease onset in 58 of 62 (93.6%) patients; 36 of 62 (58.1%) had seizures as the initial symptom. Males were more likely to exhibit seizures as the initial symptom (P = 0.039). More than a quarter of patients (17 of 62, 27.4%) manifested two or more seizure types. Focal seizures were the most common (46 of 62, 74.2%). Status epilepticus occurred in 27 of 62 (43.5%) patients, and nonconvulsive status epilepticus, in two of 62 (3.2%) patients. No patient developed refractory status epilepticus. No systemic tumors were found. Electroencephalographic abnormalities included background slowing (77.4%), absence of a posterior dominant rhythm (62.9%), interictal epileptic discharges (50.0%), and extreme delta brush (6.5%). In the acute phase, 45 patients (45 of 62, 72.6%) received antiepileptic drugs. Persistent seizures occurred in only five of 62 (8%) patients. On univariate analysis, status epilepticus and combination antiepileptic drug treatment were associated with persistent seizures, but neither independently predicted persistent seizures. CONCLUSIONS Multiple seizure types may develop at any stage of anti-N-methyl-d-aspartate receptor encephalitis. Refractory status epilepticus, systemic tumors, and extreme delta brush in electroencephalography are rare in pediatric patients. Anti-NMDAR encephalitis-associated seizures appear to have good prognosis, without the need for long-term antiepileptic drug treatment.
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Abstract
The field of autoimmune epilepsy has evolved substantially in the last few decades with discovery of several neural autoantibodies and improved mechanistic understanding of these immune-mediated syndromes. A considerable proportion of patients with epilepsy of unknown etiology have been demonstrated to have an autoimmune cause. The majority of the patients with autoimmune epilepsy usually present with new-onset refractory seizures along with subacute progressive cognitive decline and behavioral or psychiatric dysfunction. Neural specific antibodies commonly associated with autoimmune epilepsy include leucine-rich glioma-inactivated protein 1 (LGI1), N-methyl-D-aspartate receptor (NMDA-R), and glutamic acid decarboxylase 65 (GAD65) IgG. Diagnosis of these cases depends on the identification of the clinical syndrome and ancillary studies including autoantibody evaluation. Predictive models (Antibody Prevalence in Epilepsy and Encephalopathy [APE2] and Response to Immunotherapy in Epilepsy and Encephalopathy [RITE2] scores) based on clinical features and initial neurological assessment may be utilized for selection of cases for autoimmune epilepsy evaluation and management. In this article, we will review the recent advances in autoimmune epilepsy and provide diagnostic and therapeutic algorithms for epilepsies with suspected autoimmune etiology.
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Affiliation(s)
- Khalil S Husari
- Comprehensive Epilepsy Center, Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Divyanshu Dubey
- Department of Neurology and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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28
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Zhang W, Wang X, Shao N, Ma R, Meng H. Seizure characteristics, treatment, and outcome in autoimmune synaptic encephalitis: A long-term study. Epilepsy Behav 2019; 94:198-203. [PMID: 30974347 DOI: 10.1016/j.yebeh.2018.10.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The objective of this study was to report seizure characteristics, long-term outcome, and potential factors associated with persistent seizures in patients with autoimmune synaptic encephalitis (ASE). METHOD Clinical data and courses of 52 patients with ASE who presented with seizures at the Department of Neurology of the First Hospital of Jilin University from January 2015 to August 2017 were reviewed. Seizure outcomes were assessed with a median follow-up duration of 30 months (8-40 months). RESULTS Most patients (71.2%) presented with seizure at initial consultation; focal to bilateral tonic-clonic seizures (50.0%) were the most common type. The temporal lobe (73.5%) was the prominent region of seizure origin, which was incident with hippocampal lesions on magnetic resonance imaging (MRI) in 62.1% of the patients. Status epilepticus, subclinical seizures, and nonepileptic events were observed in 28.9%, 36.8%, and 28.9% of the patients, respectively. Twenty-seven out of the 43 followed-up patients (62.8%) exhibited seizure remission after initial immunotherapy. Others (37.2%) developed persistent seizures to different extents. Six out of 9 patients experienced additional seizure freedom because of antiepileptic drugs (AEDs); however, the seizures of the other three patients, with serious conditions, showed poor response. Patients with anti-N-methyl-d-aspartate receptor antibodies had a lower risk of developing persistent seizures than those with anti-leucine-rich glioma-inactivated 1 (LGI1) or anti-γ-aminobutyric acid receptor type B receptor (GABABR) antibodies (P = 0.001). CONCLUSIONS A complex of clinical and subclinical seizures, and nonepileptic events characterize ASE. Patients with anti-LGI1 or anti-GABABR antibodies have a higher risk of developing persistent seizures; AEDs are suitable for achieving additional seizure freedom, but not for patients with serious conditions. A few patients present with super-refractory epilepsy despite multiple treatments.
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Affiliation(s)
- Wuqiong Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Xue Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Na Shao
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Rui Ma
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Hongmei Meng
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, China.
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Chen D, Huang X, Lu S, Deng H, Gan H, Huang R, Zhang B. miRNA-125a modulates autophagy of thyroiditis through PI3K/Akt/mTOR signaling pathway. Exp Ther Med 2019; 17:2465-2472. [PMID: 30906434 PMCID: PMC6425124 DOI: 10.3892/etm.2019.7256] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/30/2018] [Indexed: 01/08/2023] Open
Abstract
The present study examined the potential function and underlying mechanisms of microRNA-125a (miR-125a) in thyroiditis. Mice were subcutaneously administered with 100 µg porcine thyroglobulin weekly for 2 weeks to establish the thyroiditis model. Results of the in vivo study demonstrated that miR-125a serum expression was upregulated in thyroiditis mice compared with the control group. In vitro studies were performed on a mouse macrophage cell line in which a model of thyroiditis was established using 10 ng/ml human interferon-γ. Upregulated miR-125a expression was achieved via mimic transfection. Increased miR-125a expression reduced autophagy and cell proliferation, increased the apoptotic rate and the expression of pro-inflammatory factors tumor necrosis factor-α, interleukin (IL)-1β, IL-6 and IL-18 via downregulation of the phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/Akt/mTOR) signaling pathway. PI3K inhibition enhanced the ability of miR-125a to increase the inflammatory response in vitro via regulation of the PI3K/Akt/mTOR signaling pathway. These results suggest miR-125a inhibited autophagy in a model of thyroiditis through the PI3K/Akt/mTOR signaling pathway.
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Affiliation(s)
- Danyan Chen
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
| | - Xiaolong Huang
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
| | - Song Lu
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
| | - Huacong Deng
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
| | - Hua Gan
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
| | - Rongxi Huang
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
| | - Binghan Zhang
- Department of Endocrinology and Nephrology, The Zhongshan District of Chongqing General Hospital, Chongqing 400231, P.R. China
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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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Typical clinical and imaging manifestations of encephalitis with anti-γ-aminobutyric acid B receptor antibodies: clinical experience and a literature review. Neurol Sci 2019; 40:769-777. [PMID: 30671737 DOI: 10.1007/s10072-018-3679-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 12/06/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To explore the clinical, imaging, and electroencephalogram (EEG) findings, as well as the treatment and prognosis of five patients with anti-γ-aminobutyric acid B receptor (GABABR) encephalitis and review the current literature to gain a deeper understanding and improve the clinical diagnostic ability of the disease. METHODS Clinical data such as blood examination, imaging, computed tomography (CT), EEG, and magnetic resonance imaging (MRI) findings from five patients with anti-GABABR encephalitis were retrospectively analyzed. RESULTS Based on the imaging data, autoimmune encephalitis with anti-GABABR antibodies displayed subacute onset of episodic memory loss, seizures, and confusion, in addition to signal changes in the medial temporal lobe and/or hippocampus. Anti-GABABR antibodies were found in blood and cerebrospinal fluid (CSF) in all five patients, although the CSF leukocyte count and the levels of protein, sugar, and chloride showed no obvious abnormalities. On MRI, only two patients presented with abnormal signals in the medial temporal lobe and/or hippocampus. The EEG showed a slow wave rhythm in all five patients. After treatment with methylprednisolone pulse therapy combined with antiepileptic treatment, all five patients recovered well, without any complications. CONCLUSIONS Autoimmune encephalitis with anti-GABABR antibodies may be a severe and refractory disease. Anti-GABABR antibodies tested in CSF and serum play a crucial role in the definitive diagnosis and treatment of autoimmune encephalitis. Early treatment is of vital importance to avoid serious complications and neurological sequelae.
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Prognosis in autoimmune encephalitis: Database. Data Brief 2018; 21:2694-2703. [PMID: 30761353 PMCID: PMC6290378 DOI: 10.1016/j.dib.2018.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 12/30/2022] Open
Abstract
Autoimmune encephalitis is a rare and debilitating disease. An important question in clinical neurology is what factors may be correlated with outcomes in autoimmune encephalitis. There is observational data describing statistical analyses on such variables, but there are no review articles that collaborate and interpret this information. This data in brief article represents the data collection for such a review (Broadley et al., 2018). Herein we summarize clinical information from 44 research articles, in particular pertaining to outcomes and prognostic variables.
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Broadley J, Seneviratne U, Beech P, Buzzard K, Butzkueven H, O'Brien T, Monif M. Prognosticating autoimmune encephalitis: A systematic review. J Autoimmun 2018; 96:24-34. [PMID: 30595145 DOI: 10.1016/j.jaut.2018.10.014] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To perform a systematic review of the current scientific literature in order to identify variables associated with patient prognosis in autoimmune encephalitis. METHODS We performed a systematic literature search using MEDLINE, Embase, PubMed and PsychInfo databases. We selected studies that explored the correlation between early clinical and paraclinical findings, and patient outcomes. Data was extracted, analyzed and recorded in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Forty four publications detailing 2823 subjects matched our inclusion criteria. There was considerable heterogeneity in methodology, patient profile, investigation results and clinical outcome measures. Findings were often discrepant for cases of anti-NMDAR encephalitis when compared with other causes of autoimmune encephalitis. Delay in immunotherapy contributed to a variety of worse outcomes for patients with different subsets of autoimmune encephalitis. Altered consciousness, ICU admission and no use of immunotherapy were variables associated with poor prognosis in anti-NMDAR encephalitis. Older age, sex, the presence of status epilepticus, CSF abnormalities and MRI changes were unlikely to have significant prognostic value. The influence of antibody titers, autonomic dysfunction and underlying malignancy was unclear. CONCLUSIONS A number of variables were identified to have potential predictive value for outcomes in autoimmune encephalitis. Heterogeneous study design, size and quality were major limiting factors in this review.
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Affiliation(s)
- James Broadley
- Department of Neuroscience, Monash University, Melbourne, Australia.
| | - Udaya Seneviratne
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neuroscience, Monash Health, Melbourne, Australia; Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Paul Beech
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Radiology, Monash Health, Melbourne, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurosciences, Eastern Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia
| | - Terence O'Brien
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Mastura Monif
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
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Shin YW, Ahn SJ, Moon J, Kim TJ, Jun JS, Byun JI, Lee ST, Jung KH, Park KI, Jung KY, Kim M, Lee SK, Chu K. Increased adverse events associated with antiepileptic drugs in anti-leucine-rich glioma-inactivated protein 1 encephalitis. Epilepsia 2018; 59 Suppl 2:108-112. [PMID: 30159879 DOI: 10.1111/epi.14490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2018] [Indexed: 11/28/2022]
Abstract
Anti-leucine-rich glioma-inactivated protein 1 (LGI1) encephalitis is a rare autoimmune condition presenting mainly as altered mental state, cognitive dysfunction, and seizure. Antiepileptic drugs (AEDs) are usually initiated to control seizures despite their limited efficacy; however, accumulating clinical experience suggests a high incidence of adverse reactions to AEDs in anti-LGI1 encephalitis. We reviewed the medical records of patients who were diagnosed with anti-LGI1 encephalitis to analyze the adverse effects of AEDs in these patients. Among the 20 patients who were treated with AEDs, 10 (50%) changed their AEDs due to adverse cutaneous drug reaction. Eight of them presented with maculopapular eruption, one with drug rash with eosinophilia and systemic symptoms syndrome, and one with eczema. Causative agents mostly consisted of aromatic AEDs. Oxcarbazepine was discontinued in two additional patients due to hyponatremia. Six patients (30%) discontinued their dose of levetiracetam because of psychiatric manifestations including irritability/aggressive behavior (four patients), insomnia (one patient), and depressive mood (one patient). Clinicians should consider adverse cutaneous drug reaction, psychiatric adverse events, and hyponatremia when selecting AEDs for the treatment of anti-LGI1 encephalitis.
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Affiliation(s)
- Yong-Won Shin
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Seon-Jae Ahn
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea.,Department of Neurology, National Center for Mental Health, Seoul, South Korea
| | - Jin-Sun Jun
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea.,Department of Neurology, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Jung-Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea.,Department of Neurology, Seoul National University Hospital Health Care System Gangnam Center, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Manho Kim
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
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Wagner JN, Kalev O, Sonnberger M, Krehan I, von Oertzen TJ. Evaluation of Clinical and Paraclinical Findings for the Differential Diagnosis of Autoimmune and Infectious Encephalitis. Front Neurol 2018; 9:434. [PMID: 29951031 PMCID: PMC6008545 DOI: 10.3389/fneur.2018.00434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/23/2018] [Indexed: 12/30/2022] Open
Abstract
Background: The differential diagnosis of autoimmune and infectious encephalitis is notoriously difficult. For this study, we compare the presenting clinical symptoms and paraclinical test results of autoimmune and infectious encephalitis patients. A clinical algorithm for the diagnosis of autoimmune encephalitis has recently been published. We test these Graus criteria on our cohort for diagnostic sensitivity and specificity within the first week of presentation. Methods: We included all patients seen at our department within a 10-year-period who were diagnosed with encephalitis. The discharge diagnoses served as the reference standard for testing the clinical algorithm for two conditions: use of all the clinical information available on a patient during the first week of hospital admission assuming undefined autoantibody status and microbiological test results (C1) vs. consideration of all the information available on a patient, including the results of serological and microbiological testing (C2). Results: Eighty-four patients (33 autoimmune, 51 infectious encephalitis) were included in the study. Fifty-one (17 autoimmune, 34 infectious) had a definite clinical diagnosis. The two groups differed significantly for the presence of headache, fever, epileptic seizures, and CSF cell-count at presentation. Application of the clinical algorithm resulted in a low sensitivity (58%) and very low specificity (8%) for the diagnosis of possible autoimmune encephalitis. The latter increased considerably in the subgroups of probable and definite autoimmune encephalitis. Whereas the sensitivity of the individual diagnostic categories was clearly time-dependent, the specificity rested foremost on the knowledge of the results of microbiological testing. Anti-CASPR2- and -LGI1-associated autoimmune encephalitis and tick-borne virus encephalitis presented particular diagnostic pitfalls. Conclusions: We define clinical symptoms and paraclinical test results which prove valuable for the differentiation between infectious and autoimmune encephalitis. Sensitivity and specificity of the clinical algorithm clearly depended on the amount of time passed after hospital admission and knowledge of microbiological test results. Accepting this limitation for the acute setting, the algorithm remains a valuable diagnostic aid for antibody-negative autoimmune encephalitis or in resource-poor settings. The initiation of immune therapy however should not be delayed if an autoimmune etiology is considered likely, even if the diagnostic criteria of the algorithm are not (yet) fulfilled.
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Affiliation(s)
- Judith N Wagner
- Department of Neurology 1, Kepler University Hospital, Linz, Austria
| | - Ognian Kalev
- Department of Neuropathology, Kepler University Hospital, Linz, Austria
| | | | - Ingomar Krehan
- Department of Neurology 2, Kepler University Hospital, Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Linz, Austria
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Shin JW, Koo YS, Kim YS, Kim DW, Kim KK, Lee SY, Kim HK, Moon HJ, Lim JA, Byun JI, Sunwoo JS, Moon J, Lee ST, Jung KH, Park KI, Chu K, Kim JM, Cho YW, Jung KY, Lee SK. Clinical characterization of unknown/cryptogenic status epilepticus suspected as encephalitis: A multicenter cohort study. J Neuroimmunol 2018; 315:1-8. [DOI: 10.1016/j.jneuroim.2017.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/11/2017] [Accepted: 12/11/2017] [Indexed: 01/12/2023]
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Abstract
PURPOSE OF REVIEW The aim of this study was to assess the seizure manifestations and risk of epilepsy in encephalitis associated with antibodies against neuronal cell-surface (autoimmune encephalitis) or myelin-associated antigens, and to review several chronic epileptic disorders, including Rasmussen's encephalitis, fever-induced refractory epileptic syndromes (FIRES) and new-onset refractory status epilepticus (NORSE). RECENT FINDINGS Seizures are a frequent manifestation of autoimmune encephalitis. Some autoimmune encephalitis may associate with characteristic features: faciobrachial dystonic seizures (anti-LGI1 encephalitis), electroencephalogram extreme delta brush (anti-NMDAR) or multifocal FLAIR-MRI abnormalities (anti-GABAAR). In anti-LGI1 encephalitis, cortical, limbic and basal ganglia dysfunction results in different types of seizures. Autoimmune encephalitis or myelin-antibody associated syndromes are often immunotherapy-responsive and appear to have a low risk for chronic epilepsy. In contrast patients with seizures related to GAD65-antibodies (an intracellular antigen) frequently develop epilepsy and have suboptimal response to treatment (including surgery). Rasmussen's encephalitis or FIRES may occur with autoantibodies of unclear significance and rarely respond to immunotherapy. A study of patients with NORSE showed that 30% developed chronic epilepsy. SUMMARY Although seizures are frequent in all types of autoimmune encephalitis, the risk for chronic epilepsy is dependent on the antigen: lower if located on the cell-surface, and higher if intracellular. For other disorders (Rasmussen's encephalitis, FIRES, NORSE), the prognosis remains poor.
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Farran B, McGurnaghan S, Looker HC, Livingstone S, Lahnsteiner E, Colhoun HM, McKeigue PM. Modelling cumulative exposure for inference about drug effects in observational studies. Pharmacoepidemiol Drug Saf 2017; 26:1527-1533. [DOI: 10.1002/pds.4327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/19/2017] [Accepted: 09/05/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Bassam Farran
- Institute of Genetics and Molecular Medicine; University of Edinburgh; Edinburgh UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine; University of Edinburgh; Edinburgh UK
| | | | | | | | - Helen M. Colhoun
- Institute of Genetics and Molecular Medicine; University of Edinburgh; Edinburgh UK
- NHS Fife; Kirkcaldy UK
| | - Paul M. McKeigue
- Usher Institute for Population Health Sciences and Informatics; University of Edinburgh; Edinburgh UK
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Shin YW, Lee ST, Park KI, Jung KH, Jung KY, Lee SK, Chu K. Treatment strategies for autoimmune encephalitis. Ther Adv Neurol Disord 2017; 11:1756285617722347. [PMID: 29399043 PMCID: PMC5784571 DOI: 10.1177/1756285617722347] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022] Open
Abstract
Autoimmune encephalitis is one of the most rapidly growing research topics in neurology. Along with discoveries of novel antibodies associated with the disease, clinical experience and outcomes with diverse immunotherapeutic agents in the treatment of autoimmune encephalitis are accumulating. Retrospective observations indicate that early aggressive treatment is associated with better functional outcomes and fewer relapses. Immune response to first-line immunotherapeutic agents (corticosteroids, intravenous immunoglobulin, plasma exchange, and immunoadsorption) is fair, but approximately half or more of patients are administered second-line immunotherapy (rituximab and cyclophosphamide). A small but significant proportion of patients are refractory to all first- and second-line therapies and require further treatment. Although several investigations have shown promising alternatives, the low absolute number of patients involved necessitates more evidence to establish further treatment strategies. In this review, the agents used for first- and second-line immunotherapy are discussed and recent attempts at finding new treatment options are introduced.
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Affiliation(s)
- Yong-Won Shin
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea Yeongjusi Health Center, Gyeongsangbuk-do, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National niversity Hospital, 101, Daehangno, Jongno-gu, Seoul 110-744, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
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Kaplan PW, Probasco J. Limbic and new onset refractory tonic status epilepticus (NORSE) in anti-NMDAR encephalitis. Clin Neurophysiol Pract 2017; 2:140-143. [PMID: 30214986 PMCID: PMC6123859 DOI: 10.1016/j.cnp.2017.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/01/2017] [Accepted: 06/13/2017] [Indexed: 11/24/2022] Open
Abstract
Anti-NMDA receptor encephalitis (anti-NMDAR) can present with non-convulsive status epilepticus. Novel clinical presentation of new onset refractory status epilepticus (NORSE). EEG - diffuse, high alpha/beta activity with tonic limbs; brain FDG-PET/CT - left temporo-parietal regions and cerebellum. Diagnostic and treatment challenges for refractory (dystonic)status epilepticus in anti-NMDAR NORSE.
Aims To present a case of anti-NMDA receptor encephalitis (anti-NMDAR) with new onset refractory non-convulsive status epilepticus (NORSE). Methods Case report with clinical details, MRI, PET, and EEG illustrations. Results New onset refractory status epilepticus (NORSE) may arise from anti-NMDAR, and offers diagnostic and treatment challenges for immuno-therapy and refractory status epilepticus. Non-convulsive status epilepticus with generalized fast activity, has not been reported in anti-NMDAR, in NORSE. Conclusions A patient with anti-NMDAR and generalized status with stiffening, right focal weakness, high frequency alpha/beta on EEG, brain FDG-PET/CT changes in the left temporo-parietal regions and cerebellum was presented. We discuss the unique treatment challenges of anti-NMDAR. NORSE and generalized nonconvulsive status epilepticus.
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Affiliation(s)
- Peter W. Kaplan
- Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, USA
- Corresponding author at: Johns Hopkins Bayview Medical Center, Neurology, 301 Mason F. Lord Drive, Baltimore, MD 21224, USA.
| | - John Probasco
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, USA
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Liu AH, Wu YT, Wang YP. MicroRNA-129-5p inhibits the development of autoimmune encephalomyelitis-related epilepsy by targeting HMGB1 through the TLR4/NF-kB signaling pathway. Brain Res Bull 2017; 132:139-149. [PMID: 28528202 DOI: 10.1016/j.brainresbull.2017.05.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 05/05/2017] [Accepted: 05/10/2017] [Indexed: 12/22/2022]
Abstract
The study aimed to explore the effects of microRNA-129-5p (miR-129-5p) on the development of autoimmune encephalomyelitis (AE)-related epilepsy by targeting HMGB1 through the TLR4/NF-kB signaling pathway in a rat model. AE-related epilepsy models were established. Sprague-Dawley (SD) rats were randomly divided into control, model, miR-129-5p mimics, miR-129-5p inhibitor, HMGB1 shRNA, TLR4/NF-kB (TLR4/NF-kB signaling pathway was inhibited) and miR-129-5p mimics+HMGB1 shRNA groups respectively. Latency to a first epilepsy seizure attack was recorded. Neuronal injuries in the hippocampus regions were detected using HE, Nissl and FJB staining methods 24h following model establishment. Microglial cells were detected by OX-42 immunohistochemistry. Expressions of miR-129-5p, HMGB1 and TLR4/NF-kB signaling pathway-related proteins were detected by qRT-PCR. Protein expressions of HMGB1 and TLR4/NF-kB signaling pathway-related proteins were detected by Western blotting. Dual luciferase reporter gene assay showed that miR-129-5p was negatively targeting HMGB1. Neurons of hippocampal tissues in rats were heavily injured by an injection of lithium chloride. Compared with the model and control groups, neuronal injury of the hippocampus and AE-related epilepsy decreased and microglial cells increased in the miR-129-5p mimics, HMGB1 shRNA and TLR4/NF-kB groups; however, in the miR-129-5p inhibitor group, miR-129-5p expression decreased, HMGB1 expression increased, TLR4/NF-kB signaling pathway was activated, latency to a first epilepsy seizure attack was shortened, and neuronal injury increased. This study provides evidence that miR-129-5p inhibits the development of AE-related epilepsy by suppressing HMGB1 expression and inhibiting TLR4/NF-kB signaling pathway.
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Affiliation(s)
- Ai-Hua Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Ya-Ting Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Yu-Ping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China.
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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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