1
|
Almeida FC, Pereira AI, Mendes-Pinto C, Lopes J, Moura J, Sousa JM, Videira G, Samões R, Oliveira TG. MR Imaging Findings in Anti-Leucine-Rich Glioma Inactivated Protein 1 Encephalitis: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2024; 45:977-986. [PMID: 38871367 DOI: 10.3174/ajnr.a8256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/14/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Antibodies against leucine-rich glioma inactivated protein 1 (LGI1) constitute a common form of autoimmune encephalitis. On MR imaging, it may show T2 FLAIR hyperintensities of the medial temporal lobe (T2 FLAIR-MTL), involve the basal ganglia, or be unremarkable. PURPOSE We performed a systematic review and meta-analysis to obtain prevalence estimates of abnormal findings on MR imaging in anti-LGI1 encephalitis. A human brain map of the LGI1 microarray gene expression was derived from the Allen Human Brain Atlas. DATA SOURCES PubMed and Web of Science were searched with the terms "LGI1" and "encephalitis" from inception to April 7, 2022. STUDY SELECTION Thirty-one research publications, encompassing case series and retrospective cohort and case-control studies, with >10 patients with anti-LGI1 encephalitis and MR imaging data were included. DATA ANALYSIS Pooled prevalence estimates were calculated using Freeman-Tukey double-arcsine transformation. Meta-analysis used DerSimonian and Laird random effects models. DATA SYNTHESIS Of 1318 patients in 30 studies, T2 FLAIR-MTL hyperintensities were present in 54% (95% CI, 0.48-0.60; I2 = 76%). Of 394 patients in 13 studies, 27% showed bilateral (95% CI, 0.19-0.36; I2 = 71%) and 24% unilateral T2 FLAIR-MTL abnormalities (95% CI, 0.17-0.32; I2 = 61%). Of 612 patients in 15 studies, basal ganglia abnormalities were present in 10% (95% CI, 0.06-0.15; I2 = 67%). LGI1 expression was highest in the amygdala, hippocampus, and caudate nucleus. LIMITATIONS Only part of the spectrum of MR imaging abnormalities in anti-LGI1 encephalitis could be included in a meta-analysis. MR imaging findings were not the main outcomes in most studies, limiting available information. I2 values ranged from 62% to 76%, representing moderate-to-large heterogeneity. CONCLUSIONS T2 FLAIR-MTL hyperintensities were present in around one-half of patients with anti-LGI1. The prevalence of unilateral and bilateral presentations was similar, suggesting unilaterality should raise the suspicion of this disease in the appropriate clinical context. Around 10% of patients showed basal ganglia abnormalities, indicating that special attention should be given to this region. LGI1 regional expression coincided with the most frequently reported abnormal findings on MR imaging. Regional specificity might be partially determined by expression levels of the target protein.
Collapse
Affiliation(s)
- Francisco C Almeida
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Life and Health Sciences Research Institute (F.C.A., T.G.O.), School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory (F.C.A., T.G.O.), Braga/Guimarães, Portugal
| | - Ana I Pereira
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Catarina Mendes-Pinto
- From the Department of Neuroradiology (F.C.A., A.I.P., C.M.-P.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Joana Lopes
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - João Moura
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - José Maria Sousa
- Department of Neuroradiology (J.M.S.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Gonçalo Videira
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Raquel Samões
- Department of Neurology (J.L., J.M., G.V., R.S.), Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine (R.S.), Instituto de Ciências Biomédicas de Abel Salazar da Universidade do Porto, Porto, Portugal
| | - Tiago Gil Oliveira
- Life and Health Sciences Research Institute (F.C.A., T.G.O.), School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory (F.C.A., T.G.O.), Braga/Guimarães, Portugal
- Department of Neuroradiology (T.G.O.), Hospital de Braga, Braga, Portugal
| |
Collapse
|
2
|
McCarter SK, Shen KR, Wylam ME. Occult Lung Cancer-Associated Autoimmune Encephalitis Presenting as Acute Psychosis. Mil Med 2024; 189:e1813-e1818. [PMID: 38554268 DOI: 10.1093/milmed/usae116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/12/2024] [Accepted: 03/05/2024] [Indexed: 04/01/2024] Open
Abstract
During deployment, a 52-year-old male developed acute behavioral changes. Though initially considered to have PTSD and related agitation and confusional state, his evaluation was consistent with acute encephalopathy. Magnetic resonance imaging of the brain showed T2 hyperintensities, and CSF analysis was positive for anti-N-methyl-D-aspartate receptor antibody. A nuclear protein in testis carcinoma midline carcinoma was discovered in the lung. Immunotherapy and surgical resection led to steady improvement prior to adjuvant chemotherapy. Autoimmune encephalitis due to anti-N-methyl-D-aspartate receptor antibodies is increasingly being recognized as causal of acute behavioral change.
Collapse
Affiliation(s)
- Shelly K McCarter
- Department of Surgical Services, Naval Hospital Pensacola, Pensacola, FL 32412, USA
| | - K Robert Shen
- Division of Thoracic Surgery, Department of Surgery, May Mayo Clinic Alix College of Medicine, Rochester, MN 55905, USA
| | - Mark E Wylam
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic Alix College of Medicine, Rochester, MN 55905, USA
| |
Collapse
|
3
|
Zhang W, Cao W, Tao W, Wang Y, Tangzhu C, Shen Q, Shi X. Anti-NMDAR encephalitis in a child with long impaired consciousness and persistent antibodies: a case report and mini review. Front Immunol 2024; 15:1402523. [PMID: 38863715 PMCID: PMC11165090 DOI: 10.3389/fimmu.2024.1402523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/14/2024] [Indexed: 06/13/2024] Open
Abstract
We described a challenging case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis in a young girl. Despite enduring months of reduced consciousness with ongoing antibody presence, she ultimately exhibited remarkable improvement within a 5-year follow-up period. Additionally, we conducted a concise review of relevant literature on anti-NMDAR encephalitis, with a specific focus on anti-NMDAR antibodies. Our findings enhance the clinical comprehension of anti-NMDAR encephalitis and offer valuable insights to clinicians for its management.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Xulai Shi
- Department of Pediatric Neurology, The Second Affiliated Hospital & Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| |
Collapse
|
4
|
Comer JD, Capizzano AA. Uncommon and Miscellaneous Inflammatory Disorders of the Brain and Spine. Magn Reson Imaging Clin N Am 2024; 32:277-287. [PMID: 38555141 DOI: 10.1016/j.mric.2024.01.006] [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] [Indexed: 04/02/2024]
Abstract
Inflammatory disorders of the brain and spine have a highly variable MRI appearance, often demonstrating significant overlap in imaging features. The resulting diagnostic dilemma is particularly challenging when considering the more uncommon neuroinflammatory entities. Diligent examination of the salient clinical presentation and signal alteration on imaging examination is necessary when considering neuroinflammation as a diagnostic possibility and may aid in raising suspicion for a particular neuroinflammatory entity. This article reviews a selection of uncommon and miscellaneous inflammatory disorders of the brain and spine to raise awareness of the clinical and imaging features that may assist in this challenging diagnostic task.
Collapse
Affiliation(s)
- John D Comer
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, B2-A209 UH, Ann Arbor, MI 48109, USA.
| | - Aristides A Capizzano
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, B2-A209 UH, Ann Arbor, MI 48109, USA
| |
Collapse
|
5
|
Sanvito F, Pichiecchio A, Paoletti M, Rebella G, Resaz M, Benedetti L, Massa F, Morbelli S, Caverzasi E, Asteggiano C, Businaro P, Masciocchi S, Castellan L, Franciotta D, Gastaldi M, Roccatagliata L. Autoimmune encephalitis: what the radiologist needs to know. Neuroradiology 2024; 66:653-675. [PMID: 38507081 PMCID: PMC11031487 DOI: 10.1007/s00234-024-03318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Autoimmune encephalitis is a relatively novel nosological entity characterized by an immune-mediated damage of the central nervous system. While originally described as a paraneoplastic inflammatory phenomenon affecting limbic structures, numerous instances of non-paraneoplastic pathogenesis, as well as extra-limbic involvement, have been characterized. Given the wide spectrum of insidious clinical presentations ranging from cognitive impairment to psychiatric symptoms or seizures, it is crucial to raise awareness about this disease category. In fact, an early diagnosis can be dramatically beneficial for the prognosis both to achieve an early therapeutic intervention and to detect a potential underlying malignancy. In this scenario, the radiologist can be the first to pose the hypothesis of autoimmune encephalitis and refer the patient to a comprehensive diagnostic work-up - including clinical, serological, and neurophysiological assessments.In this article, we illustrate the main radiological characteristics of autoimmune encephalitis and its subtypes, including the typical limbic presentation, the features of extra-limbic involvement, and also peculiar imaging findings. In addition, we review the most relevant alternative diagnoses that should be considered, ranging from other encephalitides to neoplasms, vascular conditions, and post-seizure alterations. Finally, we discuss the most appropriate imaging diagnostic work-up, also proposing a suggested MRI protocol.
Collapse
Affiliation(s)
- Francesco Sanvito
- Unit of Radiology, Department of Clinical, Surgical, Diagnostic, and Paediatric Sciences, University of Pavia, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
- UCLA Brain Tumor Imaging Laboratory (BTIL), Center for Computer Vision and Imaging Biomarkers, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Giacomo Rebella
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Martina Resaz
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Luana Benedetti
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Federico Massa
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Largo Daneo 3, 16132, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| | - Eduardo Caverzasi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Artificial Intelligence Center, Department of Neuroradiology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Stefano Masciocchi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Lucio Castellan
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory and Neuroimmunology Research Section, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Luca Roccatagliata
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132, Genoa, Italy
| |
Collapse
|
6
|
Ji SH, Yoo RE, Choi SH, Lee WJ, Lee ST, Jeon YH, Choi KS, Lee JY, Hwang I, Kang KM, Yun TJ. Dynamic Contrast-enhanced MRI Quantification of Altered Vascular Permeability in Autoimmune Encephalitis. Radiology 2024; 310:e230701. [PMID: 38501951 DOI: 10.1148/radiol.230701] [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: 03/20/2024]
Abstract
Background Blood-brain barrier (BBB) permeability change is a possible pathologic mechanism of autoimmune encephalitis. Purpose To evaluate the change in BBB permeability in patients with autoimmune encephalitis as compared with healthy controls by using dynamic contrast-enhanced (DCE) MRI and to explore its predictive value for treatment response in patients. Materials and Methods This single-center retrospective study included consecutive patients with probable or possible autoimmune encephalitis and healthy controls who underwent DCE MRI between April 2020 and May 2021. Automatic volumetric segmentation was performed on three-dimensional T1-weighted images, and volume transfer constant (Ktrans) values were calculated at encephalitis-associated brain regions. Ktrans values were compared between the patients and controls, with adjustment for age and sex with use of a nonparametric approach. The Wilcoxon rank sum test was performed to compare Ktrans values of the good (improvement in modified Rankin Scale [mRS] score of at least two points or achievement of an mRS score of ≤2) and poor (improvement in mRS score of less than two points and achievement of an mRS score >2) treatment response groups among the patients. Results Thirty-eight patients with autoimmune encephalitis (median age, 38 years [IQR, 29-59 years]; 20 [53%] female) and 17 controls (median age, 71 years [IQR, 63-77 years]; 12 [71%] female) were included. All brain regions showed higher Ktrans values in patients as compared with controls (P < .001). The median difference in Ktrans between the patients and controls was largest in the right parahippocampal gyrus (25.1 × 10-4 min-1 [95% CI: 17.6, 43.4]). Among patients, the poor treatment response group had higher baseline Ktrans values in both cerebellar cortices (P = .03), the left cerebellar cortex (P = .02), right cerebellar cortex (P = .045), left cerebral cortex (P = .045), and left postcentral gyrus (P = .03) than the good treatment response group. Conclusion DCE MRI demonstrated that BBB permeability was increased in all brain regions in patients with autoimmune encephalitis as compared with controls, and baseline Ktrans values were higher in patients with poor treatment response in the cerebellar cortex, left cerebral cortex, and left postcentral gyrus as compared with the good response group. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Filippi and Rocca in this issue.
Collapse
Affiliation(s)
- So-Hyun Ji
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Roh-Eul Yoo
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Seung Hong Choi
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Woo Jin Lee
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Soon Tae Lee
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Young Hun Jeon
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Kyu Sung Choi
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Ji Ye Lee
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Inpyeong Hwang
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Koung Mi Kang
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| | - Tae Jin Yun
- From the Department of Radiology, National Cancer Center, Goyang, Republic of Korea (S.H.J.); Departments of Radiology (R.E.Y., S.H.C., J.Y.L., I.H., K.M.K., T.J.Y.) and Neurology (S.T.L.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 03080, Republic of Korea (R.E.Y., S.H.C., Y.H.J., K.S.C., J.Y.L., I.H., K.M.K., T.J.Y.); Center for Nanoparticle Research, Institute for Basic Science, and School of Chemical and Biological Engineering, Seoul National University, Seoul, Republic of Korea (S.H.C.); and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (W.J.L.)
| |
Collapse
|
7
|
Miao A, Wang K. Contribution of cerebrospinal fluid antibody titers and sex to acute cerebral blood flow in patients with anti-NMDAR autoimmune encephalitis. Front Immunol 2024; 15:1299898. [PMID: 38495877 PMCID: PMC10940436 DOI: 10.3389/fimmu.2024.1299898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Objective The objective of this study was to elucidate the contribution of cerebrospinal fluid (CSF) antibody titers (AT) and sex to acute cerebral blood flow (CBF) in patients diagnosed with anti-N-methyl-d-aspartate receptor autoimmune encephalitis (NMDAR AE). Methods Forty-five patients diagnosed with NMDAR AE were recruited from December 2016 to January 2023. The acute CBF in patients with NMDAR AE at the early stage of the disease was analyzed using arterial spin labeling. The groups were compared based on CSF AT and sex. The connectivity of the CBF in the region of interest was also compared between groups. Results The patients with different CSF AT exhibited varied brain regions with CBF abnormalities compared to the healthy subjects (p = 0.001, cluster-level FWE corrected). High antibody titers (HAT) in CSF contributed to more brain regions with CBF alterations in female patients than in female patients with low antibody titers (LAT) in CSF (p = 0.001, cluster-level FWE corrected). Female patients with HAT in CSF displayed more decreased CBF in the left post cingulum gyrus, left precuneus, left calcarine, and left middle cingulum gyrus than the male patients with the same AT in CSF (p = 0.001, cluster-level FWE corrected). All patients with NMDAR AE showed increased CBF in the left putamen (Putamen_L) and left amygdala (Amygdala_L) and decreased CBF in the right precuneus (Precuneus_R), which suggests that these are diagnostic CBF markers for NMDAR AE. Conclusion CSF AT and sex contributed to CBF abnormalities in the patients diagnosed with NMDAR AE. Altered CBF might potentially serve as the diagnostic marker for NMDAR AE.
Collapse
Affiliation(s)
- Ailiang Miao
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Jiangsu, Nanjing, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, China
- Anhui Provincial Institute of Translational Medicine, Anhui Medical University, Hefei, China
| |
Collapse
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
Beutler BD, Moody AE, Thomas JM, Sugar BP, Ulanja MB, Antwi-Amoabeng D, Tsikitas LA. Anti-N-methyl-D-aspartate receptor-associated encephalitis: A review of clinicopathologic hallmarks and multimodal imaging manifestations. World J Radiol 2024; 16:1-8. [PMID: 38312349 PMCID: PMC10835429 DOI: 10.4329/wjr.v16.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/04/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
Anti-N-methyl-D-aspartate receptor-associated encephalitis (NMDARE) is a rare immune-mediated neuroinflammatory condition characterized by the rapid onset of neuropsychiatric symptoms and autonomic dysfunction. The mechanism of pathogenesis remains incompletely understood, but is thought to be related to antibodies targeting the GluN1 subunit of the NMDA receptor with resultant downstream dysregulation of dopaminergic pathways. Young adults are most frequently affected; the median age at diagnosis is 21 years. There is a strong female predilection with a female sex predominance of 4:1. NMDARE often develops as a paraneoplastic process and is most commonly associated with ovarian teratoma. However, NMDARE has also been described in patients with small cell lung cancer, clear cell renal carcinoma, and other benign and malignant neoplasms. Diagnosis is based on correlation of the clinical presentation, electroencephalography, laboratory studies, and imaging. Computed tomography, positron emission tomography, and magnetic resonance imaging are essential to identify an underlying tumor, exclude clinicopathologic mimics, and predict the likelihood of long-term functional impairment. Nuclear imaging may be of value for prognostication and to assess the response to therapy. Treatment may involve high-dose corticosteroids, intravenous immunoglobulin, and plasma exchange. Herein, we review the hallmark clinicopathologic features and imaging findings of this rare but potentially devastating condition and summarize diagnostic criteria, treatment regimens, and proposed pathogenetic mechanisms.
Collapse
Affiliation(s)
- Bryce David Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Alastair E Moody
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84132, United States
| | - Jerry Mathew Thomas
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Benjamin Phillip Sugar
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Mark B Ulanja
- Department of Internal Medicine, Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70601, United States
| | - Daniel Antwi-Amoabeng
- Department of Internal Medicine, Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70601, United States
| | - Lucas Anthony Tsikitas
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| |
Collapse
|
10
|
Budhram A, Sechi E. Antibodies to neural cell surface and synaptic proteins in paraneoplastic neurologic syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:347-364. [PMID: 38494289 DOI: 10.1016/b978-0-12-823912-4.00006-2] [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
Among patients with paraneoplastic neurologic syndromes (PNS), emphasis has historically been placed on neural antibodies against intracellular proteins that have a strong association with malignancy. Because of the intracellular location of their antigenic targets, these antibodies are typically considered to be non-pathogenic surrogate markers of immune cell-mediated neural injury. Unfortunately, patients with these antibodies often have suboptimal response to immunotherapy and poor prognosis. Over the last two decades, however, dramatic advancements have been made in the discovery and clinical characterization of neural antibodies against extracellular targets. These antibodies are generally considered to be pathogenic, given their potential to directly alter antigen structure or function, and patients with these antibodies often respond favorably to prompt immunotherapy. These antibodies also associate with tumors and may thus occur as PNS, albeit more variably than neural antibodies against intracellular targets. The updated 2021 PNS diagnostic criteria, which classifies antibodies as high-risk, intermediate-risk, or lower-risk for an associated cancer, better clarifies how neural antibodies against extracellular targets relate to PNS. Using this recently created framework, the clinical presentations, ancillary test findings, oncologic associations, and treatment responses of syndromes associated with these antibodies are discussed.
Collapse
Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| |
Collapse
|
11
|
Masciocchi S, Businaro P, Scaranzin S, Morandi C, Franciotta D, Gastaldi M. General features, pathogenesis, and laboratory diagnostics of autoimmune encephalitis. Crit Rev Clin Lab Sci 2024; 61:45-69. [PMID: 37777038 DOI: 10.1080/10408363.2023.2247482] [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: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 10/02/2023]
Abstract
Autoimmune encephalitis (AE) is a group of inflammatory conditions that can associate with the presence of antibodies directed to neuronal intracellular, or cell surface antigens. These disorders are increasingly recognized as an important differential diagnosis of infectious encephalitis and of other common neuropsychiatric conditions. Autoantibody diagnostics plays a pivotal role for accurate diagnosis of AE, which is of utmost importance for the prompt recognition and early treatment. Several AE subgroups can be identified, either according to the prominent clinical phenotype, presence of a concomitant tumor, or type of neuronal autoantibody, and recent diagnostic criteria have provided important insights into AE classification. Antibodies to neuronal intracellular antigens typically associate with paraneoplastic neurological syndromes and poor prognosis, whereas antibodies to synaptic/neuronal cell surface antigens characterize many AE subtypes that associate with tumors less frequently, and that are often immunotherapy-responsive. In addition to the general features of AE, we review current knowledge on the pathogenic mechanisms underlying these disorders, focusing mainly on the potential role of neuronal antibodies in the most frequent conditions, and highlight current theories and controversies. Then, we dissect the crucial aspects of the laboratory diagnostics of neuronal antibodies, which represents an actual challenge for both pathologists and neurologists. Indeed, this diagnostics entails technical difficulties, along with particularly interesting novel features and pitfalls. The novelties especially apply to the wide range of assays used, including specific tissue-based and cell-based assays. These assays can be developed in-house, usually in specialized laboratories, or are commercially available. They are widely used in clinical immunology and in clinical chemistry laboratories, with relevant differences in analytic performance. Indeed, several data indicate that in-house assays could perform better than commercial kits, notwithstanding that the former are based on non-standardized protocols. Moreover, they need expertise and laboratory facilities usually unavailable in clinical chemistry laboratories. Together with the data of the literature, we critically evaluate the analytical performance of the in-house vs commercial kit-based approach. Finally, we propose an algorithm aimed at integrating the present strategies of the laboratory diagnostics in AE for the best clinical management of patients with these disorders.
Collapse
Affiliation(s)
- Stefano Masciocchi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Pietro Businaro
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, Università degli Studi di Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Chiara Morandi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Research Section, IRCCS Mondino Foundation, Pavia, Italy
| |
Collapse
|
12
|
Wu D, Guo Y, Li C, Pang X, Xu S, Zhang J, Wei L, Li Q, Du J, Tian Y, Wang K. Dynamic and static changes of amplitude of low-frequency fluctuations in anti‑N‑methyl‑D‑aspartate receptor encephalitis. Brain Imaging Behav 2023; 17:652-663. [PMID: 37673808 DOI: 10.1007/s11682-023-00790-6] [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] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Previous neuroimaging research has examined static local brain activity changes in patients with anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. However, the dynamic properties of local brain activity in anti-NMDAR encephalitis remain unknown. METHODS This study used a combination of the amplitude of low-frequency fluctuation (ALFF) method and a sliding-window dynamic analysis approach to examine the time-varying local brain activity changes in anti-NMDAR encephalitis. RESULTS Results showed that patients with anti-NMDAR encephalitis exhibited increased dynamic ALFF (dALFF) variability in the left inferior occipital gyrus compared to healthy controls (HCs), while the patients exhibited decreased sALFF in widespread regions, including the left inferior frontal gyrus, left medial frontal gyrus, bilateral putamen, left medial superior frontal gyrus. dALFF had superior classification performance in distinguishing anti-NMDAR encephalitis patients from HCs over sALFF, but sALFF was correlated with multiple clinical and neuropsychological measures. CONCLUSIONS These findings may shed light on anti-NMDAR encephalitis brain dysfunction from the perspective of dynamic local brain activity. sALFF and dALFF analyses provide complementary information, emphasizing the potential usefulness of combining sALFF and dALFF in elucidating the neuropathological mechanisms of autoimmune encephalitis and may ultimately inform future disease diagnosis.
Collapse
Affiliation(s)
- Dongpeng Wu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China
| | - Yuanyuan Guo
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China
| | - Chenglong Li
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China
| | - Xiaonan Pang
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China
| | - Si Xu
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China
| | - Juanjuan Zhang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China
| | - Ling Wei
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China
| | - Qianqian Li
- Department of Psychology and Sleep Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China
| | - Jing Du
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China.
| | - Yanghua Tian
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China.
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China.
- Department of Psychology and Sleep Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, China.
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui Province, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, 230022, China
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, 230022, China
- Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, 230022, China
| |
Collapse
|
13
|
Santoro JD, Jafarpour S, Boyd NK, Nguyen L, Khoshnood MM. The Impact of Neuroimmunologic Disease and Developing Nervous System. Pediatr Neurol 2023; 148:189-197. [PMID: 37442652 DOI: 10.1016/j.pediatrneurol.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/16/2023] [Accepted: 06/10/2023] [Indexed: 07/15/2023]
Abstract
Over the last two decades, neuroimmunologic disorders of childhood have been increasingly described, phenotyped, and treated. These disorders remain rare in the general population and while sharing common therapeutic interventions due to their immune pathophysiology, are heterogeneous with regard to presentation and risk of recurrence. As such, the impact of these disorders on the developing brain has come into the forefront of emerging research in pediatric neuroimmunology. Investigations into the singular impact of monophasic disease on long-term development and the impact of early and aggressive disease-modifying therapy in relapsing conditions are quickly becoming areas of ripe investigation as the field's most optimal way to treat and monitor these conditions over time. Although critically important in evaluating the developing brain, research has been heterogeneous among these diseases and limited by small cohort size. This narrative review details the role of common neuroimmunologic disorders in long-term neurological and cognitive outcomes in children as they develop.
Collapse
Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Natalie K Boyd
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Lina Nguyen
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Mellad M Khoshnood
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| |
Collapse
|
14
|
Kurokawa R, Kurokawa M, Isshiki S, Harada T, Nakaya M, Baba A, Naganawa S, Kim J, Bapuraj J, Srinivasan A, Abe O, Moritani T. Dural and Leptomeningeal Diseases: Anatomy, Causes, and Neuroimaging Findings. Radiographics 2023; 43:e230039. [PMID: 37535461 DOI: 10.1148/rg.230039] [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: 08/05/2023]
Abstract
Meningeal lesions can be caused by various conditions and pose diagnostic challenges. The authors review the anatomy of the meninges in the brain and spinal cord to provide a better understanding of the localization and extension of these diseases and summarize the clinical and imaging features of various conditions that cause dural and/or leptomeningeal enhancing lesions. These conditions include infectious meningitis (bacterial, tuberculous, viral, and fungal), autoimmune diseases (vasculitis, connective tissue diseases, autoimmune meningoencephalitis, Vogt-Koyanagi-Harada disease, neuro-Behçet syndrome, Susac syndrome, and sarcoidosis), primary and secondary tumors (meningioma, diffuse leptomeningeal glioneuronal tumor, melanocytic tumors, and lymphoma), tumorlike diseases (histiocytosis and immunoglobulin G4-related diseases), medication-induced diseases (immune-related adverse effects and posterior reversible encephalopathy syndrome), and other conditions (spontaneous intracranial hypotension, amyloidosis, and moyamoya disease). Although meningeal lesions may manifest with nonspecific imaging findings, correct diagnosis is important because the treatment strategy varies among these diseases. ©RSNA, 2023 Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.
Collapse
Affiliation(s)
- Ryo Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Mariko Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Saiko Isshiki
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Taisuke Harada
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Moto Nakaya
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Akira Baba
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Shotaro Naganawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - John Kim
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Jayapalli Bapuraj
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Ashok Srinivasan
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Osamu Abe
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Toshio Moritani
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (R.K., M.K., A.B., S.N., J.K., J.B., A.S., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K., M.K., M.N., S.N., O.A.); Department of Radiology, Niizashiki Central General Hospital, Saitama, Japan (S.I.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| |
Collapse
|
15
|
Gombolay G, Brenton JN, Yang JH, Stredny CM, Kammeyer R, Otten CE, Vu N, Santoro JD, Robles-Lopez K, Christiana A, Steriade C, Morris M, Gorman M, Moodley M, Hardy D, Kornbluh AB, Kahn I, Sepeta LN, Yeshokumar A. MRI Features and Their Association With Outcomes in Children With Anti-NMDA Receptor Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200130. [PMID: 37236807 PMCID: PMC10219134 DOI: 10.1212/nxi.0000000000200130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/12/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES How brain MRI lesions associate with outcomes in pediatric anti-NMDA receptor encephalitis (pNMDARE) is unknown. In this study, we correlate T2-hyperintense MRI brain lesions with clinical outcomes in pNMDARE. METHODS This was a multicenter retrospective cohort study from 11 institutions. Children younger than 18 years with pNMDARE were included. One-year outcomes were assessed by the modified Rankin Score (mRS) with good (mRS ≤2) and poor (mRS ≥3) outcomes. RESULTS A total of 175 pNMDARE subjects were included, with 1-year mRS available in 142/175 (81%) and 60/175 (34%) had abnormal brain MRIs. The most common T2-hyperintense lesion locations were frontal, temporal, and parietal. MRI features that predicted poor 1-year outcomes included abnormal MRI, particularly T2 lesions in the frontal and occipital lobes. After adjusting for treatment within 4 weeks of onset, improvement within 4 weeks, and intensive care unit admission, MRI features were no longer associated with poor outcomes, but after multiple imputation for missing data, T2 frontal and occipital lesions associated with poor outcomes. DISCUSSION Abnormal frontal and occipital lesions on MRI may associate with 1-year mRS in pNMDARE. MRI of the brain may be a helpful prognostication tool that should be examined in future studies.
Collapse
Affiliation(s)
- Grace Gombolay
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.).
| | - J Nicholas Brenton
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Jennifer H Yang
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Coral M Stredny
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Ryan Kammeyer
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Catherine E Otten
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - NgocHanh Vu
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Jonathan D Santoro
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Karla Robles-Lopez
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Andrew Christiana
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Claude Steriade
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Morgan Morris
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Mark Gorman
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Manikum Moodley
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Duriel Hardy
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Alexandra B Kornbluh
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Ilana Kahn
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Leigh N Sepeta
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| | - Anusha Yeshokumar
- From the Emory University SOM and Children's Healthcare of Atlanta (G.G., M. Morris); University of Virginia Health System (J.N.B.); University of California San Diego and Rady Children's Hospital San Diego (J.H.Y.); Boston Children's Hospital and Harvard Medical School (C.M.S., M.G.); University of Colorado SOM and Children's Hospital Colorado (R.K.); Seattle Children's/University of Washington (C.E.O.); Vanderbilt University Medical Center (N.V.); Children's Hospital Los Angeles and Keck School of Medicine (J.D.S.), University of Southern California; University of Texas at Austin and Dell Medical School (K.R.-L., M. Moodley, D.H.); New York University SOM (A.C., C.S.); Children's National Hospital and George Washington University Medical School (A.B.K., I.K., L.N.S.); Mount Sinai University and Bristol Myers Squibb (A.Y.)
| |
Collapse
|
16
|
Yu S, Hua Y, Qian J, Sun M, Kang YJ. The presence of human respiratory syncytial virus in the cerebrospinal fluid of a child with Anti-N-methyl-D-aspartate receptor encephalitis of unknown trigger. Virol J 2023; 20:34. [PMID: 36829236 PMCID: PMC9951452 DOI: 10.1186/s12985-023-01997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an important type of brain inflammation caused by autoantibody. As one of the primary agents responsible for respiratory tract infection, the human respiratory syncytial virus (hRSV) has also been reported to be capable of causing extrapulmonary diseases. Here, we first describe a case of anti-NMDAR encephalitis when hRSV was shown to be present in the cerebrospinal fluid. CASE PRESENTATION The child was noted to have ataxia and positive anti-NMDA receptors in the cerebrospinal fluid, diagnosed as anti-NMDA receptor encephalitis in combination with cranial MRI images. After high-dose hormone pulse therapy and medication, the disease improved, and he was discharged. However, a relapse occurred almost a year later, and the cranial MRI imaging showed progressive cerebellar atrophy. An hRSV strain from group B was detected in his cerebrospinal fluid, and the whole genome sequence was recovered using transcriptome sequencing. CONCLUSIONS To our knowledge, this is the first report of hRSV being found in the cerebrospinal fluid of a patient with anti-NMDAR encephalitis. Even though more clinical records and experimental evidence are needed for validation, this work expands the types of diseases linked to hRSV and the likely cause of anti-NMDAR encephalitis.
Collapse
Affiliation(s)
- Siyan Yu
- Pediatric Laboratory, Wuxi Children's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China.,The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ying Hua
- Department of Neurology, Wuxi Children's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Jun Qian
- Pediatric Laboratory, Wuxi Children's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Mingxia Sun
- Department of Neurology, Wuxi Children's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China.
| | - Yan-Jun Kang
- Pediatric Laboratory, Wuxi Children's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China.
| |
Collapse
|
17
|
Wong KT, Tan CT, Lim T. Beyond Pattern Recognition. Neuroimaging Clin N Am 2023; 33:225-233. [DOI: 10.1016/j.nic.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
18
|
Piao S, Bao Y, Yang L, Zhang Y, Hu B, Li H, Geng D, Li Y. Brain MRI features of anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis secondary to central nervous system infection in adult patients. Acta Radiol 2023; 64:760-768. [PMID: 35532900 DOI: 10.1177/02841851221091443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis secondary to central nervous system (CNS) infection is a unique subtype of the autoimmune-mediated disease, of which the imaging features are unclear. PURPOSE To compare the brain magnetic resonance imaging (MRI) features between the anti-NMDAR encephalitis secondary to CNS infection and that without initial infection. MATERIAL AND METHODS A total of 70 adult patients with anti-NMDAR encephalitis were retrospectively enrolled (24 in the post-infection group, 46 in the non-infection-related group). Their clinical and imaging features (lesion distribution, lesion shape, enhancement pattern, brain atrophy) were reviewed and summarized. Lesion distributions were compared between the two groups on lesion probability maps. RESULTS The patients with normal brain MRI scans in the post-infection group were less than those in the non-infection related group (29% vs. 63%; P = 0.0113). Among the 24 patients in the post-infection group, visible lesions were shown at the anti-NMDAR encephalitis onset in 17 patients; lesion distribution was more diffuse than the non-infection-related group, showing higher lesion peak probabilities in the bilateral hippocampus, frontal lobe, temporal lobe, insula, and cingulate. The lesions with contrast enhancement were also more common in the post-infection group than the non-infection-related group (7/13 vs. 2/10). Brain atrophy was observed in eight patients in the post-infection group and three in the non-infection-related group. CONCLUSION Anti-NMDAR encephalitis secondary to CNS infection has its imaging features-extensive lesion distribution, leptomeningeal enhancement, early atrophy, and necrosis-that could deepen the understanding of the pathophysiology and manifestation of the autoimmune encephalitis besides the classic type.
Collapse
Affiliation(s)
- Sirong Piao
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China
| | - Yifang Bao
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Liqin Yang
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Yi Zhang
- Department of Infectious Disease, Huashan Hospital, 159397Fudan University, Shanghai, PR China
| | - Bin Hu
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Haiqing Li
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Daoying Geng
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China
| | - Yuxin Li
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China
| |
Collapse
|
19
|
Wu PY, Chi CS, Tsai CR, Yang YL, Lee HF. Long-Term Outcome of Pediatric Patients with Anti-NMDA Receptor Encephalitis in a Single Center. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020182. [PMID: 36832312 PMCID: PMC9954979 DOI: 10.3390/children10020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/12/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is the most common autoimmune encephalitis in children. There is a high probability of recovery if treated promptly. We aimed to analyze the clinical features and long-term outcomes of pediatric patients with anti-NMDA receptor encephalitis. METHOD We conducted a retrospective study with definite diagnoses of anti-NMDA receptor encephalitis in 11 children treated in a tertiary referral center between March 2012 and March 2022. Clinical features, ancillary tests, treatment, and outcomes were reviewed. RESULTS The median age at disease onset was 7.9 years. There were eight females (72.7%) and three males (27.3%). Three (27.3%) patients initially presented with focal and/or generalized seizures and eight (72.7%) with behavioral change. Seven patients (63.6%) revealed normal brain MRI scans. Seven (63.6%) had abnormal EEG results. Ten patients (90.1%) received intravenous immunoglobulin, corticosteroid, and/or plasmapheresis. After a median follow-up duration of 3.5 years, one patient was lost to follow-up at the acute stage, nine (90%) had an mRS ≤ 2, and only one had an mRS of 3. CONCLUSIONS With the early recognition of anti-NMDA receptor encephalitis based on its clinical features and ancillary tests, we were able to treat patients promptly with first-line treatment and achieve favorable neurological outcomes.
Collapse
Affiliation(s)
- Pei-Yu Wu
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Ching-Shiang Chi
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Chi-Ren Tsai
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Yao-Lun Yang
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Hsiu-Fen Lee
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, 250, Kuo Kuang Rd., Taichung 402, Taiwan
- Correspondence:
| |
Collapse
|
20
|
Chowdhury D, Panda AK, Gupta A, Chowdhury S, Duggal A, Koul A. Anti- N-methyl D-aspartate Receptor Encephalitis in India: A Literature Review. Ann Indian Acad Neurol 2023; 26:17-32. [PMID: 37034048 PMCID: PMC10081549 DOI: 10.4103/aian.aian_519_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Anti N-methyl D-aspartate receptor encephalitis (NMDAR-E) though rare, is currently considered as the commonest antibody mediated encephalitis in the world. No review on perspectives of NMDAR-E from India is available. The aim of the study was to review all the cases of NMDAR-E reported from India until June 2021 in terms of clinical features, diagnosis, and treatment, and perform a comparison of adult and paediatric cases. A literature review of NMDAR-E case reports/case series published from India till June 2021 was done. Demography, clinical profile, triggers, electroencephalography (EEG), neuroimaging, treatment details and outcomes were analysed. Sixteen case series and 35 case reports with a total of 249 cases were analysed. 82% of cases were from paediatric age group. The female to male ratio was 3:1. Psychiatric deficits, movement disorders, seizures, and language abnormalities were the most common clinical features. MRI brain abnormalities were seen in 45% patients. Electroencephalographic abnormalities were seen in 85% of patients. Infective triggers (herpes simplex virus and various other agents) were reported in 11% of the cases. Pediatric patients as compared with adults had more encephalopathy, autonomic dysfunctions, and normal imaging whereas the latter had more cognitive dysfunctions and delta brush pattern in electroencephalography (p<0.005). Therefore, to conclude, this literature review suggests that overall, the clinical spectrum of Indian cases is like cases described from other parts of the world. However, most reported cases from India belonged to paediatric age group who had more encephalopathy, autonomic dysfunctions, and normal brain imaging compared to adults. A few novel infectious agents as triggers were described from India.
Collapse
Affiliation(s)
- Debashish Chowdhury
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashwin K. Panda
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashutosh Gupta
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Samiran Chowdhury
- Department of Internal Medicine, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashish Duggal
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Arun Koul
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| |
Collapse
|
21
|
Chen AY, Wang DS, Sawlani K. Teaching NeuroImage: Atypical Unilateral Cortical Ribboning in Anti-NMDA Receptor Encephalitis. Neurology 2022; 99:1062-1063. [PMID: 36127147 DOI: 10.1212/wnl.0000000000201368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 08/22/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alex Y Chen
- From the Department of Neurology at Case Western Reserve University (A.Y.C., D.S.W., K.S.), Cleveland, OH; and University Hospitals (A.Y.C., D.S.W., K.S.), Cleveland Medical Center, Cleveland, OH.
| | - David S Wang
- From the Department of Neurology at Case Western Reserve University (A.Y.C., D.S.W., K.S.), Cleveland, OH; and University Hospitals (A.Y.C., D.S.W., K.S.), Cleveland Medical Center, Cleveland, OH
| | - Komal Sawlani
- From the Department of Neurology at Case Western Reserve University (A.Y.C., D.S.W., K.S.), Cleveland, OH; and University Hospitals (A.Y.C., D.S.W., K.S.), Cleveland Medical Center, Cleveland, OH
| |
Collapse
|
22
|
Liu H, Xiang Y, Liu J, Feng J, Du S, Luo T, Li Y, Zeng C. Diffusion kurtosis imaging and diffusion tensor imaging parameters applied to white matter and gray matter of patients with anti-N-methyl-D-aspartate receptor encephalitis. Front Neurosci 2022; 16:1030230. [PMID: 36507336 PMCID: PMC9730699 DOI: 10.3389/fnins.2022.1030230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives To compare parameters of diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) to evaluate which can better describe the microstructural changes of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis patients and to characterize the non-Gaussian diffusion patterns of the whole brain and their correlation with neuropsychological impairments in these patients. Materials and methods DTI and DKI parameters were measured in 57 patients with anti-NMDAR encephalitis and 42 healthy controls. Voxel-based analysis was used to evaluate group differences between white matter and gray matter separately. The modified Rankin Scale (mRS) was used to evaluate the severity of the neurofunctional recovery of patients, the Montreal Cognitive Assessment (MoCA) was used to assess global cognitive performance, and the Hamilton Depression Scale (HAMD) and fatigue severity scale (FSS) were used to evaluate depressive and fatigue states. Results Patients with anti-NMDAR encephalitis showed significantly decreased radial kurtosis (RK) in the right extranucleus in white matter (P < 0.001) and notably decreased kurtosis fractional anisotropy (KFA) in the right precuneus, the right superior parietal gyrus (SPG), the left precuneus, left middle occipital gyrus, and left superior occipital gyrus in gray matter (P < 0.001). Gray matter regions with decreased KFA overlapped with those with decreased RK in the left middle temporal gyrus, superior temporal gyrus (STG), supramarginal gyrus (SMG), postcentral gyrus (POCG), inferior parietal but supramarginal gyrus, angular gyrus (IPL) and angular gyrus (ANG) (P < 0.001). The KFA and RK in the left ANG, IPL and POCG correlated positively with MoCA scores. KFA and RK in the left ANG, IPL, POCG and SMG correlated negatively with mRS scores. KFA in the left precuneus and right SPG as well as RK in the left STG correlated negatively with mRS scores. No significant correlation between KFA and RK in the abnormal brain regions and HAMD and FSS scores was found. Conclusion The microstructural changes in gray matter were much more extensive than those in white matter in patients with anti-NMDAR encephalitis. The brain damage reflected by DKI parameters, which have higher sensitivity than parameters of DTI, correlated with cognitive impairment and the severity of the neurofunctional recovery.
Collapse
Affiliation(s)
- Hanjing Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yayun Xiang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junhang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinzhou Feng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Silin Du
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tianyou Luo
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Yongmei Li,
| | - Chun Zeng
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,Chun Zeng,
| |
Collapse
|
23
|
Zhao Y, Han B, Qin C, Shi X, Yun W, Wang M, Yuan B, Sun T, Wang H. Brain magnetic resonance imaging predictors in anti-N-methyl-D-aspartate receptor encephalitis. Ann Clin Transl Neurol 2022; 9:1974-1984. [PMID: 36314483 PMCID: PMC9735371 DOI: 10.1002/acn3.51690] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/18/2022] [Accepted: 10/20/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Brain magnetic resonance imaging (MRI) findings in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis are nonspecific and rarely have obvious associations with clinical characteristics and outcomes. This study aimed to comprehensively describe the MRI features of patients with NMDAR encephalitis, examine their associations with clinical characteristics, and evaluate their predictive power for disease recurrence and prognosis. METHODS We retrospectively extracted the clinical data and brain MRI findings of 144 patients with NMDAR encephalitis. Patients underwent a 2-year follow-up to assess disease outcomes. We evaluated the associations of brain MRI findings at the onset with clinical characteristics, recurrence, and prognosis. RESULTS Initial MRI showed typical abnormalities in 65 patients (45.1%); of these, 34 (29.3%) developed recurrence and 10 (9.4%) had poor prognosis (mRS ≥3). Binary logistic regression analyses revealed that insula abnormalities were associated with acute seizure (odds ratio [OR] = 3.048, 95% confidence interval [CI]: 1.026-9.060) and white matter lesions were associated with cognitive impairment (OR = 2.730, 95% CI: 1.096-6.799). Risk factors for a poor 2-year prognosis included a higher number of brain MRI abnormalities (OR = 1.573, 95% CI: 1.129-2.192) and intensive care unit (ICU) admissions (OR = 15.312, 95% CI: 1.684-139.198). The risk factors for 2-year recurrence included abnormalities of the thalamus (HR = 3.780, 95% CI: 1.642-8.699). INTERPRETATIONS Brain MRI features of patients with NMDAR encephalitis were associated with clinical manifestations, prognosis, and recurrence. Higher numbers of MRI abnormalities and ICU admissions were predictive of poor prognosis. Abnormalities of the thalamus constituted a recurrence-related risk factor.
Collapse
Affiliation(s)
- Ying‐Ying Zhao
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Bing Han
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Cui‐Hong Qin
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Xue‐Xiu Shi
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Wen‐Jing Yun
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Meng Wang
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Bo Yuan
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Tong‐Wen Sun
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| | - Hai‐Xu Wang
- General ICUThe First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care MedicineZhengzhouHenanChina
| |
Collapse
|
24
|
Oh SJ, Kwon YN, Lee CK, Lee JS. Anti-NMDAR encephalitis in Crohn’s disease undergoing long-term infliximab treatment: A case report. Front Immunol 2022; 13:957575. [PMID: 36389693 PMCID: PMC9659735 DOI: 10.3389/fimmu.2022.957575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/19/2022] [Indexed: 12/05/2022] Open
Abstract
Infliximab, a chimeric monoclonal antibody against anti-tumor necrosis factor-α (TNF-α), has revolutionized the management of inflammatory bowel disease. However, a recent nested case-control study showed that anti-TNF-α therapy exposure in patients with autoimmune diseases is associated with an increased risk of inflammatory central nervous system (CNS) events. A 27-year-old man diagnosed with Crohn’s disease at 17 years of age was referred to our clinic for suffering with Wernicke’s aphasia and the right-hand weakness over two weeks. Nine years of treatment for Crohn’s disease with infliximab anti-TNF-α therapy was well tolerated. An initial MRI revealed diffuse leptomeningeal enhancement along the bilateral cerebral sulci without any parenchymal abnormalities. Cerebrospinal fluid (CSF) and serum N-methyl-D-aspartate receptor (NMDAR) antibody testing yielded positive results. Anti-NMDAR encephalitis was diagnosed, and the patient was treated with rituximab. A follow-up brain MRI showed new multiple cerebral lesions in the left insular cortex and subcortical white matter of the left frontal and temporal gyri. Approximately 8 months after symptom onset, the CSF and serum NMDAR antibody converted to negative. Twelve months later, the patient fully recovered from anti-NMDAR encephalitis without any neurological deficits and is currently being treated with the anti-interleukin 12/23 agent ustekinumab for Crohn’s disease. This is the first report of not only a patient with infliximab-associated anti-NMDAR encephalitis in Crohn’s disease but also of an inflammatory non-demyelinating CNS event during long-term suppression of TNF-α. Our case highlights the need for clinicians to recognize the possibility of a paradoxical autoimmune response occurring with novel biological therapies.
Collapse
Affiliation(s)
- Shin Ju Oh
- Center for Crohn’s and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Young Nam Kwon
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Chang Kyun Lee
- Center for Crohn’s and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Jin San Lee
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, South Korea
- *Correspondence: Jin San Lee,
| |
Collapse
|
25
|
Facer L, Pham T, Rogers D. Lost in descent: Complications of cryptorchidism. Radiol Case Rep 2022; 18:161-168. [PMID: 36345463 PMCID: PMC9636006 DOI: 10.1016/j.radcr.2022.10.022] [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: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
Abstract
Cryptorchidism is a relatively common and important clinical entity and can lead to an array of downstream complications if it is not corrected in a timely manner, most notably with the development of testicular germ cell tumors. However, beyond the development of malignancy, there are other rare complications associated with cryptorchid testicular germ cell tumors which are more commonly seen in females with ovarian germ cell tumors, including torsion, rupture, and paraneoplastic syndromes. Presented is an instructive case (with literature review) of a patient who presented with NMDA encephalitis due to a torsed mixed germ cell tumor of an undescended testis, which subsequently ruptured leading to growing teratoma syndrome.
Collapse
Affiliation(s)
- Lauren Facer
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, 1A081, Salt Lake City, UT 84132, USA
| | - Theresa Pham
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, 1A081, Salt Lake City, UT 84132, USA
| | - Douglas Rogers
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, 1A081, Salt Lake City, UT 84132, USA,Department of Abdominal Imaging, University of Utah, Salt Lake City, UT, USA,Corresponding author.
| |
Collapse
|
26
|
Muacevic A, Adler JR. Severe Central Hypoventilation Syndrome in a Patient With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Case Report and Review of the Literature. Cureus 2022; 14:e30749. [PMID: 36447716 PMCID: PMC9700408 DOI: 10.7759/cureus.30749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/25/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a condition that is characterized by a variety of psychiatric and neurological symptoms, including central hypoventilation syndrome (CHS). CHS presents with apnea or hypopnea and can vary in severity and rapidity of development but rarely leads to respiratory failure that requires mechanical ventilation. Our patient was diagnosed with anti-NMDAR encephalitis after he presented with classic symptoms, and cerebrospinal fluid analysis showed positive N-methyl-D-aspartate (NMDA) receptor antibodies. During the course of the disease, he developed CHS, which led to respiratory arrest. After treatment with corticosteroids, intravenous immunoglobulin, and plasma exchange, the patient's symptoms improved with complete resolution of the apneic episodes.
Collapse
|
27
|
Martinez R, Perez Acosta C, Cormie S. “Everyone Thought She Was Crazy”: A Report on a Novel Approach to Diagnosing a Case of Anti-NMDAR Encephalitis. Cureus 2022; 14:e27671. [PMID: 36072209 PMCID: PMC9440353 DOI: 10.7759/cureus.27671] [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] [Accepted: 08/04/2022] [Indexed: 11/06/2022] Open
Abstract
We present a unique case of a 28-year-old female patient admitted to our hospital due to altered mental status, hallucinations, agitation, impaired memory, and impaired speech. The patient had a previous psychiatric admission to another hospital but she was discharged without a definitive diagnosis. During her admission, the majority of the medical staff was under the impression she was having a psychotic event. The patient was subsequently diagnosed with N-methyl-D-aspartate receptor (NMDAR) encephalitis. Our aim is to report the clinical approach to diagnose and manage a type of autoimmune encephalitis associated with ovarian teratomas, but most importantly to teach and make awareness in the medical community of how to recognize this type of encephalitis.
Collapse
|
28
|
Long Q, Lv Z, Zhao J, Shi K, Li C, Fan B, Zheng J. Cerebral gray matter volume changes in patients with anti-N-methyl-D-aspartate receptor encephalitis: A voxel-based morphometry study. Front Neurol 2022; 13:892242. [PMID: 35959389 PMCID: PMC9358280 DOI: 10.3389/fneur.2022.892242] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/04/2022] [Indexed: 01/19/2023] Open
Abstract
Background: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disease with typical clinical features. Whether and how cerebral gray matter structural damage inherent to the disorder affects cognitive function in patients is still unclear. Therefore, this study aimed to explore the changes in cerebral gray matter volume and whether these alterations contribute to cognitive impairment and mood disorders. Methods Forty patients with anti-NMDAR encephalitis and forty healthy controls (HCs) matched for gender, age, and education were recruited. All participants underwent attention network tests (ANT), neuropsychological tests and magnetic resonance imaging (MRI). Voxel-based morphological analysis (VBM) and correlation analysis was performed on all participants. Finally, according to the course of disease, patients were divided into two groups: NMDARE_SD (short duration; course ≤ 2 years since diagnosis) and NMDARE_LD (long duration; course >2 years since diagnosis), to evaluate gray matter volume changes that differ as a function of disease course. Results Compared to HCs, patients with anti-NMDAR encephalitis showed decreased executive control ability and lower MoCA score, while increased anxiety and depression as reflected by HAMA and HAMD24 scores (all P < 0.05). In VBM analysis, patients showed decreased gray matter volume in bilateral thalamus, left medial prefrontal cortex (mPFC_L), left superior temporal gyrus (STG_L), and left rectus gyrus. In the analysis stratified by disease course, the NMDARE_LD group exhibited decreased gray matter volume in the left precuneus and right posterior cerebellar lobe compared to the NMDARE_SD group. Conclusions Patients with anti-NMDAR encephalitis have cognitive, executive, and emotional dysfunction, and the sites of gray matter atrophy are concentrated in the thalamus, frontal lobe, and temporal lobe. These abnormalities may be involved in the process of cognitive and affective dysfunction.Patients with different courses of anti-NMDAR encephalitis have different brain atrophy sites. These results may help to clarify the contradiction between clinical and imaging manifestations of anti NMDAR encephalitis, which is worthy of further longitudinal studies.
Collapse
|
29
|
Karlberg M, Thoresen H, Berg DH, Ciopat OG, Alstadhaug KB. A man in his forties with acute confusion. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:21-0781. [DOI: 10.4045/tidsskr.21.0781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|
30
|
Bani-Sadr A, Ruitton-Allinieu MC, Brisset JC, Ducray F, Joubert B, Picard G, Cotton F. Contribution of diffusion-weighted imaging to distinguish herpetic encephalitis from auto-immune encephalitis at an early stage. J Neuroradiol 2022; 50:288-292. [PMID: 35662572 DOI: 10.1016/j.neurad.2022.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine whether diffusion-weighted imaging (DWI) can help to distinguish early stage autoimmune (AI) and herpes simplex virus (HSV) encephalitides. METHODS This case-control study included patients from a multi-center cohort of AI encephalitides whose initial MRI including DWI was performed within ten days after symptoms onset. They were compared with patients with HSV encephalitis enrolled prospectively in a single-center from June, 2020 to December, 2020. The final diagnosis of AI encephalitis required a positive autoantibody assay, and that of HSV encephalitis required a positive HSV polymerase chain reaction based on cerebrospinal fluid. Brain MRI were evaluated for restricted diffusion, fluid-inversion recovery (FLAIR) abnormalities, lesion topography, hemorrhagic changes, and contrast enhancement. RESULTS Forty-nine patients were included of which, 19 (38.8%) had AI encephalitis. Twenty-seven patients (55.1%) were males and the median age was 46.0 years (interquartile range (IQR):[22.0; 65.0]). Brain MRI were performed after a median of 4 days (IQR:[2.0; 7.0]) of symptom onset and time between symptom onset and MRI was not significantly different (p=0.60). Twenty-six patients had restricted diffusion lesions in the medial temporal lobe, including 25/30 in the HSV encephalitis group (p<0.001). FLAIR abnormalities were observed in 36 patients, including 29/30 in the HSV encephalitis group (p<0.001). Lesion topography, hemorrhagic changes, and contrast enhancement did not differ significantly between the two groups. CONCLUSION Our results suggest that restricted diffusion lesions in the medial temporal lobe are a hallmark of HSV encephalitis and may help distinguish it from early-stage AI encephalitis.
Collapse
Affiliation(s)
- Alexandre Bani-Sadr
- Service de Radiologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France; Service de Radiologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Marie-Camille Ruitton-Allinieu
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, F-69495, Pierre-Bénite, France
| | | | - François Ducray
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Bastien Joubert
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Géraldine Picard
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - François Cotton
- Service de Radiologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, F-69495, Pierre-Bénite, France.
| |
Collapse
|
31
|
AYVACIOĞLU ÇAĞAN C, GÖÇMEN R, ACAR ÖZEN NP, TUNCER A. Life After Tetra Hit: Anti-NMDAR Encephalitis After HSV Encephalitis in a NMOSD Coexistent with Sjögren's Syndrome. Noro Psikiyatr Ars 2022; 59:161-163. [PMID: 35685056 PMCID: PMC9142028 DOI: 10.29399/npa.27507] [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: 10/27/2020] [Accepted: 02/18/2021] [Indexed: 06/15/2023] Open
Abstract
Herpes simplex encephalitis (HSE) and anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis are associated entities. On the contrary, although both are autoimmune diseases, the association of neuromyelitis optica spectrum disorder (NMOSD) and anti-NMDAR encephalitis is not well explained. Herein, we present consecutively developed post-herpetic anti-NMDAR encephalitis in a patient with the coexistence of NMOSD and Sjogren syndrome. In our patient evaluation with MRI and clinical findings, the diagnosis of HSE after immunosuppressive drug application for NMOSD was made. Whereupon, HSE triggered NMDAR encephalitis. Many authors demonstrated the induction of anti-NMDAR encephalitis over herpes encephalitis with the presence of movement disorders, psychiatric manifestations, and cognitive dysfunction. In our patient, without biphasic disease activity; the persistence of symptoms, new MRI findings, and the positivity of anti-NMDAR antibody confirmed the anti-NMDAR encephalitis diagnosis. Our patient is a representative case mentioning the importance of close follow-up of a patient in neuroimmunology.
Collapse
Affiliation(s)
| | - Rahşan GÖÇMEN
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Aslı TUNCER
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
32
|
Zhao Y, Wang H, Wang M, Yuan B, Sun T, Xu Y. Relapse factors of patients of anti-N-methyl-D-aspartate receptor encephalitis. Acta Neurol Scand 2022; 145:434-441. [PMID: 34927233 DOI: 10.1111/ane.13568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The factors associated with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis relapse are yet to be elucidated. AIMS OF THE STUDY To investigate the factors associated with relapse and prognosis of anti-NMDA receptor encephalitis. METHODS This retrospective study included patients diagnosed with anti-NMDA receptor encephalitis admitted to the First Affiliated Hospital of Zhengzhou University from January 2013 to October 2019. The clinical features, auxiliary examinations, treatment regimens, and follow-up were recorded. The outcomes were relapse and 2-year disease prognosis. RESULTS A total of 160 patients were included. Consequently, 6 (5%) deaths, 34 (25.4%) relapses, and 19 (15.2%) patients had a poor prognosis (modified Rankin score (mRS) ≥3) were recorded. The multivariable analyses showed that age (p = .011), abnormal magnetic resonance imaging (MRI) (p = .019), glucocorticoid pulse (p = .009), and intracranial pressure (p = .023) were independently associated with the relapse, while age (p = .030) and central hypoventilation (p = .020) were independently associated with a poor prognosis at 2 years. CONCLUSION Glucocorticoid pulse therapy reduces the relapse of anti-NMDA receptor encephalitis. Age, abnormal MRI, and intracranial pressure are risk factors for relapse, while age and central hypoventilation are independently associated with poor prognosis.
Collapse
Affiliation(s)
- Ying‐Ying Zhao
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Hai‐Xu Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Meng Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Bo Yuan
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Tong‐Wen Sun
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Yu‐Ming Xu
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| |
Collapse
|
33
|
Ball C, Fisicaro R, Morris L, White A, Pacicco T, Raj K, Agarwal A, Lee WC, Yu FF. Brain on fire: an imaging-based review of autoimmune encephalitis. Clin Imaging 2022; 84:1-30. [DOI: 10.1016/j.clinimag.2021.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/28/2021] [Accepted: 12/16/2021] [Indexed: 12/28/2022]
|
34
|
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.
Collapse
|
35
|
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.
Collapse
|
36
|
Ota Y, Srinivasan A, Capizzano AA, Bapuraj JR, Kim J, Kurokawa R, Baba A, Moritani T. Central Nervous System Systemic Lupus Erythematosus: Pathophysiologic, Clinical, and Imaging Features. Radiographics 2022; 42:212-232. [PMID: 34990324 DOI: 10.1148/rg.210045] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by multiple immunologic abnormalities and has the potential to involve the central nervous system (CNS). The prevalence of SLE seems to be growing, possibly because of earlier diagnosis and improved survival; however, the associated mortality is still high. The mortality is associated with disease-related risk factors such as lupus disease activity, young age, and organ damage or with antiphospholipid syndrome (APS). Neuropsychiatric SLE (NPSLE), which is caused by SLE-related CNS involvement, comprises a broad range of neurologic and psychiatric manifestations with varying severity, which can make this disease indistinguishable from other conditions that are unrelated to SLE. No unifying pathophysiology has been found in the etiology of NPSLE, suggesting that this condition has multiple contributors such as various immune effectors and the brain-intrinsic neuroimmune interfaces that are breached by the immune effectors. The postulated neuroimmune interfaces include the blood-brain barrier, blood-cerebrospinal fluid barrier, meningeal barrier, and glymphatic system. On the basis of the immunologic, pathologic, and imaging features of NPSLE, the underlying pathophysiology can be classified as vasculitis and vasculopathy, APS, demyelinating syndrome, or autoimmune antibody-mediated encephalitis. Each pathophysiology has different imaging characteristics, although the imaging and pathophysiologic features may overlap. Moreover, there are complications due to the immunocompromised status caused by SLE per se or by SLE treatment. Radiologists and clinicians should become familiar with the underlying mechanisms, radiologic findings, and complications of NPSLE, as this information may aid in the diagnosis and treatment of NPSLE. Online supplemental material is available for this article. ©RSNA, 2022.
Collapse
Affiliation(s)
- Yoshiaki Ota
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Ashok Srinivasan
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Aristides A Capizzano
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Jayapalli R Bapuraj
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - John Kim
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Ryo Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Akira Baba
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| | - Toshio Moritani
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109
| |
Collapse
|
37
|
Progressive cortical and sub-cortical alterations in patients with anti-N-methyl-D-aspartate receptor encephalitis. J Neurol 2022; 269:389-398. [PMID: 34297178 DOI: 10.1007/s00415-021-10643-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Advanced structural analyses are increasingly being highly valued to uncover pathophysiological understanding of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. Therefore, we aimed to explore whether and how antibody-mediated NMDAR dysfunction affected cortical and sub-cortical brain morphology and their relationship with clinical symptoms. METHODS We performed surface-based morphometry analyses, hippocampal segmentation, and correlational analyses in 24 patients with anti-NMDAR encephalitis after acute disease stage and 30 normal controls (NC) in this case-control study. RESULTS Patients showed significantly decreased cortical alterations mainly in language network (LN) and default mode network (DMN), as well as decreased gray matter volume in left cornu ammonis 1 (CA1) body of hippocampus. Further correlation analyses showed that the decreased cortical thickness in the right superior frontier gyrus was associated with decreased cognitive scores, the decreased cortical volume in the right pars triangulari and decreased surface area in the right pars operculari were associated with decreased memory scores, whereas decreased gray matter volume in the left CA1 body was significantly correlated with longer time between first symptom and imaging in the patients. CONCLUSION These results suggested that cognitive impairments resulted from long-term sequelae of the encephalitis were mainly associated with cortical alterations in LN and DMN and sub-cortical atrophy of left CA1 body, which can be served as effective features to assess disease progression in clinical routine examination.
Collapse
|
38
|
Ciano-Petersen NL, Cabezudo-García P, Muñiz-Castrillo S, Honnorat J, Serrano-Castro PJ, Oliver-Martos B. Current Status of Biomarkers in Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Int J Mol Sci 2021; 22:13127. [PMID: 34884930 PMCID: PMC8658717 DOI: 10.3390/ijms222313127] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 02/05/2023] Open
Abstract
The discovery of biomarkers in rare diseases is of paramount importance to allow a better diagnosis, improve predictions of outcomes, and prompt the development of new treatments. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a rare autoimmune disorder associated with the presence of antibodies targeting the GluN1 subunit of the NMDAR. Since it was discovered in 2007, large efforts have been made towards the identification of clinical, paraclinical, and molecular biomarkers to better understand the immune mechanisms that govern the course of the disease as well as to define predictors of treatment response and long-term outcomes. However, most of these biomarkers are still in an exploratory phase, with only a few candidates reaching the final phases of the always-complex process of biomarker development, mainly due to the low incidence of the disease and its recent description. Clinical and paraclinical markers are probably the most widely explored in anti-NMDAR encephalitis, five of them combined in a clinical score to predict 1 year outcome. On the contrary, soluble molecules, such as persistent antibody positivity, antibody titers, cytokines, and other inflammatory mediators, have been proposed as biomarkers of clinical activity, inflammation, prognosis, and treatment response, but further studies are required for their clinical validation including larger and more homogenous cohorts of patients. Similarly, genetic susceptibility biomarkers are still in the exploratory phase and, therefore, weak conclusions can for now only be achieved. Thus, further studies are warranted to define biomarkers and unravel the underlying mechanisms driving rare diseases such as anti-NMDAR encephalitis. Future international collaborative studies with prospective designs that enable the enrollment of large cohorts will allow for the identification and validation of novel biomarkers for clinical decision-making.
Collapse
Affiliation(s)
- Nicolás Lundahl Ciano-Petersen
- Neuroimmunology and Neuroinflammation Group, Biomedical Research Institute of Málaga (IBIMA), 29007 Málaga, Spain; (N.L.C.-P.); (P.C.-G.)
- Red Andaluza de Investigación Clínica y Traslacional en Neurología (Neuro-RECA), 29010 Málaga, Spain
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France; (S.M.-C.); (J.H.)
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Pablo Cabezudo-García
- Neuroimmunology and Neuroinflammation Group, Biomedical Research Institute of Málaga (IBIMA), 29007 Málaga, Spain; (N.L.C.-P.); (P.C.-G.)
- Red Andaluza de Investigación Clínica y Traslacional en Neurología (Neuro-RECA), 29010 Málaga, Spain
| | - Sergio Muñiz-Castrillo
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France; (S.M.-C.); (J.H.)
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France; (S.M.-C.); (J.H.)
- SynatAc Team, Institut NeuroMyoGène, INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Pedro Jesús Serrano-Castro
- Neuroimmunology and Neuroinflammation Group, Biomedical Research Institute of Málaga (IBIMA), 29007 Málaga, Spain; (N.L.C.-P.); (P.C.-G.)
- Red Andaluza de Investigación Clínica y Traslacional en Neurología (Neuro-RECA), 29010 Málaga, Spain
| | - Begoña Oliver-Martos
- Neuroimmunology and Neuroinflammation Group, Biomedical Research Institute of Málaga (IBIMA), 29007 Málaga, Spain; (N.L.C.-P.); (P.C.-G.)
- Red Andaluza de Investigación Clínica y Traslacional en Neurología (Neuro-RECA), 29010 Málaga, Spain
- Department of Cell Biology, Genetics and Physiology, Physiology Area, University of Malaga, 29010 Málaga, Spain
| |
Collapse
|
39
|
Cavanagh JJ, Levy M. Differential diagnosis of multiple sclerosis. Presse Med 2021; 50:104092. [PMID: 34715293 DOI: 10.1016/j.lpm.2021.104092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 10/22/2021] [Accepted: 10/22/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite immense progress of imaging and updates in the MacDonald criteria, the diagnosis of multiple sclerosis remains difficult as it must integrate history, clinical presentation, biological markers, and imaging. There is a multitude of syndromes resembling multiple sclerosis both clinically or on imaging. The goal of this review is to help clinicians orient themselves in these various diagnoses. We organized our review in two categories: inflammatory and autoimmune diseases that are close or can be confused with multiple sclerosis, and non-inflammatory syndromes that can present with symptoms or imaging mimicking those of multiple sclerosis. METHOD Review of literature CONCLUSION: Progress of imaging and biological sciences have drastically changed the approach and management of multiple sclerosis. But these developments have also shined a light on a variety of diseases previously unknown or poorly known, therefore greatly expanding the differential diagnosis of multiple sclerosis. While autoimmune, many of these diseases have underlying biological mechanisms that are very different from those of multiple sclerosis, rendering MS therapies usually inefficient. It is crucial to approach these diseases with utmost thoroughness, integrating history, clinical exam, and evolving ancillary tests.
Collapse
Affiliation(s)
- Julien J Cavanagh
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit st., Wang 721J, Boston, MA 02114, United States.
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit st., Wang 721J, Boston, MA 02114, United States
| |
Collapse
|
40
|
Jan S, Anilkumar AC. Atypical Brain MRI Findings in a Child With Delayed Diagnosis of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Cureus 2021; 13:e18103. [PMID: 34692314 PMCID: PMC8525688 DOI: 10.7759/cureus.18103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/05/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is the most common cause of autoimmune encephalitis in children with a wide spectrum of clinical presentation and MRI findings. A high index of suspicion is required to avoid a delay in treatment and long-term morbidity. We present a healthy two-year-old male who developed fever and viral prodrome symptoms that rapidly progressed to acute encephalopathy, status epilepticus, quadriparesis, and abnormal movements. Brain MRI showed symmetric involvement of bilateral insula, posterior part of basal ganglia, and thalami. The patient survived the acute phase with supportive therapy but ended up with a devastating neurologic sequela, including developmental delay, inability to communicate, dysphagia, quadriparesis, and cortical visual impairment. Anti-N-methyl-D-aspartate (anti-NMDA) immunoglobulin G (IgG) antibodies were negative in serum and cerebrospinal fluid (CSF). The patient underwent an extensive inflammatory, infectious, metabolic, and genetic workup, including a whole-exome sequence (WES) and mitochondrial panel, which was unremarkable. CSF studies were unremarkable. Repeated anti-NMDA IgG antibodies were positive in serum a year after the presentation. This presentation highlights the crucial role of early immunotherapy in suspected autoimmune encephalitis (AE) cases, even at a young age, to prevent devastating neurologic outcomes. Moreover, clinicians should not rely on antibody results to treat a suspected case of AE due to possible false-negative test results, and the majority of AE cases remain without known antibodies.
Collapse
Affiliation(s)
- Saber Jan
- Pediatrics, State University of New York Upstate Medical University, Syracuse, USA
| | | |
Collapse
|
41
|
Koenig ZA, Yednock JB, Akers JL. Anti-N-methyl-D-aspartate Receptor Encephalitis as a Paraneoplastic Presentation of Mature Ovarian Teratoma. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933240. [PMID: 34665797 PMCID: PMC8544169 DOI: 10.12659/ajcr.933240] [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] [Indexed: 11/17/2022]
Abstract
Patient: Female, 26-year-old
Final Diagnosis: Anti NMDA receptor encephalitis • familial adenomatous polyposis
Symptoms: Autonomic instability • catatonia • ovarian cyst • psychosis
Medication: —
Clinical Procedure: Ovariectomy
Specialty: General and Internal Medicine
Collapse
Affiliation(s)
- Zachary A Koenig
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Joel B Yednock
- West Virginia University School of Medicine, Morgantown, WV, USA
| | | |
Collapse
|
42
|
Chadwick JW, Brooks PJ, Singh JM, Lam DK. Prevention of oral and maxillofacial trauma secondary to orofacial dyskinesias associated with anti-N-methyl-D-aspartate receptor encephalitis: a case series. BMC Oral Health 2021; 21:511. [PMID: 34629072 PMCID: PMC8502506 DOI: 10.1186/s12903-021-01783-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is a multi-stage autoimmune-mediated disease associated with a multitude of neuropsychiatric and dysautonomic features. Orofacial dyskinesias are frequently associated with this condition and manifest as abnormal movements of the orofacial musculature. These involuntary movements may result in significant trauma to the oral and maxillofacial complex including the avulsion of the dentition and orofacial lacerations.
Case presentation We describe the course of two female patients with anti-NMDARE in whom significant involuntary self-inflicted maxillofacial trauma was suffered despite the use of complex parenteral sedation regimens. The application of traditional maxillomandibular wiring techniques and pharmacologic strategies, including botulinum toxin, to immobilize the mandible were initially unsuccessful. These difficulties led to the fabrication and wire-based fixation of a patient-specific acrylic oral appliance that maintained the mandible in a depressed position and mitigated all lateral and protrusive movements. Discussion and conclusions These cases illustrate the first known successful use of an appliance-based therapy for managing orofacial dyskinesias in the anti-NMDARE patient population through an adaptation of traditional maxillomandibular fixation techniques. This approach eliminated further orofacial trauma and afforded physicians with safer means to manage and assess patients afflicted with this condition during their protracted intensive care unit admissions.
Collapse
Affiliation(s)
- Jeffrey W Chadwick
- Department of Dental Oncology and Maxillofacial Prosthetics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Room 2-933, Toronto, ON, M5G 2M9, Canada. .,Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, M5G 1G6, Canada.
| | - Patricia J Brooks
- Department of Dental Oncology and Maxillofacial Prosthetics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Room 2-933, Toronto, ON, M5G 2M9, Canada
| | - Jeffrey M Singh
- Medical-Surgical and Neuro-Intensive Care Unit, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - David K Lam
- Department of Oral and Maxillofacial Surgery, University of the Pacific, Arthur A. Dugoni School of Dentistry, 155 Fifth Street, San Francisco, CA, 94103, USA
| |
Collapse
|
43
|
Gomez-Figueroa E, Garcia-Estrada C, Paredes-Aragon E, Salado-Burbano J, Cortés-Enriquez F, Marrufo-Melendez O, Espinola-Nadurille M, Ramirez-Bermudez J, Rivas-Alonso V, Corona T, Flores-Rivera J. Brain MRI volumetric changes in the follow-up of patients with anti-NMDAr encephalitis. Clin Neurol Neurosurg 2021; 209:106908. [PMID: 34488009 DOI: 10.1016/j.clineuro.2021.106908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 08/09/2021] [Accepted: 08/18/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Autoimmune anti-NMDAr encephalitis is an antibody-mediated disorder characterized by psychiatric symptoms followed by decreased consciousness, dysautonomia and seizures. The pathophysiology of the disease is related to the internalization of NR1 subtype NMDA receptors and the dysfunction of structures where they are abundant (frontotemporal and insular regions). Some reports suggest the existence of cerebral atrophy in the follow-up of these patients, with conflicting evidence regarding its presence and usefulness as a marker of prognosis. METHODS In a longitudinal, observational study, all patients with the diagnosis of definite anti-NMDAr autoimmune encephalitis with initial and control MRI studies were included. Conventional MR Brain acquisition was performed using a 3-Tesla Skyra MRI System. Automated brain segmental analysis was performed using the Volbrain volumetry system. The differences between baseline MRI volumetric characteristics and volumetric measures at follow-up was assessed. RESULTS 25 patients were included (mean age 26.6, SD 9.6). 44% were females. The mean time between the studies was 24 (SD 21.4, 3-24) months. Significant volume loss was identified in the total brain volume (- 0.02%, p = 0.029), cerebellar volume (- 0.27%, p = 0.048) and brainstem volume (- 0.16%, p = 0.021). CONCLUSIONS This study supports previous observations regarding volume loss in several brain regions of patients with antiNMDAr encephalitis. Further analyses are required to understand the role of treatment and severe clinical forms, as well as the relationship between volume loss and functional outcome.
Collapse
Affiliation(s)
- Enrique Gomez-Figueroa
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico.
| | | | - Elma Paredes-Aragon
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | | | | | - Oscar Marrufo-Melendez
- Neuroimaging Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | | | - Jesus Ramirez-Bermudez
- Neuropsychiatry Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | - Verónica Rivas-Alonso
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | - Teresita Corona
- Neurodegenerative Diseases Laboratory, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | - José Flores-Rivera
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| |
Collapse
|
44
|
Moon S. T2/FLAIR hyperintensity in the mesial temporal lobe: challenging differential diagnosis. Curr Med Imaging 2021; 18:285-291. [PMID: 34931987 DOI: 10.2174/1573405617666210712130555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/22/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
T2/FLAIR hyperintensity in the mesial temporal lobe is the most common MR finding of herpes simplex encephalitis but may be observed in other infectious and non-infectious diseases. The former includes herpes human virus 6 encephalitis, Japanese encephalitis, and neurosyphilis, and the latter autoimmune encephalitis, gliomatosis cerebri, bilateral or paradoxical posterior cerebral artery infarction, status epilepticus, and hippocampal sclerosis. Thus, T2/FLAIR hyperintensity in the mesial temporal lobe is not a disease-specific magnetic resonance imaging finding, and these conditions must be differentiated to ensure proper treatment. We review diseases that are presented with T2/FLAIR hyperintensity in the mesial temporal lobe and provide a helpful flow chart based on clinical and radiologic features.
Collapse
Affiliation(s)
- Sungjun Moon
- Department of Radiology, College of Medicine, Yeungnam University, Daegu, South Korea
| |
Collapse
|
45
|
Bassal FC, Harwood M, Oh A, Lundberg JN, Hoffman J, Cornejo P, Chapple KM, Hughes JN, Narayan R. Anti-NMDA receptor encephalitis and brain atrophy in children and adults: A quantitative study. Clin Imaging 2021; 78:296-300. [PMID: 34186471 DOI: 10.1016/j.clinimag.2021.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/17/2021] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine whether brain atrophy was present in patients with anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) using qualitative and quantitative analyses of brain magnetic resonance imaging (MRI) and to explore clinical differences in patients with anti-NMDARE with or without brain atrophy. METHODS A retrospective observational study encompassing the serologic, cerebrospinal fluid, and brain MRI data of 23 patients with anti-NMDARE was conducted. Median patient age was 14 years (interquartile range [IQR], 12 years). The cohort included 15 children (<18 years old) and 8 adults (≥18 years old). There were 6 male and 17 female patients. Imaging analysis involved 2 expert readers' observations of MRIs and automated volumetric quantification using NeuroQuant (CorTechs Labs, Inc.) software. RESULTS Of 23 pediatric and adult patients, 11 patients had 14 brain MRIs that were quantitatively analyzed. Quantitative NeuroQuant volumetric analysis showed atrophy in 9 of 14 MRIs for 7 of 11 patients compared to age-controlled normative data. In these 9 MRIs, atrophy was present in the temporal lobes (n = 9), cerebral cortex (n = 3), and cerebellum (n = 3). Qualitative analysis of 59 MRIs (23 patients) revealed volume loss in 6 patients: 5 with global cerebral and temporal lobe volume loss and 1 with temporal lobe volume loss. No patient showed cerebellar volume loss on qualitative analysis. Mean length of stay in the intensive care unit was not significantly different for patients with or without quantitative volume loss (3.5 [5.2] vs 27.4 [23.4] days; p = 0.08). CONCLUSIONS In this cohort of patients with anti-NMDARE, quantitative volumetric analysis showed brain atrophy, particularly affecting the temporal lobes, in 64% (7/11) of the patients. Qualitative analysis showed brain atrophy in 26% (6/23). These findings highlight the increased sensitivity of quantitative methods for volume loss detection. Larger studies are needed.
Collapse
Affiliation(s)
- Frederick C Bassal
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States of America
| | - Matthew Harwood
- Department of Radiology, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America
| | - Ann Oh
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States of America
| | - Jaclyn N Lundberg
- Department of Radiology, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America
| | - Justin Hoffman
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States of America
| | - Patricia Cornejo
- Department of Radiology, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America
| | - Kristina M Chapple
- Department of Surgery, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America
| | - Jeremy N Hughes
- Department of Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America
| | - Ram Narayan
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States of America; Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America.
| |
Collapse
|
46
|
Nepal G, Balayar R, Bhatta S, Acharya S, Gajurel BP, Karn R, Rajbhandari R, Paudel S, Gautam N, Shrestha A, Ojha R. Neurobrucellosis: A differential not to be missed in patients presenting with neuropsychiatric features. Clin Case Rep 2021; 9:e04190. [PMID: 34194775 PMCID: PMC8222759 DOI: 10.1002/ccr3.4190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
When a patient presents with undulating fever and neuropsychiatric features, neurobrucellosis should be considered as a differential diagnosis. If diagnosed early, neurobrucellosis is a treatable disease with a favorable outcome.
Collapse
Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Ramesh Balayar
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Suraj Bhatta
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Sulav Acharya
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | | | - Ragesh Karn
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Reema Rajbhandari
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Sunanda Paudel
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Niraj Gautam
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Ashish Shrestha
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Rajeev Ojha
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| |
Collapse
|
47
|
Anderson D, Nathoo N, McCombe JA, Smyth P, Brindley PG. Anti-N-methyl-d-aspartate receptor encephalitis: A primer for acute care healthcare professionals. J Intensive Care Soc 2021; 22:95-101. [PMID: 34025748 PMCID: PMC8120570 DOI: 10.1177/1751143720914181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This primer summarizes the diagnosis, treatment, complications, and prognosis of anti-N-methyl-d-aspartate receptor encephalitis for healthcare professionals, especially those in acute care specialities. Anti-N-methyl-d-aspartate receptor encephalitis is an immune-mediated encephalitis that is classically paraneoplastic and associated with ovarian teratomas in young women. Other less common neoplastic triggers include testicular cancers, Hodgkin lymphoma, lung and breast cancers. It may also be triggered by infection, occurring as a para-infectious phenomenon, seen most commonly after herpes simplex-1 encephalitis. Presentation varies but typically consists of behavioural and cognitive manifestations, seizures, dysautonomia, movement disorders, central hypoventilation, and coma, necessitating intensive care unit admission. Diagnosis of anti-N-methyl-d-aspartate receptor encephalitis requires high clinical suspicion plus ancillary testing, the most sensitive being cerebrospinal fluid analysis for anti-N-methyl-d-aspartate receptor antibodies. Imaging in search of an ovarian teratoma should be exhaustive and tumours need to be surgically treated. Treatment should be expeditious with pulsed steroids and either plasma exchange or intravenous immunoglobulin. Second-line treatments include intravenous rituximab, cyclophosphamide, azathioprine, and intrathecal methotrexate. Most patients recover to be functionally independent, but the in-hospital course can be months long followed by extensive rehabilitation. Given the lengthy course of illness, we explain why education and debriefing are important for staff, and where families can obtain additional help.
Collapse
Affiliation(s)
- Dustin Anderson
- Department of Medicine, Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Nabeela Nathoo
- Department of Medicine, Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jennifer A McCombe
- Department of Medicine, Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Penelope Smyth
- Department of Medicine, Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter G Brindley
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| |
Collapse
|
48
|
Zhou R, Jiang F, Cai H, Zeng Q, Yang H. Case Report: Antibodies to the N-Methyl-D-Aspartate Receptor in a Patient With Multiple Sclerosis. Front Immunol 2021; 12:664364. [PMID: 33968065 PMCID: PMC8102820 DOI: 10.3389/fimmu.2021.664364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/12/2021] [Indexed: 01/17/2023] Open
Abstract
The association between multiple sclerosis and anti-N-Methyl-D-Aspartate receptor encephalitis is limited to merely a few case reports, and the exploration of the pathogenic mechanisms underlying the overlap of these two disease entities is very limited. Therefore, case reports and literature review on N-Methyl-D-aspartate receptor antibody in patients with multiple sclerosis are unusual and noteworthy. A young female had the first episode of paresthesia and motor symptoms with positive anti-N-Methyl-D-Aspartate receptor antibody and recovered after immunotherapy, and at the first relapse, the patient developed disorders of consciousness with positive anti-N-Methyl-D-Aspartate receptor antibody, findings of magnetic resonance imaging showed features of autoimmune encephalitis, which was also controlled by immunotherapy. At the second relapse, anti-N-Methyl-D-Aspartate receptor antibody turned negative while oligoclonal bands presented positive, and findings of magnetic resonance imaging showed features of multiple sclerosis. Afterwards, we followed the patient after receiving disease modifying treatment to monitor the efficacy and safety of teriflunomide. Based on literature review, demyelinating diseases patients with anti-neuronal antibody have complex, diverse and atypical symptoms; therefore, high attention and increased alertness are necessary for neurologists. Conclusively, anti-neuronal antibody may present in many neuroinflammatory conditions, and diagnostic criteria should be used with caution if the clinical presentation is atypical, and neurologists should not rely excessively on laboratory tests to diagnose neurological diseases. Timely and comprehensive examination and consideration as well as early standardized treatment are the key factors to reduce patient recurrence and obtain a good prognosis.
Collapse
Affiliation(s)
| | | | | | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
49
|
Thouvenin L, Olivier T, Banna G, Addeo A, Friedlaender A. Immune checkpoint inhibitor-induced aseptic meningitis and encephalitis: a case-series and narrative review. Ther Adv Drug Saf 2021; 12:20420986211004745. [PMID: 33854755 PMCID: PMC8010823 DOI: 10.1177/20420986211004745] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Along with the increasing use of immune checkpoint inhibitors comes a surge in immune-related toxicity. Here, we review the currently available data regarding neurological immune adverse events, and more specifically aseptic meningitis and encephalitis, and present treatment and diagnostic recommendations. Furthermore, we present five cases of immunotherapy-induced aseptic meningitis and encephalitis treated at our institution. RECENT FINDINGS Neurological immune-related adverse events, including aseptic meningitis and encephalitis, secondary to checkpoint inhibitors are a rare but complex and clinically relevant entity, comprising a wide range of diseases, most often presenting with symptoms with a wide range of differential diagnoses. Our case-series highlights the challenges of such entities and the importance of properly identifying and managing aseptic meningitis and encephalitis. SUMMARY Checkpoint inhibitor-induced meningoencephalitis warrants prompt investigations and treatment. Properly diagnosing aseptic meningitis, encephalitis, or mixed presentations may guide the treatment decision, as highlighted by our case-series. After rapid exclusion of alternative diagnoses, urgent corticosteroids are the therapeutic backbone but this could change in favour of highly specific cytokine-directed treatment options. PLAIN LANGUAGE SUMMARY Aseptic meningitis and encephalitis with immune checkpoint inhibitors: a single centre case-series and review of the literature Over the course of the past decade, checkpoint inhibitors have revolutionized cancer care. With their favourable toxicity profile and potential for durable and deep responses, they have become ubiquitous across the field of oncology. Furthermore, combination checkpoint inhibitors are also gaining ground, with increased efficacy and, unfortunately, immune-related toxicity. While there are guidelines based on extensive clinical experience for frequent adverse events, uncommon entities are less readily identified and treated. Neurological immune-related adverse events secondary to checkpoint inhibitors are a rare but complex entity, comprising a wide range of diseases, most often presenting with aspecific symptoms. In this paper, we discuss a single institution case-series of patients with autoimmune aseptic meningitis and encephalitis, and we perform a narrative literature review on this subject. We conclude with our treatment recommendations based on available evidence.
Collapse
Affiliation(s)
- Laure Thouvenin
- Oncology Department, Geneva University Hospital, Geneva, Switzerland
| | - Timothée Olivier
- Oncology Department, Geneva University Hospital, Geneva, Switzerland
| | - Giuseppe Banna
- Oncology Department, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Alfredo Addeo
- Oncology Department, Geneva University Hospital, Geneva, Switzerland
| | - Alex Friedlaender
- Oncology Department, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, Geneva, 1205, Switzerland
| |
Collapse
|
50
|
Banks SA, Sechi E, Flanagan EP. Autoimmune encephalopathies presenting as dementia of subacute onset and rapid progression. Ther Adv Neurol Disord 2021; 14:1756286421998906. [PMID: 33796145 PMCID: PMC7983436 DOI: 10.1177/1756286421998906] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
The terms autoimmune dementia and autoimmune encephalopathy may be used interchangeably; autoimmune dementia is used here to emphasize its consideration in young-onset dementia, dementia with a subacute onset, and rapidly progressive dementia. Given their potential for reversibility, it is important to distinguish the rare autoimmune dementias from the much more common neurodegenerative dementias. The presence of certain clinical features [e.g. facio-brachial dystonic seizures that accompany anti-leucine-rich-glioma-inactivated-1 (LGI1) encephalitis that can mimic myoclonus] can be a major clue to the diagnosis. When possible, objective assessment of cognition with bedside testing or neuropsychological testing is useful to determine the degree of abnormality and serve as a baseline from which immunotherapy response can be judged. Magnetic resonance imaging (MRI) head and cerebrospinal fluid (CSF) analysis are useful to assess for inflammation that can support an autoimmune etiology. Assessing for neural autoantibody diagnostic biomarkers in serum and CSF in those with suggestive features can help confirm the diagnosis and guide cancer search in paraneoplastic autoimmune dementia. However, broad screening for neural antibodies in elderly patients with an insidious dementia is not recommended. Moreover, there are pitfalls to antibody testing that should be recognized and the high frequency of some antibodies in the general population limit their diagnostic utility [e.g., anti-thyroid peroxidase (TPO) antibodies]. Once the diagnosis is confirmed, both acute and maintenance immunotherapy can be utilized and treatment choice varies depending on the accompanying neural antibody present and the presence or absence of cancer. The target of the neural antibody biomarker may help predict treatment response and prognosis, with antibodies to cell-surface or synaptic antigens more responsive to immunotherapy and yielding a better overall prognosis than those with antibodies to intracellular targets. Neurologists should be aware that autoimmune dementias and encephalopathies are increasingly recognized in novel settings, including post herpes virus encephalitis and following immune-checkpoint inhibitor use.
Collapse
Affiliation(s)
| | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Eoin P Flanagan
- Departments of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|