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Alaskar AM, Aljohani MA, Dionisio S, Asiry MA, Alqadi K. Time to FIRE NORSE: A single acronym for a heterogeneous presentation. Further information from a case series and discussion of the literature. J Neuroimmunol 2024; 388:578298. [PMID: 38330780 DOI: 10.1016/j.jneuroim.2024.578298] [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: 11/05/2023] [Revised: 01/12/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE New-Onset Refractory Status Epilepticus (NORSE) is a rare and severe form of refractory status epilepticus without an apparent underlying cause at presentation or prior history of epilepsy. We aimed to describe the clinical features, etiology, treatment, and outcomes of NORSE in adults in a quaternary-level hospital in Saudi Arabia. METHODOLOGY In this retrospective cohort study, inclusion criteria involved patients over 14 years old who met the 2018 consensus definition for NORSE. Patients were identified using a combination of medical record admission labels 'status epilepticus' and 'encephalitis', and continuous EEG reports documenting status epilepticus. Demographic, clinical, and radiological data were collected and then analyzed for factors correlated with specific etiologies, better functional outcomes, and future diagnosis of epilepsy. RESULTS We found 24 patients presenting with NORSE between 2010 and 2021. Fever/infectious symptoms were the most common prodrome. Elevated inflammatory serum and cerebrospinal fluid markers in most patients. Brain MRI revealed T2/FLAIR hyperintensity patterns, predominantly affecting limbic and perisylvian structures. The etiology of NORSE varied, with immune-related causes being the most common. Long-term outcomes were poor, with a high mortality rate and most survivors developing drug-resistant epilepsy. CONCLUSION This study provides valuable insights into NORSE's clinical characteristics, highlighting the heterogeneity of this condition. The poor outcome is likely related to the progressive nature of the underlying disease, where refractory seizures are a clinical symptom. Thus, we propose to focus future research on the etiology rather than the NORSE acronym.
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Affiliation(s)
| | - Majed A Aljohani
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Sasha Dionisio
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; Alfaisal University, Riyadh, Saudi Arabia; University of Queensland, Brisbane, Australia
| | - Mohammed A Asiry
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Khalid Alqadi
- King Salman Ibn Abdulaziz Medical City, Madinah, Saudi Arabia.
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Zhang C, Hao Y, Huang G, Xin M, Bai S, Guan Y, Liu J. Hypometabolism of the left middle/medial frontal lobe on FDG-PET in anti-NMDA receptor encephalitis: Comparison with MRI and EEG findings. CNS Neurosci Ther 2023; 29:1624-1635. [PMID: 36815303 PMCID: PMC10173717 DOI: 10.1111/cns.14125] [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: 11/13/2022] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES To investigate changes in brain-glucose metabolism in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, and compare results with MRI and electroencephalography (EEG) findings at different disease stages. METHODS The clinical data of 18 patients (median age, 35 years; 11 men) were retrospectively collected. Patients were divided into groups based on the time of symptom onset to examination, (≤1 month, >1 but ≤3 months, >3 months). Two-sample t-test results were compared with age and sex-paired healthy controls using statistical parametric mapping and verified using a NeuroQ software normal database with a discriminating z-score of 2. RESULTS Abnormal patterns on FDG-PET differed over time (T = 3.21-8.74, Z = 2.68-4.23, p < 0.005). Regional analysis showed hypometabolic left middle or medial frontal cortex in 4/5, 5/7, and 5/6 patients, respectively. Time-subgroup analysis revealed hypermetabolic supertemporal cortex in 4/5, 5/7, and 2/6, patients, respectively. MRI and EEG abnormalities in any region and stage occurred in 10/18 and 10/16 patients, respectively. MRI and EEG time-subgroup analysis showed abnormalities in 5/9, 4/5, and 1/4, and 1/3, 6/7, and 3/6 patients, respectively. Abnormal temporal lobes were detected most frequently in MRI analyses and occurred in 3/10 patients. CONCLUSIONS Decreased left middle/medial frontal metabolism could be common to all stages. Metabolism in other regions, MRI, and EEG results were associated with the progression of anti-NMDAR encephalitis. The sensitivity rate of FDG-PET was superior to that of MRI and EEG.
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Affiliation(s)
- Chenpeng Zhang
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Hao
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gan Huang
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mei Xin
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuwei Bai
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yangtai Guan
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianjun Liu
- Department of Nuclear Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Tharmaraja T, Ho JSY, Neligan A, Rajakulendran S. The etiology and mortality of new-onset refractory status epilepticus (NORSE) in adults: A systematic review and meta-analysis. Epilepsia 2023; 64:1113-1124. [PMID: 36727541 DOI: 10.1111/epi.17523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023]
Abstract
New-onset refractory status epilepticus (NORSE) is a devastating neurological presentation. There is a paucity of large studies on NORSE as it is a relatively new clinical syndrome. The aim of this review was to summarize the etiologies and establish a mortality rate for NORSE. Two independent authors systematically searched the following electronic databases from January 1, 2005 April 20, 2021: PubMed, Embase, OVID, Scopus, Web of Science, "Clinicaltrials.gov," and the International Standard Randomised Controlled Trial Number (ISRCTN) registry. We included all primary research studies of NORSE in adults and excluded commentaries, reviews, pre-clinical studies, and pediatric populations. Etiology was extracted from all studies meeting eligibility criteria, whereas data relating to treatments, hospital stay, functional outcomes, and mortality were extracted from studies with sample size ≥5. We conducted a random-effects meta-analysis of mortality rate with meta-regression testing for significant covariates. Of 1482 studies, 109 case reports and case series met our criteria, comprising 395 cases of NORSE. The most common etiology was cryptogenic in 197 cases (49.9%), followed by autoimmune in 143 cases (36.2%). The pooled mortality rate was 22% (95% confidence interval 17%-27%; N studies = 15), with low heterogeneity ( I 2 = 0%). Meta-regression revealed that year of study, treatment with ketogenic diet or immunotherapy, percentage of cryptogenic cases, and length of intensive care unit stay were not significant covariates for mortality. Common treatments included antiseizure medications (median 5), general anesthesia, and immunotherapy such as corticosteroids, intravenous immunoglobulin, and plasma exchange. Mean length of intensive care admission was 33.4 days, with 52% of cases diagnosed with epilepsy on discharge. Neurocognitive impairment was a common sequela of NORSE. NORSE is associated with a high mortality. Half of cases remain cryptogenic, which presents a diagnostic challenge. Future focus should be on elucidating the underlying neurobiology and determining the most effective therapeutic interventions.
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Affiliation(s)
- Thahesh Tharmaraja
- Leonard Wolfson Experimental Neurology Centre, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Jamie Sin Ying Ho
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Aidan Neligan
- UCL Queen Square Institute of Neurology, London, UK
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London, UK
- The National Hospital for Neurology and Neurosurgery, London, UK
- The North Middlesex University Hospital, London, UK
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Power spectrum analysis and outcomes of non-convulsive status epilepticus: a single-center study. Neurol Sci 2023; 44:287-295. [PMID: 36175811 DOI: 10.1007/s10072-022-06419-8] [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: 05/30/2022] [Accepted: 09/19/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Diagnosis of non-convulsive status epilepticus (NCSE) is challenging and outcomes during follow-up are not clear. This study aimed to conduct power spectrum analysis in NCSE and measure outcomes of patients. METHODS We searched continuous EEG monitoring (cEEG) recordings to identify patients of NCSE. An artifact-free cEEG epoch of continuous 60 s was chosen for spectral power analysis. We also collected electronic medical records of the patients for extracting clinical information. Patients recruited were followed up at least every half a year. RESULTS There were 48 patients with 64 independent NCSE episodes during different course of disease recruited in the study, with a mean age of 40.3 ± 19.1 years (range, 12-72 years), including 24 males (50%) and 24 females (50%). When the spectral power of 60 s equaled to 11.30 μV2 for predicting impairment of consciousness, (sensitivity, specificity) = (0.979, 0.625). When the spectral power of 60 s equaled to 52.70 μV2 for predicting myoclonic jerks, (sensitivity, specificity) = (0.783, 0.756). There were 27 patients (56.3%) followed up with a duration over 12 months. Nineteen patients (70.4%) continued to have seizures. Eleven (40.7%) resisted to at least two kinds of appropriate anti-seizure medication at maximum tolerated levels. Five patients with prolonged NCSE suffered from loss of brain parenchymal volume on follow-up MRI scans. CONCLUSION Spectral power analysis can be used to detect mental status and limb jerks. Early diagnosis and treatment of NCSE are important, which can influence outcomes of the patients during follow-up.
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Rejdak K, Pikulicka A, Piekarska M, Pacek K, Płachta K. Inflammation as Treatment Target for Status Epilepticus. Curr Neuropharmacol 2023; 21:708-714. [PMID: 36397618 PMCID: PMC10207918 DOI: 10.2174/1570159x21666221117152249] [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: 12/27/2021] [Revised: 02/17/2022] [Accepted: 07/03/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Status epilepticus (SE) is a serious neurological disease that manifests as prolonged seizures that last more than 5 minutes and between such episodes, patients do not regain consciousness. It can result in cognitive defects, brain damage, or even death. It is commonly known that one of the causes can be an inflammatory process, but here we will focus on inflammation as a result of new onset refractory status epilepticus and, related to this, new promising forms of SE treatment. Particular emphasis has been focused on new-onset refractory status epilepticus (NORSE). METHODS Based on public research databases, drugs with anti-inflammatory activity - commonly used in different spheres of medicine - have been reviewed as potentially treating status epilepticus. RESULTS There is seizable clinical research suggesting that drugs that decrease inflammatory processes might be effective in terminating status epilepticus. CONCLUSION There is growing evidence showing that adding anti-inflammatory drugs to basic antiepileptic treatment enhances the efficiency of the therapeutic process, with special potential in NORSE cases.
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Affiliation(s)
- Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Agata Pikulicka
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | | | - Katarzyna Pacek
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Kamila Płachta
- Department of Neurology, Medical University of Lublin, Lublin, Poland
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Cabezudo-García P, Mena-Vázquez N, Ciano-Petersen NL, Oliver-Martos B, Serrano-Castro PJ. Functional outcomes of patients with NORSE and FIRES treated with immunotherapy: A systematic review. Neurologia 2022:S2173-5808(22)00095-5. [PMID: 36155099 DOI: 10.1016/j.nrleng.2022.03.004] [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: 01/13/2022] [Accepted: 03/03/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the frequency of good functional outcomes in patients with NORSE and FIRES treated with immunotherapy. METHODS We performed a systematic search of the MedLine and EMBASE databases to gather studies including at least 5 patients with NORSE or FIRES and at least one patient treated with immunotherapy, and reporting functional outcomes. Good functional outcome was defined as a modified Rankin Scale (mRS) score ≤ 2 (or an equivalent measure) at the last available follow-up assessment. Only patients with known functional outcomes were included in the analysis. RESULTS We analyzed 16 studies including a total of 161 patients with NORSE. Six studies were carried out only with FIRES patients (n = 64). Of the 161 patients with NORSE, 141 (87.5%) received immunotherapy. Outcome data were available for 135, 56 of whom (41.4%) achieved good functional outcomes. Twenty-four of the 58 patients with FIRES treated with immunotherapy and for whom outcome data were available achieved good functional outcomes (41.3%). Mortality rates in patients with NORSE and FIRES treated with immunotherapy were 20/121 (16.5%) and 6/58 (10.3%), respectively. By type of immunotherapy, good functional outcomes were achieved in 36/89 patients receiving glucocorticoids (40.4%), 27/71 patients receiving IV immunoglobulins (38%), 11/37 patients treated with plasma exchange (29.7%), 5/17 patients receiving rituximab (29.4%), and 2/13 patients receiving cyclophosphamide (15.3%). CONCLUSION Despite the lack of randomised clinical trials, immunotherapy is frequently prescribed to patients with NORSE and FIRES. However, rates of functional dependence and mortality remain high in these patients. Second-line therapies achieved lower rates of good outcomes, probably because they were administered to patients with more severe, refractory disease.
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Affiliation(s)
- P Cabezudo-García
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain; UGC de Neurociencias, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - N Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain; UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - N L Ciano-Petersen
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain; UGC de Neurociencias, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - B Oliver-Martos
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain; UGC de Neurociencias, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - P J Serrano-Castro
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain; UGC de Neurociencias, Hospital Regional Universitario de Málaga, Málaga, Spain
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Cabezudo-García P, Mena-Vázquez N, Ciano-Petersen N, Oliver-Martos B, Serrano-Castro P. Pronóstico funcional de pacientes con NORSE y FIRES tratados con inmunoterapia: revisión sistemática. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Tang C, Ren P, Ma K, Li S, Wang X, Guan Y, Zhou J, Li T, Liang X, Luan G. The correspondence between morphometric MRI and metabolic profile in Rasmussen's encephalitis. Neuroimage Clin 2022; 33:102918. [PMID: 34952352 PMCID: PMC8713113 DOI: 10.1016/j.nicl.2021.102918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/01/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023]
Abstract
The GM atrophy located in the insular and temporal cortices of the affected side. Positive correlation was found in the brain region featuring MRI atrophy and FDG-PET. GM atrophy was spatially correlated with dopaminergic and serotonergic mapping in RE.
Volumetric magnetic resonance imaging (MRI) atrophy is a hallmark of Rasmussen’s encephalitis (RE). Here, we aim to investigate voxel-wise gray matter (GM) atrophy in RE, and its associations with glucose hypometabolism and neurotransmitter distribution utilizing MRI and PET data. In this study, fifteen RE patients and fourteen MRI normal subjects were included in this study. Voxel-wise GM volume and glucose metabolic uptake were evaluated using structural MRI and FDG-PET images, respectively. Spatial Spearman’s correlation was performed between GM atrophy of RE with FDG uptake alterations, and neurotransmitter distributions provided in the JuSpace toolbox. Compared with the control group, RE patients displayed extensive GM volume loss not only in the ipsilateral hemisphere, but also in the frontal lobe, basal ganglia, and cerebellum in the contralateral hemisphere. Within the RE group, the insular and temporal cortices exhibited significantly more GM atrophy on the ipsilesional than the contralesional side. FDG-PET data revealed significant hypometabolism in areas surrounding the insular cortices in the ipsilesional hemisphere. RE-related GM volumetric atrophy was spatially correlated with hypomebolism in FDG uptake, and with spatial distribution of the dopaminergic and serotonergic neurotransmitter systems. The spatial concordance of morphological changes with metabolic abnormalities suggest FDG-PET offers potential value for RE diagnosis. The GM alterations associated with neurotransmitter distribution map could provide novel insight in understanding the neuropathological mechanisms and clinical feature of RE.
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Affiliation(s)
- Chongyang Tang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Peng Ren
- Laboratory for Space Environment and Physical Science, Harbin Institute of Technology, Harbin 150001, China; School of Life Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Kaiqiang Ma
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Siyang Li
- Laboratory for Space Environment and Physical Science, Harbin Institute of Technology, Harbin 150001, China; School of Life Science and Technology, Harbin Institute of Technology, Harbin, 150001, China
| | - Xiongfei Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Yuguang Guan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Jian Zhou
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Tianfu Li
- Department of Neurology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China; Key Laboratory of Epilepsy, Beijing 100093, China; Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing 100093, China
| | - Xia Liang
- Laboratory for Space Environment and Physical Science, Harbin Institute of Technology, Harbin 150001, China.
| | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China; Key Laboratory of Epilepsy, Beijing 100093, China; Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing 100093, China.
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Kassab A, Hinnoutondji Toffa D, Robert M, Lesage F, Peng K, Khoa Nguyen D. Hemodynamic changes associated with common EEG patterns in critically ill patients: Pilot results from continuous EEG-fNIRS study. Neuroimage Clin 2021; 32:102880. [PMID: 34773798 PMCID: PMC8594770 DOI: 10.1016/j.nicl.2021.102880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/21/2022]
Abstract
Functional near-infrared spectroscopy (fNIRS) is currently the only non-invasive method allowing for continuous long-term assessment of cerebral hemodynamic. We evaluate the feasibility of using continueous electroencephalgraphy (cEEG)-fNIRS to study the cortical hemodynamic associated with status epilepticus (SE), burst suppression (BS) and periodic discharges (PDs). Eleven adult comatose patients admitted to the neuroICU for SE were recruited, and cEEG-fNIRS monitoring was performed to measure concentration changes in oxygenated (HbO) and deoxygenated hemoglobin (HbR). Seizures were associated with a large increase HbO and a decrease in HbR whose durations were positively correlated with the seizures' length. Similar observations were made for hemodynamic changes associated with bursts, showing overall increases in HbO and decreases in HbR relative to the suppression periods. PDs were seen to induce widespread HbO increases and HbR decreases. These results suggest that normal neurovascular coupling is partially retained with the hemodynamic response to the detected EEG patterns in these patients. However, the shape and distribution of the response were highly variable. This work highlighted the feasibility of conducting long-term cEEG-fNIRS to monitor hemodynamic changes over a large cortical area in critically ill patients, opening new routes for better understanding and management of abnormal EEG patterns in neuroICU.
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Affiliation(s)
- Ali Kassab
- Department of Neurological Sciences, Université de Montréal, C.P. 6128, succ. Centre-ville, Montreal, Quebec H3C 3J7, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, 900 Saint Denis St., Montreal, Quebec H2X 0A9, Canada.
| | - Dènahin Hinnoutondji Toffa
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, 900 Saint Denis St., Montreal, Quebec H2X 0A9, Canada.
| | - Manon Robert
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, 900 Saint Denis St., Montreal, Quebec H2X 0A9, Canada.
| | - Frédéric Lesage
- Biomedical Engineering Institute, École Polytechnique de Montréal, 2500 Chemin de Polytechnique, Montréal, Quebec H3T 1J4, Canada; Research Center, Montreal Heart Institute, 5000 Rue Bélanger, Montreal, Quebec H1T 1C8, Canada.
| | - Ke Peng
- Department of Neurological Sciences, Université de Montréal, C.P. 6128, succ. Centre-ville, Montreal, Quebec H3C 3J7, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, 900 Saint Denis St., Montreal, Quebec H2X 0A9, Canada.
| | - Dang Khoa Nguyen
- Department of Neurological Sciences, Université de Montréal, C.P. 6128, succ. Centre-ville, Montreal, Quebec H3C 3J7, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, 900 Saint Denis St., Montreal, Quebec H2X 0A9, Canada; Division of Neurology, Centre Hospitalier de l'Université de Montréal, Université de Montréal, 1000 Saint Denis St, Montreal, Quebec (H2X OC1), Canada.
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Bordonne M, Chawki MB, Doyen M, Kas A, Guedj E, Tyvaert L, Verger A. Brain 18F-FDG PET for the diagnosis of autoimmune encephalitis: a systematic review and a meta-analysis. Eur J Nucl Med Mol Imaging 2021; 48:3847-3858. [PMID: 33677643 DOI: 10.1007/s00259-021-05299-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/02/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To consolidate current understanding of detection sensitivity of brain 18F-FDG PET scans in the diagnosis of autoimmune encephalitis and to define specific metabolic imaging patterns for the most frequently occurring autoantibodies. METHODS A systematic and exhaustive search of data available in the literature was performed by querying the PubMed/MEDLINE and Cochrane databases for the search terms: ((PET) OR (positron emission tomography)) AND ((FDG) OR (fluorodeoxyglucose)) AND ((encephalitis) OR (brain inflammation)). Studies had to satisfy the following criteria: (i) include at least ten pediatric or adult patients suspected or diagnosed with autoimmune encephalitis according to the current recommendations, (ii) specifically present 18F-FDG PET and/or morphologic imaging findings. The diagnostic 18F-FDG PET detection sensitivity in autoimmune encephalitis was determined for all cases reported in this systematic review, according to a meta-analysis following the PRISMA method, and selected publication quality was assessed with the QUADAS-2 tool. RESULTS The search strategy identified 626 articles including references from publications. The detection sensitivity of 18F-FDG PET was 87% (80-92%) based on 21 publications and 444 patients included in the meta-analysis. We also report specific brain 18F-FDG PET imaging patterns for the main encephalitis autoantibody subtypes. CONCLUSION AND RELEVANCE Brain 18F-FDG PET has a high detection sensitivity and should be included in future diagnostic autoimmune encephalitis recommendations. Specific metabolic 18F-FDG PET patterns corresponding to the main autoimmune encephalitis autoantibody subtypes further enhance the value of this diagnostic.
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Affiliation(s)
- Manon Bordonne
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France
| | - Mohammad B Chawki
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France
| | - Matthieu Doyen
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France
- Université de Lorraine, IADI, INSERM U1254, F-54000, Nancy, France
| | - Aurelie Kas
- Nuclear Medicine Department, Pitié-Salpêtrière Hospital, APHP Sorbonne-Université, Laboratoire d'Imagerie Biomédicale, Sorbonne Université, F-75000, Paris, France
| | - Eric Guedj
- Nuclear Medicine Department, Aix Marseille Univ, APHM, CNRS, Centrale Marseille, Institut Fresnel, Timone Hospital, CERIMED, F-13000, Marseille, France
| | - Louise Tyvaert
- Department of Neurology, Université de Lorraine, CRAN UMR 7039, CHRU, F-54000, Nancy, France
| | - Antoine Verger
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France.
- Université de Lorraine, IADI, INSERM U1254, F-54000, Nancy, France.
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Shin YW. Understanding new-onset refractory status epilepticus from an immunological point of view. ENCEPHALITIS 2021; 1:61-67. [PMID: 37469848 PMCID: PMC10295883 DOI: 10.47936/encephalitis.2021.00045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/11/2021] [Accepted: 05/21/2021] [Indexed: 07/21/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is unexpected onset of refractory status epilepticus in individuals with no preexisting relevant neurologic condition. The etiologies remain largely cryptogenic; treatment is challenging after failure to control seizures despite use of multiple antiepileptic drugs and anesthetic agents. Frequent fever and other infectious prodromes, elevated proinflammatory cytokine/chemokine levels, and limbic or multifocal brain lesions indicate active inflammation in NORSE. Among identified causes, autoimmune encephalitis is the most common and accounts for more than one-third of all known NORSE cases, followed by infection-related etiologies. Although more evidence is needed, anti-cytokine therapies with tocilizumab and anakinra along with other immunotherapeutic agents used in autoimmune encephalitis can aid in alleviating or hindering the inflammatory cascade and controlling seizures.
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Affiliation(s)
- Yong-Won Shin
- Center for Hospital Medicine, Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Aboian M, Barajas R, Shatalov J, Ravanfar V, Bahroos E, Tong E, Taylor JW, Bush NO, Sneed P, Seo Y, Cha S, Hernandez-Pampaloni M. Maximizing the use of batch production of 18F-FDOPA for imaging of brain tumors to increase availability of hybrid PET/MR imaging in clinical setting. Neurooncol Pract 2020; 8:91-97. [PMID: 33664973 DOI: 10.1093/nop/npaa065] [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: 11/14/2022] Open
Abstract
Background Amino acid PET imaging of brain tumors has been shown to play an important role in predicting tumor grade, delineation of tumor margins, and differentiating tumor recurrence from the background of postradiation changes, but is not commonly used in clinical practice because of high cost. We propose that PET/MRI imaging of patients grouped to the day of tracer radiosynthesis will significantly decrease the cost of PET imaging, which will improve patient access to PET. Methods Seventeen patients with either primary brain tumors or metastatic brain tumors were recruited for imaging on 3T PET/MRI and were scanned on 4 separate days in groups of 3 to 5 patients. The first group of consecutively imaged patients contained 3 patients, followed by 2 groups of 5 patients, and a last group of 4 patients. Results For each of the patients, standard of care gadolinium-enhanced MRI and dynamic PET imaging with 18F-FDOPA amino acid tracer was obtained. The total cost savings of scanning 17 patients in batches of 4 as opposed to individual radiosynthesis was 48.5% ($28 321). Semiquantitative analysis of tracer uptake in normal brain were performed with appropriate accumulation and expected subsequent washout. Conclusion Amino acid PET tracers have been shown to play a critical role in the characterization of brain tumors but their adaptation to clinical practice has been limited because of the high cost of PET. Scheduling patient imaging to maximally use the radiosynthesis of imaging tracer significantly reduces the cost of PET and results in increased availability of PET tracer use in neuro-oncology.
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Affiliation(s)
- Mariam Aboian
- Department of Radiology, Yale University School of Medicine, New Haven, CT
| | - Ramon Barajas
- Department of Radiology, Oregon Health Sciences University
| | - Julia Shatalov
- Department of Radiology, Yale University School of Medicine, New Haven, CT
| | - Vahid Ravanfar
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Emma Bahroos
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Elizabeth Tong
- Department of Radiology, Stanford University, Palo Alto, California
| | - Jennie W Taylor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California.,Department of Neurology, University of California San Francisco, San Francisco, California
| | - N Oberheim Bush
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Patricia Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Youngho Seo
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Soonmee Cha
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Miguel Hernandez-Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
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Kim HJ, Lee SA, Kim HW, Kim SJ, Jeon SB, Koo YS. The timelines of MRI findings related to outcomes in adult patients with new-onset refractory status epilepticus. Epilepsia 2020; 61:1735-1748. [PMID: 32715470 DOI: 10.1111/epi.16620] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify the timelines of magnetic resonance imaging (MRI) abnormalities and their relationships with the clinical outcomes of patients with new-onset refractory status epilepticus (NORSE). METHODS This retrospective observational study enrolled patients with NORSE who were admitted from March 2008 to July 2018. MRI abnormalities were analyzed visually with the readers blinded to the clinical characteristics of the patients. Poor functional outcome was defined as a Glasgow Outcome Scale score ≤ 3 at discharge. Subsequent pharmacoresistant epilepsy was defined as seizures not controlled by two or more anti-seizure medications 6 months after discharge. RESULTS Among 39 patients with NORSE, 32 (82.1%) exhibited an MRI abnormality. The most common abnormalities were persisting mesial temporal lobe signal abnormality (51.3%); initial diffuse leptomeningeal enhancement within 16 days from seizure onset (15/35, 42.9%); and hippocampal atrophy, which started to appear 26 days after seizure onset (15/26, 57.7%). Only three patients had claustrum abnormalities. Patients with insular involvement had longer treatment delay than those without (24.0 vs 5.5 hours, respectively, P = .02). Duration of status epilepticus (SE) tended to have a linear association with hippocampal atrophy (P = .055). Patients with diffuse leptomeningeal enhancement were more likely to have a poor functional outcome and to develop subsequent pharmacoresistant epilepsy than those without this finding (93.3% vs 15.0%, P < .001; 75.0% vs 22.2%, P = .004, respectively); the results were significant even after adjusting for age, sex, and duration of SE. Hippocampal atrophy and diffuse cortical atrophy were also significantly associated with poor functional outcomes (P = .001 and P = .002, respectively), and patients with these conditions were more likely to develop subsequent pharmacoresistant epilepsy than those without these conditions, after adjusting for age and sex (P = .035 and P = .048, respectively), but not after adjusting for duration of SE. SIGNIFICANCE Initial diffuse leptomeningeal enhancement and later hippocampal atrophy were associated with a poor functional outcome and subsequent pharmacoresistant epilepsy.
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Affiliation(s)
- Hyo Jae Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Soo Jeong Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, Seoul, South Korea
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Abstract
PURPOSE OF REVIEW Hybrid PET- MRI is a technique that has the ability to improve diagnostic accuracy in many applications, whereas PET and MRI performed separately often fail to provide accurate responses to clinical questions. Here, we review recent studies and current developments in PET-MRI, focusing on clinical applications. RECENT FINDINGS The combination of PET and MRI imaging methods aims at increasing the potential of each individual modality. Combined methods of image reconstruction and correction of PET-MRI attenuation are being developed, and a number of applications are being introduced into clinical practice. To date, the value of PET-MRI has been demonstrated for the evaluation of brain tumours in epilepsy and neurodegenerative diseases. Continued advances in data analysis regularly improve the efficiency and the potential application of multimodal biomarkers. SUMMARY PET-MRI provides simultaneous of anatomical, functional, biochemical and metabolic information for the personalized characterization and monitoring of neurological diseases. In this review, we show the advantage of the complementarity of different biomarkers obtained using PET-MRI data. We also present the recent advances made in this hybrid imaging modality and its advantages in clinical practice compared with MRI and PET separately.
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Fitsiori A, Hiremath SB, Boto J, Garibotto V, Vargas MI. Morphological and Advanced Imaging of Epilepsy: Beyond the Basics. CHILDREN (BASEL, SWITZERLAND) 2019; 6:E43. [PMID: 30862078 PMCID: PMC6462967 DOI: 10.3390/children6030043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 12/26/2022]
Abstract
The etiology of epilepsy is variable and sometimes multifactorial. Clinical course and response to treatment largely depend on the precise etiology of the seizures. Along with the electroencephalogram (EEG), neuroimaging techniques, in particular, magnetic resonance imaging (MRI), are the most important tools for determining the possible etiology of epilepsy. Over the last few years, there have been many developments in data acquisition and analysis for both morphological and functional neuroimaging of people suffering from this condition. These innovations have increased the detection of underlying structural pathologies, which have till recently been classified as "cryptogenic" epilepsy. Cryptogenic epilepsy is often refractory to anti-epileptic drug treatment. In drug-resistant patients with structural or consistent functional lesions related to the epilepsy syndrome, surgery is the only treatment that can offer a seizure-free outcome. The pre-operative detection of the underlying structural condition increases the odds of successful surgical treatment of pharmacoresistant epilepsy. This article provides a comprehensive overview of neuroimaging techniques in epilepsy, highlighting recent advances and innovations and summarizes frequent etiologies of epilepsy in order to improve the diagnosis and management of patients suffering from seizures, especially young patients and children.
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Affiliation(s)
- Aikaterini Fitsiori
- Unit of Neurodiagnostic, Division of Neuroradiology, Geneva University Hospital, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
| | | | - José Boto
- Unit of Neurodiagnostic, Division of Neuroradiology, Geneva University Hospital, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
| | - Valentina Garibotto
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospital and Faculty of Medicine, Geneva University, 1205 Geneva, Switzerland.
| | - Maria Isabel Vargas
- Unit of Neurodiagnostic, Division of Neuroradiology, Geneva University Hospital, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
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