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Gunawan PI, Widianti N, Noviandi R, Samosir SM. N-methyl-D-aspartate receptor autoantibody levels in children with intractable and non-intractable epilepsy. Heliyon 2024; 10:e36734. [PMID: 39263117 PMCID: PMC11388750 DOI: 10.1016/j.heliyon.2024.e36734] [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: 05/07/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/13/2024] Open
Abstract
Objective Intractable epilepsy in children is a prevalent neurological disorder that can pose serious risks. The involvement of the autoimmune system is a significant factor in the pathogenesis of the disease. The N-methyl-D-aspartate-receptor (NMDAR) is a glutamate receptor and ion channel present in neurons and is associated with the mechanism of autoimmune etiology in epilepsy. This study aims to compare the levels of NMDAR auto antibodies in children with intractable and non-intractable epilepsy. Methods A prospective analytic study was conducted from June to September 2022. The study sample consisted of patients aged 1 month to 18 years diagnosed with epilepsy and receiving anti-seizure medication (ASM) therapy at Dr. Soetomo General Academic Hospital, Surabaya. The patients were divided into two groups, namely intractable epilepsy and non-intractable epilepsy. The NMDAR autoantibody levels were determined using enzyme-linked immunosorbent assay (ELISA). Statistical analysis employed the chi-squared and Wilcoxon-Mann-Whitney tests. Results Seventy-five subjects were included in the study. Of these patients, 41.3 % with intractable epilepsy and 33.4 % with non-intractable epilepsy presented NMDAR auto antibodies. Analysis of the patient characteristics revealed a correlation between seizure frequency and NMDAR autoantibody positivity (P = 0.002) but not between the number of ASM and NMDAR autoantibody positivity (P > 0.05). The NMDAR autoantibody levels were not significantly different in children with intractable and non-intractable epilepsy (P = 0.157). Conclusion The NMDAR autoantibody levels were numerically higher in children with intractable epilepsy compared with children with non-intractable epilepsy.
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Affiliation(s)
- Prastiya Indra Gunawan
- Division of Neurology, Department of Child Health, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Nurani Widianti
- Division of Neurology, Department of Child Health, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Riza Noviandi
- Division of Neurology, Department of Child Health, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Sunny Mariana Samosir
- Division of Neurology, Department of Child Health, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Dalakas MC. Stiff-person syndrome and related disorders - diagnosis, mechanisms and therapies. Nat Rev Neurol 2024:10.1038/s41582-024-01012-3. [PMID: 39227464 DOI: 10.1038/s41582-024-01012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 09/05/2024]
Abstract
Stiff-person syndrome (SPS) is the prototypical and most common autoimmune neuronal hyperexcitability disorder. It presents with stiffness in the limbs and axial muscles, stiff gait with uncontrolled falls, and episodic painful muscle spasms triggered by anxiety, task-specific phobias and startle responses, collectively leading to disability. Increased awareness of SPS among patients and physicians has created concerns about diagnosis, misdiagnosis and treatment. This Review addresses the evolving diagnostic challenges in SPS and overlapping glutamic acid decarboxylase (GAD) antibody spectrum disorders, highlighting the growing number of overdiagnoses and focusing on the progress made in our understanding of SPS pathophysiology, antibodies against GAD and other inhibitory synaptic antigens, and the fundamentals of neuronal hyperexcitability. It considers the role of impaired GABAergic or glycinergic inhibition in the cortex and at multiple levels in the neuraxis; the underlying autoimmunity and involvement of GAD antibodies; immunopathogenic mechanisms beyond antibodies, including environmental triggers; familial and immunogenetic susceptibility; and potential T cell cytotoxicity. Finally, the mechanistic rationale for target-specific therapeutic interventions is presented along with the available therapeutic approaches, including enhancers of GABA signalling drugs and immunotherapies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Dalakas MC. Stiff Person Syndrome and GAD Antibody-Spectrum Disorders. Continuum (Minneap Minn) 2024; 30:1110-1135. [PMID: 39088290 DOI: 10.1212/con.0000000000001457] [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: 08/03/2024]
Abstract
OBJECTIVE Antibodies against glutamic acid decarboxylase (GAD), originally associated with stiff person syndrome (SPS), define the GAD antibody-spectrum disorders that also include cerebellar ataxia, autoimmune epilepsy, limbic encephalitis, progressive encephalomyelitis with rigidity and myoclonus (PERM), and eye movement disorders, all of which are characterized by autoimmune neuronal excitability. This article elaborates on the diagnostic criteria for SPS and SPS spectrum disorders, highlights disease mimics and misdiagnoses, describes the electrophysiologic mechanisms and underlying autoimmunity of stiffness and spasms, and provides a step-by-step therapeutic scheme. LATEST DEVELOPMENTS Very-high serum GAD antibody titers are diagnostic for GAD antibody-spectrum disorders and also predict the presence of GAD antibodies in the CSF, increased intrathecal synthesis, and reduced CSF γ-aminobutyric acid (GABA) levels. Low serum GAD antibody titers or the absence of antibodies generates diagnostic challenges that require careful distinction in patients with a variety of painful spasms and stiffness, including functional neurologic disorders. Antibodies against glycine receptors, first found in patients with PERM, are seen in 13% to 15% of patients with SPS, whereas amphiphysin and gephyrin antibodies, seen in 5% of patients with SPS spectrum disorders, predict a paraneoplastic association. GAD-IgG from different SPS spectrum disorders recognizes the same dominant GAD intracellular epitope and, although the pathogenicity is unclear, is an excellent diagnostic marker. The biological basis of muscle stiffness and spasms is related to autoimmune neuronal hyperexcitability caused by impaired reciprocal γ-aminobutyric acid-mediated (GABA-ergic) inhibition, which explains the therapeutic response to GABA-enhancing agents and immunotherapies. ESSENTIAL POINTS It is essential to distinguish SPS spectrum disorders from disease mimics to avoid both overdiagnoses and misdiagnoses, considering that SPS is treatable if managed correctly from the outset to prevent disease progression. A step-by-step, combination therapy of GABA-enhancing medications along with immunotherapies ensures prolonged clinical benefits.
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Wei M, Bannout F, Dastjerdi M, Phan C, Batarseh S, Guo X, Baker N. Immunotherapy in a case of low titre GAD65 antibody-associated spectrum neurological disorders. BMJ Case Rep 2024; 17:e260503. [PMID: 38871638 DOI: 10.1136/bcr-2024-260503] [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: 06/15/2024] Open
Abstract
We present a rare case of low titre GAD65 antibody-associated autoimmune encephalitis and status epilepticus in a young woman. She initially presented with left arm dystonic movements, contractures and status epilepticus. Due to the concern of autoimmune encephalitis and seizures, the patient received intravenous immunoglobulin empirically. After the detection of low serum GAD65 antibodies, the patient underwent immunomodulation therapy with significant improvement. This case demonstrated that in autoimmune encephalitis, it is important to monitor serum GAD65 antibodies levels and consider immunotherapy, despite mildly elevated serum levels. The patient's history of left arm dystonic movements without impaired awareness may have been due to limb dystonia, a presenting symptom of stiff person syndrome (SPS), despite SPS more commonly affecting axial muscles. This case further demonstrates that GAD65 antibody-related syndromes can manifest with different neurological phenotypes including co-occurrence of epilepsy with possible focal SPS despite low GAD65 antibodies titres.
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Affiliation(s)
- Miao Wei
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Firas Bannout
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Mohammad Dastjerdi
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Cattien Phan
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Sanad Batarseh
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Xiaofan Guo
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Nancy Baker
- Neurology, Loma Linda University School of Medicine, Loma Linda, California, USA
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Hernández G, Sala-Padró J, Adell V, Rico I, Gasa-Roqué A, Morandeira F, Campdelacreu J, Gascon J, Falip M. Cognitive decline in adult-onset temporal lobe epilepsy: Insights from aetiology. Clin Neurol Neurosurg 2024; 237:108159. [PMID: 38354426 DOI: 10.1016/j.clineuro.2024.108159] [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: 12/28/2022] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE To identify patients with adult-onset temporal lobe epilepsy (TLE) at risk of developing cognitive decline. Detecting which patients, aetiologies, or factors are most closely related with memory decline would allow us to identify patients that would eventually benefit from more specific treatment. METHODS Single centre, retrospective analysis of a prospectively followed-up cohort study, including all patients with the diagnosis of adult-onset TLE during 2013, with a minimum follow-up of five years. Memory and cognitive decline were analysed at 5 years and at last follow-up. RESULTS Of 89 initially selected patients, 71 were included. After 5 years, 11/71 (15.5%) patients suffered cognitive decline, of which 1/71 (4%) developed dementia. At last follow-up (range 65-596 m) a total of 34/71 (47.8%) patients were diagnosed with cognitive decline, specifically either memory decline or dementia. Cognitive decline at 5 years was related to: 1. Age at onset: 62.65 years (SD 9.04) in the group with cognitive decline vs 50.33 y. (SD 13.02 in the group without cognitive decline; p=0.004); 2. Onset as status epilepticus (3/6 in patients with memory decline vs 8/65 in patients without cognitive decline; p=0.04); 3. Immune aetiology: 42% compared with unknown (10%) and structural (10%) aetiologies; p=0.036; 4. Hippocampal sclerosis on MRI: 5/11 patients with cognitive decline vs 9/51 patients without cognitive decline; p=0.035. Cognitive decline was not related to seizure frequency, sex, or age (p=0.78; p=0.40; p=0.95, respectively). CONCLUSIONS Older age at epilepsy onset, onset as status epilepticus, immune aetiology, and hippocampal sclerosis are risk factors for developing cognitive decline in patients with adult-onset temporal lobe epilepsy.
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Affiliation(s)
- G Hernández
- Epilepsy Unit, Neurology Service, Hospital Universitari de Bellvitge, Neurological Disease and Neurogenetics group, Neuroscience Area, Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - J Sala-Padró
- Epilepsy Unit, Neurology Service, Hospital Universitari de Bellvitge, Neurological Disease and Neurogenetics group, Neuroscience Area, Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - V Adell
- Hospital Consorci Sanitari Alt Penedès i Garraf, Barcelona, Spain
| | - I Rico
- Neuropsychology Department, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - A Gasa-Roqué
- Neuropsychology Department, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - F Morandeira
- Immunology Department, Biochemistry Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - J Campdelacreu
- Dementia Unit, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - J Gascon
- Dementia Unit, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - M Falip
- Epilepsy Unit, Neurology Service, Hospital Universitari de Bellvitge, Neurological Disease and Neurogenetics group, Neuroscience Area, Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain.
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Wagner JN. Anticonvulsive treatment in autoimmune encephalitis: a systematic literature review. Wien Med Wochenschr 2024; 174:22-29. [PMID: 36648700 DOI: 10.1007/s10354-022-00998-z] [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: 11/17/2022] [Accepted: 12/09/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Epileptic seizures are a common manifestation of autoimmune encephalitis (AIE). Immunosuppression (IT) is an efficient therapeutic approach, particularly in AIE associated with antibodies against extracellular structures. The role of antiseizure medication (ASM) is less clear. However, it may be beneficial in disease refractory to IT or in chronic post-AIE epilepsy. METHODS We conducted a systematic review assessing the PubMed and Cochrane databases to identify all reports on patients with epileptic seizures due to AIE in whom ASM was used and report it according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. We included case series (minimum 3 eligible patients), retrospective and prospective observational studies, and randomized controlled trials. The main outcome assessed was therapeutic efficacy of ASM. Secondary outcomes comprise number, type, and adverse effects of ASM. Descriptive statistics were used. The level of evidence was assessed according to the Centre for Evidence-Based Medicine. RESULTS We screened a total of 3371 studies and included 30 (7 prospective, 23 retrospective). The reports cover a total of 708 patients, the majority (72.5%) suffering from AIE with antibodies against extracellular structures. Type of AIE, seizure frequency, and number and type of ASM used were heterogenous. While most patients profited from IT and/or ASM, the effect of ASM could rarely be isolated. Nine studies report on patients who received ASM monotherapy or were on ASM for a relevant length of time before IT initiation or after IT failure. One study reports a significant association between seizure freedom and use of sodium channel inhibitors. However, levels of evidence were generally low. CONCLUSION Few robust data exist on the particular efficacy of ASM in autoimmune epileptic seizures. While these patients generally seem to respond less well to ASM or surgical interventions, sodium channel blockers may have an additional benefit compared to other substances. However, levels of evidence are low and early IT remains the mainstay of AIE therapy. Future trials should address optimal ASM selection and dosing in AIE.
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Affiliation(s)
- Judith N Wagner
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Academic Hospital, University Essen-Duisburg, Munckelstr. 27, 45879, Gelsenkirchen, Germany.
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Xia SQ, Fan HN, Fan LF, Xia W, Chen G. Paraneoplastic anti-GAD65 extralimbic encephalitis presented with epilepsy: A case report. Medicine (Baltimore) 2023; 102:e34780. [PMID: 37933077 PMCID: PMC10627632 DOI: 10.1097/md.0000000000034780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/26/2023] [Indexed: 11/08/2023] Open
Abstract
RATIONALE Autoimmunity targeting glutamic acid decarboxylase 65 (GAD65) is associated with type 1 diabetes mellitus as well as various neurological diseases. In the central nervous system, GAD65 autoimmunity usually presents with limbic encephalitis, whereas extralimbic encephalitis (ELE) has only been reported in a few cases. Moreover, anti-GAD65 ELE in the paraneoplastic context has not yet been reported. PATIENT CONCERNS A 60-year-old man presented with intermittent cough and sputum for 10 years, with no other diseases. The patient presented with recurrent seizures that were resistant to antiepileptic drugs (AEDs). Chest computed tomography and pathological results confirmed the diagnosis of small cell lung cancer. Paraneoplastic testing found a high level of GAD65 antibodies in his serum, and cerebrospinal fluid analysis revealed lymphocytic pleocytosis, indicating autoimmune encephalitis. Brain magnetic resonance imaging showed multifocal T2 fluid-attenuated inversion recovery hyperintensities in the extralimbic areas including the subcortex and deep white matter of the bilateral frontal lobe, parietal lobe, and insula lobes. DIAGNOSES Finally, a diagnosis of anti-GAD65 autoimmune ELE with a paraneoplastic etiology from the small cell lung cancer was suspected. INTERVENTIONS The patient refused any tumor-suppressive treatment or immunotherapy for potential side effects and only received AEDs levetiracetam, sodium valproate, and diazepam. OUTCOMES The epilepsy of the patient was resistant to AEDs, and the patient died a week after discharge due to disease progression. LESSONS Anti-GAD65 autoimmune encephalitis can be extralimbic, can present with isolated epilepsy, and extralimbic anti-GAD65 encephalitis can occur with an underlying malignancy.
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Affiliation(s)
- Si-Qi Xia
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Hao-Nan Fan
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Jiujiang University, Jiujiang, Jiangxi, China
| | - Lin-Feng Fan
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Wu Xia
- Department of Neurosurgery, Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, Zhejiang, China
| | - Gao Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
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Valinčiūtė J, Jucevičiūtė N, Balnytė R, Jurkevičienė G, Gelžinienė G. GAD65 Antibody-Associated Epilepsy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1135. [PMID: 37374339 DOI: 10.3390/medicina59061135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Autoimmune processes are an increasingly recognized cause of seizures. Antibodies against neuronal surface antigens are implicated in the development of acute symptomatic seizures secondary to autoimmune encephalitis, whereas antibodies against intracellular antigens (anti-glutamic acid decarboxylase (GAD) and onconeural antibodies) are found in cases of autoimmune-associated epilepsy (AAE). AAE is described as isolated drug-resistant epilepsy without any specific magnetic resonance imaging (MRI) or cerebrospinal fluid changes and with a very limited response to immunotherapy. We present a clinical case and a literature review on autoimmune-associated epilepsy to increase awareness of this disease and illustrate its complexity. This is a clinical case of a female with a history of refractory focal epilepsy. The patient had been given several trials of multiple antiepileptic drugs and their combinations without any clear effect. Multiple evaluations including brain MRI, PET, and interictal and ictal electroencephalograms were performed. An APE2 score was calculated with a result of 4 and, in the presence of anti-GAD65 antibodies in the serum, the diagnosis of AAE was confirmed. There was no effect after five sessions of plasma exchange; however, after a course of intravenous immunoglobulin, a positive but temporary clinical effect was noticed: anti-GAD65 levels initially decreased but rebounded to previous levels 6 months later.
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Affiliation(s)
- Justina Valinčiūtė
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Neringa Jucevičiūtė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Renata Balnytė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Giedrė Jurkevičienė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Giedrė Gelžinienė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
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Bach KT, Ananth S, Thind I, Zhong N, Lui F. Co-occurrence of Anti-GAD65 Syndrome, Type 1 Diabetes Mellitus, and Focal Seizures With Impaired Awareness. Cureus 2023; 15:e40611. [PMID: 37476109 PMCID: PMC10354376 DOI: 10.7759/cureus.40611] [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: 06/18/2023] [Indexed: 07/22/2023] Open
Abstract
Glutamic acid decarboxylase (GAD) is an intracellular enzyme found in the presynaptic end of nerve terminals that functions to synthesize gamma-aminobutyric acid (GABA) via decarboxylation. Autoantibodies to the GAD65 isoform have been found in high levels in neurological disorders including stiff person syndrome (SPS), autoimmune encephalitis, and refractory epilepsy. Low levels of anti-GAD65 have also been noted in type 1 diabetes mellitus. We present the unusual case of a woman with a longstanding history of focal seizures with impaired awareness and type 1 diabetes mellitus who was found to have extremely high titers of anti-GAD65 and clinical presentation suggestive of stiff person syndrome. This case highlights the increasing significance of autoimmune etiologies within neurologic disorders, as well as the importance of maintaining a high index of suspicion for rare anti-GAD65 syndromes. Although uncommon and with an unclear pathophysiology, we discuss the importance of establishing SPS diagnostic criteria to facilitate timely diagnosis and quickly direct patient management towards immunotherapy.
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Affiliation(s)
- Kieu-Tram Bach
- Clinical Sciences, California Northstate University College of Medicine, Sacramento, USA
| | - Shahini Ananth
- Clinical Sciences, California Northstate University College of Medicine, Sacramento, USA
| | - Ikjot Thind
- Clinical Sciences, California Northstate University College of Medicine, Sacramento, USA
| | - Ning Zhong
- Neurology, Kaiser Permanente Sacramento Medical Center, Sacramento, USA
| | - Forshing Lui
- Clinical Sciences, California Northstate University College of Medicine, Elk Grove, USA
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Lin N, Bai L, Liu Q, Chen J, Ren H, Guan H, Lu Q. Seizure semiology and predictors of outcomes in Chinese patients with glutamic acid decarboxylase antibody-associated neurological syndrome. BMC Neurol 2023; 23:149. [PMID: 37041500 PMCID: PMC10088211 DOI: 10.1186/s12883-023-03182-x] [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: 01/09/2023] [Accepted: 03/24/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND In the current study, seizure semiology and potential predictive factors of seizure outcomes in glutamic acid decarboxylase antibody (GAD Ab)-associated neurological syndrome were investigated. METHODS In this study, 32 Chinese patients with GAD Ab-associated neurological syndrome who presented with seizures at Peking Union Medical College Hospital from January 2017 to October 2022 were reviewed; 30 had a follow-up duration of more than 1 year. RESULTS Among the 32 patients, 10 presented with epilepsy alone. Concomitant neurological syndromes were observed in 22 patients, including limbic encephalitis (n = 20), stiff-person syndrome (SPS, n = 1), and cerebellar ataxia (n = 1). Bilateral tonic-clonic seizures were observed in 21 patients (65.6%). Focal seizures occurred in 27 patients (84.4%); 17 had focal motor seizures and 18 focal non-motor seizures. Among 30 patients with long-term follow-up, 11 (36.7%) were seizure-free. Acute/subacute onset (p = 0.049) and comorbidity of limbic encephalitis with epilepsy (p = 0.023) led to better seizure outcomes. Patients with persistent epilepsy were more likely to have focal seizure (p = 0.003) and higher frequency of seizure (p = 0.001). Furthermore, these patients tended to have longer intervals from onset to immunomodulatory treatments. Early immunotherapy (within 6 months from onset) was administered in 81.8% of seizure-free patients but only in 42.1% of patients with persistent seizures. However, steroid and immunosuppressant duration did not differ in the two groups. Repeated serum GAD Ab tests during the follow-up showed no association with seizure outcomes. CONCLUSIONS The seizure manifestations are diverse and variable. Approximately one third of patients achieved seizure remission during long-term follow-up. The type and frequency of seizures may influence the seizure outcomes. Early immunotherapy, especially within 6 months, may lead to better seizure outcomes.
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Affiliation(s)
- Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Qing Liu
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Jianhua Chen
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China.
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11
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Tyvaert L. How autoimmunity changed our diagnostic practice in epileptology? Rev Neurol (Paris) 2023; 179:316-329. [PMID: 36804011 DOI: 10.1016/j.neurol.2022.11.008] [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: 09/02/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023]
Abstract
Since few years, a new etiology of epilepsy emerges with the labelling of new autoantibodies against the central nervous system. In 2017, the International League Against Epilepsy (ILAE) concluded that autoimmunity is one of six etiologies contributing to epilepsy and that autoimmune epilepsy is directly caused by immune disorders in which seizures constitute a core symptom. Epileptic disorders of immune origin are now distinguished in two different entities: acute symptomatic seizures secondary to autoimmune (ASS) and autoimmune-associated epilepsy (AAE) with different expected clinical outcome under immunotherapy. If acute encephalitis is usually related to ASS with a classic good control of the disease under immunotherapy, clinical phenotype characterized by isolated seizures (new onset seizures and chronic focal epilepsy patients) may be due to either ASS or to AAE. Decision of Abs testing and early immunotherapy initiation needs the development of clinical scores able to select patients with high risk of positive Abs testings. If this selection is now included in the usual medical care of encephalitic patients, specifically with NORSE, the actual bigger challenge is in patients with non or only mild encephalitic symptoms followed for new onset seizures or chronic focal epilepsy patients of unknown origin. The emergence of this new entity provides new therapeutic strategies with specific etiologic and probably anti epileptogenic medication rather than the usual and nonspecific ASM. In the world of the epileptology, this new autoimmune entity appears as a big challenge with an exciting chance to improve or even definitely cure patients of their epilepsy. However, the detection of these patients has to be done in the early phase of the disease to offer the best outcome.
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Affiliation(s)
- L Tyvaert
- Department of neurology, hospital central, CHRU Nancy, Nancy, France; UMR 7039 CRAN, Université de Lorraine, Nancy, France.
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12
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Fortunato F, Giugno A, Sammarra I, Labate A, Gambardella A. Epilepsy, Immunity and Neuropsychiatric Disorders. Curr Neuropharmacol 2023; 21:1714-1735. [PMID: 35794773 PMCID: PMC10514543 DOI: 10.2174/1570159x20666220706094651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.
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Affiliation(s)
- Francesco Fortunato
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Alessia Giugno
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Ilaria Sammarra
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Angelo Labate
- BIOMORF Department, Neurology Unit, University of Messina, Messina, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
- Institute of Molecular Bioimaging and Physiology, National Research Council, I-88100 Catanzaro, Italy
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13
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Basnyat P, Peltola M, Raitanen J, Liimatainen S, Rainesalo S, Pesu M, Peltola J. Elevated IL-6 plasma levels are associated with GAD antibodies-associated autoimmune epilepsy. Front Cell Neurosci 2023; 17:1129907. [PMID: 37025699 PMCID: PMC10070787 DOI: 10.3389/fncel.2023.1129907] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
Background Antibodies against glutamic acid decarboxylase (GADA) are present in multiple neurological manifestations, such as stiff-person syndrome, cerebellar ataxia, limbic encephalitis, and epilepsy. Increasing data support the clinical significance of GADA as an autoimmune etiology of epilepsy, however, there is not yet definitive evidence to confirm the pathogenic link between GADA and epilepsy. Objective Interleukin-6 (IL-6), a pro-convulsive and neurotoxic cytokine, and interleukin-10 (IL-10), an anti-inflammatory and neuroprotective cytokine, are crucial inflammatory mediators in the brain. Increased production of IL-6 and its association with epileptic disease profiles are well established, suggesting the presence of chronic systemic inflammation in epilepsy. Therefore, in this study, we investigated the association of plasma cytokine concentrations of IL-6 and IL-10 and their ratio with GADA in patients with drug-resistant epilepsy. Methods Interleukin-6 and IL-10 concentrations were measured by ELISA in plasma, and the IL-6/IL-10 ratio was calculated in a cross-sectional cohort of 247 patients with epilepsy who had their GADA titers measured previously for their clinical significance in epilepsy. Based on GADA titers, patients were grouped as GADA negative (n = 238), GADA low positive (antibody titers < 1,000 RU/mL, n = 5), and GADA high positive (antibody titers ≥ 1,000 RU/mL, n = 4). Results Median IL-6 concentrations were significantly higher in patients with high GADA positivity [2.86 pg/mL, interquartile range (IQR) = 1.90-5.34 pg/mL] than in GADA-negative patients [1.18 pg/mL, interquartile range (IQR) = 0.54-2.32 pg/mL; p = 0.039]. Similarly, IL-10 concentrations were also higher in GADA high-positive patients [1.45 pg/mL, interquartile range (IQR) = 0.53-14.32 pg/mL] than in GADA-negative patients [0.50 pg/mL, interquartile range (IQR) = 0.24-1.00 pg/mL], however, the difference was not statistically significant (p = 0.110). Neither IL-6 nor IL-10 concentrations were different between GADA-negative and GADA low-positive patients (p > 0.05) or between GADA low-positive or GADA high-positive patients (p > 0.05). The IL-6/IL-10 ratio was also similar among all the study groups. Conclusion Increased circulatory concentrations of IL-6 are associated with high GADA titers in patients with epilepsy. These data provide additional pathophysiological significance of IL-6 and help to further describe the immune mechanisms involved in the pathogenesis of GADA-associated autoimmune epilepsy.
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Affiliation(s)
- Pabitra Basnyat
- Department of Neurology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Neurology, Tampere University Hospital, Tampere, Finland
- *Correspondence: Pabitra Basnyat,
| | - Maria Peltola
- Department of Psychiatry, Tampere University Hospital, Tampere, Finland
| | - Jani Raitanen
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
- UKK Institute for Health Promotion Research, Tampere, Finland
| | - Suvi Liimatainen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
- Administration Centre, Tampere University Hospital, Tampere, Finland
| | - Sirpa Rainesalo
- Division of Acute Treatment, Emergency Department, Intensive Care and Anesthesia, Tampere University Hospital, Tampere, Finland
| | - Marko Pesu
- Laboratory of Immunoregulation, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Fimlab Laboratories, Tampere, Finland
- Gilead Sciences, Vantaa, Finland
| | - Jukka Peltola
- Department of Neurology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Neurology, Tampere University Hospital, Tampere, Finland
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14
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Du J, Guo Y, Zhu Q. Use of anti-seizure medications in different types of autoimmune encephalitis: A narrative review. Front Neurol 2023; 14:1111384. [PMID: 37034075 PMCID: PMC10076804 DOI: 10.3389/fneur.2023.1111384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Seizures are the main manifestation of the acute phase of autoimmune encephalitis (AE). Anti-seizure medications (ASMs) play an important role in controlling seizures in AE patients, but there is currently a lack of consensus regarding the selection, application, and discontinuation of ASMs. This narrative review focuses on the use of ASMs in patients with AE driven by different antibodies. The PubMed, Embase, and MEDLINE databases were searched up until 30 October 2022 using prespecified search terms. We identified 2,580 studies; 23 retrospective studies, 2 prospective studies and 9 case reports were evaluated based on our inclusion criteria. Anti-N-methyl-D-aspartic-acid-receptor (anti-NMDAR) encephalitis is the type of AE that responds best to ASMs, and long-term or combined use of ASMs may be not required in most patients with seizures; these results apply to both adults and children. Sodium channel blockers may be the best option for seizures in anti-leucine-rich-glioma-inactivated-1 (anti-LGI1) encephalitis, but patients with anti-LGI1 encephalitis are prone to side effects when using ASMs. Cell surface antibody-mediated AE patients are more likely to use ASMs for a long period than patients with intracellular antibody-mediated AE. Clinicians can score AE patients' clinical characteristics on a scale to identify those who may require long-or short-term use of ASMs in the early stage. This review provides some recommendations for the rational use of ASMs in encephalitis mediated by different antibodies with the aim of controlling seizures and avoiding overtreatment.
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Affiliation(s)
- Jinyuan Du
- Department of Neurology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yi Guo
- Department of Neurology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
- *Correspondence: Yi Guo,
| | - Qiong Zhu
- Department of Neurology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
- Qiong Zhu,
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15
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Rácz A, Hummel CA, Becker A, Helmstaedter C, Schuch F, Baumgartner T, von Wrede R, Borger V, Solymosi L, Surges R, Elger CE. Histopathologic Characterization and Neurodegenerative Markers in Patients With Limbic Encephalitis Undergoing Epilepsy Surgery. Front Neurol 2022; 13:859868. [PMID: 35493848 PMCID: PMC9051082 DOI: 10.3389/fneur.2022.859868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/09/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose Limbic encephalitis is an increasingly recognized cause of medial temporal lobe epilepsy (mTLE) and associated cognitive deficits, potentially resulting in hippocampal sclerosis (HS). For several reasons, these patients usually do not undergo epilepsy surgery. Thus, histopathologic examinations in surgical specimens of clearly diagnosed limbic encephalitis are scarce. The purpose of this study was a detailed histopathologic analysis of surgical tissue alterations, including neurodegenerative markers, in patients with limbic encephalitis undergoing epilepsy surgery. Methods We investigated the surgical specimens of six patients operated on with mTLE related to limbic encephalitis (among them four patients were with GAD65 and one with Ma1/2 antibodies), and compared the findings to a control group with six patients matched according to age at the time of surgery without limbic encephalitis and without early inciting events. Results Histopathologic analysis in the group with limbic encephalitis revealed HS in four patients, while three of them also displayed signs of an active inflammatory reaction with lymphocytes. In one of the patients with GAD65-encephalitis who was suffering from a late-onset mTLE and a long disease course, neurodegenerative protein markers (β-amyloid and hyperphosphorylated tau) were found coexisting with inflammatory reactions and HS. Investigations in the control group did not reveal any inflammatory reaction or neurodegenerative marker. Conclusion Our findings suggest a possible link between long-lasting immune reactions in the medial temporal lobe, HS, and further toward the development of neurodegenerative diseases. Presently, however, a causal relationship between these entities cannot yet be established. Furthermore, our results suggest that an immunological etiology should always be considered in late onset (> 18 years) mTLE, also in cases of long disease duration and the presence of HS.
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Affiliation(s)
- Attila Rácz
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- *Correspondence: Attila Rácz
| | - Chiara A. Hummel
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Albert Becker
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | | | - Fabiane Schuch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Randi von Wrede
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - László Solymosi
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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16
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Dalakas MC. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 2022; 19:832-847. [PMID: 35084720 PMCID: PMC9294130 DOI: 10.1007/s13311-022-01188-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Although antibodies against Glutamic Acid Decarboxylase (GAD) were originally associated with Stiff Person Syndrome (SPS), they now denote the "GAD antibody-spectrum disorders (GAD-SD)" that include Cerebellar Ataxia, Autoimmune Epilepsy, Limbic Encephalitis, PERM and eye movement disorder. In spite of the unique clinical phenotype that each of these disorders has, there is significant overlapping symptomatology characterized by autoimmune neuronal excitability. In addition to GAD, three other autoantibodies, against glycine receptors, amphiphysin and gephyrin, are less frequently or rarely associated with SPS-SD. Very high serum anti-GAD antibody titers are a key diagnostic feature for all GAD-SD, commonly associated with the presence of GAD antibodies in the CSF, a reduced CSF GABA level and increased anti-GAD-specific IgG intrathecal synthesis denoting stimulation of B-cell clones in the CNS. Because anti-GAD antibodies from the various hyperexcitability syndromes recognize the same dominant GAD epitope, the clinical heterogeneity among GAD-SD patients remains unexplained. The paper highlights the biologic basis of autoimmune hyperexcitability connected with the phenomenon of reciprocal inhibition as the fundamental mechanism of the patients' muscle stiffness and spasms; addresses the importance of high-GAD antibody titers in diagnosis, pinpointing the diagnostic challenges in patients with low-GAD titers or their distinction from functional disorders; and discusses whether high GAD-antibodies are disease markers or pathogenic in the context of their association with reduced GABA level in the brain and CSF. Finally, it focuses on therapies providing details on symptomatic GABA-enhancing drugs and the currently available immunotherapies in a step-by-step approach. The prospects of future immunotherapeutic options with antibody therapies are also summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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17
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Gillinder L, Britton J. Autoimmune-Associated Seizures. Continuum (Minneap Minn) 2022; 28:363-398. [PMID: 35393963 DOI: 10.1212/con.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article focuses on the seizure manifestations and presentations of autoimmune-associated epilepsy and acute symptomatic seizures in autoimmune encephalitis. It discusses the specificity of the various central nervous system autoantibodies and clarifies when their presence can be considered indicative of an immune etiology. Finally, current recommendations regarding patient selection for autoimmune antibody evaluation are reviewed, and an approach to immunotherapy is provided. RECENT FINDINGS Although autoimmune seizures are caused by a heterogeneous group of autoantibodies, key features reported in the literature should alert clinicians to the possible diagnosis. In particular, seizure characteristics including frequency, timing, duration, and symptomatology can provide vital clues to help differentiate autoimmune-associated seizures from other causes of epilepsy. Diagnostic certainty also requires an understanding and integration of the spectrum of clinical and paraclinical presentations, and several scoring systems have been developed that may be useful to aid the identification of autoimmune seizures. SUMMARY Seizures due to autoimmune etiology are increasingly encountered in clinical practice. It is critical that clinicians recognize immune seizure etiologies early in their course given they are often responsive to immunotherapy but are usually resistant to antiseizure medications. Currently, however, it is unfortunately not uncommon for autoimmune-associated seizure disorders to remain undiagnosed, resulting in missed opportunities to administer effective therapies. Efforts to better understand autoimmune seizure manifestations and treatment strategies are ongoing.
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18
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Harmon A, Stingl C, Rikhi A, Tran L, Pizoli C, Malinzak M, Van Mater H. Pediatric GAD-65 Autoimmune Encephalitis: Assessing Clinical Characteristics and Response to Therapy With a Novel Assessment Scale. Pediatr Neurol 2022; 128:25-32. [PMID: 35032887 DOI: 10.1016/j.pediatrneurol.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/11/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Glutamic acid decarboxylase (GAD) encephalitis is a neuroinflammatory disease characterized by a broad range of symptoms including cognitive deficits, behavioral changes, and seizures. Children with this disorder have heterogeneous presentations, and little is known about symptom progression over time and response to immunotherapy. METHODS This study reports 10 pediatric GAD encephalitis cases and symptoms found at presentation and follow-up. In addition, symptom severity was reported utilizing a novel scale evaluating functional outcomes across the domains affected by autoimmune encephalitis including cognition, language, seizures, psychiatric symptoms, sleep, and movement. Retrospective chart review was conducted for 10 patients aged <18 years, diagnosed with GAD encephalitis, and followed for one year or more. Chart review included clinical, imaging, and laboratory findings at time of diagnosis and at six- and 12-month follow-ups. RESULTS At presentation, cognitive deficits were found in all patients, seizures in six of 10, and language decline in seven of 10. Psychiatric symptoms were prominent for all but one patient with three of nine patients presenting with psychosis. Fatigue, sleep disruption, and movement disorders were less prominent symptoms, occurring in approximately half of the cohort. Cognition and fatigue improved significantly over time when compared with symptom severity, whereas seizures, psychiatric symptoms, and sleep did not. Language and sleep showed improvement only in early stages. Analysis of seizure frequency and type noted variability mirroring trends noted in adult studies of GAD encephalitis. CONCLUSIONS This study demonstrated the variability of symptom profiles of pediatric GAD encephalitis and benefits of symptom severity scales. Symptom profiles and progression vary in this population.
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Affiliation(s)
- Alexis Harmon
- Duke University School of Medicine, Durham, North Carolina
| | - Cory Stingl
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aruna Rikhi
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Linh Tran
- Division of Child Neurology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Carolyn Pizoli
- Division of Child Neurology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Michael Malinzak
- Division of Neuroradiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Heather Van Mater
- Division of Rheumatology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
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Dimova P, Minkin K. Case Report: Multisystem Autoimmune and Overlapping GAD65-Antibody-Associated Neurological Disorders With Beneficial Effect of Epilepsy Surgery and Rituximab Treatment. Front Neurol 2022; 12:756668. [PMID: 35126284 PMCID: PMC8810502 DOI: 10.3389/fneur.2021.756668] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) antibodies are associated with disabling conditions such as stiff person syndrome, temporal lobe epilepsy (TLE), limbic encephalitis, cerebellar ataxia (CA), and ocular movement disorders, which are usually chronic and difficult to treat. GAD-related TLE has poor response to anti-seizure medications and immune therapies, and epilepsy surgery is rarely successful. We report on a 47-year-old female with history of migraine, autoimmune thyroid disease, ankylosing spondylitis, and drug-resistant TLE. A video electroencephalography recorded frequent seizures with temporo-insular semiology, correlating to left temporal epileptiform activity and left mesiotemporal hyperintensity on magnetic resonance imaging. GAD autoimmunity was confirmed by very high GAD antibody titers in serum and cerebrospinal fluid. Steroids, immunoglobulins, and cyclophosphamide had no effect, and selective left amygdalectomy was performed based on very restricted hypermetabolism on positron-emission tomography. After transient seizure freedom, significant epilepsy improvement was observed in spite of memory decline. Transient worsening was noted 1 year later during diabetes mellitus manifestation and 5 years later during presentation of progressive CA, which stabilized on rituximab treatment. We believe this case illustrates the diversity and the frequent overlap of GAD-associated disorders, the need of early and aggressive immunotherapy in severe patients, as well as the possible benefit from epilepsy surgery in some GAD-TLE.
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Affiliation(s)
- Petia Dimova
- Epileptology Unit at Epilepsy Surgery Center, Department of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- *Correspondence: Petia Dimova
| | - Krassimir Minkin
- Functional and Epilepsy Surgery Center, Department of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
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20
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Madkhali MA, Hao JK, Khan MS, Sharma H, Jaume A, Tiwari A, Imam S, Jaume JC. Intractable Seizures and Limbic Encephalitis, Unaccounted Complications of Type 1 Diabetes Autoimmunity. J Endocr Soc 2022; 6:bvab188. [PMID: 35128296 PMCID: PMC8807154 DOI: 10.1210/jendso/bvab188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Glutamic acid decarboxylase 65kD autoantibody (GAD65Ab) is frequently detected in patients with refractory epilepsy and stiff person syndrome. In contrast to T1D, the pathological role of GAD65Ab in neurological disorders is still debatable. As a result, the implementation of possible immunotherapy is usually delayed. This report presents 2 cases of GAD65Ab-associated brain autoimmunity and their different management. We present clinical data and discuss management based on available evidence in the reviewed literature. Both cases presented with acute on chronic neurological symptoms and were GAD65Ab positive. Case 1, a 30-year-old man with a history of early-onset type 1 diabetes mellitus at 14 months, followed by cryptogenic temporal epilepsy at 11 years of age, presented with intractable seizures. Case 2, a 48-year-old woman, presented with a history of recurrent severe headaches, cognitive impairment, decreased memory, and behavioral symptoms. GAD65Ab was detected in both patients’ sera. Cerebrospinal fluid GAD65Ab was only checked and positive in case 1. Case 2 was diagnosed with limbic encephalitis, treated with immunotherapy, and showed a remarkable clinical improvement. Case 1 with refractory epilepsy failed multiple antiepileptic drugs and responsive-stimulator system treatments. He was finally diagnosed with autoimmune epilepsy. The delay in diagnosis resulted in a lost opportunity for early immunotherapy. In conclusion, autoantibody screening and early initiation of immunotherapy should be considered to manage GAD65Ab-associated neurological disorders.
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Affiliation(s)
- Mohammed A Madkhali
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Jazan University, Jazan, Jizan, Saudi Arabia
| | - Jenifer-Kris Hao
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Mohammad Saud Khan
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Cardiology, University of Kentucky at Bowling Green, Bowling Green, KY
| | - Himani Sharma
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Alexa Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Abhinav Tiwari
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Shahnawaz Imam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Juan Carlos Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
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21
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Wang J, Gong S, Kong F, Cai D, Huang B, Zheng H, Lin S, Li J, Zhang T. Psychotic Symptoms as the Initial Presentation of a Long-Lasting Misdiagnosed Anti-GAD65 Autoimmune Encephalitis: An Emblematic Case and Literature Review. Front Psychiatry 2022; 13:754938. [PMID: 35280166 PMCID: PMC8905188 DOI: 10.3389/fpsyt.2022.754938] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To present a long-lasting misdiagnosed case of anti-GAD65 autoimmune encephalitis (AE) and promote the early identification of reversible psychotic symptoms in AE. METHODS The case report was generated through detailed assessment of clinical characteristics, cerebral magnetic resonance images, and laboratory results. Meanwhile, a literatures review related to the topic was conducted. RESULTS Psychotic symptoms could be presented in the early stage of anti-GAD65 autoimmune encephalitis. Even though there exists a transdisciplinary gap that hinder the timely recognition of early psychiatric symptoms as components of organic disease, a few strategies could be introduced to enable the earlier recognition and appropriate treatment. CONCLUSIONS Our report intends to raise awareness to promote the early identification of immune-mediated "symptomatic" forms of psychosis.
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Affiliation(s)
- Jianjun Wang
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,Global Clinical Scholars Research Training (GCSRT), Harvard Medical School, Boston, MA, United States
| | - Shenglan Gong
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China.,Sixth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Fanxin Kong
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Dongbin Cai
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Binqing Huang
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Haotao Zheng
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Songjun Lin
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jinfang Li
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Tianfeng Zhang
- Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China.,Sixth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
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22
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Wang Y, Sadaghiani MS, Tian F, Fitzgerald KC, Solnes L, Newsome SD. Brain and Muscle Metabolic Changes by FDG-PET in Stiff Person Syndrome Spectrum Disorders. Front Neurol 2021; 12:692240. [PMID: 34603180 PMCID: PMC8484315 DOI: 10.3389/fneur.2021.692240] [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: 04/07/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: To report clinical characteristics and fluorodeoxyglucose positron emission tomography (FDG-PET) findings in the brain and muscles of individuals with stiff person syndrome (SPS) spectrum disorders (SPSSDs). Methods: Retrospective cohort study from 1997 to 2018 at Johns Hopkins Hospital identified 170 individuals with SPS or cerebellar ataxia (CA) associated with anti-glutamic acid decarboxylase (anti-GAD)-65 antibodies. Fifty-one underwent FDG-PET, with 50 involving the body and 30 with dedicated brain acquisition. The clinical and immunological profiles were extracted via medical record review. The brain scans were analyzed quantitatively using the NeuroQ software, with comparison with an averaged normal database. The body scans were reviewed qualitatively by a blinded nuclear medicine radiologist. Results: Mean age of symptom onset was 41.5 years (range 12–75 years). Majority were female (68%) and White (64%). Of the patients, 82% had SPS (majority being classic phenotype), and 18% had CA. Three had a paraneoplastic process. Forty-seven had serum anti-GAD, two with anti-amphiphysin, and one with anti-glycine receptor antibodies. Brain metabolic abnormalities were seen in both SPS and CA, with significant differences between the groups noted in the right superior frontal cortex, right sensorimotor cortex, left inferior parietal cortex, bilateral thalami, vermis, and left cerebellum. Of the patients, 62% demonstrated muscle hypermetabolism, most commonly bilateral, involving the upper extremities or axial muscles. Neither brain nor muscle metabolism was correlated with functional outcomes nor treatments. Conclusions: Metabolic changes as seen by FDG-PET are present in the brain and muscle in many individuals with SPSSD. Future studies are needed to assess whether FDG-PET can help aid in the diagnosis and/or monitoring of individuals with SPSSD.
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Affiliation(s)
- Yujie Wang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mohammad S Sadaghiani
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Fan Tian
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lilja Solnes
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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23
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Akkari M, Messelmani M, Souissi W, Derbali H, Mrissa R. Subacute dementia revealing a limbic encephalitis with anti-GAD 65 antibodies in a young woman. Acta Neurol Belg 2021; 122:1651-1652. [PMID: 34562261 DOI: 10.1007/s13760-021-01766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Manel Akkari
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia.
| | | | - Wala Souissi
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia
| | - Hajer Derbali
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia
| | - Ridha Mrissa
- Department of Neurology, Military Hospital of Tunis, Tunis, Tunisia
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24
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Chen SS, Zhang YF, Di Q, Shi JP, Wang LL, Lin XJ, Yu N. Predictors and prognoses of epilepsy after anti-neuronal antibody-positive autoimmune encephalitis. Seizure 2021; 92:189-194. [PMID: 34551365 DOI: 10.1016/j.seizure.2021.09.007] [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: 03/24/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE This study aimed to investigate the incidence and predictors of epilepsy after anti-neuronal antibody-positive autoimmune encephalitis (AIE). The clinical outcomes of patients with epilepsy after AIE were also explored. METHODS A total of 111 AIE patients were retrospectively evaluated. Post-AIE epilepsy (PAEE) was defined as at least one unprovoked seizure occurring six or more months after discharge from hospital. RESULTS The incidence of acute symptomatic seizures was 80.2% (89/111) in our AIE patients. Furthermore, of the 89 AIE patients with seizures, 29 (32.6%) presented with seizures as the initial symptom. Overall, 44 out of 111 AIE patients (39.6%) had unprovoked seizures after six months, meeting our definition of PAEE. The independent risk factors for PAEE incidence included an initial presentation with new-onset refractory status epilepticus (NORSE), delayed immunotherapy treatment, the complication of a lung infection during admission, the requirement for mechanical ventilation during hospitalization, parietal lesions observed in magnetic resonance imaging (MRI), and focal slow waves on electroencephalographic (EEG) monitoring. CONCLUSIONS Early initiation of immunotherapy and lung infection treatment may reduce the risk of conversion of symptomatic seizures to chronic epilepsy in the acute phase of AIE. In general, PAEE patients could have a good prognosis if treated properly and in a timely fashion.
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Affiliation(s)
- Shan-Shan Chen
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China
| | - Yan-Fang Zhang
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China
| | - Qing Di
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China
| | - Jing-Ping Shi
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China
| | - Ling-Ling Wang
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China
| | - Xing-Jian Lin
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China.
| | - Nian Yu
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029 Nanjing, China.
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25
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Conde-Blanco E, Pascual-Diaz S, Carreño M, Muñoz-Moreno E, Pariente JC, Boget T, Manzanares I, Donaire A, Centeno M, Graus F, Bargalló N. Volumetric and shape analysis of the hippocampus in temporal lobe epilepsy with GAD65 antibodies compared with non-immune epilepsy. Sci Rep 2021; 11:10199. [PMID: 33986308 PMCID: PMC8119423 DOI: 10.1038/s41598-021-89010-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/15/2021] [Indexed: 11/09/2022] Open
Abstract
Glutamic acid decarboxylase 65 antibodies (anti-GAD65) have been found in patients with late-onset chronic temporal lobe epilepsy (TLE). No prior neuroimaging studies have addressed how they affect hippocampal volume and shape and how they relate to cognitive abnormalities. We aimed to investigate both brain structure and function in patients with isolated TLE and high anti-GAD65 levels (RIA ≥ 2000 U/ml) compared to 8 non-immune mesial TLE (niTLE) and 8 healthy controls (HC). Hippocampal subfield volume properties were correlated with the duration of the disease and cognitive test scores. The affected hippocampus of GAD-TLE patients showed no volume changes to matched HC whereas niTLE volumes were significantly smaller. Epilepsy duration in GAD-TLE patients correlated negatively with volumes in the presubiculum, subiculum, CA1, CA2-3, CA4, molecular layer and granule cell-molecular layer of the dentate nucleus. We found differences by advanced vertex-wise shape analysis in the anterior hippocampus of the left GAD-TLE compared to HC whereas left niTLE showed bilateral posterior hippocampus deformation. Verbal deficits were similar in GAD-TLE and niTLE but did not correlate to volume changes. These data might suggest a distinct expression of hippocampal structural and functional abnormalities based on the immune response.
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Affiliation(s)
- Estefanía Conde-Blanco
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain.
| | | | - Mar Carreño
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | | | | | - Teresa Boget
- Epilepsy Program, Neuropsychology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Isabel Manzanares
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - Antonio Donaire
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - María Centeno
- Epilepsy Program, Neurology Department, Hospital Clínic de Barcelona, EpiCARE: European Reference Network for Epilepsy, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer de Villarroel, 170, 08036, Barcelona, Spain
| | - Francesc Graus
- Clinical and Experimental Neuroimmunology Research Team of IDIBAPS, Barcelona, Spain
| | - Nuria Bargalló
- Magnetic Resonance Imaging Core Facility, IDIBAPS, Barcelona, Spain.,Epilepsy Program, Neuroradiology Section, Radiology Department, Center of Image Diagnosis (CDIC), Barcelona, Spain
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26
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GAD65-Related Immune Epilepsy: Are we Looking Yet? Indian J Pediatr 2021; 88:501-502. [PMID: 33420634 DOI: 10.1007/s12098-020-03582-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
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27
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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28
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Smith KM, Zalewski NL, Budhram A, Britton JW, So E, Cascino GD, Ritaccio AL, McKeon A, Pittock SJ, Dubey D. Musicogenic epilepsy: Expanding the spectrum of glutamic acid decarboxylase 65 neurological autoimmunity. Epilepsia 2021; 62:e76-e81. [PMID: 33764529 DOI: 10.1111/epi.16888] [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: 12/05/2020] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 01/01/2023]
Abstract
The objective of this study was to describe serological association of musicogenic epilepsy and to evaluate clinical features and outcomes of seropositive cases. Through retrospective chart review, musicogenic epilepsy patients were identified. Among 16 musicogenic epilepsy patients, nine underwent autoantibody evaluations and all had high-titer glutamic acid decarboxylase 65-immunoglobulin G (GAD65-IgG; >20 nmol·L-1 , serum, normal ≤ .02 nmol·L-1 , eight women). Median GAD65-IgG serum titer was 294 nmol·L-1 (20.3-3005 nmol·L-1 ), and median cerebrospinal fluid titer (n = 4) was 14.7 nmol·L-1 . All patients had temporal lobe epilepsy, and bitemporal epileptiform abnormalities were common. Right temporal lobe seizures were most frequently captured when seizures were induced by music on electroencephalogram (3/4; 75%). Intravenous (IV) methylprednisolone and/or IV Ig (IVIG) was utilized in four patients, with one having greater than 50% reduction. Rituximab (n = 2) and mycophenolate (n = 1) were ineffective. Two patients underwent right temporal lobe resections but continued to have seizures. Vagus nerve stimulation was effective at reducing seizures in one patient by 50%, and an additional patient was seizure-free by avoiding provoking music. Right temporal lobe epilepsy was more common among patients with musicogenic epilepsy when compared to nonmusicogenic GAD65 epilepsies (n = 71, 89% vs. 47%, p = .03). GAD65-IgG should be tested in patients with musicogenic epilepsy, given implications for management and screening for comorbid autoimmune conditions.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Adrian Budhram
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Elson So
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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29
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Long-term seizure outcome and antiseizure medication use in autoimmune encephalitis. Seizure 2021; 86:138-143. [DOI: 10.1016/j.seizure.2021.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 12/30/2022] Open
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30
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Diagnostic Value of Structural and Functional Neuroimaging in Autoimmune Epilepsy. CONTRAST MEDIA & MOLECULAR IMAGING 2020; 2020:8894213. [PMID: 33380947 PMCID: PMC7752299 DOI: 10.1155/2020/8894213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/14/2020] [Accepted: 12/02/2020] [Indexed: 01/15/2023]
Abstract
Epilepsy is a common nervous system disease, which affects about 70 million people all over the world. In 2017, the International League Against Epilepsy (ILAE) considered immune factors as its independent cause, and the concept of autoimmune epilepsy (AE) was widely accepted. Early diagnosis and timely treatment can effectively improve the prognosis of the disease. However, due to the diversity of clinical manifestations, the expensive cost of autoantibody detection, and the increased prevalence in Western China, the difficulty for clinicians in early diagnosis and treatment has increased. Fortunately, convenient and fast imaging examinations are expected to help even more. The imaging manifestations of AE patients were characteristic, especially the combined application of structural and functional neuroimaging, which improved the diagnostic value of imaging. In this paper, several common autoantibodies associated with AE and their structure and function changes in neuroimaging were reviewed to provide help for neurologists to achieve the goal of precision medicine.
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31
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Paredes-Aragón EM, Valdéz-Ruvalcaba HE, Santos-Peyret A, Cisneros-Otero M, Medina-Rioja R, Orozco-Suárez S, Hernandez MM, Breda-Yepes MDL, Rivas-Alonso V, Flores-Rivera JJ, Martínez-Juárez IE. Continuous Visual Focal Status Epilepticus as the Primary Presentation of NMDA-R and GAD65-R Autoimmune Epilepsy. Front Neurol 2020; 11:598974. [PMID: 33324338 PMCID: PMC7726346 DOI: 10.3389/fneur.2020.598974] [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: 08/26/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
Epilepsia partialis continua (EPC) has changed in its clinical and pathophysiological definition throughout time. Several etiologies have been described in addition to classic causes of EPC. The following case depicts a young woman who had a peculiar onset of epilepsy with a continuous visual aura becoming a form of chronic recurrent and non-progressive EPC. The patient was initially misdiagnosed as a non-neurological entity (assumed psychiatric in origin), but finally, an immune-mediated epilepsy was diagnosed, and EEG showed focal status epilepticus during evolution. Once the diagnosis was achieved and immune treatment was established, the patient is seizure free. Early identification of an immune basis in patients with epilepsy is important because immunotherapy can reverse the epileptogenic process and reduce the risk of chronic epilepsy. To date, this is the only case reported with EPC manifesting as a continuous visual aura associated with antiglutamic acid decarboxylase 65 (anti-GAD65) and anti-N-methyl-d-aspartate (anti-NMDA) antibodies.
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Affiliation(s)
| | | | - Andrea Santos-Peyret
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Marcela Cisneros-Otero
- Neuropsychiatry Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Raúl Medina-Rioja
- Neurology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Sandra Orozco-Suárez
- Unit of Medical Research in Neurologic Diseases (UIMEN), Medical National Center Century XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Miriam M. Hernandez
- Neurology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Verónica Rivas-Alonso
- Neuroimmunology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - José J. Flores-Rivera
- Neuroimmunology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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32
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Jaafar F, Haddad L, Koleilat N, Sharara-Chami R, Shbarou R. Super refractory status epilepticus secondary to anti-GAD antibody encephalitis successfully treated with aggressive immunotherapy. Epilepsy Behav Rep 2020; 14:100396. [PMID: 33305253 PMCID: PMC7710630 DOI: 10.1016/j.ebr.2020.100396] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase are reported in association with a number of neurological conditions including limbic encephalitis. We report a case of anti-GAD-antibody associated encephalitis presenting with super-refractory status epilepticus. We describe the clinical course, management, and the outcome. In addition, we review the presentation and outcomes of reported cases of anti-GAD encephalitis. Similar to the reported cases of anti-GAD encephalitis, our case was refractory to treatment with conventional antiseizure medication. Treatment with intravenous immune globulin (IVIG), high dose corticosteroids, and plasmapheresis had partial response, but escalation of treatment to the use of tocilizumab was associated with significant clinical improvement.
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Key Words
- AED, antiepileptic drug
- Autoimmune encephalitis
- CSF, cerebrospinal fluid
- EEG, electroencephalogram
- GABA, gamma-aminobutyric acid
- GAD, glutamic acid decarboxylase
- Glutamic acid decarboxylase antibodies
- IVIG, intravenous immunoglobulin
- Limbic encephalitis
- MDZ, midazolam
- MP, methylprednisolone
- MRI, magnetic resonance imaging
- NMDA, N-methyl-d-aspartate
- PCR, polymerase chain reaction
- PLEX, plasma exchange
- RNA, ribonucleic acid
- Status epilepticus
- Tocilizumab
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Affiliation(s)
- Fatima Jaafar
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Laith Haddad
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadia Koleilat
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Sharara-Chami
- Division of Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rolla Shbarou
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Rada A, Birnbacher R, Gobbi C, Kurthen M, Ludolph A, Naumann M, Neirich U, von Oertzen TJ, Ransmayr G, Riepe M, Schimmel M, Schwartz O, Surges R, Bien CG. Seizures associated with antibodies against cell surface antigens are acute symptomatic and not indicative of epilepsy: insights from long-term data. J Neurol 2020; 268:1059-1069. [PMID: 33025119 PMCID: PMC7914192 DOI: 10.1007/s00415-020-10250-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
Background Clinicians have questioned whether any disorder involving seizures and neural antibodies should be called “(auto)immune epilepsy.” The concept of “acute symptomatic seizures” may be more applicable in cases with antibodies against neural cell surface antigens. We aimed at determining the probability of achieving seizure-freedom, the use of anti-seizure medication (ASM), and immunotherapy in patients with either constellation. As a potential pathophysiological correlate, we analyzed antibody titer courses. Methods Retrospective cohort study of 39 patients with seizures and neural antibodies, follow-up ≥ 3 years. Results Patients had surface antibodies against the N-methyl-d-aspartate receptor (NMDAR, n = 6), leucine-rich glioma inactivated protein 1 (LGI1, n = 11), contactin-associated protein-2 (CASPR2, n = 8), or antibodies against the intracellular antigens glutamic acid decarboxylase 65 kDa (GAD65, n = 13) or Ma2 (n = 1). Patients with surface antibodies reached first seizure-freedom (88% vs. 7%, P < 0.001) and terminal seizure-freedom (80% vs. 7%, P < 0.001) more frequently. The time to first and terminal seizure-freedom and the time to freedom from ASM were shorter in the surface antibody group (Kaplan–Meier curves: P < 0.0001 for first seizure-freedom; P < 0.0001 for terminal seizure-freedom; P = 0.0042 for terminal ASM-freedom). Maximum ASM defined daily doses were higher in the groups with intracellular antibodies. Seizure-freedom was achieved after additional immunotherapy, not always accompanied by increased ASM doses. Titers of surface antibodies but not intracellular antibodies decreased over time. Conclusion Seizures with surface antibodies should mostly be considered acute symptomatic and transient and not indicative of epilepsy. This has consequences for ASM prescription and social restrictions. Antibody titers correlate with clinical courses. Electronic supplementary material The online version of this article (10.1007/s00415-020-10250-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Rada
- Epilepsy Center Bethel, Krankenhaus Mara, Epilepsy Centre Bethel, Krankenhaus Mara, Maraweg 17-21, 33617, Bielefeld, Germany
| | - Robert Birnbacher
- Department of Pediatrics and Adolescent Medicine, Villach General Hospital, Villach, Austria
| | - Claudio Gobbi
- Department of Neurology, Neurocenter of Southern Switzerland (NSI), 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana (USI), 6900, Lugano, Switzerland
| | | | - Albert Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University of Augsburg, Augsburg, Germany
| | - Ulrike Neirich
- Department of Pediatrics, Neurology, Stiftungskrankenhäuser Frankfurt Am Main, Clementine Kinderhospital, Frankfurt am Main, Germany
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Gerhard Ransmayr
- Department of Neurology 2, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Matthias Riepe
- Division of Gerontopsychiatry, Ulm University, Günzburg, Germany
| | - Mareike Schimmel
- Department of Pediatrics, Section of Neuropediatrics, University of Augsburg, Augsburg, Germany
| | - Oliver Schwartz
- Department of Pediatric Neurology, Münster University Hospital, Münster, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital of Bonn, Bonn, Germany
| | - Christian G Bien
- Epilepsy Center Bethel, Krankenhaus Mara, Epilepsy Centre Bethel, Krankenhaus Mara, Maraweg 17-21, 33617, Bielefeld, Germany.
- Laboratory Krone, Bad Salzuflen, Germany.
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34
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Zhu F, Shan W, Lv R, Li Z, Wang Q. Clinical characteristics of GAD 65-associated autoimmune encephalitis. Acta Neurol Scand 2020; 142:281-293. [PMID: 32416610 DOI: 10.1111/ane.13281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To examine the clinical characteristics of autoimmune encephalitis associated with the glutamate decarboxylase 65 (GAD 65) antibody. MATERIALS AND METHODS Medical records of all patients that diagnosed with GAD 65 antibody-associated encephalitis were retrospectively analyzed. Data regarding demographics and symptoms, neurological signs, laboratory and imaging results, treatment and prognosis were collected. RESULTS We collected a total of seven patients, mainly young or middle-aged women with a subacute or chronic course. The main clinical symptoms mainly included chronic epilepsy, cerebellar ataxia, stiff-person syndrome, and limbic encephalitis. Three of seven (43%) patients had high CSF (cerebrospinal fluid) protein levels. Oligoclonal IgG bands (including IgG 1) and 24 hours intrathecal synthesis of IgG were detected in CSF and serum in six patients, five patients (83%) reported increased distribution of oligoclonal IgG bands (including IgG 1) and 24 hours intrathecal synthesis of IgG in serum and CSF. And six of seven patients (86%) had abnormal thyroid function or were positive for thyroid antibodies. By electroencephalogram examination, sharp or slow waves in the temporal region were often observed for six of seven patients (86%). Abnormal imaging signals (six of seven patients, 86%) of the temporal lobe and hippocampus were detected by brain magnetic resonance imaging, and decreased metabolism of the temporal lobe was detected by positron emission tomography/computed tomography (six of six patients, 100%). These patients were mainly treated with corticosteroid and gamma globulin. The clinical symptoms of the patients were alleviated. CONCLUSIONS The course of GAD 65 antibody-associated encephalitis is longer than other autoimmune encephalitides. The clinical symptoms of GAD 65 autoimmune encephalitis mainly manifested as chronic epilepsy, cerebellar ataxia, stiff-person syndrome, and limbic encephalitis, and combined with or without thyroid autoimmune diseases, type 1 diabetes, and thymoma. A comprehensive understanding of the disease is a way to prevent misdiagnosis and delayed treatment.
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Affiliation(s)
- Fei Zhu
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Wei Shan
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Beijing Institute for Brain Disorders Beijing China
| | - Ruijuan Lv
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhimei Li
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qun Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Beijing Institute for Brain Disorders Beijing China
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de Sousa GJ, Tittel SR, Häusler M, Holterhus PM, Berger G, Holder M, Kamrath C, Golembowski S, Herrlinger S, Holl RW. Type 1 diabetes and epilepsy in childhood and adolescence: Do glutamic acid decarboxylase autoantibodies play a role? Data from the German/Austrian/Swiss/Luxembourgian DPV Registry. Pediatr Diabetes 2020; 21:766-773. [PMID: 32333480 DOI: 10.1111/pedi.13034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/23/2020] [Accepted: 04/16/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS We aimed to analyze the relationship between epilepsy and glutamic acid decarboxylase autoantibodies (GADA) in patients with type 1 diabetes mellitus (T1DM) and the impact of GADA on demographic, clinical, and metabolic data in T1DM patients with epilepsy. METHODS We searched for patients with T1DM ≤20 years and GADA measurements, and within this group for patients with epilepsy. We formed groups: T1DM + Epilepsy + GADA positive; T1DM + Epilepsy + GADA negative; T1DM + GADA positive; T1DM + GADA negative. We used logistic regression to analyze the relationship between epilepsy and GADA with odds ratio adjusted for sex, duration of diabetes (DOD), and age at diabetes onset (ADO). We used logistic regression with odds ratio adjusted for DOD and ADO onset using epilepsy as a dependent variable and GADA, HbA1c, ketoacidosis, severe hypoglycemia (SH), sex, celiac disease, and autoimmune thyroiditis as independent variables. We conducted regression analyses adjusted for sex, DOD, and ADO to analyze differences in clinical/metabolic parameters between the groups. RESULTS Epilepsy was not more frequent in GADA-positive patients (GPP). Logistic regression including all patients with GADA measurements showed that hypoglycemia with coma (HC) correlated with epilepsy when compared to no SH. We found no differences in clinical and metabolic data between GPP and GADA-negative patients (GNP) with epilepsy. SH occurred more often in GPP with epilepsy in comparison to GPP without epilepsy. GNP with epilepsy had a higher rate of HC than GPP without epilepsy. CONCLUSION We found no relationship between epilepsy and GADA. A relationship between T1DM and epilepsy might be explainable by SH.
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Affiliation(s)
- Gideon John de Sousa
- Children's Hospital Dortmund, Dortmund, Germany.,Department of Pediatrics, University of Witten/Herdecke, Witten, Germany
| | - Sascha René Tittel
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Technology, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Martin Häusler
- Division of Neuropediatrics and Social Pediatrics, Department of Pediatrics, University Hospital RWTH Aachen, Aachen, Germany
| | | | | | - Martin Holder
- Children's Hospital, Olgahospital Stuttgart, Stuttgart, Germany
| | - Clemens Kamrath
- Children's Hospital, University of Giessen, Giessen, Germany
| | - Sven Golembowski
- Children's Hospital, Sana Klinikum Lichtenberg Berlin, Berlin, Germany
| | | | - Reinhard Walter Holl
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Technology, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Seizures and epilepsy of autoimmune origin: A long-term prospective study. Seizure 2020; 81:157-165. [PMID: 32818871 DOI: 10.1016/j.seizure.2020.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To follow prospectively a group of patients with seizures or epilepsy and suggestive clinical features of autoimmune aetiology and find out how many are finally diagnosed with acute symptomatic seizures (ASS) secondary to autoimmune encephalitis or autoimmune-related epilepsy, and how many develop epilepsy. METHODS Consecutive patients meeting the inclusion criteria from 2010 to 2018 were identified. Patients were classified as confirmed, probable autoimmune, non-autoimmune, or unknown. RESULTS One-hundred and nine patients were included, 64 (48.7 %) women, mean age 55.2 years (SD 17.9). ASS were reported by 61 patients (56 %), while 48 presented epilepsy (44 %). During follow-up 18 patients died (16.5 %). Final diagnosis was autoimmune-relatedepilepsy (confirmed + probable) in 22 cases and ASS secondary to autoimmune encephalitis (confirmed or probable) in 27, non-autoimmune aetiologies or other diagnosis in 49 (44 %), and unknown aetiology in 11 (10.2 %). Neuronal antibodies (ab) were found in 27 patients (24.7 %). T-lymphocyte infiltration in temporal lobes was observed in 2/8 patients (20 %). Neuronal ab were more frequent in the autoimmune groups: 17 patients (29.8 %) vs 1(2.3 %), p:0.001, and they suffered more autoimmune diseases: 37 (75.5 %) vs 12 (24.48 %), p:0.0001, and 34 (69 %) vs 22 (44.9 %) p:0.027, respectively. All patients with GAD ab 17/17 (100 %) evolved to chronic disease. Four patients (29 %) with ASS secondary to autoimmune encephalitis developed epilepsy. SIGNIFICANCE ASS secondary to autoimmune encephalitis or autoimmune-related epilepsy will be diagnosed in nearly half of patients who have been suspected of it. The only diagnostic clue is neuronal ab. Patients who have suffered ASS secondary to autoimmune encephalitis may develop epilepsy over time.
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Chengyu L, Weixiong S, Chao C, Songyan L, Lin S, Zhong Z, Hua P, Fan J, Na C, Tao C, Jianwei W, Haitao R, Hongzhi G, Xiaoqiu S. Clinical features and immunotherapy outcomes of anti-glutamic acid decarboxylase 65 antibody-associated neurological disorders. J Neuroimmunol 2020; 345:577289. [PMID: 32563127 DOI: 10.1016/j.jneuroim.2020.577289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/07/2020] [Accepted: 06/07/2020] [Indexed: 02/07/2023]
Abstract
We described the clinical and neuroimaging characteristics of seven Chinese patients with anti-GAD65 antibody-associated neurological disorders of whom epileptic seizures were the initial and main symptoms. All patients were given immunotherapy and followed up monthly. The outcome demonstrates that immunotherapy is helpful for non-seizure manifestations of anti-GAD65-associated neurological autoimmunity and is less effective in the treatment of seizures, yet partial responses can still occur in the early stage. Taken together we suggest a trial with immunotherapy in all patients in the early stage of the disease, and in patients with non-epilepsy symptoms in the later stage.
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Affiliation(s)
- Li Chengyu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China.
| | - Shi Weixiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Chen Chao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Liu Songyan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Sang Lin
- Epilepsy Center, Medical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai Hospital, Beijing 100071, China
| | - Zheng Zhong
- Epilepsy Center, Medical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai Hospital, Beijing 100071, China
| | - Pan Hua
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Jian Fan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Chen Na
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Cui Tao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Wu Jianwei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China
| | - Ren Haitao
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guan Hongzhi
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shao Xiaoqiu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; China National Clinical Research Center for Neurological Disease, NCRC-ND, Beijing 100050, China.
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Glutamic acid decarboxylase antibodies in neurocritical patients: a culprit or a bystander? Neurol Sci 2020; 41:3691-3696. [PMID: 32514855 PMCID: PMC7278224 DOI: 10.1007/s10072-020-04466-7] [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: 02/22/2020] [Accepted: 05/09/2020] [Indexed: 11/21/2022]
Abstract
Background Glutamic acid decarboxylase (GAD) is an intracellular enzyme, which is widely expressed in central nervous system (CNS), pancreas, and other organs. GAD antibodies (GAD-Abs) are linked to various neurological disorders. However, the significance of GAD-Abs in neurocritical patients is undetermined. Materials and methods Patients with serologically positive GAD-Abs and requiring neurocritical care were included. The clinical, laboratory, and outcome data were retrospectively collected. Results We included 9 patients with serologically positive GAD-Abs. Clinical manifestations involved both CNS and peripheral nervous system (PNS). Six (66.7%) patients had other specific autoimmune antibodies. Non-specific autoimmune responses were observed in 8 (88.9%) patients. All patients clinically responded well to immunotherapy. The titers of GAD-Abs decreased in 7 (77.8%) patients but remained unchanged in the other 2 patients. One (11.1%) patient awoke before the negative conversion of GAD-Abs, and 3 (33.3%) patients remained unconscious and/or under mechanical ventilation for several weeks after the vanishing of GAD-Abs. Conclusions Most neurocritical patients with serologically positive GAD-Abs had other specific autoimmune antibodies. All patients responded well to immunotherapy, but not parallel to the titers of GAD-Abs. These results indicated that GAD-Abs might be more a bystander than a culprit in neurocritical patients, suggesting that an underlying autoimmune disease should be explored.
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39
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Graus F, Saiz A, Dalmau J. GAD antibodies in neurological disorders — insights and challenges. Nat Rev Neurol 2020; 16:353-365. [DOI: 10.1038/s41582-020-0359-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
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40
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Immune-mediated epilepsy with GAD65 antibodies. J Neuroimmunol 2020; 341:577189. [PMID: 32087461 DOI: 10.1016/j.jneuroim.2020.577189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
Anti-GAD65 antibodies have been identified in both acute/subacute seizures (limbic encephalitis and extralimbic encephalitis) and chronic isolated epilepsy. The evidence of high serum titers and intrathecal synthesis play a fundamental role in diagnosis but poorly correlate with disease severity or response to therapies. It remains controversial whether anti-GAD65 Abs are the pathogenic entity or only serve as a surrogate marker for autoimmune disorders mediated by cytotoxic T cells. Unlike other immune-mediated epilepsy, although multiple combinations of therapeutics are used, the efficacy and prognosis of patients with GAD65-epilepsy patients are poor. Besides, GAD65-epilepsy is more prone to relapse and potentially evolve into a more widespread CNS inflammatory disorder. This article reviews the recent advances of GAD65-epilepsy, focusing on the diagnosis, epidemiology, pathophysiology, clinical features, and treatment, to better promote the recognition and provide proper therapy for this condition.
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41
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Feyissa AM, Mirro EA, Wabulya A, Tatum WO, Wilmer-Fierro KE, Won Shin H. Brain-responsive neurostimulation treatment in patients with GAD65 antibody-associated autoimmune mesial temporal lobe epilepsy. Epilepsia Open 2020; 5:307-313. [PMID: 32524057 PMCID: PMC7278537 DOI: 10.1002/epi4.12395] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/13/2020] [Accepted: 03/26/2020] [Indexed: 02/04/2023] Open
Abstract
Glutamic acid decarboxylase 65‐kilodalton isoform (GAD65) antibodies have been associated with multiple nonneurological and neurological syndromes including autoimmune epilepsy (AE). Although immunotherapy remains the cornerstone for the treatment of AE, those with GAD65 Ab‐associated AE (GAD65‐AE) remain refractory to immunotherapy and antiseizure medication (ASM). Outcomes of epilepsy surgery in this patient population have also been unsatisfactory. The role of neuromodulation therapy, particularly direct brain‐responsive neurostimulation therapy, has not been previously examined in GAD65‐AE. Here, we describe four consecutive patients with refractory GAD‐65‐associated temporal lobe epilepsy (GAD65‐TLE) receiving bilateral hippocampal RNS System treatment. The RNS System treatment was well tolerated and effective in this study cohort. Three patients had a >50% clinical seizure reduction, and one patient became clinically seizure‐free following resective surgery informed by the RNS System data with continued RNS System treatment. In all four of our patients, the long‐term ambulatory data provided by the RNS System allowed us to gain objective insights on electrographic seizure lateralization, patterns, and burden as well as guided immunotherapy and ASM optimization. Our results suggest the potential utility of the RNS System in the management of ASM intractable GAD65‐AE.
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Affiliation(s)
| | | | - Angela Wabulya
- Department of Neurology University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - William O Tatum
- Department of Neurology Mayo Clinic Florida Jacksonville Florida
| | | | - Hae Won Shin
- Department of Neurology University of North Carolina at Chapel Hill Chapel Hill North Carolina
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Li TR, Zhang YD, Wang Q, Shao XQ, Li ZM, Lv RJ. Intravenous methylprednisolone or immunoglobulin for anti-glutamic acid decarboxylase 65 antibody autoimmune encephalitis: which is better? BMC Neurosci 2020; 21:13. [PMID: 32228575 PMCID: PMC7106675 DOI: 10.1186/s12868-020-00561-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Patients positive for anti-glutamic acid decarboxylase 65 (GAD65) antibodies have attracted increasing attention. Their clinical manifestations are highly heterogeneous and can be comorbid with tumors. Currently, there is no consensus on the therapeutic regimen for anti-GAD65-associated neurological diseases due to the clinical complexity, rarity and sporadic distribution. We reported six anti-GAD65 autoimmune encephalitis (AE) patients who received intravenous methylprednisolone (IVMP) or immunoglobulin (IVIG) or both. Then, we evaluated the therapeutic effect of both by summarizing results in previous anti-GAD65 AE patients from 70 published references. RESULTS Our six patients all achieved clinical improvements in the short term. Unfortunately, there was no significant difference between IVMP and IVIG in terms of therapeutic response according to the previous references, and the effectiveness of IVMP and IVIG was 45.56% and 36.71%, respectively. We further divided the patients into different subgroups according to their prominent clinical manifestations. The response rates of IVMP and IVIG were 42.65% and 32.69%, respectively, in epilepsy patients; 60.00% and 77.78%, respectively, in patients with stiff-person syndrome; and 28.57% and 55.56%, respectively, in cerebellar ataxia patients. Among 29 anti-GAD65 AE patients with tumors, the response rates of IVMP and IVIG were 29.41% and 42.11%, respectively. There was no significant difference in effectiveness between the two regimens among the different subgroups. CONCLUSION Except for stiff-person syndrome, we found that this kind of AE generally has a poor response to IVMP or IVIG. Larger prospective studies enrolling large numbers of patients are required to identify the optimal therapeutic strategy in the future.
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Affiliation(s)
- Tao-Ran Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Chang Chun Road, Xicheng District, Beijing, 100053, People's Republic of China
| | - Yu-Di Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Neurology, the Second Hospital of Hebei Medical University, Hebei Medical University, 215 Heping West Road, Xinhua District, Shijiazhuang, 050000, People's Republic of China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Zhi-Mei Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
| | - Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.
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Pelkey KA, Calvigioni D, Fang C, Vargish G, Ekins T, Auville K, Wester JC, Lai M, Mackenzie-Gray Scott C, Yuan X, Hunt S, Abebe D, Xu Q, Dimidschstein J, Fishell G, Chittajallu R, McBain CJ. Paradoxical network excitation by glutamate release from VGluT3 + GABAergic interneurons. eLife 2020; 9:e51996. [PMID: 32053107 PMCID: PMC7039679 DOI: 10.7554/elife.51996] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/12/2020] [Indexed: 12/18/2022] Open
Abstract
In violation of Dale's principle several neuronal subtypes utilize more than one classical neurotransmitter. Molecular identification of vesicular glutamate transporter three and cholecystokinin expressing cortical interneurons (CCK+VGluT3+INTs) has prompted speculation of GABA/glutamate corelease from these cells for almost two decades despite a lack of direct evidence. We unequivocally demonstrate CCK+VGluT3+INT-mediated GABA/glutamate cotransmission onto principal cells in adult mice using paired recording and optogenetic approaches. Although under normal conditions, GABAergic inhibition dominates CCK+VGluT3+INT signaling, glutamatergic signaling becomes predominant when glutamate decarboxylase (GAD) function is compromised. CCK+VGluT3+INTs exhibit surprising anatomical diversity comprising subsets of all known dendrite targeting CCK+ interneurons in addition to the expected basket cells, and their extensive circuit innervation profoundly dampens circuit excitability under normal conditions. However, in contexts where the glutamatergic phenotype of CCK+VGluT3+INTs is amplified, they promote paradoxical network hyperexcitability which may be relevant to disorders involving GAD dysfunction such as schizophrenia or vitamin B6 deficiency.
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Affiliation(s)
- Kenneth A Pelkey
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Daniela Calvigioni
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Calvin Fang
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Geoffrey Vargish
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Tyler Ekins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Kurt Auville
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Jason C Wester
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Mandy Lai
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Connie Mackenzie-Gray Scott
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Xiaoqing Yuan
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Steven Hunt
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Daniel Abebe
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Qing Xu
- Center for Genomics and Systems Biology, NYUAbu-DhabiUnited Arab Emirates
| | - Jordane Dimidschstein
- Stanley Center for Psychiatric Research, Broad Institute of MIT and HarvardCambridgeUnited States
| | - Gordon Fishell
- Stanley Center for Psychiatric Research, Broad Institute of MIT and HarvardCambridgeUnited States
- Department of Neurobiology, Blavatnik Institute, Harvard Medical SchoolBostonUnited States
| | - Ramesh Chittajallu
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
| | - Chris J McBain
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaUnited States
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Brunker L, Hirst P, Schlesinger JJ. New-Onset Refractory Status Epilepticus with Underlying Autoimmune Etiology: a Case Report. ACTA ACUST UNITED AC 2019; 2:103-107. [PMID: 32435752 PMCID: PMC7223986 DOI: 10.1007/s42399-019-00185-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 11/30/2022]
Abstract
Management of new-onset refractory status epilepticus and the approach to burst suppression variable is often challenging. We present the unusual case of a previously healthy 18-year-old male with new-onset status epilepticus admitted to the neurologic intensive care unit for 70 days. Despite treatment with multiple anti-epileptic drugs in addition to IV anesthetics, burst suppression was initially unsustainable and the patient remained in super-refractory status epilepticus. Extensive evaluation revealed an underlying autoimmune-mediated etiology with positivity for glutamic acid decarboxylase-65 antibody. Clinical response with a goal of 1–2 bursts per screen on EEG monitor was eventually achieved after a course of rituximab and plasma exchange therapy as well as a 7-day barbiturate coma with a regimen of clobazam, lacosamide, Keppra, and oxcarbazepine followed by a slow taper of phenobarbital and the addition of fosphenytoin. Remarkably, the patient was subsequently discharged to a rehabilitation facility with complete neurologic recovery. We discuss treatment strategies for new-onset refractory status epilepticus and highlight the role of rapid initiation of burst suppression with high-dose IV anesthetics to ensure neuroprotection while the underlying etiology is addressed with immune-modulating therapy.
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Affiliation(s)
- Lucille Brunker
- 1Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Priscilla Hirst
- 2Department of Medicine, Montefiore Health System, New Rochelle, United States
| | - Joseph J Schlesinger
- 3Department of Anesthesiology, Department of Hearing and Speech Sciences, Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN USA
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45
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Vogrig A, Joubert B, André‐Obadia N, Gigli GL, Rheims S, Honnorat J. Seizure specificities in patients with antibody‐mediated autoimmune encephalitis. Epilepsia 2019; 60:1508-1525. [DOI: 10.1111/epi.16282] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/15/2019] [Accepted: 06/18/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Alberto Vogrig
- French Reference Center for Paraneoplastic Neurological Syndromes Hospital for Neurology and Neurosurgery Pierre Wertheimer Lyon University Hospital Lyon France
- SynatAc Team NeuroMyoGene InstituteINSERM U1217/CNRSUMR5310 Lyon France
- University Claude Bernard Lyon 1, University of Lyon Lyon France
- Clinical Neurology Unit Santa Maria della Misericordia University Hospital Udine Italy
| | - Bastien Joubert
- French Reference Center for Paraneoplastic Neurological Syndromes Hospital for Neurology and Neurosurgery Pierre Wertheimer Lyon University Hospital Lyon France
- SynatAc Team NeuroMyoGene InstituteINSERM U1217/CNRSUMR5310 Lyon France
- University Claude Bernard Lyon 1, University of Lyon Lyon France
| | - Nathalie André‐Obadia
- Department of Functional Neurology and Epileptology Hospital for Neurology and Neurosurgery Pierre Wertheimer Lyon University Hospital Lyon France
- Lyon's Neurosciences Research Center INSERM U1028/CNRSUMR 5292University of Lyon Lyon France
| | - Gian Luigi Gigli
- Clinical Neurology Unit Santa Maria della Misericordia University Hospital Udine Italy
- Department of Medicine (DAME) University of Udine Medical School Udine Italy
- Department of Mathematics, Informatics and Physics (DMIF) University of Udine Udine Italy
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology Hospital for Neurology and Neurosurgery Pierre Wertheimer Lyon University Hospital Lyon France
- Lyon's Neurosciences Research Center INSERM U1028/CNRSUMR 5292University of Lyon Lyon France
| | - Jérome Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes Hospital for Neurology and Neurosurgery Pierre Wertheimer Lyon University Hospital Lyon France
- SynatAc Team NeuroMyoGene InstituteINSERM U1217/CNRSUMR5310 Lyon France
- University Claude Bernard Lyon 1, University of Lyon Lyon France
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Baizabal-Carvallo JF. The neurological syndromes associated with glutamic acid decarboxylase antibodies. J Autoimmun 2019; 101:35-47. [DOI: 10.1016/j.jaut.2019.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022]
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