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Zhong R, Chen X, Liao F, Lin Z, Zhang Z, Chen Y, Cui L. FLAMES overlaying anti-N-methyl-D-aspartate receptor encephalitis: a case report and literature review. BMC Neurol 2024; 24:140. [PMID: 38664672 PMCID: PMC11044310 DOI: 10.1186/s12883-024-03617-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/29/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND In recent years, simultaneous or sequential occurrence of MOG antibody disease and anti-NMDAR encephalitis in the same patient has been reported with increasing frequency. Scholars refer to the overlapping occurrence of these two disorders as MOG antibody disease and anti-NMDAR encephalitis overlap syndrome (MNOS). Cortical T2-weighted fluid-attenuated inversion recovery (FLAIR) -hyperintense lesions in anti-MOG-associated encephalitis with seizures (FLAMES) is a rare clinical phenotype of MOGAD in which cortical FLAIR high-signal lesions are unilateral, with little spread to the cortex and meninges bilaterally. Although cases of FLAMES have been consistently reported. However, to our knowledge, such cases of FLAMES combined with NMDARE are rare. CASE PRESENTATION Here, we describe a case of FLAMES combined with anti-NMDARE. The patient was a young male, 29 years old, admitted to our hospital with isolated seizures, whose MRI showed unilateral thalamic and bilateral frontal and parietal leptomeningeal involvement. Since we were unaware of the possibility of bilateral meningo-cortical MOGAD manifestations, the case was initially diagnosed as viral encephalitis and was given antiviral therapy. The diagnosis was not clarified until anti-NMDAR-IgG and MOG-IgG positivity was detected in the cerebrospinal fluid and serum. The patient was then treated with high-dose corticosteroids and his symptoms responded well to the steroids. Therefore, this case expands the clinical spectrum of MNOS overlap syndrome. In addition, we describe the clinical features of MNOS by summarizing the existing literature and exploring the possible mechanisms of its immune response. CONCLUSIONS Our case serves as a reminder to clinicians that when patients present with atypical clinical manifestations such as seizures, consideration should be given to MNOS and conduct testing for various relevant autoantibodies (including MOG abs) and viruses in both serum and cerebrospinal fluid, as it is easy to misdiagnose the disease as other CNS diseases, such as viral meningoencephalitis. This syndrome exhibits a high responsiveness to steroids, highlighting the critical importance of recognizing the clinical and neuroimaging features of this overlap syndrome for prompt diagnosis and treatment. Furthermore, it enriches the disease spectrum of MNOS.
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Affiliation(s)
- Rimei Zhong
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524000, China
| | - Xiongjin Chen
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Feng Liao
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524000, China
| | - Zhijun Lin
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524000, China
| | - Zhijian Zhang
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524000, China
| | - Yusen Chen
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524000, China.
| | - Lili Cui
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.
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Qin M, Chen J, Guo X, Xiang X, Nie L, Wang Y, Mao L. Movement disorders in autoimmune encephalitis: an update. J Neurol 2023; 270:5288-5302. [PMID: 37523063 DOI: 10.1007/s00415-023-11881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Autoimmune encephalitis (AE) is a form of encephalitis resulting from an immune response targeting central nervous system antigens, which is characterized by cognitive impairment, neuropsychiatric symptoms, seizures, movement disorders (MDs), and other encephalopathy symptoms. MDs frequently manifest throughout the progression of the disease, with recurrent involuntary movements leading to discomfort and, in some cases, necessitating admission to the intensive care unit. Prompt identification and management of MDs can aid in the diagnosis and prognosis of AE. This review synthesizes current knowledge on the characteristics, underlying mechanisms, and treatment options for MDs in the context of AE.
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Affiliation(s)
- Mengting Qin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaojiao Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqing Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuying Xiang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Valdrighi A, Douglas AG, Knowlton RC, Shah M, Kleen JK. Clinical Reasoning: A Young Adult With New Seizures and Chapeau de Gendarme. Neurology 2023; 101:e1821-e1827. [PMID: 37580161 PMCID: PMC10634645 DOI: 10.1212/wnl.0000000000207827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023] Open
Abstract
The evaluation of new seizures is a common clinical query for neurologists. It can be challenging to delineate between the numerous etiologies of new focal or generalized seizures and, if focal, to localize their onset. In this case report, we present a 26-year-old patient with a new onset of stereotyped events concerning for seizures featuring facial grimacing, dystonic left-hand posturing, and convulsions with immediate return to baseline. Throughout the case, we highlight a stepwise diagnostic approach to the evaluation of new-onset seizures, discuss clues that seizure semiology can provide for localization of ictal onset, and review a novel and atypical presentation of a disease entity frequently encountered by neurologists.
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Affiliation(s)
- Alexandria Valdrighi
- From the Department of Child Neurology (A.V.), University of California, San Francisco; Department of Neurology (A.G.D.), University of Pennsylvania, Philadelphia; and Department of Neurology (R.C.K., M.S., J.K.K.), University of California, San Francisco.
| | - Anne G Douglas
- From the Department of Child Neurology (A.V.), University of California, San Francisco; Department of Neurology (A.G.D.), University of Pennsylvania, Philadelphia; and Department of Neurology (R.C.K., M.S., J.K.K.), University of California, San Francisco
| | - Robert C Knowlton
- From the Department of Child Neurology (A.V.), University of California, San Francisco; Department of Neurology (A.G.D.), University of Pennsylvania, Philadelphia; and Department of Neurology (R.C.K., M.S., J.K.K.), University of California, San Francisco
| | - Maulik Shah
- From the Department of Child Neurology (A.V.), University of California, San Francisco; Department of Neurology (A.G.D.), University of Pennsylvania, Philadelphia; and Department of Neurology (R.C.K., M.S., J.K.K.), University of California, San Francisco
| | - Jonathan K Kleen
- From the Department of Child Neurology (A.V.), University of California, San Francisco; Department of Neurology (A.G.D.), University of Pennsylvania, Philadelphia; and Department of Neurology (R.C.K., M.S., J.K.K.), University of California, San Francisco
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He J, Lian Y. Clinical study of autonomic dysfunction in patients with autoimmune encephalitis. Immunobiology 2023; 228:152711. [PMID: 37543010 DOI: 10.1016/j.imbio.2023.152711] [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: 04/20/2023] [Revised: 06/25/2023] [Accepted: 07/15/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a collective name, covering an emerging spectrum of autoimmune-mediated neurological diseases related to antibodies and synaptic or intracellular proteins. Anti-NMDAR, anti-LGI1, and anti-GABABR are three types of neuronal cell surface antibodies. Autonomic dysfunction represents a frequently occurring clinical manifestation. This observational study purposes to investigate comparisons between two groups with or without autonomic dysfunction and detect the autonomic dysfunction and other indexes in anti-NMDAR, anti-LGI1, and anti-GABABR cohorts. METHODS Patients with anti-NMDAR, anti-LGI1 and anti-GABABR encephalitis were recruited from the May 2017 to the April 2022. The following information was recorded: age, age at onset, tumor presence, gender, prodromal symptoms, clinical manifestations, cranial magnetic resonance imaging, cerebrospinal fluid and blood examinations, and immunotherapy. RESULTS There were totally 161 patients enrolled in this study. Among these participants, 104 individuals (64.6%) presented autonomic dysfunction and the remaining 57 (35.4%) were free of autonomic dysfunction. Sinus tachycardia was the most common autonomic dysfunction, followed by pollakiuria/uroclepsia, feverscence, central hypoventilation, sinus bradycardia, constipation, uroschesis, hyperhidrosis, hypersalivation, hypotension, and early satiety/emesis. Compared to patients without autonomic dysfunction, those with autonomic dysfunction had a higher incidence of central hypoventilation and ICU admissions. Meanwhile, in both groups with or without autonomic dysfunction, meatal behavior disorder, cognitive impairment, and epileptic seizure were three most common clinical manifestations. There were no significant differences in cranial magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) examination, antibody titers and number of immunotherapy types. Further analysis of AE mediated by distinct neuronal surface antibodies demonstrated that there were 85 anti-NMDAR, 56 anti-LGI1, and 20 anti-GABABR encephalitis patients. The significant differences between these three cohorts appeared in age, tumor presence, fervescence presence and antibody titers. CONCLUSION This study demonstrated the comparisons between autonomic dysfunction group and autonomic dysfunction-free group and provided insights into better diagnosis and treatment.
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Affiliation(s)
- Jiao He
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China.
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Wang Y, Ren X, Shen Y, Hua Y, Xu L, Zhang W, Sheng G, Jiang P, Yuan Z, Liu L, Gao F. Case report: Pediatric anti-gamma aminobutyric acid-B receptor encephalitis with benign prognosis. Front Pediatr 2023; 11:1104001. [PMID: 36937947 PMCID: PMC10020610 DOI: 10.3389/fped.2023.1104001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Objective To explore the clinical characteristics of pediatric anti-gamma-aminobutyric acid-B receptor (GABABR) encephalitis to enhance the understanding and improve the diagnostic and therapeutic strategies for this disease. Methods We report a rare case of a female pediatric patient with anti-GABABR encephalitis who was treated at the Children's Hospital of Zhejiang University School of Medicine. Literature search was performed to explore the clinical characteristics of pediatric anti-GABABR encephalitis. Results The patient exhibited recurrent epileptic seizure, status epilepticus, and psychiatric symptoms at the age of 11 years and 10 months. Anti-GABABR antibodies were positive in cerebrospinal fluid and serum. Brain magnetic resonance imaging (MRI) exhibited abnormal signals in the left hippocampus. Symptoms and abnormality of brain MRI were improved after administration of immunosuppressants, anti-seizure and antipsychotic drugs. Two of pediatric anti-GABABR encephalitis with clinical data were identified through literature search. Analysis of these three cases suggested that the pediatric patients primarily experienced limbic encephalitis, with no tumor incidence. A favorable immunotherapy response was demonstrated with a superior prognosis in all the cases. Conclusions We reported a pediatric anti-GABABR encephalitis case with early age of onset. Promt autoimmune antibody testing and tumor screening, as well as immunomodulatory treatment immediately after a definitive diagnosis are warranted to improve prognosis.
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Affiliation(s)
- Yeping Wang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Department of Pediatric, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Xiaoyan Ren
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Department of Neurology, Ningbo Women and Children’s Hospital, Ningbo, China
| | - Yu Shen
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Department of Neurology, Ningbo Women and Children’s Hospital, Ningbo, China
| | - Yi Hua
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lu Xu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weiran Zhang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guoxia Sheng
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Peifang Jiang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhefeng Yuan
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Liu Liu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Correspondence: Feng Gao Liu Liu
| | - Feng Gao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Correspondence: Feng Gao Liu Liu
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Zhong R, Chen Q, Zhang X, Zhang H, Lin W. Risk Factors for Mortality in Anti-NMDAR, Anti-LGI1, and Anti-GABABR Encephalitis. Front Immunol 2022; 13:845365. [PMID: 35320933 PMCID: PMC8934853 DOI: 10.3389/fimmu.2022.845365] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/11/2022] [Indexed: 12/23/2022] Open
Abstract
ObjectiveWe aimed to investigate the mortality rate and identify the predictors of death in patients with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis.MethodsPatients with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis were recruited from the Neurology Department of the First Hospital of Jilin University from March 2015 to November 2021. The primary outcome variable was a binary variable of death vs. survival. The potential risk factors for mortality were evaluated. The mortality rates were determined, and the independent predictors of death were identified using multivariable logistic regression analysis.ResultsA total of 100 hospitalized patients with anti-NMDAR, anti-LGI1, or anti-GABABR encephalitis were included in the final analysis. Fifteen patients (15%) died during a median follow-up period of 18 months. The mortality rates were 10% for anti-NMDAR encephalitis, 2.8% for anti-LGI1 encephalitis, and 41.7% for anti-GABABR encephalitis. The multivariable analysis results showed that older age at onset [adjusted odds ratio (OR) = 1.017, 95% confidence interval (CI) = 1.009–1.136; p = 0.023] was independently associated with an increased risk of death. Antibody type was also associated with mortality. Patients with anti-GABABR encephalitis had 13.458-fold greater odds of dying than patients with anti-LGI1 encephalitis (adjusted OR = 13.458, 95% CI = 1.270–142.631; p = 0.031).ConclusionThe general mortality rate of anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis was 15%. Age at onset and type of autoimmune encephalitis antibody were independent predictors of death in these patients.
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Affiliation(s)
- Rui Zhong
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qingling Chen
- Department of Hepatology, Second People’s Clinical College of Tianjin Medical University, Tianjin, China
| | - Xinyue Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hanyu Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Weihong Lin,
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Huang F, Wu Y, Nong W, Mao F, Cao X, Huang W, Zheng J. Factors Influencing the Withdrawal of Antiepileptic Drugs in Adult Patients with Symptomatic Seizures Secondary to Neuronal Surface Antibodies-Associated Autoimmune Encephalitis. J Inflamm Res 2022; 15:927-937. [PMID: 35173460 PMCID: PMC8842726 DOI: 10.2147/jir.s347893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/16/2022] [Indexed: 12/27/2022] Open
Affiliation(s)
- Fang Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
| | - Yu Wu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
| | - Weidong Nong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
| | - Fengping Mao
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
| | - Xiaoli Cao
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
| | - Wen Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
- Correspondence: Wen Huang; Jinou Zheng, Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, No. 6 shuangyong Road, Qingxiu District, Nanning, 530021, Guangxi, People’s Republic of China, Tel +86-18277197957; 86-13977166059, Email ;
| | - Jinou Zheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, People’s Republic of China
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Shan W, Yang H, Wang Q. Neuronal Surface Antibody-Medicated Autoimmune Encephalitis (Limbic Encephalitis) in China: A Multiple-Center, Retrospective Study. Front Immunol 2021; 12:621599. [PMID: 33679765 PMCID: PMC7928315 DOI: 10.3389/fimmu.2021.621599] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/27/2021] [Indexed: 12/15/2022] Open
Abstract
Objective: The epidemiological characteristics of patients with antibody-medicated autoimmune encephalitis in China remain unclear, and a large-scale epidemiological survey is necessary. Methods: A multiple-center retrospective study was performed. We collected 1,047 patients with suspected autoimmune encephalitis and ultimately enrolled 778 defined patients across centers in China. All patients were positive for serum [or cerebrospinal fluid (CSF)] antibodies. Demographic information and clinical data from January 2014 to January 2019 from 22 centers in China were reviewed. Results: A total of 778 patients with autoimmune encephalitis were enrolled in the study. In general, the ratio of males to females was ~1.2:1. The main subtypes of autoimmune encephalitis were NMDAR-AE (61.35%), LGI-1-AE (20.61%), and GABAbR-AE (12.40%). According to the characteristics of age of onset, the incidence of autoimmune encephalitis showed a “double peak” distribution entailing a 20-year-old age group and a 60-year-old age group. We next analyzed the proportion of patients with tumors in this cohort. More specifically, there were 34 patients with tumors and 85 with tumor marker positivity. Relapse occurred in 81 patients within at least 1 year's follow up study: 52 with NMDAR-AE (18.2%); 19 with LGI-1-AE (16.8%); 5 with GABAbR-AE (9%); and 3 with CASPR2-AE. Interpretation: Due to the vast differences in demographic features, the incidence of cancer and the genetic characteristics between the populations in China and Western countries, the demographics, sex distribution, concomitant tumor rate, clinical features, and relapse characteristics associated with autoimmune encephalitis in China shows a similar profile with Western countries with some minor differences.
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Affiliation(s)
- Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Clinical Medicine of Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - Huajun Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Clinical Medicine of Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Clinical Medicine of Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
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