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Damman S, Sukpornchairak P, Ahituv A, Chen A, Wang D, Sawlani K, Steriade C, Abboud H. Unilateral cortical autoimmune encephalitis: A case series and comparison to late-onset Rasmussen's encephalitis. J Neuroimmunol 2024; 391:578350. [PMID: 38728930 DOI: 10.1016/j.jneuroim.2024.578350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To report a novel anatomical pattern of autoimmune encephalitis characterized by strictly unilateral cortical inflammation and a clinical picture overlapping with late-onset Rasmussen's encephalitis. METHODS We retrospectively gathered data of patients identified at two tertiary referral academic centers who met inclusion criteria. RESULTS We identified twelve cases (average age 65, +/- 19.8 years, 58% female). All patients had unilateral cortical inflammation manifesting with focal seizures, cognitive decline, hemicortical deficits, and unilateral MRI and/or EEG changes. Six cases were idiopathic, two paraneoplastic, two iatrogenic (in the setting of immune checkpoint inhibitors), and two post-COVID-19. Serologically, ten patients were seronegative, one had high titer anti-GAD65, and one had anti-NMDAR. Five patients met Rasmussen's encephalitis criteria, and six did not fully meet the criteria but had symptoms significantly overlapping with the condition. Most patients had significant improvement with immunotherapy. DISCUSSION Unilateral cortical AE seems to be more prevalent in the elderly and more frequently idiopathic and seronegative. Patients with this anatomical variant of autoimmune encephalitis have overlapping features with late-onset Rasmussen's encephalitis but are more responsive to immunotherapy. In cases refractory to immunotherapy, interventions used in refractory Rasmussen's encephalitis may be considered, such as functional hemispherectomy.
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Affiliation(s)
- Sophia Damman
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Persen Sukpornchairak
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Amit Ahituv
- Department of Neurology, New York University Langone Health, 222 East 41st Street, 14th Floor New York, NY 10017, USA
| | - Alex Chen
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - David Wang
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Komal Sawlani
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, 222 East 41st Street, 14th Floor New York, NY 10017, USA
| | - Hesham Abboud
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Multiple Sclerosis and Neuroimmunology Program, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Daoud M, Durelle C, Fierain A, N EY, Wendling F, Ruffini G, Benquet P, Bartolomei F. Long-term Effect of Multichannel tDCS Protocol in Patients with Central Cortex Epilepsies Associated with Epilepsia Partialis Continua. Brain Topogr 2024:10.1007/s10548-024-01045-3. [PMID: 38446345 DOI: 10.1007/s10548-024-01045-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/21/2024] [Indexed: 03/07/2024]
Abstract
Epilepsia partialis continua (EPC) is a rare type of focal motor status epilepticus that causes continuous muscle jerking in a specific part of the body. Experiencing this type of seizure, along with other seizure types, such as focal motor seizures and focal to bilateral tonic-clonic seizures, can result in a disabling situation. Non-invasive brain stimulation methods like transcranial direct current stimulation (tDCS) show promise in reducing seizure frequency (SF) when medications are ineffective. However, research on tDCS for EPC and related seizures is limited. We evaluated personalized multichannel tDCS in drug-resistant EPC of diverse etiologies for long-term clinical efficacy We report three EPC patients undergoing a long-term protocol of multichannel tDCS. The patients received several cycles (11, 9, and 3) of five consecutive days of stimulation at 2 mA for 2 × 20 min, targeting the epileptogenic zone (EZ), including the central motor cortex with cathodal electrodes. The primary measurement was SF changes. In three cases, EPC was due to Rasmussen's Encephalitis (case 1), focal cortical dysplasia (case 2), or remained unknown (case 3). tDCS cycles were administered over 6 to 22 months. The outcomes comprised a reduction of at least 75% in seizure frequency for two patients, and in one case, a complete cessation of severe motor seizures. However, tDCS had no substantial impact on the continuous myoclonus characterizing EPC. No serious side effects were reported. Long-term application of tDCS cycles is well tolerated and can lead to a considerable reduction in disabling seizures in patients with various forms of epilepsy with EPC.
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Affiliation(s)
- M Daoud
- Aix-Marseille Univ, INSERM U1106, Institut de Neurosciences des Systèmes, Marseille, France
| | - C Durelle
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France
| | - A Fierain
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France
| | - El Youssef N
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France
| | - F Wendling
- Univ Rennes, INSERM, LTSI-U1099, Rennes, F-35000, France
| | - G Ruffini
- Neuroelectrics Barcelona, Av. Tibidabo 47 bis, Barcelona, 08035, Spain
| | - P Benquet
- Univ Rennes, INSERM, LTSI-U1099, Rennes, F-35000, France
| | - F Bartolomei
- Aix-Marseille Univ, INSERM U1106, Institut de Neurosciences des Systèmes, Marseille, France.
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France.
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Trapp N, Co DO, Rebsamen S, Ikonomidou C, Ahmed R, Knox A. Bilateral Rasmussen Encephalitis: Good Outcome Following Hemispherotomy. Pediatr Neurol 2024; 151:1-4. [PMID: 38041904 DOI: 10.1016/j.pediatrneurol.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/20/2023] [Accepted: 10/16/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Bilateral Rasmussen encephalitis is a rare variant of a debilitating, typically unihemispheric disease with limited treatment options. Few cases with bilateral histopathology have been reported, all with poor seizure control following surgery. Here we report a favorable outcome following hemispherotomy in a four-year-old male with biopsy-confirmed bilateral disease. CASE The patient presented with right hemispheric focal seizures with behavioral arrest and over a year progressed to left lower extremity clonic seizures, epilepsia partialis continua, and loss of ambulation, with transient response to steroids and tacrolimus. Histopathology confirmed bilateral disease. The patient developed super-refractory status epilepticus and underwent right functional hemispherotomy 4.5 years after initial presentation. In a 2.5-year follow-up period, an Engel 1D outcome classification was observed with substantially improved quality of life. CONCLUSION Previous reports of bilateral Rasmussen encephalitis describe universally poor outcomes, and hemispherotomy is often considered contraindicated. However, hemispherotomy in a patient with bilateral Rasmussen encephalitis may have a good outcome if seizures are unihemispheric.
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Affiliation(s)
- Noah Trapp
- Section of Pediatric Neurology, Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Dominic O Co
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Susan Rebsamen
- Section of Neuroradiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris Ikonomidou
- Section of Pediatric Neurology, Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Raheel Ahmed
- Section of Pediatric Neurosurgery, Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrew Knox
- Section of Pediatric Neurology, Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Thomé U, Batista LA, Rocha RP, Terra VC, Hamad APA, Sakamoto AC, Santos AC, Santos MV, Machado HR. The Important Role of Hemispherotomy for Rasmussen Encephalitis: Clinical and Functional Outcomes. Pediatr Neurol 2024; 150:82-90. [PMID: 37992429 DOI: 10.1016/j.pediatrneurol.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/05/2023] [Accepted: 10/20/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is characterized by pharmacoresistant epilepsy and progressive neurological deficits concurrent with unilateral hemispheric atrophy. Evidence of an inflammatory autoimmune process has been extensively described in the literature; however, the precise etiology of RE is still unknown. Despite data supporting a beneficial effect of early immunosuppressive and immunomodulatory interventions, surgical disconnection of the affected hemisphere is considered the treatment of choice for these patients. The aim of this study was to report a series of children and adolescents who underwent hemispheric surgery (HS) for the treatment of RE, analyzing their clinical, electrographic, and neuroimaging features pre-operatively, as well as their postoperative status, including seizure and functional outcomes. METHODS All patients with RE who underwent HS in the Epilepsy Surgery Center (CIREP) of the University Hospital of Ribeirão Preto Medical School, between 1995 and 2020 were retrospectively reviewed. Preoperative and postoperative analyses included gender; age at epilepsy onset; seizure semiology; seizure frequency; interictal and ictal electroencephalographic (EEG) findings; age at surgery; duration of epilepsy; surgical complications; duration of follow-up; histopathological findings; and postoperative seizure, cognitive, and functional outcomes. RESULTS Forty-four patients were evaluated. Mean age at seizure onset and epilepsy duration was 6 years and 2.5 years, respectively. Mean age at surgery was 9 years, with an average follow-up ranging from 3 months to 23 years. All patients presented with severe epilepsy and distinct neurological abnormalities on MRI. Before HS, different degrees of abnormal intellectual performance as well as hemiparesis were seen in 86% and 90%, respectively. Histopathology examination confirmed this diagnosis in 95% patients. At the last follow-up, 68% of patients were seizure free, and 70% were classified as Engel Class I or II. Postoperatively, the cognitive status remained unchanged in 64% of patients. Likewise, the gross motor function remained unchanged in 54% of patients and 74% had functional hand ability after HS. CONCLUSIONS Considering the progressive damage course of RE, hemispheric surgery should be offered to pediatric patients. It has manageable risks and results in good seizure outcome, and the preoperative functional status of these children is often preserved (even when the left hemisphere is involved), thus improving their quality of life.
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Affiliation(s)
- Ursula Thomé
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - Larissa A Batista
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Renata P Rocha
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Vera C Terra
- Epilepsy Center, Nsa Sra das Graças Hospital, Curitiba, Brazil
| | - Ana Paula A Hamad
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Americo C Sakamoto
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Antônio C Santos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Marcelo V Santos
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Hélio R Machado
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
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Han J, Fan X, Chen S. Misdirection due to early magnetoencephalographic presentation and management in Rasmussen encephalitis: a case report. Front Neurol 2023; 14:1261104. [PMID: 38099072 PMCID: PMC10720357 DOI: 10.3389/fneur.2023.1261104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Rasmussen encephalitis is a rare and unexplained chronic brain hemispheric inflammatory disease. We report a case of epilepsy in which magnetoencephalography showed dipoles localized only in the operculum. Because the patient's clinical presentation and examination findings did not meet the diagnostic criteria for Rasmussen encephalitis, he underwent cortical electroencephalogram (ECoG) record and limited resection surgery. However, the seizures were not relieved after surgery, and imaging findings showed significant features of hemisphere atrophy. This young male patient was eventually diagnosed with Rasmussen encephalitis and the seizures was completely vanished following hemispherectomy. His data can provide a reference for the early identification of this devastating disease.
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Affiliation(s)
| | | | - Sichang Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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Yahya EH, Khadija L, Nourrelhouda B, Nazik A, Latifa C, Siham EH. A Case Report of Rasmussen Encephalitis and its Stages: The Important Role of Imaging. Glob Pediatr Health 2023; 10:2333794X231214084. [PMID: 38033766 PMCID: PMC10685761 DOI: 10.1177/2333794x231214084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
Relatively rare, Rasmussen encephalitis is a chronic inflammatory disease conditioning a single cerebral hemisphere. It is a progressive pathology with different stages clinically and on MRI. Therefore, imaging has an important role in evoking the diagnosis and also excluding other possible etiologies. We report a case of Rasmussen encephalitis with 2 different stages on MRI and also provide a review of the role of imaging in diagnostic criteria, differential diagnoses, and stages of this pathology.
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Nava BC, Costa UT, Hamad APA, Garcia CAB, Sakamoto AC, Aragon DC, Machado HR, Santos MV. Long-term seizure outcome and mobility after surgical treatment for Rasmussen encephalitis in children: A single-center experience. Epileptic Disord 2023; 25:749-757. [PMID: 37589547 DOI: 10.1002/epd2.20147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Rasmussen Encephalitis (RE) is a rare inflammatory neurodegenerative disease associated with refractory seizures, hemiparesis, and cognitive deterioration, due to lateralized cortical atrophy. Hemispheric surgery (hemispherotomy) is the mainstay of treatment, but its unavoidable motor deficits and lack of long-term data regarding seizure outcomes can make patients and families apprehensive to undergo this procedure. The present study aimed at analyzing the results of surgical treatment for RE from a motor and epilepsy standpoint, and mitigate such concerns. METHODS Clinical and operative data were retrospectively collected from medical records of pharmacoresistant patients treated with functional hemispherectomy at a tertiary reference center for epilepsy surgery, during a 24-year period (1996-2020). Variables such as age of epilepsy onset, seizure semiology, seizure frequency, immunomodulatory therapy, age at surgery, duration of epilepsy, surgical procedures and complications, number of medications used preoperatively and postoperatively were described and statistically analyzed. RESULTS Forty-three (43) patients were included in this study. Mean age of epilepsy onset was 6.14 years, the average interval between epilepsy onset and hemispherotomy was 2.21 years. and the mean age at surgery was 8.28 years. Thirty patients (69.7%) were Engel I at their last follow-up, of whom 23 (56.4%) were Engel Ia, within a mean follow-up of 11.3 years. Duration of epilepsy, seizure frequency, and age at surgery, among others, did not correlate with seizure outcome, except the use of immunotherapy which led to worse outcomes (p < .05). Also, after surgery, motor functionality was significantly recovered (i.e., most patients returned to their previous status) with time. SIGNIFICANCE This study tackled some issues regarding the surgical treatment of this disease, particularly showing that hemispherotomy is safe and leads to potentially recoverable disability of motor functions while providing high rates of effective and long-lasting seizure control; therefore, early surgical indication should be warranted once medical refractoriness has been established.
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Affiliation(s)
- Brenda Cristina Nava
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ursula Thome Costa
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Paula Andrade Hamad
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Camila Araujo Bernardino Garcia
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Americo Ceiki Sakamoto
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Davi Casale Aragon
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Helio Rubens Machado
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcelo Volpon Santos
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Jaafar F, Obeid M, Beydoun A. Role of Early Intravenous Immunoglobulins in Halting Clinical and Radiographic Disease Progression in Rasmussen Encephalitis. Pediatr Neurol 2023; 145:30-35. [PMID: 37269621 DOI: 10.1016/j.pediatrneurol.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/29/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is a rare progressive presumed autoimmune disorder characterized by pharmacoresistant epilepsy and progressive motor and cognitive deterioration. Despite immunomodulation, more than half of the patients with RE ultimately require functional hemispherotomy. In this study, we evaluated the potential beneficial effects of early initiation of immunomodulation in slowing disease progression and preventing the need for surgical interventions. METHODS A retrospective chart review over a 10-year period was conducted at the American University of Beirut Medical Center to identify patients with RE. Data were collected on seizure characteristics, neurological deficits, electroencephalography, brain magnetic resonance imaging results (including volumetric analyses for an objective assessment of radiographic progression), and treatment modalities. RESULTS Seven patients met the inclusion criteria for RE. All patients received intravenous immunoglobulins (IVIGs) as soon as the diagnosis was entertained. Five patients with only monthly to weekly seizures at the time of IVIG initiation had favorable outcomes without resorting to surgery, along with a relative preservation of the gray matter volumes in the affected cerebral hemispheres. Motor strength was preserved in those patients, and three were seizure free at their last follow-up visit. The two patients who required hemispherotomy were already severely hemiparetic and experiencing daily seizures at the time of IVIG initiation. CONCLUSIONS Our data suggest that the early initiation of IVIG as soon as a diagnosis of RE is suspected, and particularly before the appearance of motor deficits and intractable seizures, can maximize the beneficial effects of immunomodulation in terms of controlling seizures and reducing the rate of cerebral atrophy.
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Affiliation(s)
- Fatima Jaafar
- Division of Child Neurology, Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Makram Obeid
- Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
| | - Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon.
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Jagtap SA, Deshmukh Y, Joshi A, Patil S, Kurwale N, Nilegaonkar S. "Epilepsia partialis continua (EPC) and unilateral cortical-subcortical FLAIR-hyperintense Lesion in Rasmussen's Encephalitis: is it diagnostic?". Epileptic Disord 2023. [PMID: 36939721 DOI: 10.1002/epd2.20033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/22/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Rasmussen encephalitis (RE) is a focal encephalitis, characterised by epilepsia partialis continua (EPC) with or without seizures and progressive unilateral deficits. Imaging characteristics of RE has been rarely described in detail in relation with EPC. So, the study aimed to explore if any relationship exists between the imaging characteristics and the presence or evolution of EPC in patients with RE. METHODS This retrospective study included eleven patients with RE fulfilling the European consensus statement on RE followed between 2015 and 2020. RESULTS The mean age for onset of seizures was 12 years (range 2.5 -24 years). Seven patients had limb EPCs, two had face EPCs, face and limb EPC in one and lingual EPC in one patient. The first MRI was done within one day to one month of onset of seizures. It was normal in two patients, and showed only cortical atrophy, focal or hemispheric in four patients, caudate atrophy in two, and cortical or subcortical hyperintensity (HI) in six patients. Follow up MRI, within 3 weeks to 6 months of onset of EPC (mean 1.6 month) showed paramedian frontal HI with limb EPC in six patients. Insular HI in four patients; two had facial EPCs while lingual EPC and limb EPC with facial EPC was observed in one patient each. SIGNIFICANCE FLAIR HI and focal cortical atrophy on MRI is most common finding in early course of RE. T2 and FLAIR hyper intensity in the paramedian frontal or insular cortex may antedate the onset of EPC or may occur simultaneously with EPC.
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Affiliation(s)
- Sujit A Jagtap
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar hospital and research centre, Pune, India
| | - Yogeshwari Deshmukh
- Department of Radiology, Star imaging centre and research centre, Pune, India
| | - Aniruddha Joshi
- Department of Radiology, Deenanath Mangeshkar hospital and research centre, Pune, India
| | - Sandeep Patil
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar hospital and research centre, Pune, India.,D.Y. Patil Medical College, Pune.,Deenanath Mangeshkar hospital and research centre, Pune, India
| | - Nilesh Kurwale
- Bajaj Allianz Comprehensive Center for Epilepsy Care, Deenanath Mangeshkar hospital and research centre, Pune, India.,D.Y. Patil Medical College, Pune.,Deenanath Mangeshkar hospital and research centre, Pune, India
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Leitner DF, Lin Z, Sawaged Z, Kanshin E, Friedman D, Devore S, Ueberheide B, Chang JW, Mathern GW, Anink JJ, Aronica E, Wisniewski T, Devinsky O. Brain molecular mechanisms in Rasmussen encephalitis. Epilepsia 2023; 64:218-230. [PMID: 36336987 PMCID: PMC9852002 DOI: 10.1111/epi.17457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study was undertaken to identify molecular mechanisms in brain tissue of Rasmussen encephalitis (RE) when compared to people with non-RE epilepsy (PWE) and control cases using whole exome sequencing (WES), RNAseq, and proteomics. METHODS Frozen brain tissue (ages = 2-19 years) was obtained from control autopsy (n = 14), surgical PWE (n = 10), and surgical RE cases (n = 27). We evaluated WES variants in RE associated with epilepsy, seizures, RE, and human leukocyte antigens (HLAs). Differential expression was evaluated by RNAseq (adjusted p < .05) and label-free quantitative mass spectrometry (false discovery rate < 5%) in the three groups. RESULTS WES revealed no common pathogenic variants in RE, but several rare and likely deleterious variants of unknown significance (VUS; ANGPTL7/MTOR, SCN1A, FCGR3B, MTOR) and more common HLA VUS in >25% of RE cases (HLA-DRB1, HLA-DQA2), all with allele frequency < 5% in the general population. RNAseq in RE versus PWE (1516 altered transcripts) revealed significant activation of crosstalk between dendritic and natural killer cells (p = 7.94 × 10-6 , z = 2.65), in RE versus control (7466 transcripts) neuroinflammation signaling activation (p = 6.31 × 10-13 , z = 5.07), and in PWE versus control (945 transcripts) phagosome formation activation (p = 2.00 × 10-13 , z = 5.61). Proteomics detected fewer altered targets. SIGNIFICANCE In RE, we identified activated immune signaling pathways and immune cell type annotation enrichment that suggest roles of the innate and adaptive immune responses, as well as HLA variants that may increase vulnerability to RE. Follow-up studies could evaluate cell type density and subregional localization associated with top targets, clinical history (neuropathology, disease duration), and whether modulating crosstalk between dendritic and natural killer cells may limit disease progression.
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Affiliation(s)
- Dominique F. Leitner
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ziyan Lin
- Applied Bioinformatics Laboratories, NYU Grossman School of Medicine, New York, NY, USA
| | - Zacharia Sawaged
- Applied Bioinformatics Laboratories, NYU Grossman School of Medicine, New York, NY, USA
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Sasha Devore
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Beatrix Ueberheide
- Center for Cognitive Neurology, Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Proteomics Laboratory, Division of Advanced Research Technologies, NYU Grossman School of Medicine, New York, NY, USA
- Department of Biochemistry and Molecular Pharmacology, NYU Grossman School of Medicine, New York, NY, USA
| | - Julia W. Chang
- Departments of Neurosurgery and Psychiatry, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gary W. Mathern
- Departments of Neurosurgery and Psychiatry, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jasper J. Anink
- Department of (Neuro) Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, the Netherlands
| | - Eleonora Aronica
- Department of (Neuro) Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, the Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
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11
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Liu P, Lin X, Zong S, Yan Y, Liu Z, Lu Q, Chang Q, Wu S. A Special Case of Relapsing-Remitting Bilateral Encephalitis: Without Epilepsy, but Responding to Rituximab and with a Brain Biopsy Coinciding with Rasmussen Encephalitis. Brain Sci 2022; 13. [PMID: 36671998 DOI: 10.3390/brainsci13010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/05/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
A nine-year-old boy manifested with headache, progressive mild cognitive decline and hemiparesis, but without clinical epileptic seizures (with abnormal EEG waves). Brain magnetic resonance imaging (MRI) showed bilateral cortical lesions mainly on the right hemisphere, and new lesions developed in frontal, parietal, occipital and temporal lobes around the old lesions presenting as a lace-like or ring-like enhancement in T1 with contrast over a disease course of five years. A suspected diagnosis of primary angiitis of the central nervous system was initially considered. Treated with high-dose corticosteroids, intravenous immunoglobulins and monthly pulse cyclophosphamide, his symptoms worsened with the intracranial lesion progression. Brain biopsy of the right frontal lobe was performed nearly five years after onset; prominent neuronal loss, a microglial nodule, as well as parenchymal and perivascular lymphocytic infiltrate within the cortex were found, which coincided with RE pathology changes. Encouragingly, after a regimen of rituximab, lesions on the follow-up brain MRI tended to be stable. Apparently, it was immune-mediated, but did not strictly fit any known disease entity, although it was similar to RE. We summarize this unique case, including clinical characteristics, imaging and pathology findings. We also discuss the diagnosis and treatment, focusing on comparison to RE as well as other possible neurological diseases.
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12
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Borne A, Perrone-Bertolotti M, Jambaqué I, Castaignède C, Dorfmüller G, Ferrand-Sorbets S, Baciu M, Bulteau C. Cognitive outcome after left functional hemispherectomy on dominant hemisphere in patients with Rasmussen encephalitis: beyond the myth of aphasia. Patient series. J Neurosurg Case Lessons 2022; 4:CASE22410. [PMID: 36443955 PMCID: PMC9705523 DOI: 10.3171/case22410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Rasmussen encephalitis is a rare chronic neurological pathology frequently treated with functional hemispherectomy (or hemispherotomy). This surgical procedure frees patients of their severe epilepsy associated with the disease but may induce cognitive disorders and notably language alterations after disconnection of the left hemisphere. OBSERVATIONS The authors describe longitudinally 3 cases of female patients with Rasmussen encephalitis who underwent left hemispherotomy in childhood and benefited from a favorable cognitive outcome. In the first patient, the hemispherotomy occurred at a young age, and the recovery of language and cognitive abilities was rapid and efficient. The second patient benefited from the surgery later in childhood. In addition, she presented a reorganization of language and memory functions that seem to have been at the expense of nonverbal ones. The third patient was a teenager during surgery. She benefited from a more partial cognitive recovery with persistent disorders several years after the surgery. LESSONS Recovery of cognitive functions, including language, occurs after left hemispherotomy, even when performed late in childhood. Therefore, the surgery should be considered as early as possible to promote intercognitive reorganization.
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Affiliation(s)
- Anna Borne
- University of Grenoble Alpes, CNRS, LPNC, Grenoble, France
| | | | - Isabelle Jambaqué
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
- University of Paris Cité, MCLab, Institute of Psychology, Boulogne-Billancourt, France
| | - Clémence Castaignède
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
| | - Georg Dorfmüller
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
| | - Sarah Ferrand-Sorbets
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
| | - Monica Baciu
- University of Grenoble Alpes, CNRS, LPNC, Grenoble, France
| | - Christine Bulteau
- Department of Paediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France; and
- University of Paris Cité, MCLab, Institute of Psychology, Boulogne-Billancourt, France
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13
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Prager C, Kühne F, Tietze A, Kaindl AM. Is cannabidiol worth a trial in Rasmussen encephalitis? Eur J Paediatr Neurol 2022; 37:53-55. [PMID: 35093803 DOI: 10.1016/j.ejpn.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 01/04/2022] [Accepted: 01/09/2022] [Indexed: 11/30/2022]
Abstract
We report 3 patients (age 8, 13 and 14 years) with drug-resistant epilepsy due to Rasmussen encephalitis treated with cannabidiol in addition to their current antiseizure medication (ASM). In all three patients we observed a positive effect, which seemed to surpass the efficacy that would be expected from a different fourth or fifth antiseizure drug used during the course of the disease.
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Affiliation(s)
- Christine Prager
- Charité - Universitätsmedizin Berlin, Department of Pediatric Neurology, Augustenburger Platz 1, 13353, Berlin, Germany; Charité - Universitätsmedizin Berlin, Center for Chronically Sick Children (Sozialpädiatrisches Zentrum, SPZ), Augustenburger Platz 1, 13353, Berlin, Germany
| | - Fabienne Kühne
- Charité - Universitätsmedizin Berlin, Department of Pediatric Neurology, Augustenburger Platz 1, 13353, Berlin, Germany; Charité - Universitätsmedizin Berlin, Center for Chronically Sick Children (Sozialpädiatrisches Zentrum, SPZ), Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Anna Tietze
- Charité - Universitätsmedizin Berlin, Institute of Neuroradiology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Angela M Kaindl
- Charité - Universitätsmedizin Berlin, Department of Pediatric Neurology, Augustenburger Platz 1, 13353, Berlin, Germany; Charité - Universitätsmedizin Berlin, Center for Chronically Sick Children (Sozialpädiatrisches Zentrum, SPZ), Augustenburger Platz 1, 13353, Berlin, Germany; Charité - Universitätsmedizin Berlin, Institute of Cell- and Neurobiology, Charitéplatz 1, 10117, Berlin, Germany
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14
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Liu D, Yuguang G, Zhou J, Zhai F, Chen L, Li T, Wang M, Luan G. The influencing factors and changes of cognitive function within 40 Rasmussen encephalitis patients that received a hemispherectomy. Neurol Res 2022; 44:700-707. [PMID: 35172696 DOI: 10.1080/01616412.2022.2039526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the influencing factors and cognitive functional changes in Rasmussen encephalitis (RE) patients who received a hemispherectomy. METHODS Forty RE patients underwent a hemispherectomy with at least a 2 years follow- up were included in this study . Postoperative seizure outcomes were evaluated according to the Engle classification scale. Univariate analysis and a multivariate logistic regression model in a backward fashion were used to identify the potential predictors of cognitive function. RESULTS All 40 patients had an Engle classification outcome at a 2 years follow-up. Univariate and multivariate analyses revealed that seizure duration (OR 10.06, 95% CI 1.54-3.85, p = 0.038), age at surgery (OR 3.06, 95% CI 1.21-3.56, p = 0.043), and MRI score (OR 0.09, 95% CI 0.01-0.67 p = 0.024) are associated with postoperative cognitive outcomes respectively. Moreover, VIQ and PIQ were negatively correlated linearly with duration of seizures and MRI score. Patients with a good VIQ and PIQ before the operation were more likely to have a better VIQ and PIQ postoperatively (p < 0.001 and p < 0.001, respectively). And, operation side is an important factor affecting cognitive function; therefore, a left hemispherectomy has a greater impact on the patient's IQ and language. CONCLUSIONS RE patients' cognitive dysfunctions are improved after a hemispherectomy. Right-side operation can achieve better postoperative cognitive outcomes especially in VIQ and language. A shorter duration of seizures, early age at surgery, and less severe brain atrophy suggest better cognitive outcomes after a hemispherectomy.
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Affiliation(s)
- Dong Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guan Yuguang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Zhou
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Lingling Chen
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Mengyang Wang
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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15
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Fauser S, Elger CE, Woermann F, Bien CG. Rasmussen encephalitis: Predisposing factors and their potential role in unilaterality. Epilepsia 2021; 63:108-119. [PMID: 34820830 DOI: 10.1111/epi.17131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Rasmussen encephalitis (RE) is a progressive and destructive inflammatory disease of one hemisphere. Its cause is unknown. We investigated comorbidity and laterality factors that might predispose to RE. METHODS We retrospectively compared the histories of 160 RE patients to those with genetic generalized epilepsy (n = 154) and those with focal cortical dysplasia Type II (FCD II; n = 148). RESULTS The median/mean age at symptom onset in RE was 7/10 years (range = 1-53 years), and 58.1% of the patients were female. The female sex predominated in RE patients, with age > 7 years at disease manifestation. The left hemisphere was affected in 65.6%. Perinatal complications (preterm birth, twin pregnancies, early acquired brain lesions) were more frequent in RE than in control patients. Ipsilateral facial autoimmune conditions (scleroderma en coup de sabre, uveitis, or chorioretinitis) were only observed in RE patients (6.9%). Onset of RE was more frequently associated with fever than that of FCD II. In 33.1% of RE patients, ≥1 potential risk factor was found. Interestingly, 11.9% of patients had one-sided early brain lesions or facial autoimmune lesions ipsilateral to subsequent RE; none had such a lesion contralaterally. SIGNIFICANCE Perinatal complications and facial autoimmune conditions may act as predisposing factors for RE. Fever might trigger RE manifestation. Further genetic or infectious contributors may be identified in the future. Single or combined hits may be required to elicit or facilitate the start of the disease. Ipsilateral early comorbid lesions or facial autoimmune processes might in part explain the enigmatic unilaterality of RE.
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Affiliation(s)
- Susanne Fauser
- Department of Epileptology (Mara Hospital), Medical School, Bielefeld University, Bielefeld, Germany
| | | | - Friedrich Woermann
- Department of Epileptology (Mara Hospital), Medical School, Bielefeld University, Bielefeld, Germany.,Society of Epilepsy Research, Bielefeld, Germany
| | - Christian G Bien
- Department of Epileptology (Mara Hospital), Medical School, Bielefeld University, Bielefeld, Germany
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16
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Bakhtadze S, Lim M, Craiu D, Cazacu C. Vaccination in acute immune-mediated/inflammatory disorders of the central nervous system. Eur J Paediatr Neurol 2021; 34:118-122. [PMID: 34487956 DOI: 10.1016/j.ejpn.2021.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/13/2021] [Accepted: 07/21/2021] [Indexed: 01/06/2023]
Abstract
This review article covers the vaccination related issues in autoimmune disorders of central nervous system (CNS) including narcolepsy, anti-NMDAR encephalitis, Rasmussen encephalitis and febrile infection related epilepsy syndrome (FIRES). Beyond these conditions the immune mediated epilepsies related with autoimmune CNS disorders are discussed and indications and contraindications of vaccinations in these cases are also considered.
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Affiliation(s)
- Sophia Bakhtadze
- Department of Paediatric Neurology, Tbilisi State Medical University, 33 Vazha Pshavela ave, 0160, Tbilisi, Georgia.
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, Westminister Bridge Road, SE1 7EH, London, UK; Department Women and Children's Health, School of Life Course Sciences (SoLCS), King's College, Strand, WC2R 2LS, London, UK.
| | - Dana Craiu
- Department of Neurosciences, Pediatric Neurology Discipline II, Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Strada Dionisie Lupu No. 37, 020021, Bucharest/S2, Romania; Pediatric Neurology Clinic, Center of Expertise for Rare Disorders in Pediatric Neurology, EpiCARE Member, Sos. Berceni 10, Bucharest/S4, Romania.
| | - Cristina Cazacu
- Pediatric Neurology Clinic, Center of Expertise for Rare Disorders in Pediatric Neurology, EpiCARE Member, Sos. Berceni 10, Bucharest/S4, Romania.
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17
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Lemos VR, Aires R, Côco LZ, Domingues RB, Meyrelles SS, Vasquez EC, Pereira TMC, Campagnaro BP. Benefits of multi-day supplementation with probiotic kefir in Rasmussen encephalitis: the first case report. Nutr Neurosci 2021; 25:2390-2397. [PMID: 34459722 DOI: 10.1080/1028415x.2021.1970299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Rasmussen encephalitis (RE) is a rare inflammatory disease, characterized by unilateral hemispheric atrophy, focal intractable seizures, progressive hemiparesis, and neurological deficits. CASE REPORT The patient is a young man under pharmacotherapy for epilepsy, exhibiting classical abnormal movements, which are consider typical hallmarks of RE. During clinical care sessions, he presented many episodes of tonic-clonic seizures involving sudden loss of consciousness followed by a post-ictal phase with weakness and interaction difficulty. During the kefir supplementation, the patient presented only short-term absence seizures, quickly returning to activities. Additionally, he presented cognitive and language improvement, being more responsive to commands. The daily diary control of patient's mother and caregiver at school reported an impressive reduction in number and severity of seizures, becoming less aggressive and more involved in school activities. The serum biochemical markers showed that kefir administration caused a significant decrease of pro-inflammatory and a simultaneous increase of anti-inflammatory cytokine levels. In parallel, after treatment, this probiotic reduced reactive oxygen species levels, increased NO bioavailability, revealing antiapoptotic and antigenotoxic effects. Regarding the microbiological analysis, kefir increased Lactobacillus and Bifidobacterium species. CONCLUSION To our knowledge, this is the first case reporting remarkable beneficial effects of the probiotic kefir in RE. This case report strongly suggests kefir supplementation as a potential and safe-effective adjuvant therapeutic strategy in the control and treatment of RE.
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Affiliation(s)
- Valéria R Lemos
- Laboratory of Translational Physiology and Pharmacology, Pharmaceutical Sciences Graduate Program, Vila Velha University, Vila Velha, Espírito Santo, Brazil
| | - Rafaela Aires
- Laboratory of Translational Physiology, Physiological Sciences Graduate Program, Federal University of Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Larissa Z Côco
- Laboratory of Translational Physiology and Pharmacology, Pharmaceutical Sciences Graduate Program, Vila Velha University, Vila Velha, Espírito Santo, Brazil
| | | | - Silvana S Meyrelles
- Laboratory of Translational Physiology, Physiological Sciences Graduate Program, Federal University of Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Elisardo C Vasquez
- Laboratory of Translational Physiology and Pharmacology, Pharmaceutical Sciences Graduate Program, Vila Velha University, Vila Velha, Espírito Santo, Brazil
| | - Thiago M C Pereira
- Laboratory of Translational Physiology and Pharmacology, Pharmaceutical Sciences Graduate Program, Vila Velha University, Vila Velha, Espírito Santo, Brazil
| | - Bianca P Campagnaro
- Laboratory of Translational Physiology and Pharmacology, Pharmaceutical Sciences Graduate Program, Vila Velha University, Vila Velha, Espírito Santo, Brazil
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18
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Hammed A, Badour M, Baqla S, Amer F. Diagnosis and treatment of Rasmussen's encephalitis pose a big challenge: Two case reports and literature review. Ann Med Surg (Lond) 2021; 68:102606. [PMID: 34401124 PMCID: PMC8358639 DOI: 10.1016/j.amsu.2021.102606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 11/12/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare disease of unknown etiology that causes severe chronic unihemispheric inflammatory disease of the central nervous system mainly in children. It leads to intractable seizures, cognitive decline and progressive neurological deficits in the affected hemisphere. We report two cases of RE, as defined by fulfillment of the 2005 Bien criteria. The diagnostic challenge of characterizing this rare disease will be highlighted by the extensive serum, CSF, MR imaging and EEG data in the two patients. In addition, we will review the various forms of therapy attempted in these two patients, namely anti-epileptic drug therapy and immunomodulatory therapy. Hemispherectomy was done for the second patient with favorable outcomes of controlling seizures, but unfortunately, he died because of meningitis. Until the causes of Rasmussen's encephalitis are known, it is difficult to anticipate how treatments will improve. Such a situation creates a therapeutic dilemma; hemispherectomy is not favored because of the inevitable postoperative functional deficits, but a real risk exists that treatments used to delay progression of the disease will defer definitive surgical treatment beyond the time when an optimum post-hemispherectomy outcome could be expected. Rasmussen encephalitis (RE) causes severe chronic unihemispheric inflammatory disease. RE should be suspected in any patient with refractory seizures. Its recognition is important because early intervention with surgery can improve outcomes.
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Affiliation(s)
- Ali Hammed
- Tishreen University Hospital, Department of Neurosurgery, Lattakia, Syria
| | - Maysaa Badour
- Pediatric University Hospital, Division of Neurology, Damascus, Syria
| | - Sameer Baqla
- Pediatric University Hospital, Division of Neurology, Damascus, Syria
| | - Fatema Amer
- Pediatric University Hospital, Division of Neurology, Damascus, Syria
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19
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Narayana S, Embury LM, Shah N, Weatherspoon S, Choudhri AF, Boop FA. Noninvasive Localization of Language Cortex in an Awake 4-Year-Old Child with Rasmussen Encephalitis: A Case Report. Oper Neurosurg (Hagerstown) 2021; 18:E175-E180. [PMID: 31342072 DOI: 10.1093/ons/opz202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 04/18/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Presurgical mapping of eloquent cortex in young patients undergoing neurosurgery is critical for timely intervention, surgical planning, and minimizing postoperative deficits. However, invasive direct cortical stimulation has limited success in young children and noninvasive modalities, such as magnetoencephalography and functional MRI, require sedation, often precluding localization of critical language cortices. Transcranial magnetic stimulation (TMS), a noninvasive brain stimulation technique, is well suited to evaluate language areas in young children because it does not require the patient to remain still during mapping. CLINICAL PRESENTATION A 4-yr and 11-mo-old female patient diagnosed with epilepsia partialis continua of the right arm and face and right-sided weakness was evaluated at our institution. MRI findings and clinical examination led to the diagnosis of Rasmussen encephalitis involving left frontal lobe and insula. Language cortices were successfully identified in both hemispheres using TMS. The TMS findings aided in discussing with the family the risks of postsurgical deficits of left functional hemispherectomy, the definitive treatment for Rasmussen encephalitis. Postoperatively, the patient had intact speech and was seizure free. CONCLUSION We illustrate the feasibility and utility of TMS as a noninvasive functional mapping tool in this young child. The preoperative demonstration of bilateral language organization indicated a greater likelihood of preserved language functions postsurgery. We demonstrate that TMS is a safe and noninvasive tool to map language cortices in young children with serious epilepsy syndromes.
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Affiliation(s)
- Shalini Narayana
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Luke M Embury
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Namrata Shah
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Sarah Weatherspoon
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Asim F Choudhri
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Frederick A Boop
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
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20
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Mancardi MM, Nesti C, Febbo F, Cordani R, Siri L, Nobili L, Lampugnani E, Giacomini T, Granata T, Marucci G, Consales A, Rossi A, Luria G, Santorelli FM, Buratti S. Focal status and acute encephalopathy in a 13-year-old boy with de novo DNM1L mutation: Video-polygraphic pattern and clues for differential diagnosis. Brain Dev 2021; 43:644-651. [PMID: 33485697 DOI: 10.1016/j.braindev.2020.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pathogenic variants in the dynamin 1 like gene are related to abnormal mitochondrial dynamics and distributions and are associated to variable clinical phenotypes. A few patients harboring the p.Arg403Cys missense variant appears to be different from the classical, more severe phenotypes, showing sudden onset of drug resistant seizures after a previously normal or slightly delayed development. CASE REPORT We report on a boy with abrupt onset of focal status and coma at the age of 13, initially treated as autoimmune encephalitis, with final diagnosis of de novo missense p.Arg403Cys variant in the DNM1L gene. DISCUSSION We compare his clinical, electrophysiological, biochemical, neuroradiological and histopathological picture to the rare cases reported to date and provide diagnostic clues that can help clinicians in differentiate p.Arg403Cys-related phenotype from that of immune-mediated encephalopathies. CONCLUSION The clinical picture related to p.Arg403Cys mutations should be considered alongside acquired pathologies in the differential diagnosis of young patients with focal refractory epilepsy and encephalopathy, also occurring during late childhood or adolescence. Prompt genetic testing allows to avoid unnecessary treatments and procedures and to better define the prognosis and management strategies.
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Affiliation(s)
- Maria Margherita Mancardi
- Unit of Child Neuropsichiatry, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genoa, Italy.
| | - Claudia Nesti
- Molecular Medicine, IRCCS Fondazione Stella Maris, Pisa, Italy
| | - Francesca Febbo
- Neonatal and Pediatric Intensive Care Unit, Department of Critical Care, IRCCS Giannina Gaslini, Genova, Italy
| | - Ramona Cordani
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Laura Siri
- Unit of Child Neuropsichiatry, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genoa, Italy
| | - Lino Nobili
- Unit of Child Neuropsichiatry, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Elisabetta Lampugnani
- Neonatal and Pediatric Intensive Care Unit, Department of Critical Care, IRCCS Giannina Gaslini, Genova, Italy
| | - Thea Giacomini
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Tiziana Granata
- Department of Pediatric Neuroscience, Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianluca Marucci
- Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandro Consales
- Unit of Neurosurgery, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | | | | | - Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Department of Critical Care, IRCCS Giannina Gaslini, Genova, Italy
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21
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Chang JW, Reyes SD, Faure-Kumar E, Lam SK, Lawlor MW, Leventer RJ, Lew SM, Lockhart PJ, Pope K, Weiner HL, Salamon N, Vinters HV, Mathern GW, Fallah A, Owens GC. Clonally Focused Public and Private T Cells in Resected Brain Tissue From Surgeries to Treat Children With Intractable Seizures. Front Immunol 2021; 12:664344. [PMID: 33889159 PMCID: PMC8056262 DOI: 10.3389/fimmu.2021.664344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022] Open
Abstract
Using a targeted transcriptomics approach, we have analyzed resected brain tissue from a cohort of 53 pediatric epilepsy surgery cases, and have found that there is a spectrum of involvement of both the innate and adaptive immune systems as evidenced by the differential expression of immune-specific genes in the affected brain tissue. The specimens with the highest expression of immune-specific genes were from two Rasmussen encephalitis cases, which is known to be a neuro-immunological disease, but also from tuberous sclerosis complex (TSC), focal cortical dysplasia, and hemimegalencephaly surgery cases. We obtained T cell receptor (TCR) Vβ chain sequence data from brain tissue and blood from patients with the highest levels of T cell transcripts. The clonality indices and the frequency of the top 50 Vβ clonotypes indicated that T cells in the brain were clonally restricted. The top 50 Vβ clonotypes comprised both public and private (patient specific) clonotypes, and the TCR Vβ chain third complementarity region (CDR3) of the most abundant public Vβ clonotype in each brain sample was strikingly similar to a CDR3 that recognizes an immunodominant epitope in either human cytomegalovirus or Epstein Barr virus, or influenza virus A. We found that the frequency of 14 of the top 50 brain Vβ clonotypes from a TSC surgery case had significantly increased in brain tissue removed to control recurrent seizures 11 months after the first surgery. Conversely, we found that the frequency in the blood of 18 of the top 50 brain clonotypes from a second TSC patient, who was seizure free, had significantly decreased 5 months after surgery indicating that T cell clones found in the brain had contracted in the periphery after removal of the brain area associated with seizure activity and inflammation. However, the frequency of a public and a private clonotype significantly increased in the brain after seizures recurred and the patient underwent a second surgery. Combined single cell gene expression and TCR sequencing of brain-infiltrating leukocytes from the second surgery showed that the two clones were CD8 effector T cells, indicating that they are likely to be pathologically relevant.
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Affiliation(s)
- Julia W Chang
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Samuel D Reyes
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Emmanuelle Faure-Kumar
- Department of Medicine: Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Sandi K Lam
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States
| | - Michael W Lawlor
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - Richard J Leventer
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Sean M Lew
- Department of Neurosurgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - Paul J Lockhart
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Kathryn Pope
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Howard L Weiner
- Department of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Noriko Salamon
- Department of Radiological Sciences, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Harry V Vinters
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States.,Mattel Children's Hospital, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Geoffrey C Owens
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
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22
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Abstract
A 43-year-old man with a preceding infection was transferred to our hospital for febrile status epilepticus (SE). Although treatment for SE was immediately initiated, it failed. Therefore, continuous anesthetics treatment with mechanical ventilation was initiated. No epileptic discharge was found on an electroencephalogram. However, total aphasia and right hemiplegia due to left hemispheric swelling were noted on day 5. His aphasia and hemiplegia did not improve. The mechanism underlying the hemispheric involvement remains unclear. The initial diagnosis should be made with care in patients with febrile SE; furthermore, intensive treatment should be administered in the acute phase.
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Affiliation(s)
- Tameto Naoi
- Rehabilitation Center, Jichi Medical University, Japan
| | - Mitsuya Morita
- Rehabilitation Center, Jichi Medical University, Japan
- Division of Neurology, Department of Medicine, Jichi Medical University, Japan
| | - Kansuke Koyama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University, Japan
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23
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Liba Z, Vaskova M, Zamecnik J, Kayserova J, Nohejlova H, Ebel M, Sanda J, Ramos-Rivera GA, Brozova K, Liby P, Tichy M, Krsek P. An immunotherapy effect analysis in Rasmussen encephalitis. BMC Neurol 2020; 20:359. [PMID: 32972372 PMCID: PMC7517818 DOI: 10.1186/s12883-020-01932-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/14/2020] [Indexed: 01/16/2023] Open
Abstract
Background Immune-mediated mechanisms substantially contribute to the Rasmussen encephalitis (RE) pathology, but for unknown reasons, immunotherapy is generally ineffective in patients who have already developed intractable epilepsy; overall laboratory data regarding the effect of immunotherapy on patients with RE are limited. We analyzed multiple samples from seven differently treated children with RE and evaluated the effects of immunotherapies on neuroinflammation. Immunotherapy was introduced to all patients at the time of intractable epilepsy and they all had to undergo hemispherothomy. Methods Immunohistochemistry, flow cytometry, Luminex multiplex bead and enzyme-linked immunosorbent assay techniques were combined to determine: 1) inflammatory changes and lymphocyte subpopulations in 45 brain tissues; 2) lymphocyte subpopulations and the levels of 12 chemokines/cytokines in 24 cerebrospinal fluid (CSF) samples and 30 blood samples; and 3) the dynamics of these parameters in four RE patients from whom multiple samples were collected. Results Sustained T cell-targeted therapy with cyclophosphamide, natalizumab, alemtuzumab, and intrathecal methotrexate (ITMTX), but not with azathioprine, substantially reduced inflammation in brain tissues. Despite the therapy, the distributions of CD8+ T cells and the levels of C-X-C motif ligand (CXCL) 10, CXCL13, and B cell activating factor (BAFF) in patients’ CSF remained increased compared to controls. A therapeutic approach combining alemtuzumab and ITMTX was the most effective in producing simultaneous reductions in histopathological inflammatory findings and in the numbers of activated CD8+ T cells in the brain tissue, as well as in the overall CD8+ T cell population and chemokine/cytokine production in the CSF. Conclusions We provide evidence that various T cell-targeted immunotherapies reduced inflammation in the brains of RE patients. The observation that intractable epilepsy persisted in all of the patients suggests a relative independence of seizure activity on the presence of T cells in the brain later in the disease course. Thus, new therapeutic targets must be identified. CXCL10, CXCL13 and BAFF levels were substantially increased in CSF from all patients and their significance in RE pathology remains to be addressed.
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Affiliation(s)
- Zuzana Liba
- Department of Pediatric Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague, Czech Republic.
| | - Martina Vaskova
- CLIP - Childhood Leukaemia Investigation Prague, Department of Pediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Josef Zamecnik
- Department of Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jana Kayserova
- Department of Immunology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.,Imunale s.r.o, Prague, Czech Republic
| | - Hana Nohejlova
- Department of Pediatric Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague, Czech Republic.,Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Matyas Ebel
- Department of Pediatric Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague, Czech Republic
| | - Jan Sanda
- Department of Radiology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Gonzalo Alonso Ramos-Rivera
- Department of Pediatric Neurology, Comenius University Faculty of Medicine and National Institute of Children's Diseases, Bratislava, Slovak Republic
| | - Klara Brozova
- Department of Pediatric Neurology, Thomayer Hospital, Prague, Czech Republic.,Department of Neurology and Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Petr Liby
- Department of Neurosurgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Michal Tichy
- Department of Neurosurgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Pavel Krsek
- Department of Pediatric Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague, Czech Republic
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24
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Surana S, Rossor T, Hassell J, Boyd S, D'Arco F, Aylett S, Bhate S, Carr L, Das K, DeVile C, Eltze C, Hemingway C, Kaliakatsos M, O'Callaghan F, Prabhakar P, Robinson R, Varadkar S, Helen Cross J, Hacohen Y. Diagnostic algorithm for children presenting with epilepsia partialis continua. Epilepsia 2020; 61:2224-2233. [PMID: 32875551 DOI: 10.1111/epi.16650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To characterize a cohort of children with epilepsia partialis continua (EPC) and develop a diagnostic algorithm incorporating key differential diagnoses. METHODS Children presenting with EPC to a tertiary pediatric neurology center between 2002 and 2019 were characterized. RESULTS Fifty-four children fulfilled EPC criteria. Median age at onset was 7 years (range 0.6-15), with median follow-up of 4.3 years (range 0.2-16). The diagnosis was Rasmussen encephalitis (RE) in 30 of 54 (56%), a mitochondrial disorder in 12 of 54 (22.2%), and magnetic resonance imaging (MRI) lesion-positive focal epilepsy in 6 of 54 (11.1%). No diagnosis was made in 5 of 54 (9%). Children with mitochondrial disorders developed EPC earlier; each additional year at presentation reduced the odds of a mitochondrial diagnosis by 26% (P = .02). Preceding developmental concerns (odds ratio [OR] 22, P < .001), no seizures prior to EPC (OR 22, P < .001), bilateral slowing on electroencephalogram (EEG) (OR 26, P < .001), and increased cerebrospinal fluid (CSF) protein level (OR 16) predicted a mitochondrial disorder. Asymmetry or hemiatrophy was evident on MRI at presentation with EPC in 18 of 30 (60%) children with RE, and in the remainder at a median of 6 months (range 3-15) after EPC onset. The first diagnostic test is brain MRI. Hemiatrophy may permit a diagnosis of RE with unilateral clinical and EEG findings. For children in whom a diagnosis of RE cannot be made on first scan but the clinical and radiological presentation resembles RE, repeat imaging every 6 months is recommended to detect progressive unicortical hemiatrophy, and brain biopsy should be considered. Evidence of intrathecal inflammation (oligoclonal bands and raised neopterin) can be supportive. In children with bihemispheric EPC, rapid polymerase gamma testing is recommended and if negative, sequencing mtDNA and whole-exome sequencing on blood-derived DNA should be performed. SIGNIFICANCE Children presenting with EPC due to a mitochondrial disorder show clinical features distinguishing them from RE and structural epilepsies. A diagnostic algorithm for children with EPC will allow targeted investigation and timely diagnosis.
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Affiliation(s)
- Snehal Surana
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Thomas Rossor
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Jane Hassell
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Stewart Boyd
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Felice D'Arco
- Department of Neuroradiology, Great Ormond Street Hospital for Children, London, UK
| | - Sarah Aylett
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Sanjay Bhate
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Lucinda Carr
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Krishna Das
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Catherine DeVile
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Christin Eltze
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Marios Kaliakatsos
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Finbar O'Callaghan
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Developmental of Neuroscience, Institute of Child Health, UCL, London, UK
| | - Prab Prabhakar
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Robert Robinson
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Sophia Varadkar
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - J Helen Cross
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Developmental of Neuroscience, Institute of Child Health, UCL, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
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25
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Bellamkonda N, Phillips HW, Chen JS, Tucker AM, Maniquis C, Mathern GW, Fallah A. Epilepsy surgery for Rasmussen encephalitis: the UCLA experience. J Neurosurg Pediatr 2020; 26:389-397. [PMID: 32679562 DOI: 10.3171/2020.4.peds2098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rasmussen encephalitis (RE) is a rare inflammatory neurological disorder typically involving one hemisphere and resulting in drug-resistant epilepsy and progressive neurological decline. Here, the authors present seizure outcomes in children who underwent epilepsy surgery for RE at a single institution. METHODS The records of consecutive patients who had undergone epilepsy surgery for RE at the UCLA Mattel Children's Hospital between 1982 and 2018 were retrospectively reviewed. Basic demographic information, seizure history, procedural notes, and postoperative seizure and functional outcome data were analyzed. RESULTS The cohort included 44 patients, 41 of whom had sufficient data for analysis. Seizure freedom was achieved in 68%, 48%, and 22% of the patients at 1, 5, and 10 years, respectively. The median time to the first seizure for those who experienced seizure recurrence after surgery was 39 weeks (IQR 11-355 weeks). Anatomical hemispherectomy, as compared to functional hemispherectomy, was independently associated with a longer time to postoperative seizure recurrence (HR 0.078, p = 0.03). There was no statistically significant difference in postoperative seizure recurrence between patients with complete hemispherectomy and those who had less-than-hemispheric surgery. Following surgery, 68% of the patients could ambulate and 84% could speak regardless of operative intervention. CONCLUSIONS A large proportion of RE patients will have seizure relapse after surgery, though patients with anatomical hemispherectomies may have a longer time to postoperative seizure recurrence. Overall, the long-term data in this study suggest that hemispheric surgery can be seen as palliative treatment for seizures rather than a cure for RE.
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Affiliation(s)
| | | | - Jia-Shu Chen
- Departments of1Neurosurgery.,4Department of Neuroscience, Brown University, Providence, Rhode Island; and
| | - Alexander M Tucker
- 5Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | | | - Gary W Mathern
- Departments of1Neurosurgery.,3Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Aria Fallah
- Departments of1Neurosurgery.,2Pediatrics, and
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26
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Sansevere AJ, Henderson LA, Stredny CM, Prabhu SP, Shah A, Sundel R, Madsen J, Dufreney C, Poduri A, Gorman MP. Posterior-onset Rasmussen's encephalitis with ipsilateral cerebellar atrophy and uveitis resistant to rituximab. Epilepsy Behav Rep 2020; 14:100360. [PMID: 32368732 PMCID: PMC7184158 DOI: 10.1016/j.ebr.2020.100360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 02/03/2023] Open
Abstract
Rasmussen encephalitis (RE) is a disorder characterized by drug-resistant seizures and progressive unihemispheric atrophy, hemiparesis, and varying degrees of cognitive decline. The pathophysiology of RE remains elusive, with hypotheses suggesting underlying autoimmune- and T cell-mediated processes. In this case report, we describe a single patient's clinical course from the first day of presentation until definitive treatment for atypical Rasmussen encephalitis at a tertiary care pediatric center. The patient exhibited several atypical features of Rasmussen encephalitis, including a posterior predominance of initial seizure onset with the development of severe choreoathetosis and ipsilateral cerebellar atrophy. He subsequently developed coexistent autoimmune disorders in the form of psoriasis and uveitis, and underwent multiple forms of immunotherapy with limited benefit. This patient shows an association of RE with other autoimmune conditions supporting an autoimmune mechanism of disease while exhibiting several atypical features of RE. Rarely, occipital lobe seizures have been documented as the presenting semiology of this syndrome. This case highlights the need to be mindful of atypical features that may delay hemispherectomy, which remains the definitive treatment. It also suggests that children may be predisposed to the development of autoimmune disorders in later stages of the disease. Occipital seizure localization and semiology should not dissuade the diagnosis of Rasmussen's encephalitis Movement disorders, can accompany Rasmussen's encephalitis Ipsilateral cerebellar atrophy has been described in Rasmussen's encephalitis Children with Rasmussen's encephalitis may be predisposed to autoimmune disorders in the later stages of the disease
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Affiliation(s)
- Arnold J Sansevere
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Coral M Stredny
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ankoor Shah
- Department of Ophthalmology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Robert Sundel
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Joseph Madsen
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | | | - Annapurna Poduri
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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27
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He X, Chen F, Zhang Y, Gao Q, Guan Y, Wang J, Zhou J, Zhai F, Boison D, Luan G, Li T. Upregulation of adenosine A2A receptor and downregulation of GLT1 is associated with neuronal cell death in Rasmussen's encephalitis. Brain Pathol 2019; 30:246-260. [PMID: 31353670 DOI: 10.1111/bpa.12770] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023] Open
Abstract
Rasmussen encephalitis (RE) is a severe pediatric inflammatory brain disease characterized by unilateral inflammation and atrophy of the cerebral cortex, drug-resistant focal epilepsy and progressive neurological and cognitive deterioration. The etiology and pathogenesis of RE remain unclear. Our previous results demonstrated that the adenosine A1 receptor (A1R) and the major adenosine-removing enzyme adenosine kinase play an important role in the etiology of RE. Because the downstream pathways of inhibitory A1R signaling are modulated by stimulatory A2AR signaling, which by itself controls neuro-inflammation, glial activation and glial glutamate homeostasis through interaction with glutamate transporter GLT-1, we hypothesized that maladaptive changes in adenosine A2A receptor (A2AR) expression are associated with RE. We used immunohistochemistry and Western blot analysis to examine the expression of A2ARs, glutamate transporter-I (GLT-1) and the apoptotic marker Bcl-2 in surgically resected cortical specimens from RE patients (n = 18) in comparison with control cortical tissue. In lesions of the RE specimen we found upregulation of A2ARs, downregulation of GLT-1 and increased apoptosis of both neurons and astroglia. Double staining revealed colocalization of A2ARs and Bcl-2 in RE lesions. These results suggest that maladaptive changes in A2AR expression are associated with a decrease in GLT-I expression as a possible precipitator for apoptotic cell loss in RE. Because A2AR antagonists are already under clinical evaluation for Parkinson's disease, the A2AR might likewise be a tractable target for the treatment of RE.
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Affiliation(s)
- Xinghui He
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Fan Chen
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China.,Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Yifan Zhang
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China.,Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Qing Gao
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Yuguang Guan
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Jing Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Jian Zhou
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Feng Zhai
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Detlev Boison
- Department of Neurosurgery, Robert Wood Jones & New Jersey Medical Schools, Rutgers University, Piscataway, NJ, 08854, USA
| | - Guoming Luan
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Tianfu Li
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China.,Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
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28
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Pan PJ, Ullman HE, Mathern GW, Salamon N. Physical Growth of the Contralateral Cerebrum is Preserved After Hemispherotomy in Childhood. Pediatr Neurol 2019; 96:48-52. [PMID: 30928301 DOI: 10.1016/j.pediatrneurol.2019.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hemispherotomy can be an effective treatment for refractory childhood epilepsy. However, the extent of postoperative brain development after hemispherotomy remains incompletely understood. This study aims to provide an anatomic foundation in assessing development of the contralateral hemisphere, by measuring volumetric growth after hemispherotomy. METHODS Eleven patients with hemimegalencephaly, Rasmussen's encephalitis, and cerebral infarction who underwent hemispherotomy before age 12 years, an immediate preoperative magnetic resonance imaging, and at least three years of follow-up magnetic resonance imagings were retrospectively analyzed. The volume of the contralateral hemisphere was measured before and after surgery. Growth curves were compared with those of healthy individuals from an open database. The growth rate relative to the healthy individuals ("catch-up rate") was calculated. RESULTS A positive volumetric growth of the contralateral hemisphere was observed across all pathologies. The hemimegalencephaly subgroup underwent hemispherotomy at the earliest time and had the largest postoperative growth rate, which exceeded that of healthy individuals. The Rasmussen subgroup underwent surgery at the second earliest time and had an intermediate growth rate, which was similar to that of healthy individuals. The infarction subgroup underwent surgery at the latest time and had the slowest growth rate, which was less than that of healthy individuals. CONCLUSIONS The contralateral hemisphere continues to increase in volume after hemispherotomy in childhood. Further studies with a larger sample size and correlation with cognitive outcomes may aid in characterizing the prognosis after hemispherotomy.
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Affiliation(s)
- Patrick J Pan
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Henrik E Ullman
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gary W Mathern
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Noriko Salamon
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California.
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29
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Tröscher AR, Wimmer I, Quemada-Garrido L, Köck U, Gessl D, Verberk SGS, Martin B, Lassmann H, Bien CG, Bauer J. Microglial nodules provide the environment for pathogenic T cells in human encephalitis. Acta Neuropathol 2019; 137:619-635. [PMID: 30663001 PMCID: PMC6426829 DOI: 10.1007/s00401-019-01958-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/03/2019] [Accepted: 01/03/2019] [Indexed: 02/07/2023]
Abstract
Microglia nodule formation is a common feature in inflammatory brain diseases mediated by T lymphocytes such as viral and paraneoplastic encephalitis, multiple sclerosis, and Rasmussen encephalitis (RE). However, its role has not been fully understood yet. We hypothesized that, in RE, microglial nodules provide an environment for the initiation of the later dominating T-cell cytotoxicity. In RE stage 0, small primary microglia nodules could be identified in the absence of T cells. These primary nodules showed inflammasome activation and endosomal Toll-like receptor upregulation. In stage 1, T cells migrate into the parenchyma and intermingle with microglial cells, thereby forming secondary nodules in which neurons are destroyed. Whole-genome transcriptome analysis at this point showed upregulation of several inflammatory pathways including interferon signaling and major histocompatibility complex-I signaling. Inflammatory profiles, like the ones observed in RE, could be induced upon TLR3 stimulation in neonatal microglial cell cultures. Taken together, our results point towards activation of endosomal TLRs, resulting in increased interferon signaling, inflammasome activation, and chemokine upregulation as early steps in RE pathogenesis. This activity sets the scene for subsequent infiltration of T cells and destruction of neurons. Similar to RE, this microglial microenvironment might be a crucial step in other T-cell-mediated inflammatory brain diseases.
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Affiliation(s)
- Anna R Tröscher
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Isabella Wimmer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Lucía Quemada-Garrido
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Ulrike Köck
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Denise Gessl
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Sanne G S Verberk
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Bethany Martin
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Christian G Bien
- Epilepsy Center Bethel, Krankenhaus Mara, Bielefeld, Germany
- Laboratory Krone, Bad Salzuflen, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria.
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Nardone R, Langthaler PB, Orioli A, Versace V, Scarano GI, Brigo F, Saltuari L, Carnicelli L, Trinka E, Sebastianelli L. Ipsilateral motor evoked potentials in a patient with unihemispheric cortical atrophy due to Rasmussen encephalitis. Neural Regen Res 2019; 14:1025-1028. [PMID: 30762014 PMCID: PMC6404490 DOI: 10.4103/1673-5374.250581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The role of the ipsilaterally descending motor pathways in the recovery mechanisms after unilateral hemispheric damage is still poorly understood. Motor output reorganization was investigated in a 56-year-old male patient with acquired unilateral hemispheric atrophy due to Rasmussen encephalitis. In particular, the ipsilateral corticospinal pathways were explored using focal transcranial magnetic stimulation. In the first dorsal interosseous and wrist extensors muscles, the median amplitudes of the ipsilateral motor evoked potentials induced by transcranial magnetic stimulation in the patient were higher than those of 10 age-matched healthy control subjects. In the biceps brachii muscle, the median amplitudes of the ipsilateral motor evoked potentials were the second largest in the patient compared to the controls. This study demonstrated a reinforcement of ipsilateral motor projections from the unaffected motor cortex to the hemiparetic hand in a subject with acquired unihemispheric cortical damage.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University; Spinal Cord Injury and Tissue Regeneration Center; Karl Landsteiner Institut für Neurorehabilitation und Raumfahrtneurologie, Salzburg, Austria
| | - Patrick B Langthaler
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University; Department of Mathematics, Paris Lodron University of Salzburg, Austria
| | - Andrea Orioli
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno; Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | | | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno; Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy; Department of Neurology, Hochzirl Hospital, Zirl, Austria
| | - Luca Carnicelli
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University; Centre for Cognitive Neurosciences Salzburg, Salzburg; University for Medical Informatics and Health Technology, UMIT, Hall in Tirol, Austria
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno; Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
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Matricardi S, Farello G, Savasta S, Verrotti A. Understanding Childhood Neuroimmune Diseases of the Central Nervous System. Front Pediatr 2019; 7:511. [PMID: 31921724 PMCID: PMC6930888 DOI: 10.3389/fped.2019.00511] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Immune-mediated diseases of the central nervous system (CNS) in childhood are a heterogeneous group of rare conditions sharing the inflammatory involvement of the CNS. This review highlights the growing knowledge of childhood neuroimmune diseases that primarily affect the CNS, outlining the clinical and diagnostic features, the pathobiological mechanisms and genetics, current treatment options, and emerging challenges. The clinical spectrum of these conditions is increasingly expanded, and the underlying mechanisms of dysregulation of the immune system could vary widely. Cell-mediated and antibody-mediated disorders, infection-triggered and paraneoplastic conditions, and genetically defined mechanisms can occur in previously healthy children and can contribute to different stages of the disease. The careful evaluation of the clinical presentation and temporal course of symptoms, the specific neuroimaging and immunological findings, and the exclusion of alternative causes are mandatory in clinical practice for the syndromic diagnosis. A common feature of these conditions is that immunotherapeutic agents could modulate the clinical course and outcomes of the disease. Furthermore, specific symptomatic treatments and comprehensive multidisciplinary care are needed in the overall management. We focus on recent advances on immune-mediated demyelinating CNS disorders, autoimmune encephalitis, interferonopathies, and possible neuroimmune disorders as Rasmussen encephalitis. Better knowledge of these conditions could allow prompt diagnosis and targeted immunotherapy, to decrease morbidity and mortality as well as to improve clinical outcomes, reducing the burden of the disease due to possible long-term neuropsychiatric sequelae. Persisting controversies remain in the rigorous characterization of each specific clinical entity because of the relative rarity in children; moreover, in a large proportion of suspected neuroimmune diseases, the immune "signature" remains unidentified; treatment guidelines are mostly based on retrospective cohort studies and expert opinions; then advances in specific molecular therapies are required. In the future, a better characterization of specific immunological biomarkers may provide a useful understanding of the underlying pathobiological mechanisms of these conditions in order to individualize more tailored therapeutic options and paradigms. Multicenter collaborative research on homogeneous groups of patients who may undergo immunological studies and therapeutic trials could improve the characterization of the underlying mechanisms, the specific phenotypes, and tailored management.
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Affiliation(s)
- Sara Matricardi
- Department of Neuropsychiatry, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Ancona, Italy
| | - Giovanni Farello
- Pediatric Clinic, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Salvatore Savasta
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
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Pranzatelli MR. Advances in Biomarker-Guided Therapy for Pediatric- and Adult-Onset Neuroinflammatory Disorders: Targeting Chemokines/Cytokines. Front Immunol 2018; 9:557. [PMID: 29670611 PMCID: PMC5893838 DOI: 10.3389/fimmu.2018.00557] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/05/2018] [Indexed: 12/26/2022] Open
Abstract
The concept and recognized components of “neuroinflammation” are expanding at the intersection of neurobiology and immunobiology. Chemokines (CKs), no longer merely necessary for immune cell trafficking and positioning, have multiple physiologic, developmental, and modulatory functionalities in the central nervous system (CNS) through neuron–glia interactions and other mechanisms affecting neurotransmission. They issue the “help me” cry of neurons and astrocytes in response to CNS injury, engaging invading lymphoid cells (T cells and B cells) and myeloid cells (dendritic cells, monocytes, and neutrophils) (adaptive immunity), as well as microglia and macrophages (innate immunity), in a cascade of events, some beneficial (reparative), others destructive (excitotoxic). Human cerebrospinal fluid (CSF) studies have been instrumental in revealing soluble immunobiomarkers involved in immune dysregulation, their dichotomous effects, and the cells—often subtype specific—that produce them. CKs/cytokines continue to be attractive targets for the pharmaceutical industry with varying therapeutic success. This review summarizes the developing armamentarium, complexities of not compromising surveillance/physiologic functions, and insights on applicable strategies for neuroinflammatory disorders. The main approach has been using a designer monoclonal antibody to bind directly to the chemo/cytokine. Another approach is soluble receptors to bind the chemo/cytokine molecule (receptor ligand). Recombinant fusion proteins combine a key component of the receptor with IgG1. An additional approach is small molecule antagonists (protein therapeutics, binding proteins, and protein antagonists). CK neutralizing molecules (“neutraligands”) that are not receptor antagonists, high-affinity neuroligands (“decoy molecules”), as well as neutralizing “nanobodies” (single-domain camelid antibody fragment) are being developed. Simultaneous, more precise targeting of more than one cytokine is possible using bispecific agents (fusion antibodies). It is also possible to inhibit part of a signaling cascade to spare protective cytokine effects. “Fusokines” (fusion of two cytokines or a cytokine and CK) allow greater synergistic bioactivity than individual cytokines. Another promising approach is experimental targeting of the NLRP3 inflammasome, amply expressed in the CNS and a key contributor to neuroinflammation. Serendipitous discovery is not to be discounted. Filling in knowledge gaps between pediatric- and adult-onset neuroinflammation by systematic collection of CSF data on CKs/cytokines in temporal and clinical contexts and incorporating immunobiomarkers in clinical trials is a challenge hereby set forth for clinicians and researchers.
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Affiliation(s)
- Michael R Pranzatelli
- National Pediatric Neuroinflammation Organization, Inc., Orlando, FL, United States.,College of Medicine, University of Central Florida, Orlando, FL, United States
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Abstract
Paraneoplastic and autoimmune encephalitis comprise a group of immune-mediated disorders that are associated with different immune effector mechanisms. Classic paraneoplastic neurologic syndromes are triggered by an antitumor immune response. The disease is considered to result from a T-cell response; in addition, patients harbour high titers of autoantibodies against intracellular antigens that are considered as epiphenomenon but are useful diagnostic markers. Neuropathology consists of T-cell-dominated inflammation, marked neuronal loss, and microglial activation with upregulation of HLA-DR. In the last decade, an increasing number of diseases associated with autoantibodies against neuronal surface antigens have been described. There is strong evidence that these autoantibodies are pathogenic and the associated syndromes are generally termed as antineuronal autoimmune encephalitis. Patients typically present with limbic, multifocal, or diffuse encephalitis and respond to immunotherapy. Neuropathologic descriptions are restricted to few biopsy and autopsy specimens and show mild inflammatory infiltrates and microglial activation, together with reduced expression of the respective target antigens, immunoglobulin deposits, and a variable degree of complement activation. Other putative autoimmune disorders of the central nervous system include, among others, Rasmussen encephalitis, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), acute cerebellitis, Susac syndrome, and Hashimoto encephalitis. While pathologic studies suggest an immune-mediated disease for Rasmussen encephalitis, CLIPPERS, acute cerebellitis, and Susac syndrome, neuropathologic descriptions of Hashimoto encephalitis are rare and the pathogenesis deserves further study.
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Affiliation(s)
- Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria.
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Dandekar S, Wijesuriya H, Geiger T, Hamm D, Mathern GW, Owens GC. Shared HLA Class I and II Alleles and Clonally Restricted Public and Private Brain-Infiltrating αβ T Cells in a Cohort of Rasmussen Encephalitis Surgery Patients. Front Immunol 2016; 7:608. [PMID: 28066418 PMCID: PMC5165278 DOI: 10.3389/fimmu.2016.00608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 12/01/2016] [Indexed: 11/26/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare pediatric neuroinflammatory disease characterized by intractable seizures and unilateral brain atrophy. T cell infiltrates in affected brain tissue and the presence of circulating autoantibodies in some RE patients have indicated that RE may be an autoimmune disease. The strongest genetic links to autoimmunity reside in the MHC locus, therefore, we determined the human leukocyte antigen (HLA) class I and class II alleles carried by a cohort of 24 RE surgery cases by targeted in-depth genomic sequencing. Compared with a reference population the allelic frequency of three alleles, DQA1*04:01:01, DQB1*04:02:01, and HLA-C*07:02:01:01 indicated that they might confer susceptibility to the disease. It has been reported that HLA-C*07:02 is a risk factor for Graves disease. Further, eight patients in the study cohort carried HLA-A*03:01:01:01, which has been linked to susceptibility to multiple sclerosis. Four patients carried a combination of three HLA class II alleles that has been linked to type 1 diabetes (DQA1*05:01:01:01~DQB1*02:01:01~DRB1*03:01:01:01), and five patients carried a combination of HLA class II alleles that has been linked to the risk of contracting multiple sclerosis (DQA1*01:02:01:01, DQB1*06:02:01, DRB1*15:01:01:01). We also analyzed the diversity of αβ T cells in brain and blood specimens from 14 of these RE surgery cases by sequencing the third complementarity regions (CDR3s) of rearranged T cell receptor β genes. A total of 31 unique CDR3 sequences accounted for the top 5% of all CDR3 sequences in the 14 brain specimens. Thirteen of these sequences were found in sequencing data from healthy blood donors; the remaining 18 sequences were patient specific. These observations provide evidence for the clonal expansion of public and private T cells in the brain, which might be influenced by the RE patient’s HLA haplotype.
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Affiliation(s)
- Sugandha Dandekar
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles , Los Angeles, CA , USA
| | - Hemani Wijesuriya
- Pathology and Laboratory Medicine, David Geffen School of Medicine at the University of California Los Angeles , Los Angeles, CA , USA
| | - Tim Geiger
- Adaptive Biotechnologies Inc. , Seattle, WA , USA
| | - David Hamm
- Adaptive Biotechnologies Inc. , Seattle, WA , USA
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA; Mattel Children's Hospital, Los Angeles, CA, USA
| | - Geoffrey C Owens
- Department of Neurosurgery, David Geffen School of Medicine at the University of California Los Angeles , Los Angeles, CA , USA
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Holec M, Nagahama Y, Kovach C, Joshi C. Rethinking the Magnetic Resonance Imaging Findings in Early Rasmussen Encephalitis: A Case Report and Review of the Literature. Pediatr Neurol 2016; 59:85-9. [PMID: 27004940 DOI: 10.1016/j.pediatrneurol.2015.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/12/2015] [Accepted: 12/13/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We present a child with Rasmussen encephalitis and highlight the pitfalls of diagnosis when magnetic resonance imaging (MRI) is negative for atrophy. We review the literature regarding this issue, introduce the FreeSurfer software as a potential means of noninvasive diagnosis, and discuss methods for prompt and definitive treatment. METHODS In addition to the patient description, we review the English language literature regarding pathologic diagnosis of Rasmussen encephalitis using the key words Rasmussen encephalitis, focal lesions, MRI, atrophy, epilepsia partialis continua and hemiparesis in PubMed. We conducted a retrospective, volumetric analysis of our patient's MRIs using FreeSurfer. RESULTS Unlike the majority of patients in the literature with Rasmussen encephalitis, our patient's initial MRI was normal and later showed only a small area of T2 and fluid-attenuated inversion recovery high signal despite the presence of epilepsia partialis continua and a rapidly deteriorating clinical course. She did not meet the Rasmussen encephalitis diagnostic criteria until biopsy was obtained but is now seizure-free after functional hemispherotomy performed six months after her initial seizure. FreeSurfer analysis did not show cortical atrophy. CONCLUSION The Bien criteria have poor sensitivity for the diagnosis of Rasmussen encephalitis when the MRI is negative for atrophy. Tissue diagnosis is essential in such instances. We suggest a high clinical index of suspicion and multidisciplinary collaboration between radiology, pathology, and neurosurgery to facilitate a greater emphasis on biopsy followed by hemispherotomy as definitive therapy for individuals with early Rasmussen encephalitis.
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Affiliation(s)
- Megan Holec
- Pediatric Neurology, University of Iowa Children's Hospital, Iowa City, Iowa.
| | - Yasunori Nagahama
- Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Christopher Kovach
- Department of Neurosurgery, University of Iowa Children's Hospital, Iowa City, Iowa
| | - Charuta Joshi
- Pediatric Neurology, University of Iowa Children's Hospital, Iowa City, Iowa
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36
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Luan G, Gao Q, Zhai F, Chen Y, Li T. Upregulation of HMGB1, toll-like receptor and RAGE in human Rasmussen's encephalitis. Epilepsy Res 2016; 123:36-49. [PMID: 27108105 DOI: 10.1016/j.eplepsyres.2016.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 02/15/2016] [Accepted: 03/23/2016] [Indexed: 10/21/2022]
Abstract
Rasmussen encephalitis (RE) is a rare neurological disorder of childhood characterized by uni-hemispheric inflammation, progressive neurological deficits and intractable focal epilepsy. The pathogenesis of RE is still enigmatic. Activation of endogenous high-mobility group box-1 (HMGB1) and Toll-like receptor (TLR) has been proved to be with pro-inflammatory as well as pro-convulsant effects. We hypothesized that the epileptogenic mechanisms underlying RE are related to activation of HMGB1/TLR signaling. Immunnohistochemistry approach was used to examine the expression of HMGB1, TLR2, TLR4, receptor for advanced glycation end products (RAGE) in surgically resected human epileptic cortical specimens from RE (n=12), and compared that with control cortical issue (n=6). HMGB1 was ubiquitously detected in nuclei of astrocytes while its receptors were not detected in control cortex specimens. Marked expression of the receptors were observed in the lesions of RE. In particular, HMGB1 was in stead detected in cytoplasm of reactive astrocytes in RE cortex, predictive its release from glial cells. Significant greater HMGB1 and its receptors expression in RE vs. control was demonstrated by western blot. These results provide the novel evidence of intrinsic activation of these pro-inflammation pathways in RE, which suggest the specific targets in the treatment of epilepsy associated with RE.
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Affiliation(s)
- Guoming Luan
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Qing Gao
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Feng Zhai
- Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Yin Chen
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Tianfu Li
- Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China; Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China.
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37
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Owens GC, Chang JW, Huynh MN, Chirwa T, Vinters HV, Mathern GW. Evidence for Resident Memory T Cells in Rasmussen Encephalitis. Front Immunol 2016; 7:64. [PMID: 26941743 PMCID: PMC4763066 DOI: 10.3389/fimmu.2016.00064] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/09/2016] [Indexed: 12/19/2022] Open
Abstract
Rasmussen encephalitis (RE) is a rare pediatric neuroinflammatory disease of unknown etiology characterized by intractable seizures, and progressive atrophy usually confined to one cerebral hemisphere. Surgical removal or disconnection of the affected cerebral hemisphere is currently the only intervention that effectively stops the seizures. Histopathological evaluation of resected brain tissue has shown that activated brain resident macrophages (microglia) and infiltrating T cells are involved in the inflammatory reaction. Here, we report that T cells isolated from seven RE brain surgery specimens express the resident memory T cell (TRM) marker CD103. CD103 was expressed by >50% of CD8+ αβ T cells and γδ T cells irrespective of the length of time from seizure onset to surgery, which ranged from 0.3 to 8.4 years. Only ~10% of CD4+ αβ were CD103+, which was consistent with the observation that few CD4+ T cells are found in RE brain parenchyma. Clusters of T cells in brain parenchyma, which are a characteristic of RE histopathology, stained for CD103. Less than 10% of T cells isolated from brain specimens from eight surgical cases of focal cortical dysplasia (FCD), a condition that is also characterized by intractable seizures, were CD103+. In contrast to the RE cases, the percent of CD103+ T cells increased with the length of time from seizure onset to surgery. In sections of brain tissue from the FCD cases, T cells were predominantly found around blood vessels, and did not stain for CD103. The presence of significant numbers of TRM cells in RE brain irrespective of the length of time between clinical presentation and surgical intervention supports the conclusion that a cellular immune response to an as yet unidentified antigen(s) occurs at an early stage of the disease. Reactivated TRM cells may contribute to disease progression.
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Affiliation(s)
- Geoffrey C Owens
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Julia W Chang
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - My N Huynh
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Thabiso Chirwa
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Harry V Vinters
- Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Mattel Children's Hospital, Los Angeles, CA, USA
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Samanta D, Gokden M, Albert GW. Absence of seizures in Rasmussen encephalitis with active inflammation. J Clin Neurosci 2016; 28:175-8. [PMID: 26775150 DOI: 10.1016/j.jocn.2015.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/22/2015] [Accepted: 11/29/2015] [Indexed: 11/30/2022]
Abstract
Severe focal motor epilepsy is considered a clinical hallmark of Rasmussen encephalitis (RE). The authors report a 6-year-old girl with progressive right sided hemiparesis, loss of language skills, left sided hemispheric atrophy, and brain pathologic features characteristic for RE. The patient did not experience seizures over a 2year period after symptom onset and for several months during follow-up. This report expands the clinical spectrum of RE and suggests that seizures are not a universal symptom of RE. Our patient's quite remarkable neurologic deficits along with active inflammation in the absence of epilepsy supports that, at least in some individuals, unilateral hemispheric progressive inflammation can occur without active seizure activity.
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Affiliation(s)
- Debopam Samanta
- Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72202, USA.
| | - Murat Gokden
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital, and Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Ravindra VM, Mazur MD, Mohila CA, Sweney MT, Hersh A, Bollo RJ. Rasmussen encephalitis with dual pathology in a patient without seizures: case report and literature review. Childs Nerv Syst 2015; 31:2165-71. [PMID: 26033376 DOI: 10.1007/s00381-015-2757-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/21/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Rasmussen encephalitis without seizures is rare. We report a case of Rasmussen encephalitis and cortical dysplasia without epilepsy as well as describe the imaging, pathology, and clinical course and review the literature to investigate whether this may represent a rare subset of Rasmussen encephalitis. CASE REPORT We report the case of a 12-year-old girl with a history of cognitive decline and right arm weakness. Magnetic resonance imaging demonstrated diffuse left hemispheric cortical and subcortical atrophy suggestive of Rasmussen encephalitis. The patient had no clinical history of seizures, and electroencephalography did not demonstrate epileptiform abnormalities. Craniotomy for open brain biopsy was performed, and histopathologic evaluation identified Rasmussen encephalitis with cortical dysplasia (dual pathology). CONCLUSIONS To the best of our knowledge, this is the third case of Rasmussen encephalitis diagnosed by both imaging and histopathology that had no clinical or electroencephalographic evidence of seizures and is the only case of Rasmussen encephalitis with cortical dysplasia without epilepsy.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA
| | - Carrie A Mohila
- Department of Pathology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Matthew T Sweney
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Aimee Hersh
- Department of Rheumatology/Immunology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Rheumatology/Immunology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Robert J Bollo
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA.
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Grosmaitre C, Jambaqué I, Dorfmuller G, Rodrigo S, Ville D, Delalande O, Bulteau C. Exceptional verbal intelligence after hemispherotomy in a child with Rasmussen encephalitis. Neurocase 2015; 21:144-7. [PMID: 24471481 DOI: 10.1080/13554794.2013.878724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report a longitudinal case study of a left-handed girl who underwent left hemispherotomy at 7 years for Rasmussen encephalitis (RE). Presurgical evaluation showed mild hemiparesis, no visual defect, and light neuropsychological impairment with short-term memory weakness. Language fMRI showed a right hemispheric dominance. Postoperatively, the patient exhibited right hemiplegia and hemianopsia but preserved intellectual capacities. She became seizure-free, and antiepileptic medication was discontinued. Long-term follow-up showed very high verbal intelligence at 11 years of age (VCI of 155) and improvement in working memory as well as language and reading abilities. Furthermore, a significant visuoverbal discrepancy became increasingly pronounced. Thus, early surgical treatment of epilepsy avoided the global cognitive deterioration usually associated with RE. Finally, such a high level of verbal functioning combined with low spatial reasoning with a single hemisphere provides additional information on the neurocognitive profile of children with RE after hemispherotomy.
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Cepeda C, Chang JW, Owens GC, Huynh MN, Chen JY, Tran C, Vinters HV, Levine MS, Mathern GW. In Rasmussen encephalitis, hemichannels associated with microglial activation are linked to cortical pyramidal neuron coupling: a possible mechanism for cellular hyperexcitability. CNS Neurosci Ther 2014; 21:152-63. [PMID: 25438677 DOI: 10.1111/cns.12352] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 10/16/2014] [Accepted: 10/20/2014] [Indexed: 12/21/2022] Open
Abstract
AIMS Rasmussen encephalitis (RE) is a rare but devastating condition, mainly in children, characterized by sustained brain inflammation, atrophy of one cerebral hemisphere, epilepsy, and progressive cognitive deterioration. The etiology of RE-induced seizures associated with the inflammatory process remains unknown. METHODS Cortical tissue samples from children undergoing surgical resections for the treatment of RE (n = 16) and non-RE (n = 12) were compared using electrophysiological, morphological, and immunohistochemical techniques to examine neuronal properties and the relationship with microglial activation using the specific microglia/macrophage calcium-binding protein, IBA1 in conjunction with connexins and pannexin expression. RESULTS Compared with non-RE cases, pyramidal neurons from RE cases displayed increased cell capacitance and reduced input resistance. However, neuronal somatic areas were not increased in size. Instead, intracellular injection of biocytin led to increased dye coupling between neurons from RE cases. By Western blot, expression of IBA1 and pannexin was increased while connexin 32 was decreased in RE cases compared with non-RE cases. IBA1 immunostaining overlapped with pannexin and connexin 36 in RE cases. CONCLUSIONS In RE, these results support the notion that a possible mechanism for cellular hyperexcitability may be related to increased intercellular coupling from pannexin linked to increased microglial activation. Such findings suggest that a possible antiseizure treatment for RE may involve the use of gap junction blockers.
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Affiliation(s)
- Carlos Cepeda
- Intellectual and Developmental Disabilities Research Center, Brain Research Institute, Los Angeles, CA, USA
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Granata T, Matricardi S, Ragona F, Freri E, Casazza M, Villani F, Deleo F, Tringali G, Gobbi G, Tassi L, Lo Russo G, Marras CE, Specchio N, Vigevano F, Fusco L. Hemispherotomy in Rasmussen encephalitis: long-term outcome in an Italian series of 16 patients. Epilepsy Res 2014; 108:1106-19. [PMID: 24815913 DOI: 10.1016/j.eplepsyres.2014.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/13/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
Surgical disconnection of the affected hemisphere is considered the treatment of choice for Rasmussen encephalitis (RE), however few data on long-term outcomes after disconnective surgery are available. We report on long-term seizure, cognitive and motor outcomes after disconnective surgery in 16 (8 M, 8 F) RE patients. Pre- and post-operative evaluations included long-term video-EEG monitoring, MRI, assessment of motor function, and cognitive evaluation. Hemispherotomy, by various techniques was used to obtain functional disconnection of the affected hemisphere. The patients, of median current age 23.5 years, range 12-33, were operated on between 1993 and 2009. Median age at disease onset was 5.8 years (range 3-11.4). Median time from seizure onset to surgery was 3.8 years, range 8 months to 21 years. Post-surgical follow-up was a median of 9.5 years, range 3-20. At surgery all patients were receiving two or more antiepileptic drugs (AEDs). All but three patients were seizure-free at latest follow-up. AEDs had been stopped in ten patients; in the remaining six AEDs were markedly reduced. Postural control improved in all patients. Gain in cognitive functioning was significantly (p=0.002) related to disease duration. The long-term outcomes, in terms of seizure control, motor improvement, and cognitive improvement provide important support for disconnective surgery as first choice treatment for RE.
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Affiliation(s)
- Tiziana Granata
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy.
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy; Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Marina Casazza
- Department of Neurophysiology, Carlo Besta Neurological Institute, Milan, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Francesco Deleo
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Giovanni Tringali
- Department of Neurosurgery, Carlo Besta Neurological Institute, Milan, Italy
| | - Giuseppe Gobbi
- Child Neurology Unit, IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy
| | - Laura Tassi
- Epilepsy Surgery Centre C. Munari, Milan, Italy
| | | | | | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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Varghese B, Aneesh M, Singh N, Gilwaz P. A case of rasmussen encephalitis: the differential diagnoses and role of diagnostic imaging. Oman Med J 2014; 29:67-70. [PMID: 24498485 DOI: 10.5001/omj.2014.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/02/2013] [Indexed: 11/03/2022] Open
Abstract
Rasmussen encephalitis is an extremely rare chronic inflammatory neurodegenerative disease affecting a single cerebral hemisphere, causing progressive neurological deterioration and intractable seizures. Imaging plays an important role in diagnosis by demonstrating focal or unihemispheric involvement and excluding other possible causes. Here, we report a case of Rasmussen encephalitis with an update on recent diagnostic criteria and emphasis on differential diagnoses which can be excluded on imaging.
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Affiliation(s)
- Binoj Varghese
- Department of Radiodiagnosis, Amala Institute of Medical sciences(AIMS), Thrissur, Kerala, India-680055
| | - Mk Aneesh
- Department of Radiodiagnosis, Jubilee Mission Medical College & Research Institute, Thrissur, Kerala, India- 680005
| | - Navdeep Singh
- Department of Radiodiagnosis, Jubilee Mission Medical College & Research Institute, Thrissur, Kerala, India- 680005
| | - Percival Gilwaz
- Department of Neurology, Jubilee Mission Medical College & Research Institute, Thrissur, Kerala, India - 680005
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Abstract
Inflammatory brain diseases (IBrainDs) are a leading cause of devastating neurological deficits or neuropsychiatric syndromes in previously healthy children. The spectrum is expanding rapidly and new disease entities have been discovered in the last decade. IBrainD can occur as a primary disease or may occur secondary to an underlying cause. This review focuses on the clinical presentation, diagnostic features, pathology and histology characteristics and treatment of the primary childhood IBrainDs.
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Affiliation(s)
- Marinka Twilt
- Division of Rheumatology, Department of Paediatrics and Institute of Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.Division of Rheumatology, Department of Paediatrics and Institute of Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Susanne M Benseler
- Division of Rheumatology, Department of Paediatrics and Institute of Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.Division of Rheumatology, Department of Paediatrics and Institute of Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.
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Olson HE, Lechpammer M, Prabhu SP, Ciarlini PDSC, Poduri A, Gooty VD, Anjum MW, Gorman MP, Loddenkemper T. Clinical application and evaluation of the Bien diagnostic criteria for Rasmussen encephalitis. Epilepsia 2013; 54:1753-60. [PMID: 23980696 DOI: 10.1111/epi.12334] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE The 2005 diagnostic criteria for Rasmussen encephalitis (RE) are based on seizures, clinical deficits, electroencephalography (EEG), neuroimaging, and pathology (Brain, 128, 2005, 451). We applied these criteria to patients evaluated for RE and epilepsy surgery controls to determine the sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) using pathology as the gold standard. METHODS We identified patients evaluated for RE based on medical records from 1993 to 2011. Fifty-two control patients with refractory epilepsy, unilateral magnetic resonance imaging (MRI) changes, and biopsies were selected from an epilepsy surgery database from matching years. Patients meeting all three of group A and/or two of three group B criteria were classified as meeting full criteria (positive). Patients not meeting full criteria were classified as negative. When available, pathology findings were re-reviewed with neuropathologists, and MRI imaging was re-reviewed with a neuroradiologist. KEY FINDINGS RE was considered in the differential diagnosis for 82 patients, of whom 35 had biopsies. Twenty patients met full criteria (positive) without another explanation, including seven for whom biopsy was required to meet criteria and one in whom another etiology was identified. Two patients met full criteria but had another explanation. Thirty-five met partial criteria (negative), of whom 14 had another etiology identified. Twenty-five met no criteria (negative). The diagnostic criteria had a sensitivity of 81% with four false negatives (criteria-negative, biopsy-positive) when compared to pathology as a gold standard. Five false positives (criteria positive, biopsy negative) had identifiable alternate diagnoses. SIGNIFICANCE The 2005 Bien clinical diagnostic criteria for RE have reasonably high sensitivity and specificity and good clinical-pathologic correlation in most cases. We suggest modification of the criteria to allow inclusion of cases with well-described but less common features. Specifically we suggest making the diagnosis in the absence of epilepsia partialis continua (EPC) or clear progression of focal cortical deficits or MRI findings if biopsy is positive and two of the A criteria are met (B3 plus two of three A criteria). This would improve the sensitivity of the criteria.
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Affiliation(s)
- Heather E Olson
- Division of Epilepsy, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, U.S.A; Harvard Medical School, Boston, Massachusetts, U.S.A
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