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Hanin A, Zhang L, Huttner AJ, Plu I, Mathon B, Bielle F, Navarro V, Hirsch LJ, Hafler DA. Single-Cell Transcriptomic Analyses of Brain Parenchyma in Patients With New-Onset Refractory Status Epilepticus (NORSE). NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200259. [PMID: 38810181 PMCID: PMC11139018 DOI: 10.1212/nxi.0000000000200259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/25/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND AND OBJECTIVES New-onset refractory status epilepticus (NORSE) occurs in previously healthy children or adults, often followed by refractory epilepsy and poor outcomes. The mechanisms that transform a normal brain into an epileptic one capable of seizing for prolonged periods despite treatment remain unclear. Nonetheless, several pieces of evidence suggest that immune dysregulation could contribute to hyperexcitability and modulate NORSE sequelae. METHODS We used single-nucleus RNA sequencing to delineate the composition and phenotypic states of the CNS of 4 patients with NORSE, to better understand the relationship between hyperexcitability and immune disturbances. We compared them with 4 patients with chronic temporal lobe epilepsy (TLE) and 2 controls with no known neurologic disorder. RESULTS Patients with NORSE and TLE exhibited a significantly higher proportion of excitatory neurons compared with controls, with no discernible difference in inhibitory GABAergic neurons. When examining the ratio between excitatory neurons and GABAergic neurons for each patient individually, we observed a higher ratio in patients with acute NORSE or TLE compared with controls. Furthermore, a negative correlation was found between the ratio of excitatory to GABAergic neurons and the proportion of GABAergic neurons. The ratio between excitatory neurons and GABAergic neurons correlated with the proportion of resident or infiltrating macrophages, suggesting the influence of microglial reactivity on neuronal excitability. Both patients with NORSE and TLE exhibited increased expression of genes associated with microglia activation, phagocytic activity, and NLRP3 inflammasome activation. However, patients with NORSE had decreased expression of genes related to the downregulation of the inflammatory response, potentially explaining the severity of their presentation. Microglial activation in patients with NORSE also correlated with astrocyte reactivity, possibly leading to higher degrees of demyelination. DISCUSSION Our study sheds light on the complex cellular dynamics in NORSE, revealing the potential roles of microglia, infiltrating macrophages, and astrocytes in hyperexcitability and demyelination, offering potential avenues for future research targeting the identified pathways.
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Affiliation(s)
- Aurélie Hanin
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Le Zhang
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Anita J Huttner
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Isabelle Plu
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Bertrand Mathon
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Franck Bielle
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Vincent Navarro
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Lawrence J Hirsch
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - David A Hafler
- From the Departments of Neurology and Immunobiology (A.H., L.Z., D.A.H.); Comprehensive Epilepsy Center (A.H., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Sorbonne Université (A.H., I.P., B.M., V.N.), Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP; AP-HP (A.H., V.N.), Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France; Department of Pathology (A.J.H.), Yale University School of Medicine, New Haven, CT; AP-HP (I.P., F.B.), Department of Neuropathology, DMU Neurosciences; AP-HP (B.M.), Department of Neurosurgery, Hôpital de la Pitié-Salpêtrière; and Center of Reference for Rare Epilepsies (V.N.), EpiCare, Hôpital de la Pitié-Salpêtrière, Paris, France
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Guillén N, Pérez-Millan A, Falgàs N, Lledó-Ibáñez GM, Rami L, Sarto J, Botí MA, Arnaldos-Pérez C, Ruiz-García R, Naranjo L, Segura B, Balasa M, Sala-Llonch R, Lladó A, Gray SM, Johannesen JK, Pantoni MM, Rutledge GA, Sawant R, Wang Y, Watson LS, Dalmau J, Sanchez-Valle R. Cognitive profile, neuroimaging and fluid biomarkers in post-acute COVID-19 syndrome. Sci Rep 2024; 14:12927. [PMID: 38839833 PMCID: PMC11153491 DOI: 10.1038/s41598-024-63071-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/24/2024] [Indexed: 06/07/2024] Open
Abstract
We aimed to characterize the cognitive profile of post-acute COVID-19 syndrome (PACS) patients with cognitive complaints, exploring the influence of biological and psychological factors. Participants with confirmed SARS-CoV-2 infection and cognitive complaints ≥ 8 weeks post-acute phase were included. A comprehensive neuropsychological battery (NPS) and health questionnaires were administered at inclusion and at 1, 3 and 6 months. Blood samples were collected at each visit, MRI scan at baseline and at 6 months, and, optionally, cerebrospinal fluid. Cognitive features were analyzed in relation to clinical, neuroimaging, and biochemical markers at inclusion and follow-up. Forty-nine participants, with a mean time from symptom onset of 10.4 months, showed attention-executive function (69%) and verbal memory (39%) impairment. Apathy (64%), moderate-severe anxiety (57%), and severe fatigue (35%) were prevalent. Visual memory (8%) correlated with total gray matter (GM) and subcortical GM volume. Neuronal damage and inflammation markers were within normal limits. Over time, cognitive test scores, depression, apathy, anxiety scores, MRI indexes, and fluid biomarkers remained stable, although fewer participants (50% vs. 75.5%; p = 0.012) exhibited abnormal cognitive evaluations at follow-up. Altered attention/executive and verbal memory, common in PACS, persisted in most subjects without association with structural abnormalities, elevated cytokines, or neuronal damage markers.
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Affiliation(s)
- Núria Guillén
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Agnès Pérez-Millan
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Department of Biomedicine, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Neus Falgàs
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | | | - Lorena Rami
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Jordi Sarto
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Maria A Botí
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Cristina Arnaldos-Pérez
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Immunology Service, Biomedical Diagnostic Center, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Raquel Ruiz-García
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Immunology Service, Biomedical Diagnostic Center, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laura Naranjo
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Immunology Service, Biomedical Diagnostic Center, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Bàrbara Segura
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Medical Psychology Unit, Department of Medicine, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Mircea Balasa
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
| | - Roser Sala-Llonch
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Department of Biomedicine, Faculty of Medicine, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - Albert Lladó
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | - Yi Wang
- Sage Therapeutics, Cambridge, USA
| | | | - Josep Dalmau
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain
- Department of Neurology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
- Enfermedades Raras, Centro de Investigación Biomédica en Red, Madrid, Spain
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Catalan Institute for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Raquel Sanchez-Valle
- Alzheimer's Disease and Other Cognitive Disorders Unit, Service of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain.
- Fundació Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain.
- Institut de Neurociències, Faculty of Medicine and Medical Sciences, University of Barcelona, Barcelona, Spain.
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Hanin A, Jimenez AD, Gopaul M, Asbell H, Aydemir S, Basha MM, Batra A, Damien C, Day GS, Eka O, Eschbach K, Fatima S, Fields MC, Foreman B, Gerard EE, Gofton TE, Haider HA, Hantus ST, Hocker S, Jongeling A, Kalkach Aparicio M, Kandula P, Kang P, Kazazian K, Kellogg MA, Kim M, Lee JW, Marcuse LV, McGraw CM, Mohamed W, Orozco J, Pimentel CM, Punia V, Ramirez AM, Steriade C, Struck AF, Taraschenko O, Treister AK, Wainwright MS, Yoo JY, Zafar S, Zhou DJ, Zutshi D, Gaspard N, Hirsch LJ. Trends in management of patients with new-onset refractory status epilepticus (NORSE) from 2016 to 2023: An interim analysis. Epilepsia 2024. [PMID: 38837761 DOI: 10.1111/epi.18014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/02/2024] [Accepted: 05/03/2024] [Indexed: 06/07/2024]
Abstract
In response to the evolving treatment landscape for new-onset refractory status epilepticus (NORSE) and the publication of consensus recommendations in 2022, we conducted a comparative analysis of NORSE management over time. Seventy-seven patients were enrolled by 32 centers, from July 2016 to August 2023, in the NORSE/FIRES biorepository at Yale. Immunotherapy was administered to 88% of patients after a median of 3 days, with 52% receiving second-line immunotherapy after a median of 12 days (anakinra 29%, rituximab 25%, and tocilizumab 19%). There was an increase in the use of second-line immunotherapies (odds ratio [OR] = 1.4, 95% CI = 1.1-1.8) and ketogenic diet (OR = 1.8, 95% CI = 1.3-2.6) over time. Specifically, patients from 2022 to 2023 more frequently received second-line immunotherapy (69% vs 40%; OR = 3.3; 95% CI = 1.3-8.9)-particularly anakinra (50% vs 13%; OR = 6.5; 95% CI = 2.3-21.0), and the ketogenic diet (OR = 6.8; 95% CI = 2.5-20.1)-than those before 2022. Among the 27 patients who received anakinra and/or tocilizumab, earlier administration after status epilepticus onset correlated with a shorter duration of status epilepticus (ρ = .519, p = .005). Our findings indicate an evolution in NORSE management, emphasizing the increasing use of second-line immunotherapies and the ketogenic diet. Future research will clarify the impact of these treatments and their timing on patient outcomes.
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Affiliation(s)
- Aurelie Hanin
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, INSERM, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
- Epilepsy Unit, Department of Clinical Neurophysiology, DMU Neurosciences, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Anthony D Jimenez
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hannah Asbell
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Seyhmus Aydemir
- Department of Neurology, Weill Cornell Medicine, New York City, New York, USA
| | | | - Ayush Batra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Gregory S Day
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Onome Eka
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krista Eschbach
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elizabeth E Gerard
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Teneille E Gofton
- London Health Sciences Center, University Hospital, London, Ontario, Canada
| | - Hiba A Haider
- Epilepsy Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen T Hantus
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, Ohio, USA
| | | | - Amy Jongeling
- Department of Neurology, NYU Langone Medical Center, New York, New York, USA
| | | | - Padmaja Kandula
- Department of Neurology, Weill Cornell Medicine, New York City, New York, USA
| | - Peter Kang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Karnig Kazazian
- London Health Sciences Center, University Hospital, London, Ontario, Canada
| | | | - Minjee Kim
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lara V Marcuse
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wazim Mohamed
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Janet Orozco
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Vineet Punia
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, Ohio, USA
| | - Alexandra M Ramirez
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Claude Steriade
- Department of Neurology, NYU Langone Medical Center, New York, New York, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Mark S Wainwright
- Divison of Pediatric Neurology, University of Washington, Seattle, Washington, USA
| | - Ji Yeoun Yoo
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nicolas Gaspard
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
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4
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Jimenez AD, Gopaul M, Asbell H, Aydemir S, Basha MM, Batra A, Damien C, Day GS, Eka O, Eschbach K, Fatima S, Fields MC, Foreman B, Gerard EE, Gofton TE, Haider HA, Hantus ST, Hocker S, Jongeling A, Kalkach Aparicio M, Kandula P, Kang P, Kazazian K, Kellogg MA, Kim M, Lee JW, Marcuse LV, McGraw CM, Mohamed W, Orozco J, Pimentel C, Punia V, Ramirez AM, Steriade C, Struck AF, Taraschenko O, Treister AK, Yoo JY, Zafar S, Zhou DJ, Zutshi D, Gaspard N, Hirsch LJ, Hanin A. Comparative analysis of patients with new onset refractory status epilepticus preceded by fever (febrile infection-related epilepsy syndrome) versus without prior fever: An interim analysis. Epilepsia 2024; 65:e87-e96. [PMID: 38625055 DOI: 10.1111/epi.17988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a subset of new onset refractory status epilepticus (NORSE) that involves a febrile infection prior to the onset of the refractory status epilepticus. It is unclear whether FIRES and non-FIRES NORSE are distinct conditions. Here, we compare 34 patients with FIRES to 30 patients with non-FIRES NORSE for demographics, clinical features, neuroimaging, and outcomes. Because patients with FIRES were younger than patients with non-FIRES NORSE (median = 28 vs. 48 years old, p = .048) and more likely cryptogenic (odds ratio = 6.89), we next ran a regression analysis using age or etiology as a covariate. Respiratory and gastrointestinal prodromes occurred more frequently in FIRES patients, but no difference was found for non-infection-related prodromes. Status epilepticus subtype, cerebrospinal fluid (CSF) and magnetic resonance imaging findings, and outcomes were similar. However, FIRES cases were more frequently cryptogenic; had higher CSF interleukin 6, CSF macrophage inflammatory protein-1 alpha (MIP-1a), and serum chemokine ligand 2 (CCL2) levels; and received more antiseizure medications and immunotherapy. After controlling for age or etiology, no differences were observed in presenting symptoms and signs or inflammatory biomarkers, suggesting that FIRES and non-FIRES NORSE are very similar conditions.
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Affiliation(s)
- Anthony D Jimenez
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hannah Asbell
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seyhmus Aydemir
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Maysaa M Basha
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ayush Batra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Gregory S Day
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Onome Eka
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krista Eschbach
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elizabeth E Gerard
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Teneille E Gofton
- University Hospital London Health Sciences Center, London, Ontario, Canada
| | - Hiba A Haider
- Epilepsy Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Stephen T Hantus
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara Hocker
- Mayo Clinic, Minnesota, Rochester, Minnesota, USA
| | - Amy Jongeling
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, New York, New York, USA
| | | | - Padmaja Kandula
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Peter Kang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Karnig Kazazian
- University Hospital London Health Sciences Center, London, Ontario, Canada
| | | | - Minjee Kim
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lara V Marcuse
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wazim Mohamed
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Janet Orozco
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Cederic Pimentel
- Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vineet Punia
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alexandra M Ramirez
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Claude Steriade
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, New York, New York, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Ji Yeoun Yoo
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nicolas Gaspard
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aurelie Hanin
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, Assistance Publique- Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
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5
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Costello DJ, Matthews E, Aurangzeb S, Doran E, Stack J, Wesselingh R, Dugan P, Choi H, Depondt C, Devinsky O, Doherty C, Kwan P, Monif M, O'Brien TJ, Sen A, Gaspard N. Clinical outcomes among initial survivors of cryptogenic new-onset refractory status epilepsy (NORSE). Epilepsia 2024; 65:1581-1588. [PMID: 38498313 DOI: 10.1111/epi.17950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE New-onset refractory status epilepticus (NORSE) is a rare but severe clinical syndrome. Despite rigorous evaluation, the underlying cause is unknown in 30%-50% of patients and treatment strategies are largely empirical. The aim of this study was to describe clinical outcomes in a cohort of well-phenotyped, thoroughly investigated patients who survived the initial phase of cryptogenic NORSE managed in specialist centers. METHODS Well-characterized cases of cryptogenic NORSE were identified through the EPIGEN and Critical Care EEG Monitoring Research Consortia (CCEMRC) during the period 2005-2019. Treating epileptologists reported on post-NORSE survival rates and sequelae in patients after discharge from hospital. Among survivors >6 months post-discharge, we report the rates and severity of active epilepsy, global disability, vocational, and global cognitive and mental health outcomes. We attempt to identify determinants of outcome. RESULTS Among 48 patients who survived the acute phase of NORSE to the point of discharge from hospital, 9 had died at last follow-up, of whom 7 died within 6 months of discharge from the tertiary care center. The remaining 39 patients had high rates of active epilepsy as well as vocational, cognitive, and psychiatric comorbidities. The epilepsy was usually multifocal and typically drug resistant. Only a minority of patients had a good functional outcome. Therapeutic interventions were heterogenous during the acute phase of the illness. There was no clear relationship between the nature of treatment and clinical outcomes. SIGNIFICANCE Among survivors of cryptogenic NORSE, longer-term outcomes in most patients were life altering and often catastrophic. Treatment remains empirical and variable. There is a pressing need to understand the etiology of cryptogenic NORSE and to develop tailored treatment strategies.
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Affiliation(s)
- Daniel J Costello
- Epilepsy service, Department of Neurology, Cork University Hospital & College of Medicine and Health, University College Cork, Cork, Ireland
- The SFI Futureneuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sidra Aurangzeb
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Elisabeth Doran
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin
| | - Jessica Stack
- Epilepsy service, Department of Neurology, Cork University Hospital & College of Medicine and Health, University College Cork, Cork, Ireland
| | - Robb Wesselingh
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Patricia Dugan
- New York University Langone Health Comprehensive Epilepsy Center, New York, New York, USA
| | - Hyunmi Choi
- Department of Neurology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Chantal Depondt
- Department of Neurology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Orrin Devinsky
- New York University Langone Health Comprehensive Epilepsy Center, New York, New York, USA
| | - Colin Doherty
- The SFI Futureneuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Patrick Kwan
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Mastura Monif
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Terence J O'Brien
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Arjune Sen
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Route de Lennik, Brussels, Belgium
- Department of Neurology, Yale University Medical School, New Haven, Connecticut, USA
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6
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Bolle AE, Gaist T, Kuljis AME, Blaabjerg M, Beier CP. NORSE seasonality may vary geographically in adults. Epilepsia Open 2024; 9:1088-1095. [PMID: 38635008 PMCID: PMC11145602 DOI: 10.1002/epi4.12944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/19/2024] Open
Abstract
The mechanisms causing new onset refractory status epilepticus (NORSE) are often unknown. Recently, a seasonal variation with NORSE peaking during the summer was described in a mixed cohort of adults and children why we here studied the seasonal variation in a Danish status epilepticus (SE) cohort. This retrospective cohort study comprised SE patients aged ≥18 diagnosed and treated 2008-2017 at the Odense University Hospital. Clinical characteristics and seasonality of patients fulfilling the diagnostic criteria for NORSE were compared with patients with refractory SE (RSE) due to other reasons and with the seasonal variation of autoantibodies associated with autoimmune encephalitis in the Danish autoimmune encephalitis register. In this cohort, 26 patients met NORSE criteria. As compared to RSE patients not fulfilling NORSE criteria (n = 152), NORSE patients were more likely to have symptoms of systemic inflammation (C-reactive protein concentrations ≥10 mg/L or fever ≥38°C) at admission; nine fulfilled the criteria for febrile infection related epilepsy syndrome (FIRES). In contrast to the even seasonal distribution of patients with RSE not fulfilling the NORSE criteria, admissions due to NORSE peaked during the winter (46.1%, p = 0.04 as compared to non-NORSE RSE); six out of nine FIRES episodes occurred in the winter season. The seasonal variation was not explained by a seasonal variation of the detection rates of autoantibodies associated with autoimmune encephalitis (incl. NMDAR, LGI1, CASPR2, GABAR, GFAP) in a Danish nationwide register (n = 259). In conclusion, we confirm the seasonality of NORSE in a Danish cohort, however, with a peak during winter suggesting a geographical variation not solely explained by autoimmune encephalitis associated with known autoantibodies. PLAIN LANGUAGE SUMMARY: The study investigated the seasonal patterns of new-onset refractory status epilepticus (NORSE), i.e. severe seizures that occur without an obvious cause and require very intensive treatment. In contrast to the previously observed peak frequency in summer, this Danish study found that NORSE cases peak in winter. Furthermore, the seasonal variation in NORSE cases was not found to be associated with autoimmune encephalitis caused by known autoantibodies. Together with the high rate of patients showing symptoms of systemic inflammation compared to other status epilepticus patients, the data suggest a link between misdirected immune system responses and NORSE. The study can therefore help in the further search for the currently unknown causes of NORSE.
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Affiliation(s)
- Andrea Enerstad Bolle
- Department of NeurologyOdense University HospitalOdenseDenmark
- BRIDGE – Brain Research Inter Disciplinary Guided ExcellenceOdense University HospitalOdenseDenmark
| | - Thomas Gaist
- Department of NeurologyOdense University HospitalOdenseDenmark
| | | | - Morten Blaabjerg
- Department of NeurologyOdense University HospitalOdenseDenmark
- BRIDGE – Brain Research Inter Disciplinary Guided ExcellenceOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Christoph Patrick Beier
- Department of NeurologyOdense University HospitalOdenseDenmark
- BRIDGE – Brain Research Inter Disciplinary Guided ExcellenceOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
- OPEN, Open Patient Data Explorative NetworkOdense University HospitalOdenseDenmark
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7
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Smith KM, Budhram A, Geis C, McKeon A, Steriade C, Stredny CM, Titulaer MJ, Britton JW. Autoimmune-associated seizure disorders. Epileptic Disord 2024. [PMID: 38818801 DOI: 10.1002/epd2.20231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024]
Abstract
With the discovery of an expanding number of neural autoantibodies, autoimmune etiologies of seizures have been increasingly recognized. Clinical phenotypes have been identified in association with specific underlying antibodies, allowing an earlier diagnosis. These phenotypes include faciobrachial dystonic seizures with LGI1 encephalitis, neuropsychiatric presentations associated with movement disorders and seizures in NMDA-receptor encephalitis, and chronic temporal lobe epilepsy in GAD65 neurologic autoimmunity. Prompt recognition of these disorders is important, as some of them are highly responsive to immunotherapy. The response to immunotherapy is highest in patients with encephalitis secondary to antibodies targeting cell surface synaptic antigens. However, the response is less effective in conditions involving antibodies binding intracellular antigens or in Rasmussen syndrome, which are predominantly mediated by cytotoxic T-cell processes that are associated with irreversible cellular destruction. Autoimmune encephalitides also may have a paraneoplastic etiology, further emphasizing the importance of recognizing these disorders. Finally, autoimmune processes and responses to novel immunotherapies have been reported in new-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES), warranting their inclusion in any current review of autoimmune-associated seizure disorders.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Christian Geis
- Department of Neurology and Section Translational Neuroimmunology, Jena University Hospital, Jena, Germany
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, New York, New York, USA
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
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8
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Taraschenko O, Fox HS, Eldridge E, Heliso P, Al-Saleem F, Dessain S, Casale G, Willcockson G, Anderson K, Wang W, Dingledine R. MyD88-mediated signaling is critical for the generation of seizure responses and cognitive impairment in a model of anti-N-methyl-D-aspartate receptor encephalitis. Epilepsia 2024; 65:1475-1487. [PMID: 38470097 PMCID: PMC11087204 DOI: 10.1111/epi.17931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE We previously demonstrated that interleukin-1 receptor-mediated immune activation contributes to seizure severity and memory loss in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. In the present study, we assessed the role of the myeloid differentiation primary response gene 88 (MyD88), an adaptor protein in Toll-like receptor signaling, in the key phenotypic characteristics of anti-NMDAR encephalitis. METHODS Monoclonal anti-NMDAR antibodies or control antibodies were infused into the lateral ventricle of MyD88 knockout mice (MyD88-/-) and control C56BL/6J mice (wild type [WT]) via osmotic minipumps for 2 weeks. Seizure responses were measured by electroencephalography. Upon completion of the infusion, the motor, anxiety, and memory functions of the mice were assessed. Astrocytic (glial fibrillary acidic protein [GFAP]) and microglial (ionized calcium-binding adaptor molecule 1 [Iba-1]) activation and transcriptional activation for the principal inflammatory mediators involved in seizures were determined using immunohistochemistry and quantitative real-time polymerase chain reaction, respectively. RESULTS As shown before, 80% of WT mice infused with anti-NMDAR antibodies (n = 10) developed seizures (median = 11, interquartile range [IQR] = 3-25 in 2 weeks). In contrast, only three of 14 MyD88-/- mice (21.4%) had seizures (0, IQR = 0-.25, p = .01). The WT mice treated with antibodies also developed memory loss in the novel object recognition test, whereas such memory deficits were not apparent in MyD88-/- mice treated with anti-NMDAR antibodies (p = .03) or control antibodies (p = .04). Furthermore, in contrast to the WT mice exposed to anti-NMDAR antibodies, the MyD88-/- mice had a significantly lower induction of chemokine (C-C motif) ligand 2 (CCL2) in the hippocampus (p = .0001, Sidak tests). There were no significant changes in the expression of GFAP and Iba-1 in the MyD88-/- mice treated with anti-NMDAR or control antibodies. SIGNIFICANCE These findings suggest that MyD88-mediated signaling contributes to the seizure and memory phenotype in anti-NMDAR encephalitis and that CCL2 activation may participate in the expression of these features. The removal of MyD88 inflammation may be protective and therapeutically relevant.
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Affiliation(s)
- Olga Taraschenko
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Howard S. Fox
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Ember Eldridge
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Priscilla Heliso
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | | | - Scott Dessain
- Lankenau Institute for Medical Research, Wynnewood, PA
| | - George Casale
- Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, NE
| | | | - Kayley Anderson
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE
| | - Wenyi Wang
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA
| | - Raymond Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA
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9
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Hanin A, Muscal E, Hirsch LJ. Second-line immunotherapy in new onset refractory status epilepticus. Epilepsia 2024; 65:1203-1223. [PMID: 38430119 DOI: 10.1111/epi.17933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
Several pieces of evidence suggest immune dysregulation could trigger the onset and modulate sequelae of new onset refractory status epilepticus (NORSE), including its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES). Consensus-driven recommendations have been established to guide the initiation of first- and second-line immunotherapies in these patients. Here, we review the literature to date on second-line immunotherapy for NORSE/FIRES, presenting results from 28 case reports and series describing the use of anakinra, tocilizumab, or intrathecal dexamethasone in 75 patients with NORSE. Among them, 52 patients were managed with anakinra, 21 with tocilizumab, and eight with intrathecal dexamethasone. Most had elevated serum or cerebrospinal fluid cytokine levels at treatment initiation. Treatments were predominantly initiated during the acute phase of the disease (92%) and resulted, within the first 2 weeks, in seizure control for up to 73% of patients with anakinra, 70% with tocilizumab, and 50% with intrathecal dexamethasone. Cytokine levels decreased after treatment for most patients. Anakinra and intrathecal dexamethasone were mainly initiated in children with FIRES, whereas tocilizumab was more frequently prescribed for adults, with or without a prior febrile infection. There was no clear correlation between the response to treatment and the time to initiate the treatment. Most patients experienced long-term disability and drug-resistant post-NORSE epilepsy. Initiation of second-line immunotherapies during status epilepticus (SE) had no clear effect on the emergence of post-NORSE epilepsy or long-term functional outcomes. In a small number of cases, the initiation of anakinra or tocilizumab several years after SE onset resulted in a reduction of seizure frequency for 67% of patients. These data highlight the potential utility of anakinra, tocilizumab, and intrathecal dexamethasone in patients with NORSE. There continues to be interest in the utilization of early cytokine measurements to guide treatment selection and response. Prospective studies are necessary to understand the role of early immunomodulation and its associations with epilepsy and functional outcomes.
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Affiliation(s)
- Aurélie Hanin
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute-ICM, Inserm, CNRS, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
- Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences 6, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Eyal Muscal
- Department of Pediatrics, Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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10
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Hanin A, Eschbach K, Gofton TE, Gopaul M, Howe CL, Lai YC, Koh S, Shen H, Hirsch LJ. New onset refractory status epilepticus: Summary of the NORSE Institute roundtable during the 2023 American Epilepsy Society meeting, Orlando, Florida. Epilepsia 2024; 65:1145-1146. [PMID: 38421053 DOI: 10.1111/epi.17934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Aurélie Hanin
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Teneille E Gofton
- University Hospital, London Health Sciences Center, London, Ontario, Canada
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles L Howe
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi-Chen Lai
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sookyong Koh
- Children's Hospital and Medical Center, Department of Pediatrics, University of Nebraska, Omaha, Nebraska, USA
| | - Haying Shen
- Children's Hospital and Medical Center, Department of Pediatrics, University of Nebraska, Omaha, Nebraska, USA
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
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11
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Benghanem S, Robieux EP, Neligan A, Walker MC. Status epilepticus: what's new for the intensivist. Curr Opin Crit Care 2024; 30:131-141. [PMID: 38441162 DOI: 10.1097/mcc.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Status epilepticus (SE) is a common neurologic emergency affecting about 36.1/100 000 person-years that frequently requires intensive care unit (ICU) admission. There have been advances in our understanding of epidemiology, pathophysiology, and EEG monitoring of SE, and there have been large-scale treatment trials, discussed in this review. RECENT FINDINGS Recent changes in the definitions of SE have helped guide management protocols and we have much better predictors of outcome. Observational studies have confirmed the efficacy of benzodiazepines and large treatment trials indicate that all routinely used second line treatments (i.e., levetiracetam, valproate and fosphenytoin) are equally effective. Better understanding of the pathophysiology has indicated that nonanti-seizure medications aimed at underlying pathological processes should perhaps be considered in the treatment of SE; already immunosuppressant treatments are being more widely used in particular for new onset refractory status epilepticus (NORSE) and Febrile infection-related epilepsy syndrome (FIRES) that sometimes revealed autoimmune or paraneoplastic encephalitis. Growing evidence for ICU EEG monitoring and major advances in automated analysis of the EEG could help intensivist to assess the control of electrographic seizures. SUMMARY Research into the morbi-mortality of SE has highlighted the potential devastating effects of this condition, emphasizing the need for rapid and aggressive treatment, with particular attention to cardiorespiratory and neurological complications. Although we now have a good evidence-base for the initial status epilepticus management, the best treatments for the later stages are still unclear and clinical trials of potentially disease-modifying therapies are long overdue.
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Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, Cochin hospital, APHP.Centre
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
| | - Estelle Pruvost Robieux
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
- Neurophysiology and epileptology department, Sainte Anne hospital, Paris, France
| | - Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row
- UCL Queen Square Institute of Neurology, Queen Square, London
- Centre for Preventive Neurology, Wolfson Institute of Population Health, QMUL, UK
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12
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Nguyen TL, Simon DW, Lai YC. Beyond the brain: General intensive care considerations in pediatric neurocritical care. Semin Pediatr Neurol 2024; 49:101120. [PMID: 38677799 DOI: 10.1016/j.spen.2024.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 04/29/2024]
Abstract
Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients. The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.
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Affiliation(s)
- Thao L Nguyen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGovern Medical School, UT Health Houston, Houston, TX
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yi-Chen Lai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
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13
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Hanin A, Chollet C, Demeret S, Di Meglio L, Castelli F, Navarro V. Metabolomic changes in adults with status epilepticus: A human case-control study. Epilepsia 2024; 65:929-943. [PMID: 38339978 DOI: 10.1111/epi.17899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Status epilepticus (SE) is a life-threatening prolonged epileptic seizure that affects ~40 per 100 000 people yearly worldwide. The persistence of seizures may lead to excitotoxic processes, neuronal loss, and neuroinflammation, resulting in long-term neurocognitive and functional disabilities. A better understanding of the pathophysiological mechanisms underlying SE consequences is crucial for improving SE management and preventing secondary neuronal injury. METHODS We conducted a comprehensive untargeted metabolomic analysis, using liquid chromatography coupled with high-resolution mass spectrometry (LC-HRMS), on plasma and cerebrospinal fluid (CSF) samples from 78 adult patients with SE and 107 control patients without SE, including 29 with CSF for both groups. The metabolomic fingerprints were compared between patients with SE and controls. Metabolites with differences in relative abundances that could not be attributed to treatment or nutrition provided in the intensive care unit were isolated. Enrichment analysis was performed on these metabolites to identify the most affected pathways. RESULTS We identified 76 metabolites in the plasma and 37 in the CSF that exhibited differential expression in patients with SE compared to controls. The enrichment analysis revealed that metabolic dysregulations in patients with SE affected primarily amino acid metabolism (including glutamate, alanine, tryptophan, glycine, and serine metabolism), pyrimidine metabolism, and lipid homeostasis. Specifically, patients with SE had elevated levels of pyruvate, quinolinic acid, and keto butyric acid levels, along with lower levels of arginine, N-acetylaspartylglutamate (NAAG), tryptophan, uracil, and uridine. The tryptophan kynurenine pathway was identified as the most significantly altered in SE, resulting in the overproduction of quinolinic acid, an N-methyl-d-aspartate (NMDA) receptor agonist with pro-inflammatory properties. SIGNIFICANCE This study has identified several pathways that may play pivotal roles in SE consequences, such as the tryptophan kynurenine pathway. These findings offer novel perspectives for the development of neuroprotective therapeutics.
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Affiliation(s)
- Aurélie Hanin
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié-Salpêtrière, Paris, France
- AP-HP, Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Céline Chollet
- Université Paris Saclay, CEA, INRAE, Médicaments et Technologies pour la Santé (MTS), MetaboHUB, Gif-sur-Yvette, France
| | - Sophie Demeret
- AP-HP, Neuro-Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Lucas Di Meglio
- AP-HP, Neuro-Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Florence Castelli
- Université Paris Saclay, CEA, INRAE, Médicaments et Technologies pour la Santé (MTS), MetaboHUB, Gif-sur-Yvette, France
| | - Vincent Navarro
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié-Salpêtrière, Paris, France
- AP-HP, Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences, Hôpital de la Pitié-Salpêtrière, Paris, France
- Center of Reference for Rare Epilepsies, Epicare, Hôpital de la Pitié-Salpêtrière, Paris, France
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14
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der Heijden HV, Rameh V, Golden E, Ronen I, Sundel RP, Knight A, Chang JC, Upadhyay J. Implications of Inflammatory Processes on a Developing Central Nervous System in Childhood-Onset Systemic Lupus Erythematosus. Arthritis Rheumatol 2024; 76:332-344. [PMID: 37901986 PMCID: PMC10922196 DOI: 10.1002/art.42736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/20/2023] [Accepted: 10/25/2023] [Indexed: 10/31/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is increasingly affecting pediatric and adult populations. Neuropsychiatric manifestations (ie, cognitive dysfunction and mood disorders) appear to occur with greater severity and poorer prognosis in childhood-onset SLE (cSLE) versus adult-onset SLE, negatively impacting school function, self-management, and psychosocial health, as well as lifelong health-related quality of life. In this review, we describe pathogenic mechanisms active in cSLE, such as maladaptive inflammatory processes and ischemia, which are hypothesized to underpin central phenotypes in patients with cSLE, and the role of alterations in protective central nervous system (CNS) barriers (ie, the blood-brain barrier) are also discussed. Recent findings derived from novel neuroimaging approaches are highlighted because the methods employed in these studies hold potential for identifying CNS abnormalities that would otherwise remain undetected with conventional multiple resonance imaging studies (eg, T2-weighted or fluid-attenuated inversion recovery sequences). Furthermore, we propose that a more robust presentation of neuropsychiatric symptoms in cSLE is in part due to the harmful impact of a chronic inflammatory insult on a developing CNS. Although the immature status of the CNS may leave patients with cSLE more vulnerable to harboring neuropsychiatric manifestations, the same property may represent a greater urgency to reverse the maladaptive effects associated with a proneuroinflammatory state, provided that effective diagnostic tools and treatment strategies are available. Finally, considering the crosstalk among the CNS and other organ systems affected in cSLE, we postulate that a finer understanding of this interconnectivity and its role in the clinical presentation in cSLE is warranted.
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Affiliation(s)
- Hanne Van der Heijden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
- Faculty of Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Vanessa Rameh
- Division of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Emma Golden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Itamar Ronen
- Clinical Imaging Science Center, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Andrea Knight
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Joyce C. Chang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Jaymin Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA USA
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15
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Carson R, Stredny CM. Severe, Refractory Seizures: New-Onset Refractory Status Epilepticus and Febrile Infection-Related Epilepsy Syndrome. Med Clin North Am 2024; 108:201-213. [PMID: 37951651 DOI: 10.1016/j.mcna.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
NORSE (new-onset refractory status epilepticus) and FIRES (febrile infection-related epilepsy syndrome) represent presentations of new-onset status epilepticus without apparent underlying structural, metabolic, or toxic etiology. The cause of NORSE/FIRES remains cryptogenic in up to half of cases, and an abnormal response of the innate immune system has been implicated. Consensus guidelines recommend broad diagnostic investigation and empiric treatment with immunotherapy. NORSE/FIRES is associated with poor outcomes including cognitive impairment and epilepsy, but early recognition and treatment may be important for improving outcomes.
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Affiliation(s)
- Ross Carson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Division of Epilepsy and Clinical Neurophysiology, Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Brigo F, Zelano J, Abraira L, Bentes C, Ekdahl CT, Lattanzi S, Ingvar Lossius M, Redfors P, Rouhl RPW, Russo E, Sander JW, Vogrig A, Wickström R. Proceedings of the "International Congress on Structural Epilepsy & Symptomatic Seizures" (STESS, Gothenburg, Sweden, 29-31 March 2023). Epilepsy Behav 2024; 150:109538. [PMID: 38039602 DOI: 10.1016/j.yebeh.2023.109538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy.
| | - Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Laura Abraira
- Neurology Department, Epilepsy Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Carla Bentes
- Neurophysiological Monitoring Unit - EEG/Sleep Laboratory, Refractory Epilepsy Reference Centre (member of EpiCARE), Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Centro de Estudos Egas Moniz, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - Christine T Ekdahl
- Division of Clinical Neurophysiology and Department of Clinical Sciences, Lund University, Sweden; Lund Epilepsy Center, Department of Clinical Sciences, Lund University, Sweden
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Morten Ingvar Lossius
- National Centre for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Member of the ERN EpiCARE, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Petra Redfors
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Academic Centre for Epileptology Kempenhaeghe/MUMC+ Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Italy
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK; Centre for Epilepsy, Chalfont St Peter, Bucks., SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede 2103 SW, The Netherlands; Neurology Department, West of China Hospital, Sichuan University, Chengdu 610041, China
| | - Alberto Vogrig
- Department of Medicine (DAME), University of Udine, Udine, Italy; Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Ronny Wickström
- Neuropediatric Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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17
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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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18
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Grebenciucova E, VanHaerents S. Interleukin 6: at the interface of human health and disease. Front Immunol 2023; 14:1255533. [PMID: 37841263 PMCID: PMC10569068 DOI: 10.3389/fimmu.2023.1255533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Interleukin 6 (IL-6) is a pleiotropic cytokine executing a diverse number of functions, ranging from its effects on acute phase reactant pathways, B and T lymphocytes, blood brain barrier permeability, synovial inflammation, hematopoiesis, and embryonic development. This cytokine empowers the transition between innate and adaptive immune responses and helps recruit macrophages and lymphocytes to the sites of injury or infection. Given that IL-6 is involved both in the immune homeostasis and pathogenesis of several autoimmune diseases, research into therapeutic modulation of IL-6 axis resulted in the approval of a number of effective treatments for several autoimmune disorders like neuromyelitis optica spectrum disorder (NMOSD), rheumatoid arthritis, juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, giant cell arteritis (GCA), and cytokine release syndrome, associated with SARS-CoV2 pneumonia. This review discusses downstream inflammatory pathways of IL-6 expression and therapeutic applications of IL-6 blockade, currently investigated for the treatment of several other autoimmune conditions such as autoimmune encephalitis, autoimmune epilepsy, as well as myelin oligodendrocyte glycoprotein associated demyelination (MOGAD). This review further highlights the need for clinical trials to evaluate IL-6 blockade in disorders such neuropsychiatric lupus erythematosus (SLE), sarcoidosis and Behcet's.
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Affiliation(s)
- Elena Grebenciucova
- Feinberg School of Medicine, Department of Neurology, Northwestern University, Chicago, IL, United States
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