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Costanza M, Ciotti A, Consonni A, Cipelletti B, Cattalini A, Cagnoli C, Baggi F, de Curtis M, Colciaghi F. CNS autoimmune response in the MAM/pilocarpine rat model of epileptogenic cortical malformation. Proc Natl Acad Sci U S A 2024; 121:e2319607121. [PMID: 38635635 PMCID: PMC11047071 DOI: 10.1073/pnas.2319607121] [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: 11/29/2023] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
The development of seizures in epilepsy syndromes associated with malformations of cortical development (MCDs) has traditionally been attributed to intrinsic cortical alterations resulting from abnormal network excitability. However, recent analyses at single-cell resolution of human brain samples from MCD patients have indicated the possible involvement of adaptive immunity in the pathogenesis of these disorders. By exploiting the MethylAzoxyMethanol (MAM)/pilocarpine (MP) rat model of drug-resistant epilepsy associated with MCD, we show here that the occurrence of status epilepticus and subsequent spontaneous recurrent seizures in the malformed, but not in the normal brain, are associated with the outbreak of a destructive autoimmune response with encephalitis-like features, involving components of both cell-mediated and humoral immune responses. The MP brain is characterized by blood-brain barrier dysfunction, marked and persisting CD8+ T cell invasion of the brain parenchyma, meningeal B cell accumulation, and complement-dependent cytotoxicity mediated by antineuronal antibodies. Furthermore, the therapeutic treatment of MP rats with the immunomodulatory drug fingolimod promotes both antiepileptogenic and neuroprotective effects. Collectively, these data show that the MP rat could serve as a translational model of epileptogenic cortical malformations associated with a central nervous system autoimmune response. This work indicates that a preexisting brain maldevelopment predisposes to a secondary autoimmune response, which acts as a precipitating factor for epilepsy and suggests immune intervention as a therapeutic option to be further explored in epileptic syndromes associated with MCDs.
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Affiliation(s)
- Massimo Costanza
- Neuro-Oncology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Arianna Ciotti
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Alessandra Consonni
- Neuroimmunology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Barbara Cipelletti
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Alessandro Cattalini
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Cinzia Cagnoli
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Fulvio Baggi
- Neuroimmunology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Marco de Curtis
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
| | - Francesca Colciaghi
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan20133, Italy
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Galev G, Prayson RA. Focal cortical dysplasia is a frequent coexistent pathology in patients with Rasmussen's encephalitis. Ann Diagn Pathol 2024; 68:152224. [PMID: 37976976 DOI: 10.1016/j.anndiagpath.2023.152224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Rasmussen's encephalitis (RE) is a rare, predominantly pediatric epilepsy disorder of unknown etiology. It classically affects one of the cerebral hemispheres and histologically shows cortical chronic inflammation, gliosis, and neuronal loss. The etiopathogenesis of RE remains unknown, with genetic, infectious, and autoimmune factors all speculated to play a role. Although the histologic findings in RE are well described, few studies have investigated a large cohort of cases looking for the coexistence of RE with focal cortical dysplasia (FCD). DESIGN The study is a retrospective review of RE patients who underwent surgical resection of brain tissue between 1979 and 2021. Relevant patient history was retrieved, and available histologic slides were reviewed. The histologic severity of RE was described according to the Pardo criteria. In cases where FCD was present, the observed patterns of FCD (namely Ia, Ib, IIa, IIb, etc.) were described using the International League Against Epilepsy (ILAE) classification. RESULTS Thirty-eight resection specimens from 31 patients formed the study cohort. Seventeen patients (54.8 %) were male; average age at surgery was 8 years (range: 2-28 years). Twenty-seven resection specimens (71.1 %) from 23 patients (74 %) showed evidence of coexistent FCD. Most cases with FCD resembled the ILAE type Ib (n = 23) pattern. Cases of RE that did not show FCD were either Pardo stage 1 (n = 5) or 4 (n = 6), with all Pardo stage 2 and 3 cases demonstrating FCD. CONCLUSIONS FCD was found in most patients with RE (74 %). The most observed pattern of FCD was ILAE Ib.
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Affiliation(s)
- Georgi Galev
- Department of Anatomic Pathology, L25, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Richard A Prayson
- Department of Anatomic Pathology, L25, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America.
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Alfonso MA, Piñeros-Fernández MC, Jaimes LF, Ramos NI. Atypical Rasmussen's Encephalitis. Cureus 2023; 15:e46647. [PMID: 37808599 PMCID: PMC10560088 DOI: 10.7759/cureus.46647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 10/10/2023] Open
Abstract
A three-year-old female patient was admitted to our institution due to subacute fever, intermittent vomiting, persistent bilateral mydriasis after cycloplegia, right central facial palsy, and mild right hemiparesis with hyperreflexia. Brain MRI shows encephalitis in frontal, parietal, insular, and left putamen course and loss of cortical volume and white matter of the entire left hemisphere which are features described in Rasmussen's encephalitis (RE). Therapy with intravenous methylprednisolone bolus was initiated, with adequate clinical response. We consider in this case the diagnosis of atypical RE by imaging criteria in the subacute stage. There are few reports of atypical RE without epilepsy or continuous partial epilepsy. Our purpose is to present a case of a patient with RE images without epilepsy seizures and review the diagnostic and therapeutic approach of RE.
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Affiliation(s)
| | - Martha C Piñeros-Fernández
- Pediatric Neurology, Los Cobos Medical Center, Bogotá, COL
- Pediatric Neurology, Fundación Cardioinfantil - La Cardio, Bogotá, COL
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Rasmussen's encephalitis: Early diagnostic criteria in children. Rev Neurol (Paris) 2022; 178:666-674. [PMID: 35568516 DOI: 10.1016/j.neurol.2022.03.012] [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: 12/27/2021] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/21/2022]
Abstract
Rasmussen's encephalitis (RE) is a rare chronic inflammatory brain disorder resulting in progressive neurodegeneration in one cerebral hemisphere. The inflammatory process is accompanied by progressive loss of function of the affected hemisphere, associated with drug-resistant partial epilepsy. The diagnosis is based on a range of clinical, electroencephalographic, radiological and biochemical arguments, without any specific formal marker, which makes the diagnosis of the disease complex, especially in its initial phase. Seizures are refractory to anti-seizures medication (ASM) and to classical immunomodulatory treatments. These treatments are also ineffective to stop the degenerative process. Only surgical treatment with hemispherotomy (surgical disconnection of a cerebral hemisphere) allows definitive cessation of seizures but this leads to definitive motor and cognitive deficits. The etiology of RE is not known, but there is strong evidence for an immunopathogenic mechanism involving T-cell mediated immunity. The emergence of biotherapies targeting against various cytokines offers potential therapeutic perspectives. This disease is currently a real challenge in terms of: (i) early diagnosis, before the constitution of marked hemispheric atrophy and the appearance of neurological and cognitive consequences; (ii) recognition of incomplete form; (iii) therapeutic management due to advances in the field of targeted treatment of inflammation; (iv) surgery and recovery possibilities.
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Agarwal A, Makkar A, Komakula S, Sahu S, Suri V, Srivasatava A. Triple pathology in Rasmussen's encephalitis: A new pathological phenotype. Ann Indian Acad Neurol 2022; 25:534-536. [PMID: 35936621 PMCID: PMC9350790 DOI: 10.4103/aian.aian_815_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/10/2021] [Indexed: 11/04/2022] Open
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Tang C, Luan G, Li T. Rasmussen's encephalitis: mechanisms update and potential therapy target. Ther Adv Chronic Dis 2020; 11:2040622320971413. [PMID: 33294146 PMCID: PMC7705182 DOI: 10.1177/2040622320971413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/15/2020] [Indexed: 12/11/2022] Open
Abstract
Rasmussen’s encephalitis (RE) is rare neurological diseases characterized as epilepsia partialis continua, invariably hemiparesis, and cognitive impairment. This disease is encountered frequently in childhood and presents with progressive atrophy of the unilateral hemisphere, and there are also sustained neurological complications. Owing to uncertain pathogenesis, the most effective way to limit the influence of seizures currently is cerebral hemispherectomy. In this review, we focus on four main lines of pathogenesis: virus infection, antibody-mediated, cell-mediated immunity, and microglia activation. Although one or more antigenic epitopes may give rise to infiltrating T cell responses in RE brain tissue, no exact antigen was confirmed as the definite cause of the disease. On the other hand, the appearance of antibodies related with RE seem to be a secondary pathological process. Synthetic studies have suggested an adaptive immune mechanism mediated by CD8+ T cells and an innate immune mechanism mediated by activated microglia and neuroglia. Accordingly, opinions have been raised that immunomodulatory treatments aimed at initial damage to the brain that are induced by cytotoxic CD8+ T cell lymphocytes and microglia in the early stage of RE slow down disease progression. However, systematic exploration of the theory behind these therapeutic effects based on multicenter and large sample studies are needed. In addition, dysfunction of the adenosine system, including the main adenosine removing enzyme adenosine kinase and adenosine receptors, has been demonstrated in RE, which might provide a novel therapeutic target for treatment of RE in future.
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Affiliation(s)
- Chongyang Tang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, SanBo Brain Hospital, Capital Medical University No. 50 Xiangshanyikesong Road, Haidian District, Beijing, 100093, China
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Ipe TS, Meyer EK, Sanford KW, Joshi SK, Wong ECC, Raval JS. Use of therapeutic plasma exchange for pediatric neurological diseases. J Clin Apher 2020; 36:161-176. [PMID: 33063869 DOI: 10.1002/jca.21850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/10/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
Therapeutic plasma exchange is used to treat neurological diseases in the pediatric population. Since its first use in pediatric patients with hepatic coma in the form of manual whole blood exchange, therapeutic plasma exchange has been increasingly used to treat these disorders of the nervous system. This expansion is a result of improved techniques and apheresis instruments suitable for small children, as well as the recognition of its applicability to many diseases in the pediatric population. This review provides a historical overview of the use of therapeutic apheresis in children and highlights the most common applications for therapeutic plasma exchange to treat neurological disorders in children.
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Affiliation(s)
- Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Erin K Meyer
- American Red Cross, Columbus, Ohio, USA.,Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kimberly W Sanford
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sarita K Joshi
- Department of Hematology/Oncology and Bone Marrow Transplant, University of Washington, Seattle, Washington, USA
| | - Edward C C Wong
- Department of Pediatrics and Pathology, George Washington School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jay S Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Rasmussen's encephalitis: From immune pathogenesis towards targeted-therapy. Seizure 2020; 81:76-83. [DOI: 10.1016/j.seizure.2020.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/09/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022] Open
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Dupont S, Gales A, Sammey S, Vidailhet M, Lambrecq V. Late-onset Rasmussen Encephalitis: A literature appraisal. Autoimmun Rev 2017; 16:803-810. [DOI: 10.1016/j.autrev.2017.05.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/20/2022]
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Abstract
Epilepsy is one of the most common neurologic disorders, affecting about 50 million people worldwide. The disease is characterized by recurrent seizures, which are due to aberrant neuronal networks resulting in synchronous discharges. The term epilepsy encompasses a large spectrum of syndromes and diseases with different etiopathogenesis. The recent development of imaging and epilepsy surgery techniques is now enabling the identification of structural abnormalities that are part of the epileptic network, and the removal of these lesions may result in control of seizures. Access of this clinically well-characterized neurosurgical material has provided neuropathologists with the opportunity to study a variety of structural brain abnormalities associated with epilepsy, by combining traditional routine histopathologic methods with molecular genetics and functional analysis of the resected tissue. This approach has contributed greatly to a better diagnosis and classification of these structural lesions, and has provided important new insights into their pathogenesis and epileptogenesis. The present chapter provides a detailed description of the large spectrum of histopathologic findings encountered in epilepsy surgery patients, addressing in particular the nonneoplastic pathologies, including hippocampal sclerosis, malformations of cortical development, Sturge-Weber syndrome, and Rasmussen encephalitis, and reviews current knowledge regarding the underlying molecular pathomechanisms and cellular mechanisms mediating hyperexcitability.
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Affiliation(s)
- Eleonora Aronica
- Department of Neuropathology, Academic Medical Center and Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands; Stichting Epilepsie Instellingen Nederland, the Netherlands.
| | - Angelika Mühlebner
- Department of Neuropathology, Academic Medical Center and Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands
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Gorman KM, Farrell M, Madigan C, King MD, Shahwan A. Rasmussen's encephalitis, should absence of seizures influence or delay treatment? Childs Nerv Syst 2015; 31:2009-10. [PMID: 26409880 DOI: 10.1007/s00381-015-2917-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 10/23/2022]
Affiliation(s)
- K M Gorman
- Department of Child Neurology & Clinical Neurophysiology, Children's University Hospital, Temple St., Dublin, Ireland.
| | - M Farrell
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland.
| | - C Madigan
- Department of Child Neurology & Clinical Neurophysiology, Children's University Hospital, Temple St., Dublin, Ireland.
| | - M D King
- Department of Child Neurology & Clinical Neurophysiology, Children's University Hospital, Temple St., Dublin, Ireland. .,Academic Centre on Rare Diseases, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
| | - A Shahwan
- Department of Child Neurology & Clinical Neurophysiology, Children's University Hospital, Temple St., Dublin, Ireland.
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