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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; 26:415-434. [PMID: 38818801 DOI: 10.1002/epd2.20231] [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: 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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Mori T, Matsuda S, Nishida H, Kohyama K, Fukuda M, Sakuma H. Paediatric antibody prevalence in seizure score to predict autoimmune aetiology in seizure disorders. Dev Med Child Neurol 2024. [PMID: 38641898 DOI: 10.1111/dmcn.15927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 04/21/2024]
Abstract
AIM To modify the antibody prevalence in epilepsy (APE) score of children with suspected autoimmune central nervous system disease with seizures. METHODS We retrospectively analysed the cerebrospinal fluid of 157 children (aged 0-18 years) with suspected autoimmune central nervous system disease for antineuronal antibodies in our laboratory from 2016 to 2023. Participants were randomly divided into the development cohort (n = 79, 35 females; median 7 years, SD 4 years 7 months, range 4-11 years) and validation cohort (n = 78, 28 females; median 7 years, SD 4 years 5 months, range 4-12 years). A paediatric antibody prevalence in seizure (PAPS) score was created for one cohort and evaluated in the other. Seven variables were selected through univariate and multivariate analysis to create a PAPS score. RESULTS One hundred and fifty-seven children who fulfilled the inclusion criteria were enrolled; 49 tested positive for antineuronal antibodies. The sensitivity and specificity of an APE score of 4 and greater were 92% and 22.2% respectively; the sensitivity and specificity of a PAPS score of 2.5 and greater were 83.3% and 77.8% respectively. The area under the curve was 0.832 (95% confidence interval = 0.743-0.921), which was significantly better than that for the APE score (p < 0.001). INTERPRETATION The APE score had high sensitivity but low specificity in children. The PAPS score may be useful for determining the need for antineuronal antibody testing.
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Affiliation(s)
- Takayuki Mori
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Shimpei Matsuda
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Hiroya Nishida
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Kuniko Kohyama
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Mitsumasa Fukuda
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hiroshi Sakuma
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
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Hernández G, Sala-Padró J, Adell V, Rico I, Gasa-Roqué A, Morandeira F, Campdelacreu J, Gascon J, Falip M. Cognitive decline in adult-onset temporal lobe epilepsy: Insights from aetiology. Clin Neurol Neurosurg 2024; 237:108159. [PMID: 38354426 DOI: 10.1016/j.clineuro.2024.108159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE To identify patients with adult-onset temporal lobe epilepsy (TLE) at risk of developing cognitive decline. Detecting which patients, aetiologies, or factors are most closely related with memory decline would allow us to identify patients that would eventually benefit from more specific treatment. METHODS Single centre, retrospective analysis of a prospectively followed-up cohort study, including all patients with the diagnosis of adult-onset TLE during 2013, with a minimum follow-up of five years. Memory and cognitive decline were analysed at 5 years and at last follow-up. RESULTS Of 89 initially selected patients, 71 were included. After 5 years, 11/71 (15.5%) patients suffered cognitive decline, of which 1/71 (4%) developed dementia. At last follow-up (range 65-596 m) a total of 34/71 (47.8%) patients were diagnosed with cognitive decline, specifically either memory decline or dementia. Cognitive decline at 5 years was related to: 1. Age at onset: 62.65 years (SD 9.04) in the group with cognitive decline vs 50.33 y. (SD 13.02 in the group without cognitive decline; p=0.004); 2. Onset as status epilepticus (3/6 in patients with memory decline vs 8/65 in patients without cognitive decline; p=0.04); 3. Immune aetiology: 42% compared with unknown (10%) and structural (10%) aetiologies; p=0.036; 4. Hippocampal sclerosis on MRI: 5/11 patients with cognitive decline vs 9/51 patients without cognitive decline; p=0.035. Cognitive decline was not related to seizure frequency, sex, or age (p=0.78; p=0.40; p=0.95, respectively). CONCLUSIONS Older age at epilepsy onset, onset as status epilepticus, immune aetiology, and hippocampal sclerosis are risk factors for developing cognitive decline in patients with adult-onset temporal lobe epilepsy.
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Affiliation(s)
- G Hernández
- Epilepsy Unit, Neurology Service, Hospital Universitari de Bellvitge, Neurological Disease and Neurogenetics group, Neuroscience Area, Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - J Sala-Padró
- Epilepsy Unit, Neurology Service, Hospital Universitari de Bellvitge, Neurological Disease and Neurogenetics group, Neuroscience Area, Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - V Adell
- Hospital Consorci Sanitari Alt Penedès i Garraf, Barcelona, Spain
| | - I Rico
- Neuropsychology Department, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - A Gasa-Roqué
- Neuropsychology Department, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - F Morandeira
- Immunology Department, Biochemistry Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - J Campdelacreu
- Dementia Unit, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - J Gascon
- Dementia Unit, Neurology Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - M Falip
- Epilepsy Unit, Neurology Service, Hospital Universitari de Bellvitge, Neurological Disease and Neurogenetics group, Neuroscience Area, Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain.
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Morillos MB, Borelli WV, Noll G, Piccini CD, Leite MB, Finkelsztejn A, Bianchin MM, Castilhos RM, Torres CM. Autoimmune encephalitis in a resource-limited public health setting: a case series analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-10. [PMID: 38325385 PMCID: PMC10849825 DOI: 10.1055/s-0044-1779054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/22/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Autoimmune encephalitis (AE) consists of a group of acquired diseases that affect the central nervous system. A myriad of phenotypes may be present at the onset. Due to the heterogeneity of clinical presentations, it is difficult to achieve uniformity for the diagnostic and therapeutic processes and follow-up strategies. OBJECTIVE To describe a series of patients diagnosed with AE in a resource-limited public hospital in southern Brazil and to analyze therapeutics and outcomes. METHODS We retrospectively reviewed the electronic medical records of patients diagnosed with AE at the Hospital de Clínicas de Porto Alegre from 2014 to 2022. Data collected included clinical presentation, neuroimaging, cerebrospinal fluid testings, electroencephalogram, autoantibodies, treatments, outcomes, follow-up time, degree of neurological impairment, and mortality. RESULTS Data from 17 patients were retrieved. Eleven cases were classified as definite AE and 6 as possible AE. Autoantibodies were identified in 9 patients. Timing for diagnosis was impacted by the high costs associated with autoantibody testing. Most patients became functionally dependent (82.4%) and most survivors remained with autoimmune-associated epilepsy (75%). Five patients died during hospitalization, and one after a 26-month of follow-up. CONCLUSION In this resource-limited hospital, patients with AE had a worse clinical outcome than that previously described in the literature. Development of epilepsy during follow-up and mortality were greater, whilst functional outcome was inferior. Autoantibody testing was initially denied in most patients, which impacted the definitive diagnosis and the use of second-line therapies.
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Affiliation(s)
| | | | - Giovani Noll
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
| | | | - Martim Bravo Leite
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
| | | | - Marino Muxfeldt Bianchin
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Medicina Interna, Porto Alegre RS, Brazil.
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Medicina: Ciências Médicas, Porto Alegre RS, Brazil.
| | - Raphael Machado Castilhos
- Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre RS, Brazil.
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Medicina: Ciências Médicas, Porto Alegre RS, Brazil.
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Budhram A, Flanagan EP. Optimizing the diagnostic performance of neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:365-382. [PMID: 38494290 DOI: 10.1016/b978-0-12-823912-4.00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The detection of neural antibodies in patients with paraneoplastic and autoimmune encephalitis has majorly advanced the diagnosis and management of neural antibody-associated diseases. Although testing for these antibodies has historically been restricted to specialized centers, assay commercialization has made this testing available to clinical chemistry laboratories worldwide. This improved test accessibility has led to reduced turnaround time and expedited diagnosis, which are beneficial to patient care. However, as the utilization of these assays has increased, so too has the need to evaluate how they perform in the clinical setting. In this chapter, we discuss assays for neural antibody detection that are in routine use, draw attention to their limitations and provide strategies to help clinicians and laboratorians overcome them, all with the aim of optimizing neural antibody testing for paraneoplastic and autoimmune encephalitis in clinical practice.
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Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Serrano-Castro PJ, Rodríguez-Uranga JJ, Cabezudo-García P, García-Martín G, Romero-Godoy J, Estivill-Torrús G, Ciano-Petersen NL, Oliver B, Ortega-Pinazo J, López-Moreno Y, Aguilar-Castillo MJ, Gutierrez-Cardo AL, Ramírez-García T, Sanchez-Godoy L, Carreño M. Cenobamate and Clobazam Combination as Personalized Medicine in Autoimmune-Associated Epilepsy With Anti-Gad65 Antibodies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200151. [PMID: 37607753 PMCID: PMC10443460 DOI: 10.1212/nxi.0000000000200151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/09/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Autoimmune-associated epilepsy (AAE) with antiglutamic acid decarboxylase 65 (GAD65) antibodies is considered a T-cell-mediated encephalitis that evolves to drug-resistant epilepsy. We do not have an effective therapeutic strategy for these patients. Because the GAD enzyme is primarily responsible for the conversion of glutamate to GABA, the mechanism of epileptogenesis in this condition predicts decreased levels of GABA content in synaptic vesicles. Cenobamate (CNB) acts as a positive allosteric modulator at synaptic and extra synaptic GABAA receptors, producing increased inhibitory neurotransmission in the brain. This mechanism could be especially beneficial in AAE with anti-GAD65 antibodies because it would be able to correct the imbalance due to the GABAergic stimulation deficit in postsynaptic neurons. METHODS We recruit a retrospective multicentric consecutive case series of AAE with anti-GAD65 antibodies from 5 epilepsy units in Spain who have received treatment with CNB. RESULTS A total of 8 patients were recruited. This cohort of highly refractory patients have failed a mean of 9.50 (SD = 3.20) ASM without control of seizures for sustained periods of time. The average number of seizures per month during the previous 3 months before CNB treatment was 19.63 (SD = 17.03). After the introduction of CNB improvement was achieved in all our patients, with a median reduction in the number of seizures of 92.22% (interquartile range [IQR]: 57.25-98.75). The mean follow-up was 156.75 days (SD = 68.23). In patients with concomitant treatment with clobazam (CLB), the median percentage of seizure reduction was higher than those not taking CLB: 94.72% (IQR: 87.25-100) vs 41.50% (p = 0.044) and also higher than the control group of patients with refractory epilepsy not related to anti-GAD65 treated with the same combination: 94.72% (IQR: 87.25-100) vs 45.00% (IQR: 25.00-87.00) (p = 0.019). DISCUSSION Treatment with the combination CNB + CLB could be a type of personalized medicine in patients with AAE with anti-GAD65. Our preliminary data will need to be endorsed with new prospective and controlled studies.
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Affiliation(s)
- Pedro J Serrano-Castro
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain.
| | - Juan J Rodríguez-Uranga
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Pablo Cabezudo-García
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain.
| | - Guillermina García-Martín
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Jorge Romero-Godoy
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Guillermo Estivill-Torrús
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Nicolás Lundahl Ciano-Petersen
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Begoña Oliver
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Jesús Ortega-Pinazo
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Yolanda López-Moreno
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Maria J Aguilar-Castillo
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Antonio L Gutierrez-Cardo
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Teresa Ramírez-García
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Lorenzo Sanchez-Godoy
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
| | - Mar Carreño
- From the Epilepsy Unit, Regional University Hospital of Málaga (P.J.S.-C., P.C.-G., G.G.-M., Y.L.-M); Institute for Biomedical Research of Málaga (IBIMA-Plataforma Bionand), Málaga (P.J.S.-C., P.C.-G., G.G.-M., N.L.C.-P., B.O., G.E.-T., J.O.-P., T.R.-G., L.S.-G.); Andalusian Network for Clinical and Translational Research in Neurology (Neuro-RECA), Spain (P.J.S.-C., J.J.R.-U., P.C.-G., G.G.-M., B.O.) University of Málaga (P.J.S.-C., B.O.); Vithas Hospital of Málaga, Spain (P.J.S.-C., P.C.-G.); Epilepsy Unit, Center for Avanced Neurology of Seville (J.J.R.-U.); Epilepsy Unit, Virgen de la Victoria University Hospital of Málaga (J.R.-G.), Biotechnology Unit, Regional University Hospital of Málaga (M.J.A.-C., L.S.-G.); Nuclear Medicina Unit, Regional University Hospital of Málaga (A.L.G.-C.); Epilepsy Unit, Clinic Hospital of Barcelona (M.C.), August Pi i Sunyer Biomedical Research Institute, Barcelona (M.C.), European Reference Network for Rare and Complex Epilepsies (EPICARE) (M.C.), Spain
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Peng Y, Yang H, Xue YH, Chen Q, Jin H, Liu S, Yao SY, Du MQ. An update on malignant tumor-related stiff person syndrome spectrum disorders: clinical mechanism, treatment, and outcomes. Front Neurol 2023; 14:1209302. [PMID: 37859648 PMCID: PMC10582361 DOI: 10.3389/fneur.2023.1209302] [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: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023] Open
Abstract
Stiff person syndrome (SPS) is a rare central nervous system disorder associated with malignancies. In this review, we retrieved information from PubMed, up until August 2023, using various search terms and their combinations, including SPS, stiff person syndrome spectrum disorders (SPSSDs), paraneoplastic, cancer, and malignant tumor. Data from peer-reviewed journals printed in English were organized to explain the possible relationships between different carcinomas and SPSSD subtypes, as well as related autoantigens. From literature searching, it was revealed that breast cancer was the most prevalent carcinoma linked to SPSSDs, followed by lung cancer and lymphoma. Furthermore, classic SPS was the most common SPSSD subtype, followed by stiff limb syndrome and progressive encephalomyelitis with rigidity and myoclonus. GAD65 was the most common autoantigen in patients with cancer and SPSSDs, followed by amphiphysin and GlyR. Patients with cancer subtypes might have multiple SPSSD subtypes, and conversely, patients with SPSSD subtypes might have multiple carcinoma subtypes. The first aim of this review was to highlight the complex nature of the relationships among cancers, autoantigens, and SPSSDs as new information in this field continues to be generated globally. The adoption of an open-minded approach to updating information on new cancer subtypes, autoantigens, and SPSSDs is recommended to renew our database. The second aim of this review was to discuss SPS animal models, which will help us to understand the mechanisms underlying the pathogenesis of SPS. In future, elucidating the relationship among cancers, autoantigens, and SPSSDs is critical for the early prediction of cancer and discovery of new therapeutic modalities.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shun-yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Miao-qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
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Thevarkalam M, Kannoth S, Nambiar V, Gopinath S, Mathai A, Anandakuttan A, Krishnan S, Bhaskaran R. Neurological Manifestations of Glutamic Acid Decarboxylase Autoimmunity in Indian Patients. Ann Indian Acad Neurol 2023; 26:663-671. [PMID: 38022450 PMCID: PMC10666894 DOI: 10.4103/aian.aian_392_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/05/2023] [Accepted: 06/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To study the neurological manifestations of glutamic acid decarboxylase (GAD 65) autoimmunity in Indian patients. Methods Retrospective study conducted in a tertiary care referral hospital in South India. Patients who tested positive for GAD 65 antibodies from February 2013 to July 2019 were included. Results We identified 922 patients who underwent GAD 65 testing, of which 81 tested positive (8.78%) [mean age 55.42 years (SD 17.39, range 9-86 years, median age 57 years)]. Males (n = 47) outnumbered the females (n = 34). All the GAD values measured were <5000 IU/ml. There were 34 cases (42%) of atypical parkinsonism (16/34, 47% fulfilled the diagnostic criteria for autoimmune atypical parkinsonism) in our series forming the most common group with GAD 65 positivity, followed by autoimmune encephalitis (8 cases, 9.88%). Men were more affected with atypical parkinsonism (22/34; 64.70%), stiff person syndrome (2/3; 66.66%), and neuropathy (4/7; 57.1%) while women were more with autoimmune encephalitis (6/8; 75%). Eighteen (22.6%) had underlying autoimmunity (three had type 1 diabetes mellitus). Six (7.4%) had underlying neoplasm. Thirty-three out of 43 patients responded to immunotherapy (76.74%). Five had spontaneous improvement. Conclusion Glutamic acid decarboxylase65 antibody values were much lower in our study population. Male-dominant autoimmunity was seen unlike that in Western literature. The most striking was the high preponderance of atypical parkinsonism in GAD 65-positive patients. We also found that GAD 65 positivity is a useful marker for a positive response to immunotherapy in suspected autoimmune neurological syndromes irrespective of their titers.
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Affiliation(s)
- Meena Thevarkalam
- Department of Biochemistry, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Sudheeran Kannoth
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
- Department of Neuroimmunology Laboratory, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Siby Gopinath
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Annamma Mathai
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
- Department of Neuroimmunology Laboratory, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Anandkumar Anandakuttan
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Sajitha Krishnan
- Department of Biochemistry, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita Viswavidyapeetham University, Kochi, Kerala, India
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Rada A, Bien CG. What is autoimmune encephalitis-associated epilepsy? Proposal of a practical definition. Epilepsia 2023; 64:2249-2255. [PMID: 37353891 DOI: 10.1111/epi.17699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 06/25/2023]
Abstract
Seizures resulting from cerebral autoimmunity are either acutely symptomatic in the context of autoimmune encephalitis (AIE) with neural surface antibodies, or they are indicative of an enduring predisposition to seizures, that is, epilepsy. Here, we propose a practical definition for autoimmune encephalitis-associated epilepsy (AEAE): Seizures associated with antibodies against glutamic acid decarboxylase, paraneoplastic syndromes, or Rasmussen encephalitis are classified as AEAE. AEAE secondary to AIE with antibodies against the N-methyl-D-aspartate receptor, leucine-rich glioma inactivated protein 1, contactin-associated protein-2, or γ-aminobutyric acid-B receptor can be diagnosed if the following criteria are met: seizures persist for at least 2 years after immunotherapy initiation; no signs of encephalitis on magnetic resonance imaging and no fluorodeoxyglucose positron emission tomography hypermetabolism; normal cerebrospinal fluid cell count; and a substantial decrease in antibody titers. This classification corresponds to different disease mechanisms. While AIE results from the pathogenic effects of neural antibodies, AEAE is probably the consequence of encephalitis-related tissue damage and thereby mainly structurally mediated. The distinction between AIE and AEAE also has practical consequences: In AIE, immunotherapy is usually highly beneficial, whereas anti-seizure medication has little effect. In AEAE, immunotherapy is less promising and the usual anti-seizure interventions are preferable. In addition, the diagnosis of AEAE has social consequences in terms of driving and professional limitations.
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Affiliation(s)
- Anna Rada
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
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Tröscher AR, Mair KM, Verdú de Juan L, Köck U, Steinmaurer A, Baier H, Becker A, Blümcke I, Finzel M, Geis C, Höftberger R, Mawrin C, von Oertzen TJ, Pitsch J, Surges R, Voges B, Weis S, Winklehner M, Woermann F, Bauer J, Bien CG. Temporal lobe epilepsy with GAD antibodies: neurons killed by T cells not by complement membrane attack complex. Brain 2023; 146:1436-1452. [PMID: 36314080 PMCID: PMC10115353 DOI: 10.1093/brain/awac404] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 11/14/2022] Open
Abstract
Temporal lobe epilepsy (TLE) is one of the syndromes linked to antibodies against glutamic acid decarboxylase (GAD). It has been questioned whether 'limbic encephalitis with GAD antibodies' is a meaningful diagnostic entity. The immunopathogenesis of GAD-TLE has remained enigmatic. Improvement of immunological treatability is an urgent clinical concern. We retrospectively assessed the clinical, MRI and CSF course as well as brain tissue of 15 adult patients with GAD-TLE who underwent temporal lobe surgery. Brain tissue was studied by means of immunohistochemistry, multiplex fluorescent microscopy and transcriptomic analysis for inflammatory mediators and neuronal degeneration. In 10 patients, there was a period of mediotemporal swelling and T2 signal increase; in nine cases this occurred within the first 6 years after symptom onset. This resulted in unilateral or bilateral hippocampal sclerosis; three cases developed hippocampal sclerosis within the first 2 years. All CSF studies done within the first year (n = 6) revealed intrathecal synthesis of immunoglobulin G. Temporal lobe surgeries were done after a median disease duration of 9 years (range 3 weeks to 60 years). Only two patients became seizure-free. Brain parenchyma collected during surgery in the first 6 years revealed high numbers of plasma cells but no signs of antibody-mediated tissue damage. Even more dense was the infiltration by CD8+ cytotoxic T lymphocytes (CTLs) that were seen to locally proliferate. Further, a portion of these cells revealed an antigen-specific resident memory T cell phenotype. Finally, CTLs with cytotoxic granzyme B+ granules were also seen in microglial nodules and attached to neurons, suggesting a CTL-mediated destruction of these cells. With longer disease duration, the density of all lymphocytes decreased. Whole transcriptome analysis in early/active cases (but not in late/inactive stages) revealed 'T cell immunity' and 'Regulation of immune processes' as the largest overrepresented clusters. To a lesser extent, pathways associated with B cells and neuronal degeneration also showed increased representation. Surgically treated patients with GAD-TLE go through an early active inflammatory, 'encephalitic' stage (≤6 years) with CTL-mediated, antigen-driven neuronal loss and antibody-producing plasma cells but without signs of complement-mediated cell death. Subsequently, patients enter an apparently immunologically inactive or low-active stage with ongoing seizures, probably caused by the structural damage to the temporal lobe. 'Limbic encephalitis' with GAD antibodies should be subsumed under GAD-TLE. The early tissue damage explains why immunotherapy does not usually lead to freedom from seizures.
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Affiliation(s)
- Anna R Tröscher
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
- Department of Neurology I, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Katharina M Mair
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Laia Verdú de Juan
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Ulrike Köck
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Anja Steinmaurer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Albert Becker
- Section for Translational Epilepsy Research Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Ingmar Blümcke
- Department of Neuropathology, Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Christian Geis
- Section Translational Neuroimmunology, Department of Neurology, University Hospital Jena, Jena, Germany
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian Mawrin
- Department of Neuropathology, University Hospital Magdeburg, Magdeburg, Germany
| | - Tim J von Oertzen
- Department of Neurology I, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Julika Pitsch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Berthold Voges
- Hamburg Epilepsy Centre, Protestant Hospital Alsterdorf, Department of Neurology and Epileptology, Hamburg, Germany
| | - Serge Weis
- Division of Neuropathology, Department of Pathology and Molecular Pathology, Neuromed Campus, Kepler University Hospital Linz, Linz, Austria
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Friedrich Woermann
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
- Epilepsy Centre Bodensee, Ravensburg, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Campus Bielefeld-Bethel, Bielefeld University, Bielefeld, Germany
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Lin N, Bai L, Liu Q, Chen J, Ren H, Guan H, Lu Q. Seizure semiology and predictors of outcomes in Chinese patients with glutamic acid decarboxylase antibody-associated neurological syndrome. BMC Neurol 2023; 23:149. [PMID: 37041500 PMCID: PMC10088211 DOI: 10.1186/s12883-023-03182-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/24/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND In the current study, seizure semiology and potential predictive factors of seizure outcomes in glutamic acid decarboxylase antibody (GAD Ab)-associated neurological syndrome were investigated. METHODS In this study, 32 Chinese patients with GAD Ab-associated neurological syndrome who presented with seizures at Peking Union Medical College Hospital from January 2017 to October 2022 were reviewed; 30 had a follow-up duration of more than 1 year. RESULTS Among the 32 patients, 10 presented with epilepsy alone. Concomitant neurological syndromes were observed in 22 patients, including limbic encephalitis (n = 20), stiff-person syndrome (SPS, n = 1), and cerebellar ataxia (n = 1). Bilateral tonic-clonic seizures were observed in 21 patients (65.6%). Focal seizures occurred in 27 patients (84.4%); 17 had focal motor seizures and 18 focal non-motor seizures. Among 30 patients with long-term follow-up, 11 (36.7%) were seizure-free. Acute/subacute onset (p = 0.049) and comorbidity of limbic encephalitis with epilepsy (p = 0.023) led to better seizure outcomes. Patients with persistent epilepsy were more likely to have focal seizure (p = 0.003) and higher frequency of seizure (p = 0.001). Furthermore, these patients tended to have longer intervals from onset to immunomodulatory treatments. Early immunotherapy (within 6 months from onset) was administered in 81.8% of seizure-free patients but only in 42.1% of patients with persistent seizures. However, steroid and immunosuppressant duration did not differ in the two groups. Repeated serum GAD Ab tests during the follow-up showed no association with seizure outcomes. CONCLUSIONS The seizure manifestations are diverse and variable. Approximately one third of patients achieved seizure remission during long-term follow-up. The type and frequency of seizures may influence the seizure outcomes. Early immunotherapy, especially within 6 months, may lead to better seizure outcomes.
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Affiliation(s)
- Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Qing Liu
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Jianhua Chen
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, NO.1 Shuaifuyuan Hutong of Dongcheng District, Beijing, 100730, China.
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12
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Tyvaert L. How autoimmunity changed our diagnostic practice in epileptology? Rev Neurol (Paris) 2023; 179:316-329. [PMID: 36804011 DOI: 10.1016/j.neurol.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023]
Abstract
Since few years, a new etiology of epilepsy emerges with the labelling of new autoantibodies against the central nervous system. In 2017, the International League Against Epilepsy (ILAE) concluded that autoimmunity is one of six etiologies contributing to epilepsy and that autoimmune epilepsy is directly caused by immune disorders in which seizures constitute a core symptom. Epileptic disorders of immune origin are now distinguished in two different entities: acute symptomatic seizures secondary to autoimmune (ASS) and autoimmune-associated epilepsy (AAE) with different expected clinical outcome under immunotherapy. If acute encephalitis is usually related to ASS with a classic good control of the disease under immunotherapy, clinical phenotype characterized by isolated seizures (new onset seizures and chronic focal epilepsy patients) may be due to either ASS or to AAE. Decision of Abs testing and early immunotherapy initiation needs the development of clinical scores able to select patients with high risk of positive Abs testings. If this selection is now included in the usual medical care of encephalitic patients, specifically with NORSE, the actual bigger challenge is in patients with non or only mild encephalitic symptoms followed for new onset seizures or chronic focal epilepsy patients of unknown origin. The emergence of this new entity provides new therapeutic strategies with specific etiologic and probably anti epileptogenic medication rather than the usual and nonspecific ASM. In the world of the epileptology, this new autoimmune entity appears as a big challenge with an exciting chance to improve or even definitely cure patients of their epilepsy. However, the detection of these patients has to be done in the early phase of the disease to offer the best outcome.
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Affiliation(s)
- L Tyvaert
- Department of neurology, hospital central, CHRU Nancy, Nancy, France; UMR 7039 CRAN, Université de Lorraine, Nancy, France.
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13
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Lin CYR, Kuo SH. Ataxias: Hereditary, Acquired, and Reversible Etiologies. Semin Neurol 2023; 43:48-64. [PMID: 36828010 DOI: 10.1055/s-0043-1763511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
A variety of etiologies can cause cerebellar dysfunction, leading to ataxia symptoms. Therefore, the accurate diagnosis of the cause for cerebellar ataxia can be challenging. A step-wise investigation will reveal underlying causes, including nutritional, toxin, immune-mediated, genetic, and degenerative disorders. Recent advances in genetics have identified new genes for both autosomal dominant and autosomal recessive ataxias, and new therapies are on the horizon for targeting specific biological pathways. New diagnostic criteria for degenerative ataxias have been proposed, specifically for multiple system atrophy, which will have a broad impact on the future clinical research in ataxia. In this article, we aim to provide a review focus on symptoms, laboratory testing, neuroimaging, and genetic testing for the diagnosis of cerebellar ataxia causes, with a special emphasis on recent advances. Strategies for the management of cerebellar ataxia is also discussed.
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Affiliation(s)
- Chi-Ying R Lin
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas.,Department of Neurology, Alzheimer's Disease and Memory Disorders Center, Baylor College of Medicine, Houston, Texas
| | - Sheng-Han Kuo
- Department of Neurology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Initiative for Columbia Ataxia and Tremor, Columbia University Irving Medical Center, New York, New York
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14
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Budhram A, Burneo JG. Acute symptomatic seizures, epilepsy, and autoimmune encephalitis: Clarifying terminology in neural antibody-associated disease. Epilepsia 2023; 64:306-310. [PMID: 36471647 PMCID: PMC10107142 DOI: 10.1111/epi.17478] [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: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Jorge G Burneo
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
- Neuroepidemiology Unit, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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15
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Mueller C, Elben S, Day GS, Alves P, Hebert J, Tang-Wai DF, Holtmann O, Iorio R, Perani D, Titulaer MJ, Hansen N, Bartsch T, Johnen A, Illes Z, Borm L, Willison AG, Wiendl H, Meuth SG, Kovac S, Bölte J, Melzer N. Review and meta-analysis of neuropsychological findings in autoimmune limbic encephalitis with autoantibodies against LGI1, CASPR2, and GAD65 and their response to immunotherapy. Clin Neurol Neurosurg 2022; 224:107559. [PMID: 36549220 DOI: 10.1016/j.clineuro.2022.107559] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES It is assumed that autoimmune limbic encephalitis (ALE) demonstrates distinct neuropsychological manifestations with differential responses to immunotherapy according to which associated autoantibody (AAB), if any, is identified. Towards investigating whether this is the case, this study aims to summarize respective findings from the primary literature on ALE with AABs binding to cell surface neural antigens and ALE with AABs against intracellular neural antigens. METHODS We chose ALE with AABs against leucine-rich, glioma inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) as the most frequent cell surface membrane antigens, and ALE with AABs to Embryonic Lethal, Abnormal Vision, Like 1 (ELAVL) proteins (anti-Hu) and glutamic acid decarboxylase 65 (GAD65) as the most frequent intracellular neural antigens. The PubMed and Scopus databases were searched on March 1st, 2021 for neuropsychological test and -screening data from patients with ALE of these AAB-types. Findings were reviewed according to AAB-type and immunotherapy status and are presented in a review section and are further statistically evaluated and presented in a meta-analysis section in this publication. RESULTS Of the 1304 initial hits, 32 studies on ALE with AABs against LGI1, CASPR2, and GAD65 reporting cognitive screening data could be included in a review. In ALE with AABs against LGI1, CASPR2 and GAD65, memory deficits are the most frequently reported deficits. However, deficits in attention and executive functions including working memory, fluency, and psychological function have also been reported. This review shows that ALE patients with AABs against both LGI1 and CASPR2 show higher percentages of neuropsychological deficits compared to ALE patients with AABs against GAD65 before and after initiation of immunotherapy. However, the methodologies used in these studies were heterogenous, and longitudinal studies were not comparable. Moreover, 21 studies including ALE patients with AABs against LGI1 and GAD65 were also suitable for meta-analysis. No suitable study on ALE with AABs against ELAVL proteins could be identified. Meta-Analyses could be executed for cognitive screening data and only partially, due to the small number of studies. However, in statistical analysis no consistent effect of AAB or immunotherapy on performance in cognitive screening tests could be found. CONCLUSION Currently, there is no definite evidence supporting the notion that different AAB-types of ALE exhibit distinct neuropsychological manifestations and respond differently to immunotherapy. Overall, we could not identify evidence for any effect of immunotherapy on cognition in ALE. More systematic, in-depth and longitudinal neuropsychological assessments of patients with different AAB-types of ALE are required in the future to investigate these aspects.
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Affiliation(s)
- Christoph Mueller
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Saskia Elben
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Gregory S Day
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, United States.
| | - Pedro Alves
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, CHULN, Lisboa, Portugal; Laboratório de Estudos de Linguagem, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal.
| | - Julien Hebert
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada.
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada; Memory Clinic, Toronto Western Hospital (University Health Network), Toronto, Canada.
| | - Olga Holtmann
- Institute of Medical Psychology and Systems Neuroscience, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Daniela Perani
- Division of Neuroscience, University Vita-Salute San Raffaele, Via Olgettina, 58, 20132 Milano, MI, Italy.
| | - Maarten J Titulaer
- Department of Neurology, Neuropsychology and Immunology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University of Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Germany.
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Rosalind-Franklin-Straße 10, 24105 Kiel, Germany.
| | - Andreas Johnen
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Zslot Illes
- Department of Neurology with Institute of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
| | - Leah Borm
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Alice G Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Jens Bölte
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
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16
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Bai L, Ren H, Liang M, Lu Q, Lin N, Liu M, Fan S, Cui R, Guan H. Neurological disorders associated with glutamic acid decarboxylase 65 antibodies: Clinical spectrum and prognosis of a cohort from China. Front Neurol 2022; 13:990553. [PMID: 36277926 PMCID: PMC9581312 DOI: 10.3389/fneur.2022.990553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To describe clinical phenotypes and prognosis of neurological autoimmunity related to glutamic acid decarboxylase 65 (GAD65) antibodies in China. Method In this retrospective observational study from Peking Union Medical College Hospital, we identified patients with neurological disorders related to GAD65 antibodies (cell-based assay) from May 2015 to September 2021. Clinical manifestations, immunotherapy responsiveness, and outcomes were collected after obtaining informed consent from all patients. Results Fifty-five patients were included: 40 (72.73%) were women and initial neurological symptoms developed at 42(34-55) years of age. The median time to the nadir of the disease was 5 months (range from 1 day to 48 months). The clinical syndromes included limbic encephalitis (LE) or epilepsy (Ep) (n = 34, 61.82%), stiff-person syndromes (SPS) (n = 18, 32.73%), autoimmune cerebellar ataxia (ACA) (n = 11, 20%), and overlap syndrome in eight (14.55%) patients. Thirty-two (58.2%) patients had comorbidities of other autoimmune diseases, including Hashimoto thyroiditis (n = 17, 53.13%), T1DM (n = 11, 34.78%), vitiligo (n = 6, 18.75%), and others (n=5, 15.63%). Two (3.64%) patients had tumors, including thymoma and small cell lung cancer. Fifty-one (92.7%) patients received first-line immunotherapy (glucocorticoids and/or IV immunoglobulin), and 4 (7.3%) received second-line immunotherapy (rituximab). Long-term immunotherapy (mycophenolate mofetil) was administered to 23 (41.8%) patients. At the median time of 15 months (IQR 6–33.75 month, range 3–96 month) of follow-up, the patients' median modified Rankin Score (mRS) had declined from 2 to 1. Thirty-eight (70.4%) patients experienced clinical improvement (mRS declined ≥1), 47 (87%) had favorable clinical outcomes (mRS ≤2), and nine were symptom-free (16.7%). The sustained response to immunotherapy ranged from 7/15 (63.63%) in ACA patients and 22/34 (64.7%) in LE/Ep patients to 14/17 (82.35%) in SPS patients. Conclusions LE/Ep was the most common neurological phenotype of GAD65 antibody neurological autoimmunity in our cohort. Most patients had comorbidities of other autoimmune diseases, but underlying tumors were rare. Most patients responded to immunotherapy. However, the long-term prognosis varied among different clinical phenotypes.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Menglin Liang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Hongzhi Guan
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Spilioti M, Kiryttopoulos A, Panou T, Simos P, Alexopoulos H, Karafyles G, Geroukis T, Kalevrosoglou I, Kimiskidis V. Nonparaneoplastic Anti-GAD Limbic Encephalitis: Seizure Outcome and Long-term Neuropsychological Follow-up After Immunotherapy. Cogn Behav Neurol 2022; 35:212-220. [PMID: 35856876 DOI: 10.1097/wnn.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
Antibodies against glutamate decarboxylase (GAD-Abs), especially GAD65 antibodies, are associated with limbic encephalitis (LE) manifested by temporal lobe epilepsy and neuropsychological deficits. We present the case of a 42-year-old Greek woman with nonparaneoplastic anti-GAD LE, discussing the therapeutic management and highlighting the role of neuropsychological assessment. The patient underwent functional and structural brain studies and was investigated longitudinally over a 6-year period with a battery of neuropsychological tests that were designed to document her intellectual function and verbal and visual memory. The patient suffered from refractory temporal-impaired awareness seizures and memory impairment that was mediated by autoimmune nonparaneoplastic LE and comorbid autoimmune disorders (ie, Hashimoto thyroiditis and vitiligo). Neuroimaging studies demonstrated hyperintensities in the medial temporal lobes bilaterally on T2WI MRI sequences. Serial EEGs showed bitemporal intermittent delta activity as well as epileptiform discharges. Tumor blood markers and onconeural antibodies were negative. Immunological screening revealed extremely high GAD-Abs titers in both serum and CSF, as well as the presence of CSF oligoclonal bands. Neuropsychological testing revealed anterograde amnesia with relative preservation of more remote, premorbid memories. The patient underwent first-line immunotherapy followed by immunosuppressive maintenance treatment that led to a reduction of seizures, EEG improvement, and a significant decline in GAD-Abs titers. Neuropsychological evaluations at 5 months, 1 year, and 6 years posttreatment demonstrated improvement, particularly in recent memory and everyday functionality. In this case of anti-GAD LE, the long-term seizure reduction and the improvement of neuropsychological deficits were most likely related to the immunotherapy.
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Affiliation(s)
| | | | - Theodora Panou
- Department of Psychiatry & Laboratory of Neuropsychology, University of Crete, Medical School, Heraklion, Greece
| | - Panagiotis Simos
- Department of Psychiatry & Laboratory of Neuropsychology, University of Crete, Medical School, Heraklion, Greece
| | - Haris Alexopoulos
- Department of Pathophysiology, Neuroimmunology Unit, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Ioannis Kalevrosoglou
- First Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Lai Q, Li Q, Li X, Wang H, Zhang W, Song X, Hu P, Yao R, Fan H, Xu X. GluR3B Antibody Was a Biomarker for Drug-Resistant Epilepsy in Patients With Focal to Bilateral Tonic-Clonic Seizures. Front Immunol 2022; 13:838389. [PMID: 35464426 PMCID: PMC9018978 DOI: 10.3389/fimmu.2022.838389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/14/2022] [Indexed: 12/05/2022] Open
Abstract
Considering the role of GluR3B antibody-mediated excitotoxicity in the progression of epilepsy, the purpose of this study was to evaluate the clinical significance of GluR3B antibody level as a novel biomarker for the prognosis of unknown etiology drug-resistant epilepsy (DRE) in patients with focal to bilateral tonic-clonic seizures. The study included 193 patients with focal to bilateral tonic-clonic seizures in the modeling cohort. Serum and CSF samples from patients were collected, and GluR3B antibody levels were detected by an ELISA kit. Serum and CSF GluR3B antibody levels in patients with DRE were significantly increased compared with those in patients with drug-responsive epilepsy. Univariate logistic regression analysis underlined that patients with high GluR3B antibody levels had a significantly increased risk of developing DRE. A logistic regression model demonstrated that increased GluR3B antibody levels were an independent factor in predicting DRE. External verification showed that the model constructed for the prediction of DRE had good adaptability. Finally, decision curve analysis highlighted the superior clinical net benefit in DRE prognosis by GluR3B antibody level. In summary, elevated levels of GluR3B antibody are an early biomarker to predict the prognosis of DRE; in addition, targeting GluR3B antibody may be a promising treatment strategy for patients with DRE.
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Affiliation(s)
- Qingwei Lai
- Department of Neurology, the Second Affiliated Hospital of Soochow University, Suzhou City, China.,Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Qingyun Li
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xinyu Li
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Heng Wang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Wei Zhang
- Xuzhou Key Laboratory of Neurobiology, Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou City, China
| | - Xiaotao Song
- Xuzhou Key Laboratory of Neurobiology, Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou City, China
| | - Peng Hu
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Ruiqin Yao
- Xuzhou Key Laboratory of Neurobiology, Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou City, China
| | - Hongbin Fan
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xingshun Xu
- Department of Neurology, the Second Affiliated Hospital of Soochow University, Suzhou City, China.,Institute of Neuroscience, Soochow University, Suzhou City, China.,Jiangsu Key Laboratory of Neuropsychiatric Diseases, Soochow University, Suzhou, China
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Gillinder L, Britton J. Autoimmune-Associated Seizures. Continuum (Minneap Minn) 2022; 28:363-398. [PMID: 35393963 DOI: 10.1212/con.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article focuses on the seizure manifestations and presentations of autoimmune-associated epilepsy and acute symptomatic seizures in autoimmune encephalitis. It discusses the specificity of the various central nervous system autoantibodies and clarifies when their presence can be considered indicative of an immune etiology. Finally, current recommendations regarding patient selection for autoimmune antibody evaluation are reviewed, and an approach to immunotherapy is provided. RECENT FINDINGS Although autoimmune seizures are caused by a heterogeneous group of autoantibodies, key features reported in the literature should alert clinicians to the possible diagnosis. In particular, seizure characteristics including frequency, timing, duration, and symptomatology can provide vital clues to help differentiate autoimmune-associated seizures from other causes of epilepsy. Diagnostic certainty also requires an understanding and integration of the spectrum of clinical and paraclinical presentations, and several scoring systems have been developed that may be useful to aid the identification of autoimmune seizures. SUMMARY Seizures due to autoimmune etiology are increasingly encountered in clinical practice. It is critical that clinicians recognize immune seizure etiologies early in their course given they are often responsive to immunotherapy but are usually resistant to antiseizure medications. Currently, however, it is unfortunately not uncommon for autoimmune-associated seizure disorders to remain undiagnosed, resulting in missed opportunities to administer effective therapies. Efforts to better understand autoimmune seizure manifestations and treatment strategies are ongoing.
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From the North Sea to Drug Repurposing, the Antiseizure Activity of Halimide and Plinabulin. Pharmaceuticals (Basel) 2022; 15:ph15020247. [PMID: 35215359 PMCID: PMC8878679 DOI: 10.3390/ph15020247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023] Open
Abstract
PharmaSea performed large-scale in vivo screening of marine natural product (MNP) extracts, using zebrafish embryos and larvae, to identify compounds with the potential to treat epilepsy. In this study, we report the discovery of two new antiseizure compounds, the 2,5-diketopiperazine halimide and its semi-synthetic analogue, plinabulin. Interestingly, these are both known microtubule destabilizing agents, and plinabulin could have the potential for drug repurposing, as it is already in clinical trials for the prevention of chemotherapy-induced neutropenia and treatment of non-small cell lung cancer. Both halimide and plinabulin were found to have antiseizure activity in the larval zebrafish pentylenetetrazole (PTZ) seizure model via automated locomotor analysis and non-invasive local field potential recordings. The efficacy of plinabulin was further characterized in animal models of drug-resistant seizures, i.e., the larval zebrafish ethyl ketopentenoate (EKP) seizure model and the mouse 6 Hz psychomotor seizure model. Plinabulin was observed to be highly effective against EKP-induced seizures, on the behavioral and electrophysiological level, and showed activity in the mouse model. These data suggest that plinabulin could be of interest for the treatment of drug-resistant seizures. Finally, the investigation of two functional analogues, colchicine and indibulin, which were observed to be inactive against EKP-induced seizures, suggests that microtubule depolymerization does not underpin plinabulin’s antiseizure action.
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21
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Madkhali MA, Hao JK, Khan MS, Sharma H, Jaume A, Tiwari A, Imam S, Jaume JC. Intractable Seizures and Limbic Encephalitis, Unaccounted Complications of Type 1 Diabetes Autoimmunity. J Endocr Soc 2022; 6:bvab188. [PMID: 35128296 PMCID: PMC8807154 DOI: 10.1210/jendso/bvab188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Glutamic acid decarboxylase 65kD autoantibody (GAD65Ab) is frequently detected in patients with refractory epilepsy and stiff person syndrome. In contrast to T1D, the pathological role of GAD65Ab in neurological disorders is still debatable. As a result, the implementation of possible immunotherapy is usually delayed. This report presents 2 cases of GAD65Ab-associated brain autoimmunity and their different management. We present clinical data and discuss management based on available evidence in the reviewed literature. Both cases presented with acute on chronic neurological symptoms and were GAD65Ab positive. Case 1, a 30-year-old man with a history of early-onset type 1 diabetes mellitus at 14 months, followed by cryptogenic temporal epilepsy at 11 years of age, presented with intractable seizures. Case 2, a 48-year-old woman, presented with a history of recurrent severe headaches, cognitive impairment, decreased memory, and behavioral symptoms. GAD65Ab was detected in both patients’ sera. Cerebrospinal fluid GAD65Ab was only checked and positive in case 1. Case 2 was diagnosed with limbic encephalitis, treated with immunotherapy, and showed a remarkable clinical improvement. Case 1 with refractory epilepsy failed multiple antiepileptic drugs and responsive-stimulator system treatments. He was finally diagnosed with autoimmune epilepsy. The delay in diagnosis resulted in a lost opportunity for early immunotherapy. In conclusion, autoantibody screening and early initiation of immunotherapy should be considered to manage GAD65Ab-associated neurological disorders.
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Affiliation(s)
- Mohammed A Madkhali
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Jazan University, Jazan, Jizan, Saudi Arabia
| | - Jenifer-Kris Hao
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Mohammad Saud Khan
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Cardiology, University of Kentucky at Bowling Green, Bowling Green, KY
| | - Himani Sharma
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Alexa Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Abhinav Tiwari
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Shahnawaz Imam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Juan Carlos Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
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Wang J, Gong S, Kong F, Cai D, Huang B, Zheng H, Lin S, Li J, Zhang T. Psychotic Symptoms as the Initial Presentation of a Long-Lasting Misdiagnosed Anti-GAD65 Autoimmune Encephalitis: An Emblematic Case and Literature Review. Front Psychiatry 2022; 13:754938. [PMID: 35280166 PMCID: PMC8905188 DOI: 10.3389/fpsyt.2022.754938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To present a long-lasting misdiagnosed case of anti-GAD65 autoimmune encephalitis (AE) and promote the early identification of reversible psychotic symptoms in AE. METHODS The case report was generated through detailed assessment of clinical characteristics, cerebral magnetic resonance images, and laboratory results. Meanwhile, a literatures review related to the topic was conducted. RESULTS Psychotic symptoms could be presented in the early stage of anti-GAD65 autoimmune encephalitis. Even though there exists a transdisciplinary gap that hinder the timely recognition of early psychiatric symptoms as components of organic disease, a few strategies could be introduced to enable the earlier recognition and appropriate treatment. CONCLUSIONS Our report intends to raise awareness to promote the early identification of immune-mediated "symptomatic" forms of psychosis.
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Affiliation(s)
- Jianjun Wang
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,Global Clinical Scholars Research Training (GCSRT), Harvard Medical School, Boston, MA, United States
| | - Shenglan Gong
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China.,Sixth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Fanxin Kong
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Dongbin Cai
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Binqing Huang
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Haotao Zheng
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Songjun Lin
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Jinfang Li
- Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Tianfeng Zhang
- Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China.,Sixth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
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Abstract
Limbic encephalitis (LE) is a clinical syndrome defined by subacutely evolving limbic signs and symptoms with structural and functional evidence of mediotemporal damage in the absence of a better explanation than an autoimmune (or paraneoplastic) cause. There are features common to all forms of LE. In recent years, antibody(ab)-defined subtypes have been established. They are distinct regarding underlying pathophysiologic processes, clinical and magnetic resonance imaging courses, cerebrospinal fluid signatures, treatment responsivity, and likelihood of a chronic course. With immunotherapy, LE with abs against surface antigens has a better outcome than LE with abs to intracellular antigens. Diagnostic and treatment challenges are, on the one hand, to avoid overlooking and undertreatment and, on the other hand, to avoid overdiagnoses and overtreatment. LE can be conceptualized as a model disease for the consequences of new onset mediotemporal damage by different mechanisms in adult life. It may be studied as an example of mediotemporal epileptogenesis.
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Affiliation(s)
- Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Bielefeld University, Bielefeld, Germany; Laboratory Krone, Bad Salzuflen, Germany.
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24
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Budhram A, Sechi E, Flanagan EP, Dubey D, Zekeridou A, Shah SS, Gadoth A, Naddaf E, McKeon A, Pittock SJ, Zalewski NL. Clinical spectrum of high-titre GAD65 antibodies. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-325275. [PMID: 33563803 PMCID: PMC8142435 DOI: 10.1136/jnnp-2020-325275] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine clinical manifestations, immunotherapy responsiveness and outcomes of glutamic acid decarboxylase-65 (GAD65) neurological autoimmunity. METHODS We identified 323 Mayo Clinic patients with high-titre (>20 nmol/L in serum) GAD65 antibodies out of 380 514 submitted anti-GAD65 samples (2003-2018). Patients classified as having GAD65 neurological autoimmunity after chart review were analysed to determine disease manifestations, immunotherapy responsiveness and predictors of poor outcome (modified Rankin score >2). RESULTS On review, 108 patients were classified as not having GAD65 neurological autoimmunity and 3 patients had no more likely alternative diagnoses but atypical presentations (hyperkinetic movement disorders). Of remaining 212 patients with GAD65 neurological autoimmunity, median age at symptom onset was 46 years (range: 5-83 years); 163/212 (77%) were female. Stiff-person spectrum disorders (SPSD) (N=71), cerebellar ataxia (N=55), epilepsy (N=35) and limbic encephalitis (N=7) could occur either in isolation or as part of an overlap syndrome (N=44), and were designated core manifestations. Cognitive impairment (N=38), myelopathy (N=23) and brainstem dysfunction (N=22) were only reported as co-occurring phenomena, and were designated secondary manifestations. Sustained response to immunotherapy ranged from 5/20 (25%) in epilepsy to 32/44 (73%) in SPSD (p=0.002). Complete immunotherapy response occurred in 2/142 (1%). Cerebellar ataxia and serum GAD65 antibody titre >500 nmol/L predicted poor outcome. INTERPRETATION High-titre GAD65 antibodies were suggestive of, but not pathognomonic for GAD65 neurological autoimmunity, which has discrete core and secondary manifestations. SPSD was most likely to respond to immunotherapy, while epilepsy was least immunotherapy responsive. Complete immunotherapy response was rare. Serum GAD65 antibody titre >500 nmol/L and cerebellar ataxia predicted poor outcome.
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Affiliation(s)
- Adrian Budhram
- Clinical Neurological Sciences, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Sassari, Italy
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shailee S Shah
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Avi Gadoth
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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25
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Muñiz-Castrillo S, Vogrig A, Montagnac C, Joubert B, Benaiteau M, Casez O, Chaumont H, Hopes L, Lanoiselée HM, Navarro V, Thomas B, Ursu R, Gonçalves D, Fabien N, Ducray F, Julier C, Honnorat J. Familial autoimmunity in neurological patients with GAD65 antibodies: an interview-based study. J Neurol 2021; 268:2515-2522. [PMID: 33544221 DOI: 10.1007/s00415-021-10424-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Abstract
The common co-occurrence of autoimmune systemic diseases in patients with neurological disorders and antibodies against glutamic acid decarboxylase 65 (GAD65) suggests a shared genetic predisposition to these disorders. However, the nature and frequency of familial aggregation of autoimmune diseases, which might also support this hypothesis, have been poorly investigated. Herein, an exploratory, interview-based study was conducted with the aim of describing the autoimmune diseases displayed by the relatives of GAD65 neurological patients, their frequency, kinship, and potential patterns of inheritance. Patients were enrolled only if they had GAD65 antibodies in the cerebrospinal fluid and typical clinical phenotypes associated with such antibodies (stiff-person syndrome, cerebellar ataxia, limbic encephalitis, or temporal lobe epilepsy). A total of 65 patients were included in the study, and 44/65 (67.7%) reported family history of autoimmunity, including first-degree relatives in 36/65 (55.4%); the sibling recurrence risk (λS) was 5.5, reinforcing the hypothesis of an underlying strong genetic predisposition. Most pedigrees with familial autoimmunity (38/44, 86.4%) showed multiple autoimmune diseases, all but 2 of them with diabetes mellitus or autoimmune thyroid disease, therefore resembling autoimmune polyendocrine syndromes. Inheritance patterns were diverse, possibly autosomal dominant in 17/44 (38.6%) pedigrees or autosomal recessive in 5/44 (11.4%), and un-defined or complex in 24/44 (54.5%). However, a total of 21/65 (32.3%) patients had no identified family history of autoimmunity. In conclusion, these results suggest a variable and heterogeneous genetic predisposition to GAD65 neurological disorders, possibly involving multiple loci and modes of inheritance with different contribution in each family.
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Affiliation(s)
- Sergio Muñiz-Castrillo
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Clémentine Montagnac
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Marie Benaiteau
- Neurology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Casez
- Neurology Department, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Hugo Chaumont
- Neurology Department, Centre Hospitalier Universitaire de la Guadeloupe, Point-à-Pitre, France
| | - Lucie Hopes
- Neurology Department, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | | | - Vincent Navarro
- Neurology Department, GH Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Benjamin Thomas
- Neurology Department, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Renata Ursu
- Neurology Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - David Gonçalves
- Immunology Department, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Nicole Fabien
- Immunology Department, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - François Ducray
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France
- SynatAc Team, Institut NeuroMyoGène, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Cécile Julier
- Institut Cochin, Inserm U1016, CNRS UMR-8104, Université de Paris, Paris, France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France.
- SynatAc Team, Institut NeuroMyoGène, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
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26
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Lourenço DM, Ribeiro-Rodrigues L, Sebastião AM, Diógenes MJ, Xapelli S. Neural Stem Cells and Cannabinoids in the Spotlight as Potential Therapy for Epilepsy. Int J Mol Sci 2020; 21:E7309. [PMID: 33022963 PMCID: PMC7582633 DOI: 10.3390/ijms21197309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 01/18/2023] Open
Abstract
Epilepsy is one of the most common brain diseases worldwide, having a huge burden in society. The main hallmark of epilepsy is the occurrence of spontaneous recurrent seizures, having a tremendous impact on the lives of the patients and of their relatives. Currently, the therapeutic strategies are mostly based on the use of antiepileptic drugs, and because several types of epilepsies are of unknown origin, a high percentage of patients are resistant to the available pharmacotherapy, continuing to experience seizures overtime. Therefore, the search for new drugs and therapeutic targets is highly important. One key aspect to be targeted is the aberrant adult hippocampal neurogenesis (AHN) derived from Neural Stem Cells (NSCs). Indeed, targeting seizure-induced AHN may reduce recurrent seizures and shed some light on the mechanisms of disease. The endocannabinoid system is a known modulator of AHN, and due to the known endogenous antiepileptic properties, it is an interesting candidate for the generation of new antiepileptic drugs. However, further studies and clinical trials are required to investigate the putative mechanisms by which cannabinoids can be used to treat epilepsy. In this manuscript, we will review how cannabinoid-induced modulation of NSCs may promote neural plasticity and whether these drugs can be used as putative antiepileptic treatment.
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Affiliation(s)
- Diogo M. Lourenço
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal; (D.M.L.); (L.R.-R.); (A.M.S.); (M.J.D.)
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
| | - Leonor Ribeiro-Rodrigues
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal; (D.M.L.); (L.R.-R.); (A.M.S.); (M.J.D.)
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
| | - Ana M. Sebastião
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal; (D.M.L.); (L.R.-R.); (A.M.S.); (M.J.D.)
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
| | - Maria J. Diógenes
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal; (D.M.L.); (L.R.-R.); (A.M.S.); (M.J.D.)
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
| | - Sara Xapelli
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal; (D.M.L.); (L.R.-R.); (A.M.S.); (M.J.D.)
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
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Gaspard N. How Much GAD65 Do You Have? High Levels of GAD65 Antibodies in Autoimmune Encephalitis. Epilepsy Curr 2020; 20:267-270. [PMID: 34025238 PMCID: PMC7653657 DOI: 10.1177/1535759720949238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Neurologic Syndromes Related to Anti-GAD65 Clinical and Serologic
Response to Treatment Muñoz-Lopetegi A, de Bruijn MAAM, Boukhrissi S, Bastiaansen AEM, Nagtzaam
MMP, Hulsenboom ESP, Boon AJW, Neuteboom RF, de Vries JM, Sillevis Smitt
PAE, Schreurs MWJ, Titulaer MJ. Neurol Neuroimmunol
Neuroinflamm. 2020;7(3):e696. doi:10.1212/NXI.0000000000000696 Objective: Antibodies against glutamic acid decarboxylase 65 (anti-GAD65) are
associated with a number of neurologic syndromes. However, their
pathogenic role is controversial. Our objective was to describe
clinical and paraclinical characteristics of anti-GAD65 patients and
analyze their response to immunotherapy. Methods: Retrospectively, we studied patients (n = 56) with positive
anti-GAD65 and any neurologic symptom. We tested serum and
cerebrospinal fluid with enzyme-linked immunosorbent assay (ELISA),
immunohistochemistry, and cell-based assay. Accordingly, we set a
cutoff value of 10 000 IU/mL in serum by ELISA to group patients
into high-concentration (n = 36) and low-concentration (n = 20)
groups. We compared clinical and immunologic features and analyzed
response to immunotherapy. Results: Classical anti–GAD65-associated syndromes were seen in 34 of 36
patients with high concentration (94%): stiff-person syndrome (7),
cerebellar ataxia (3), chronic epilepsy (9), limbic encephalitis
(9), or an overlap of 2 or more of the former (6). Patients with low
concentrations had a broad, heterogeneous symptom spectrum.
Immunotherapy was effective in 19 of 27 treated patients (70%),
although none of them completely recovered. Antibody concentration
reduction occurred in 15 of 17 patients with available pre- and
posttreatment samples (median reduction 69%; range 27%-99%), of
which 14 improved clinically. The 2 patients with unchanged
concentrations showed no clinical improvement. No differences in
treatment responses were observed between specific syndromes. Conclusion: Most patients with high anti-GAD65 concentrations (>10 000 IU/mL)
showed some improvement after immunotherapy, unfortunately without
complete recovery. Serum antibody concentrations’ course might be
useful to monitor response. In patients with low anti-GAD65
concentrations, especially in those without typical clinical
phenotypes, diagnostic alternatives are more likely.
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28
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Fundamental Mechanisms of Autoantibody-Induced Impairments on Ion Channels and Synapses in Immune-Mediated Cerebellar Ataxias. Int J Mol Sci 2020; 21:ijms21144936. [PMID: 32668612 PMCID: PMC7404345 DOI: 10.3390/ijms21144936] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022] Open
Abstract
In the last years, different kinds of limbic encephalitis associated with autoantibodies against ion channels and synaptic receptors have been described. Many studies have demonstrated that such autoantibodies induce channel or receptor dysfunction. The same mechanism is discussed in immune-mediated cerebellar ataxias (IMCAs), but the pathogenesis has been less investigated. The aim of the present review is to evaluate what kind of cerebellar ion channels, their related proteins, and the synaptic machinery proteins that are preferably impaired by autoantibodies so as to develop cerebellar ataxias (CAs). The cerebellum predictively coordinates motor and cognitive functions through a continuous update of an internal model. These controls are relayed by cerebellum-specific functions such as precise neuronal discharges with potassium channels, synaptic plasticity through calcium signaling pathways coupled with voltage-gated calcium channels (VGCC) and metabotropic glutamate receptors 1 (mGluR1), a synaptic organization with glutamate receptor delta (GluRδ), and output signal formation through chained GABAergic neurons. Consistently, the association of CAs with anti-potassium channel-related proteins, anti-VGCC, anti-mGluR1, and GluRδ, and anti-glutamate decarboxylase 65 antibodies is observed in IMCAs. Despite ample distributions of AMPA and GABA receptors, however, CAs are rare in conditions with autoantibodies against these receptors. Notably, when the autoantibodies impair synaptic transmission, the autoimmune targets are commonly classified into three categories: release machinery proteins, synaptic adhesion molecules, and receptors. This physiopathological categorization impacts on both our understanding of the pathophysiology and clinical prognosis.
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Dade M, Berzero G, Izquierdo C, Giry M, Benazra M, Delattre JY, Psimaras D, Alentorn A. Neurological Syndromes Associated with Anti-GAD Antibodies. Int J Mol Sci 2020; 21:E3701. [PMID: 32456344 PMCID: PMC7279468 DOI: 10.3390/ijms21103701] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) is an intracellular enzyme whose physiologic function is the decarboxylation of glutamate to gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter within the central nervous system. GAD antibodies (Ab) have been associated with multiple neurological syndromes, including stiff-person syndrome, cerebellar ataxia, and limbic encephalitis, which are all considered to result from reduced GABAergic transmission. The pathogenic role of GAD Ab is still debated, and some evidence suggests that GAD autoimmunity might primarily be cell-mediated. Diagnosis relies on the detection of high titers of GAD Ab in serum and/or in the detection of GAD Ab in the cerebrospinal fluid. Due to the relative rarity of these syndromes, treatment schemes and predictors of response are poorly defined, highlighting the unmet need for multicentric prospective trials in this population. Here, we reviewed the main clinical characteristics of neurological syndromes associated with GAD Ab, focusing on pathophysiologic mechanisms.
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Affiliation(s)
- Maëlle Dade
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Giulia Berzero
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
- Neuroncology Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Cristina Izquierdo
- Department of Neuroscience, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | - Marine Giry
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Marion Benazra
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Jean-Yves Delattre
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Dimitri Psimaras
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Agusti Alentorn
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
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