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Morgan A, Li Y, Thompson NR, Milinovich A, Abbatemarco JR, Cohen JA, Ontaneda D, Punia V, Rae-Grant A, Galioto R, Kunchok A. Longitudinal Disability, Cognitive Impairment, and Mood Symptoms in Patients With Anti-NMDA Receptor Encephalitis. Neurology 2024; 102:e208019. [PMID: 38266213 DOI: 10.1212/wnl.0000000000208019] [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: 06/12/2023] [Accepted: 09/27/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Longitudinal outcomes in anti-NMDA receptor encephalitis (anti-NMDARe) are still not fully understood and may not be adequately captured with the modified Rankin Scale (mRS), often the sole reported outcome. We aim to characterize longitudinal outcomes in anti-NMDARe using multiple outcome measures. METHODS This single-center, retrospective, observational study examined outcome measures (mRS and Clinical Assessment Scale in Autoimmune Encephalitis [CASE]) in adults with NMDA receptor-IgG in CSF at short- and long-term follow-ups using linear and logistic regression modeling. Patients with evaluations for cognitive impairment (Montreal Cognitive Assessment/Mini-Mental State Examination), depression (Patient Health Questionnaire-9), and anxiety (General Anxiety Disorder-7) >6 months from symptom onset were correlated with final CASE scores. RESULTS Thirty-eight patients (76% female, median disease onset age = 28 years, range = 1-75 years) were included. The majority received first-line immunosuppressants (97%) at a median of 3.9 weeks (interquartile range [IQR] = 2.1-9.7) from symptom onset and 68% received second-line therapies. At baseline, median/mean mRS and CASE were 4 (IQR = 3-5) and 12.9 (SD = 7.2), respectively. At short-term follow-up (median = 10 weeks, IQR = 6-17), factors associated with higher CASE and mRS included dysautonomia, coma/lethargy, seizures/status epilepticus, and intensive care unit admission (p < 0.05). At long-term follow-up (median = 70 weeks, IQR = 51-174), median/mean mRS and CASE were 2 (IQR = 1-3) and 4.4 (SD = 4.2), respectively. Only weakness at symptom onset predicted higher mRS scores (odds ratio = 5.6, 95% confidence interval 1.02-30.9, p = 0.047). Despite both mRS and CASE improving from baseline (p < 0.001), only 9 patients (31%) returned to their premorbid function. Among patients with cognitive and mood evaluations >6 months from onset, moderate-severe cognitive impairment (42%), depression (28%), and anxiety (30%) were frequent. Cognitive and depression measures were associated with final CASE subscores (including memory, language, weakness, and psychiatric). DISCUSSION Multiple clinical factors influenced short-term outcomes, but only onset weakness influenced long-term mRS, highlighting that mRS is predominantly affected by global motor function. Although mRS and CASE improved over time for most patients, these outcome measures did not capture the full extent of long-term functional impairment in terms of mood, cognition, and the ability to return to premorbid function. This emphasizes the need for increased utilization of more nuanced cognitive and mood outcome measures.
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Affiliation(s)
- Annalisa Morgan
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Yadi Li
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Nicolas R Thompson
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Alex Milinovich
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Justin R Abbatemarco
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Jeffrey A Cohen
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Daniel Ontaneda
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Vineet Punia
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Alex Rae-Grant
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Rachel Galioto
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
| | - Amy Kunchok
- From the Department of Neurology, Neurological Institute (A. Morgan, J.R.A., J.A.C., D.O., V.P., A.K.), Department of Quantitative Health Sciences, Lerner Research Institute (Y.L., N.R.T., A. Milinovich), Center for Outcomes Research and Evaluation, Neurological Institute (Y.L., N.R.T.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute (J.R.A., J.A.C., D.O., R.G., A.K.), Charles Shor Epilepsy Center, Neurological Institute (V.P.), Cleveland Clinic; and Cleveland Clinic Lerner College of Medicine (A.R.-G.), OH
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Liu F, Zhang B, Huang T, Wang B, Wang C, Hao M, Guo S. Influential Factors, Treatment and Prognosis of Autoimmune Encephalitis Patients With Poor Response to Short-Term First-Line Treatment. Front Neurol 2022; 13:861988. [PMID: 35493830 PMCID: PMC9046540 DOI: 10.3389/fneur.2022.861988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/16/2022] [Indexed: 11/19/2022] Open
Abstract
Objective This study was performed to assess the potential factors for poor short-term first-line treatment response, the appropriate further treatment options, and the prognosis in patients with autoimmune encephalitis (AE). Methods This retrospective study consisted of 135 patients with AE. According to their short-term first-line treatment response, patients were divided into the response group and the non-response group. The demographics, clinical characteristics, main accessory examinations, immunotherapy, and outcomes of patients were compared between the two groups. Univariate and multivariate logistic regression models were used to analyze whether non-responders have poor long-term outcomes. Further treatment and prognosis of non-responders were also analyzed. Results Of the 128 patients who were treated with first-line immunotherapy, 59 (46.1%) were non-responders. Patients in the non-response group had more symptoms and exhibited a higher proportion of mental behavior disorder, central hypoventilation, and autonomic nervous dysfunction. The modified Rankin scale (mRS) scores and neutrophil-to-lymphocyte ratio (NLR) levels were significantly higher and albumin, high-density lipoprotein cholesterol (HDL-C), apolipoprotein A (apoA) levels were significantly lower in the non-response group (p < 0.05, all). Multivariate logistic regression analysis showed that the number of clinical symptoms, mental behavior disorder, central hypoventilation, maximum mRS score, and albumin level was independently associated with non-response to short-term first-line treatment. Non-responders had poor long-term outcomes compared with the responders at all times of followed-up (p < 0.05, all). In multivariable analysis, initial first-line treatment response was independently associated with the long-term prognosis, both at 12-month [odds ratio (OR), 4.74, 95% CI, 1.44–15.59, and p=0.010] and 24-month follow-ups (OR, 8.81, 95% CI, 1.65–47.16; and p = 0.011). Among the non-responders, a higher improvement of mRS scores was observed in those who received second-line treatment than those who had no further treatment or repetition of first-line immunotherapy in the follow-up. However, the rate of a good outcome and median mRS scores were not significantly different among the three groups. Conclusion Disease severity, clinical features, anti-N-methyl-D-aspartate receptor subtypes, antibody titers, NLR, albumin, HDL-C, and apoA levels were all associated with non-response to short-term first-line treatment. The short-term first-line treatment response is a valuable predictor of long-term outcomes in patients with AE. Second-line immunotherapy may be a more aggressive treatment option for patients who failed short-term first-line immunotherapy.
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Affiliation(s)
- Fei Liu
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bingbing Zhang
- Department of Resident Trainint, Qilu Hospital of Shandong University, Jinan, China
| | - Teng Huang
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Baojie Wang
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Chunjuan Wang
- Department of Neurology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
| | - Maolin Hao
- Department of Neurology, Shandong Second Provincial General Hospital, Jinan, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
- *Correspondence: Shougang Guo
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