1
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Doherty A, Knudson K, Fuller C, Leach JL, Wang AC, Marupudi N, Han RH, Tomko S, Ojemann J, Smyth MD, Mangano F, Skoch J. MRI and pathology comparisons in Rasmussen's encephalitis: a multi-institutional examination of hemispherotomy outcomes relative to imaging and histological severity. Childs Nerv Syst 2024; 40:1799-1806. [PMID: 38489033 PMCID: PMC11111524 DOI: 10.1007/s00381-024-06353-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE Rasmussen encephalitis (RE) is a very rare chronic neurological disorder of unilateral inflammation of the cerebral cortex. Hemispherotomy provides the best chance at achieving seizure freedom in RE patients, but with significant risks and variable long-term outcomes. The goal of this study is to utilize our multicenter pediatric cohort to characterize if differences in pathology and/or imaging characterization of RE may provide a window into post-operative seizure outcomes, which in turn could guide decision-making for parents and healthcare providers. METHODS This multi-institutional retrospective review of medical record, imaging, and pathology samples was approved by each individual institution's review board. Data was collected from all known pediatric cases of peri-insular functional hemispherotomy from the earliest available electronic medical records. Mean follow-up time was 4.9 years. Clinical outcomes were measured by last follow-up visit using both Engel and ILAE scoring systems. Relationships between categorical and continuous variables were analyzed with Pearson correlation values. RESULTS Twenty-seven patients met study criteria. No statistically significant correlations existed between patient imaging and pathology data. Pathology stage, MRI brain imaging stages, and a combined assessment of pathology and imaging stages showed no statistically significant correlation to post-operative seizure freedom rates. Hemispherectomy Outcome Prediction Scale scoring demonstrated seizure freedom in only 71% of patients receiving a score of 1 and 36% of patients receiving a score of 2 which were substantially lower than predicted. CONCLUSIONS Our analysis did not find evidence for either independent or combined analysis of imaging and pathology staging being predictive for post peri-insular hemispherotomy seizure outcomes, prompting the need for other biomarkers to be explored. Our data stands in contrast to the recently proposed Hemispherectomy Outcome Prediction Scale and does not externally validate this metric for an RE cohort.
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Affiliation(s)
| | - Kathleen Knudson
- Department of Neurosurgery and Spine, ECU Health, Greenville, NC, USA
| | | | - James L Leach
- Radiology, Cincinnati Childrens Hospital and Medical Center, Cincinnati, OH, USA
| | - Anthony C Wang
- Department of Neurosurgery, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Neena Marupudi
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Rowland H Han
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Stuart Tomko
- Neurology, Washington University, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Jeff Ojemann
- Department of Neurosurgery, Seattle Childrens Hospital, Seattle, WA, USA
| | - Matthew D Smyth
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Francesco Mangano
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
| | - Jesse Skoch
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA.
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2
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Andzelm MM, Stredny CM. Mechanisms and Emerging Therapies for Treatment of Seizures in Pediatric Autoimmune Encephalitis and Autoinflammatory/Autoimmune-Associated Epilepsy. Rheum Dis Clin North Am 2023; 49:875-893. [PMID: 37821201 DOI: 10.1016/j.rdc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There has been increasing understanding of the role of inflammation in seizures and epilepsy, as well as targeted immunomodulatory treatments. In children, immune-mediated seizures often present acutely in the setting of autoimmune encephalitis and are very responsive to immunotherapy with low rates of subsequent epilepsy. Conversely, seizures in autoimmune-associated epilepsies, such as Rasmussen syndrome, can remain refractory to multimodal therapy, including immunomodulation. In this review, the authors discuss the presentations of immune-mediated seizures in children, underlying mechanisms, and emerging therapies.
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Affiliation(s)
- Milena M Andzelm
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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3
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Leitner DF, Lin Z, Sawaged Z, Kanshin E, Friedman D, Devore S, Ueberheide B, Chang JW, Mathern GW, Anink JJ, Aronica E, Wisniewski T, Devinsky O. Brain molecular mechanisms in Rasmussen encephalitis. Epilepsia 2023; 64:218-230. [PMID: 36336987 PMCID: PMC9852002 DOI: 10.1111/epi.17457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study was undertaken to identify molecular mechanisms in brain tissue of Rasmussen encephalitis (RE) when compared to people with non-RE epilepsy (PWE) and control cases using whole exome sequencing (WES), RNAseq, and proteomics. METHODS Frozen brain tissue (ages = 2-19 years) was obtained from control autopsy (n = 14), surgical PWE (n = 10), and surgical RE cases (n = 27). We evaluated WES variants in RE associated with epilepsy, seizures, RE, and human leukocyte antigens (HLAs). Differential expression was evaluated by RNAseq (adjusted p < .05) and label-free quantitative mass spectrometry (false discovery rate < 5%) in the three groups. RESULTS WES revealed no common pathogenic variants in RE, but several rare and likely deleterious variants of unknown significance (VUS; ANGPTL7/MTOR, SCN1A, FCGR3B, MTOR) and more common HLA VUS in >25% of RE cases (HLA-DRB1, HLA-DQA2), all with allele frequency < 5% in the general population. RNAseq in RE versus PWE (1516 altered transcripts) revealed significant activation of crosstalk between dendritic and natural killer cells (p = 7.94 × 10-6 , z = 2.65), in RE versus control (7466 transcripts) neuroinflammation signaling activation (p = 6.31 × 10-13 , z = 5.07), and in PWE versus control (945 transcripts) phagosome formation activation (p = 2.00 × 10-13 , z = 5.61). Proteomics detected fewer altered targets. SIGNIFICANCE In RE, we identified activated immune signaling pathways and immune cell type annotation enrichment that suggest roles of the innate and adaptive immune responses, as well as HLA variants that may increase vulnerability to RE. Follow-up studies could evaluate cell type density and subregional localization associated with top targets, clinical history (neuropathology, disease duration), and whether modulating crosstalk between dendritic and natural killer cells may limit disease progression.
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Affiliation(s)
- Dominique F. Leitner
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ziyan Lin
- Applied Bioinformatics Laboratories, NYU Grossman School of Medicine, New York, NY, USA
| | - Zacharia Sawaged
- Applied Bioinformatics Laboratories, NYU Grossman School of Medicine, New York, NY, USA
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Sasha Devore
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Beatrix Ueberheide
- Center for Cognitive Neurology, Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Proteomics Laboratory, Division of Advanced Research Technologies, NYU Grossman School of Medicine, New York, NY, USA
- Department of Biochemistry and Molecular Pharmacology, NYU Grossman School of Medicine, New York, NY, USA
| | - Julia W. Chang
- Departments of Neurosurgery and Psychiatry, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gary W. Mathern
- Departments of Neurosurgery and Psychiatry, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jasper J. Anink
- Department of (Neuro) Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, the Netherlands
| | - Eleonora Aronica
- Department of (Neuro) Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, the Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
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4
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A Special Case of Relapsing-Remitting Bilateral Encephalitis: Without Epilepsy, but Responding to Rituximab and with a Brain Biopsy Coinciding with Rasmussen Encephalitis. Brain Sci 2022; 13:brainsci13010017. [PMID: 36671998 PMCID: PMC9856488 DOI: 10.3390/brainsci13010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/05/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
A nine-year-old boy manifested with headache, progressive mild cognitive decline and hemiparesis, but without clinical epileptic seizures (with abnormal EEG waves). Brain magnetic resonance imaging (MRI) showed bilateral cortical lesions mainly on the right hemisphere, and new lesions developed in frontal, parietal, occipital and temporal lobes around the old lesions presenting as a lace-like or ring-like enhancement in T1 with contrast over a disease course of five years. A suspected diagnosis of primary angiitis of the central nervous system was initially considered. Treated with high-dose corticosteroids, intravenous immunoglobulins and monthly pulse cyclophosphamide, his symptoms worsened with the intracranial lesion progression. Brain biopsy of the right frontal lobe was performed nearly five years after onset; prominent neuronal loss, a microglial nodule, as well as parenchymal and perivascular lymphocytic infiltrate within the cortex were found, which coincided with RE pathology changes. Encouragingly, after a regimen of rituximab, lesions on the follow-up brain MRI tended to be stable. Apparently, it was immune-mediated, but did not strictly fit any known disease entity, although it was similar to RE. We summarize this unique case, including clinical characteristics, imaging and pathology findings. We also discuss the diagnosis and treatment, focusing on comparison to RE as well as other possible neurological diseases.
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5
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Tang C, Yang W, Luan G. Progress in pathogenesis and therapy of Rasmussen's encephalitis. Acta Neurol Scand 2022; 146:761-766. [PMID: 36189924 DOI: 10.1111/ane.13712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/20/2022] [Indexed: 01/15/2023]
Abstract
Rasmussen's encephalitis (RE) is a rare condition of unknown etiology that causes a severe chronically neurological disorder with mostly affecting children. The main clinical feature of RE includes frequent seizures with drug-resistant, unilateral hemispheric atrophy, and progressive neurological deficits. In this review, we summarized five pathogenesis on the basis of the current research including virus infection, antibody-mediated degeneration, cell-mediated immunity, microglia-induced degeneration, and genetic mutations. So far, no exact virus in RE brain tissue or definite antigen in humoral immune system was confirmed as the determined etiology. The importance of cytotoxic CD8+ T lymphocytes and activated microglial and the role of their immune mechanism in RE development are gradually emerging with the deep study. Genetic researches support the notion that the pathogenesis of RE is probably associated with single nucleotide polymorphisms on immune-related genes, which is driven by affecting inherent antiretroviral innate immunity. Recent advances in treatment suggest immunotherapy could partially slows down the progression of RE according to the histopathology and clinical presentation, which aimed at the initial damage to the brain by T cells and microglia in the early stage. However, the cerebral hemispherectomy is an effective means to controlling the intractable seizure, which is accompanied by neurological complications inevitably. So, the optimal timing for surgical intervention is still a challenge for RE patient. On the contrary, exploration on other aspects of pathogenesis such as dysfunction of adenosine system may offer a new therapeutic option for the treatment of RE in future.
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Affiliation(s)
- Chongyang Tang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Wei Yang
- Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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6
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Rasmussen's encephalitis: Early diagnostic criteria in children. Rev Neurol (Paris) 2022; 178:666-674. [PMID: 35568516 DOI: 10.1016/j.neurol.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/21/2022]
Abstract
Rasmussen's encephalitis (RE) is a rare chronic inflammatory brain disorder resulting in progressive neurodegeneration in one cerebral hemisphere. The inflammatory process is accompanied by progressive loss of function of the affected hemisphere, associated with drug-resistant partial epilepsy. The diagnosis is based on a range of clinical, electroencephalographic, radiological and biochemical arguments, without any specific formal marker, which makes the diagnosis of the disease complex, especially in its initial phase. Seizures are refractory to anti-seizures medication (ASM) and to classical immunomodulatory treatments. These treatments are also ineffective to stop the degenerative process. Only surgical treatment with hemispherotomy (surgical disconnection of a cerebral hemisphere) allows definitive cessation of seizures but this leads to definitive motor and cognitive deficits. The etiology of RE is not known, but there is strong evidence for an immunopathogenic mechanism involving T-cell mediated immunity. The emergence of biotherapies targeting against various cytokines offers potential therapeutic perspectives. This disease is currently a real challenge in terms of: (i) early diagnosis, before the constitution of marked hemispheric atrophy and the appearance of neurological and cognitive consequences; (ii) recognition of incomplete form; (iii) therapeutic management due to advances in the field of targeted treatment of inflammation; (iv) surgery and recovery possibilities.
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7
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Riney K, Bogacz A, Somerville E, Hirsch E, Nabbout R, Scheffer IE, Zuberi SM, Alsaadi T, Jain S, French J, Specchio N, Trinka E, Wiebe S, Auvin S, Cabral-Lim L, Naidoo A, Perucca E, Moshé SL, Wirrell EC, Tinuper P. International League Against Epilepsy classification and definition of epilepsy syndromes with onset at a variable age: position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1443-1474. [PMID: 35503725 DOI: 10.1111/epi.17240] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 03/12/2022] [Accepted: 03/16/2022] [Indexed: 01/15/2023]
Abstract
The goal of this paper is to provide updated diagnostic criteria for the epilepsy syndromes that have a variable age of onset, based on expert consensus of the International League Against Epilepsy Nosology and Definitions Taskforce (2017-2021). We use language consistent with current accepted epilepsy and seizure classifications and incorporate knowledge from advances in genetics, electroencephalography, and imaging. Our aim in delineating the epilepsy syndromes that present at a variable age is to aid diagnosis and to guide investigations for etiology and treatments for these patients.
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Affiliation(s)
- Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia
| | - Alicia Bogacz
- Institute of Neurology, University of the Republic, Montevideo, Uruguay
| | - Ernest Somerville
- Prince of Wales Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Edouard Hirsch
- Francis Rohmer Epilepsy Unit, Hautepierre Hospital, Strasbourg, France.,National Institute of Health and Medical Research 1258, Strasbourg, France.,Federation of Translational Medicine of Strasbourg, University of Strasbourg, Strasbourg, France
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Assistance Publique - Hôpitaux de Paris, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Member of Epicare, Paris, France.,Imagine Institute, National Institute of Health and Medical Research Mixed Unit of Research 1163, Paris, France.,University City University, Paris, France
| | - Ingrid E Scheffer
- Austin Health, Royal Children's Hospital, Florey Institute and Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Sameer M Zuberi
- University City University, Paris, France.,Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | | | - Jacqueline French
- New York University Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, member of EpiCARE, Rome, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria.,Neuroscience Institute, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Salzburg, Austria.,Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Stéphane Auvin
- Institut Universitaire de France, Paris, France.,Paediatric Neurology, Assistance Publique - Hôpitaux de Paris, Robert-Debré Hospital, Paris, France.,University of Paris, Paris, France
| | - Leonor Cabral-Lim
- Department of Neurosciences, College of Medicine and Philippine General Hospital, Health Sciences Center, University of the Philippines Manila, Manila, the Philippines
| | - Ansuya Naidoo
- Neurology Unit, Greys Hospital, Pietermaritzburg, South Africa.,Department of Neurology, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Emilio Perucca
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, New York, New York, USA.,Montefiore Medical Center, Bronx, New York, USA
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Reference Centre for Rare and Complex Epilepsies, IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
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8
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Liu D, Yuguang G, Zhou J, Zhai F, Chen L, Li T, Wang M, Luan G. The influencing factors and changes of cognitive function within 40 Rasmussen encephalitis patients that received a hemispherectomy. Neurol Res 2022; 44:700-707. [PMID: 35172696 DOI: 10.1080/01616412.2022.2039526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the influencing factors and cognitive functional changes in Rasmussen encephalitis (RE) patients who received a hemispherectomy. METHODS Forty RE patients underwent a hemispherectomy with at least a 2 years follow- up were included in this study . Postoperative seizure outcomes were evaluated according to the Engle classification scale. Univariate analysis and a multivariate logistic regression model in a backward fashion were used to identify the potential predictors of cognitive function. RESULTS All 40 patients had an Engle classification outcome at a 2 years follow-up. Univariate and multivariate analyses revealed that seizure duration (OR 10.06, 95% CI 1.54-3.85, p = 0.038), age at surgery (OR 3.06, 95% CI 1.21-3.56, p = 0.043), and MRI score (OR 0.09, 95% CI 0.01-0.67 p = 0.024) are associated with postoperative cognitive outcomes respectively. Moreover, VIQ and PIQ were negatively correlated linearly with duration of seizures and MRI score. Patients with a good VIQ and PIQ before the operation were more likely to have a better VIQ and PIQ postoperatively (p < 0.001 and p < 0.001, respectively). And, operation side is an important factor affecting cognitive function; therefore, a left hemispherectomy has a greater impact on the patient's IQ and language. CONCLUSIONS RE patients' cognitive dysfunctions are improved after a hemispherectomy. Right-side operation can achieve better postoperative cognitive outcomes especially in VIQ and language. A shorter duration of seizures, early age at surgery, and less severe brain atrophy suggest better cognitive outcomes after a hemispherectomy.
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Affiliation(s)
- Dong Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guan Yuguang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Zhou
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Lingling Chen
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Mengyang Wang
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Epilepsy, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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9
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Agarwal A, Makkar A, Komakula S, Sahu S, Suri V, Srivasatava A. Triple pathology in Rasmussen's encephalitis: A new pathological phenotype. Ann Indian Acad Neurol 2022; 25:534-536. [PMID: 35936621 PMCID: PMC9350790 DOI: 10.4103/aian.aian_815_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/10/2021] [Indexed: 11/04/2022] Open
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Fauser S, Elger CE, Woermann F, Bien CG. Rasmussen encephalitis: Predisposing factors and their potential role in unilaterality. Epilepsia 2021; 63:108-119. [PMID: 34820830 DOI: 10.1111/epi.17131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Rasmussen encephalitis (RE) is a progressive and destructive inflammatory disease of one hemisphere. Its cause is unknown. We investigated comorbidity and laterality factors that might predispose to RE. METHODS We retrospectively compared the histories of 160 RE patients to those with genetic generalized epilepsy (n = 154) and those with focal cortical dysplasia Type II (FCD II; n = 148). RESULTS The median/mean age at symptom onset in RE was 7/10 years (range = 1-53 years), and 58.1% of the patients were female. The female sex predominated in RE patients, with age > 7 years at disease manifestation. The left hemisphere was affected in 65.6%. Perinatal complications (preterm birth, twin pregnancies, early acquired brain lesions) were more frequent in RE than in control patients. Ipsilateral facial autoimmune conditions (scleroderma en coup de sabre, uveitis, or chorioretinitis) were only observed in RE patients (6.9%). Onset of RE was more frequently associated with fever than that of FCD II. In 33.1% of RE patients, ≥1 potential risk factor was found. Interestingly, 11.9% of patients had one-sided early brain lesions or facial autoimmune lesions ipsilateral to subsequent RE; none had such a lesion contralaterally. SIGNIFICANCE Perinatal complications and facial autoimmune conditions may act as predisposing factors for RE. Fever might trigger RE manifestation. Further genetic or infectious contributors may be identified in the future. Single or combined hits may be required to elicit or facilitate the start of the disease. Ipsilateral early comorbid lesions or facial autoimmune processes might in part explain the enigmatic unilaterality of RE.
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Affiliation(s)
- Susanne Fauser
- Department of Epileptology (Mara Hospital), Medical School, Bielefeld University, Bielefeld, Germany
| | | | - Friedrich Woermann
- Department of Epileptology (Mara Hospital), Medical School, Bielefeld University, Bielefeld, Germany.,Society of Epilepsy Research, Bielefeld, Germany
| | - Christian G Bien
- Department of Epileptology (Mara Hospital), Medical School, Bielefeld University, Bielefeld, Germany
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11
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Jamoussi M, Jamoussi H, Fray S, Echebbi S, Ben Ali N, Fredj M. Adult-onset Rasmussen encephalitis and Parry Romberg syndrome overlap. Neurol Sci 2021; 42:4815-4820. [PMID: 34357473 DOI: 10.1007/s10072-021-05488-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Maha Jamoussi
- Department of Neurology, Charles Nicolle Hospital, 1006, Tunis, Tunisia
| | - Hela Jamoussi
- Department of Neurology, Charles Nicolle Hospital, 1006, Tunis, Tunisia. .,Université de Tunis El ManarFaculté de Médecine de Tunis, 1007, Tunis, Tunisia. .,Research Laboratory LR12SP01, Charles Nicolle Hospital, 1006, Tunis, Tunisia.
| | - Saloua Fray
- Department of Neurology, Charles Nicolle Hospital, 1006, Tunis, Tunisia.,Université de Tunis El ManarFaculté de Médecine de Tunis, 1007, Tunis, Tunisia.,Research Laboratory LR12SP01, Charles Nicolle Hospital, 1006, Tunis, Tunisia
| | - Slim Echebbi
- Department of Neurology, Charles Nicolle Hospital, 1006, Tunis, Tunisia.,Research Laboratory LR12SP01, Charles Nicolle Hospital, 1006, Tunis, Tunisia
| | - Nadia Ben Ali
- Department of Neurology, Charles Nicolle Hospital, 1006, Tunis, Tunisia.,Université de Tunis El ManarFaculté de Médecine de Tunis, 1007, Tunis, Tunisia.,Research Laboratory LR12SP01, Charles Nicolle Hospital, 1006, Tunis, Tunisia
| | - Mohamed Fredj
- Department of Neurology, Charles Nicolle Hospital, 1006, Tunis, Tunisia.,Université de Tunis El ManarFaculté de Médecine de Tunis, 1007, Tunis, Tunisia.,Research Laboratory LR12SP01, Charles Nicolle Hospital, 1006, Tunis, Tunisia
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12
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Tang C, Luan G, Li T. Rasmussen's encephalitis: mechanisms update and potential therapy target. Ther Adv Chronic Dis 2020; 11:2040622320971413. [PMID: 33294146 PMCID: PMC7705182 DOI: 10.1177/2040622320971413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/15/2020] [Indexed: 12/11/2022] Open
Abstract
Rasmussen’s encephalitis (RE) is rare neurological diseases characterized as epilepsia partialis continua, invariably hemiparesis, and cognitive impairment. This disease is encountered frequently in childhood and presents with progressive atrophy of the unilateral hemisphere, and there are also sustained neurological complications. Owing to uncertain pathogenesis, the most effective way to limit the influence of seizures currently is cerebral hemispherectomy. In this review, we focus on four main lines of pathogenesis: virus infection, antibody-mediated, cell-mediated immunity, and microglia activation. Although one or more antigenic epitopes may give rise to infiltrating T cell responses in RE brain tissue, no exact antigen was confirmed as the definite cause of the disease. On the other hand, the appearance of antibodies related with RE seem to be a secondary pathological process. Synthetic studies have suggested an adaptive immune mechanism mediated by CD8+ T cells and an innate immune mechanism mediated by activated microglia and neuroglia. Accordingly, opinions have been raised that immunomodulatory treatments aimed at initial damage to the brain that are induced by cytotoxic CD8+ T cell lymphocytes and microglia in the early stage of RE slow down disease progression. However, systematic exploration of the theory behind these therapeutic effects based on multicenter and large sample studies are needed. In addition, dysfunction of the adenosine system, including the main adenosine removing enzyme adenosine kinase and adenosine receptors, has been demonstrated in RE, which might provide a novel therapeutic target for treatment of RE in future.
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Affiliation(s)
- Chongyang Tang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, SanBo Brain Hospital, Capital Medical University No. 50 Xiangshanyikesong Road, Haidian District, Beijing, 100093, China
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Pellegrin S, Baldeweg T, Pujar S, D'Arco F, Cantalupo G, Varadkar S, Cross JH. Immunomodulation With Azathioprine Therapy in Rasmussen Syndrome: A Multimodal Evaluation. Neurology 2020; 96:e267-e279. [PMID: 33046614 DOI: 10.1212/wnl.0000000000011004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/25/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To verify safety and efficacy of the corticosteroid-sparing drug azathioprine (AZA) in Rasmussen syndrome (RS), we retrospectively analyzed a cohort of patients with RS recruited in a single pediatric neuroscience center. METHODS We compared outcomes in 30 patients with RS who received AZA with 23 patients who were not treated with this drug. We used a multimodal approach to correlate therapy with clinical features (seizures, epilepsia partialis continua [EPC], hemiparesis) and neuroimaging markers of progressive brain atrophy. RESULTS AZA was well tolerated; only 1 patient discontinued treatment due to pancytopenia. In 27 of 30 patients receiving AZA, all of whom were corticosteroid responders, corticosteroid therapy could be weaned or reduced without worsening of seizures in 89%. Patients receiving AZA had a lower prevalence of EPC (42% vs 67% in controls) and hemiparesis (64% vs 92%, respectively). Cox regression showed for the AZA group compared to controls a delayed time to (1) EPC (≈2 years, exp[B] = 0.295, 95% confidence interval [CI] 0.108-0.807; p = 0.017), (2) hemiparesis (≈1 year, exp[B] = 0.315, 95% CI 0.137-0.724; p = 0.007), and (3) surgery (≈2 years, exp[B] = 2.068, 95% CI 1.012-4.227; p = 0.046). However, there were no group differences in cognitive decline over time (IQ change per year) or in hemispheric gray matter atrophy on serial MRI scans. CONCLUSION AZA treatment appears to slow clinical progression of RS in steroid responders; this will give the greatest advantage in patients in the early stages of the disease in whom surgical decision-making may require further time. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for pediatric patients with RS AZA is well tolerated and slows hemiparesis and appearance of EPC.
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Affiliation(s)
- Serena Pellegrin
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Torsten Baldeweg
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Suresh Pujar
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Felice D'Arco
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Gaetano Cantalupo
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Sophia Varadkar
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - J Helen Cross
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK.
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14
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Rasmussen's encephalitis: From immune pathogenesis towards targeted-therapy. Seizure 2020; 81:76-83. [DOI: 10.1016/j.seizure.2020.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/09/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022] Open
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15
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Rasmussen's Encephalitis: A Report of a Tunisian Pediatric Case and Literature Review. Case Rep Neurol Med 2020; 2020:6810237. [PMID: 32670646 PMCID: PMC7333059 DOI: 10.1155/2020/6810237] [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: 03/07/2020] [Accepted: 06/10/2020] [Indexed: 12/05/2022] Open
Abstract
Rasmussen's encephalitis (RE) is a rare progressive inflammatory disease of the central nervous system. It is characterized by unilateral hemispheric atrophy, pharmacoresistant focal seizures, and progressive neurological deficit. The exact etiopathogenesis still remains unknown. Brain imaging plays an important role in diagnosis and follow-up. Fluctuation of lesions in brain imaging was reported in few cases. Herein, we report an additional pediatric case of Rasmussen encephalitis with fluctuating changes in brain MRI.
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Sansevere AJ, Henderson LA, Stredny CM, Prabhu SP, Shah A, Sundel R, Madsen J, Dufreney C, Poduri A, Gorman MP. Posterior-onset Rasmussen's encephalitis with ipsilateral cerebellar atrophy and uveitis resistant to rituximab. Epilepsy Behav Rep 2020; 14:100360. [PMID: 32368732 PMCID: PMC7184158 DOI: 10.1016/j.ebr.2020.100360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 02/03/2023] Open
Abstract
Rasmussen encephalitis (RE) is a disorder characterized by drug-resistant seizures and progressive unihemispheric atrophy, hemiparesis, and varying degrees of cognitive decline. The pathophysiology of RE remains elusive, with hypotheses suggesting underlying autoimmune- and T cell-mediated processes. In this case report, we describe a single patient's clinical course from the first day of presentation until definitive treatment for atypical Rasmussen encephalitis at a tertiary care pediatric center. The patient exhibited several atypical features of Rasmussen encephalitis, including a posterior predominance of initial seizure onset with the development of severe choreoathetosis and ipsilateral cerebellar atrophy. He subsequently developed coexistent autoimmune disorders in the form of psoriasis and uveitis, and underwent multiple forms of immunotherapy with limited benefit. This patient shows an association of RE with other autoimmune conditions supporting an autoimmune mechanism of disease while exhibiting several atypical features of RE. Rarely, occipital lobe seizures have been documented as the presenting semiology of this syndrome. This case highlights the need to be mindful of atypical features that may delay hemispherectomy, which remains the definitive treatment. It also suggests that children may be predisposed to the development of autoimmune disorders in later stages of the disease. Occipital seizure localization and semiology should not dissuade the diagnosis of Rasmussen's encephalitis Movement disorders, can accompany Rasmussen's encephalitis Ipsilateral cerebellar atrophy has been described in Rasmussen's encephalitis Children with Rasmussen's encephalitis may be predisposed to autoimmune disorders in the later stages of the disease
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Affiliation(s)
- Arnold J Sansevere
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Coral M Stredny
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ankoor Shah
- Department of Ophthalmology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Robert Sundel
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Joseph Madsen
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | | | - Annapurna Poduri
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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17
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Szabó CÁ, Garvin R, Hafeez S, Seifi A, Leary L, Bhavaraju-Sanka R, Henry JM, Papanastassiou AM. Adult-onset Rasmussen's Syndrome with associated cortical dysplasia. EPILEPSY & BEHAVIOR CASE REPORTS 2019; 11:54-57. [PMID: 30705820 PMCID: PMC6349012 DOI: 10.1016/j.ebcr.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/26/2018] [Accepted: 11/20/2018] [Indexed: 11/16/2022]
Abstract
We describe a 23-year-old woman with previous right temporal lobe surgeries for underlying cortical dysplasia, presenting with drug-resistant right hemispheric seizures and epilepsia partialis continua (EPC). After anti-seizure medication adjustments, she developed focal status epilepticus with progressive EEG and neuroimaging changes. Cerebrospinal fluid and serum autoimmune panels were negative except for an elevated serum acetylcholine-receptor antibody titer, but she underwent immunosuppressive therapy. Stereotactic-EEG evaluation demonstrated multifocal independent ictal patterns in the right hemisphere. Rasmussen's Syndrome was confirmed by brain biopsy, and a hemispherectomy was performed. This patient demonstrates the rare association of adult-onset EPC with cortical dysplasia, precipitously evolving into Rasmussen's Syndrome. Rasmussen's Syndrome (RS) can be associated with focal cortical dysplasia. Autoimmunity underlies evolution of new-onset EPC in the setting of chronic focal epilepsy, and support a diagnosis of RS. Hemispherectomy can be an effective intervention in adult-onset RS.
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Affiliation(s)
- C Ákos Szabó
- Department of Neurology, UT Health San Antonio, San Antonio, TX, United States of America.,South Texas Comprehensive Epilepsy Center, San Antonio, TX, United States of America
| | - Rachel Garvin
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX, United States of America
| | - Shaheryar Hafeez
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX, United States of America
| | - Ali Seifi
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX, United States of America
| | - Linda Leary
- Department of Neurology, UT Health San Antonio, San Antonio, TX, United States of America.,South Texas Comprehensive Epilepsy Center, San Antonio, TX, United States of America
| | - Ratna Bhavaraju-Sanka
- Department of Neurology, UT Health San Antonio, San Antonio, TX, United States of America
| | - James M Henry
- Department of Pathology, UT Health San Antonio, San Antonio, TX, United States of America
| | - Alex M Papanastassiou
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX, United States of America.,South Texas Comprehensive Epilepsy Center, San Antonio, TX, United States of America
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Abstract
Brain has been considered as an immune-privileged site for centuries owing to the presence of blood-brain barrier, absent lymphatic drainage, and antigen-presenting cells. However, the present prevailing concept is of immune surveillance where brain is continuously surveyed by immune cells. However, the presence of immune cells in central nervous system (CNS) brings the risk of inflammation and autoimmunity involving both T and B cell mediated pathways. These mechanisms form the underlying pathology in a wide spectrum of pediatric CNS diseases manifesting as acquired neurological deficits. Overlapping, heterogenous, and ambiguous clinical features often delays the diagnosis. Although not always pathognomonic, magnetic resonance imaging can be an important biomarker leading to early diagnosis, prognostication, and systematic follow-up pf these diseases. This review describes the spectrum of different pediatric inflammatory disorders and their pertinent imaging features illustrated with clinical examples.
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Affiliation(s)
| | - Karthik Muthusamy
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manohar Shroff
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
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19
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Abstract
INTRODUCTION Cerebral hemiatrophy is an uncommon neuroimaging finding of diverse etiologies, conventionally classified into two broad categories: congenital and acquired. The authors propose an alternative pragmatic clinical approach to cerebral hemiatrophy, classifying its diverse etiologies into a single event insult such as an in utero stroke, or a progressive disorder from an inflammatory or neoplastic process, the latter of which needs urgent intervention and will be the focus of our review paper. Illustrative cases will also be presented to facilitate the understanding of the discussed disorders. CONCLUSION A systematic approach, linking both clinical and neuroimaging features, is important to facilitate the diagnostic workup of cerebral hemiatrophy. This may potentially help avoid large-scale investigations. Determining the underlying aetiology of cerebral hemiatrophy may impact treatment and prognostication as some conditions such as Rasmussen encephalitis and Parry-Romberg syndrome may benefit from timely implementation of immunomodulatory therapy.
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20
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Castellano JF, Meyer JA, Lado FA. A Case Series of Adult-Onset Rasmussen's Encephalitis: Diagnostic and Therapeutic Challenges. Front Neurol 2017; 8:564. [PMID: 29118737 PMCID: PMC5660978 DOI: 10.3389/fneur.2017.00564] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 10/09/2017] [Indexed: 12/22/2022] Open
Abstract
Rasmussen’s encephalitis (RE) is a rare neurologic disorder characterized by progressive cerebral hemiatrophy and medically refractory epilepsy. The majority of current literature on this topic is focused on the pediatric population. In this case series, we will review three cases of adult-onset RE, as defined by fulfillment of the 2005 Bien criteria. The diagnostic challenge of characterizing this rare disease will be highlighted by the extensive serum, CSF, and pathologic sampling in all three patients. MR imaging and EEG data will be examined over time to characterize hallmark findings as well as progression. In addition, we will review the various forms of therapy attempted in these three patients, namely anti-epileptic drug therapy and immunomodulatory therapy. We will also utilize this case series to critically evaluate the broader context of atypical presentations of this disease and the value of current diagnostic criteria.
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Affiliation(s)
| | - Jenny A Meyer
- Saul Korey Department of Neurology, Montefiore Medical Center, Bronx, NY, United States
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Rossi Sebastiano D, Visani E, Duran D, Freri E, Panzica F, Chiapparini L, Ragona F, Granata T, Franceschetti S. Epileptic spikes in Rasmussen's encephalitis: Migratory pattern and short-term evolution. A MEG study. Clin Neurophysiol 2017; 128:1898-1905. [PMID: 28826020 DOI: 10.1016/j.clinph.2017.07.401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed this study at identifying cortical areas involved in the generation of interictal spikes in Rasmussen's Encephalitis (RE) patients using magnetoencephalography (MEG), at comparing spike localization with the degree of cortical atrophy detected by MRI, and at identifying short-term changes during the follow-up. METHODS Five patients with RE underwent two MEG and magnetic resonance imaging (MRI) (six months interval). The sources of visually detected spikes were estimated using equivalent current dipoles technique; these were then superimposed on individual MRI and clustered; the locations of the clusters were related to the MRI stage of cortical atrophy. RESULTS All patients showed spikes and clusters located in different cortical areas in both recordings; the locations had a limited correspondence with cortical atrophy. The second recordings showed changes in the localisation of spikes and clusters, and confirmed the dissimilarities with neuroradiological abnormalities. CONCLUSIONS The presence of clusters of spikes of variable localisation suggests that RE progresses in a multifocal and fluctuating manner. The cortical areas most involved in epileptogenesis did not completely coincide with the most atrophic areas. SIGNIFICANCE MEG can contribute to evaluating multifocal hemispheric spikes in RE and to better understand the time course of epileptogenic process.
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Affiliation(s)
| | - Elisa Visani
- Neurophysiopathology Department and Epilepsy Centre, IRCCS Foundation, Milan, Italy
| | - Dunja Duran
- Neurophysiopathology Department and Epilepsy Centre, IRCCS Foundation, Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, IRCCS Foundation, Milan, Italy
| | - Ferruccio Panzica
- Neurophysiopathology Department and Epilepsy Centre, IRCCS Foundation, Milan, Italy
| | - Luisa Chiapparini
- Neuroradiology Department, Carlo Besta Neurological Institute, IRCCS Foundation, Milan, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, IRCCS Foundation, Milan, Italy
| | - Tiziana Granata
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, IRCCS Foundation, Milan, Italy
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Abstract
Autoimmune epilepsies describe clinical syndromes wherein the immune system is suspected to be involved in the pathogenesis of seizures or as a mechanism for neuronal injury following seizures. These diseases typically affect otherwise healthy children and are characterized by explosive onset of focal seizures, encephalopathy, cognitive deterioration, or other focal neurological deficits, or all of these. Traditional neurological diagnostics lack sensitivity and specificity in the diagnosis of autoimmune epilepsies, and results must be considered in the clinical context. Consideration of an autoimmune etiology early in the clinical course is important to ensure timely initiation of immunotherapy, as appropriate, as conventional antiepileptic drugs alone are typically unable to control seizures and other neurological symptoms. This article discusses the autoimmune epilepsies of autoimmune encephalitis (including anti-N-methyl-D-aspartate receptor encephalitis), Rasmussen's encephalitis, and febrile infection-related epilepsy syndrome. Further research is needed to better understand pathogenic mechanisms, optimal immunotherapy, and the effect of treatment on prognosis.
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Affiliation(s)
- Anusha K Yeshokumar
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD
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Kavčič A, Hofmann WE. Unprovoked seizures in multiple sclerosis: Why are they rare? Brain Behav 2017; 7:e00726. [PMID: 28729933 PMCID: PMC5516601 DOI: 10.1002/brb3.726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 02/19/2017] [Accepted: 03/31/2017] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The frequency of seizures in patients with multiple sclerosis (MS) ranges from 1.5% to 7.8% and is considerably more common than chance events. The etiopathogenesis of seizures in MS is still poorly understood. METHOD A review of the literature on seizures and MS using PubMed. RESULTS Cortical gray matter involvement appears to be an all-too-common pathological finding in MS to play a primary role in the pathogenesis of seizures in MS patients. There is no clear relationship between seizures and the severity of MS. In approximately 10% of cases, a seizure is actually an initial neurological symptom of MS. CONCLUSION Searching for coherence in the occurrence of unprovoked seizures in MS directs attention to the dichotomy in MS pathology characterized by a complex intertwining of neuroinflammatory and neurodegenerative processes. The appearance (or nonappearance) of seizures in MS in relation to disease activity and disease progression indicates a distinct clinical phenotype of MS that opens up new perspectives in MS research.
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Affiliation(s)
- Anamarija Kavčič
- Gemeinschaftspraxis Dr. Hofmann & Olschewski Aschaffenburg Germany
| | - Werner E Hofmann
- Gemeinschaftspraxis Dr. Hofmann & Olschewski Aschaffenburg Germany
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Liba Z, Sedlacek P, Sebronova V, Maulisova A, Rydenhag B, Zamecnik J, Kyncl M, Krsek P. Alemtuzumab and intrathecal methotrexate failed in the therapy of Rasmussen encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e354. [PMID: 28534039 PMCID: PMC5427667 DOI: 10.1212/nxi.0000000000000354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/06/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Zuzana Liba
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Petr Sedlacek
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Vera Sebronova
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Alice Maulisova
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Josef Zamecnik
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Martin Kyncl
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Pavel Krsek
- Department of Pediatric Neurology (Z.L., V.S., A.M., P.K.), Department of Pediatric Hematology and Oncology (P.S.), Department of Pathology and Molecular Medicine (J.Z.), Department of Radiology (M.K.), Charles University, 2nd Faculty of Medicine and Motol University Hospital; Department of Clinical Psychology (A.M.), Charles University, Faculty of Arts, Prague, Czech Republic; and Institute of Neuroscience and Physiology (B.R.), Department of Clinical Neuroscience, Sahlgrenska Academy at the University of Gothenburg, Sweden
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Guan Y, Chen S, Liu C, Du X, Zhang Y, Chen S, Wang J, Li T, Luan G. Timing and type of hemispherectomy for Rasmussen’s encephalitis: Analysis of 45 patients. Epilepsy Res 2017; 132:109-115. [DOI: 10.1016/j.eplepsyres.2017.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/24/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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Gurcharran K, Karkare S. Anti-N-Methyl-D-Aspartate Receptor Encephalitis and Rasmussen-like Syndrome: An Association? Pediatr Neurol 2017; 66:104-107. [PMID: 27913085 DOI: 10.1016/j.pediatrneurol.2016.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/27/2016] [Accepted: 10/01/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND N-methyl-D-aspartate (NMDA) receptor encephalitis is an immune-mediated condition that has a broad spectrum of manifestations, including seizures, coma, psychosis, and focal neurological deficits. Although usually a diffuse process, unihemispheric involvement mimicking early stages of Rasmussen encephalitis can occur. Rasmussen's encephalitis is a unique syndrome characterized by progressive hemiplegia, drug-resistant focal epilepsy, cognitive decline, and hemispheric brain atrophy contralateral to the hemiplegia. PATIENT DESCRIPTION We describe a two-year-old girl with progressive right weakness and epilepsia partialis continua, concerning for early Rasmussen's encephalitis, who tested positive for anti-NMDA receptor antibodies. She experienced complete clinical recovery after immunotherapy. Anti-NMDA receptor antibodies were absent at three weeks and again at one year after the first treatment of intravenous immunoglobulin. CONCLUSIONS There are few reports of Rasmussen-like encephalitis in individuals with anti-NMDA receptor antibody positivity. Thus the clinical significance of this association is yet to be determined. In addition, several other antibodies have been documented in individuals with Rasmussen encephalitis. The lack of a consistently reported antibody in Rasmussen encephalitis patients and the temporary nature of the anti-NMDA receptor antibody in our patient raise the following question: Is the presence of anti-NMDA receptor antibodies the cause of the symptoms or secondary to the pathogenic process?
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Affiliation(s)
- Kevin Gurcharran
- Pediatric Neurology, Cohen Children's Medical Center, New Hyde Park, New York.
| | - Shefali Karkare
- Pediatric Neurology, Cohen Children's Medical Center, New Hyde Park, New York
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Holec M, Nagahama Y, Kovach C, Joshi C. Rethinking the Magnetic Resonance Imaging Findings in Early Rasmussen Encephalitis: A Case Report and Review of the Literature. Pediatr Neurol 2016; 59:85-9. [PMID: 27004940 DOI: 10.1016/j.pediatrneurol.2015.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/12/2015] [Accepted: 12/13/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We present a child with Rasmussen encephalitis and highlight the pitfalls of diagnosis when magnetic resonance imaging (MRI) is negative for atrophy. We review the literature regarding this issue, introduce the FreeSurfer software as a potential means of noninvasive diagnosis, and discuss methods for prompt and definitive treatment. METHODS In addition to the patient description, we review the English language literature regarding pathologic diagnosis of Rasmussen encephalitis using the key words Rasmussen encephalitis, focal lesions, MRI, atrophy, epilepsia partialis continua and hemiparesis in PubMed. We conducted a retrospective, volumetric analysis of our patient's MRIs using FreeSurfer. RESULTS Unlike the majority of patients in the literature with Rasmussen encephalitis, our patient's initial MRI was normal and later showed only a small area of T2 and fluid-attenuated inversion recovery high signal despite the presence of epilepsia partialis continua and a rapidly deteriorating clinical course. She did not meet the Rasmussen encephalitis diagnostic criteria until biopsy was obtained but is now seizure-free after functional hemispherotomy performed six months after her initial seizure. FreeSurfer analysis did not show cortical atrophy. CONCLUSION The Bien criteria have poor sensitivity for the diagnosis of Rasmussen encephalitis when the MRI is negative for atrophy. Tissue diagnosis is essential in such instances. We suggest a high clinical index of suspicion and multidisciplinary collaboration between radiology, pathology, and neurosurgery to facilitate a greater emphasis on biopsy followed by hemispherotomy as definitive therapy for individuals with early Rasmussen encephalitis.
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Affiliation(s)
- Megan Holec
- Pediatric Neurology, University of Iowa Children's Hospital, Iowa City, Iowa.
| | - Yasunori Nagahama
- Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Christopher Kovach
- Department of Neurosurgery, University of Iowa Children's Hospital, Iowa City, Iowa
| | - Charuta Joshi
- Pediatric Neurology, University of Iowa Children's Hospital, Iowa City, Iowa
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Hoffman CE, Ochi A, Snead OC, Widjaja E, Hawkins C, Tisdal M, Rutka JT. Rasmussen's encephalitis: advances in management and patient outcomes. Childs Nerv Syst 2016; 32:629-40. [PMID: 26780781 DOI: 10.1007/s00381-015-2994-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 12/22/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Rasmussen's encephalitis (RE) is a hemispheric inflammatory disorder resulting in progressive epilepsy, hemiparesis, and cognitive decline. Controversy surrounds the most effective timing of surgery with respect to language dominance, functional status, and seizure outcome. We describe our experience with RE to inform treatment decisions. METHODS A retrospective chart review was performed in children diagnosed with RE from 1983 to 2012. RESULTS Thirteen consecutive cases were identified: six males and seven females with a mean age of 10.6 years (range 5-18). Nine patients received immunotherapy, with transient benefit in three, treatment-associated complications in two, and no difference in their mean time to treatment (5.38 vs 6.37 years p = 0.74) or long-term outcome. Mean follow-up was 5.6 years (range 0.58-12.25). There was no difference in outcome based on pre-operative duration of seizures. At last follow-up, 63 % of surgically treated patients achieved seizure freedom, 100 % had improved seizure control, 90 % had improved cognitive function, 36 % stopped medication, and 63 % tapered medication. Language improved in 83 % of patients with dominant disease. These findings were not associated with age at treatment. All surgical patients were ambulatory at last follow-up. CONCLUSIONS Hemispherotomy achieves good seizure control with cognitive improvement and ambulatory status post-operatively. Time to surgery and dominant disease were not associated with outcome, suggesting that hemispherotomy can be offered early or late, with expectations of good seizure control and functional outcome, even with dominant disease.
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Affiliation(s)
- Caitlin E Hoffman
- Division of Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA.
| | - Ayako Ochi
- Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Orlando Carter Snead
- Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Elysa Widjaja
- Division of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cynthia Hawkins
- Division of Neuropathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Martin Tisdal
- Division of Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - James T Rutka
- Division of Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Abstract
Approximately 20% of paediatric patients with epilepsy are refractory to medical therapies. In this subgroup of patients, neuroimaging plays an important role in identifying an epileptogenic focus. Successful identification of a structural lesion results in a better outcome following epilepsy surgery. Advances in imaging technologies, methods of epileptogenic region localisation and refinement of clinical evaluation of this group of patients in epilepsy centres have helped to widen the spectrum of children who could potentially benefit from surgical treatment. In this review, we discuss ways to optimise imaging techniques, list typical imaging features of common pathologies that can cause epilepsy, and potential pitfalls to be aware of whilst reviewing imaging studies in this challenging group of patients. The importance of multidisciplinary meetings to analyse and synthesise all the non-invasive data is emphasised. Our objectives are: to describe the four phases of evaluation of children with drug-resistant localisation-related epilepsy; to describe optimal imaging techniques that can help maximise detection of epileptogenic foci; to describe a systematic approach to reviewing magnetic resonance imaging of children with intractable epilepsy; to describe the features of common epileptogenic substrates; to list potential pitfalls whilst reviewing imaging studies in these patients; and to highlight the value of multimodality and interdisciplinary approaches to the management of this group of children.
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Pardo CA, Nabbout R, Galanopoulou AS. Mechanisms of epileptogenesis in pediatric epileptic syndromes: Rasmussen encephalitis, infantile spasms, and febrile infection-related epilepsy syndrome (FIRES). Neurotherapeutics 2014; 11:297-310. [PMID: 24639375 PMCID: PMC3996116 DOI: 10.1007/s13311-014-0265-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The mechanisms of epileptogenesis in pediatric epileptic syndromes are diverse, and may involve disturbances of neurodevelopmental trajectories, synaptic homeostasis, and cortical connectivity, which may occur during brain development, early infancy, or childhood. Although genetic or structural/metabolic factors are frequently associated with age-specific epileptic syndromes, such as infantile spasms and West syndrome, other syndromes may be determined by the effect of immunopathogenic mechanisms or energy-dependent processes in response to environmental challenges, such as infections or fever in normally-developed children during early or late childhood. Immune-mediated mechanisms have been suggested in selected pediatric epileptic syndromes in which acute and rapidly progressive encephalopathies preceded by fever and/or infections, such as febrile infection-related epilepsy syndrome, or in chronic progressive encephalopathies, such as Rasmussen encephalitis. A definite involvement of adaptive and innate immune mechanisms driven by cytotoxic CD8(+) T lymphocytes and neuroglial responses has been demonstrated in Rasmussen encephalitis, although the triggering factor of these responses remains unknown. Although the beneficial response to steroids and adrenocorticotropic hormone of infantile spasms, or preceding fever or infection in FIRES, may support a potential role of neuroinflammation as pathogenic factor, no definite demonstration of such involvement has been achieved, and genetic or metabolic factors are suspected. A major challenge for the future is discovering pathogenic mechanisms and etiological factors that facilitate the introduction of novel targets for drug intervention aimed at interfering with the disease mechanisms, therefore providing putative disease-modifying treatments in these pediatric epileptic syndromes.
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Affiliation(s)
- Carlos A Pardo
- Department of Neurology, Division of Neuroimmunology and Neuroinfectious Disorders, Center for Pediatric Rasmussen Syndrome, Johns Hopkins University School of Medicine, Baltimore, MD, USA,
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Varadkar S, Bien CG, Kruse CA, Jensen FE, Bauer J, Pardo CA, Vincent A, Mathern GW, Cross JH. Rasmussen's encephalitis: clinical features, pathobiology, and treatment advances. Lancet Neurol 2014; 13:195-205. [PMID: 24457189 DOI: 10.1016/s1474-4422(13)70260-6] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Rasmussen's encephalitis is a rare chronic neurological disorder, characterised by unilateral inflammation of the cerebral cortex, drug-resistant epilepsy, and progressive neurological and cognitive deterioration. Neuropathological and immunological studies support the notion that Rasmussen's encephalitis is probably driven by a T-cell response to one or more antigenic epitopes, with potential additional contribution by autoantibodies. Careful analysis of the association between histopathology and clinical presentation suggests that initial damage to the brain is mediated by T cells and microglia, suggesting a window for treatment if Rasmussen's encephalitis can be diagnosed early. Advances in neuroimaging suggest that progression of the inflammatory process seen with MRI might be a good biomarker in Rasmussen's encephalitis. For many patients, families, and doctors, choosing the right time to move from medical management to surgery is a real therapeutic dilemma. Cerebral hemispherectomy remains the only cure for seizures, but there are inevitable functional compromises. Decisions of whether or when surgery should be undertaken are challenging in the absence of a dense neurological deficit, and vary by institutional experience. Further, the optimum time for surgery, to give the best language and cognitive outcome, is not yet well understood. Immunomodulatory treatments seem to slow rather than halt disease progression in Rasmussen's encephalitis, without changing the eventual outcome.
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Affiliation(s)
- Sophia Varadkar
- Epilepsy Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and UCL Institute of Child Health, London, UK.
| | | | - Carol A Kruse
- Department of Neurosurgery, Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Frances E Jensen
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Carlos A Pardo
- Department of Neurology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Gary W Mathern
- Departments of Neurosurgery and Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine, Mattel Children's Hospital, University of California, Los Angeles, CA, USA
| | - J Helen Cross
- Neurosciences Unit, UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS Foundation Trust, London, and Young Epilepsy, Lingfield, UK
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Millichap JG. Immunomodulatory Therapy for Rasmussen Syndrome. Pediatr Neurol Briefs 2013. [DOI: 10.15844/pedneurbriefs-27-10-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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