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Smith KM, Budhram A, Geis C, McKeon A, Steriade C, Stredny CM, Titulaer MJ, Britton JW. Autoimmune-associated seizure disorders. Epileptic Disord 2024. [PMID: 38818801 DOI: 10.1002/epd2.20231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/28/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024]
Abstract
With the discovery of an expanding number of neural autoantibodies, autoimmune etiologies of seizures have been increasingly recognized. Clinical phenotypes have been identified in association with specific underlying antibodies, allowing an earlier diagnosis. These phenotypes include faciobrachial dystonic seizures with LGI1 encephalitis, neuropsychiatric presentations associated with movement disorders and seizures in NMDA-receptor encephalitis, and chronic temporal lobe epilepsy in GAD65 neurologic autoimmunity. Prompt recognition of these disorders is important, as some of them are highly responsive to immunotherapy. The response to immunotherapy is highest in patients with encephalitis secondary to antibodies targeting cell surface synaptic antigens. However, the response is less effective in conditions involving antibodies binding intracellular antigens or in Rasmussen syndrome, which are predominantly mediated by cytotoxic T-cell processes that are associated with irreversible cellular destruction. Autoimmune encephalitides also may have a paraneoplastic etiology, further emphasizing the importance of recognizing these disorders. Finally, autoimmune processes and responses to novel immunotherapies have been reported in new-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES), warranting their inclusion in any current review of autoimmune-associated seizure disorders.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Christian Geis
- Department of Neurology and Section Translational Neuroimmunology, Jena University Hospital, Jena, Germany
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Claude Steriade
- Department of Neurology, New York University Langone Health, New York, New York, USA
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Rafferty T, Koeppen-Babcock A, Muppidi S, Li Y, Le S. Utilization of APE2 and RITE2 scores in autoimmune encephalitis patients with seizures. Epilepsy Behav 2024; 154:109737. [PMID: 38518672 DOI: 10.1016/j.yebeh.2024.109737] [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: 11/02/2023] [Revised: 03/07/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE Immune-mediated seizures are rare but are increasingly recognized as an etiology of seizures resistant to anti-seizure medications (ASMs). Antibody Prevalence in Epilepsy 2 (APE2) and Response to Immunotherapy in Epilepsy 2 (RITE2) scores were developed recently to identify patients who may be seropositive for serum central nervous system (CNS) specific antibodies (Ab) and may benefit from immunotherapy (Dubey et al. 2018). The goal of this study was to apply APE2 and RITE2 scores to an independent cohort of patients with seizures secondary to autoimmune encephalitis (AE) and to further verify the sensitivity and specificity of the scores. PRINCIPAL RESULTS We conducted a retrospective study at Stanford University Hospital between 2008 and 2021 and included patients who had acute seizures and AE using diagnostic criteria from Graus (n = 34 definite AE, 10 probable AE, and 12 possible AE) (Graus et al. 2016). Patients were excluded if they did not have a serum Ab panel investigated or had alternate diagnoses (n = 55). APE2 and RITE2 scores were calculated based on clinical and diagnostic data (n = 56). Serum Ab were positive in 73 % of patients, in which 63 % cases carried CNS specific Ab. An APE2 score ≥ 4 had a sensitivity of 97 % and specificity of 14 % to predict a positive serum CNS specific Ab. A RITE2 score ≥ 7 had a sensitivity of 93 % and specificity of 60 % to predict seizure responsiveness to immunotherapy. CONCLUSION APE2 and RITE2 scores had high sensitivities but low specificities to predict seropositivity and seizure responsiveness to immunotherapy in patients with autoimmune encephalitis with seizures.
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Affiliation(s)
- Trevor Rafferty
- Department of Neurology and Neurological Sciences, Stanford University, CA, USA
| | | | - Srikanth Muppidi
- Department of Neurology and Neurological Sciences, Stanford University, CA, USA
| | - Yi Li
- Department of Neurology and Neurological Sciences, Stanford University, CA, USA
| | - Scheherazade Le
- Department of Neurology and Neurological Sciences, Stanford University, CA, USA.
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Peng W, Wang M, Shi W, Wang J, Zhou D, Li J. Performance of assessment tools in predicting neural autoantibody positivity in patients with seizures. Int Immunopharmacol 2024; 130:111763. [PMID: 38412674 DOI: 10.1016/j.intimp.2024.111763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The identification of patients with seizures of unknown etiology who would benefit from neural antibody testing necessitates effective assessment tools. The study aimed to compare the performance of the Antibody Prevalence in Epilepsy and Encephalopathy (APE2) score and the "Obvious" Indications for Neural Antibody Testing in Epilepsy or Seizures (ONES) checklist. We also intended to evaluate whether the performance of the tools varied by types of antibody. METHODS Patients diagnosed with epilepsy, seizures, or status epilepticus of unknown etiology at West China Hospital from January 2019 to December 2021 were included. Paired serum/cerebrospinal fluid samples were analyzed for antineuronal and antiglial antibodies. The APE2 score and ONES checklist were applied, and their outcomes were compared to laboratory antibody test results. Possible false positive neuronal antibody results were excluded in sensitivity/specificity analysis reasonably. RESULTS A total of 113 antibody-positive and 159 antibody-negative patients were enrolled in sensitivity/specificity analysis. The ONES checklist showed superior sensitivity than APE2 score (95.6 % vs.79.6 %, P < 0.001). Specificity was not statistically different (60.4 % vs. 57.9 %, P = 0.557). The negative predictive value (NPV) of ONES checklist was higher than that of APE2 score (94.8 % vs 80.7 %, P < 0.001). The positive predictive value of them was not statistically different (61.7 % vs 58.8 %, P = 0.557). APE2 score exhibited lower sensitivity for predicting LGI-Abs (52.9 % vs. 80.3 %, P = 0.022) compared to NMDAR-Abs. Similarly, ONES checklist showed lower sensitivity for LGI1-Abs than NMDAR-Abs (82.4 % vs. 100.0 %, P = 0.009). CONCLUSIONS The ONES checklist demonstrates superior sensitivity for neural antibody positivity than APE2 score. Specificity of the two assessment tools was similar. ONES checklist performed better NPV than the APE2 score. Both assessment tools performed less well in predicting the presence of LGI1- Abs when compared to NMDAR-Abs.
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Affiliation(s)
- Wei Peng
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Minjin Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China; Department of Laboratory Medicine, West China Hospital, Sichuan University, 610041, China.
| | - Wenyan Shi
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Jierui Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Jinmei Li
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
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Wagner B, Irani S. Autoimmune and paraneoplastic seizures. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:151-172. [PMID: 38494275 DOI: 10.1016/b978-0-12-823912-4.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Seizures are a common feature of autoimmune encephalitis and are especially prevalent in patients with the commonest autoantibodies, against LGI1, CASPR2 and the NMDA, GABAB, and GABAA receptors. In this chapter, we discuss the classification, clinical, investigation, and treatment aspects of patients with these, and other autoantibody-mediated and -associated, illnesses. We highlight distinctive and common seizure semiologies which, often alongside other features we outline, can help the clinical diagnosis of an autoantibody-associated syndrome. Next, we classify these syndromes by either focusing on whether they represent underlying causative autoantibodies or T-cell-mediated syndromes and on the distinction between acute symptomatic seizures and a more enduring tendency to autoimmune-associated epilepsy, a practical and valuable distinction for both patients and clinicians which relates to the pathogenesis. We emphasize the more effective immunotherapy response in patients with causative autoantibodies, and discuss the emerging evidence for various first-, second-, and third-line immunotherapies. Finally, we highlight available clinical rating scales which can guide autoantibody testing and immunotherapy in patients with seizures of unknown etiology. Throughout, we relate the clinical and therapeutic observations to the immunobiology and neuroscience which drive these seizures.
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Affiliation(s)
- Barbara Wagner
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom; Kantonsspital Aarau Switzerland, Tellstrasse, Aarau, Switzerland
| | - Sarosh Irani
- Neuroscience Department, NDCN, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom.
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Macher S, Bsteh G, Pataraia E, Berger T, Höftberger R, Rommer PS. The three pillars in treating antibody-mediated encephalitis. Wien Klin Wochenschr 2024; 136:13-24. [PMID: 37278857 PMCID: PMC10776469 DOI: 10.1007/s00508-023-02214-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/20/2023] [Indexed: 06/07/2023]
Abstract
The rapid initiation of immunotherapy has a decisive impact on the course of the disease in patients with antibody-mediated encephalitis (AE). The importance of treating AE with antiseizure medication and antipsychotics is discussed controversially; however, standardized procedures should be ensured, especially for the initiation of treatment in severe disease. Recommendations and guidelines for further interventions in refractory courses are needed. In this review, we contrast the three mainstays of treatment options in patients with AE and attempt to highlight the importance of 1) antiseizure therapy, 2) antipsychotic therapy, and 3) immunotherapy/tumor resection from today's perspective.
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Affiliation(s)
- S Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - G Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - E Pataraia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - T Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - R Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - P S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
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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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Sun Y, Zhao X, Ai L, Wang Q. Metabolic phenotyping of pilomotor seizures in autoimmune encephalitis. CNS Neurosci Ther 2023; 29:2522-2529. [PMID: 36971194 PMCID: PMC10401145 DOI: 10.1111/cns.14192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVES Ictal piloerection (IP) is an uncommon symptom in focal epilepsy and is associated with autoimmune encephalitis (AE). However, the networks involved in AE-associated IP are still unclear. To have a better understanding of IP underlying mechanisms, the current study investigated whole-brain metabolic networks for the analysis of AE-associated IP. METHODS Patients with AE and IP diagnosed at our Institute between 2018 and 2022 were selected. We then investigated the brain regions associated with AE-associated IP using positron emission tomography (PET). Anatomometabolic changes (interictal 18 F fluorodeoxyglucose PET) in AE patients with IP were compared with those of AE patients of similar age without IP (p-voxel <0.001, uncorrected). RESULTS Sixteen patients showed significant IP. The overall IP prevalence was 4.09% of patients with AE and 12.9% of patients with limbic encephalitis. The most common autoantibodies were against LGI1 (68.8%) followed by GAD65 (6.3%), NMDA (6.3%), GABAb (6.3%), CASPR2 (6.3%), and antibodies recognizing both GAD65 and mGLUR5 (6.3%). Most patients responded well to immunotherapy. Analysis of the imaging results at the voxel level showed that patients with IP had hypermetabolic changes in the right inferior temporal gyrus, suggesting involvement of this brain region in IP. CONCLUSIONS Our findings indicate that IP as an uncommon AE-associated manifestations should be recognized. We observed that the metabolic pattern of IP was conspicuous in the right inferior temporal gyrus.
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Affiliation(s)
- Yueqian Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaobin Zhao
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lin Ai
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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Feng J, Li J, Xie Y, Lü Y, Bi F, Zhou J. Clinical features of 28 cases of anti -leucine -rich glioma -inactivated protein 1 encephalitis and anti -contactin -associated protein -like 2 encephalitis. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:386-396. [PMID: 37164922 PMCID: PMC10930077 DOI: 10.11817/j.issn.1672-7347.2023.220548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Autoimmune encephalitis arising from autoantibodies against leucine-rich glioma-inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) are rare and with high clinical heterogeneity. They are easily misdiagnosed and missing diagnosed. This study aims to explore the clinical characteristics, auxiliary examinations, therapies and prognosis of anti-LGI1 and anti-CASPR2 encephalitis. METHODS Seventeen anti-LGI1 and 11 anti-CASPR2 encephalitis patients who were admitted to the Department of Neurology, Xiangya Hospital, Central South University between January 2018 and January 2021 were collected and retrospectively analyzed. Autoimmune encephalitis related antibodies and paraneoplastic antibodies were screened in all patients. The clinical manifestations, results of laboratory tests, imaging features, treatments and outcomes of 2 encephalitis groups were analyzed and compared. RESULTS In the anti-LGI1 encephalitis group, the age of 17 patients was 28-83 (53.18±19.08) years old, and the ratio of male to female was 9꞉8. There were 10 patients with cognitive impairment, 7 seizures, 4 faciobrachial dystonic seizures, and 1 psychiatric disturbance. Hyponatremia was observed in 7 patients. Eight patients had increased slow waves and 5 had epileptic discharge in electroencephalogram (EEG). Brain magnetic resonance (MRI) showed T2-weighted imaging (T2WI) and fluid attenuated inversion recovery (FLAIR) hyperintense signal in the temporal lobe, hippocampus and basal ganglia in 13 patients. In the anti-CASPR2 group, the age of 11 patients was 17-68 (47.18±16.20) years old, and the ratio of male to female was 5꞉6, with 7 limbic encephalitis, 1 Morvan syndrome, and 3 acquired neuromyotonia (NMT). Three patients had increased slow waves and 2 had epileptic discharge in EEG. Brain MRI showed T2WI and FLAIR hyperintense signal in the temporal lobe, hippocampus in 2 patients. Steroids, intravenous immunoglobin, and plasma exchange were administrated in 16 anti-LGI1 encephalitis and 8 anti-CASPR2 encephalitis patients with good therapeutic responses. Among them, 1 patient with anti-LGI1 encephalitis and 3 with anti-CASPR2 encephalitis were administrated with mycophenolate mofetil for immune maintenance therapy. No recurrences were observed in all patients with immunotherapy except for 2 patients who lost of follow-up. There were significant differences in cognitive impairment, hyponatremia, and brain MRI abnormalities between anti-LGI1 and anti-CASPR2 encephalitis patients (all P<0.05). CONCLUSIONS Limbic encephalitis is a common syndrome in both anti-LGI1 and anti-CASPR2 encephalitis patients. Anti-CASPR2 encephalitis has a wider clinical spectrum than anti-LGI1 encephalitis, presenting as NMT and Morvan syndrome, which has a closer relationship with tumors. Both of these 2 antibodies associated disorders are sensitive to immunotherapy and have a good prognosis.
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Affiliation(s)
- Jie Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Jingwen Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yuanyuan Xie
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yefan Lü
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Fangfang Bi
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jinxia Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008, China.
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Shi X, Cai W, Zhang X, Pan H, Huang C, Wang S, Xu J. Early predictors of new-onset immune-related seizures: a preliminary study. BMC Neurol 2022; 22:503. [PMID: 36581882 PMCID: PMC9798624 DOI: 10.1186/s12883-022-03042-0] [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: 09/08/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Approximately 60% of patients with autoimmune encephalitis (AE) exhibit secondary acute symptomatic seizures and showed highly sensitive to immunotherapy. However, it is difficult for many patients to receive early immunotherapy since the early identification of the cause in AE is more complex. This study aimed to investigate the early predictors of initial immune-related seizures and to guide the evaluation of treatment and prognosis. METHODS One hundred and fifty-four patients with new-onset "unknown etiology" seizures with a course of disease less than 6 months were included. Serum and/or cerebrospinal fluid neuron-specific autoantibodies (NSAbs), including N-methyl-D-aspartate receptor (NMDAR), α-amino-3-hydroxy-5- Methyl-4-isoxazole propionic acid receptor 1 (AMPAR1), AMPAR2, anti-leucine rich glioma inactivated 1 antibody (LGI1), anti-gamma-aminobutyric acid type B receptor (GABABR), anti-contact protein-related protein-2 (CASPR2) were used to screen for immune etiology of the seizures. In addition, patients with epilepsy and encephalopathy were also examined via brain MRI, long-term video EEG, antibody prevalence in epilepsy and encephalopathy (APE2) score, and modified Rankin Scale (mRS). A logistic regression model was used to analyze the early predictors of immune etiology. RESULTS Thirty-four cases (22.1%) were positive for NSAbs. Among all 154 patients, 23 cases of autoimmune encephalitis (AE) (21 cases of NSAbs positive), 1 case of ganglionic glioma (NSAbs positive), 130 cases of epilepsy or seizures (12 cases of NSAbs positive) were recorded. Also, there were 17 patients (11.0%) with APE2 ≥ 4 points, and all of them met the clinical diagnosis of AE. The sensitivity and specificity of APE2 ≥ 4 points for predicting AE were 73.9% and 100%. The results of multivariate analysis showed that the NSAbs and APE2 scores independently influenced the early prediction of initial immune-related seizures (P < 0.05). CONCLUSION NSAbs and APE2 scores could act as early predictors of initial immune-related seizures.
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Affiliation(s)
- Xiangsong Shi
- Department of Neurology, Huai’an Third People’s Hospital, No. 272, Huaihai West Road, 223001 Huai’an, China
| | - Weiwei Cai
- Department of Neurology, Huai’an Third People’s Hospital, No. 272, Huaihai West Road, 223001 Huai’an, China
| | - Xiulin Zhang
- Department of Neurology, Huai’an Third People’s Hospital, No. 272, Huaihai West Road, 223001 Huai’an, China
| | - Heyue Pan
- Department of Neurology, Huai’an Third People’s Hospital, No. 272, Huaihai West Road, 223001 Huai’an, China
| | - Chengbing Huang
- Department of Psychiatry, Huai’an Third People’s Hospital, 223001 Huai’an, China
| | - Shouyong Wang
- Department of Neurology, Huai’an Third People’s Hospital, No. 272, Huaihai West Road, 223001 Huai’an, China
| | - Jianyang Xu
- Department of Neurology, Huai’an Third People’s Hospital, No. 272, Huaihai West Road, 223001 Huai’an, China
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Binks S, Lamquet S, Crawford AH, Meurs A, Irani SR, Pakozdy A. Parallel roles of neuroinflammation in feline and human epilepsies. Vet J 2022; 290:105912. [PMID: 36209994 PMCID: PMC10912827 DOI: 10.1016/j.tvjl.2022.105912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Autoimmune encephalitis refers to a group of disorders characterised by a non-infectious encephalitis, often with prominent seizures and surface neuronal autoantibodies. AE is an important cause of new-onset refractory status epilepticus in humans and is frequently responsive to immunotherapies including corticosteroids, plasma exchange, intravenous immunoglobulin G and rituximab. Recent research suggests that parallel autoantibodies can be detected in non-human mammalian species. The best documented example is leucine-rich glioma-inactivated 1 (LGI1)-antibodies in domestic cats with limbic encephalitis (LE). In this review, we discuss the role of neuroinflammation and autoantibodies in human and feline epilepsy and LE.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK.
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Abbe H Crawford
- Clinical Science and Services, The Royal Veterinary College, Hertfordshire AL9 7TA, UK
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK; Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Akos Pakozdy
- University Clinic for Small Animals, University of Veterinary Medicine Vienna, Austria
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Uy CE, Mayxay M, Harrison R, Al-Diwani A, Jacobson L, Rattanavong S, Dubot-Pérès A, Vongsouvath M, Davong V, Chansamouth V, Phommasone K, Waters P, Irani SR, Newton PN. Detection and significance of neuronal autoantibodies in patients with meningoencephalitis in Vientiane, Lao PDR. Trans R Soc Trop Med Hyg 2022; 116:959-965. [PMID: 35385878 PMCID: PMC9526827 DOI: 10.1093/trstmh/trac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/11/2022] [Accepted: 03/10/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The importance of autoimmune encephalitis and its overlap with infectious encephalitides are not well investigated in South-East Asia. METHODS We report autoantibody testing, using antigen-specific live cell-based assays, in a series of 134 patients (cerebrospinal fluid and sera) and 55 blood donor controls (sera), undergoing lumbar puncture for suspected meningoencephalitis admitted in Vientiane, Lao People's Democratic Republic (PDR). RESULTS Eight of 134 (6%) patients showed detectable serum neuronal autoantibodies, against the N-methyl-D-aspartate and gamma-aminobutyric acid A receptors (NMDAR and GABAAR), and contactin-associated protein-like 2 (CASPR2). Three of eight patients had accompanying autoantibodies in cerebrospinal fluid (two with NMDAR and one with GABAAR antibodies), and in two of these the clinical syndromes were typical of autoimmune encephalitis. Three of the other five patients had proven central nervous system infections, highlighting a complex overlap between diverse infectious and autoimmune causes of encephalitis. No patients in this cohort were treated with immunotherapy, and the outcomes were poor, with improvement observed in a single patient. CONCLUSIONS In Lao PDR, autoimmune encephalitis is underdiagnosed and has a poor prognosis. Empiric immunotherapy should be considered after treatable infectious aetiologies are considered unlikely. Awareness and diagnostic testing resources for autoimmune encephalitis should be enhanced in South-East Asia.
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Affiliation(s)
- Christopher E Uy
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Division of Neurology, Department of Medicine, University of British Columbia Hospital, Vancouver, British Columbia V6T 2B5, Canada
- Department of Neurology, Oxford University Hospitals, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, New Richards Building, Oxford University, Oxford OX3 7LG, UK
- Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of Health, Vientiane, Lao PDR
| | - Ruby Harrison
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Adam Al-Diwani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Leslie Jacobson
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sayaphet Rattanavong
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Audrey Dubot-Pérès
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, New Richards Building, Oxford University, Oxford OX3 7LG, UK
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-INSERM 1207), IHU Méditerranée Infection, 19-21, Bd Jean Moulin, Marseille 13005, France
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Viengmon Davong
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Vilada Chansamouth
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, New Richards Building, Oxford University, Oxford OX3 7LG, UK
| | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Patrick Waters
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Department of Neurology, Oxford University Hospitals, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit OX3 7JX (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, New Richards Building, Oxford University, Oxford OX3 7LG, UK
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12
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Sakamoto M, Matsumoto R, Shimotake A, Togawa J, Takeyama H, Kobayashi K, Leypoldt F, Wandinger KP, Kondo T, Takahashi R, Ikeda A. Diagnostic value of an algorithm for autoimmune epilepsy in a retrospective cohort. Front Neurol 2022; 13:902157. [PMID: 36188368 PMCID: PMC9518792 DOI: 10.3389/fneur.2022.902157] [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: 03/22/2022] [Accepted: 07/19/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose This study aims to propose a diagnostic algorithm for autoimmune epilepsy in a retrospective cohort and investigate its clinical utility. Methods We reviewed 60 patients with focal epilepsy with a suspected autoimmune etiology according to board-certified neurologists and epileptologists. To assess the involvement of the autoimmune etiology, we used the patients' sera or cerebrospinal fluid (CSF) samples to screen for antineuronal antibodies using rat brain immunohistochemistry. Positive samples were analyzed for known antineuronal antibodies. The algorithm applied to assess the data of all patients consisted of two steps: evaluation of clinical features suggesting autoimmune epilepsy and evaluation using laboratory and imaging findings (abnormal CSF findings, hypermetabolism on fluorodeoxyglucose-positron emission tomography, magnetic resonance imaging abnormalities, and bilateral epileptiform discharges on electroencephalography). Patients were screened during the first step and classified into five groups according to the number of abnormal laboratory findings. The significant cutoff point of the algorithm was assessed using a receiver-operating characteristic curve analysis. Results Fourteen of the 60 patients (23.3%) were seropositive for antineuronal antibodies using rat brain immunohistochemistry. Ten patients had antibodies related to autoimmune epilepsy/encephalitis. The cutoff analysis of the number of abnormal laboratory and imaging findings showed that the best cutoff point was two abnormal findings, which yielded a sensitivity of 78.6%, a specificity of 76.1%, and an area under the curve of 0.81. Conclusion The proposed algorithm could help predict the underlying autoimmune etiology of epilepsy before antineuronal antibody test results are available.
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Affiliation(s)
- Mitsuhiro Sakamoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Riki Matsumoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
- *Correspondence: Riki Matsumoto
| | - Akihiro Shimotake
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jumpei Togawa
- Department of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirofumi Takeyama
- Department of Respiratory Care and Sleep Control Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Takayuki Kondo
- Department of Neurology, Kansai Medical University Medical Center, Moriguchi, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Akio Ikeda
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13
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Chen B, Lundstrom BN, Crepeau AZ, Dacpano L, Lopez-Chiriboga AS, Tatum WO, Freund B, Feyissa AM. Brain responsive neurostimulation device safety and effectiveness in patients with drug-resistant autoimmune-associated epilepsy. Epilepsy Res 2022; 184:106974. [DOI: 10.1016/j.eplepsyres.2022.106974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/23/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
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14
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Bartolini E, Ferrari AR, Lattanzi S, Pradella S, Zaccara G. Drug-resistant epilepsy at the age extremes: Disentangling the underlying etiology. Epilepsy Behav 2022; 132:108739. [PMID: 35636351 DOI: 10.1016/j.yebeh.2022.108739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
The incidence of epilepsy is highest at the extreme age ranges: childhood and elderly age. The most common syndromes in these demographics - self-limited epilepsies of childhood and idiopathic generalized epilepsies in pediatric age, focal epilepsy with structural etiology in older people - are expected to be drug responsive. In this work, we focus on such epilepsy types, overviewing the complex clinical background of unexpected drug-resistance. For self-limited epilepsies of childhood and idiopathic generalized epilepsies, we illustrate drug-resistance resulting from syndrome misinterpretation, reason on possible unexpected courses of epilepsy, and explicate the influence of inappropriate treatments. For elderly-onset epilepsy, we show the challenges in differential diagnosis possibly leading to pseudoresistance and analyze how drug-resistant epilepsy can arise in stroke, neurocognitive disorders, brain tumors, and autoimmune encephalitis. In children and senior people, drug-resistance can be regarded as a hint to review the diagnosis or explore alternative therapeutic strategies. Refractory seizures are not only a therapeutic challenge, but also a cardinal sign not to be overlooked in syndromes commonly deemed to be drug-responsive.
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Affiliation(s)
- Emanuele Bartolini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy.
| | - Anna Rita Ferrari
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Silvia Pradella
- USL Centro Toscana, Neurology Unit, Nuovo Ospedale Santo Stefano, Prato, Italy.
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15
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Chen TS, Lai MC, Huang HYI, Wu SN, Huang CW. Immunity, Ion Channels and Epilepsy. Int J Mol Sci 2022; 23:ijms23126446. [PMID: 35742889 PMCID: PMC9224225 DOI: 10.3390/ijms23126446] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 12/10/2022] Open
Abstract
Epilepsy is a common chronic neurological disorder in modern society. One of the major unmet challenges is that current antiseizure medications are basically not disease-modifying. Among the multifaceted etiologies of epilepsy, the role of the immune system has attracted considerable attention in recent years. It is known that both innate and adaptive immunity can be activated in response to insults to the central nervous system, leading to seizures. Moreover, the interaction between ion channels, which have a well-established role in epileptogenesis and epilepsy, and the immune system is complex and is being actively investigated. Some examples, including the interaction between ion channels and mTOR pathways, will be discussed in this paper. Furthermore, there has been substantial progress in our understanding of the pathophysiology of epilepsy associated with autoimmune encephalitis, and numerous neural-specific autoantibodies have been found and documented. Early recognition of immune-mediated epilepsy is important, especially in cases of pharmacoresistant epilepsy and in the presence of signs of autoimmune encephalitis, as early intervention with immunotherapy shows promise.
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Affiliation(s)
- Tsang-Shan Chen
- Department of Neurology, Tainan Sin-Lau Hospital, Tainan 701002, Taiwan;
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan;
| | | | - Sheng-Nan Wu
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan;
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan 70101, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5485)
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16
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Liu X, Yu T, Qi J, Lv R, Wang Q. Factors predicting neuronal surface antibodies in the elderly with new-onset and unknown seizures. Ann Clin Transl Neurol 2022; 9:1039-1049. [PMID: 35598111 PMCID: PMC9268868 DOI: 10.1002/acn3.51597] [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: 03/23/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate risk factors of neuronal surface antibodies (NSAbs) and develop a nomogram that could identify patients at the odds of NSAbs among the elderly (aged 60 years or older) with new‐onset seizures of unknown etiology. Methods Clinical data for aged ≥60 years diagnosed with new‐onset seizures of unknown etiology were retrospectively reviewed. A nomogram based on multivariable logistic regression was constructed. Model performance of nomogram was evaluated using area under the curve (AUC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC). Meanwhile, it was internally validated by bootstrap validation in current cohort. Results Of 147 patients included in final analysis, 68 (46.3%) had NSAbs‐mediated encephalitis. Six factors were identified: duration of seizures less than 3 months (OR:14.259; 95% CI: 4.480–45.386), focal‐onset seizures (OR:12.457; 95% CI: 2.710–57.261), psychiatric deficits (OR:10.063; 95% CI: 3.231–31.343), sleep disorders (OR:3.091; 95% CI: 1.011–9.454), hyponatremia (OR:6.252; 95% CI: 1.445–27.043), and medial temporal lobe (MTL) lesions on MRI (OR:4.102; 95% CI: 1.382–12.169). The nomogram had a good discrimination with an AUC of 0.916 and with a corrected AUC of 0.881 after the bootstrapping validation, our model also exhibited a better predictive performance than scoring systems commonly used clinically. Additionally, the calibration curve showed that predicted NSAbs‐positive rates of nomogram were closely aligned with actual observed results. Moreover, the nomogram achieved well on clinical utility by using the DCA and CIC. Interpretation Our nomogram may provide a convenient and useful tool for identifying the elderly with new‐onset seizures of unknown etiology who are at risk of NSAbs‐mediated encephalitis, which would allow these patients receive earlier immunotherapy.
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Affiliation(s)
- Xiao Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tingting Yu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Qi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruijuan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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17
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Pondrelli F, Giannoccaro MP, Bisulli F, Ferri L, Menghi V, Mostacci B, Avoni P, Liguori R, Tinuper P, Licchetta L. Pilomotor seizures in autoimmune limbic encephalitis: description of two GAD65 antibodies - related cases and literature review. Seizure 2022; 98:71-78. [DOI: 10.1016/j.seizure.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/07/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022] Open
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18
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Gillinder L, Britton J. Autoimmune-Associated Seizures. Continuum (Minneap Minn) 2022; 28:363-398. [PMID: 35393963 DOI: 10.1212/con.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article focuses on the seizure manifestations and presentations of autoimmune-associated epilepsy and acute symptomatic seizures in autoimmune encephalitis. It discusses the specificity of the various central nervous system autoantibodies and clarifies when their presence can be considered indicative of an immune etiology. Finally, current recommendations regarding patient selection for autoimmune antibody evaluation are reviewed, and an approach to immunotherapy is provided. RECENT FINDINGS Although autoimmune seizures are caused by a heterogeneous group of autoantibodies, key features reported in the literature should alert clinicians to the possible diagnosis. In particular, seizure characteristics including frequency, timing, duration, and symptomatology can provide vital clues to help differentiate autoimmune-associated seizures from other causes of epilepsy. Diagnostic certainty also requires an understanding and integration of the spectrum of clinical and paraclinical presentations, and several scoring systems have been developed that may be useful to aid the identification of autoimmune seizures. SUMMARY Seizures due to autoimmune etiology are increasingly encountered in clinical practice. It is critical that clinicians recognize immune seizure etiologies early in their course given they are often responsive to immunotherapy but are usually resistant to antiseizure medications. Currently, however, it is unfortunately not uncommon for autoimmune-associated seizure disorders to remain undiagnosed, resulting in missed opportunities to administer effective therapies. Efforts to better understand autoimmune seizure manifestations and treatment strategies are ongoing.
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19
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Karakis I. Merging Art with Science: A Detection Score for Autoimmune Epilepsy. Epilepsy Curr 2022; 22:170-172. [DOI: 10.1177/15357597221086114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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20
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Küçükali Cİ, Şengül B, Gezen-Ak D, Dursun E, Erdağ E, Akpınar G, Kasap M, Karaaslan Z, Şirin NG, Tektürk P, Baykan B, Tüzün E. Kv5.1 antibody in epilepsy patients with unknown etiology. Epilepsy Res 2022; 182:106911. [PMID: 35305445 DOI: 10.1016/j.eplepsyres.2022.106911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/26/2022] [Accepted: 03/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neuronal autoantibodies and favorable response to immunosuppressive treatment have been described in patients with chronic epilepsy of unknown cause, suggesting autoimmune etiology. Our aim was to identify novel epilepsy-specific autoantibodies reactive with neuronal surface antigens. METHODS Sera of 172 epilepsy patients with unknown cause and 30 healthy controls were screened with indirect immunofluorescence to identify IgG reacting with primary rat neuronal cultures. Putative target autoantigens were investigated with immunoprecipitation (IP) and liquid chromatography-mass/mass spectrometry (LC-MS/MS) studies using SH-SY5Y cells. Validation of LC-MS/MS results was carried out by IP and immunocytochemistry assays. RESULTS Antibodies to neuronal cell surface antigens were detected in 18 epilepsy patients. LC-MS/MS analysis identified voltage-gated potassium channel modifier subfamily F member 1 (KCNF1, Kv5.1) as the single common cell surface antigen in 4 patients with Lennox-Gastaut syndrome (n = 2), focal epilepsy of unknown cause (n = 1) and mesial temporal lobe epilepsy with hippocampal sclerosis (n = 1). These patients had the common features of early seizure onset and treatment-resistance. IP assays and co-localization (serum IgG and commercial Kv5.1-antibody) studies done with non-fixed Kv5.1-transfected HEK293 cells and primary neuronal cultures confirmed the presence of Kv5.1-antibody in 4 epilepsy patients identified by LC-MS/MS. Similar findings were not obtained by sera of other patients with epilepsy, patients with autoimmune encephalitis and healthy controls. CONCLUSION The herein described novel neuronal surface antibody to Kv5.1 appears to be associated with treatment-resistant epilepsy of unknown cause. Exact clinical and pathogenic significance of this antibody remains to be elucidated.
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Affiliation(s)
- Cem İsmail Küçükali
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Büşra Şengül
- Brain and Neurodegenerative Disorders Research Laboratories, Department of Medical Biology, Cerrahpaşa Faculty of Medicine, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Duygu Gezen-Ak
- Brain and Neurodegenerative Disorders Research Laboratories, Department of Medical Biology, Cerrahpaşa Faculty of Medicine, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Erdinç Dursun
- Brain and Neurodegenerative Disorders Research Laboratories, Department of Medical Biology, Cerrahpaşa Faculty of Medicine, Istanbul University, Cerrahpaşa, Istanbul, Turkey; Department of Neuroscience, Institute of Neurological Sciences, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Ece Erdağ
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Gürler Akpınar
- Medical Biology, Department of Basic Medical Sciences, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Murat Kasap
- Medical Biology, Department of Basic Medical Sciences, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Zerrin Karaaslan
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Nermin Görkem Şirin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Pınar Tektürk
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Betül Baykan
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey; Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey.
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21
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Hébert J, Muccilli A, Wennberg RA, Tang-Wai DF. Autoimmune Encephalitis and Autoantibodies: A Review of Clinical Implications. J Appl Lab Med 2022; 7:81-98. [PMID: 34996085 DOI: 10.1093/jalm/jfab102] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a common cause of encephalitis. We review the most recent evidence on this neuroimmune condition and autoantibody testing currently available. CONTENT Clinical criteria, neuroimaging and electroencephalography can facilitate the diagnosis of AE prior to obtaining autoantibody testing results, and lead to a diagnosis of AE even in the absence of a recognized antibody. Early treatment of AE has been found to correlate with improved long-term functional and cognitive outcomes. We suggest a clinical approach to diagnosis based on the predominant area of nervous system involvement and the results of ancillary testing that are widely available. We also propose a 2-tiered approach to the acute management of probable or definite AE. We, finally, provide guidance on the long-term management of AE-a challenging and understudied area. SUMMARY Much work remains to be done to improve the care of patients with AE. As understanding of the pathophysiology and predisposing factors underlying this condition steadily increases, a more evidence-based, targeted approach to the treatment of AE is still desired. Nonetheless, looking at the progress made over the past 2 decades, since the discovery of the first autoantibodies associated with AE, one cannot help but feel optimistic about the road ahead.
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Affiliation(s)
- Julien Hébert
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Alexandra Muccilli
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Multiple Sclerosis Clinic, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard A Wennberg
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Epilepsy Clinic and Neurophysiology Lab, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Memory Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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22
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Steriade C, Gillinder L, Rickett K, Hartel G, Higdon L, Britton J, French J. Discerning the Role of Autoimmunity and Autoantibodies in Epilepsy: A Review. JAMA Neurol 2021; 78:1383-1390. [PMID: 34515743 DOI: 10.1001/jamaneurol.2021.3113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance The literature on neural autoantibody positivity in epilepsy has expanded over the last decade, with an increased interest among clinicians in identifying potentially treatable causes of otherwise refractory seizures. Observations Prior studies have reported a wide range of neural autoantibody positivity rates among various epilepsy populations, with the highest frequency reported in individuals with focal epilepsy of unknown cause and new-onset seizures. The antibodies in some cases are of uncertain significance, and their presence can cause conundrums regarding therapy. Conclusions and Relevance There is likely some role for neural autoantibody assessment in patients with unexplained epilepsy who lack clear evidence of autoimmune encephalitis, but the clinical implications of such testing remain unclear owing to limitations in previous published studies. A framework for study design to bridge the current gaps in knowledge on autoimmune-associated epilepsy is proposed.
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Affiliation(s)
- Claude Steriade
- NYU Comprehensive Epilepsy Center, New York University, New York
| | - Lisa Gillinder
- Mater Advanced Epilepsy Unit, Brisbane, Australia.,The University of Queensland, Brisbane, Australia
| | | | - Gunter Hartel
- Department of Statistics, QIMR Berghofer Institute, Brisbane, Australia
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23
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Steriade C. The Search for Autoimmune-Associated Epilepsy Continues-Are We Getting Closer to Our Target? Epilepsy Curr 2021; 21:255-257. [PMID: 34690560 PMCID: PMC8512914 DOI: 10.1177/15357597211010816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Clinical Features Which Predict Neuronal Surface Autoantibodies in New-Onset
Focal Epilepsy: Implications for Immunotherapies McGinty RN, Handel A, Moloney T, et al. J Neurol Neurosurg
Psychiatry. 2020;92(3):291-294. doi:10.1136/jnnp-2020-325011 Objective: To generate a score which clinically identifies surface-directed autoantibodies in
adults with new-onset focal epilepsy and evaluate the value of immunotherapy in this
clinical setting. Methods: Prospective clinical and autoantibody evaluations in a cohort of 219 consecutive
patients with new-onset focal epilepsy. Results: A total of 10.5% (23/219) of people with new-onset focal epilepsy had detectable
serum autoantibodies to known or novel cell surface antigenic targets. Nine of 23
with autoantibodies were diagnosed with encephalitis, by contrast to 0/196 without
autoantibodies (P < .0001). Multivariate analysis identified 6
features which predicted autoantibody positivity (area under the curve = 0.83): age
≥54 years, ictal piloerection, lowered self-reported mood, reduced attention,
magnetic resonance imaging limbic system changes, and the absence of conventional
epilepsy risk factors. Eleven (79%) of 14 patients with detectable autoantibodies,
but without encephalitis, showed excellent long-term outcomes (modified Rankin Score
= 0) despite no immunotherapy. These outcomes were superior to those of
immunotherapy-treated patients with confirmed autoantibody-mediated encephalitis
(P < .05). Conclusions: Seizure semiology, cognitive and mood phenotypes, alongside inflammatory
investigation findings, aid the identification of surface autoantibodies among
unselected people with new-onset focal epilepsy. The excellent
immunotherapy-independent outcomes of autoantibody-positive patients without
encephalitis suggest immunotherapy administration should be guided by clinical
features of encephalitis, rather than autoantibody positivity. Our findings suggest
that, in this cohort, immunotherapy-responsive seizure syndromes with autoantibodies
largely fall under the umbrella of autoimmune encephalitis. Antibodies Contributing to Focal Epilepsy Signs and Symptoms Score. de Bruijn M, Bastiaansen AEM, Mojzisova H, et al. Ann Neurol.
2021;89(4):698-710. doi:https://doi.org/10.1002/ana.26013. Objective: Diagnosing autoimmune encephalitis (AIE) is difficult in patients with less
fulminant diseases such as epilepsy. However, recognition is important, as patients
require immunotherapy. This study aims to identify antibodies in patients with focal
epilepsy of unknown etiology and to create a score to preselect patients requiring
testing. Methods: In this prospective, multicenter cohort study, adults with focal epilepsy of
unknown etiology, without recognized AIE, were included, between December 2014 and
December 2017, and followed for 1 year. Serum, and if available cerebrospinal fluid,
were analyzed using different laboratory techniques. The ACES score was created
using factors favoring an autoimmune etiology of seizures (AES), as determined by
multivariate logistic regression. The model was externally validated and evaluated
using the Concordance (C) statistic. Results: We included 582 patients, with median epilepsy duration of 8 years (interquartile
range = 2-18). Twenty (3.4%) patients had AES, of whom 3 had anti-leucine-rich
glioma inactivated 1, 3 had anti-contactin-associated protein-like 2, 1 had
anti-N-methyl-d-aspartate receptor, and 13 had
antiglutamic acid decarboxylase 65 (enzyme-linked immunosorbent assay concentrations
>10 000 IU/mL). Risk factors for AES were temporal magnetic resonance imaging
hyperintensities (odds ratio [OR] = 255.3, 95% CI = 19.6-3332.2, P
< .0001), autoimmune diseases (OR = 13.31, 95% CI = 3.1-56.6, P
= .0005), behavioral changes (OR = 12.3, 95% CI = 3.2-49.9, P =
.0003), autonomic symptoms (OR = 13.3, 95% CI = 3.1-56.6, P =
.0005), cognitive symptoms (OR = 30.6, 95% CI = 2.4-382.7, P =
.009), and speech problems (OR = 9.6, 95% CI = 2.0-46.7, P = .005).
The internally validated C-statistic was 0.95 and 0.92 in the validation cohort (n =
128). Assigning each factor 1 point, an antibodies contributing to focal epilepsy
signs and symptoms (ACES) score ≥2 had a sensitivity of 100% to detect AES, and a
specificity of 84.9%. Interpretation: Specific signs point toward AES in focal epilepsy of unknown etiology. The ACES
score (cutoff ≥ 2) is useful to select patients requiring antibody testing.
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24
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Chen B, Lopez Chiriboga AS, Sirven JI, Feyissa AM. Autoimmune Encephalitis-Related Seizures and Epilepsy: Diagnostic and Therapeutic Approaches. Mayo Clin Proc 2021; 96:2029-2039. [PMID: 34353466 DOI: 10.1016/j.mayocp.2021.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Baibing Chen
- Department of Neurology, Mayo Clinic, Jacksonville, FL
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25
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Sechi E, Flanagan EP. Antibody-Mediated Autoimmune Diseases of the CNS: Challenges and Approaches to Diagnosis and Management. Front Neurol 2021; 12:673339. [PMID: 34305787 PMCID: PMC8292678 DOI: 10.3389/fneur.2021.673339] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/28/2021] [Indexed: 12/25/2022] Open
Abstract
Antibody-mediated disorders of the central nervous system (CNS) are increasingly recognized as neurologic disorders that can be severe and even life-threatening but with the potential for reversibility with appropriate treatment. The expanding spectrum of newly identified autoantibodies targeting glial or neuronal (neural) antigens and associated clinical syndromes (ranging from autoimmune encephalitis to CNS demyelination) has increased diagnostic precision, and allowed critical reinterpretation of non-specific neurological syndromes historically associated with systemic disorders (e.g., Hashimoto encephalopathy). The intracellular vs. cell-surface or synaptic location of the different neural autoantibody targets often helps to predict the clinical characteristics, potential cancer association, and treatment response of the associated syndromes. In particular, autoantibodies targeting intracellular antigens (traditionally termed onconeural autoantibodies) are often associated with cancers, rarely respond well to immunosuppression and have a poor outcome, although exceptions exist. Detection of neural autoantibodies with accurate laboratory assays in patients with compatible clinical-MRI phenotypes allows a definite diagnosis of antibody-mediated CNS disorders, with important therapeutic and prognostic implications. Antibody-mediated CNS disorders are rare, and reliable autoantibody identification is highly dependent on the technique used for detection and pre-test probability. As a consequence, indiscriminate neural autoantibody testing among patients with more common neurologic disorders (e.g., epilepsy, dementia) will necessarily increase the risk of false positivity, so that recognition of high-risk clinical-MRI phenotypes is crucial. A number of emerging clinical settings have recently been recognized to favor development of CNS autoimmunity. These include antibody-mediated CNS disorders following herpes simplex virus encephalitis or occurring in a post-transplant setting, and neurological autoimmunity triggered by TNFα inhibitors or immune checkpoint inhibitors for cancer treatment. Awareness of the range of clinical and radiological manifestations associated with different neural autoantibodies, and the specific settings where autoimmune CNS disorders may occur is crucial to allow rapid diagnosis and early initiation of treatment.
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.,Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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26
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Abstract
Autoimmune encephalitis defines brain inflammation caused by a misdirected immune response against self-antigens expressed in the central nervous system. It comprises a heterogeneous group of disorders that are at least as common as infectious causes of encephalitis. The rapid and ongoing expansion of this field has been driven by the identification of several pathogenic autoantibodies that cause polysymptomatic neurological and neuropsychiatric diseases. These conditions often show highly distinctive cognitive, seizure and movement disorder phenotypes, making them clinically recognisable. Their early identification and treatment improve patient outcomes, and may aid rapid diagnosis of an underlying associated tumour. Here we summarise the well-known autoantibody-mediated encephalitis syndromes with neuronal cell-surface antigens. We focus on practical aspects of their diagnosis and treatment, offer our clinical experiences of managing such cases and highlight more basic neuroimmunological advances that will inform their future diagnosis and treatments.
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Affiliation(s)
- Christopher E Uy
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford, UK.,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford, UK.,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford, UK .,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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27
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McGinty RN, Larner AJ. Transient epileptic amnesia and pathological tearfulness. Cortex 2021; 147:206-208. [PMID: 34148639 DOI: 10.1016/j.cortex.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Ronan N McGinty
- Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
| | - Andrew J Larner
- Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom.
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28
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Mongay-Ochoa N, Sala-Padró J, Reynés-Llompart G, Rodríguez-Bel L, Jaraba S, Morandeira F, Falip M. Brain FDG-PET findings in glutamic acid decarboxylase antibody-associated epilepsy. J Neuroimaging 2021; 31:869-873. [PMID: 33955107 DOI: 10.1111/jon.12874] [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: 01/16/2021] [Revised: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Glutamic acid decarboxylase antibodies (GAD-Ab) are sometimes associated with chronic drug-resistant focal epilepsy. Clinically, it may manifest as mesial temporal lobe epilepsy (mTLE), with GAD-Ab patients difficult to distinguish. Therefore, the aim of this study is to compare brain metabolism of patients with mTLE and high serum titers of GAD-Ab (>2000 UI/ml) to those with mTLE and hippocampal sclerosis (HS) and confirmed GAD-ab negativity. METHODS Images from PET studies were normalized to an SPM 12 template. Voxel to voxel comparisons were made using a two-sample one-tailed t-test. RESULTS In both patients with GAD-Ab and controls (mTLE-HS), hypometabolism in mesial temporal lobe areas was observed. When comparing the two groups, GAD-Ab patients had statistically significant reduced metabolism in both insulae and medial inferior frontal-hypothalamus area (p < 0.001). CONCLUSIONS Hypometabolism in mesial temporal lobe areas together with hypometabolism in insulae and medial inferior frontal-hypothalamus may be characteristic of patients with epilepsy and GAD-ab. This PET pattern could be a useful diagnostic tool to identify GAD-Ab patients.
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Affiliation(s)
- Neus Mongay-Ochoa
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jacint Sala-Padró
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Gabriel Reynés-Llompart
- Medical Physics Department, Institut Català d'Oncolgia, L'Hospitalet de Llobregat, Barcelona, Spain.,PET Unit, Nuclear Medicine Department, IDI, Hospital U. de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Rodríguez-Bel
- PET Unit, Nuclear Medicine Department, IDI, Hospital U. de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sònia Jaraba
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Francisco Morandeira
- Laboratory, Immunology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Mercè Falip
- Epilepsy Unit, Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain
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29
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Cabezudo-García P, Mena-Vázquez N, Ciano-Petersen NL, García-Martín G, Estivill-Torrús G, Serrano-Castro PJ. Prevalence of Neural Autoantibodies in Epilepsy of Unknown Etiology: Systematic Review and Meta-Analysis. Brain Sci 2021; 11:392. [PMID: 33808902 PMCID: PMC8003737 DOI: 10.3390/brainsci11030392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The prevalence of neural autoantibodies in epilepsy of unknown etiology varies among studies. We aimed to conduct a systematic review and meta-analysis to determine the pooled global prevalence and the prevalence for each antibody. METHODS A systematic search was conducted for studies that included prospectively patients ≥16 years old with epilepsy of unknown etiology and systematically determined neural autoantibodies. A meta-analysis was undertaken to estimate pooled prevalence in total patients with a positive result for at least one neural autoantibody in serum and/or cerebrospinal fluid (CSF) and for each autoantibody. RESULTS Ten of the eleven studies that met the inclusion criteria and a total of 1302 patients with epilepsy of unknown etiology were included in themeta-analysis. The global pooled prevalence (IC95%) was 7.6% (4.6-11.2) in a total of 82 patients with a positive result for any neural autoantibody. None of the controls available in the studies had a positive result. Individual pooled prevalence for each autoantibody was: glycine receptor (GlyR) (3.2%), glutamic acid decarboxylase (GAD) (1.9%), N-methyl-d-aspartate receptor (NMDAR) (1.8%), leucine-rich glioma inactivated-1 protein (LGI1) (1.1%), contactin-2-associated protein (CASPR2) (0.6%) and onconeuronal (0.2%). CONCLUSIONS The pooled prevalence of neural autoantibodies in patients with epilepsy of unknown etiology is small but not irrelevant. None of the controls had a positive result. There was high heterogeneity among studies. In the future, a homogeneous protocol for testing neural autoantibodies is recommended.
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Affiliation(s)
- Pablo Cabezudo-García
- Instituto de Investigación Biomédica de Málaga-IBIMA, 29010 Málaga, Spain; (N.L.C.-P.); (G.G.-M.); (G.E.-T.); (P.J.S.-C.)
- Unidad de Gestión Clínica de Neurociencias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga-IBIMA, 29010 Málaga, Spain; (N.L.C.-P.); (G.G.-M.); (G.E.-T.); (P.J.S.-C.)
- Unidad de Gestión Clínica de Reumatología, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Nicolás L. Ciano-Petersen
- Instituto de Investigación Biomédica de Málaga-IBIMA, 29010 Málaga, Spain; (N.L.C.-P.); (G.G.-M.); (G.E.-T.); (P.J.S.-C.)
- Unidad de Gestión Clínica de Neurociencias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Guillermina García-Martín
- Instituto de Investigación Biomédica de Málaga-IBIMA, 29010 Málaga, Spain; (N.L.C.-P.); (G.G.-M.); (G.E.-T.); (P.J.S.-C.)
- Unidad de Gestión Clínica de Neurociencias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Guillermo Estivill-Torrús
- Instituto de Investigación Biomédica de Málaga-IBIMA, 29010 Málaga, Spain; (N.L.C.-P.); (G.G.-M.); (G.E.-T.); (P.J.S.-C.)
- Unidad de Gestión Clínica de Neurociencias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Pedro J. Serrano-Castro
- Instituto de Investigación Biomédica de Málaga-IBIMA, 29010 Málaga, Spain; (N.L.C.-P.); (G.G.-M.); (G.E.-T.); (P.J.S.-C.)
- Unidad de Gestión Clínica de Neurociencias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
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30
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Rüegg S. Antineuronal antibodies and epilepsy: treat the patient, not the lab. J Neurol Neurosurg Psychiatry 2021; 92:230. [PMID: 33402418 PMCID: PMC7892368 DOI: 10.1136/jnnp-2020-325350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Stephan Rüegg
- Medical Faculty, University of Basel, Basel, Switzerland .,Neurology, University Hospital Basel, Basel, Switzerland
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31
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Hansen N, Timäus C. Immunotherapy in Autoantibody-Associated Psychiatric Syndromes in Adults. Front Psychiatry 2021; 12:611346. [PMID: 33584385 PMCID: PMC7875861 DOI: 10.3389/fpsyt.2021.611346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Autoantibody-associated psychiatric syndromes are often distinct from, but might also be part of autoimmune encephalitis. Our article focuses on potential immunotherapy in these patients with a probable autoimmune origin of their psychiatric syndrome. Methods: We searched through PubMed for appropriate articles on immunotherapy in autoantibody-associated psychiatric syndromes between 2010 and 2020 for this narrative review. Results: In line with prior recommendations for autoimmune encephalitis and autoimmune psychosis, we suggest that in patients with a probable autoimmune-based psychiatric syndrome should be given early corticosteroids, intravenous immunoglobulins, or plasmapheresis as first line immunotherapy. If these therapeutic options fail, second-line immunotherapy should be applied within 1 month consisting of rituximab or cyclophosphamide. Maintenance therapy is best for those patients responding to steroids including mycofenolate mofetil or azathioprine. So far, there is evidence from a few retrospective cohort studies supporting the usage of first- and second-line, and maintenance immunotherapies for autoantibody-associated psychiatric syndromes. Some immunological agents are discussed that might exert an effect in autoimmune-based psychiatric syndromes, but the latest evidence is low and derived from case reports or series with autoimmune encephalitis patients. Conclusions: Taken together, the immunotherapeutic landscape for patients with autoantibody-associated psychiatric syndromes is delineated. Our suggestions rely on observational studies in autoantibody-associated psychiatric syndromes and a few placebo-controlled, randomized trials for patients with autoimmune encephalitis and psychosis. Thus, adequate powered, prospective as well as placebo-controlled clinical trials in patients with autoantibody-associated psychiatric syndromes are warranted in order to enlighten efficacy and safety aspects of current and novel therapy strategies.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, University of Goettingen, Goettingen, Germany
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