[An Update on Therapeutic Management in Autoimmune Encephalitis].

In the last 15 years, the continual discovery of newly identified forms of autoimmune encephalitis (AE) associated with antibodies to the cell surface or synaptic proteins has changed the paradigms for diagnosing and treating disorders. AE is one of the most common causes of noninfectious encephalitis. It can be triggered by tumors or, infections, or it may be cryptogenic. These disorders can occur in children or young adults with or without cancer who develop psychosis, catatonic or autistic features, memory problems, abnormal movements, or seizures. Here, we review the therapeutic management of AE. The importance of early recognition and diagnosis of AE is paramount to the ultimate goal of optimal immunotherapy. Although no specific data are available for all autoantibody-mediated encephalitis syndromes, the two most common forms of AE, which are NMDA receptor encephalitis and LGI-1 encephalitis, are clear exemplars where improved patient outcomes are associated with early immunotherapy. First-line treatments for AE include intravenous steroids and intravenous immunoglobulins, which can be combined in most severe cases. Rituximab and cyclophosphamide are administered as second-line agents in unresponsive cases. A minority of patients may remain refractory to treatment, thus representing a major clinical challenge. In these cases, the treatment strategies are controversial, and no guidelines exist. Treatments proposed for refractory AE include (1) cytokine-based drugs such as tocilizumab, and (2) plasma cell-depleting agents such as bortezomib.

Risk factors and pathogen characteristics associated with unfavorable outcomes among adults with pneumococcal meningitis in Japan, 2006 to 2016.

PURPOSE: In this study, we aimed to clarify the risk factors associated with unfavorable outcomes in adults with pneumococcal meningitis (PnM). METHODS: Surveillance was conducted between 2006 and 2016. Adults with PnM (n = 268) were followed up for outcomes within 28 days after admission using the Glasgow Outcome Scale (GOS). After classifying the patients into the unfavorable (GOS1-4) and favorable (GOS5) outcome groups, i) the underlying diseases, ii) biomarkers at admission, and iii) serotype, genotype, and antimicrobial susceptibility for all isolates were compared between both groups. RESULTS: Overall, 58.6% of patients with PnM survived,15.3% died, and 26.1% had sequelae. The number of living days in the GOS1 group was highly heterogeneous. Motor dysfunction, disturbance of consciousness, and hearing loss were the commonest sequelae. Of the underlying diseases identified in 68.9% of the PnM patients, liver and kidney diseases were significantly associated with unfavorable outcomes. Of the biomarkers, creatinine and blood urea nitrogen, followed by platelet and C-reactive protein had the most significant associations with unfavorable outcomes. There was a significant difference in the high protein concentrations in the cerebrospinal fluid between the groups. Serotypes 23F, 6C, 4, 23A, 22F, 10A, and 12F were associated with unfavorable outcomes. These serotypes were not penicillin-resistant isolates possessing three abnormal pbp genes (pbp1a, 2x, and 2b), except for 23F. The expected coverage rate of the pneumococcal conjugate vaccine (PCV) was 50.7% for PCV15 and 72.4% for PCV20. CONCLUSIONS: In the introduction of PCV for adults, the risk factors for underlying diseases should be prioritized over age, and serotypes with unfavorable outcomes should be considered.

Clinical Features of Acute Ischemic Stroke Patients with Hypoesthesia as an Initial Symptom.

This study aimed to evaluate the clinical characteristics of acute ischemic stroke (AIS) patients who experienced hypoesthesia as the initial symptom. We retrospectively analyzed the medical records of 176 hospitalized AIS patients who met our inclusion and exclusion criteria and evaluated their clinical features and MRI findings. Among this cohort, 20 (11%) patients presented with hypoesthesia as the initial symptom. MRI scans of these 20 patients identified lesions in the thalamus or pontine tegmentum in 14 and brain lesions at other sites in 6. The 20 hypoesthesia patients had higher systolic (p = 0.031) and diastolic blood pressure (p = 0.037) on admission, and a higher rate of small-vessel occlusion (p < 0.001) than patients without hypoesthesia. The patients with hypoesthesia had a significantly shorter average hospital stay (p = 0.007) but did not differ significantly from those without hypoesthesia in National Institutes of Health Stroke Scale scores on admission (p = 0.182) or the modified Rankin Scale scores for neurologic disability on discharge (p = 0.319). In the patients with acute onset hypoesthesia, high blood pressure, and neurological deficits were more likely to be due to AIS than other causes. Since most of the lesions in AIS patients with hypoesthesia as the initial symptom were found to be small, we recommend performing MRI scans with such patients to confirm AIS.

[The Exorcist, The 8-Year Engagement, and Brain on Fire: Three Films about Anti-N-methyl-D-aspartate Receptor Encephalitis].

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is one of the most common forms of autoimmune encephalitis. It is more prevalent in young adult women than it is in men. The disease is characterized by a rapid progression of psychiatric symptoms and/or cognitive impairment. Common symptoms include changes in behavior (i.e. hallucination, paranoia, and aggression etc.), seizures, memory deficit, abnormal movements, and coma. Based on these symptoms, it was historically thought that this 'behavior' was the work of the devil, and exorcism by a shaman was sometimes required. In line with this, it has been suggested that the patient who the original Exorcist movie was based on had this disease. Although immunotherapy is an effective treatment for anti-NMDA encephalitis, recovery is slow with the majority of patients requiring more than a year after disease onset to make a full recovery. In light of this, the stories and experiences of patients with this disease have been depicted in films. Examples of the films include: The 8-year engagement (2017), a Japanese film directed by Takahisa Zeze, and Brain on fire (2016), directed by Irish filmmaker Gerrard Barrett. These films help to raise awareness and make this disease more recognized by the general public.

[Meningitis, Encephalitis, and Myelitis].

Infections of the central nervous system such as meningitis, encephalitis, and myelitis are a life-threatening neurological emergences. Early recognition, efficient decision-making, and rapid initiation of therapy can be lifesaving. Adequate clinical management of central nervous system infections is important for neurosurgeons during neurological emergences. This article describes recent trends in central nervous system infections and the pitfalls faced by neurosurgeons.

Locked-in Syndrome Due to Meningovascular Syphilis: A Case Report and Literature Review.

We herein report a 46-year-old man presenting with locked-in syndrome secondary to meningovascular syphilis. Brain magnetic resonance imaging (MRI) demonstrated multiple acute infarctions in the left ventromedial pons, right basis pontis, and left basal ganglia. His locked-in syndrome was hypothesized to have been caused by thrombosis of the small paramedian branches of the basilar artery due to syphilitic arteritis. This is a unique case of bilateral ventromedial pontine infarction caused by meningovascular syphilis that presented as locked-in syndrome. Meningovascular syphilis should be included in the differential diagnosis of uncommon stroke, particularly in young men.

Characteristics of clinical relapses and patient-oriented long-term outcomes of patients with anti-N-methyl-D-aspartate receptor encephalitis.

OBJECTIVE: The main syndrome of anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) is well-characterized, however, the difference in main symptoms between the initial episode and relapses and patient-oriented long-term outcomes has not been previously described. METHODS: To investigate the difference in syndrome symptoms between episodes and patient-oriented outcomes, we administered a structured questionnaire survey for the patients with anti-NMDARE or their family members. From the answers, we analyzed the frequency of main symptoms (e.g., prodromes, abnormal behaviors, memory deficit, speech disorders, involuntary movements, hypo-ventilation) between episodes and patient-oriented outcomes that included the recovery rate for return to previous work or school. RESULTS: Fifty-six patients were enrolled, and 14 (25%) showed clinical relapse. Details of symptoms at relapse were obtained from 11 patients. Prodrome (27% vs. 96%, p < 0.001), decreased level of consciousness (55% vs. 88%, p = 0.021), seizures (36% vs. 77%, p = 0.012), and involuntary movements (27% vs. 84%, p < 0.001) were significantly less frequent at relapse than initial episode. Although 80% (35/44) of the patients achieved favorable long-term outcomes (modified Rankin Scale score, 0-2), only 61% (27/44) returned to their previous work or school life. CONCLUSION: Anti-NMDARE can relapse with milder and more limited symptoms than those of initial episode, and some patients did not return to their previous activities even after achieving a neurologically favorable outcome.

[Role of the liaison officer in disaster countermeasures implemented by the Japanese Society of Neurology: Hope for the best and prepare for the worst].

Disaster countermeasures have been implemented by the Japanese Society of Neurology based on the experience of support to the areas affected by the Great East Japan Earthquake on March 11, 2011. The countermeasures activity began at the end of 2011. We, the Committee for Measures Against Disaster, officially started work in 2014. We developed a support network to urgently deal with patients with intractable neurological disease at the time of disaster and strengthen disaster measures, including effective disaster countermeasure training. During the 2016 Kumamoto earthquake, we realized the need to prepare for natural disasters, leading to a state of emergency, at normal times. A list of vulnerable people should be prepared and the individual support plan for disaster should be confirmed during normal times. Furthermore, during disaster, livelihood support is required for patients with intractable neurological disease living in evacuation centers in affected areas. Therefore, we compiled and published the book, titled "The manual of disaster countermeasures," in 2017. The Committee for Measures Against Disaster in the Japanese Society of Neurology has appointed a liaison officer for patients with intractable neurological disease in each prefecture. The liaison's role of is gathering and disseminating information on the disaster-hit areas, arranging medical support, and coordinating health activities, when natural disasters occur. It is hoped that the liaison officer will play an active role both at normal times and during disaster, even unforeseen ones. Although we hope for the best, we aim to be prepared for the worst.

A case of prosopometamorphopsia caused by infarction of the splenium of the corpus callosum and major forceps.

An adult female complained of enlargement of right eyes in other people. Diffusion-weighted imaging detected an abnormal high-intensity area in the region from the splenium of the corpus callosum to the major forceps on the right side. The patient reported that right eyes appeared larger in size, which suggested prosopometamorphopsia. Adichotic listening test identified left-ear deficit. Acombination of prosopometamorphopsia and left-ear deficit was not identified in the reported patients. Prosopometamorphopsia in most of the reported patients included the eye as did that in our patient. This result suggested the importance of information on the eye in recognizing faces.

Late-onset MELAS syndrome with mtDNA 14453G→A mutation masquerading as an acute encephalitis: a case report.

BACKGROUND: A unique patient with MELAS syndrome, who initially masqueraded as having acute encephalitis and was eventually diagnosed with MELAS syndrome harboring a mtDNA 14453G → A mutation, is described. CASE PRESENTATION: A 74-year-old Japanese man was admitted to another hospital due to acute onset of cognitive impairment and psychosis. After 7 days he was transferred to our hospital with seizures and deteriorating psychosis. The results of primary ancillary tests that included EEG, CSF findings, and brain MRI supported the diagnosis of an acute encephalitis. HSV-DNA and antibodies against neuronal surface antigens in the CSF were all negative. With the assistance of the lactate peak on the brain lesions in the magnetic resonance spectroscopy image and genetic analysis of the biopsied muscle, he was eventually diagnosed with MELAS syndrome harboring mtDNA 14453G → A mutation in the ND6 gene. CONCLUSIONS: This case provides a caveat that MELAS syndrome can manifest in the symptoms and ancillary tests masquerading as an acute encephalitis caused by infection or autoimmunity. This is the first adult patient seen to harbor the mtDNA14453G → A with a unique onset, which broadens the phenotypic spectrum of MELAS syndrome associated with ND6 gene mutation.

Multimodal visual exploration disturbances in Parkinson's disease detected with an infrared eye-movement assessment system.

Parkinson's disease (PD) reportedly show disturbed visual exploration. However, whether this disturbance is due to dysfunctional visual information processing remains unclear. To clarify the effects of PD on visual information processing when exploring for targets and to compare disease effects with aging effects, we used an infrared eye-movement assessment system. Cognitively normal PD patients (n = 13), healthy age-matched (n = 17) and young controls (n = 36) participated in this study, and were evaluated using two figure-matching tasks representing visual information processing (clock-matching and inverted clock-matching tasks) and saccade tasks representing oculomotor function. With figure-matching tasks, PD patients showed significantly larger numbers of images watched in a single trial compared to healthy age-matched controls on the inverted clock-matching task. No aging effects was found in these variables. In contrast, no disease effect was apparent for reaction time, which was significantly longer in healthy age-matched controls than in healthy young controls. For saccade tasks, PD patients showed significantly smaller saccade size than healthy age-matched controls on the antisaccade task, but no aging effects were evident. Our approaches highlighted that visual exploration disturbance in PD may be due to dysfunctional visual information processing in addition to dysfunctional oculomotor processing. These disease effects may differ from aging effects.

Clinical Study of Thirteen Patients with Spinal Cord Infarction.

BACKGROUND: A concept of sensory tracts in the spinal cord has been established in relation to a dorsolateral pathway which is located in the posterior part of the lateral column and conveys the deep sense. METHODS: The clinical status at onset, neurological symptoms, and magnetic resonance imaging (MRI) findings in 13 patients of spinal cord infarction were studied. RESULTS: The clinical status was acute in 11 patients and subacute in 2 patients. Palsy of the extremities was noted in 11 patients. Segmental sensory disturbance was shown in all patients. One patient showed disturbance of all senses and paraplegia, which indicated transverse myelopathy. In the other 12 patients, 11 patients showed impairment of pain sense although joint position sense was preserved, excluding 1 patient whose sensory disturbance showed dysesthesia alone. In these 11 patients, soft touch and vibration senses were impaired in 7 patients. Abnormality of spinal cord MRI was detected 7 patients. The lesions were located in the cervical cord in 3 patients, cervical to thoracic cord in 1 patient, and thoracic cord in 3 patients. CONCLUSIONS: In the 11 patients in whom pain sense was impaired and joint position sense was preserved, involvement of the anterior spinal cord artery (ASCA) was the mainstay. Impairment of vibration sense was accompanied in 7 patients in patients of ASCA infarction. It was speculated that impairment of vibration sense can occur in patients with ASCA infarction whose ischemia spread to the dorsolateral pathway in the posterior part of the lateral column.

Hemichorea after hypoglycemic episodes with negative MRI findings in an elderly woman with poorly controlled type 2 diabetes mellitus: a case report.

BACKGROUND: Diabetic chorea appears during the course of poorly-controlled diabetes. While chorea associated with diabetes mellitus usually occurs during hyperglycemic episodes, hypoglycemia can also cause diabetic chorea. Brain magnetic resonance imaging (MRI) is useful for evaluating the pathogenesis of diabetic chorea. However, several diabetic chorea cases have reportedly not shown abnormal high-intensity in the putamen and striatum on T1-weighted images. CASE PRESENTATION: We report a 74-year-old woman who was admitted to our hospital for treatment of poorly-controlled type 2 diabetes mellitus. Intensified insulin treatment gradually normalizeed blood glucose, but on the 19th hospital day, after a blood glucose measurement of 49 mg/dL, she showed hemichorea of the left face, shoulder, arm and leg. MRI revealed no abnormalities of either the putamen or the striatum on T1-weighted images. She was treated with dopamine receptor antagonists, which alleviated her hemichorea symptoms and allowed discharge from the hospital. 1 year after the first hospitalization, she had to be readmitted because her glycemic control had markedly deteriorated. Glycemic control improved rapidly, and, because hemichorea did not recur, the dopamine receptor antagonists were stopped. 1 month later, however, hemichorea recurred. She resumed taking the dopamine receptor antagonists, resulting in immediate disappearance of the hemichorea. CONCLUSIONS: We herein describe a rare case of diabetes-associated hemichorea occurring after hypoglycemic episodes without abnormal high-intensity findings in the basal ganglia on T1-weighted images. The hemichorea relapsed with cessation of dopamine receptor antagonists. This case also underscores the importance of longitudinal assessment and treatment for hemichorea after hypoglycemic episodes, even in the absence of MRI findings, in elderly diabetic patients.

Acute retinal necrosis following herpes simplex encephalitis: a nationwide survey in Japan.

PURPOSE: Acute retinal necrosis (ARN) is a severe necrotizing retinitis caused by varicella-zoster virus or herpes simplex virus (HSV) that often results in blindness. Occasionally, HSV-caused ARN develops after herpes simplex encephalitis (HSE). It remains unknown, however, when and how often ARN develops after HSE. To investigate the actual conditions of patients with ARN following HSE and the interval period between the prior HSE and the onset of ARN, a retrospective nationwide survey of the Japanese population was performed. STUDY DESIGN: Retrospective. METHODS: Questionnaires were sent out to the neurology and ophthalmology departments of teaching hospitals in Japan. They inquired about HSE patients in neurology departments and ARN patients diagnosed with HSV in ophthalmology departments. The proportion of the HSV-ARN patients with a history of HSE and their interval periods were obtained from the questionnaires returned by the ophthalmology departments. RESULTS: Neurology departments of 324 hospitals responded to the questionnaires (response proportion: 40.9%), and 53 HSE cases were reported. Ophthalmology departments of 535 hospitals responded the questionnaires (response proportion: 54.3%), and 67 HSV-ARN cases were reported. Among the 67 HSV-ARN cases, 16 (23.9%) had histories of prior HSE. Although the interval periods from the prior HSE to the onset of HSV-ARN varied among cases, nearly half developed HSV-ARN within 2 years. CONCLUSIONS: This nationwide survey of the Japanese population showed that HSV-ARN develops after HSE in higher frequency within 2 years. Neurologists and ophthalmologists should be aware that HSE survivors have a risk of contracting HSV-ARN.

How to demix Alzheimer-type and PSP-type tau lesions out of their mixture -hybrid approach to dissect comorbidity.

Neurofibrillary tangles (NFTs), are shared between progressive supranuclear palsy (PSP) and Alzheimer disease (AD). Histological distinction of PSP and AD is possible based on the distribution of NFTs. However, neuropathologists may encounter diagnostic difficulty with comorbidity of PSP and AD. In this study, we tried to circumvent this difficulty by analyzing five autopsied brains harboring both PSP and AD pathology. Tau-positive lesions were sorted based on their cell type (neuron versus glia), and tau isoforms: three-repeat (3R) versus four-repeat (4R) tau. 16 regions were selected to map these lesions throughout the brain. 4R-tau lesions were present in all areas examined. Among them, 3R-tau lesions were absent in some areas. These 4R selective (4R+/3R-) areas dictate prototypic distribution of PSP, not usually found in AD, such as pontine nucleus, red nucleus, inferior olivary nucleus, dentate nucleus, globus pallidus and putamen, each contained both glial and neuronal lesions. In contrast, additional 3R-tau lesions were found in hippocampal formation to neocortex, where 3R immunoreactivity (IR) was predominant over the 4R counterpart mainly in neurons as found in AD but not in PSP. Although tau lesions in central grey matter, substantia nigra and locus coeruleus are found in both AD and PSP, 4R-selectivity with glial component suggests PSP origin. Even if the presence of 3 R IR in these areas suggests AD pathology, it does not exclude the involvement of PSP-type lesion because distinction of 4R IR into PSP or AD is not yet possible. Further demixing may be possible if biochemical difference of 4R tau between PSP and AD is identified.

[Acute sensory neuropathy associated with Hodgkin's lymphoma: a case study].

The case of a 17-year-old man with Hodgkin's lymphoma who presented with paraneoplastic sensory neuropathy is presented. The patient visited our hospital because of acute progression of dysesthesiae in the bilateral face and extremities. He also developed an ataxic gait due to decreased deep sensation. Post-contrast T1-weighted MRI showed enhancement of both trigeminal nerves and the cauda equina. Cerebrospinal fluid examination was unremarkable. Intravenous immunoglobulin therapy and subsequent steroid pulse therapy did not improve his symptoms. Laboratory data showed an elevated serum soluble interleukin-2 receptor level. His chest X-ray and CT showed enlarged lymph nodes in the mediastinum, and the histopathologic examination of a lymph node biopsy specimen showed classical Hodgkin's lymphoma. He was treated with chemotherapy. His symptoms of neuropathy improved promptly while the lymphoma was being successfully treated, and he was able to walk with a cane. The present case was characterized by paraneoplastic sensory neuropathy as the initial clinical feature in association with Hodgkin's lymphoma. It is necessary to consider a paraneoplastic neurological syndrome even in a young patient with acute/subacute sensory neuropathy. Paraneoplastic sensory neuropathy associated with Hodgkin's lymphoma could be expected to improve with oncotherapy, and examination of the malignancy and early treatment are important.

Postural Abnormality in Parkinson's Disease: A Large Comparative Study With General Population.

BACKGROUND: Postural abnormalities in Parkinson's disease (PD) patients and unimpaired elderly are not well differentiated. Factors related to postural abnormality associated with PD are controversial. OBJECTIVE: We assessed differences in postural change between PD patients and unimpaired elderly and elucidated factors related to abnormal posture in PD patients. METHODS: We measured the dropped head angle (DHA), anterior flexion angle (AFA), and lateral flexion angle (LFA) of the thoracolumbar spine of an unprecedented 1,117 PD patients and 2,732 general population participants (GPPs) using digital photographs. Two statistical analyses were used for elucidating factors related to these angles. RESULTS: In GPPs, age was correlated with DHA, AFA, and LFA. DHAs, AFAs, and LFAs of PD patients and age-matched GPPs were 21.70° ± 14.40° and 13.13° ± 10.79°, 5.98° ± 12.67,°and - 3.82° ± 4.04°, and 0.86° ± 4.25° and 1.33° ± 2.16°, respectively. In PD patients, factors related to DHA were age, male sex, and H & Y stage during ON time. Factors related to AFA were age, duration of disease, H & Y stage during ON and OFF times, pain, vertebral disease, and bending to the right. A factor related to LFA was AFA. CONCLUSIONS: DHA and AFA of GGPs correlated with age and were larger in PD patients than those with in GPPs. Some PD patients showed angles far beyond the normal distribution. Thus, factors associated with disease aggravation affected postural abnormality in PD patients.

Nationwide survey of influenza-associated acute encephalopathy in Japanese adults.

BACKGROUND: Knowledge of adult patients with influenza-associated acute encephalopathy (IAE) is limited. We conducted a detailed survey to investigate the prevalence, clinical features, associated outcomes, and prognostic factors in adult IAE patients. METHOD: A nationwide questionnaire on IAE patients was sent to the departments of Internal Medicine, Neurology, Neurosurgery, and Emergency and Critical Care at all hospitals with ≥200 beds in Japan. RESULTS: 118 patients were diagnosed with IAE during the 2013/14 to 2015/16 influenza seasons, and the estimated annual incidence of IAE in Japanese adults was 0.98/1000,000 population. 44 patients were subsequently enrolled in the detailed study. 93% of patients exhibited disturbance of consciousness. Convulsions and delirious behavior were present in 26% and 40% of patients, respectively. 65% of patients received pulse corticosteroid therapy with methylprednisolone and 21% of patients received intravenous gamma-globulin therapy. 63% of patients achieved a good recovery, but 7% died. Multiple logistic regression analysis revealed that plasma glucose level demonstrated a statistically significant association with poor outcome. CONCLUSION: This nationwide survey provided data for the annual incidence and clinical features of IAE in Japanese adults. Hyperglycemia was indicated as an independent predictor of poor prognosis in IAE patients and reflected systemic hypercytokinemia in IAE pathogenesis.

Clinical Study on 3 Patients with Infarction of the Vermis/Tonsil in the Cerebellum.

BACKGROUND: Infarction of the vermis and the tonsil in the cerebellum presents as truncal and gait ataxia. Acute rotatory vertigo is often present in infarction of the nodulus in the caudal vermis, which is closely associated with the vestibular pathway, but is minor in infarction of the rostral vermis. The rostral vermis receives input from the dorsal spinocerebellar tract (DSCT) which conveys unconsciousness proprioceptive signals from the ipsilateral lower trunk and leg. The present study investigated the characteristics of infarction of the vermis and the tonsil. PATIENTS AND METHODS: Neuroradiological findings of 3 patients whose lesions were located in the vermis or the tonsil were analyzed. RESULTS: All lesions were located in the anterior lobe in the rostral vermis, the nodulus in the caudal vermis, or the tonsil. Truncal and gait ataxia were exhibited by 3 patients. Rotatory vertigo was exhibited by 2 patients whose lesions were located in the nodulus and the tonsil, but absent in a patient with infarction of the anterior lobe. Lateropulsion opposite the lesion was apparent in a patient with infarction of the tonsil. Gaze-evoked nystagmus was observed in 2 patients with infarction of the nodulus and the tonsil. CONCLUSIONS: The tonsil and the nodulus were considered to have a close relationship with the vestibular pathway. Absence of rotatory vertigo indicated impairment of the DSCT. Our data suggested that the cause of truncal and gait ataxia differed between the rostral vermis and the caudal vermis/tonsil.