title: Anti-NMDA-R encephalitis: Should we consider extreme delta brush as electrical status epilepticus?
abstract: Seizures are common clinical manifestations in anti-N-methyl-d-aspartate receptor (anti-NMDA-R) encephalitis, among other neurological and psychiatric symptoms. During the course of the disease, some specific EEG patterns have been described: generalized rhythmic delta activity (GRDA) and extreme delta brush (EDB). In comatose patients, the association of these EEG abnormalities with subtle motor manifestations can suggest ongoing non-convulsive status epilepticus (NCSE). We report the case of a 28-year-old woman admitted for a clinical presentation typical of anti-NMDA-R encephalitis, which was confirmed by CSF analysis. She was rapidly intubated because of severe dysautonomia and disturbed consciousness. Clinical examination revealed subtle paroxysmal and intermittent myoclonic and tonic movements, correlated on video-EEG with GRDA and/or EDB. NCSE was then suspected, but electroclinical manifestations persisted despite many anti-epileptic drugs combinations, or reappeared when barbiturate anesthesia was decreased. In order to confirm or dismiss the diagnosis, intracranial pressure (ICP) and surface video-EEG monitoring were performed simultaneously and revealed no ICP increase, thus being strongly against a diagnosis of seizures. Sedation was progressively weaned, and clinical condition as well as EEG appearance progressively improved. Literature review revealed 11 similar cases, including 2 with focal NCSE. Of the nine other cases, NCSE diagnosis was finally excluded in 5 cases. NCSE diagnosis in association with anti-NMDA-R encephalitis is sometimes very difficult and its occurrence might be overestimated. Video-EEG is highly recommended and more invasive techniques may sometimes be necessary.
authors.affiliation: Service de neurologie et unité de neurophysiologie clinique, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France. Electronic address: eve.chanson@hotmail.fr.
authors.forename: Eve
authors.initials: E
authors.lastname: Chanson
authors.affiliation: Service de neurologie et unité de neurophysiologie clinique, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France.
authors.forename: Élodie
authors.initials: É
authors.lastname: Bicilli
authors.affiliation: Service de neurologie et unité de neurophysiologie clinique, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Lauxerois
authors.affiliation: Service de neuroreanimation, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France.
authors.forename: Sophie
authors.initials: S
authors.lastname: Kauffmann
authors.affiliation: Service de neuroreanimation, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France.
authors.forename: Russell
authors.initials: R
authors.lastname: Chabanne
authors.affiliation: Centre de référence des syndromes paranéoplasique, hôpital neurologique, hospices civils de Lyon, 69677 Bron, France; Lyon Neuroscience Research Center, Inserm U1028/CNRS UMR 5292, 69372 Lyon, France.
authors.forename: François
authors.initials: F
authors.lastname: Ducray
authors.affiliation: Centre de référence des syndromes paranéoplasique, hôpital neurologique, hospices civils de Lyon, 69677 Bron, France; Lyon Neuroscience Research Center, Inserm U1028/CNRS UMR 5292, 69372 Lyon, France.
authors.forename: Jérome
authors.initials: J
authors.lastname: Honnorat
authors.affiliation: Service de neurologie et unité de neurophysiologie clinique, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France; UMR 1107, NeuroDol, université d'Auvergne, 63000 Clermont-Ferrand, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Clavelou
authors.affiliation: Service de neurologie et unité de neurophysiologie clinique, CHU Gabriel-Montpied, 63000 Clermont-Ferrand, France; EA 7282, IGCNC (Image-Guided Clinical Neuroscience and Connectomics), UMR 6284 ISIT, UFR médecine, université d'Auvergne, 63000 Clermont-Ferrand, France.
authors.forename: Sarah
authors.initials: S
authors.lastname: Rosenberg
mesh_terms: D000328:Adult; D060426:Anti-N-Methyl-D-Aspartate Receptor Encephalitis / Q000134:cerebrospinal fluid / Q000175:diagnosis*; D002540:Cerebral Cortex / Q000503:physiopathology*; D003700:Delta Rhythm; D004569:Electroencephalography; D005260:Female; D006801:Humans; D013226:Status Epilepticus / Q000175:diagnosis*
keywords: Activité delta; Autoimmune encephalitis; Delta activity; Encéphalite auto-immune; N-methyl-d-aspartate receptor; Récepteur N-méthyl-d-aspartate; Status epilepticus; État de mal épileptique